U.S. patent application number 17/607641 was filed with the patent office on 2022-08-11 for allogeneic cell therapy of b cell malignancies using genetically engineered t cells targeting cd19.
This patent application is currently assigned to CRISPR Therapeutics AG. The applicant listed for this patent is CRISPR Therapeutics AG. Invention is credited to Mark Benton, Tony Ho, Demetrios Kalaitzidis, Ewelina Morawa, Jonathan Alexander Terrett.
Application Number | 20220249558 17/607641 |
Document ID | / |
Family ID | |
Filed Date | 2022-08-11 |
United States Patent
Application |
20220249558 |
Kind Code |
A1 |
Benton; Mark ; et
al. |
August 11, 2022 |
ALLOGENEIC CELL THERAPY OF B CELL MALIGNANCIES USING GENETICALLY
ENGINEERED T CELLS TARGETING CD19
Abstract
A population of genetically engineered immune cells (e.g., T
cells), which express a chimeric antigen receptor (CAR) specific to
CD19 and contain a disrupted TRAC gene, a disrupted B2M gene, or
both, for use in treating a B cell malignancy.
Inventors: |
Benton; Mark; (Cambridge,
MA) ; Ho; Tony; (Cambridge, MA) ; Kalaitzidis;
Demetrios; (Cambridge, MA) ; Morawa; Ewelina;
(Cambridge, MA) ; Terrett; Jonathan Alexander;
(Cambridge, MA) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
CRISPR Therapeutics AG |
Zug |
|
CH |
|
|
Assignee: |
CRISPR Therapeutics AG
Zug
CH
|
Appl. No.: |
17/607641 |
Filed: |
April 30, 2020 |
PCT Filed: |
April 30, 2020 |
PCT NO: |
PCT/IB2020/054118 |
371 Date: |
October 29, 2021 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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62840913 |
Apr 30, 2019 |
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International
Class: |
A61K 35/17 20060101
A61K035/17; C12N 5/0783 20060101 C12N005/0783; C12N 15/62 20060101
C12N015/62; C12N 15/90 20060101 C12N015/90; C12N 15/11 20060101
C12N015/11; C12N 9/22 20060101 C12N009/22; C12N 15/86 20060101
C12N015/86; C07K 16/28 20060101 C07K016/28; A61K 38/17 20060101
A61K038/17; A61K 31/7076 20060101 A61K031/7076; A61P 35/00 20060101
A61P035/00 |
Claims
1. A method for treating a B-cell malignancy in a human patient,
the method comprising: (i) subjecting a human patient having a
B-cell malignancy to a lymphodepletion treatment; and (ii)
administering to the human patient a population of genetically
engineered T cells after step (i), wherein the population of
genetically engineered T cells comprising T cells that comprise:
(a) a disrupted T cell receptor alpha constant (TRAC) gene, (b) a
nucleic acid coding for a chimeric antigen receptor (CAR) that
binds CD19, wherein the CAR comprises an anti-CD19 single chain
variable fragment (scFv) that comprises a heavy chain variable
region set forth in SEQ ID NO: 51, and a light chain variable
region set forth in SEQ ID NO: 52, and wherein the nucleic acid is
inserted in the disrupted TRAC gene, and (c) a disrupted beta
2-microglobulin (.beta.2M) gene; wherein the population of
genetically engineered T cells is administered to the human patient
at a dose of about 1.times.10.sup.7 to about 1.times.10.sup.9
CAR.sup.+ T cells.
2. The method of claim 1, wherein the disrupted TRAC gene comprises
a deletion of a fragment comprising the nucleotide sequence of SEQ
ID NO: 26,
3. The method of claim 1, wherein the population of genetically
engineered T cells administered to the human patient per dose
contains no more than 7.times.10.sup.4 TCR.sup.+ T cells/kg.
4. The method of claim 1, wherein the lymphodepletion treatment in
step (i) comprises co-administration to the human patient
fludarabine at about 30 mg/m.sup.2 and cyclophosphamide at about
500-750 mg/m.sup.2 per day for three days.
5. The method of claim 4, wherein the lymphodepletion treatment in
step (i) comprises co-administration to the human patient
fludarabine at about 30 mg/m.sup.2 and cyclophosphamide at about
500 mg/m.sup.2 per day for three days, or fludarabine at about 30
mg/m.sup.2 and cyclophosphamide at about 750 mg/m.sup.2 per day for
three days.
6. The method of claim 1, wherein the population of genetically
engineered T cells is administered to the human patient at a dose
of about 1.times.10.sup.7, about 3.times.10.sup.7, about
1.times.10.sup.8, about 3.times.10.sup.8, or about 1.times.10.sup.9
CAR' T cells.
7. The method of claim 1, wherein prior to step (i), the human
patient does not show one or more of the following features: (a)
significant worsening of clinical status, (b) requirement for
supplemental oxygen to maintain a saturation level of greater than
91%, (c) uncontrolled cardiac arrhythmia, (d) hypotension requiring
vasopressor support, (e) active infection, and (f) grade .gtoreq.2
acute neurological toxicity.
8. The method of claim 1, wherein step (i) is performed about 2-7
days prior to step (ii).
9. The method of claim 1, wherein after step (i) and prior to step
(ii), the human patient does not show one or more of the following
features: (a) active uncontrolled infection; (b) worsening of
clinical status compared to the clinical status prior to step (i);
and (c) grade .gtoreq.2 acute neurological toxicity.
10. The method of claim 1, further comprising (iii) monitoring the
human patient for development of acute toxicity after step (ii);
and (iv) managing the acute toxicity if occurs.
11. The method of claim 10, wherein step (iii) is performed for at
least 28 days after administration of the population of genetically
engineered T cells.
12. The method of claim 10, wherein the acute toxicity comprises
tumor lysis syndrome (TLS), cytokine release syndrome (CRS), immune
effector cell-associated neurotoxicity syndrome (ICANS), B cell
aplasia, hemophagocytic lymphohistiocytosis (HLH), cytopenia,
graft-versus-host disease (GvHD), hypertension, renal
insufficiency, or a combination thereof.
13. The method of claim 1, wherein the B cell malignancy is
non-Hodgkin lymphoma, which optionally is selected from the group
consisting of diffuse large B cell lymphoma (DLBCL), high grade B
cell lymphoma with MYC and BCL2 and/or BCL6 rearrangement,
transformed follicular lymphoma (FL), and grade 3b FL.
14. The method of claim 13, wherein DLBCL is DLBCL not otherwise
specified (NOS).
15. The method of claim 1, wherein the human patient has at least
one measurable lesion that is fluorodeoxyglucose positron emission
tomography (PET)-positive.
16. The method of claim 1, wherein the B cell malignancy is
refractory and/or relapsed.
17. The method of claim 1, wherein the human patient has undergone
one or more lines of prior anti-cancer therapies.
18. The method of claim 17, wherein the human patient has undergone
two or more lines of prior anti-cancer therapies.
19. The method of claim 17, wherein the prior anti-cancer therapies
comprise an anti-CD20 antibody, an anthracycline-containing
regimen, or a combination thereof.
20. The method of claim 17, wherein the human patient has
refractory or relapsed transformed FL and has undergone at least
one line of chemotherapy for disease after transformation to
DLBCL.
21. The method of claim 16, wherein the B cell malignancy is
refractory, and the human patient has progressive disease on last
therapy, or has stable disease following at least two cycles of
therapy with duration of stable disease of up to 6 months.
22. The method of claim 1, wherein the human patient has failed
prior autologous hematopoietic stem cell transplantation (HSCT) or
ineligible for prior autologous HSCT.
23. The method of claim 1, wherein the human patient is subject to
an additional anti-cancer therapy after treatment with the
population of genetically engineered T cells.
24. The method of claim 1, wherein the human patient has one or
more of the following features: (a) has an Eastern Cooperative
Oncology Group (ECOG) performance status 0 or 1; (b) adequate
renal, liver, cardiac, and/or pulmonary function; (c) free of prior
gene therapy or modified cell therapy; (d) free of prior treatment
comprising an anti-CD19 antibody; (e) free of prior allogeneic
HSCT; (f) free of detectable malignant cells from cerebrospinal
fluid; (g) free of brain metastases; (h) free of prior central
nervous system disorders; (i) free of unstable angina, arrhythmia,
and/or myocardial infarction; (j) free of uncontrolled infection;
(k) free of immunodeficiency disorders or autoimmune disorders that
require immunosuppressive therapy; and (l) free of infection by
human immunodeficiency virus, hepatitis B virus, or hepatitis C
virus.
25. The method of claim 1, wherein the anti-CD19 scFv comprises the
amino acid sequence of SEQ ID NO: 47.
26. The method of claim 25, wherein the CAR that binds CD19
comprises the amino acid sequence of SEQ ID NO: 40.
27. The method of claim 1, wherein the nucleic acid encoding the
anti-CD19 CAR is inserted at the site of deletion in the disrupted
TRAC gene.
28. The method of claim 1, wherein the disrupted TRAC gene
comprises the nucleotide sequence of SEQ ID NO: 54.
29. The method of claim 1, wherein the disrupted 32M gene in the
population of genetically engineered T cells comprises at least one
of the nucleotide sequence set forth in SEQ ID NOs: 9-14.
30. The method of claim 1, wherein the population of genetically
engineered T cells is allogeneic.
31. The method of claim 1, wherein at least 90% of the T cells in
the population of genetically engineered T cells do not express a
detectable level of TCR surface protein.
32. The method of claim 1, wherein at least 70% of the T cells in
the population of genetically engineered T cells do not express a
detectable level of TCR surface protein, wherein at least 50% of
the T cells in the population of genetically engineered T cells do
not express a detectable level of B2M surface protein; and/or
wherein at least 30% of the T cells in the population of
genetically engineered T cells express a detectable level of the
CAR.
33. The method of claim 32, wherein at least 99.5% of the T cells
in the population of genetically engineered T cells do not express
a detectable level of TCR surface protein.
34. The method of claim 1, wherein at least 70% of the T cells in
the population of genetically engineered T cells do not express a
detectable level of B2M surface protein.
35. The method of claim 34, wherein at least 85% of the T cells in
the population of the genetically engineered T cells do not express
a detectable level of B2M surface protein.
36. The method of claim 1, wherein at least 50% of the T cells in
the population of genetically engineered T cells express a
detectable level of the CAR.
37. The method of claim 36, wherein at least 70% of the T cells in
the population of genetically engineered T cells express a
detectable level of the CAR.
38. The method of claim 1, wherein the population of genetically
engineered T cells are administered to the human patient via
intravenous infusion.
39. The method of claim 1, wherein the population of genetically
engineered T cells are suspended in a cryopreservation
solution.
40. A pharmaceutical composition for use in treating a B-cell
malignancy, the pharmaceutical composition comprising a population
of genetically engineered T cells that comprises: (a) a disrupted T
cell receptor alpha constant (TRAC) gene, which optionally
comprises a deletion of a fragment comprising the nucleotide
sequence of SEQ ID NO: 26, (b) a nucleic acid coding for a chimeric
antigen receptor (CAR) that binds CD19, wherein the CAR comprises
an anti-CD19 single chain variable fragment (scFv) that comprises a
heavy chain variable region set forth in SEQ ID NO: 51 and a light
chain variable region set forth in SEQ ID NO: 52, and wherein the
nucleic acid is inserted in the disrupted TRAC gene, and (c) a
disrupted beta 2-microglobulin (32M) gene; wherein the composition
comprises about 1.times.10.sup.7 to about 1.times.10.sup.9
CAR.sup.+ T cells.
41-42. (canceled)
Description
CROSS REFERENCE TO RELATED APPLICATIONS
[0001] This application claims the benefit of the filing dates of
U.S. Provisional Application No. 62/840,913, filed Apr. 30, 2019,
the entire contents of which are incorporated by reference
herein.
BACKGROUND OF THE INVENTION
[0002] Chimeric antigen receptor (CAR) T cell therapies are
adoptive T cell therapeutics used to treat human malignancies.
Although CAR T cell therapy has led to tremendous clinical success,
including durable remission in relapsed/refractory non-Hodgkin
lymphoma (NHL) and pediatric acute lymphoblastic leukemia (ALL),
the approved products are autologous and require patient-specific
cell collection and manufacturing. Because of this, some patients
have experienced disease progression or death while awaiting
treatment. Accordingly, there remains a need for improved CAR T
cell therapeutics.
SUMMARY OF THE INVENTION
[0003] The present disclosure is based, at least in part, on the
development of allogeneic cell therapy for B cell malignancies such
as transformed FL or DLBCL using genetically engineered T cells
(e.g., CTX110 cells, a.k.a., TC1 cells) expressing an anti-CD19
chimeric antigen receptor (CAR) and having disrupted TRAC gene and
B2M gene. The allogeneic CAR-T cell therapy disclosed herein showed
treatment efficacies in human patients having B cell malignancies
disclosed herein, including complete responses in certain patients
and long durability of responses. Further, the allogeneic CAR-T
cell therapy disclosed herein exhibited desired pharmacokinetic
features in the human patients, including prolonged CAR-T cell
expansion and persistence after infusion.
[0004] Accordingly, some aspects of the present disclosure provides
a method for treating a B-cell malignancy in a human patient, the
method comprising: (i) subjecting a human patient having a B-cell
malignancy to a lymphodepletion treatment; and (ii) administering
to the human patient a population of genetically engineered T cells
after step (i). In some embodiments, step (i) can be performed
about 2-7 days prior to step (ii). In some embodiments, the
population of genetically engineered T cells is allogeneic.
[0005] The population of the genetically engineered T cells may
comprise T cells that comprise: (a) a disrupted T cell receptor
alpha constant (TRAC) gene, (b) a nucleic acid coding for a
chimeric antigen receptor (CAR) that binds CD19, wherein the CAR
comprises an anti-CD19 single chain variable fragment (scFv) that
comprises a heavy chain variable region set forth in SEQ ID NO: 51,
and a light chain variable region set forth in SEQ ID NO: 52, and
wherein the nucleic acid is inserted in the disrupted TRAC gene,
and (c) a disrupted beta 2-microglobulin (.beta.2M) gene. In some
embodiments, the disrupted TRAC gene comprises a deletion of a
fragment comprising the nucleotide sequence of SEQ ID NO: 26.
[0006] In some embodiments, the population of genetically
engineered T cells is administered to the human patient at a dose
of about 1.times.10.sup.7 to about 1.times.10.sup.9 CAR.sup.+ T
cells. In some examples, the population of genetically engineered T
cells is administered to the human patient at a dose of about
1.times.10.sup.7 CAR.sup.+ T cells. In some examples, the
population of genetically engineered T cells is administered to the
human patient at a dose of about 3.times.10.sup.7 CAR T cells. In
some examples, the population of genetically engineered T cells is
administered to the human patient at a dose of about
1.times.10.sup.8 CAR.sup.+ T cells. In some examples, the
population of genetically engineered T cells is administered to the
human patient at a dose of about 3.times.10.sup.8 CAR.sup.+ T
cells. In some examples, the population of genetically engineered T
cells is administered to the human patient at a dose of about
1.times.10.sup.9 CAR.sup.+ T cells. In any event, the population of
genetically engineered T cells administered to the human patient
per dose contains no more than 7.times.10.sup.4 TCR.sup.+ T
cells/kg.
[0007] In some embodiments, the lymphodepletion treatment in step
(i) comprises co-administration to the human patient fludarabine at
about 30 mg/m.sup.2 and cyclophosphamide at about 500-750
mg/m.sup.2 per day for three days. For example, the lymphodepletion
treatment in step (i) comprises co-administration to the human
patient fludarabine at about 30 mg/m.sup.2 and cyclophosphamide at
about 500 mg/m.sup.2 per day for three days. In other examples, the
lymphodepletion treatment in step (i) comprises co-administration
to the human patient fludarabine at about 30 mg/m.sup.2 and
cyclophosphamide at about 750 mg/m.sup.2 per day for three
days.
[0008] In some embodiments, prior to step (i), the human patient
does not show one or more of the following features: (a)
significant worsening of clinical status, (b) requirement for
supplemental oxygen to maintain a saturation level of greater than
91%, (c) uncontrolled cardiac arrhythmia, (d) hypotension requiring
vasopressor support, (e) active infection, and (f) grade .gtoreq.2
acute neurological toxicity.
[0009] In some embodiments, after step (i) and prior to step (ii),
the human patient does not show one or more of the following
features: (a) active uncontrolled infection; (b) worsening of
clinical status compared to the clinical status prior to step (i);
and (c) grade .gtoreq.2 acute neurological toxicity.
[0010] Any of the methods disclosed herein may further comprise
(iii) monitoring the human patient for development of acute
toxicity after step (ii); and (iv) managing the acute toxicity if
occurs. In some embodiments, step (iii) can be performed for at
least 28 days after administration of the population of genetically
engineered T cells. Exemplary acute toxicity may comprise tumor
lysis syndrome (TLS), cytokine release syndrome (CRS), immune
effector cell-associated neurotoxicity syndrome (ICANS), B cell
aplasia, hemophagocytic lymphohistiocytosis (HLH), cytopenia,
graft-versus-host disease (GvHD), hypertension, renal
insufficiency, or a combination thereof.
[0011] In some embodiments, the B cell malignancy is non-Hodgkin
lymphoma. Examples include, but are not limited to, diffuse large B
cell lymphoma (DLBCL), high grade B cell lymphoma with MYC and BCL2
and/or BCL6 rearrangement, transformed follicular lymphoma (FL), or
grade 3b FL. In some instances, DLBCL is DLBCL not otherwise
specified (NOS). In some examples, the B cell malignancy is
refractory and/or relapsed.
[0012] In some embodiments, the human patient may have at least one
measurable lesion that is fluorodeoxyglucose positron emission
tomography (PET)-positive. In some embodiments, the human patient
has undergone one or more lines of prior anti-cancer therapies. In
some examples, the human patient has undergone two or more lines of
prior anti-cancer therapies. Exemplary prior anti-cancer therapies
may comprise an anti-CD20 antibody, an anthracycline-containing
regimen, or a combination thereof.
[0013] In some examples, the human patient has refractory or
relapsed transformed FL and has undergone at least one line of
chemotherapy for disease after transformation to DLBCL. In other
examples, the B cell malignancy is refractory, and the human
patient has progressive disease on last therapy, or has stable
disease following at least two cycles of therapy with duration of
stable disease of up to 6 months. In yet other examples, the human
patient has failed prior autologous hematopoietic stem cell
transplantation (HSCT) or ineligible for prior autologous HSCT.
Alternatively or in addition, the human patient is subject to an
additional anti-cancer therapy after treatment with the population
of genetically engineered T cells.
[0014] In any of the methods disclosed herein, the human patient
has one or more of the following features:
[0015] (a) has an Eastern Cooperative Oncology Group (ECOG)
performance status 0 or 1;
[0016] (b) adequate renal, liver, cardiac, and/or pulmonary
function;
[0017] (c) free of prior gene therapy or modified cell therapy;
[0018] (d) free of prior treatment comprising an anti-CD19
antibody;
[0019] (e) free of prior allogeneic HSCT;
[0020] (f) free of detectable malignant cells from cerebrospinal
fluid;
[0021] (g) free of brain metastases;
[0022] (h) free of prior central nervous system disorders;
[0023] (i) free of unstable angina, arrhythmia, and/or myocardial
infarction;
[0024] (j) free of uncontrolled infection;
[0025] (k) free of immunodeficiency disorders or autoimmune
disorders that require immunosuppressive therapy; and
[0026] (l) free of infection by human immunodeficiency virus,
hepatitis B virus, or hepatitis C virus.
[0027] In any of the methods disclosed herein, the anti-CD19 CAR
expressed by the genetically engineered T cells may comprise an
extracellular antigen binding domain, which is an anti-CD19 scFv
comprising the amino acid sequence of SEQ ID NO: 47. In some
embodiments, the anti-CD19 CAR may comprise the amino acid sequence
of SEQ ID NO: 40.
[0028] In some embodiments, the nucleic acid encoding the anti-CD19
CAR is inserted at the site of deletion in the disrupted TRAC gene.
In some examples, the disrupted TRAC gene comprises the nucleotide
sequence of SEQ ID NO: 54. Alternatively or in addition, the
disrupted .beta.2M gene in the population of genetically engineered
T cells comprises at least one of the nucleotide sequence set forth
in SEQ ID NOs: 9-14.
[0029] In some embodiments, at least 90% of the T cells in the
population of genetically engineered T cells do not express a
detectable level of TCR surface protein. For example, at least 70%
of the T cells in the population of genetically engineered T cells
do not express a detectable level of TCR surface protein; at least
50% of the T cells in the population of genetically engineered T
cells do not express a detectable level of B2M surface protein;
and/or at least 30% of the T cells in the population of genetically
engineered T cells express a detectable level of the CAR. In some
examples, at least 99.5% of the T cells in the population of
genetically engineered T cells do not express a detectable level of
TCR surface protein. In some examples, at least 70% of the T cells
in the population of genetically engineered T cells do not express
a detectable level of B2M surface protein. In specific examples, at
least 85% of the T cells in the population of the genetically
engineered T cells do not express a detectable level of B2M surface
protein. In some examples, at least 50% of the T cells in the
population of genetically engineered T cells express a detectable
level of the CAR. In specific examples, at least 70% of the T cells
in the population of genetically engineered T cells express a
detectable level of the CAR.
[0030] In a specific example, the population of genetically
engineered T cells for use in any of the methods disclosed herein
are CTX110 cells.
[0031] In any of the methods disclosed herein, the population of
genetically engineered T cells are administered to the human
patient via intravenous infusion. In some examples, the population
of genetically engineered T cells may be suspended in a
cryopreservation solution.
[0032] Also within the scope of the present disclosure are
pharmaceutical compositions for use in treating a B-cell
malignancy, the pharmaceutical composition comprising any of the
population of genetically engineered T cells disclosed herein
(e.g., the CTX110 cells), as well as use of the genetically
engineered T cells for manufacturing a medicament for use in
treating a B-cell malignancy as disclosed herein.
[0033] The details of one or more embodiments of the invention are
set forth in the description below. Other features or advantages of
the present invention will be apparent from the following drawings
and detailed description of several embodiments, and also from the
appended claims.
BRIEF DESCRIPTION OF THE DRAWINGS
[0034] FIG. 1 is a series of flow cytometry plots of human primary
T-cells, TRAC-/B2M-CD19CAR+T cells (TC1), 8 days post-editing. The
graphs show reduced surface expression of TRAC and B2M. TCR/MHC I
double knockout cells express high levels of the CAR transgene
(bottom panel). Negative selection of TC1 cells with purification
beads leads to a reduction in TCR positive cells (right panel).
[0035] FIG. 2 is a graph depicting high editing rates achieved at
the TRAC and B2M loci in TRAC-/B2M-CD19CAR+T cells (TC1). Surface
expression of TCR and MHCI, which is the functional output of gene
editing, was measured and plotted as editing percentage on the
y-axis. High efficiency (e.g., greater than 50%) site-specific
integration and expression of the CAR from the TRAC locus were
detected. These data demonstrate greater than 50% efficiency for
the generation of TRAC-/B2M-/anti-CD19CAR+ T cells.
[0036] FIG. 3 is a graph depicting a statistically significant
decrease in tumor volume (mm.sup.3) (p=0.007) in NOG Raji mice
following treatment with TRAC-/.beta.2M-/CD19 CAR+ T cells
(TC1).
[0037] FIG. 4 is a survival curve graph demonstrating increased
survival of NOG Raji mice treated with TC1 cells in comparison to
NOG Raji mice receiving no treatment.
[0038] FIG. 5 is a survival curve graph demonstrating increased
survival of NOG Raji mice treated with TC1 cells on day 4, in
comparison to control mice receiving no treatment on day 1.
[0039] FIGS. 6A and 6B include diagrams showing persistence and
anti-tumor activity of TC1 cells in mice. 6A: a series of flow
cytometry plots demonstrating that TC1 cells persist in NOG Raji
mice. 6B: a graph demonstrating that TC1 cells selectively
eradicate splenic Raji cells in NOG Raji mice treated with TC1 in
comparison to controls (NOG Raji mice with no treatment or NOG
mice). The effect is depicted as a decreased splenic mass in NOG
Raji mice treated with TC1 in comparison to controls.
[0040] FIG. 7 is a series of flow cytometry plots demonstrating
that persistent splenic TC1 cells are edited in two independent NOG
Raji mice with TC1 treatment.
[0041] FIG. 8 is a Kaplan-Meier survival plot demonstrating
increased survival of NOG Nalm6 mice treated with TC1 cells on day
4, in comparison to control mice receiving no treatment on day
1.
[0042] FIG. 9 is a Kaplan-Meier survival plot demonstrating an
increase survival of mice bearing a disseminated Nalm6 B-cell acute
lymphoblastic leukemia (B-ALL) after treatment with different
concentrations of TC1, in comparison to control mice receiving no
treatment.
[0043] FIG. 10 is a graph depicting a statistically significant
inhibition in tumor cell expansion in the disseminated Nalm6 B-cell
acute lymphoblastic leukemia (B-ALL) tumor model following
treatment with TC1 cells.
[0044] FIG. 11 is a Kaplan-Meier survival plot of healthy mice
treated with TC1 cells or various control cells (PBMCs or
electroporated (EP) T cells) after radiation, or mice that only
received radiation ("RT only").
[0045] FIG. 12 is a graph showing percentage of body weight change
of the mice treated in FIG. 18.
[0046] FIG. 13 is a Kaplan-Meier survival plot of healthy mice
treated with a low dose (2.times.10.sup.7) or high dose
(4.times.10.sup.7) of TC1 cells, or unedited T cells after
radiation, or mice that only received radiation ("Vehicle-RT").
[0047] FIG. 14 is a graph showing percentage of body weight change
of the mice treated in FIG. 20, in addition to mice that were not
irradiated and not dosed with cells ("Vehicle--no RT").
[0048] FIG. 15 is a bar graph showing percentage of CD27+CD45RO-
cells within the unedited CD8+ T cell subset of peripheral blood
cells from six different donors.
[0049] FIG. 16 provides flow cytometry results of TCR.alpha..beta.
and B2M expression on TC1 cells before and after depletion of
TCR.alpha..beta.+ cells.
[0050] FIG. 17 is a graph the percentage loss of protein for TCR-
and MHC I-(B2M) after gene editing, and percentage of cells
expressing an anti-CD19 CAR in edited TC1 cells from individual
lots of TC1 production.
[0051] FIG. 18 provides graphs showing the percentage of PD1+(top
left), LAG3+(top right), TIM3+(bottom left) or CD57+(bottom right)
in the T cell population from six different donors before and after
editing.
[0052] FIG. 19 is a graph showing the percentage of cell lysis of
CD19-positive cell lines (Nalm6; Raji; and K562-CD19) and
CD19-negative cells (K562) when co-cultured at different ratios
with TC1 cells or unedited T cells.
[0053] FIG. 20 is a graph showing the number of viable TC1 cells
when cultured in the presence of T-cell media (serum+IL2+IL7;
Complete Media), media containing serum but no IL2 or IL7 cytokines
(5% Serum, No cytokines) or no serum or cytokines (No Serum, No
Cytokines). Cells were counted on the indicated days post gene
editing. Mean values from three lots shown.+-.SD.
[0054] FIG. 21 is a schematic depicting the clinical study design
to evaluate CTX110 cells, (a.k.a., TC1 cells) administered after
lymphodepletion to human subjects having CD19+ malignancies.
DETAILED DESCRIPTION OF THE INVENTION
[0055] Cluster of Differentiation 19 (CD19) is an antigenic
determinant detectable on leukemia precursor cells. The human and
murine amino acid and nucleic acid sequences can be found in a
public database, such as GenBank, UniProt and Swiss-Prot. For
example, the amino acid sequence of human CD19 can be found as
UniProt/Swiss-Prot Accession No. P15391 and the nucleotide sequence
encoding of the human CD19 can be found at Accession No.
NM_001178098. CD19 is expressed on most B lineage cancers,
including, e.g., acute lymphoblastic leukemia, chronic lymphocyte
leukemia and non-Hodgkin's lymphoma. It is also an early marker of
B cell progenitors. See, e.g., Nicholson et al. Mol. Immun. 34
(16-17): 1157-1165 (1997).
[0056] The present disclosure provides an allogeneic CAR-T cell
therapy for B cell malignancies. The CAR-T cell therapy involves a
population of genetically engineered T cells expressing an
anti-CD19 CAR and having disrupted TRAC gene and B2M gene, the
nucleic acid coding for the anti-CD19 CAR being inserted into the
TRAC gene locus, thereby disrupting expression of the TRAC gene.
The allogenic anti-CD19 CAR-T cells are prepared using parent T
cells obtained from healthy donors. As such, the CAR-T therapy is
available to a patient having the target B cell malignancy
immediately after diagnosis, as opposed to at least three week gap
between diagnosis and treatment in autologous CAR-T therapy
required for manufacturing the CAR-T cells from the patient's own T
cells. The allogeneic CAR T therapy can be stored and inventoried
at the site of care to facilitate treatment immediately following
diagnosis. The immediate availability of the allogeneic anti-CD19
CAR T therapy eliminates the need for bridging chemo-therapy, which
may be required when autologous CAR-T cells are manufactured from
the patient's own cells. The allogeneic anti-CD19 CAR-T cell
therapy disclosed herein showed treatment efficacies in human
patients having B cell malignancies disclosed herein, including
complete responses in certain patients and long durability of
responses. Further, the allogeneic CAR-T cell therapy disclosed
herein exhibited desired pharmacokinetic features in the human
patients, including prolonged CAR-T cell expansion and persistence
after infusion.
[0057] Accordingly, provided herein are methods for treating a
B-cell malignancy in a human patient using a population of
genetically engineered immune cells such as T cells, which
collectively comprises a disrupted TRAC gene, a disrupted B2M, and
a nucleic acid encoding an anti-CD19 CAR (e.g., SEQ ID NO: 40,
encoded by SEQ ID NO:39). The nucleic acid encoding the anti-CD19
CAR and optionally comprising a promoter sequence and one or more
regulatory elements may be inserted in the disrupted TRAC gene
locus, e.g., replacing the segment of SEQ ID NO: 26 in the TRAC
gene. The human patient is subject to a lymphodepletion treatment
prior to administration of the population of genetically engineered
T cells.
I. Anti-CD19 CAR T Cells
[0058] Disclosed herein are anti-CD19 CAR T cells (e.g., CTX110
cells) for use in treating B cell malignancies. In some
embodiments, the anti-CD19 CAR T cells are human T cells expressing
an anti-CD19 CAR and having a disrupted TRAC gene, a disrupted B2M
gene, or a combination thereof. In specific examples, the anti-CD19
CART cells express an anti-CD19 CAR and have endogenous TRAC and
B2M genes disrupted.
[0059] (i) Anti-CD19 Chimeric Antigen Receptor (CAR)
[0060] The genetically engineered immune cells such as T cells
disclosed here express a chimeric antigen receptor (CAR) that binds
CD19 (an anti-CD19 CAR). A chimeric antigen receptor (CAR) refers
to an artificial immune cell receptor that is engineered to
recognize and bind to an antigen expressed by undesired cells, for
example, disease cells such as cancer cells. A T cell that
expresses a CAR polypeptide is referred to as a CAR T cell. CARs
have the ability to redirect T-cell specificity and reactivity
toward a selected target in a non-MHC-restricted manner. The
non-MHC-restricted antigen recognition gives CAR-T cells the
ability to recognize an antigen independent of antigen processing,
thus bypassing a major mechanism of tumor escape. Moreover, when
expressed on T-cells, CARs advantageously do not dimerize with
endogenous T-cell receptor (TCR) alpha and beta chains.
[0061] There are various generations of CARs, each of which
contains different components. First generation CARs join an
antibody-derived scFv to the CD3zeta ((or z) intracellular
signaling domain of the T-cell receptor through hinge and
transmembrane domains. Second generation CARs incorporate an
additional co-stimulatory domain, e.g., CD28, 4-1BB (41BB), or
ICOS, to supply a costimulatory signal. Third-generation CARs
contain two costimulatory domains (e.g., a combination of CD27,
CD28, 4-1BB, ICOS, or OX40) fused with the TCR CD3.zeta. chain.
Maude et al., Blood. 2015; 125(26):4017-4023; Kakarla and
Gottschalk, Cancer J. 2014; 20(2):151-155). Any of the various
generations of CAR constructs is within the scope of the present
disclosure.
[0062] Generally, a CAR is a fusion polypeptide comprising an
extracellular domain that recognizes a target antigen (e.g., a
single chain fragment (scFv) of an antibody or other antibody
fragment) and an intracellular domain comprising a signaling domain
of the T-cell receptor (TCR) complex (e.g., CD3.zeta.) and, in most
cases, a co-stimulatory domain. (Enblad et al., Human Gene Therapy.
2015; 26(8):498-505). A CAR construct may further comprise a hinge
and transmembrane domain between the extracellular domain and the
intracellular domain, as well as a signal peptide at the N-terminus
for surface expression. Examples of signal peptides include
MLLLVTSLLLCELPHPAFLLIP (SEQ ID NO: 30) and MALPVTALLLPLALLLHAARP
(SEQ ID NO: 31). Other signal peptides may be used.
[0063] The anti-CD19 CAR may comprise an anti-CD19 single-chain
variable fragment (scFv) specific for CD19, followed by hinge
domain and transmembrane domain (e.g., a CD8 hinge and
transmembrane domain) that is fused to an intracellular
co-signaling domain (e.g., a CD28 co-stimulatory domain) and a
CD3.zeta. signaling domain. Exemplary components for use in
constructing the anti-CD19 CAR disclosed herein can be found in the
Sequence Table provided below.
[0064] (a) Antigen Binding Extracellular Domain
[0065] The antigen-binding extracellular domain is the region of a
CAR polypeptide that is exposed to the extracellular fluid when the
CAR is expressed on cell surface. In some instances, a signal
peptide may be located at the N-terminus to facilitate cell surface
expression. In some embodiments, the antigen binding domain can be
a single-chain variable fragment (scFv, which may include an
antibody heavy chain variable region (V.sub.H) and an antibody
light chain variable region (V.sub.L) (in either orientation). In
some instances, the V.sub.H and V.sub.L fragment may be linked via
a peptide linker. The linker, in some embodiments, includes
hydrophilic residues with stretches of glycine and serine for
flexibility as well as stretches of glutamate and lysine for added
solubility. The scFv fragment retains the antigen-binding
specificity of the parent antibody, from which the scFv fragment is
derived. In some embodiments, the scFv may comprise humanized
V.sub.H and/or V.sub.L domains. In other embodiments, the V.sub.H
and/or V.sub.L domains of the scFv are fully human.
[0066] The antigen-binding extracellular domain in the CAR
polypeptide disclosed herein is specific to CD19 (e.g., human
CD19). In some examples, the antigen-binding extracellular domain
may comprise a scFv extracellular domain capable of binding to
CD19. The anti-CD19 scFv may comprise a heavy chain variable domain
(V.sub.H) having the same heavy chain complementary determining
regions (CDRs) as those in SEQ ID NO: 51 and a light chain variable
domain (V.sub.L) having the same light chain CDRs as those in SEQ
ID NO: 52. Two antibodies having the same V.sub.H and/or V.sub.L
CDRs means that their CDRs are identical when determined by the
same approach (e.g., the Kabat approach, the Chothia approach, the
AbM approach, the Contact approach, or the IMGT approach as known
in the art. See, e.g., bioinf.org.uk/abs/). In some examples, the
anti-CD19 scFv comprises the V.sub.H of SEQ ID NO: 51 and/or the
V.sub.L of SEQ ID NO: 52. In specific examples, the anti-CD19 scFv
may comprise the amino acid sequence of SEQ ID NO: 47.
[0067] (b) Transmembrane Domain
[0068] The anti-CD19 CAR polypeptide disclosed herein may contain a
transmembrane domain, which can be a hydrophobic alpha helix that
spans the membrane. As used herein, a "transmembrane domain" refers
to any protein structure that is thermodynamically stable in a cell
membrane, preferably a eukaryotic cell membrane. The transmembrane
domain can provide stability of the CAR containing such.
[0069] In some embodiments, the transmembrane domain of a CAR as
provided herein can be a CD8 transmembrane domain. In other
embodiments, the transmembrane domain can be a CD28 transmembrane
domain. In yet other embodiments, the transmembrane domain is a
chimera of a CD8 and CD28 transmembrane domain. Other transmembrane
domains may be used as provided herein. In one specific example,
the transmembrane domain in the anti-CD19 CAR is a CD8a
transmembrane domain having the amino acid sequence of SEQ ID NO:
32.
[0070] (c) Hinge Domain
[0071] In some embodiments, a hinge domain may be located between
an extracellular domain (comprising the antigen binding domain) and
a transmembrane domain of a CAR, or between a cytoplasmic domain
and a transmembrane domain of the CAR. A hinge domain can be any
oligopeptide or polypeptide that functions to link the
transmembrane domain to the extracellular domain and/or the
cytoplasmic domain in the polypeptide chain. A hinge domain may
function to provide flexibility to the CAR, or domains thereof, or
to prevent steric hindrance of the CAR, or domains thereof.
[0072] In some embodiments, a hinge domain may comprise up to 300
amino acids (e.g., 10 to 100 amino acids, or 5 to 20 amino acids).
In some embodiments, one or more hinge domain(s) may be included in
other regions of a CAR. In some embodiments, the hinge domain may
be a CD8 hinge domain. Other hinge domains may be used.
[0073] (d) Intracellular Signaling Domains
[0074] Any of the anti-CD19 CAR constructs disclosed herein contain
one or more intracellular signaling domains (e.g., CD3.zeta., and
optionally one or more co-stimulatory domains), which are the
functional end of the receptor. Following antigen recognition,
receptors cluster and a signal is transmitted to the cell.
[0075] CD3.zeta. is the cytoplasmic signaling domain of the T cell
receptor complex. CD3.zeta. contains three (3) immunoreceptor
tyrosine-based activation motif (ITAM)s, which transmit an
activation signal to the T cell after the T cell is engaged with a
cognate antigen. In many cases, CD3.zeta. provides a primary T cell
activation signal but not a fully competent activation signal,
which requires a co-stimulatory signaling. In some examples, the
anti-CD19 CAR construct disclosed herein comprise a CD3.zeta.
cytoplasmic signaling domain, which may have the amino acid
sequence of SEQ ID NO: 38.
[0076] In some embodiments, the anti-CD19 CAR polypeptides
disclosed herein may further comprise one or more co-stimulatory
signaling domains. For example, the co-stimulatory domains of CD28
and/or 4-1BB may be used to transmit a full proliferative/survival
signal, together with the primary signaling mediated by CD3.zeta..
In some examples, the CAR disclosed herein comprises a CD28
co-stimulatory molecule, for example, a CD28 co-stimulatory
signaling domain having the amino acid sequence of SEQ ID NO:36. In
other examples, the CAR disclosed herein comprises a 4-1BB
co-stimulatory molecule, for example, a 4-1BB co-stimulatory
signaling domain having the amino acid sequence of SEQ ID NO:
34.
[0077] In specific examples, an anti-CD19 CAR disclosed herein may
include a CD3.zeta. signaling domain (e.g., SEQ ID NO: 38) and a
CD28 co-stimulatory domain (e.g., SEQ ID NO: 36).
[0078] It should be understood that methods described herein
encompasses more than one suitable CAR that can be used to produce
genetically engineered T cells expressing the CAR, for example,
those known in the art or disclosed herein. Examples can be found
in, e.g., International Application Number PCT/IB2018/001619, filed
May 11, 2018, which published as WO 2019/097305A2, and
International Application Number PCT/IB2019/000500, filed May 10,
2019, the relevant disclosures of each of the prior applications
are incorporated by reference herein for the purpose and subject
matter referenced herein.
[0079] In specific examples, the anti-CD19 CAR disclosed herein may
comprise the amino acid sequence of SEQ ID NO: 40, which may be
encoded by the nucleotide sequence of SEQ ID NO: 39. See the
sequence table provided below.
[0080] In the genetically engineered T cells disclosed herein, a
nucleic acid comprising the coding sequence of the anti-CD19 CAR,
and optionally regulatory sequences for expression of the anti-CD19
CAR (e.g., a promoter such as the EF1a promoter provided in the
sequence Table) may be inserted into a genomic locus of interest.
In some examples, the nucleic acid is inserted in the endogenous
TRAC gene locus, thereby disrupting expression of the TRAC gene. In
specific examples, the nucleic acid may replace a fragment in the
TRAC gene, for example, a fragment comprising the nucleotide
sequence of SEQ ID NO: 26.
[0081] (ii) Knock-Out of TRAC and B2M Genes
[0082] The anti-CD19 CAR-T cells disclosed herein may further have
a disrupted TRAC gene, a disrupted B2M gene, or a combination
thereof. The disruption of the TRAC locus results in loss of
expression of the T cell receptor (TCR) and is intended to reduce
the probability of Graft versus Host Disease (GvHD), while the
disruption of the .beta.2M locus results in lack of expression of
the major histocompatibility complex type I (MHC I) proteins and is
intended to improve persistence by reducing the probability of host
rejection. The addition of the anti-CD19 CAR directs the modified T
cells towards CD19-expressing tumor cells.
[0083] As used herein, the term "a disrupted gene" refers to a gene
containing one or more mutations (e.g., insertion, deletion, or
nucleotide substitution, etc.) relative to the wild-type
counterpart so as to substantially reduce or completely eliminate
the activity of the encoded gene product. The one or more mutations
may be located in a non-coding region, for example, a promoter
region, a regulatory region that regulates transcription or
translation; or an intron region. Alternatively, the one or more
mutations may be located in a coding region (e.g., in an exon). In
some instances, the disrupted gene does not express or expresses a
substantially reduced level of the encoded protein. In other
instances, the disrupted gene expresses the encoded protein in a
mutated form, which is either not functional or has substantially
reduced activity. In some embodiments, a disrupted gene is a gene
that does not encode functional protein. In some embodiments, a
cell that comprises a disrupted gene does not express (e.g., at the
cell surface) a detectable level (e.g. by antibody, e.g., by flow
cytometry) of the protein encoded by the gene. A cell that does not
express a detectable level of the protein may be referred to as a
knockout cell. For example, a cell having a .beta.2M gene edit may
be considered a .beta.2M knockout cell if .beta.2M protein cannot
be detected at the cell surface using an antibody that specifically
binds .beta.2M protein.
[0084] In some embodiments, a disrupted gene may be described as
comprising a mutated fragment relative to the wild-type
counterpart. The mutated fragment may comprise a deletion, a
nucleotide substitution, an addition, or a combination thereof. In
other embodiments, a disrupted gene may be described as having a
deletion of a fragment that is present in the wild-type
counterpart. In some instances, the 5' end of the deleted fragment
may be located within the gene region targeted by a designed guide
RNA such as those disclosed herein (known as on-target sequence)
and the 3' end of the deleted fragment may go beyond the targeted
region. Alternatively, the 3' end of the deleted fragment may be
located within the targeted region and the 5' end of the deleted
fragment may go beyond the targeted region.
[0085] In some instances, the disrupted TRAC gene in the anti-CD19
CAR-T cells disclosed herein may comprise a deletion, for example,
a deletion of a fragment in Exon 1 of the TRAC gene locus. In some
examples, the disrupted TRAC gene comprises a deletion of a
fragment comprising the nucleotide sequence of SEQ ID NO: 26, which
is the target site of TRAC guide RNA TA-1. See sequence table
below. In some examples, the fragment of SEQ ID NO: 26 may be
replaced by a nucleic acid encoding the anti-CD19 CAR. Such a
disrupted TRAC gene may comprise the nucleotide sequence of SEQ ID
NO: 39.
[0086] The disrupted B2M gene in the anti-CD19 CAR-T cells
disclosed herein may be generated using the CRISPR/Cas technology.
In some examples, a B2M gRNA provided in the sequence table below
can be used. The disrupted B2M gene may comprise a nucleotide
sequence of any one of SEQ ID Nos: 9-14.
[0087] (iii) Exemplary Population of Anti-CD19 CAR-T Cells for
Allogeneic Therapy
[0088] Also provided herein is population of genetically engineered
immune cells (e.g., T cells such as human T cells) comprising the
anti-CD19 CAR-T cells disclosed herein, which express any of the
anti-CD19 CAR disclosed herein (e.g., the anti-CD19 CAR comprising
the amino acid sequence of SEQ ID NO: 40), and a disrupted TRAC
gene and/or a disrupted B2M gene as also disclosed herein. In some
examples, the population of genetically engineered T cells are
CTX110 cells, which are CD19-directed T cells having disrupted TRAC
gene and B2M gene. The nucleic acid encoding the anti-CD19 CAR can
be inserted in the disrupted TRAC gene at the site of SEQ ID NO:
26, which is replaced by the nucleic acid encoding the anti-CD19
CAR, thereby disrupting expression of the TRAC gene. The disrupted
TRAC gene in the CTX110 cells may comprise the nucleotide sequence
of SEQ ID NO: 39.
[0089] CTX110 cells can be produced via ex vivo genetic
modification using the CRISPR/Cas9 (Clustered Regularly Interspaced
Short Palindromic Repeats/CRISPR associated protein 9) technology
to disrupt targeted genes (TRAC and B2M genes), and
adeno-associated virus (AAV) transduction to deliver the anti-CD19
CAR construct. CRISPR-Cas9-mediated gene editing involves two guide
RNAs (sgRNAs): TA-1 sgRNA (SEQ ID NO: 18), which targets the TRAC
locus, and B2M-1 sgRNA (SEQ ID NO: 20), which targets the .beta.2M
locus. For any of the gRNA sequences provided herein, those that do
not explicitly indicate modifications are meant to encompass both
unmodified sequences and sequences having any suitable
modifications.
[0090] The anti-CD19 CAR of CTX110 cells is composed of an
anti-CD19 single-chain antibody fragment (scFv, which may comprise
the amino acid sequence of SEQ ID NO: 47), followed by a CD8 hinge
and transmembrane domain (e.g., comprising the amino acid sequence
of SEQ ID NO: 32) that is fused to an intracellular co-signaling
domain of CD28 (e.g., SEQ ID NO: 36) and a CD3.zeta. signaling
domain (e.g., SEQ ID NO: 38). In specific examples, the anti-CD19
CAR in CTX110 cells comprises the amino acid sequence of SEQ ID
NO:40.
[0091] In some embodiments, at least 30% of a population of CTX110
cells express a detectable level of the anti-CD19 CAR. For example,
at least 40%, at least 50%, at least 60%, at least 70%, at least
75%, at least 80%, at least 85%, at least 90%, or at least 95% of
the CTX110 cells express a detectable level of the anti-CD19
CAR.
[0092] In some embodiments, at least 50% of a population of CTX110
cells may not express a detectable level of .beta.2M surface
protein. For example, at least 55%, at least 60%, at least 70%, at
least 75%, at least 80%, at least 85%, at least 90%, or at least
95% of the CTX110 cells may not express a detectable level of
.beta.2M surface protein. In some embodiments, 50%-100%, 50%-90%,
50%-80%, 50%-70%, 50%-60%, 60%-100%, 60%-90%, 60%-80%, 60%-70%,
70%-100%, 70%-90%, 70%-80%, 80%-100%, 80%-90%, or 90%-100% of the
engineered T cells of a population does not express a detectable
level of .beta.2M surface protein.
[0093] Alternatively or in addition, at least 50% of a population
of CTX110 cells may not express a detectable level of TCR surface
protein. For example, at least 55%, at least 60%, at least 70%, at
least 75%, at least 80%, at least 85%, at least 90%, or at least
95% of the CTX110 cells may not express a detectable level of TCR
surface protein. In some embodiments, 50%-100%, 50%-90%, 50%-80%,
50%-70%, 50%-60%, 60%-100%, 60%-90%, 60%-80%, 60%-70%, 70%-100%,
70%-90%, 70%-80%, 80%-100%, 80%-90%, or 90%-100% of the engineered
T cells of a population does not express a detectable level of TRAC
surface protein. In specific examples, more than 90% (e.g., more
than 99.5%) of the CTX110 cells do not express a detectable TCR
surface protein.
[0094] In some embodiments, a substantial percentage of the
population of CTX110 T cells may comprise more than one gene edit,
which results in a certain percentage of cells not expressing more
than one gene and/or protein.
[0095] For example, at least 50% of a population of CTX110 cells
may not express a detectable level of two surface proteins, e.g.,
does not express a detectable level of $2M and TRAC proteins. In
some embodiments, 50%-100%, 50%-90%, 50%-80%, 50%-70%, 50%-60%,
60%-100%, 60%-90%, 60%-80%, 60%-70%, 70%-100%, 70%-90%, 70%-80%,
80%-100%, 80%-90%, or 90%-100% of the CTX110 T cells do not express
a detectable level of TRAC and B2M surface proteins. In another
example, at least 50% of a population of the CTX110 cells do not
express a detectable level of TRAC and B2M surface proteins.
[0096] In some embodiments, the population of CTX110 T cells may
comprise more than one gene edit (e.g., in more than one gene),
which may be an edit described herein. For example, the population
of CTX110 T cells may comprise a disrupted TRAC gene via the
CRISPR/Cas technology using the TA-1 TRAC gRNA. In some examples,
the CTX110 cells may comprise a deletion in the TRAC gene relative
to unmodified T cells. For example, the CTX110 T cells may comprise
a deletion of the fragment AGAGCAACAGTGCTGTGGCC (SEQ ID NO: 26) in
the TRAC gene. This fragment can be replaced by the nucleic acid
encoding the anti-CD19 CAR (e.g., SEQ ID NO: 39). Alternatively or
in addition, the population of CTX110 cells may comprise a
disrupted .beta.2M gene via CRISPR/Cas9 technology using the gRNA
of B2M-1. Such CTX110 cells may comprise Indels in the .beta.2M
gene, which comprise one or more of the nucleotide sequences of SEQ
ID NOs: 9-14. In specific examples, CTX110 cells comprise
.gtoreq.30% CAR T cells, .ltoreq.50% B2M.sup.+ cells, and
.ltoreq.30% TCR.alpha..beta..sup.+ cells. In additional specific
examples, CTX110 cells comprise .gtoreq.30% CAR.sup.+ T cells,
.ltoreq.30% B2M.sup.+ cells, and .ltoreq.0.5%
TCR.alpha..beta..sup.+ cells.
[0097] See also WO 2019/097305A2, and WO2019215500, the relevant
disclosures of each of which are incorporated by reference for the
subject matter and purpose referenced herein.
[0098] (iv) Pharmaceutical Compositions
[0099] In some aspects, the present disclosure provides
pharmaceutical compositions comprising any of the populations of
genetically engineered anti-CD19 CAR T cells as disclosed herein,
for example, CTX110 cells, and a pharmaceutically acceptable
carrier. Such pharmaceutical compositions can be used in cancer
treatment in human patients, which is also disclosed herein.
[0100] As used herein, the term "pharmaceutically acceptable"
refers to those compounds, materials, compositions, and/or dosage
forms which are, within the scope of sound medical judgment,
suitable for use in contact with the tissues, organs, and/or bodily
fluids of the subject without excessive toxicity, irritation,
allergic response, or other problems or complications commensurate
with a reasonable benefit/risk ratio. As used herein, the term
"pharmaceutically acceptable carrier" refers to solvents,
dispersion media, coatings, antibacterial agents, antifungal
agents, isotonic and absorption delaying agents, or the like that
are physiologically compatible. The compositions can include a
pharmaceutically acceptable salt, e.g., an acid addition salt or a
base addition salt. See, e.g., Berge et al., (1977) J Pharm Sci
66:1-19.
[0101] In some embodiments, the pharmaceutical composition further
comprises a pharmaceutically acceptable salt. Non-limiting examples
of pharmaceutically acceptable salts include acid addition salts
(formed from a free amino group of a polypeptide with an inorganic
acid (e.g., hydrochloric or phosphoric acids), or an organic acid
such as acetic, tartaric, mandelic, or the like). In some
embodiments, the salt formed with the free carboxyl groups is
derived from an inorganic base (e.g., sodium, potassium, ammonium,
calcium or ferric hydroxides), or an organic base such as
isopropylamine, trimethylamine, 2-ethylamino ethanol, histidine,
procaine, or the like).
[0102] In some embodiments, the pharmaceutical composition
disclosed herein comprises a population of the genetically
engineered anti-CD19 CAR-T cells (e.g., CTX110 cells) suspended in
a cryopreservation solution (e.g., CryoStor.RTM. C55). The
cryopreservation solution for use in the present disclosure may
also comprise adenosine, dextrose, dextran-40, lactobionic acid,
sucrose, mannitol, a buffer agent such as N-)2-hydroxethyl)
piperazine-N'-(2-ethanesulfonic acid) (HEPES), one or more salts
(e.g., calcium chloride, magnesium chloride, potassium chloride,
potassium bicarbonate, potassium phosphate, etc.), one or more base
(e.g., sodium hydroxide, potassium hydroxide, etc.), or a
combination thereof. Components of a cryopreservation solution may
be dissolved in sterile water (injection quality). Any of the
cryopreservation solution may be substantially free of serum
(undetectable by routine methods).
[0103] In some instances, a pharmaceutical composition comprising a
population of genetically engineered anti-CD19 CAR-T cells such as
the CTX110 cells suspended in a cryopreservation solution (e.g.,
substantially free of serum) may be placed in storage vials.
[0104] Any of the pharmaceutical compositions disclosed herein,
comprising a population of genetically engineered anti-CD19 CAR T
cells as also disclosed herein (e.g., CTX110 cells), which
optionally may be suspended in a cryopreservation solution as
disclosed herein may be stored in an environment that does not
substantially affect viability and bioactivity of the T cells for
future use, e.g., under conditions commonly applied for storage of
cells and tissues. In some examples, the pharmaceutical composition
may be stored in the vapor phase of liquid nitrogen at
.ltoreq.-135.degree. C. No significant changes were observed with
respect to appearance, cell count, viability, % CAR.sup.+ T cells,
% TCR.sup.+ T cells, and % B2M.sup.+ T cells after the cells have
been stored under such conditions for a period of time.
II. Preparation of Genetically Engineered Immune Cells
[0105] Any suitable gene editing methods known in the art can be
used for making the genetically engineered immune cells (e.g., T
cells such as CTX110 cells) disclosed herein, for example,
nuclease-dependent targeted editing using zinc-finger nucleases
(ZFNs), transcription activator-like effector nucleases (TALENs),
or RNA-guided CRISPR-Cas9 nucleases (CRISPR/Cas9; Clustered Regular
Interspaced Short Palindromic Repeats Associated 9). In specific
examples, the genetically engineered immune cells such as CTX110
cells are produced by the CRISPR technology in combination with
homologous recombination using an adeno-associated viral vector
(AAV) as a donor template.
[0106] (1) CRISPR-Cas9-Mediated Gene Editing System
[0107] The CRISPR-Cas9 system is a naturally-occurring defense
mechanism in prokaryotes that has been repurposed as an RNA-guided
DNA-targeting platform used for gene editing. It relies on the DNA
nuclease Cas9, and two noncoding RNAs, crisprRNA (crRNA) and
trans-activating RNA (tracrRNA), to target the cleavage of DNA.
CRISPR is an abbreviation for Clustered Regularly Interspaced Short
Palindromic Repeats, a family of DNA sequences found in the genomes
of bacteria and archaea that contain fragments of DNA (spacer DNA)
with similarity to foreign DNA previously exposed to the cell, for
example, by viruses that have infected or attacked the prokaryote.
These fragments of DNA are used by the prokaryote to detect and
destroy similar foreign DNA upon re-introduction, for example, from
similar viruses during subsequent attacks. Transcription of the
CRISPR locus results in the formation of an RNA molecule comprising
the spacer sequence, which associates with and targets Cas
(CRISPR-associated) proteins able to recognize and cut the foreign,
exogenous DNA. Numerous types and classes of CRISPR/Cas systems
have been described (see, e.g., Koonin et al., (2017) Curr Opin
Microbiol 37:67-78).
[0108] crRNA drives sequence recognition and specificity of the
CRISPR-Cas9 complex through Watson-Crick base pairing typically
with a 20 nucleotide (nt) sequence in the target DNA. Changing the
sequence of the 5' 20 nt in the crRNA allows targeting of the
CRISPR-Cas9 complex to specific loci. The CRISPR-Cas9 complex only
binds DNA sequences that contain a sequence match to the first 20
nt of the crRNA, if the target sequence is followed by a specific
short DNA motif (with the sequence NGG) referred to as a
protospacer adjacent motif (PAM).
[0109] TracrRNA hybridizes with the 3' end of crRNA to form an
RNA-duplex structure that is bound by the Cas9 endonuclease to form
the catalytically active CRISPR-Cas9 complex, which can then cleave
the target DNA.
[0110] Once the CRISPR-Cas9 complex is bound to DNA at a target
site, two independent nuclease domains within the Cas9 enzyme each
cleave one of the DNA strands upstream of the PAM site, leaving a
double-strand break (DSB) where both strands of the DNA terminate
in a base pair (a blunt end).
[0111] After binding of CRISPR-Cas9 complex to DNA at a specific
target site and formation of the site-specific DSB, the next key
step is repair of the DSB. Cells use two main DNA repair pathways
to repair the DSB: non-homologous end joining (NHEJ) and
homology-directed repair (HDR).
[0112] NHEJ is a robust repair mechanism that appears highly active
in the majority of cell types, including non-dividing cells. NHEJ
is error-prone and can often result in the removal or addition of
between one and several hundred nucleotides at the site of the DSB,
though such modifications are typically <20 nt. The resulting
insertions and deletions (indels) can disrupt coding or noncoding
regions of genes. Alternatively, HDR uses a long stretch of
homologous donor DNA, provided endogenously or exogenously, to
repair the DSB with high fidelity. HDR is active only in dividing
cells, and occurs at a relatively low frequency in most cell types.
In many embodiments of the present disclosure, NHEJ is utilized as
the repair operant.
[0113] (a) Cas9
[0114] In some embodiments, the Cas9 (CRISPR associated protein 9)
endonuclease is used in a CRISPR method for making the genetically
engineered T cells as disclosed herein. The Cas9 enzyme may be one
from Streptococcus pyogenes, although other Cas9 homologs may also
be used. It should be understood, that wild-type Cas9 may be used
or modified versions of Cas9 may be used (e.g., evolved versions of
Cas9, or Cas9 orthologues or variants), as provided herein. In some
embodiments, Cas9 comprises a Streptococcus pyogenes-derived Cas9
nuclease protein that has been engineered to include C- and
N-terminal SV40 large T antigen nuclear localization sequences
(NLS). The resulting Cas9 nuclease (sNLS-spCas9-sNLS) is a 162 kDa
protein that is produced by recombinant E. coli fermentation and
purified by chromatography. The spCas9 amino acid sequence can be
found as UniProt Accession No. Q99ZW2, which is provided herein as
SEQ ID NO: 55.
[0115] (b) Guide RNAs (gRNAs)
[0116] CRISPR-Cas9-mediated gene editing as described herein
includes the use of a guide RNA or a gRNA. As used herein, a "gRNA"
refers to a genome-targeting nucleic acid that can direct the Cas9
to a specific target sequence within a TRAC gene or a .beta.2M gene
for gene editing at the specific target sequence. A guide RNA
comprises at least a spacer sequence that hybridizes to a target
nucleic acid sequence within a target gene for editing, and a
CRISPR repeat sequence.
[0117] An exemplary gRNA targeting a TRAC gene is provided in SEQ
ID NO: 18 or 22. See the sequence table below. See also WO
2019/097305A2, the relevant disclosures of which are incorporated
by reference herein for the subject matter and purpose referenced
herein. Other gRNA sequences may be designed using the TRAC gene
sequence located on chromosome 14 (GRCh38: chromosome 14:
22,547,506-22,552,154; Ensembl; ENSG00000277734). In some
embodiments, gRNAs targeting the TRAC genomic region and Cas9
create breaks in the TRAC genomic region resulting Indels in the
TRAC gene disrupting expression of the mRNA or protein.
[0118] An exemplary gRNA targeting a .beta.2M gene is provided in
SEQ ID NO: 20 or 24. See the sequence table below. See also WO
2019/097305A2, the relevant disclosures of which are incorporated
by reference herein for the purpose and subject matter referenced
herein. Other gRNA sequences may be designed using the .beta.2M
gene sequence located on Chromosome 15 (GRCh38 coordinates:
Chromosome 15: 44,711,477-44,718,877; Ensembl: ENSG00000166710). In
some embodiments, gRNAs targeting the .beta.2M genomic region and
RNA-guided nuclease create breaks in the .beta.2M genomic region
resulting in Indels in the .beta.2M gene disrupting expression of
the mRNA or protein.
[0119] In Type II systems, the gRNA also comprises a second RNA
called the tracrRNA sequence. In the Type II gRNA, the CRISPR
repeat sequence and tracrRNA sequence hybridize to each other to
form a duplex. In the Type V gRNA, the crRNA forms a duplex. In
both systems, the duplex binds a site-directed polypeptide, such
that the guide RNA and site-direct polypeptide form a complex. In
some embodiments, the genome-targeting nucleic acid provides target
specificity to the complex by virtue of its association with the
site-directed polypeptide. The genome-targeting nucleic acid thus
directs the activity of the site-directed polypeptide.
[0120] As is understood by the person of ordinary skill in the art,
each guide RNA is designed to include a spacer sequence
complementary to its genomic target sequence. See Jinek et al.,
Science, 337, 816-821 (2012) and Deltcheva et al., Nature, 471,
602-607 (2011).
[0121] In some embodiments, the genome-targeting nucleic acid
(e.g., gRNA) is a double-molecule guide RNA. In some embodiments,
the genome-targeting nucleic acid (e.g., gRNA) is a single-molecule
guide RNA.
[0122] A double-molecule guide RNA comprises two strands of RNA
molecules. The first strand comprises in the 5' to 3' direction, an
optional spacer extension sequence, a spacer sequence and a minimum
CRISPR repeat sequence. The second strand comprises a minimum
tracrRNA sequence (complementary to the minimum CRISPR repeat
sequence), a 3' tracrRNA sequence and an optional tracrRNA
extension sequence.
[0123] A single-molecule guide RNA (referred to as a "sgRNA") in a
Type II system comprises, in the 5' to 3' direction, an optional
spacer extension sequence, a spacer sequence, a minimum CRISPR
repeat sequence, a single-molecule guide linker, a minimum tracrRNA
sequence, a 3' tracrRNA sequence and an optional tracrRNA extension
sequence. The optional tracrRNA extension may comprise elements
that contribute additional functionality (e.g., stability) to the
guide RNA. The single-molecule guide linker links the minimum
CRISPR repeat and the minimum tracrRNA sequence to form a hairpin
structure. The optional tracrRNA extension comprises one or more
hairpins. A single-molecule guide RNA in a Type V system comprises,
in the 5' to 3' direction, a minimum CRISPR repeat sequence and a
spacer sequence.
[0124] The "target sequence" is in a target gene that is adjacent
to a PAM sequence and is the sequence to be modified by Cas9. The
"target sequence" is on the so-called PAM-strand in a "target
nucleic acid," which is a double-stranded molecule containing the
PAM-strand and a complementary non-PAM strand. One of skill in the
art recognizes that the gRNA spacer sequence hybridizes to the
complementary sequence located in the non-PAM strand of the target
nucleic acid of interest. Thus, the gRNA spacer sequence is the RNA
equivalent of the target sequence.
[0125] For example, if the TRAC target sequence is
5'-AGAGCAACAGTGCTGTGGCC-3' (SEQ ID NO: 26), then the gRNA spacer
sequence is 5'-AGAGCAACAGUGCUGUGGCC-3' (SEQ ID NO: 19). In another
example, if the .beta.2M target sequence is
5'-GCTACTCTCTCTTTCTGGCC-3' (SEQ ID NO: 27), then the gRNA spacer
sequence is 5'-GCUACUCUCUCUUUCUGGCC-3' (SEQ ID NO: 21). The spacer
of a gRNA interacts with a target nucleic acid of interest in a
sequence-specific manner via hybridization (i.e., base pairing).
The nucleotide sequence of the spacer thus varies depending on the
target sequence of the target nucleic acid of interest.
[0126] In a CRISPR/Cas system herein, the spacer sequence is
designed to hybridize to a region of the target nucleic acid that
is located 5' of a PAM recognizable by a Cas9 enzyme used in the
system. The spacer may perfectly match the target sequence or may
have mismatches. Each Cas9 enzyme has a particular PAM sequence
that it recognizes in a target DNA. For example, S. pyogenes
recognizes in a target nucleic acid a PAM that comprises the
sequence 5'-NRG-3', where R comprises either A or G, where N is any
nucleotide and N is immediately 3' of the target nucleic acid
sequence targeted by the spacer sequence.
[0127] In some embodiments, the target nucleic acid sequence has 20
nucleotides in length. In some embodiments, the target nucleic acid
has less than 20 nucleotides in length. In some embodiments, the
target nucleic acid has more than 20 nucleotides in length. In some
embodiments, the target nucleic acid has at least: 5, 10, 15, 16,
17, 18, 19, 20, 21, 22, 23, 24, 25, 30 or more nucleotides in
length. In some embodiments, the target nucleic acid has at most:
5, 10, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 30 or more
nucleotides in length. In some embodiments, the target nucleic acid
sequence has 20 bases immediately 5' of the first nucleotide of the
PAM. For example, in a sequence comprising
5'-NNNNNNNNNNNNNNNNNNNNNRG-3', the target nucleic acid can be the
sequence that corresponds to the Ns, wherein N can be any
nucleotide, and the underlined NRG sequence is the S. pyogenes PAM.
Examples are provides as SEQ ID NOs: 15-17.
[0128] The guide RNA disclosed herein may target any sequence of
interest via the spacer sequence in the crRNA. In some embodiments,
the degree of complementarity between the spacer sequence of the
guide RNA and the target sequence in the target gene can be about
60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, 97%, 98%, 99%, or 100%. In
some embodiments, the spacer sequence of the guide RNA and the
target sequence in the target gene is 100% complementary. In other
embodiments, the spacer sequence of the guide RNA and the target
sequence in the target gene may contain up to 10 mismatches, e.g.,
up to 9, up to 8, up to 7, up to 6, up to 5, up to 4, up to 3, up
to 2, or up to 1 mismatch.
[0129] Non-limiting examples of gRNAs that may be used as provided
herein are provided in WO 2019/097305A2, and WO2019/215500, the
relevant disclosures of each of which are herein incorporated by
reference for the purposes and subject matter referenced herein.
For any of the gRNA sequences provided herein, those that do not
explicitly indicate modifications are meant to encompass both
unmodified sequences and sequences having any suitable
modifications.
[0130] The length of the spacer sequence in any of the gRNAs
disclosed herein may depend on the CRISPR/Cas9 system and
components used for editing any of the target genes also disclosed
herein. For example, different Cas9 proteins from different
bacterial species have varying optimal spacer sequence lengths.
Accordingly, the spacer sequence may have 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, 35, 40, 45, 50, or more than 50 nucleotides in length. In
some embodiments, the spacer sequence may have 18-24 nucleotides in
length. In some embodiments, the targeting sequence may have 19-21
nucleotides in length. In some embodiments, the spacer sequence may
comprise nucleotides in length.
[0131] In some embodiments, the gRNA can be a sgRNA, which may
comprise a 20 nucleotide spacer sequence at the 5' end of the sgRNA
sequence. In some embodiments, the sgRNA may comprise a less than
20 nucleotide spacer sequence at the 5' end of the sgRNA sequence.
In some embodiments, the sgRNA may comprise a more than 20
nucleotide spacer sequence at the 5' end of the sgRNA sequence. In
some embodiments, the sgRNA comprises a variable length spacer
sequence with 17-30 nucleotides at the 5' end of the sgRNA
sequence.
[0132] In some embodiments, the sgRNA comprises no uracil at the 3'
end of the sgRNA sequence. In other embodiments, the sgRNA may
comprise one or more uracil at the 3' end of the sgRNA sequence.
For example, the sgRNA can comprise 1-8 uracil residues, at the 3'
end of the sgRNA sequence, e.g., 1, 2, 3, 4, 5, 6, 7, or 8 uracil
residues at the 3' end of the sgRNA sequence.
[0133] Any of the gRNAs disclosed herein, including any of the
sgRNAs, may be unmodified. Alternatively, it may contain one or
more modified nucleotides and/or modified backbones. For example, a
modified gRNA such as a sgRNA can comprise one or more 2'-O-methyl
phosphorothioate nucleotides, which may be located at either the 5'
end, the 3' end, or both.
[0134] In certain embodiments, more than one guide RNAs can be used
with a CRISPR/Cas nuclease system. Each guide RNA may contain a
different targeting sequence, such that the CRISPR/Cas system
cleaves more than one target nucleic acid. In some embodiments, one
or more guide RNAs may have the same or differing properties such
as activity or stability within the Cas9 RNP complex. Where more
than one guide RNA is used, each guide RNA can be encoded on the
same or on different vectors. The promoters used to drive
expression of the more than one guide RNA is the same or
different.
[0135] It should be understood that more than one suitable Cas9 and
more than one suitable gRNA can be used in methods described
herein, for example, those known in the art or disclosed herein. In
some embodiments, methods comprise a Cas9 enzyme and/or a gRNA
known in the art. Examples can be found in, e.g., WO 2019/097305A2,
and WO2019/215500, the relevant disclosures of each of which are
herein incorporated by reference for the purposes and subject
matter referenced herein.
[0136] (ii) AAV Vectors for Delivery of CAR Constructs to T
Cells
[0137] A nucleic acid encoding an anti-CD19 CAR construct as
disclosed herein can be delivered to a cell using an
adeno-associated virus (AAV). AAVs are small viruses which
integrate site-specifically into the host genome and can therefore
deliver a transgene, such as CAR. Inverted terminal repeats (ITRs)
are present flanking the AAV genome and/or the transgene of
interest and serve as origins of replication. Also present in the
AAV genome are rep and cap proteins which, when transcribed, form
capsids which encapsulate the AAV genome for delivery into target
cells. Surface receptors on these capsids which confer AAV
serotype, which determines which target organs the capsids will
primarily bind and thus what cells the AAV will most efficiently
infect. There are twelve currently known human AAV serotypes. In
some embodiments, the AAV for use in delivering the CAR-coding
nucleic acid is AAV serotype 6 (AAV6).
[0138] Adeno-associated viruses are among the most frequently used
viruses for gene therapy for several reasons. First, AAVs do not
provoke an immune response upon administration to mammals,
including humans. Second, AAVs are effectively delivered to target
cells, particularly when consideration is given to selecting the
appropriate AAV serotype. Finally, AAVs have the ability to infect
both dividing and non-dividing cells because the genome can persist
in the host cell without integration. This trait makes them an
ideal candidate for gene therapy.
[0139] A nucleic acid encoding an anti-CD19 CAR can be designed to
insert into a genomic site of interest in the host T cells. In some
embodiments, the target genomic site can be in a safe harbor
locus.
[0140] In some embodiments, a nucleic acid encoding the anti-CD19
CAR (e.g., via a donor template, which can be carried by a viral
vector such as an adeno-associated viral (AAV) vector) can be
designed such that it can insert into a location within a TRAC gene
to disrupt the TRAC gene in the genetically engineered T cells and
express the CAR polypeptide. Disruption of TRAC leads to loss of
function of the endogenous TCR. For example, a disruption in the
TRAC gene can be created with an endonuclease such as those
described herein and one or more gRNAs targeting one or more TRAC
genomic regions. Any of the gRNAs specific to a TRAC gene and the
target regions can be used for this purpose, e.g., those disclosed
herein.
[0141] In some examples, a genomic deletion in the TRAC gene and
replacement by a CAR coding segment can be created by homology
directed repair or HDR (e.g., using a donor template, which may be
part of a viral vector such as an adeno-associated viral (AAV)
vector). In some embodiments, a disruption in the TRAC gene can be
created with an endonuclease as those disclosed herein and one or
more gRNAs targeting one or more TRAC genomic regions, and
inserting a CAR coding segment into the TRAC gene.
[0142] A donor template as disclosed herein can contain a coding
sequence for a CAR. In some examples, the CAR-coding sequence may
be flanked by two regions of homology to allow for efficient HDR at
a genomic location of interest, for example, at a TRAC gene using
CRISPR-Cas9 gene editing technology. In this case, both strands of
the DNA at the target locus can be cut by a CRISPR Cas9 enzyme
guided by gRNAs specific to the target locus. HDR then occurs to
repair the double-strand break (DSB) and insert the donor DNA
coding for the CAR. For this to occur correctly, the donor sequence
is designed with flanking residues which are complementary to the
sequence surrounding the DSB site in the target gene (hereinafter
"homology arms"), such as the TRAC gene. These homology arms serve
as the template for DSB repair and allow HDR to be an essentially
error-free mechanism. The rate of homology directed repair (HDR) is
a function of the distance between the mutation and the cut site so
choosing overlapping or nearby target sites is important. Templates
can include extra sequences flanked by the homologous regions or
can contain a sequence that differs from the genomic sequence, thus
allowing sequence editing.
[0143] Alternatively, a donor template may have no regions of
homology to the targeted location in the DNA and may be integrated
by NHEJ-dependent end joining following cleavage at the target
site.
[0144] A donor template can be DNA or RNA, single-stranded and/or
double-stranded, and can be introduced into a cell in linear or
circular form. If introduced in linear form, the ends of the donor
sequence can be protected (e.g., from exonucleolytic degradation)
by methods known to those of skill in the art. For example, one or
more dideoxynucleotide residues are added to the 3' terminus of a
linear molecule and/or self-complementary oligonucleotides are
ligated to one or both ends. See, for example, Chang et al., (1987)
Proc. Natl. Acad. Sci. USA 84:4959-4963; Nehls et al., (1996)
Science 272:886-889. Additional methods for protecting exogenous
polynucleotides from degradation include, but are not limited to,
addition of terminal amino group(s) and the use of modified
internucleotide linkages such as, for example, phosphorothioates,
phosphoramidates, and O-methyl ribose or deoxyribose residues.
[0145] A donor template can be introduced into a cell as part of a
vector molecule having additional sequences such as, for example,
replication origins, promoters and genes encoding antibiotic
resistance. Moreover, a donor template can be introduced into a
cell as naked nucleic acid, as nucleic acid complexed with an agent
such as a liposome or poloxamer, or can be delivered by viruses
(e.g., adenovirus, AAV, herpesvirus, retrovirus, lentivirus and
integrase defective lentivirus (IDLV)).
[0146] A donor template, in some embodiments, can be inserted at a
site nearby an endogenous promoter (e.g., downstream or upstream)
so that its expression can be driven by the endogenous promoter. In
other embodiments, the donor template may comprise an exogenous
promoter and/or enhancer, for example, a constitutive promoter, an
inducible promoter, or tissue-specific promoter to control the
expression of the CAR gene. In some embodiments, the exogenous
promoter is an EF1a promoter. Other promoters may be used.
[0147] Furthermore, exogenous sequences may also include
transcriptional or translational regulatory sequences, for example,
promoters, enhancers, insulators, internal ribosome entry sites,
sequences encoding 2A peptides and/or polyadenylation signals.
[0148] To prepare the genetically engineered immune cells (e.g., T
cells disclosed herein), immune cells such as T cells from a
suitable source may be obtained, e.g., blood cells from a human
donor, who may be a healthy donor or a patient need CAR-T cell
therapy. The CTX110 cells can be made using blood cells from one or
more healthy human donors. Manufacturing from healthy donor cells
minimizes the risk of unintentionally transducing malignant
lymphoma/leukemia cells and potentially may improve the
functionality of the CAR T cells. The components of the CRISPR
system (e.g., Cas9 protein and the gRNAs), optionally the AAV donor
template, may be delivered into the host immune cells via
conventional approaches. In some examples, the Cas9 and the gRNAs
can form a ribonucleoprotein complex (RNP), which can be delivered
to the host immune cells by electroporation. Optionally, the AAV
donor template may be delivered to the immune cells concurrently
with the RNP complex. Alternatively, delivery of the RNPs and the
AAV donor template can be performed sequentially. In some examples,
the T cells may be activated prior to delivery of the gene editing
components.
[0149] After delivery of the gene editing components and optionally
the donor template, the cells may be recovered and expanded in
vitro. Gene editing efficiency can be evaluated using routine
methods for confirm knock-in of the anti-CD19 CAR and knock-out of
the target genes (e.g., TRAC, B2M, or both). In some examples,
TCR.alpha..beta..sup.+ T cells may be removed. Additional
information for preparation of the genetically engineered immune
cells disclosed herein such as the CTX110 cells can be found in
U.S. Patent Application No. 62/934,991, the relevant disclosures of
which are incorporated by reference for the purpose and subject
matter referenced herein.
III. Allogeneic CAR-T Cell Therapy of B Cell Malignancies
[0150] In some aspects, provided herein are methods for treating a
human patient having a B cell malignancy using a population of any
of the genetically engineered anti-CD19 CAR T cells such as the
CTX110 T cells as disclosed herein. The allogeneic anti-CD19 CART
cell therapy may comprise two stages of treatment: (i) a
conditioning regimen (lymphodepleting treatment), which comprises
giving one or more doses of one or more lymphodepleting agents to a
suitable human patient, and (ii) a treatment regimen (allogeneic
anti-CD19 CAR T cell therapy), which comprises administration of
the population of allogeneic anti-CD19 CAR T cells such as the
CTX110 T cells as disclosed herein to the human patient.
[0151] (i) Patient Population
[0152] A human patient may be any human subject for whom diagnosis,
treatment, or therapy is desired. A human patient may be of any
age. In some embodiments, the human patient is an adult (e.g., a
person who is at least 18 years old). In some examples, the human
patient may have a body weight of 50 kg or higher. In some
embodiments, the human patient can be a child.
[0153] A human patient to be treated by the methods described
herein can be a human patient having, suspected of having, or a
risk for having a B cell malignancy. A subject suspected of having
a B cell malignancy might show one or more symptoms of B cell
malignancy, e.g., unexplained weight loss, fatigue, night sweats,
shortness of breath, or swollen glands. A subject at risk for a B
cell malignancy can be a subject having one or more of the risk
factors for B cell malignancy, e.g., a weakened immune system, age,
male, or infection (e.g., Epstein-Barr virus infection). A human
patient who needs the anti-CD19 CAR T cell (e.g., CTX110 T cell)
treatment may be identified by routine medical examination, e.g.,
physical examination, laboratory tests, biopsy (e.g., bone marrow
biopsy and/or lymph node biopsy), magnetic resonance imaging (MRI)
scans, or ultrasound exams.
[0154] Examples of B cell malignancies that may be treated using
the methods described herein include, but are not limited to,
diffuse large B cell lymphoma (DLBCL), high grade B cell lymphoma
with MYC and BCL2 and/or BCL6 rearrangement, transformed follicular
lymphoma (FL), grade 3b FL, or Richter's transformation of chronic
lymphocytic leukemia (CLL). In some examples, the B cell malignancy
is DLBCL, e.g., high grade DLBCL or DLBCL not otherwise specified
(NOS). In some examples, the B cell malignancy is transformed FL or
grade 3b FL. In some examples, the human patient has at least one
measurable lesion that is fluorodeoxyglucose positron emission
tomography (PET)-positive.
[0155] In some embodiment, the human patient to be treated has
DLBCL and exhibits pararectal mass, retroperitoneal mass, diffuse
lymph nodes (LN), lytic lesions, tonsillar lesion, or a combination
thereof. Alternatively or in addition, the human patient may have
bone marrow diffusion. In other examples, the human patient is free
of bone marrow diffusion.
[0156] In some embodiments, the human patient to be treated has
transformed FL. Such a human patient may exhibit diffuse LN. In
some instances, the human patient may have bone marrow diffusion.
In other instances, the human patient may be free of bone marrow
diffusion.
[0157] A human patient to be treated by methods described herein
may be a human patient that has relapsed following a treatment
and/or that has been become resistant to a treatment and/or that
has been non-responsive to a treatment. As used herein, "relapsed"
or "relapses" refers to a B cell malignancy such as those disclosed
herein that returns following a period of complete response.
Progressive disease refers to an instance when a disease worsens
after the last evaluation (e.g., stable disease or partial
response). In some embodiments, progression occurs during the
treatment. In some embodiments, relapse occurs after the treatment.
A lack of response may be determined by routine medical practice.
For example, the human patient to be treated by methods described
herein may be a human patient that has had one or more lines of
prior anti-cancer therapies. In some instances, the human patient
may have undergone two or more lines of prior anti-cancer
therapies, e.g., a chemotherapy, an immunotherapy, a surgery, or a
combination thereof. In some examples, the prior anti-cancer
therapies may comprise an anti-CD20 antibody therapy, an
anthracycline-containing therapy, or a combination thereof.
[0158] In some instances, the human patient has a refractory B cell
malignancy. As used herein, "refractory" refers to a B cell
malignancy such as those disclosed herein that does not respond to
or becomes resistant to a treatment. A human patient having a
refractory B cell malignancy may have progressive disease on last
therapy, or has stable disease following at least two cycles of
therapy with duration of stable disease of up to 6 months (e.g., up
to 5 months, up to 4 months, or up to 3 months or up to 2 months or
up to 1 month). In some instances, the human patient may have
undergone a prior autologous hematopoietic stem cell
transplantation (HSCT) and showed no response to such (failed) or
have progressed or relapsed after achieving some response. In other
instances, the human patient may not be eligible for prior
autologous HSCT.
[0159] A human patient may be screened to determine whether the
patient is eligible to undergo a conditioning regimen
(lymphodepleting treatment) and/or an allogeneic anti-CD19 CAR-T
cell therapy as disclosed herein. For example, a human patient who
is eligible for lymphodepletion treatment does not show one or more
of the following features: (a) significant worsening of clinical
status, (b) requirement for supplemental oxygen to maintain a
saturation level of greater than 90%, (c) uncontrolled cardiac
arrhythmia, (d) hypotension requiring vasopressor support, (e)
active infection, and (f) grade .gtoreq.2 acute neurological
toxicity. In another example, a human patient who is eligible for a
treatment regimen does not show one or more of the following
features: (a) active uncontrolled infection, (b) worsening of
clinical status compared to the clinical status prior to
lymphodepletion treatment, and (c) grade .gtoreq.2 acute
neurological toxicity.
[0160] A human patient may be screened and excluded from the
conditioning regimen and/or treatment regimen based on such
screening results. For example, a human patient may be excluded
from a conditioning regimen and/or the allogeneic anti-CD19 CAR-T
cell therapy, if the patient meets one or more of the following
exclusion criteria: (a) has an Eastern Cooperative Oncology Group
(ECOG) performance status 0 or 1; (b) adequate renal, liver,
cardiac, and/or pulmonary function; (c) free of prior gene therapy
or modified cell therapy; (d) free of prior treatment comprising an
anti-CD19 antibody; (e) free of prior allogeneic HSCT; (f) free of
detectable malignant cells from cerebrospinal fluid; (g) free of
brain metastases; (h) free of prior central nervous system
disorders; (i) free of unstable angina, arrhythmia, and/or
myocardial infarction; (j) free of uncontrolled infection; (k) free
of immunodeficiency disorders or autoimmune disorders that require
immunosuppressive therapy; and (1) free of infection by human
immunodeficiency virus, hepatitis B virus, or hepatitis C
virus.
[0161] (ii) Conditioning Regimen (Lymphodepleting Therapy)
[0162] Any human patients suitable for the treatment methods
disclosed herein may receive a lymphodepleting therapy to reduce or
deplete the endogenous lymphocyte of the subject.
[0163] Lymphodepletion refers to the destruction of endogenous
lymphocytes and/or T cells, which is commonly used prior to
immunotransplantation and immunotherapy. Lymphodepletion can be
achieved by irradiation and/or chemotherapy. A "lymphodepleting
agent" can be any molecule capable of reducing, depleting, or
eliminating endogenous lymphocytes and/or T cells when administered
to a subject. In some embodiments, the lymphodepleting agents are
administered in an amount effective in reducing the number of
lymphocytes by at least 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%,
90%, 95%, 96%, 96%, 97%, 98%, or at least 99% as compared to the
number of lymphocytes prior to administration of the agents. In
some embodiments, the lymphodepleting agents are administered in an
amount effective in reducing the number of lymphocytes such that
the number of lymphocytes in the subject is below the limits of
detection. In some embodiments, the subject is administered at
least one (e.g., 2, 3, 4, 5 or more) lymphodepleting agents.
[0164] In some embodiments, the lymphodepleting agents are
cytotoxic agents that specifically kill lymphocytes. Examples of
lymphodepleting agents include, without limitation, fludarabine,
cyclophosphamide, bendamustin, 5-fluorouracil, gemcitabine,
methotrexate, dacarbazine, melphalan, doxorubicin, vinblastine,
cisplatin, oxaliplatin, paclitaxel, docetaxel, irinotecan, etopside
phosphate, mitoxantrone, cladribine, denileukin diftitox, or
DAB-IL2. In some instances, the lymphodepleting agent may be
accompanied with low-dose irradiation. The lymphodepletion effect
of the conditioning regimen can be monitored via routine
practice.
[0165] In some embodiments, the method described herein involves a
conditioning regimen that comprises one or more lymphodepleting
agents, for example, fludarabine and cyclophosphamide. A human
patient to be treated by the method described herein may receive
multiple doses of the one or more lymphodepleting agents for a
suitable period (e.g., 1-5 days) in the conditioning stage. The
patient may receive one or more of the lymphodepleting agents once
per day during the lymphodepleting period. In one example, the
human patient receives fludarabine at about 20-50 mg/m.sup.2 (e.g.,
30 mg/m.sup.2) per day for 2-4 days (e.g., 3 days) and
cyclophosphamide at about 500-750 mg/m.sup.2 (e.g., 500 or 750
mg/m.sup.2) per day for 2-4 days (e.g., 3 days). In specific
examples, the human patient may receive fludarabine at about 30
mg/m.sup.2 and cyclophosphamide at about 500 mg/m.sup.2 per day for
three days. In other specific examples, the human patient may
receive fludarabine at about 30 mg/m.sup.2 and cyclophosphamide at
about 750 mg/m.sup.2 per day for three days.
[0166] The human patient may then be administered any of the
anti-CD19 CAR T cells such as CTX110 cells within a suitable period
after the lymphodepleting therapy as disclosed herein. For example,
a human patient may be subject to one or more lymphodepleting agent
about 2-7 days (e.g., for example, 2, 3, 4, 5, 6, 7 days) before
administration of the anti-CD19 CAR+ T cells (e.g., CTX110 cells).
In some instances, a human patient is administered the anti-CD19
CAR+ T cells (e.g., CTX110 cells) within about 4-5 days after the
lymphodepleting therapy.
[0167] Since the allogeneic anti-CD19 CAR-T cells such as CTX110
cells can be prepared in advance and may be stored at the treatment
site, the lymphodepleting therapy as disclosed herein may be
applied to a human patient having a B cell malignancy within a
short time window (e.g., within 2 weeks) after the human patient is
identified as suitable for the allogeneic anti-CD19 CAR-T cell
therapy disclosed herein. For example, the first dose of the
lymphodepleting therapy (e.g., fludarabine at about 30 mg/m.sup.2
and cyclophosphamide at about 500 mg/m.sup.2 or 750 mg/m.sup.2) may
be administered to the human patient within two weeks (e.g., within
10 days, within 9 days, within 8 days, within 7 days, within 6
days, within 5 days, within 4 days, within 3 days, within two days,
or less) after the human patient is identified as suitable for the
allogeneic anti-CD19 CAR-T cell therapy. In some examples, the
lymphodepleting therapy may be performed to the human patient
within 24-72 hours (e.g., within 24 hours) after the human patient
is identified as suitable for the treatment. The patient can then
be administered the CAR-T cells within 2-7 days (e.g., for example,
2, 3, 4, 5, 6, or 7 days) after the lymphodepleting treatment. This
allows for timely treatment of the human patient with the
allogeneic anti-CD19 CAR-T cells disclosed herein such as CTX110
cells after disease diagnosis and/or patient identification without
delay (e.g., delay due to preparation of the therapeutic cells). In
certain instances, a patient may receive the treatment during
inpatient hospital care. In certain instances, a patient may
receive the treatment in outpatient care.
[0168] Prior to any of the lymphodepletion steps, a human patient
may be screened for one or more features to determine whether the
patient is eligible for lymphodepletion treatment. For example,
prior to lymphodepletion, a human patient eligible for
lymphodepletion treatment does not show one or more of the
following features: (a) significant worsening of clinical status,
(b) requirement for supplemental oxygen to maintain a saturation
level of greater than 90%, (c) uncontrolled cardiac arrhythmia, (d)
hypotension requiring vasopressor support, (e) active infection,
and (f) grade .gtoreq.2 acute neurological toxicity.
[0169] Following lymphodepletion, a human patient may be screened
for one or more features to determine whether the patient is
eligible for treatment with anti-CD19 CAR T cells such as the
CTX110 cells. For example, prior to anti-CD19 CART cell treatment
and after lymphodepletion treatment, a human patient eligible for
anti-CD19 CAR T cells treatment does not show one or more of the
following features: (a) active uncontrolled infection, (b)
worsening of clinical status compared to the clinical status prior
to lymphodepletion treatment, and (c) grade .gtoreq.2 acute
neurological toxicity.
[0170] (iii) Administration of Anti-CD19 CAR T Cells
[0171] Administering anti-CD19 CAR T cells may include placement
(e.g., transplantation) of a genetically engineered T cell
population as disclosed herein (e.g., the CTX110 cells) into a
human patient as also disclosed herein by a method or route that
results in at least partial localization of the genetically
engineered T cell population at a desired site, such as a tumor
site, such that a desired effect(s) can be produced. The
genetically engineered T cell population can be administered by any
appropriate route that results in delivery to a desired location in
the subject where at least a portion of the implanted cells or
components of the cells remain viable. The period of viability of
the cells after administration to a subject can be as short as a
few hours, e.g., twenty-four hours, to a few days, to several weeks
or months, to as long as several years, or even the life time of
the subject, i.e., long-term engraftment. In certain instances, a
patient may receive the genetically engineered T cell population
(e.g., CTX110 cells) during inpatient hospital care. In certain
instances, a patient may receive genetically engineered T cell
population (e.g., CTX110 cells) in outpatient care.
[0172] For example, in some aspects described herein, an effective
amount of the genetically engineered T cell population can be
administered via a systemic route of administration, such as an
intraperitoneal or intravenous route.
[0173] In some embodiments, the genetically engineered T cell
population is administered systemically, which refers to the
administration of a population of cells other than directly into a
target site, tissue, or organ, such that it enters, instead, the
subject's circulatory system and, thus, is subject to metabolism
and other like processes. Suitable modes of administration include
injection, infusion, instillation, or ingestion. Injection
includes, without limitation, intravenous, intramuscular,
intra-arterial, intrathecal, intraventricular, intracapsular,
intraorbital, intracardiac, intradermal, intraperitoneal,
transtracheal, subcutaneous, subcuticular, intraarticular, sub
capsular, subarachnoid, intraspinal, intracerebro spinal, and
intrasternal injection and infusion. In some embodiments, the route
is intravenous.
[0174] An effective amount refers to the amount of a genetically
engineered T cell population needed to prevent or alleviate at
least one or more signs or symptoms of a medical condition (e.g., a
B cell malignancy), and relates to a sufficient amount of a
genetically engineered T cell population to provide the desired
effect, e.g., to treat a subject having a medical condition. An
effective amount also includes an amount sufficient to prevent or
delay the development of a symptom of the disease, alter the course
of a symptom of the disease (for example but not limited to, slow
the progression of a symptom of the disease), or reverse a symptom
of the disease. It is understood that for any given case, an
appropriate effective amount can be determined by one of ordinary
skill in the art using routine experimentation.
[0175] An effective amount of a genetically engineered T cell
population may comprise about 1.times.10.sup.7 CAR+ cells to about
1.times.10.sup.9 CAR+ cells, e.g., about 1.times.10.sup.7 cells to
about 1.times.10.sup.9 cells that express a CAR that binds CD19
(CAR+ cells). In some embodiments, an effective amount of a
genetically engineered T cell population may comprise at least
1.times.10.sup.7 CAR.sup.+ CTX110 cells, at least 3.times.10.sup.7
CAR.sup.+ CTX110 cells, at least 1.times.10.sup.8 CAR.sup.+ CTX110
cells, at least 3.times.10.sup.8 CAR.sup.+ CTX110 cells, or at
least 1.times.10.sup.9 CAR.sup.+ CTX110 cells. In some embodiments,
an effective amount of a genetically engineered T cell population
may comprise a dose of the genetically engineered T cell
population, e.g., a dose comprising about 1.times.10.sup.7 CTX110
cells to about 1.times.10.sup.9 CTX110 cells.
[0176] The efficacy of anti-CD19 CAR T cell therapy described
herein can be determined by the skilled clinician. An anti-CD19
CART cell therapy (e.g., involving CTX110 cells) is considered
"effective", if any one or all of the signs or symptoms of, as but
one example, levels of CD19 are altered in a beneficial manner
(e.g., decreased by at least 10%), or other clinically accepted
symptoms or markers of a B cell malignancy are improved or
ameliorated. Efficacy can also be measured by failure of a subject
to worsen as assessed by hospitalization or need for medical
interventions (e.g., progression of the B cell malignancy is halted
or at least slowed). Methods of measuring these indicators are
known to those of skill in the art and/or described herein.
Treatment includes any treatment of a B cell malignancy in a human
patient and includes: (1) inhibiting the disease, e.g., arresting,
or slowing the progression of symptoms; or (2) relieving the
disease, e.g., causing regression of symptoms; and (3) preventing
or reducing the likelihood of the development of symptoms.
[0177] Following each dosing of anti-CD110 CAR T cells, a human
patient may be monitored for acute toxicities such as tumor lysis
syndrome (TLS), cytokine release syndrome (CRS), immune effector
cell-associated neurotoxicity syndrome (ICANS), B cell aplasia,
hemophagocytic lymphohistiocytosis (HLH), cytopenia,
graft-versus-host disease (GvHD), hypertension, renal
insufficiency, or a combination thereof.
[0178] When a human patient exhibits one or more symptoms of acute
toxicity, the human patient may be subjected to toxicity
management. Treatments for patients exhibiting one or more symptoms
of acute toxicity are known in the art. For example, a human
patient exhibiting a symptom of CRS (e.g., cardiac, respiratory,
and/or neurological abnormalities) may be administered an
anti-cytokine therapy. In addition, a human patient that does not
exhibit a symptom of CRS may be administered an anti-cytokine
therapy to promote proliferation of anti-CTX110 CAR T cells.
[0179] Alternatively, or in addition to, when a human patient
exhibits one or more symptoms of acute toxicity, treatment of the
human patient may be terminated. Patient treatment may also be
terminated if the patient exhibits one or more signs of an adverse
event (AE), e.g., the patient has an abnormal laboratory finding
and/or the patient shows signs of disease progression.
[0180] The allogeneic anti-CD19 CAR T cell therapy (e.g., involving
the CTX110 cells) described herein may also be used in combination
therapies. For example, anti-CD19 CAR T cells treatment methods
described herein may be co-used with other therapeutic agents, for
treating a B cell malignancy, or for enhancing efficacy of the
genetically engineered T cell population and/or reducing side
effects of the genetically engineered T cell population.
IV. Kit for Allogeneic CAR-T Cell Therapy of B Cell
Malignancies
[0181] The present disclosure also provides kits for use of a
population of anti-CD19 CAR T cells such as CTX110 cells as
described herein in methods for treating a B cell malignancy. Such
kits may include one or more containers comprising a first
pharmaceutical composition that comprises one or more
lymphodepleting agents, and a second pharmaceutical composition
that comprises any nucleic acid or population of genetically
engineered T cells (e.g., those described herein), and a
pharmaceutically acceptable carrier. Kits comprising the
genetically engineered CAR-T cells as disclosed herein, such at the
CTX110 cells, may be stored and inventoried at the site of care,
allowing for rapid treatment of human patients following
diagnosis.
[0182] In some embodiments, the kit can comprise instructions for
use in any of the methods described herein. The included
instructions can comprise a description of administration of the
first and/or second pharmaceutical compositions to a subject to
achieve the intended activity in a human patient. The kit may
further comprise a description of selecting a human patient
suitable for treatment based on identifying whether the human
patient is in need of the treatment. In some embodiments, the
instructions comprise a description of administering the first and
second pharmaceutical compositions to a human patient who is in
need of the treatment.
[0183] The instructions relating to the use of a population of
anti-CD19 CAR T cells such as CTX110 T cells described herein
generally include information as to dosage, dosing schedule, and
route of administration for the intended treatment. The containers
may be unit doses, bulk packages (e.g., multi-dose packages) or
sub-unit doses. Instructions supplied in the kits of the disclosure
are typically written instructions on a label or package insert.
The label or package insert indicates that the population of
genetically engineered T cells is used for treating, delaying the
onset, and/or alleviating a T cell or B cell malignancy in a
subject.
[0184] The kits provided herein are in suitable packaging. Suitable
packaging includes, but is not limited to, vials, bottles, jars,
flexible packaging, and the like. Also contemplated are packages
for use in combination with a specific device, such as an inhaler,
nasal administration device, or an infusion device. A kit may have
a sterile access port (for example, the container may be an
intravenous solution bag or a vial having a stopper pierceable by a
hypodermic injection needle). The container may also have a sterile
access port. At least one active agent in the pharmaceutical
composition is a population of the anti-CD19 CAR-T cells such as
the CTX110 T cells as disclosed herein.
[0185] Kits optionally may provide additional components such as
buffers and interpretive information. Normally, the kit comprises a
container and a label or package insert(s) on or associated with
the container. In some embodiment, the disclosure provides articles
of manufacture comprising contents of the kits described above.
General Techniques
[0186] The practice of the present disclosure will employ, unless
otherwise indicated, conventional techniques of molecular biology
(including recombinant techniques), microbiology, cell biology,
biochemistry, and immunology, which are within the skill of the
art. Such techniques are explained fully in the literature, such as
Molecular Cloning: A Laboratory Manual, second edition (Sambrook,
et al., 1989) Cold Spring Harbor Press; Oligonucleotide Synthesis
(M. J. Gait, ed. 1984); Methods in Molecular Biology, Humana Press;
Cell Biology: A Laboratory Notebook (J. E. Cellis, ed., 1989)
Academic Press; Animal Cell Culture (R. I. Freshney, ed. 1987);
Introduction to Cell and Tissue Culture (J. P. Mather and P. E.
Roberts, 1998) Plenum Press; Cell and Tissue Culture: Laboratory
Procedures (A. Doyle, J. B. Griffiths, and D. G. Newell, eds.
1993-8) J. Wiley and Sons; Methods in Enzymology (Academic Press,
Inc.); Handbook of Experimental Immunology (D. M. Weir and C. C.
Blackwell, eds.): Gene Transfer Vectors for Mammalian Cells (J. M.
Miller and M. P. Calos, eds., 1987); Current Protocols in Molecular
Biology (F. M. Ausubel, et al. eds. 1987); PCR: The Polymerase
Chain Reaction, (Mullis, et al., eds. 1994); Current Protocols in
Immunology (J. E. Coligan et al., eds., 1991); Short Protocols in
Molecular Biology (Wiley and Sons, 1999); Immunobiology (C. A.
Janeway and P. Travers, 1997); Antibodies (P. Finch, 1997);
Antibodies: a practice approach (D. Catty, ed., IRL Press,
1988-1989); Monoclonal antibodies: a practical approach (P.
Shepherd and C. Dean, eds., Oxford University Press, 2000); Using
antibodies: a laboratory manual (E. Harlow and D. Lane (Cold Spring
Harbor Laboratory Press, 1999); The Antibodies (M. Zanetti and J.
D. Capra, eds. Harwood Academic Publishers, 1995); DNA Cloning: A
practical Approach, Volumes I and II (D. N. Glover ed. 1985);
Nucleic Acid Hybridization (B. D. Hames & S. J. Higgins eds.
(1985; Transcription and Translation (B. D. Hames & S. J.
Higgins, eds. (1984; Animal Cell Culture (R. I. Freshney, ed.
(1986; Immobilized Cells and Enzymes (IRL Press, (1986; and B.
Perbal, A practical Guide To Molecular Cloning (1984); F. M.
Ausubel et al. (eds.).
[0187] Without further elaboration, it is believed that one skilled
in the art can, based on the above description, utilize the present
invention to its fullest extent. The following specific embodiments
are, therefore, to be construed as merely illustrative, and not
limitative of the remainder of the disclosure in any way
whatsoever. All publications cited herein are incorporated by
reference for the purposes or subject matter referenced herein.
Example 1: Preparation of CD19 Targeting Allogeneic CAR-T Cells
[0188] Allogeneic T cells expressing a chimeric antigen receptor
(CAR) specific for CD19 were prepared from healthy donor peripheral
blood mononuclear cells as described in US Publication No. US
2018-0325955, incorporated herein by reference. Briefly, primary
human T cells were first electroporated with Cas9 or Cas9:sgRNA
ribonucleoprotein (RNP) complexes targeting TRAC
(AGAGCAACAGTGCTGTGGCC (SEQ ID NO: 26)) and B2M
(GCTACTCTCTCTTTCTGGCC (SEQ ID NO: 27)). The DNA double stranded
break at the TRAC locus was repaired by homology directed repair
with an AAV6-delivered DNA template (SEQ ID NO: 56) containing
right and left homology arms to the TRAC locus flanking a chimeric
antigen receptor (CAR) cassette. The CAR comprised a single-chain
variable fragment (scFv) derived from a murine antibody specific
for CD19, a CD8 hinge region and transmembrane domain and a
signaling domain comprising CD3z and CD28 signaling domains. The
amino acid sequence of the CAR, and nucleotide sequence encoding
the same, is set forth in SEQ ID NOs: 40 and 39, respectively. The
gRNAs used in this Example comprise the following spacer sequences:
TRAC gRNA spacer (AGAGCAACAGUGCUGUGGCC (SEQ ID NO: 19)); and B2M
gRNA spacer (GCUACUCUCUCUUUCUGGCC (SEQ ID NO: 21)). A population of
cells comprising TRAC.sup.-/.beta.2M.sup.-/anti-CD19 CAR.sup.+ T
cells are referred to herein as "TC1 cells" or "CTX110 cells".
[0189] With CRISPR/Cas9 editing technology, high frequency knockout
of the constant region of the TCR.alpha. gene (TRAC) with
.about.98% reduction of TCR surface expression in human primary
T-cells from healthy donors, which aims to significantly impair
graft-versus-host disease (GVHD), was achieved. High frequency
knockout of the .beta.-2-microglobulin (B2M) gene could also be
obtained, which aims to increase persistence in patients,
potentially leading to increased potency overall. TRAC/B2M double
knockout frequencies have been obtained in .about.80% of T cells
without any subsequent antibody-based purification or enrichment.
Human T cells expressing a CD19-specific CAR from within a
disrupted TRAC locus, produced by homology-directed repair using an
AAV6-delivered donor template, along with knockout of the B2M gene
have been consistently produced at a high efficiency. This
site-specific integration of the CAR protects against the potential
outgrowth of CD3+CAR+ cells, further reducing the risk of GVHD,
while also reducing the risk of insertional mutagenesis associated
with retroviral or lentiviral delivery mechanisms. These engineered
allogeneic CAR-T cells show CD19-dependent T-cell cytokine
secretion and potent CD19-specific cancer cell lysis.
[0190] The production of allogeneic anti-CD19 CAR-T product (FIG.
1) exhibited efficiency editing (e.g., greater than 50%
TRAC-/B2M-/anti-CD19 CAR+T cells efficiency) (FIG. 2).
Example 2: Dose Escalation Study to Determine the Efficacy of CAR-T
Cells in the Subcutaneous Raji Human Burkitt's Lymphoma Tumor
Xenograft Model in NOG Mice
[0191] The efficacy of CD19 targeting CAR-T cells against the
subcutaneous Raji Human Burkitt's Lymphoma tumor xenograft model in
NOG mice was evaluated using methods employed by Translational Drug
Development, LLC (Scottsdale, Ariz.). In brief, 12, 5-8 week old
female, CIEA NOG (NOD.Cg-Prkd.sup.scidIl2rg.sup.tm1Sug/JicTac) mice
were individually housed in ventilated microisolator cages,
maintained under pathogen-free conditions, 5-7 days prior to the
start of the study. On Day 1 mice received a subcutaneous
inoculation of 5.times.10.sup.6 Raji cells/mouse. The mice were
further divided into 3 treatment groups as shown in Table 1. On Day
8 (7 days post inoculation with the Raji cells), treatment group 2
and group 3 received a single 200 .mu.l intravenous dose of
TRAC.sup.-/B2M.sup.-/anti-CD19 CAR+ cells (TC1) according to Table
1.
TABLE-US-00001 TABLE 1 Treatment groups. Group Raji Cells (s.c.)
TC1 Treatment (i.v.) N 1 5 .times. 10.sup.6 cells/mouse None 4 2 5
.times. 10.sup.6 cells/mouse 5 .times. 10.sup.6 cells/mouse 4 3 5
.times. 10.sup.6 cells/mouse 1 .times. 10.sup.7 cells/mouse 4
[0192] Tumor volume and body weight was measured and individual
mice were euthanized when tumor volume was .gtoreq.500
mm.sup.3.
[0193] By Day 18, the data show a statistically significant
decrease in the tumor volume in response to TC1 cells as compared
to untreated mice (FIG. 3). The effect on tumor volume was
dose-dependent (Table 2); mice receiving higher doses of TC1 cells
showed significantly reduced tumor volume when compared to mice
receiving either a lower dose of TC1 cells or no treatment. An
increase in survival was also observed in the treated group (Table
2).
TABLE-US-00002 TABLE 2 Tumor response and survival. Tumor Tumor
Group volume (Day 18) volume (Day 20) Survival (Days) N 1 379.6
.+-. 67.10 482 .+-. 47.37 20-22 4 2 214.0 .+-. 20.73 372.2 .+-.
78.21 25 4 3 107.5 .+-. 7.33* 157.1 .+-. 10.62** 27 (end of study)
4 p = 0.007 compared to control (Group 1) **p = 0.0005 compared to
control (Group 1)
Example 3: Assessment of CD19 Targeting CAR-T Cells Efficacy in
Intravenous Disseminated Models in NOG Mice
[0194] To further assess the efficacy of
TRAC.sup.-/B2M.sup.-/anti-CD19 CAR+ cells (TC1), disseminated mouse
models were utilized.
[0195] Intravenous Disseminated Raji Human Burkitt's Lymphoma Tumor
Xenograft Model
[0196] The Intravenous Disseminated Model (Disseminated Model)
using the Raji Human Burkitt's Lymphoma tumor cell line in NOG mice
was used to further demonstrate the efficacy of TC1. Efficacy of
TC1 was evaluated in the Disseminated Model using methods employed
by Translations Drug Development, LLC (Scottsdale, Ariz.) and
described herein. In brief, 24, 5-8 week old female CIEA NOG
(NOD.Cg-Prkde.sup.scidI12rg.sup.t1Sug/JicTac) mice were
individually housed in ventilated microisolator cages, maintained
under pathogen-free conditions, 5-7 days prior to the start of the
study. At the start of the study, the mice were divided into 5
treatment groups as shown in Table 9. On Day 1 mice in Groups 2-5
received an intravenous injection of 0.5.times.10.sup.6 Raji
cells/mouse. The mice were inoculated intravenously to model
disseminated disease. On Day 8 (7 days post injection with the Raji
cells), treatment Groups 3-5 received a single 200 .mu.l
intravenous dose of TC1 cells (Table 3).
TABLE-US-00003 TABLE 3 Treatment groups. Group Raji Cells (i.v.)
TC1 Treatment (i.v.) N 1 None None 8 2 0.5 .times. 10.sup.6
cells/mouse None 4 3 0.5 .times. 10.sup.6 cells/mouse 1 .times.
10.sup.6 cells/mouse 4 (~0.5 .times. 10.sup.6 CAR-T+ cells) 4 0.5
.times. 10.sup.6 cells/mouse 2 .times. 10.sup.6 cells/mouse 4 (~1.0
.times. 10.sup.6 CAR-T+ cells) 5 0.5 .times. 10.sup.6 cells/mouse 4
.times. 10.sup.6 cells/mouse 4 (~2.0 .times. 10.sup.6 CAR-T+
cells)
[0197] During the course of the study mice were monitored daily and
body weight was measured two times weekly. A significant endpoint
was the time to peri-morbidity and the effect of T-cell engraftment
was also assessed. The percentage of animal mortality and time to
death were recorded for every group in the study. Mice were
euthanized prior to reaching a moribund state. Mice may be defined
as moribund and sacrificed if one or more of the following criteria
were met:
[0198] Loss of body weight of 20% or greater sustained for a period
of greater than 1 week;
[0199] Tumors that inhibit normal physiological function such as
eating, drinking, mobility and ability to urinate and or
defecate;
[0200] Prolonged, excessive diarrhea leading to excessive weight
loss (>20%); or
[0201] Persistent wheezing and respiratory distress.
[0202] Animals were also considered moribund if there was prolonged
or excessive pain or distress as defined by clinical observations
such as: prostration, hunched posture, paralysis/paresis, distended
abdomen, ulcerations, abscesses, seizures and/or hemorrhages.
[0203] Similar to the subcutaneous xenograph model (Example 2), the
Disseminated Model revealed a statistically significant survival
advantage in mice treated with TRAC.sup.-/B2M.sup.-/anti-CD19 CAR+
cells (TC1) as shown in FIG. 4, p<0.0001. The effect of TC1
treatment on survival in the disseminated model was also dose
dependent (Table 4).
TABLE-US-00004 TABLE 4 Animal survival. Raji TC1 Max Median Group
Cells (i.v.) Treatment (i.v.) survival (days) survival (days) 1 No
No Max Max 2 Yes No 20 20 3 Yes 1 .times. 10.sup.6 cells/mouse 21
21 4 Yes 2 .times. 10.sup.6 cells/mouse 25 25 5 Yes 4 .times.
10.sup.6 cells/mouse 32 26
[0204] A second experiment was run using the Intravenous
Disseminated model described above.
[0205] On Day 1 mice in Groups 2-4 received an intravenous
injection of 0.5.times.10.sup.6 Raji cells/mouse. The mice were
inoculated intravenously to model disseminated disease. On Day 4 (3
days post injection with the Raji cells), treatment Groups 2-4
received a single 200 .mu.l intravenous dose of TC1 cells per Table
5.
TABLE-US-00005 TABLE 5 Treatment groups. Group Raji Cells (i.v.)
TC1 Treatment (i.v.) N 1 0.5 .times. 10.sup.6 cells/mouse None 6 2
0.5 .times. 10.sup.6 cells/mouse 0.6 .times. 10.sup.6 CAR.sup.+
cells/mouse 7 3 0.5 .times. 10.sup.6 cells/mouse 1.2 .times.
10.sup.6 CAR.sup.+ cells/mouse 5 4 0.5 .times. 10.sup.6 cells/mouse
2.4 .times. 10.sup.6 CAR.sup.+ cells/mouse 5
[0206] Again, the Disseminated Model revealed a statistically
significant survival advantage in mice treated with
TRAC.sup.-/B2M.sup.-/anti-CD19 CAR+ cells (TC1) as shown in FIG. 5,
p=0.0016. The effect of TC1 treatment on survival in the
disseminated model was also dose dependent (Table 6).
TABLE-US-00006 TABLE 6 Animal survival. Raji Max Median Cells TC1
survival survival Group (i.v.) Treatment (i.v.) (days) (days)
Significance 1 Yes No 20 20 2 Yes 0.6 .times. 10.sup.6 CAR.sup.+ 35
27 p = 0.005 cells/mouse 3 Yes 1.2 .times. 10.sup.6 CAR.sup.+ 39 37
p = 0.016 cells/mouse 4 Yes 2.4 .times. 10.sup.6 CAR.sup.+ 49 46 p
= 0.016 cells/mouse
[0207] Evaluation of Splenic Response to TC1 Treatment
[0208] The spleen was collected from mice 2-3 weeks following Raji
injection and the tissue was evaluated by flow cytometry for the
persistence of TC1 cells and eradication of Raji cells in the
spleen.
[0209] The spleen was transferred to 3 mL of 1.times.DPBS CMF in a
C tube and dissociated using the MACS Octo Dissociator. The sample
was transferred through a 100 micron screen into a 15 mL conical
tube, centrifuged (1700 rpm, 5 minutes, ART with brake) and
resuspended in 1 mL of 1.times.DPBS CMF for counting using the
Guava PCA. Bone marrow was centrifuged and resuspended in 1 mL of
1.times.DPBS CMF for counting using the Guava PCA. Cells were
resuspended at a concentration of 10.times.10.sup.6 cells/mL in
1.times.DPBS CMF for flow cytometry staining.
[0210] Specimens (50 .mu.L) were added to 1 mL 1.times. Pharm Lyse
and incubated for 10-12 minutes at room temperature (RT). Samples
were centrifuged and then washed once with 1.times.DPBS CMF.
Samples were resuspended in 50 .mu.L of 1.times.DPBS and incubated
with Human and Mouse TruStain for 10-15 minutes at RT. The samples
were washed once with 1 mL 1.times.DPBS CMF and resuspend in 50
.mu.L of 1.times.DPBS CMF for staining. Surface antibodies were
added and the cells incubated for 15-20 minutes in the dark at RT
and then washed with 1 mL 1.times.DPBS CMF. Then samples were
resuspended in 125 .mu.L of 1.times.DPBS CMF for acquisition on the
flow cytometer. Cells were stained with the following surface
antibody panel:
TABLE-US-00007 TABLE 7 Antibody panel. FITC PE APC C3 APCCy7 V421
V510 huCD3 huCD45 huCD19 7AAD CD8 CD4 mCD45 (UCHT1) (HI30) (HIB19)
(SK1) (RPA-T4) (30-F11)
[0211] Cell populations were determined by electronic gating
(Pl=total leukocytes) on the basis of forward versus side scatter.
Compensation to address spill over from one channel to another was
performed upon initial instrument set up using Ultra Comp Beads
from Thermo Fisher. The flow cytometer was set to collect 10,000
CD45+ events in each tube. Flow cytometric data acquisition was
performed using the FACSCantoll.TM. flow cytometer. Data was
acquired using BO FACSDiva.TM. software (version 6.1.3 or 8.0.1).
Flow cytometry data analysis was in the form of Flow Cytograms,
which are graphical representations generated to measure relative
percentages for each cell type.
[0212] This example demonstrates that following TC1 cell treatment,
the therapeutically beneficial TRAC.sup.-/B2M.sup.-/anti-CD19 CAR+
cells persist in the spleen and selectively eradicate Raji cells
from the tissue (FIG. 6A). In addition, treatment with TC1 cells do
not exhibit Raji induced increase in cell mass (FIG. 6A). Further,
FIG. 7 shows that the remaining human cells in spleens of mice
treated with TRAC.sup.-/B2M.sup.-/anti-CD19 CAR+ cells are CD8+.
These CD8+ T cells are also CD3 negative proving that persistent T
cells in this model remain TCR/CD3 negative and are thus
edited.
[0213] Intravenous Disseminated Nalm-6 Human Acute Lymphoblastic
Leukemia Tumor Xenograft Model
[0214] The Intravenous Disseminated Model (Disseminated Model)
using the Nalm-6 Human Acute Lymphoblastic Leukemia tumor cell line
in NOG mice was used in to further demonstrate the efficacy of TC1.
Efficacy of TC1 was evaluated in the Disseminated Model using
methods employed by Translations Drug Development, LLC (Scottsdale,
Ariz.) and described herein. In brief, 24, 5-8 week old female CIEA
NOG (NOD.Cg-Prkd.sup.scidIl2rg.sup.tm1Sug/JicTac) mice were
individually housed in ventilated microisolator cages, maintained
under pathogen-free conditions, 5-7 days prior to the start of the
study. At the start of the study, the mice were divided into 5
treatment groups as shown in Table 14. On Day 1 mice in Groups 2-4
received an intravenous injection of 0.5.times.10.sup.6 Nalm6
cells/mouse. The mice were inoculated intravenously to model
disseminated disease. On Day 4 (3 days post injection with the
Nalm6 cells), treatment Groups 2-4 received a single 200 .mu.l
intravenous dose of TC1 cells per Table 8.
TABLE-US-00008 TABLE 8 Treatment groups. Group Nalm6 Cells (i.v.)
TC1 Treatment (i.v.) N 1 0.5 .times. 10.sup.6 cells/mouse None 6 2
0.5 .times. 10.sup.6 cells/mouse 1 .times. 10.sup.6 CAR.sup.+
cells/mouse 6 3 0.5 .times. 10.sup.6 cells/mouse 2 .times. 10.sup.6
CAR.sup.+ cells/mouse 6 4 0.5 .times. 10.sup.6 cells/mouse 4
.times. 10.sup.6 CAR.sup.+ cells/mouse 6
[0215] During the course of the study mice were monitored daily and
body weight was measured two times weekly as described above.
[0216] Similar to the Raji intravenous disseminated model (above),
the Nalm6 Model also showed a statistically significant survival
advantage in mice treated with TRAC.sup.-/B2M.sup.-/anti-CD19 CAR+
cells (TC1) as shown in FIG. 8, p=0.0004. The effect of TC1
treatment on survival in the Nalm6 disseminated model was also dose
dependent (Table 9).
TABLE-US-00009 TABLE 9 Animal survival. Nalm6 TC1 Max Median Cells
Treatment survival Survival Group (i.v.) (i.v.) (days) (days)
Significance 1 Yes No 31 25.5 2 Yes 1 .times. 10.sup.6 CAR.sup.+ 32
31 p = 0.03 cells/mouse 3 Yes 2 .times. 10.sup.6 CAR.sup.+ 38 36 p
= 0.0004 cells/mouse 4 Yes 4 .times. 10.sup.6 CAR.sup.+ 52 46 p =
0.0004 cells/mouse
Example 4: Further Assessment of CD19 Targeting CAR-T Cells
Efficacy in Intravenous Disseminated Models in NOG Mice
[0217] The purpose of this study was to evaluate the anti-tumor
activity of anti-CD19 CAR+ T cells at multiple dose levels against
the Nalm6-Fluc-GFP acute lymphoblastic leukemia tumor cell line in
NOG mice. The mice were inoculated intravenously to model
disseminated disease. Significant endpoint was time to
pen-morbidity. Bioluminescent imaging was performed to monitor
progression of disseminated disease.
[0218] In brief, 6 week old female, CIEA NOG
(NOD.Cg-Prkdc.sup.scidIl2rg.sup.tm1Sug/JicTac) mice were housed in
ventilated microisolator cages, maintained under pathogen-free
conditions, 5-7 days prior to the start of the study. On Day 1 mice
received an intravenous inoculation of 5.times.10.sup.4
Nalm6-Fluc-GFP (Nalm6-Fluc-Neo/eGFP--Puro; Imanis Life Sciences
(Rochester, Minn.)) cells/mouse. Three (3) days post inoculation
with Nalm6-Fluc-GFP cells, the mice were divided into treatment
groups and dosed with T cell populations comprising
TRAC-/B2M-/anti-CD19 CAR+ T cells, as indicated in Table 10. Region
of Interest values (ROI) values were captured and reported. Body
weight was measured twice daily and bioluminescence was measured
twice weekly starting on Day 4 (3 Days Post inoculation of
Nalm6-Fluc-GFP cells) through Day 67, once weekly starting Day 74
to study end. To measure bioluminescence mice were injected
intraperitoneally with 200 .mu.l of D-Luciferin 150 mg/kg. Kinetics
images were taken at the beginning of the study and as needed
throughout to determine optimal post D-Luciferin dose and exposure
time to image the mice. Mice were imaged by capturing luminescence
signal (open emission) using an AMI 1000 imaging unit with software
version 1.2.0 (Spectral Instruments Imaging Inc.; Tucson,
Ariz.).
TABLE-US-00010 TABLE 10 Treatment groups. # of T Cells Anti-CD19
Group Anti-CD19 CAR T Cell injected (iv) CAR+ T cells N 1 N/A N/A
N/A 5 2 TRAC-/.beta.2M-/anti-CD19 3 .times. 10.sup.6 ~1.8 .times.
10.sup.6 5 cells/mouse 3 TRAC-/.beta.2M-/anti-CD19 6 .times.
10.sup.6 ~3.6 .times. 10.sup.6 5 cells/mouse 4
TRAC-/.beta.2M-/anti-CD19 12 .times. 10.sup.6 7.2 .times. 10.sup.6
4 cells/mouse
[0219] Individual mice were euthanized at pen-morbidity (clinical
signs suggesting high tumor burden (e.g., lack of motility, hunch
back, hypoactivity) or 20% or greater body weight loss sustained
for a period of greater than 1-week). Mice were euthanized prior to
reaching a moribund state. The study was ended on Day 99 when the
final mouse was euthanized as a long-term survivor.
[0220] FIG. 9 shows prolonged survival of mice that received
different doses of TC1 cells relative to untreated mice. FIG. 10
shows low to undetectable levels of bioluminescence in mice that
received the highest dose of TC1 cells (12.times.10.sup.6
cells/mouse) and which resulted in the longest survival as shown in
FIG. 9. At day 74 bioluminescence was detected in all 4 mice,
indicative of tumor cell expansion in the treatment group.
[0221] Overall, these results show a single injection of TC1 cells
can prolong survival of mice that were administered a lethal dose
of Nalm6 B-ALL cells. This prolonged survival is dose dependent
with a graded survival response observed between low, middle and
high doses of TC1 cells.
Example 5: Analysis of Graft Versus Host Disease in Mice
Administered Allogeneic CD19 Targeting CAR T Cells
[0222] A study in mice was conducted to evaluate the potential for
both unedited human T cells and TC1 cells to cause graft versus
host disease (GvHD). After total body irradiation with 200 cGy, NOG
female mice were administered a single intravenous slow bolus
injection of unedited human T cells or TC1 cells. Animals were
followed for up to 119 days after radiation only (Group 1) or
radiation plus a single dose administration of PBMCs (Group 2),
electroporated T cells (Group 3) or TC1 cells (Group 4). Cells were
administered approximately 6 hours post radiation on Day 1. Table
11 summarizes the groups and study design.
TABLE-US-00011 TABLE 11 Treatment groups. Total Number of Group
Dose Level Irradiation Animals Number Test Article (cells/mouse)
Dose (Female) 1 Radiation Only 0 200 cGy 12 2 Radiation + PBMCs 6
.times. 10P.sup.6 6 3 Radiation + EP T cells 3 .times. 10P.sup.7 6
4 Radiation + TC1 cells 3 .times. 10P.sup.7 6
[0223] The endpoints of the study were survival, kinetics of
appearance of GvHD symptoms, and body weight measurements.
[0224] Mortality was observed in Group 1 (3 of 12 animals), Group 2
(6 of 6 animals) and Group 3 (2 of 6 animals) during the first 30
days post-treatment (FIG. 11). All animals in Group 4 (TC1 cells)
survived until scheduled necropsy (FIG. 11). Moribund animals in
Groups 1, 2 and 3 experienced weight loss and/or clinical
observations consistent with the development of GvHD (slight to
severe cold to touch, slight to moderate emaciation, slight to
marked hunched posture, severe weight loss, mild to severe
alopecia, severe hypoactivity, moderate labored respiration, and
marked tachypnea). Animals in Groups 1 and 4, and non-moribund
animals in Group 3, experienced mild weight loss following
radiation which improved over the course of the study (FIG. 12). No
notable clinical observations were recorded.
[0225] This study demonstrated that unedited human PBMCs induce
fatal GvHD in irradiated NOG mice in all animals (Group 2), with
onset 2 to 3 weeks after administration of cells. In contrast, no
mice that received TC1 cells (Group 4) developed GvHD during the
study (119 days), despite the higher number of cells that were
administered to these animals (3.times.10.sup.7 TC1 cells per mouse
compared to 6.times.10.sup.6 PBMCs per mouse). The irradiation
procedure induced transient weight loss in all groups and recovered
in all groups that did not receive unedited PBMCs.
[0226] A second study was conducted to further evaluate the
potential for both unedited human T cells and TC1 cells to cause
GvHD. Specifically, NOD/SCID/IL2R.gamma.null (NSG) female mice were
administered a single intravenous slow bolus injection of unedited
human T cells or TC1 cells after a total body irradiation (total
irradiation dose of 200 cGy, 160 cGy/min; targeted LDR.sub.0/140R).
The endpoints of this study were survival, kinetics of appearance
of symptoms of GvHD and body weight measurements. Histopathology
was also performed on all collected tissues. Exposure was assessed
in mouse blood and tissues by flow cytometry and
immunohistochemistry (IHC), where appropriate.
[0227] The cells were administered as a single dose via intravenous
slow bolus as described in Table 12.
TABLE-US-00012 TABLE 12 Study Design. Concen- Total Number Dose
tration Ir- of Group (Cells/ (Cells/ radiation Animals Number Test
Article Mouse) mL) Dose M F 1 Vehicle - no RT.sup.a 0 0 0 cGy 5 5 2
Vehicle - RT.sup.a 0 0 200 cGy 15 15 3 Unedited T cells 1 .times.
10.sup.7 4 .times. 10.sup.7 15 15 4 TC1 - low dose 2 .times.
10.sup.7 8 .times. 10.sup.7 15 15 5 TC1 - high dose 4 .times.
10.sup.7 16 .times. 10.sup.7 15 15 .sup.aGroup 1 animals were not
irradiated and were not dosed with cells (animals were administered
with vehicle, PBS 1X). Group 2 animals were irradiated but were not
dosed with cells (animals were administered with vehicle,
phosphate-buffered saline [PBS]).
[0228] Animals were randomized into treatment groups by body weight
using a validated preclinical software system (Provantis). Due to
the large size of this study, dosing and necropsy activities were
staggered over nine days. To minimize bias, animals from the
control and TC1 groups (Groups 4 and 5) were dosed and necropsied
on the same day. Necropsy occurred on Study Day 85 for all
groups.
[0229] Mortality was observed for all animals that received
unedited human T cells (Group 3), with onset at Day 14 (FIG. 13).
All mice that received unedited human T cells (Group 3), were
either found dead or sent to unscheduled euthanasia by Day 29.
Clinical signs in these animals were consistent with the
development of GvHD and included dull fur, slight to severe
decreased activity, hunched back posture, slight to moderate
thinness, and increased respiratory rate. Marked changes in
hematology parameters were observed at euthanasia in mice that
received unedited human T cells (Group 3), including decreases in
red blood cells, hemoglobin, platelets, white blood cells and
reticulocyte counts. Minimal to moderate inflammation was observed
in the liver, lung, kidney, spleen, and thymus of Group 3 animals.
Necrosis often accompanied inflammation in these tissues. These
findings were consistent with the development of GvHD.
Additionally, mild to severe hypocellularity in the femoral and
sternal bone marrow was also present in the majority of Group 3
animals, which was likely attributable to the effects of total body
irradiation. This was likely only observed in this group due to the
early necropsy dates (2-4 weeks post-radiation), compared to 12
weeks for all other groups. Consistent with the presence of GvHD,
immunohistochemical analysis of Group 3 animals revealed the
presence of human CD45P.sup.+P cells in all tissues examined
(kidney, liver, spleen, lung, skin, and the digestive tract). All
animals in the other Groups survived until the scheduled
necropsy.
[0230] Further, no significant weight loss was observed in Groups
1, 2, 4, or 5 (FIG. 14). No notable clinical observations that were
consistent with GvHD, characterized by observations of at least two
symptoms considered likely to denote GvHD, were recorded in these
groups. Several animals from Groups 4 and 5 exhibited symptoms such
as dull fur, slight to moderate decreased activity, and/or slight
thinness throughout the study. Although these symptoms are often
associated with GvHD, they did not appear to be TC1-related as they
were infrequently observed, transient and of short duration, and
were also seen in some irradiated control animals (Group 2).
[0231] Overall the results from these two studies confirmed TC1
cells do not induce graft versus host disease.
Example 6: Preparation and Characterization of Developmental Lots
of Allogeneic CD19 Targeting CAR T Cells
[0232] TC1 cells for the purposes of the clinical study were
prepared from healthy donor peripheral blood mononuclear cells
obtained via a standard leukopheresis procedure. The mononuclear
cells were enriched for T cells and activated with anti-CD3/CD28
antibody-coated beads, then electroporated with CRISPR-Cas9
ribonucleoprotein complexes and transduced with a CAR
gene-containing recombinant adeno-associated virus (AAV) vector.
The modified T cells were expanded in cell culture, purified,
formulated into a suspension, and cryopreserved.
[0233] Prior to modifying the cells, T cells from six different
healthy donors were evaluated for expression of various cell
surface markers. CD27+CD45RO- T cells within the CD8+ subset were
previously shown to correlate with complete responses in chronic
lymphocytic leukemia (CLL) when treated with anti-CD19 CAR T cell
therapy (Fraietta et al., Nat Med, Vol. 24(5): 563-571, 2018).
Accordingly, the percent of CD27+CD45O- T cells within the CD8+
subset of six different donors was evaluated by flow cytometry. In
brief, 1.times.10.sup.6 cells were incubated with Fab-Biotin or
IgG-Biotin antibodies as a negative control. Cells were washed with
staining buffer and incubated with mouse anti-IgG to capture excess
primary antibodies. Cells were washed again and incubated with the
full panel of secondary antibodies (CD8, Biolegend: Catalog
#300924, CD45RO, Biolegend: Catalog #304230, CD27, Biolegend:
Catalog #560612) and viability dye. Cells were washed a final time
with staining buffer and run on the flow cytometer to capture
various stained populations. FIG. shows the levels of CD27+CD45RO-
T cells within their CD8+ subsets. Allogeneic CAR-T manufacturing
allows for the selection of donor input material with favorable
characteristics, such as high CD27+CD45RO- cells in the CD8+
fraction of a donor of interest.
[0234] More specifically, leukopaks from 18 to 40 year-old male
donors were used to isolate CD4+ and CD8+ T cells. After isolation,
enrichment and activation of CD4+ and CD8+ T cells, cells were
electroporated with ribonucleoprotein complexes comprising Cas9
nuclease protein, TRAC sgRNA (SEQ ID NO: 26) or B2M sgRNA (SEQ ID
NO: 27). The TRAC and B2M ribonucleoprotein complexes were combined
prior to electroporation. After electroporation, freshly thawed
rAAV comprising a donor template (SEQ ID NO: 54) encoding the
anti-CD19 CAR (SEQ ID NO: 40) was added to the cells, and cells
were incubated. Cells were then expanded in culture and
supplemented with rhIL-2 and rhIL-7 every three to four days. Cells
set up for monitoring were tested for T cell identity and gene
editing with a TCR panel (CD5, CD4, CD8, TCR.alpha..beta., B2M and
CD45). Upon confirmation of T cell identity, TCR.alpha..beta.
depletion was performed by incubating the cells with a
biotin-conjugated anti-TCR.alpha..beta. antibody and anti-biotin
beads. The depleted cells were recovered and formulated for
administration. The resulting population of cells had less than
0.5% TCR.alpha..beta.+ cells. FIG. 16 shows the analysis of
TCR.alpha..beta.+ cells before and after purification.
[0235] Eight development lots of TC1 cells were tested for T cell
identity. Average results from eight tested lots showed 84.58%
knock-out of B2M (i.e., 15.42% B2M.sup.+ cells) and 99.98% of cells
were TCR- (i.e., 0.2% TCR+), and .about.50% knock-in of anti-CD19
CAR (FIG. 17).
[0236] In addition, exhaustion and senescent markers were evaluated
in donors before and after T cell editing. Specifically, the
percentage of PD1+, LAG3+, TIM3+ and CD57+ cells were determined
from total T cell populations. Expression of the markers was
assessed by flow cytometry, as described above, using the following
secondary antibodies: Mouse Anti-PD1 PeCy7, Biolegend, Catalog
#329918; Mouse Anti-TIM3BV421, Biolegend, Catalog #345008; Mouse
Anti-CD57 PerCp Cy5.5, Biolegend, Catalog #359622; and Mouse
Anti-LAG3 PE, Biolegend, Catalog #369306. FIG. 18 shows that
exhaustion or senescent markers never increased over 15% of the
total T cell population after genome editing.
[0237] In addition, selective killing by three different lots of
TC1 cells was evaluated in vitro. Specifically, TC1 cells were
incubated with CD19-positive cell lines (K562-CD19; Raji; and
Nalm6), or a CD19-negative cell line (K562). Killing was measured
using a flow cytometry-based cytotoxicity assay after .about.24
hours. Specifically, target cells were labeled with 5 .mu.M
efluor670 (Thermo Fisher Scientific, Waltham, Mass.), washed and
incubated overnight (50,000 target cells/well; 96-well U-bottom
plate [Corning, Tewksbury, Mass.]) in co-cultures with TC1 or
control T cells at varying ratios (from 0.1:1 up to 4:1 T cells to
target cells). The next day, wells were washed and media was
replaced with 200 .mu.L of fresh media containing a 1:500 dilution
of 5 mg/mL 4',6-diamidino-2-phenylindole (DAPI) (Thermo Fisher
Scientific, Waltham, Mass.) to enumerate dead/dying cells. Finally,
25 .mu.L of CountBright beads (Thermo Fisher Scientific) was added
to each well, and cells were then analyzed by flow cytometry using
a Novocyte flow cytometer (ACEA Biosciences, San Diego, Calif.).
Flowjo software (v10, Flowjo, Ashland, Oreg.) was used to analyze
flow cytometry data files (fcs files). TCR.alpha..beta.+ T cells
(unedited cells) were used as controls. TC1 cells efficiently
killed CD19-positive cells at higher rates than unedited T cells,
and CD19-negative cells showed low levels of cell lysis in the
presence of TC1 cells that were no more than when co-cultured with
unedited T cells (FIG. 19).
[0238] TC1 cells produced from three unique donors were also used
to assess growth in the absence of cytokine and/or serum.
Specifically, TC1 cells were grown in full T cell media for 14
days. On Day 0, cells from culture were grown either in complete
T-cell media (containing X-VIVO 15 (Lonza, Basel, Switzerland), 5%
human AB serum (Valley Biomedical, Winchester, Va.), IL-2
(Miltenyi, Bergisch Gladbach, Germany) and IL-7 (Cellgenix,
Frieburg, Germany)) (Complete Media), media containing serum but no
IL-2 or IL-7 cytokines (5% serum, no cytokines), or no serum or
cytokines (No serum, No Cytokines). Cells were enumerated as above
for up to 35 days after removal of cytokines and/or serum. No
outgrowth of TC1 cells was observed in the absence of cytokine
and/or serum (FIG. 20).
[0239] For administration, TC1 cells are resuspended in
cryopreservative solution (CryoStor CS-5) and supplied in a 6 mL
infusion vial. The total dose is contained in one or more vials.
The infusion of each vial occurs within 20 minutes of thawing.
Example 7: A Phase I, Open-Label, Multicenter, Dose Escalation and
Cohort Expansion Study of the Safety and Efficacy of Allogeneic
CRISPR-Cas9 Engineered T Cells (CTX110) in Subjects with Relapsed
or Refractory B Cell Malignancies
[0240] CTX110 is a CD19-directed chimeric antigen receptor (CAR) T
cell immunotherapy comprised of allogeneic T cells that are
genetically modified ex vivo using CRISPR-Cas9 (clustered regularly
interspaced short palindromic repeats/CRISPR-associated protein 9)
gene editing components (single guide RNA and Cas9 nuclease). The
modifications include targeted disruption of the T cell receptor
(TCR) alpha constant (TRAC) and beta-2 microglobulin (B2M) loci,
and the insertion of an anti-CD19 CAR transgene into the TRAC locus
via an adeno-associated virus expression cassette. The anti-CD19
CAR (SEQ ID NO: 40) is composed of an anti-CD19 single-chain
variable fragment comprising the SEQ ID NO: 47, the CD8
transmembrane domain of SEQ ID NO: 32, a CD28 co-stimulatory domain
of SEQ ID NO: 36, and a CD3.zeta. signaling domain of SEQ ID NO:
38.
[0241] In this study, eligible human patients received an
intravenous (IV) infusion of CTX110 following lymphodepleting (LD)
chemotherapy.
Study Population
[0242] Dose escalation and cohort expansion include adult subjects
with B cell malignancies. Subjects are assigned to independent dose
escalation groups based on disease histology. Enrolled adult
subjects include those with select subtypes of non-Hodgkin lymphoma
(NHL), including diffuse large B cell lymphoma (DLBCL) not
otherwise specified (NOS), high grade B cell lymphoma with MYC and
BCL2 and/or BCL6 rearrangements, transformed follicular lymphoma
(FL), grade 3b FL or Richter's transformation of CLL.
Study Purpose and Rationale
[0243] The purpose of the Phase 1 dose escalation study is to
evaluate the safety and efficacy of anti-CD19 allogeneic
CRISPR-Cas9 engineered T cells (CTX110 cells) in subjects with
relapsed or refractory B cell malignancies.
[0244] Outcomes for patients with relapsed/refractory B cell
malignancies are historically poor. However, the use of autologous
CAR T cell therapy in this setting has produced complete and
durable responses where previous treatment options were palliative
(June et al., (2018) Science, 359, 1361-1365; Maus and June, (2016)
Clin Cancer Res, 22, 1875-1884; Neelapu et al., (2017) N Engl J
Med, 377,2531-2544; Schuster et al., (2019) N Engl J Med, 380,
45-56; Schuster et al., (2017) N Engl J Med, 377, 2545-2554).
Autologous CAR T cell therapies require patient-specific cell
collection and manufacturing. Unfortunately, some patients are not
candidates to undergo leukapheresis, or they experience disease
progression or death while awaiting treatment. An allogeneic
off-the-shelf CAR T cell product such as CTX110 could provide the
benefit of immediate availability, reduce manufacturing
variability, and prevent individual subject manufacturing
failures.
[0245] Further, patients treated with multiple rounds of
chemotherapy may have T cells with exhausted or senescent
phenotypes. The low response rates in patients with chronic
lymphocytic leukemia (CLL) treated with autologous CAR T cell
therapy have been partially attributed to the exhausted T cell
phenotype (Fraietta et al., (2018) Nat Med, 24, 563-571; Riches et
al., (2013) Blood, 121, 1612-1621). By starting with
chemotherapy-naive T cells from a healthy donor, allogeneic
approaches could increase the consistency and potency of CAR T
therapy as compared to autologous products.
[0246] The main barrier to the use of allogeneic CAR T cells has
been the risk of graft versus host disease (GvHD). CRISPR Cas9
gene-editing technology allows for reliable multiplex cellular
editing. The CTX110 manufacturing process couples the introduction
of the CAR construct to the disruption of the TRAC locus through
homologous recombination. The delivery and precise insertion of the
CAR at the TRAC genomic locus using an AAV-delivered DNA donor
template and HDR contrasts with the random insertion of genetic
material using lentiviral and retroviral transduction methods. CAR
gene insertion at the TRAC locus results in elimination of TCR in
nearly all cells expressing the CAR, which minimizes risk of GvHD.
Furthermore, manufacturing from healthy donor cells removes the
risk of unintentionally transducing malignant B cells (Ruella et
al., (2018) Nat Med, 24, 1499-1503). This first-in-human trial in
subjects with relapsed/refractory B cell malignancies aims to
evaluate the safety as well as efficacy of CTX110 with this
CRISPR-Cas9-modified allogeneic CAR T cell approach.
[0247] CTX110, a CD19-directed genetically modified allogeneic
T-cell immunotherapy, is manufactured from the cells of healthy
donors; therefore, the resultant manufactured cells are intended to
provide each subject with a consistent, final product of reliable
quality. Furthermore, the manufacturing of CTX110, through precise
delivery and insertion of the CAR at the TRAC site using AAV and
homology-directed repair (HDR), does not present the risks
associated with random insertion of lentiviral and retroviral
vectors.
Objectives
[0248] Primary objective, Part A (Dose escalation): To assess the
safety of escalating doses of CTX110 in combination with various
lymphodepletion agents in subjects with relapsed or refractory B
cell malignancies to determine the recommended Part B dose.
[0249] Primary objective, Part B (Cohort expansion): To assess the
efficacy of CTX110 in subjects with relapsed or refractory B cell
malignancies, as measured by objective response rate (ORR).
[0250] Secondary objectives (Parts A and B): To further
characterize the efficacy, safety, and pharmacokinetics of
CTX110.
[0251] Exploratory objectives (Parts A and B): To identify genomic,
metabolic, and/or proteomic biomarkers associated with CTX110 that
may indicate or predict clinical response, resistance, safety, or
pharmacodynamic activity.
Endpoints
Primary Endpoints
[0252] Part A: The incidence of adverse events, defined as
dose-limiting toxicities. [0253] Part B: The objective response
rate (ORR) defined as complete response (CR)+partial response (PR)
per the Lugano Response Criteria for Malignant Lymphoma (Cheson et
al., (2014) J Clin Oncol, 32, 3059-3068), as determined by
independent central radiology review.
[0254] The Lugano Classification provides a standardized way to
assess imaging in lymphoma subjects. It is comprised of radiologic
assessments of tumor burden on diagnostic CT, and metabolic
assessments on F.sup.18 FDG-PET for FDG-avid histologies (see
Tables 13-14).
TABLE-US-00013 TABLE 13 Lugano Classification Assessment
Components. Diagnostic CT/MRI F.sup.18 FDC-PET Target Lymph Nodes
and Extra Nodal 5 Point Scale (Deauville) PET Score Lesions (Lymph
Nodes and Extra Lymphatic Sites) * Up to 6 of the largest target
nodes, nodal masses, The 5-point scale scores the site of the most
or other lymphomatous lesions that are intense FDG uptake for the
time point, as follows: measurable in two diameters (longest
diameter Score Criteria [LDi] and shortest diameter) should be
identified 1 No uptake from different body regions representative
of the 2 Uptake .ltoreq. mediastinum subject's overall disease
burden and include 3 Uptake > mediastinum but .ltoreq. liver
mediastinal and retroperitoneal disease, if 4 Uptake moderately
higher than liver involved. (moderately indicates uptake greater
Nodal disease: Must have an LDi > 1.5 cm than normal liver)
Extranodal disease: Must have an 5 Uptake markedly higher than
liver LDi > 1.0 cm (markedly indicates much higher than
Non-Measured Lesions normal liver) All other lesions (including
nodal, extranodal, and/or and assessable disease) should be
followed as New lesions nonmeasured disease (e.g., cutaneous, GI,
bone, X New areas of uptake unlikely to be spleen, liver, kidneys,
pleural or pericardial related to lymphoma effusions, ascites).
Bone Marrow: FDG uptake assessed as Organ Enlargement (Spleen) No
FDG uptake consistent with lymphoma The spleen is considered
enlarged Focal FDG uptake consistent with (splenomegaly) when
>13 cm in the cranial to lymphoma caudal dimension. Diffuse FDG
uptake consistent with New Lesions lymphoma Nodal disease: Must
have an LDi > 1.5 cm Extranodal disease: Any size CT: computed
tomography; F.sup.18 FDG: fluorodeoxyglucose F18; LDi: longest
diameter; MRI: magnetic resonance imaging; PET: positron emission
tomography. * See (Barrington et al., (2014) J Clin Oncol, 32,
3048-3058).
TABLE-US-00014 TABLE 14 Lugano Criteria for Response Assessment. At
each follow-up time point, a PET-based response and a CT-based
response is made per the definitions below. Response and Site
PET-based Response CT-based Response COMPLETE Complete Metabolic
Response* Complete Radiologic Response ALL of the following ALL of
the following Lymph nodes, Score of 1, 2, or 3* Lymph nodes: All
<1.5 cm in longest extranodal lesions diameter. Extralymphatic
disease absent. Nonmeasured lesion N/A Absent Organ enlargement N/A
Spleen: normal size New lesions No new metabolically active lesions
None (new lesions drive score 5) Bone marrow No FDG-avid disease in
marrow Normal by morphology; if indeterminate, IHC negative.
PARTIAL Partial Remission Partial Metabolic Response ALL of the
following Lymph nodes, Score of 4, or 5 with reduced uptake
.gtoreq.50% decrease in SPD of all extranodal lesions from baseline
and residual masses of target lesions from baseline any size
Nonmeasured lesion N/A Absent, normal, or regressed, but no
increase Organ enlargement N/A Spleen: .gtoreq.50% decrease from
baseline in enlarged portion New lesions None None Bone marrow
Residual uptake higher than uptake in N/A normal marrow but reduced
compared with baseline (e.g., persistent focal changes in the
marrow with nodal response) NO RESPONSE/STABLE DISEASE No Metabolic
Response Stable Disease Lymph nodes, Score of 4, or 5 with no
significant <50% decrease in SPD of all target extranodal
lesions change in FDG uptake from baseline lesion from baseline No
progression Nonmeasured lesion N/A No increase consistent with
progression Organ enlargement N/A Spleen: No increase consistent
with progression New lesions None None Bone marrow No change from
baseline N/A PROGRESSION Progressive Disease Progressive Metabolic
Response ANY of the following Lymph nodes, Lymph nodes/nodal
masses: PPD Progression extranodal lesions Score of 4 or 5 with
increased An individual node/extranodal lesion must uptake compared
to baseline. be abnormal (nodal disease with LDi > 1.5
Extranodal lesions: New FDG cm, extranodal disease with and LDi
> 1.0 avid foci consistent with cm) with: lymphoma. Increase of
.gtoreq.50% from the product of the perpendicular diameters (PPD)
from nadir AND Increase in LDi or SDi from nadir .gtoreq.0.5 cm for
lesions .ltoreq.2 cm .gtoreq.1.0 cm for lesions >2 cm
Nonmeasured lesion None Unequivocal progression Organ enlargement
None Progression of pre-existing splenomegaly: Splenic length must
increase by 50% of the extent of its prior increase beyond baseline
(e.g., a 15-cm spleen must increase to 16 cm). New splenomegaly:
Spleen must increase by at least 2 cm from baseline Or Recurrent
splenomegaly New lesions New FDG-avid foci consistent with Regrowth
of previously resolved lesions lymphoma rather than another
etiology New node > 1.5 cm in any axis New extranodal site >
1.0 cm in any axis New extranodal site < 1.0 cm in any axis or
unequivocal/attributable to lymphoma New assessable disease
unequivocal/ attributable to lymphoma of any size Bone marrow
New/recurrent FDG-avid foci New or recurrent involvement FDG:
fluorodeoxyglucose; NC: immunohistochemistry; LDi: longest
diameter; N/A: not applicable; PPD: perpendicular diameters; SDi:
shortest diameter; SPD: sum of the products of diameters.
*Deauville score of 3 represent a complete metabolic response
(Barrington et al., (2014) J Clin Oncol, 32, 3048-3058). Note: It
is recognized that in Waldeyer's ring or extranodal sites with high
physiologic uptake or with activation within spleen or marrow
(e.g., with chemotherapy or myeloid colony-stimulating factors),
uptake may be greater than normal mediastinum and/or liver. In this
circumstance, complete metabolic response may be inferred if uptake
at sites of initial involvement is no greater than surrounding
normal tissue even if the tissue has high physiologic uptake.
[0255] Secondary Endpoints (Dose Escalation and Cohort
Expansion)
[0256] Efficacy [0257] Duration of response/remission (central
read/assessment). Duration of response/remission is reported only
for subjects who have had objective response events. This is
calculated as the time between first objective response and date of
disease progression or death due to any cause. [0258]
Progression-free/event-free survival (central read/assessment).
Progression-free survival (PFS) and event-free survival is
calculated as the difference between date of CTX110 infusion and
date of disease progression or death due to any cause. Subjects who
have not progressed and are still on study at the data cutoff date
are censored at their last assessment date. [0259] Overall
survival. Overall survival is calculated as the time between date
of first dose of CTX110 and death due to any cause. Subjects who
are alive at the data cutoff date are censored at their last date
known to be alive.
[0260] Safety
[0261] Frequency and severity of AEs and clinically significant
laboratory abnormalities.
[0262] Pharmacokinetic [0263] Levels of CTX110 in blood over
time.
[0264] Exploratory Endpoints (Dose Escalation and Cohort Expansion)
[0265] Levels of CTX110 in tissues (e.g., trafficking of CTX110 in
bone marrow, CSF, and/or tumor tissue may be evaluated in any
samples collected per protocol-specific sampling). [0266] Levels of
cytokines in blood and other tissues. [0267] Incidence of
anti-CTX110 antibodies. [0268] Levels of B cells and
immunoglobulins overtime. [0269] Impact of anti-cytokine therapy on
CTX110 proliferation, CRS, and response. [0270] Incidence of
autologous or allogeneic HSCT following CTX110 therapy. [0271]
Incidence and type of subsequent anticancer therapy. [0272] Time to
complete response/remission. [0273] First subsequent therapy-free
survival. [0274] Other genomic, protein, metabolic, or
pharmacodynamic endpoints.
Study Design
[0275] This is an open-label, multicenter, Phase 1 study evaluating
the safety and efficacy of CTX110 in subjects with relapsed or
refractory B cell malignancies. The study is divided into 2 parts:
dose escalation (Part A) followed by cohort expansion (Part B).
[0276] Part A investigates escalating doses of CTX110 in Cohort A
in adult subjects with 1 of the following NHL subtypes: DLBCL NOS,
high grade B cell lymphoma with MYC and BCL2 and/or BCL6
rearrangements, grade 3b FL, or transformed FL.
[0277] In the dose escalation part of the study, 1 additional
cohort (Cohort B) with an NHL population similar to Cohort A has
been added to explore an increased dose of cyclophosphamide (750
mg/m.sup.2) relative to Cohort A (500 mg/m.sup.2). Subjects in
Cohort B are treated with an increased dose of cyclophosphamide to
explore the effects of a longer suppression of lymphocytes on CAR T
cell expansion following CTX110 infusion (see Table 15).
TABLE-US-00015 TABLE 15 Cohort A and Cohort B. Cohort Disease
Subset Treatment A Adult subjects with DLBCL NOS, LD chemotherapy:
Co-administration of high grade B cell lymphoma with fludarabine
MYC and BCL2 and/or BCL6 30 mg/m.sup.2 + cyclophosphamide 500
mg/m.sup.2 IV rearrangements, grade 3b FL, and daily for 3 days
transformed FL CTX110 starting at DL1 B Same as Cohort A LD
chemotherapy: Co-administration of fludarabine 30 mg/m.sup.2 +
cyclophosphamide 750 mg/m.sup.2 IV daily for 3 days CTX110 starting
at DL2 DL1/2: Dose Level 1 or 2; DLBCL: diffuse large B cell
lymphoma; FL: follicular lymphoma; IV: intravenously; LD:
lymphodepleting.
[0278] The study is divided into 2 parts: dose escalation (Part A)
followed by cohort expansion (Part B). Both parts of the study will
consist of 3 main stages: screening, treatment, and follow-up. A
schematic depiction of the study schema is shown in FIG. 21.
[0279] A schedule of assessments is provided in Table 16 and Table
17.
Stage 1--Screening to determine eligibility for treatment (up to 14
days). Stage 2--Lymphodepleting (LD) chemotherapy and infusion of
CTX110 (1-2 weeks). Prior to both the initiation of LD chemotherapy
and infusion of CTX110, the clinical eligibility of subjects must
be reconfirmed.
[0280] Stage 2A--LD chemotherapy: [0281] Cohort A:
Co-administration of fludarabine 30 mg/m.sup.2 and cyclophosphamide
500 mg/m.sup.2 intravenously (IV) daily for 3 days. [0282] Cohort
B: Co-administration of fludarabine 30 mg/m.sup.2 and
cyclophosphamide 750 mg/m.sup.2 intravenously (IV) daily for 3
days.
[0283] Stage 2B--CTX110 infusion: [0284] Cohort A (NHL subsets):
Lymphodepleting (LD) chemotherapy (fludarabine 30 mg/m.sup.2 and
cyclophosphamide 500 mg/m.sup.2 intravenously [IV] daily for 3
days) completed at least 48 hours (but no more than 7 days) prior
to CTX110 infusion (dose escalation from Dose Level [DL] 1). [0285]
Cohort B (higher LD chemotherapy dose): LD chemotherapy
(fludarabine 30 mg/m.sup.2 and cyclophosphamide 750 mg/m.sup.2 IV
daily for 3 days) completed at least 48 hours (but no more than 7
days) prior to CTX110 infusion (dose escalation from Dose Level
[DL] 2).
[0286] Stage 3--Follow up (5 years after the last CTX110
infusion).
[0287] For both dose escalation and cohort expansion, subjects must
remain within proximity of the investigative site (i.e., 1-hour
transit time) for 28 days after CTX110 infusion. During this acute
toxicity monitoring period, subjects will be routinely assessed for
adverse events (AEs), including cytokine release syndrome (CRS),
neurotoxicity, and GvHD. Toxicity management guidelines are
provided in the study protocol. During dose escalation, all
subjects will be hospitalized for the first 7 days following CTX110
infusion, or longer if required by local regulation or site
practice.
[0288] After the acute toxicity monitoring period, subjects will be
subsequently followed for up to 5 years after CTX110 infusion with
physical exams, regular laboratory and imaging assessments, and AE
evaluations. After completion of this study, subjects will be
required to participate in a separate long-term follow-up study for
an additional 10 years to assess long-term safety and survival.
[0289] LD chemotherapy it to be delayed if any of the following
signs or symptoms are present: [0290] Significant worsening of
clinical status that, according to the investigator, increases the
potential risk of AEs associated with LD chemotherapy. [0291]
Requirement for supplemental oxygen to maintain a saturation level
of >91%. [0292] New uncontrolled cardiac arrhythmia. [0293]
Hypotension requiring vasopressor support. [0294] Active infection:
Positive blood cultures for bacteria, fungus, or virus not
responding to treatment. [0295] Grade .gtoreq.2 acute neurological
toxicity.
TABLE-US-00016 [0295] TABLE 16 Schedule of Assessments (Screening
to Month 24). Treat- ment Screen- (Stage 2) Study ing .sup.1 D-5
Follow-up (Stage 3) Stage (Stage to D2 .+-. D3 .+-. D5 .+-. D8 .+-.
D10 .+-. D14 .+-. D21 .+-. Day 1) D-3 D1.sup.2 2 d 2 d 2 d 2 d 2 d
2 d 2 d Informed X consent Medical X history.sup.3 Physical X X X X
X X X X X X exam Vital X X X X X X X X X X signs .sup.4 Height, X X
X X X weight .sup.5 Preg- X X nancy test .sup.6 ECOG X X status
Echo- X cardio- gram 12-lead X X X ECG .sup.7 Brain X MRI Lumbar X
punc- ture .sup.8 ICE X X X X X X assess- ment .sup.9 Patient- X
reported outcome Con- Continuous comitant meds .sup.10 Adverse
Continuous events .sup.11 Hospital Continuous util- ization Treat-
ment LD X chemo- ther- apy .sup.12 CTX110 X infu- sion .sup.13 NHL
Disease Re- sponse/ Assess- ment (Central and Local) PET/CT X scan
.sup.14 BM X biopsy .sup.15 Tumor biopsy .sup.16 Tumor X path-
ology.sup.17 Adult B Cell ALL Disease Re- sponse/ Assess- ment BM X
biopsy and aspirate (central and lo- cal) .sup.14, 15 Peri- X
pheral blood chim- erism (local) .sup.19 Lab - oratory Assess-
ments (Local) CBC w/ X X X X X X X X X X differ- ential Serum X X X
X X X X X X X chemistry Coagu- X X X X X X X X X lation para-
meters Viral X serol- ogy .sup.20 Immuno- X X globulins Ferritin, X
X X X X X X X X CRP Lympho- X X X X X X X X cyte subsets .sup.21 B
cells X X X (CD19, CD20) Blood type, Ab screen .sup.22 Bio- markers
(Blood, Central) CTX110 X X25 X X X X X X X PK .sup.23, 24 pre/
post Cyto- X X X X X X X X X kines .sup.26 Anti- X Cas9 Ab .sup.24
Anti- X CTX110 Ab .sup.24 Immuno- X X25 X X X X X pheno- pre/ type
post DNA X Cell-free X DNA PBMCs X Explor- X X.sup.28 X X X X X X X
X atory bio- mar- kers .sup.27 Study Follow-up (Stage 3) Stage D28
.+-. M2 .+-. M3 .+-. M6 .+-. M9 .+-. M12 .+-. M15 .+-. M18 .+-. M24
.+-. Day 4 d 7 d 7 d 14 d 14 d 14 d 14 d 14 d 21 d Informed consent
Medical history.sup.3 Physical X X X X X X X X X exam Vital X X X X
X X X X X signs .sup.4 Height, X X X X X X X X X weight .sup.5
Preg- nancy test .sup.6 ECOG X X status Echo- cardio- gram 12-lead
X ECG .sup.7 Brain MRI Lumbar punc- ture .sup.8 ICE X assess- ment
.sup.9 Patient- X X X X reported outcome Con- Continuous comitant
meds .sup.10 Adverse Continuous events .sup.11 Hospital Continuous
util- ization Treat- ment LD chemo- ther- apy .sup.12 CTX110 infu-
sion .sup.13 NHL Disease Re- sponse/ Assess- ment (Central and
Local) PET/CT X X X X X X X scan .sup.14 BM X biopsy .sup.15 Tumor
X biopsy .sup.16 Tumor path- ology.sup.17 Adult B Cell ALL Disease
Re- sponse/ Assess- ment BM X X.sup.18 X.sup.18 biopsy and aspirate
(central and lo- cal) .sup.14, 15 Peri- pheral blood
chim- erism (local) .sup.19 Lab - oratory Assess- ments (Local) CBC
w/ X X X X X X X X X differ- ential Serum X X X X X X X X X
chemistry Coagu- X lation para- meters Viral serol- ogy .sup.20
Immuno- X X X X X X X X X globulins Ferritin, X CRP Lympho- X X X X
X X cyte subsets .sup.21 B cells X X X X X X X X X (CD19, CD20)
Blood type, Ab screen .sup.22 Bio- markers (Blood, Central) CTX110
X X X X X X X X X PK .sup.23, 24 Cyto- X X kines .sup.26 Anti- X X
X X Cas9 Ab .sup.24 Anti- X X X X CTX110 Ab .sup.24 Immuno- X X X X
X X X X X pheno- type DNA Cell-free X X X X X X X DNA PBMCs X X X X
X X X Explor- X X X X X X X X X atory bio- mar- kers .sup.27 Ab:
antibody; AE: adverse event; BM: bone marrow; Cas9:
CRISPR-associated protein 9; CBC: complete blood count; CNS:
central nervous system; CRISPR: clustered regularly interspaced
short palindromic repeats; CRP: C-reactive protein; CT: computed
tomography; D or d: day; EC.sub.90: 90% effectiveconcentration;
ECG: electrocardiogram; ECOG: Eastern Cooperative Oncology Group;
HBV: hepatitis B virus; HCV: hepatitis C virus; HIV-1/-2: human
immunodeficiency virus type 1 or 2; HSCT: hematopoietic stem cell
transplant; ICE: immune effector cell-associated encephalopathy;
ICF: informed consent form; IPI: International Prognostic Index;
LD: lymphodepleting; LP: lumbar puncture; M: month; MRI: magnetic
resonance imaging; PBMC: peripheral blood mononuclear cell; PCR:
polymerase chain reaction; PET: positron emission tomography; PK:
pharmacokinetic(s); Q: every; TBNK: T-, B-, natural killer (cells).
.sup.1 Screening assessments completed within 14 days of informed
consent. Subjects allowed 1-time rescreening within 3 months of
initial consent. .sup.2 All baseline assessments on Day 1 are to be
performed prior to CTX110 infusion unless otherwise specified.
.sup.3 Includes complete surgical and cardiac history. .sup.4
Includes sitting blood pressure, heart rate, respiratory rate,
pulse oximetry, and temperature. .sup.5 Height at screening only.
.sup.6 For female subjects of childbearing potential. Serum
pregnancy test at screening. Serum or urine pregnancy test within
72 hours before start of LD chemotherapy. .sup.7 Prior to LD
chemotherapy, and prior to CTX110 infusion. .sup.8 LP at screening
on subjects with high risk for CNS involvement (e.g., high-grade B
cell lymphoma with MYC and BCL2 and/or BCL6 rearrangements,
subjects with testicular involvement of lymphoma, or subjects with
high-risk CNS IPI score). For LPs performed during neurotoxicity,
samples should be sent to central laboratory for CTX110 PK and
exploratory biomarkers whenever possible. .sup.9 On Day 1 prior to
CTX110 administration. If CNS symptoms persist after Day 28, ICE
assessment should continue to be performed approximately every 2
days until symptom resolution to grade 1 or baseline. .sup.10 All
concomitant medications will be collected .ltoreq. 3 months
post-CTX110, after which only select concomitant medications will
be collected. 11 Collect all AEs from informed consent to Month 3
visit, collect all SAEs and AESIs after Month 3 visit to Month 60
visit. Only SAEs and AESIs should be reported for .ltoreq. 3 months
post-CTX110 if subject begins new anticancer therapy before Month 3
visit. Only AESIs will be reported if subject begins new anticancer
therapy after Month 3 visit. .sup.12 Start LD chemotherapy within 7
days of study enrollment. After completion of LD chemotherapy,
ensure washout period of .gtoreq. 48 hours (but .ltoreq. 7 days)
before CTX110 infusion. Physical exam, weight, and coagulation
laboratories performed prior to first dose of LD chemotherapy.
Vital signs, CBC, clinical chemistry, and AEs/concomitant
medications assessed and recorded daily (i.e., 3 times) during LD
chemotherapy. .sup.13 CTX110 administered 48 hours to 7 days after
completion of LD chemotherapy. .sup.14 Baseline disease assessment
(PET/CT for subjects with NHL) to be performed within 28 days prior
to CTX110 infusion. MRI with contrast allowed if CT clinically
contraindicated, or as required by local regulation. .sup.15 BM
biopsy to confirm complete response as part of disease evaluation.
BM biopsy may also be performed at time of disease relapse. Samples
from BM aspirate after CTX110 infusion should be sent for CTX110 PK
and exploratory biomarkers. To be performed .+-. 5 days of visit
date. .sup.16 Optional: For subjects who have disease amenable to
biopsy and who provide separate consent. To be performed .+-. 5
days of visit date. .sup.17It is preferred that subjects undergo
tumor biopsy during screening. However, if a biopsy of
relapsed/refractory disease was performed within 3 months prior to
enrollment and after the most recent line of therapy, archival
tissue may be used. If relapse occurs on study, every attempt
should be made to obtain biopsy of relapsed tumor and send to
central pathology. Tumor biopsy refers to tissue other than bone
marrow. .sup.18 Assessments at Months 2 and 3 to confirm CR if not
achieved at Month 1. .sup.19 To be performed only in subjects who
have received prior allogeneic HSCT. .sup.20 Infectious disease
testing (HIV-1, HIV-2, HCV antibody/PCR, HBV surface antigen, HBV
surface antibody, HBV core antibody) .ltoreq. 30 days of signing
ICF may be considered for subject eligibility. .sup.21 Lymphocyte
subset assessment at screening, before start of first day of LD
chemotherapy, before CTX110 infusion, then all listed time points.
To include 6-color TBNK panel, or equivalent for T, B, and natural
killer cells. .sup.22 Blood type and antibody screen. .sup.23
Samples for CTX110 PK should be sent from any LP, BM biopsy, or
tissue biopsy performed following CTX110 infusion. If CRS occurs,
samples for assessment of CTX110 levels will be collected every 48
hours between scheduled visits until CRS resolves. .sup.24 Sponsor
may request discontinuation of sample collection if consecutive
tests are negative. Continue sample collection for all listed time
points until otherwise instructed by sponsor. .sup.25 Two samples
collected on Day 1: One pre-CTX110 infusion and one 20 (.+-. 5)
minutes after the end of CTX110 infusion. .sup.26 Additional
cytokine samples should be collected daily for the duration of CRS.
Day 1 samples to be collected prior to CTX110 infusion. .sup.27
Samples for exploratory biomarkers should be sent from any LP or BM
biopsy performed following CTX110 infusion. If CRS occurs, samples
for assessment of exploratory biomarkers will be collected every 48
hours between scheduled visits until CRS resolves. .sup.28 Prior to
first day of LD chemotherapy only.
TABLE-US-00017 TABLE 17 Schedule of Assessments (Months 30-60). M30
(.+-. M36 (.+-. M42 (.+-. M48(.+-. M54(.+-. M60 (.+-. Progressive
Secondary Assessments 21 days) 21 days) 21 days) 21 days) 21 days)
21 days) Disease Follow-Up .sup.1 Vital signs .sup.2 X X X X X X X
X Physical exam X X X X X X X X Concomitant medications .sup.3 X X
X X X X X X Disease assessment .sup.4 X X X X X X X CBC with
differential .sup.5 X X X X X X X X Serum chemistry .sup.5 X X X X
X X X X Immunoglobulins .sup.5, 6 X X X X X X X Lymphocyte subsets
.sup.5, 6 X X X X X X X CTX110 persistence X X X X X X X X (blood,
central) .sup.6, 7 Exploratory biomarkers X X X X X X X X (blood,
central) Anti-Cas9 Ab X X X X (blood, central) .sup.6 Anti-CTX110 ,
X X X X anti-daratumumab Ab (blood, central) .sup.6
Patient-reported outcome X X X X Adverse events .sup.8 X X X X X X
X X Ab: antibody; AESI: adverse event of special interest; BM: bone
marrow; Cas9: CRISPR-associated protein 9; CBC: complete blood
count; CRISPR: clustered regularly interspaced short palindromic
repeats; CT: computed tomography; NHL: non-Hodgkin lymphoma; PET:
positron emission tomography; PK: pharmacokinetic; SAE: serious
adverse event; TBNK: T-, B-, natural killer (cells). .sup.1
Subjects with progressive disease or who undergo stem cell
transplant will discontinue the normal schedule of assessments and
attend annual study visits. Visits will occur at 12-month
intervals. Subjects who partially withdraw consent will undergo
these procedures at minimum. .sup.2 Includes temperature, blood
pressure, pulse rate, and respiratory rate. .sup.3 Only select
concomitant medications will be collected. .sup.4 Disease
assessment will consist of investigator review of physical exam,
CBC, clinical chemistry, and lactate dehydrogenase for NHL
subjects, and of physical exam, CBC with differential, and clinical
chemistry for B cell ALL. NHL subjects with suspected malignancy
will undergo PET/CT imaging and/or a BM biopsy to confirm relapse.
Every attempt should be made to obtain a biopsy of the relapsed
tumor in subjects who progress. Assessed at local laboratory. To
include 6-color TBNK panel, or equivalent for T, B, and natural
killer cells. .sup.6 Sponsor may request discontinuation of sample
collection. Continue sample collection for all listed time points
until otherwise instructed by sponsor. .sup.7 Samples for CTX110 PK
analysis should be sent to the central laboratory from any lumbar
puncture, BM biopsy, or tissue biopsy performed following CTX110
infusion. .sup.8 SAEs and AESIs should be reported for up to 3
months after CTX110 infusion if a subject begins new anticancer
therapy before Month 3 study visit. Only AESIs will be reported if
a subject begins new anticancer therapy after Month 3 study
visit.
[0296] The goal of lymphodepletion is to allow for significant CAR
T cell expansion following infusion. LD chemotherapy consisting of
fludarabine and cyclophosphamide across different doses has been
successfully utilized in several autologous CAR T cell trials. The
rationale for the use of LD chemotherapy is to eliminate regulatory
T cells and other competing elements of the immune system that act
as `cytokine sinks,` enhancing the availability of cytokines such
as interleukin 7 (IL-7) and interleukin 15 (IL-15) (Dummer et al.,
(2002) J Clin Invest, 110, 185-192; Gattinoni et al., (2005) J Exp
Med, 202, 907-912). Additionally, it is postulated that naive T
cells begin to proliferate and differentiate into memory-like T
cells when total numbers of naive T cells are reduced below a
certain threshold (Dummer et al., (2002) J Clin Invest, 110,
185-192). Cohort A will use cyclophosphamide (500 mg/m.sup.2) and
fludarabine (30 mg/m.sup.2) at doses that are consistent with doses
used in registrational clinical trials of axicabtagene ciloleucel.
Cohort B will use a higher dose of cyclophosphamide (750
mg/m.sup.2) to evaluate whether increased intensity of
lymphodepletion may facilitate expansion of an allogeneic CAR T
cell product. Doses of cyclophosphamide within this range (total of
>120 mg/kg or 3 g/m.sup.2) have been used in prior CAR T cell
therapy studies in hematological malignancies (Brentjens et al.,
(2011) Blood, 118, 4817-4828; Kochenderfer et al., (2015) J Clin
Oncol, 33, 540-549; Turtle et al., (2016) Sci Transl Med, 8,
355ra116). When used as a part of higher intensity LD chemotherapy,
increased doses of cyclophosphamide are associated with improved
efficacy (Hirayama et al., (2019) Blood, 133, 1876-1887).
[0297] CTX110 infusion is to be delayed if any of the following
signs or symptoms are present: [0298] New active uncontrolled
infection. [0299] Worsening of clinical status compared to prior to
start of LD chemotherapy that, in the opinion of the investigator,
places the subject at increased risk of toxicity. [0300] Grade
.gtoreq.2 acute neurological toxicity.
CTX110 Dose
[0301] CTX110 cells are administered IV using a flat dosing schema
based on the number of CAR+ T cells. The starting dose is
3.times.10.sup.7 CAR+ T cells, which is approximately 1 log lower
than the doses of autologous CAR T cells currently approved for NHL
including KYMRIAH.RTM. (5.times.10.sup.8 total CAR T cells) and
YESCARTA.RTM. (2.times.10.sup.6 kg, maximum 2.times.10.sup.8 CAR T
cells).
Dose Escalation
[0302] Dose escalation will be performed using a standard 3+3
design. The following doses of CTX110, based on CAR.sup.+ T cells,
may be evaluated in this study beginning with DL1 for Cohort A.
Only after assessment and confirmation of safety of DL2 in Cohort A
by the Safety Review Committee (SRC) may subsequent Cohort B be
opened/enrolled and begin dose escalation from DL2. Due to the
study's dose limit of 7.times.10.sup.4 TCR+ cells/kg, the study may
proceed with DL4 in Cohort A and/or Cohort B if a subject weighs
.gtoreq.60 kg (see Table 18).
TABLE-US-00018 TABLE 18 Dose Levels. Dose Level Total CAR+ T Cell
Dose -1 1 .times. 10.sup.7 1 3 .times. 10.sup.7 2 1 .times.
10.sup.8 3 3 .times. 10.sup.8 4 1 .times. 10.sup.9 CAR: chimeric
antigen receptor.
[0303] The DLT evaluation period begins with CTX110 infusion and
last for 28 days. The first 3 subjects in each cohort will be
treated in a staggered manner, such that the 2.sup.nd and 3.sup.rd
subjects will only receive CTX110 after the previous subject has
completed the DLT evaluation period. In subsequent dose levels or
expansion of the same dose level, cohorts of up to 3 subjects may
be enrolled and dosed concurrently.
[0304] Subjects must receive CTX110 to be evaluated for DLT. If a
subject discontinues the study any time prior to CTX110 infusion,
the subject will not be evaluated for DLT and a replacement subject
will be enrolled at the same dose level as the discontinued
subject. If a DLT-evaluable subject has signs or symptoms of a
potential DLT, the DLT evaluation period will be extended according
to the protocol-defined window to allow for improvement or
resolution before a DLT is declared.
[0305] Toxicities are graded and documented according to National
Cancer Institute Common Terminology Criteria for Adverse Events
(CTCAE) version 5, except for CRS (Lee criteria), neurotoxicity
(ICANS, immune effector cell-associated neurotoxicity syndrome
criteria and CTCAE v5.0), and GvHD (Mount Sinai Acute GVHD
International Consortium [MAGIC] criteria).
[0306] A DLT will be defined as any of the following events
occurring during the DLT evaluation period that persists beyond the
specified duration (relative to the time of onset): [0307] Grade
.gtoreq.2 GvHD that is steroid-refractory (e.g., progressive
disease after 3 days of steroid treatment [e.g., 1 mg/kg/day],
stable disease after 7 days, or partial response after 14 days of
treatment). [0308] Death during the DLT period (except due to
disease progression). [0309] Any grade 3 or 4 toxicity that is
clinically significant according to the investigator's judgement
and does not improve within 72 hours. [0310] The following will NOT
be considered as DLTs: [0311] Grade 3 or 4 CRS that improves to
grade .ltoreq.2 within 72 hours. [0312] Grade 3 or 4 neurotoxicity
(e.g., encephalopathy, confusion) that improves to grade .ltoreq.2
within 14 days. [0313] Grade 3 or 4 fever. [0314] Bleeding in the
setting of thrombocytopenia (platelet count
<50.times.10.sup.9/L); documented bacterial infections or fever
in the setting of neutropenia (absolute neutrophil count
<1000/mm.sup.3). [0315] Grade 3 or 4 hypogammaglobulinemia.
[0316] Grade 3 or 4 pulmonary toxicity that resolves to grade
.ltoreq.2 within 7 days. For subjects intubated due to fluid
overload from supportive care, this may be extended to 14 days.
[0317] Grade 3 or 4 liver function studies that improve to grade
.ltoreq.2 within 14 days. [0318] Grade 3 or 4 renal insufficiency
that improves to grade .ltoreq.2 within 21 days. [0319] Grade 3 or
4 thrombocytopenia or neutropenia will be assessed retrospectively.
After at least 6 subjects are infused, if .gtoreq.50% of subjects
have prolonged cytopenias (i.e., lasting more than 28 days
post-infusion), dose escalation will be suspended pending SRC
assessment.
[0320] AEs that have no plausible causal relationship with CTX110
will not be considered DLTs.
Toxicity Management
[0321] Subjects must be closely monitored for at least 28 days
after CTX110 infusion. Significant toxicities have been reported
with autologous CAR T cell therapies and investigators are required
to proactively monitor and treat all adverse events in accordance
with protocol guidance.
[0322] The following general recommendations are provided based on
prior experience with CD19-directed autologous CAR T cell
therapies: [0323] Fever is the most common early manifestation of
cytokine release syndrome (CRS); however, subjects may also
experience weakness, hypotension, or confusion as first
presentation. [0324] Diagnosis of CRS should be based on clinical
symptoms and NOT laboratory values. [0325] In subjects who do not
respond to CRS-specific management, always consider sepsis and
resistant infections. Subjects should be continually evaluated for
resistant or emergent bacterial infections, as well as fungal or
viral infections. [0326] CRS, hemophagocytic lymphohistiocytosis
(HLH), and tumor lysis syndrome (TLS) may occur at the same time
following CAR T cell infusion. Subjects should be consistently
monitored for signs and symptoms of all the conditions and managed
appropriately. [0327] Neurotoxicity may occur at the time of CRS,
during CRS resolution, or following resolution of CRS. Grading and
management of neurotoxicity will be performed separately from CRS.
[0328] Tocilizumab must be administered within 2 hours from the
time of order.
[0329] The safety profile of CTX110 will be continually assessed
throughout the study, and investigators will be updated on a
regular basis with new information regarding the identification and
management of potential CTX110-related toxicity.
Infusion Reactions
[0330] Infusion reactions have been reported in autologous
CD19-directed CAR T cell trials, including transient fever, chills,
and/or nausea. Acetaminophen (paracetamol) and diphenhydramine
hydrochloride (or another H1-antihistamine) may be repeated every 6
hours after CTX110 infusion, as needed, if an infusion reaction
occurs. Nonsteroidal anti-inflammatory medications may be
prescribed, as needed, if the subject continues to have fever not
relieved by acetaminophen. Systemic steroids should not be
administered except in cases of life-threatening emergency, as this
intervention may have a deleterious effect on CAR T cells.
Febrile Reaction and Infection Prophylaxis
[0331] Infection prophylaxis should occur according to the
institutional standard of care for patients with B cell
malignancies in an immunocompromised setting. In the event of
febrile reaction, an evaluation for infection should be initiated
and the subject managed appropriately with antibiotics, fluids, and
other supportive care as medically indicated and determined by the
treating physician. Viral and fungal infections should be
considered throughout a subject's medical management if fever
persists. If a subject develops sepsis or systemic bacteremia
following CTX110 infusion, appropriate cultures and medical
management should be initiated. Additionally, consideration of CRS
should be given in any instances of fever following CTX110 infusion
within 30 days post-infusion.
Tumor Lysis Syndrome (TLS)
[0332] Subjects receiving CAR T cell therapy are at increased risk
of TLS. Subjects should be closely monitored for TLS via laboratory
assessments and symptoms from the start of LD chemotherapy until 28
days following CTX110 infusion. All subjects should receive
prophylactic allopurinol (or a non-allopurinol alternative, such as
febuxostat) and increased oral/IV hydration during screening and
before initiation of LD chemotherapy. Prophylaxis can be stopped
after 28 days following CTX110 infusion or once the risk of TLS
passes.
[0333] Sites should monitor and treat TLS as per their
institutional standard of care, or according to published
guidelines (Cairo and Bishop, (2004) Br J Haematol, 127, 3-11). TLS
management, including administration of rasburicase, should be
instituted promptly when clinically indicated.
Cytokine Release Syndrome (CRS)
[0334] CRS is a major toxicity reported with autologous
CD19-directed CAR T cell therapy. CRS is due to hyperactivation of
the immune system in response to CAR engagement of the target
antigen, resulting in multi-cytokine elevation from rapid T cell
stimulation and proliferation (Frey et al., (2014) Blood, 124,
2296; Maude et al., (2014) Cancer J, 20, 119-122). When cytokines
are released, a variety of clinical signs and symptoms associated
with CRS may occur, including cardiac, gastrointestinal (GI),
neurological, respiratory (dyspnea, hypoxia), skin, cardiovascular
(hypotension, tachycardia), and constitutional (fever, rigors,
sweating, anorexia, headaches, malaise, fatigue, arthralgia,
nausea, and vomiting) symptoms, and laboratory (coagulation, renal,
and hepatic) abnormalities.
[0335] The goal of CRS management is to prevent life-threatening
sequelae while preserving the potential for the antitumor effects
of CTX110. Symptoms usually occur 1 to 14 days after autologous CAR
T cell therapy, but the timing of symptom onset has not been fully
defined for allogeneic CAR T cells.
[0336] CRS should be identified and treated based on clinical
presentation and not laboratory cytokine measurements. If CRS is
suspected, grading and management should be performed according to
the recommendations in Table 19, which are adapted from published
guidelines (Lee et al., (2014) Blood, 124, 188-195). Since the
development of the original Lee CRS grading criteria, physicians
using CAR T cell therapies have gained further understanding of the
presentation and time course of CRS. The recent American Society
for Blood and Marrow Transplantation (ASBMT) consensus criteria
(Lee et al., (2018) Biol Blood Marrow Transplant) recommend that
grading should be based on the presence of fever with hypotension
and/or hypoxia, and that other end organ toxicities should be
managed separately with supportive care. Accordingly, in this
protocol neurotoxicity will be graded and managed using a different
scale (see section entitled "Immune Effector Cell-Associated
Neurotoxicity Syndrome (ICANS)"), and end organ toxicity in the
context of CRS management refers only to hepatic and renal systems
(as in the Penn Grading criteria; (Porter et al., (2018) J Hematol
Oncol, 11, 35). The sponsor may elect to revise the CRS grading
criteria and toxicity management algorithms to reflect the ASBMT
consensus proposal based on clinical experience with CTX110 and
other CAR T cell therapies.
TABLE-US-00019 TABLE 19 Cytokine Release Syndrome Grading and
Management Guidance. CRS Severity .sup.1 Tocilizumab
Corticosteroids Grade 1 N/A N/A Symptoms require symptomatic
treatment only (e.g., fever, fatigue, headache, myalgia, malaise).
Grade 2 Administer tocilizumab.sup.3 8 mg/kg Manage per grade 3 if
no Symptoms require and respond to IV over 1 hour (not to exceed
improvement within 24 hours moderate intervention. Oxygen 800 mg).
after starting tocilizumab. requirement < 40% FiO.sub.2 or
Repeat tocilizumab every 8 hypotension responsive to fluids hours
as needed if not responsive or low dose of 1 vasopressor or to IV
fluids or increasing grade 2 organ toxicity..sup.2 supplemental
oxygen. Limit to .ltoreq.3 doses in a 24-hour period; maximum total
of 4 doses. Grade 3 Per grade 2. If no improvement within 24
Symptoms require and respond to hours after starting tocilizumab,
aggressive intervention. Oxygen administer methylprednisolone
requirement .gtoreq.40% FiO.sub.2 or 1 mg/kg IV twice daily.
hypotension requiring high-dose Continue corticosteroid use until
or multiple vasopressors.sup.4 or grade the event is grade
.ltoreq.1, then taper 3 organ toxicity or grade 4 over 3 days.
transaminitis Grade 4 Per grade 2. Per grade 3. Life-threatening
symptoms. If no response to multiple doses Requirements for
ventilator of tocilizumab and steroids, support, continuous
veno-venous consider using other anti- hemodialysis or grade 4
organ cytokine therapies (e.g., toxicity (excluding transaminitis)
siltuximab). CRS: cytokine release syndrome; FiO.sub.2: fraction of
inspired oxygen; IV: intravenously; N/A: not applicable. .sup.1 See
(Lee et al., (2014) Blood, 124, 188-195). .sup.2Refer to entitled
"Immune Effector Cell-Associated Neurotoxicity Syndrome (ICANS)"
for management of neurologic toxicity. Organ toxicity refers to
hepatic and renal systems only. .sup.3Refer to tocilizumab
prescribing information. .sup.4 See Table 20 for information on
high-dose vasopressors.
TABLE-US-00020 TABLE 20 High-dose Vasopressors. Pressor Dose*
Norepinephrine monotherapy .gtoreq.20 .mu.g/min Dopamine
monotherapy .gtoreq.10 .mu.g/kg/min Phenylephrine monotherapy
.gtoreq.200 .mu.g/min Epinephrine monotherapy .gtoreq.10 .mu.g/min
If on vasopressin Vasopressin + norepinephrine equivalent of
.gtoreq.10 .mu.g/min** If on combination vasopressors
Norepinephrine equivalent (not vasopressin) of .gtoreq.20
.mu.g/min** *All doses are required for .gtoreq.3 hours. **VASST
Trial vasopressor equivalent equation: norepinephrine equivalent
dose = [norepinephrine (.mu.g/min) + (.mu.g/min)/2] + [epinephrine
(.mu.g/min)] + [phenylephrine (.mu.g/min)/10]
[0337] Throughout the duration of CRS, subjects should be provided
with supportive care consisting of antipyretics, IV fluids, and
oxygen. Subjects who experience grade .gtoreq.2 CRS (e.g.,
hypotension, not responsive to fluids, or hypoxia requiring
supplemental oxygenation) should be monitored with continuous
cardiac telemetry and pulse oximetry. For subjects experiencing
grade 3 CRS, consider performing an echocardiogram to assess
cardiac function. For grade 3 or 4 CRS, consider intensive care
supportive therapy. Intubation for airway protection due to
neurotoxicity (e.g., seizure) and not due to hypoxia should not be
captured as grade 4 CRS. Similarly, prolonged intubation due to
neurotoxicity without other signs of CRS (e.g., hypoxia) is not
considered grade 4 CRS. Investigators should always consider the
potential of an underlying infection in cases of severe CRS, as the
presentation (fever, hypotension, hypoxia) is similar. Resolution
of CRS is defined as resolution of fever (temperature
.gtoreq.38.degree. C.), hypoxia, and hypotension (Lee et al.,
(2018) Biol Blood Marrow Transplant).
[0338] Immune Effector Cell-associated Neurotoxicity Syndrome
(ICANS) Neurotoxicity has been observed with autologous
CD19-directed CAR T cell therapies. It may occur at the time of
CRS, during the resolution of CRS, or following resolution of CRS,
and its pathophysiology is unclear. The recent ASBMT consensus
further defined neurotoxicity associated with CRS as immune
effector cell-associated neurotoxicity syndrome (ICANS), a disorder
characterized by a pathologic process involving the CNS following
any immune therapy that results in activation or engagement of
endogenous or infused T cells and/or other immune effector cells
(Lee et al., (2018) Biol Blood Marrow Transplant). Signs and
symptoms can be progressive and may include aphasia, altered level
of consciousness, impairment of cognitive skills, motor weakness,
seizures, and cerebral edema. ICANS grading was developed based on
CAR T cell-therapy-associated TOXicity (CARTOX) working group
criteria used previously in autologous CAR T cell trials (Neelapu
et al., (2018) N Engl J Med, 377, 2531-2544). ICANS incorporates
assessment of level of consciousness, presence/absence of seizures,
motor findings, presence/absence of cerebral edema, and overall
assessment of neurologic domains by using a modified assessment
tool called the ICE (immune effector cell-associated
encephalopathy) assessment tool (see Table 21).
[0339] Evaluation of any new onset neurotoxicity should include a
neurological examination (including ICE assessment tool, Table 22),
brain MRI, and examination of the CSF (via lumbar puncture) as
clinically indicated. If a brain MRI is not possible, all subjects
should receive a non-contrast CT to rule out intracerebral
hemorrhage. Electroencephalogram should also be considered as
clinically indicated. Endotracheal intubation may be needed for
airway protection in severe cases.
[0340] Non-sedating, anti-seizure prophylaxis (e.g., levetiracetam)
should be considered in all subjects for at least 21 days following
CTX110 infusion or upon resolution of neurological symptoms (unless
the investigator considers the antiseizure medication to be
contributing to the detrimental symptoms). Subjects who experience
ICANS grade .gtoreq.2 should be monitored with continuous cardiac
telemetry and pulse oximetry. For severe or life-threatening
neurologic toxicities, intensive care supportive therapy should be
provided. Neurology consultation should always be considered.
Monitor platelets and for signs of coagulopathy, and transfuse
blood products appropriately to diminish risk of intracerebral
hemorrhage. Table 21 provides neurotoxicity grading and Table 23
provides management guidance.
[0341] For subjects who receive active steroid management for more
than 3 days, antifungal and antiviral prophylaxis is recommended to
mitigate a risk of severe infection with prolonged steroid use.
Consideration for antimicrobial prophylaxis should also be
given.
TABLE-US-00021 TABLE 21 ICANS Grading. Neuro- toxicity Grade Grade
Grade Grade Domain 1 2 3 4 ICE 7-9 3-6 0-2 0 (subject is score
.sup.1 unarousable and unable to undergo ICE assessment) Depressed
Awakens Awakens Awakens only to Subject is level of spon- to voice
tactile stimulus unarousable or conscious- taneously requires
vigorous ness .sup.2 or repetitive tactile stimuli to arise; stupor
or coma Seizure N/A N/A Any clinical Life-threatening seizure,
focal or prolonged seizure generalized, that (>5 min) or
resolves rapidly, repetitive or nonconvulsive clinical or
electrical seizures on seizures without EEG that resolve return to
baseline with intervention in between Motor N/A N/A N/A Deep focal
motor findings .sup.3 weakness such as hemiparesis or paraparesis
Elevated N/A N/A Focal/local Diffuse cerebral ICP/ edema on edema
on cerebral neuroimaging .sup.4 neuroimaging, edema decerebrate or
decorticate posturing, cranial nerve VI palsy, papilladema, or
Cushing's triad CTCAE: Common Terminology Criteria for Adverse
Events; EEG: electroencephalogram; ICANS: immune effector
cell-associated neurotoxicity syndrome; ICE: immune effector
cell-associated encephalopathy (assessment tool); ICP: intracranial
pressure; N/A: not applicable. ICANS grade is determined by the
most severe event (ICE score, level of consciousness, seizure,
motor findings, raised ICP/cerebral edema) not attributable to any
other cause. .sup.1 A subject with an ICE score of 0 may be
classified as grade 3 ICANS if awake with global aphasia, but a
subject with an ICE score of 0 may be classified as grade 4 ICANS
if unarousable. .sup.2 Depressed level of consciousness should be
attributable to no other cause (e.g., sedating medication). .sup.3
Tremors and myoclonus associated with immune effector therapies
should be graded according to CTCAE v5.0 but do not influence ICANS
grading.
TABLE-US-00022 TABLE 22 ICE Assessment. Maximum Domain Assessment
Score Orientation Orientation to year, month, city, hospital 4
points Naming Name 3 objects (e.g., point to clock, pen, 3 points
button) Following Ability to follow commands (e.g., "Show 1 point
command me 2 fingers" or "Close your eyes and stick out your
tongue") Writing Ability to write a standard sentence 1 point
(includes a noun and verb) Attention Ability to count backward from
100 by 10 1 point ICE score will be reported as the total number of
points (0-10) across all assessments.
[0342] The ICE assessment will be performed at screening, before
administration of CTX110 on Day 1, and on Days 2, 3, 5, 8, and 28.
If a subject experiences CNS symptoms, the ICE assessment should
continue to be performed approximately every 2 days until
resolution of symptoms. To minimize variability, whenever possible
the assessment should be performed by the same research staff
member who is familiar with or trained in administration of the ICE
assessment.
TABLE-US-00023 TABLE 23 ICANS Management Guidance. Severity
Management Grade 2 Consider administering dexamethasone 10 mg IV
every 6 hours (or equivalent methylprednisolone) unless subject
already on equivalent dose of steroids for CRS. Continue
dexamethasone use until event is grade Grade 3 Administer
dexamethasone 10 mg IV every 6 hours, unless subject already on
equivalent dose of steroids for CRS. Continue dexamethasone use
until event is grade Grade 4 Administer methylprednisolone 1000 mg
IV per day for 3 days; if improves, manage as above. CRS: cytokine
release syndrome; ICANS: immune effector cell-associated
neurotoxicity syndrome; IV: intravenously.
[0343] Headache, which may occur in a setting of fever or after
chemotherapy, is a nonspecific symptom. Headache alone may not
necessarily be a manifestation of ICANS and further evaluation
should be performed. Weakness or balance problem resulting from
deconditioning and muscle loss are excluded from definition of
ICANS. Similarly, is intracranial hemorrhage with or without
associated edema may occur due to coagulopathies in these subjects
and are also excluded from definition of ICANS. These and other
neurotoxicities should be captured in accordance with CTCAE
v5.0.
B Cell Aplasia
[0344] B cell aplasia may occur and will be monitored by following
immunoglobulin G blood levels. IV gammaglobulin will be
administered for clinically significant hypogammaglobulinemia
(systemic infections) according to institutional standard of
care.
Hemophagocytic Lymphohistiocytosis (HLH)
[0345] HLH has been reported after treatment with autologous
CD19-directed CAR T cells (Barrett et al., (2014) Curr Opin
Pediatr, 26, 43-49; Maude et al., (2014) N Engl J Med, 371,
1507-1517; Maude et al., (2015) Blood, 125, 4017-4023; Porter et
al., (2015) Sci Transl Med, 7, 303ra139; Teachey et al., (2013)
Blood, 121, 5154-5157. HLH is a clinical syndrome that is a result
of an inflammatory response following infusion of CAR T cells in
which cytokine production from activated T cells leads to excessive
macrophage activation. Signs and symptoms of HLH may include
fevers, cytopenias, hepatosplenomegaly, hepatic dysfunction with
hyperbilirubinemia, coagulopathy with significantly decreased
fibrinogen, and marked elevations in ferritin and C-reactive
protein (CRP). Neurologic findings have also been observed (Jordan
et al., (2011) Blood, 118, 4041-4052; La Rosde, (2015) Hematology
Am Soc Hematol Educ Program, 190-196.
[0346] CRS and HLH may possess similar clinical syndromes with
overlapping clinical features and pathophysiology. HLH will likely
occur at the time of CRS or as CRS is resolving. HLH should be
considered if there are unexplained elevated liver function tests
or cytopenias with or without other evidence of CRS. Monitoring of
CRP and ferritin may assist with diagnosis and define the clinical
course.
[0347] If HLH is suspected: [0348] Frequently monitor coagulation
parameters, including fibrinogen. These tests may be done more
frequently than indicated in the schedule of assessments, and
frequency should be driven based on laboratory findings. [0349]
Fibrinogen should be maintained .gtoreq.100 mg/dL to decrease risk
of bleeding. [0350] Coagulopathy should be corrected with blood
products. [0351] Given the overlap with CRS, subjects should also
be managed per CRS treatment guidance in Table 19.
Cytopenias
[0352] Grade 3 neutropenia and thrombocytopenia, at times lasting
more than 28 days post-infusion, have been reported in subjects
treated with autologous CD19-directed CAR T cell products (Kymriah
USPI, 2017; Yescarta USPI, 2017). Therefore, subjects receiving
CTX110 should be monitored for such toxicities and appropriately
supported. Consideration should be given to antimicrobial and
antifungal prophylaxis for any subject with prolonged
neutropenia.
[0353] G-CSF may be considered in cases of grade 4 neutropenia 21
days post-CTX110 infusion, when the risk of CRS has passed.
Graft Versus Host Disease
[0354] GvHD is seen in the setting of allogeneic HSCT and is the
result of immunocompetent donor T cells (the graft) recognizing the
recipient (the host) as foreign. The subsequent immune response
activates donor T cells to attack the recipient to eliminate
foreign antigen-bearing cells. GvHD is divided into acute, chronic,
and overlap syndromes based on both the time from allogeneic HSCT
and clinical manifestations. Signs of acute GvHD may include a
maculopapular rash; hyperbilirubinemia with jaundice due to damage
to the small bile ducts, leading to cholestasis; nausea, vomiting,
and anorexia; and watery or bloody diarrhea and cramping abdominal
pain (Zeiser and Blazar, (2017) N Engl J Med, 377, 2167-2179.
[0355] To support the proposed clinical study, a nonclinical Good
Laboratory Practice (GLP)-compliant GvHD and tolerability study was
performed in immunocompromised mice at 2 doses that exceed all
proposed clinical dose levels by at least 10-fold. Further, due to
the specificity of CAR insertion at the TRAC locus, it is highly
unlikely for a T cell to be both CAR+ and TCR+. Remaining TCR+
cells are removed during the manufacturing process by
immunoaffinity chromatography on an anti-TCR antibody column to
achieve <0.5% TCR+ cells in the final product. A dose limit of
7.times.10.sup.4 TCR+ cells/kg will be imposed for all dose levels.
This limit is lower than the limit of 1.times.10.sup.5 TCR+
cells/kg based on published reports on the number of allogeneic
cells capable of causing severe GvHD during SCT with haploidentical
donors (Bertaina et al., (2014) Blood, 124, 822-826. Through this
specific editing, purification, and strict product release
criteria, the risk of GvHD following CTX110 should be low, although
the true incidence is unknown. Subjects should be monitored closely
for signs of acute GvHD following infusion of CTX110. The timing of
potential symptoms is unknown. However, given that CAR T cell
expansion is antigen-driven and will likely occur only in TCR-
cells, it is unlikely that the number of TCR+ cells will
appreciably increase above the number infused.
[0356] Diagnosis and grading of GvHD should be based on published
criteria (Harris et al., (2016) Biol Blood Marrow Transplant, 22,
4-10), as outlined in Table 24.
TABLE-US-00024 TABLE 24 Criteria for Grading Acute GvHD Skin Liver
Lower GI (active (bilirubin Upper (stool Stage erythema only)
mg/dL) GI output/day) 0 No active <2 No or <500 ml/day or
(erythematous) intermittent <3 episodes/day GvHD rash nausea,
vomiting, or anorexia 1 Maculopapular 2-3 Persistent 500-999 ml/day
or rash <25% nausea, 3-4 episodes/day BSA vomiting, or anorexia
2 Maculopapular 3.1-6 1000-1500 ml/day or rash 25-50% 5-7
episodes/day BSA 3 Maculopapular 6.1-15 >1500 ml/day or rash
>50% >7 episodes/day BSA 4 Generalized >15 Severe
abdominal erythroderma pain with or (>50% BSA) without ileus, or
plus bullous grossly bloody formation and stool (regardless
desquamation of stool >5% BSA volume) BSA: body surface area;
GI: gastrointestinal; GvHD: graft versus host disease.
[0357] Overall GvHD grade will be determined based on most severe
target organ involvement. [0358] Grade 0: No stage 1-4 of any
organ. [0359] Grade 1: Stage 1-2 skin without liver, upper GI, or
lower GI involvement. [0360] Grade 2: Stage 3 rash and/or stage 1
liver and/or stage 1 upper GI and/or stage 1 lower GI. [0361] Grade
3: Stage 2-3 liver and/or stage 2-3 lower GI, with stage 0-3 skin
and/or stage 0-1 upper GI. [0362] Grade 4: Stage 4 skin, liver, or
lower GI involvement, with stage 0-1 upper GI.
[0363] Potential confounding factors that may mimic GvHD such as
infections and reactions to medications should be ruled out. Skin
and/or GI biopsy should be obtained for confirmation before or soon
after treatment has been initiated. In instance of liver
involvement, liver biopsy should be attempted if clinically
feasible. Sample(s) of all biopsies will also be sent to a central
laboratory for pathology assessment. Details of sample preparation
and shipment are contained in the Laboratory Manual.
[0364] Recommendations for management of acute GvHD are outlined in
Table 25. To allow for intersubject comparability at the end of the
trial, investigators should follow these recommendations except in
specific clinical scenarios in which following them could put the
subject at risk.
TABLE-US-00025 TABLE 25 Acute GvHD Management Grade Management 1
Skin: Topical steroids or immunosuppressants; if stage 2:
prednisone 1 mg/kg (or equivalent dose). 2-4 Initiate prednisone 2
mg/kg daily (or equivalent dose). IV form of steroid such as
methylprednisolone should be considered if there are concerns with
malabsorption. Steroid taper may begin after improvement is seen
after .gtoreq.3 days of steroids. Taper should be 50% decrease of
total daily steroid dose every 5 days. GI: In addition to steroids,
start anti-diarrheal agents per standard practice. GI:
gastrointestinal; IV: intravenous.
[0365] Decisions to initiate second-line therapy should be made
sooner for subjects with more severe GvHD. For example, secondary
therapy may be indicated after 3 days with progressive
manifestations of GvHD, after 1 week with persistent grade 3 GvHD,
or after 2 weeks with persistent grade 2 GvHD. Second-line systemic
therapy may be indicated earlier in subjects who cannot tolerate
high-dose glucocorticoid treatment (Martin et al., (2012) Biol
Blood Marrow Transplant, 18, 1150-1163). Choice of secondary
therapy and when to initiate will be based on the treating
investigator's clinical judgement and local practice.
[0366] Management of refractory acute GvHD or chronic GvHD will be
per institutional guidelines. Anti-infective prophylaxis measures
should be instituted per local guidelines when treating subjects
with immunosuppressive agents (including steroids).
Hypotension and Renal Insufficiency
[0367] Hypotension and renal insufficiency have been reported with
CAR T cell therapy and should be treated with IV administration of
normal saline boluses according to institutional practice
guidelines. Dialysis should be considered when appropriate.
Study Eligibility
Inclusion Criteria
[0368] To be considered eligible to participate in this study, a
subject must meet the inclusion criteria listed below (unless
indicated as optional):
[0369] 1. .gtoreq.18 years of age and weight >50 kg
(optional).
[0370] 2. Able to understand and comply with protocol-required
study procedures and voluntarily sign a written informed consent
document.
[0371] 3. Diagnosed with 1 of the following B cell malignancies:
Histologically confirmed B cell NHLs: DLBCL NOS, high grade B cell
lymphoma with MYC and BCL2 and/or BCL6 rearrangements, transformed
FL, or grade 3b FL. [0372] Confirmation of tumor histology from
local pathology lab (archival tissue from last relapse/progression
[within 3 months of enrollment] or biopsy during screening). [0373]
At least 1 measurable lesion that is fluorodeoxyglucose positron
emission tomography (PET)-positive, as defined by Lugano criteria
(score of 4 or 5 on Lugano criteria 5-point scale). Previously
irradiated lesions will be considered measurable only if
progression is documented following completion of radiation
therapy.
[0374] 4. Refractory or relapsed disease, as evidenced by the
following cohort-specific criteria:
[0375] Two or more lines of prior therapy, including an anti-CD20
monoclonal antibody and an anthracycline-containing regimen, and
have failed prior autologous hematopoietic stem cell
transplantation (HSCT) or ineligible for or refused prior
autologous HSCT. Subjects who have received autologous HSCT must
have recovered from HSCT-related toxicities. [0376] For refractory
disease, subjects must have progressive disease on last therapy, or
have stable disease following at least 2 cycles of therapy with
duration of stable disease of up to 6 months. [0377] For subjects
with transformed FL, subjects must have received at least 1 line of
chemotherapy for disease after transformation to DLBCL.
[0378] 5. Eastern Cooperative Oncology Group (ECOG) performance
status 0 or 1.
[0379] 6. Meets criteria to undergo LD chemotherapy and CAR T cell
infusion.
[0380] 7. Adequate organ function: [0381] Renal: Estimated
glomerular filtration rate >50 mL/min/1.73 m.sup.2. [0382]
Liver: Aspartate transaminase or alanine transaminase <3.times.
upper limit of normal (ULN); total bilirubin <1.5.times.ULN (for
subjects with Gilbert's syndrome, total bilirubin <2 mg/dL).
[0383] Cardiac: Hemodynamically stable and left ventricle ejection
fraction .gtoreq.45% by echocardiogram. [0384] Pulmonary: Oxygen
saturation level on room air >91% per pulse oximetry.
[0385] 8. Female subjects of childbearing potential (postmenarcheal
with an intact uterus and at least 1 ovary, who are less than 1
year postmenopausal) must agree to use acceptable method(s) of
contraception from enrollment through at least 12 months after
CTX110 infusion.
[0386] 9. Male subjects must agree to use effective contraception
from enrollment through at least 12 months after CTX110
infusion.
[0387] 10. Agree to participate in an additional long-term
follow-up study after completion of this study.
Exclusion Criteria
[0388] To be eligible for entry into the study, the subject must
not meet any of the exclusion criteria listed below:
[0389] 1. Eligible for and agrees to autologous HSCT.
[0390] 2. Treatment with the following therapies as described
below: [0391] Prior treatment with any gene therapy or genetically
modified cell therapy, including CAR T cells. [0392] Prior
treatment with a CD19-directed antibody, bispecific T cell engager,
or antibody-drug conjugate, unless there is confirmed CD19
expression (by immunohistochemistry or flow cytometry) after
progression or relapse following most recent CD19-directed
treatment.
[0393] 3. Prior allogeneic HSCT.
[0394] 4. Known contraindication to cyclophosphamide, fludarabine,
or any of the excipients of CTX110 product.
[0395] 5. Detectable malignant cells from cerebrospinal fluid (CSF)
or magnetic resonance imaging (MRI) indicating brain metastases
during screening, or a history of central nervous system (CNS)
involvement by malignancy (CSF or imaging).
[0396] 6. History of a seizure disorder, cerebrovascular
ischemia/hemorrhage, dementia, cerebellar disease, or any
autoimmune disease with CNS involvement.
[0397] 7. Unstable angina, clinically significant arrhythmia, or
myocardial infarction within 6 months prior to screening.
[0398] 8. Uncontrolled, acute life-threatening bacterial, viral, or
fungal infection.
[0399] 9. Positive for presence of human immunodeficiency virus
(HIV) type 1 or 2, or active hepatitis B virus (HBV) or hepatitis C
virus (HCV) infection. Subjects with prior history of HBV or HBC
infection who have documented undetectable viral load (by
quantitative polymerase chain reaction [PCR] or nucleic acid
testing) are permitted. Infectious disease testing (HIV-1, HIV-2,
HCV antibody and PCR, HBV surface antigen, HBV surface antibody,
HBV core antibody) performed within 30 days of signing the informed
consent form may be considered for subject eligibility.
[0400] 10. Previous or concurrent malignancy, except basal cell or
squamous cell skin carcinoma, adequately resected and in situ
carcinoma of cervix, or a previous malignancy that was completely
resected and has been in remission for .gtoreq.5 years.
[0401] 11. Radiation therapy within 14 days of enrollment.
[0402] 12. Use of systemic antitumor therapy or investigational
agent within 14 days or 5 half-lives, whichever is longer, of
enrollment. Exceptions are made for 1) prior inhibitory/stimulatory
immune checkpoint molecule therapy, which is prohibited within 3
half-lives of enrollment, and 2) rituximab use within 30 days prior
to screening is prohibited.
[0403] 13. Primary immunodeficiency disorder or active autoimmune
disease requiring steroids and/or other immunosuppressive
therapy.
[0404] 14. Diagnosis of significant psychiatric disorder or other
medical condition that could impede the subject's ability to
participate in the study.
[0405] 15. Women who are pregnant or breastfeeding.
Statistical Methods
Sample Size
[0406] The sample size in the dose escalation part of the study
will be approximately 6 to 54 subjects, depending on the number of
dose levels and cohorts evaluated, and the occurrence of DLTs.
[0407] If the study proceeds to cohort expansion, an optimal Simon
2-stage design will be employed. The sample size for each cohort
will depend on the assumption of effect size for the specific
indication.
[0408] For expansion of Cohort A, in the first stage, up to 30
subjects will be enrolled. If 10 or more of the first 30 subjects
in the full analysis set achieve an objective response, the study
will expand enrollment to include an additional 47 subjects (77
total) in the second stage. A final sample size of 77 subjects will
have 90% power (.alpha.=0.05, 2-sided test) to test for a
difference between a ORR of 45% with CTX110 and an ORR of 26%, the
estimated ORR to standard salvage therapy in patients with
relapsed/refractory DLBCL.
[0409] As in Cohort A, upon completion of the dose escalation part
of the study, Cohort B may go on to cohort expansion after a
protocol amendment.
[0410] To date, all subjects that participated in this study have
completed Stage 1 (eligibility screening) within 14 days. One
subject completed Stage 1 within 2 days. A subject who met the
eligibility criteria started lymphodepleting therapy within 24
hours of completing Stage 1. All eligible subjects have completed
the screening period (stage 1) and received LD chemotherapy in less
than 15 days, with one patient completing screening and starting an
LD chemo dose within 72 hrs. Some of the eligible subjects have
DLBCL (e.g., NOS, high grade); others have transformed FL and
Richter's transformation.
[0411] All subjects receiving LD chemotherapy have progressed to
receiving the DL1 or DL2 dose of CTX110 within 2-7 days following
completion of the LD chemotherapy. Results obtained from these
patients to date are summarized below.
[0412] Subjects in both DL1 and DL2 doses experienced decreased
tumor metabolic activity (FDG uptake on PET scan) and/or decrease
in tumor size. A dose dependent response has been observed,
including a complete and durable response for >60 days at DL2.
None of the treated patients exhibited any DLTs so far. Further,
the allogeneic CAR-T cell therapy exhibited desired pharmacokinetic
features in the treated human subjects, including CAR-T cell
expansion and persistence after infusion. A dose dependent effect
has also been observed in both CTX110 expansion and persistence.
All subjects in DL2 have exhibited CTX110 expansion and persistence
Up to 90-fold expansion of CTX110 in peripheral blood has been
observed in one subject. Further, persistence of CTX110 cells can
be detected in DL2 subjects at least 8-10 days following treatment
and has been detected up to 28 days post-infusion.
TABLE-US-00026 SEQUENCE TABLE SEQ ID NO Description Sequence 1 TRAC
gene-edit AAGAGCAACAAATCTGACT 2 TRAC gene-edit
AAGAGCAACAGTGCTGTGCCTGGAGCAACAAATCTGACT AAGAGCAACAAATCTGACT 3 TRAC
gene-edit AAGAGCAACAGTGCTGGAGCAACAAATCTGACT AAGAGCAACAAATCTGACT 4
TRAC gene-edit AAGAGCAACAGTGCCTGGAGCAACAAATCTGACT
AAGAGCAACAAATCTGACT 5 TRAC gene-edit
AAGAGCAACAGTGCTGACTAAGAGCAACAAATCTGACT 6 TRAC gene-edit
AAGAGCAACAGTGCTGTGGGCCTGGAGCAACAAATCTGA CT AAGAGCAACAAATCTGACT 7
TRAC gene-edit AAGAGCAACAGTGCTGGCCTGGAGCAACAAATCTGACT
AAGAGCAACAAATCTGACT 8 TRAC gene-edit
AAGAGCAACAGTGCTGTGTGCCTGGAGCAACAAATCTGA CT AAGAGCAACAAATCTGACT 9
B2M gene-edit CGTGGCCTTAGCTGTGCTCGCGCTACTCTCTCTTTCTGCCT
GGAGGCTATCCAGCGTGAGTCTCTCCTACCCTCCCGCT 10 B2M gene-edit
CGTGGCCTTAGCTGTGCTCGCGCTACTCTCTCTTTCGCCTG
GAGGCTATCCAGCGTGAGTCTCTCCTACCCTCCCGCT 11 B2M gene-edit
CGTGGCCTTAGCTGTGCTCGCGCTACTCTCTCTTTCTGGA
GGCTATCCAGCGTGAGTCTCTCCTACCCTCCCGCT 12 B2M gene-edit
CGTGGCCTTAGCTGTGCTCGCGCTACTCTCTCTTTCTGGAT
AGCCTGGAGGCTATCCAGCGTGAGTCTCTCCTACCCTCCC GCT 13 B2M gene-edit
CGTGGCCTTAGCTGTGCTCGCGCTATCCAGCGTGAGTCTC TCCTACCCTCCCGCT 14 B2M
gene-edit CGTGGCCTTAGCTGTGCTCGCGCTACTCTCTCTTTCTGTGG
CCTGGAGGCTATCCAGCGTGAGTCTCTCCTACCCTCCCGC T 15 sgRNA
nnnnnnnnnnnnnnnnnnnnguuuuagagcuagaaauagcaaguuaaaauaaggcu
aguccguuaucaacuugaaaaaguggcaccgagucggugcuuuu 16 sgRNA
nnnnnnnnnnnnnnnnnnnnguuuuagagcuagaaauagcaaguuaaaauaaggcu
aguccguuaucaacuugaaaaaguggcaccgagucggugc 17 sgRNA
n.sub.(17-30)guuuuagagcuagaaauagcaaguuaaaauaaggcuaguccguuauc
aacuugaaaaaguggcaccgagucggugcu.sub.(1-8) 18 TRAC sgRNA (TA-1)
AGAGCAACAGUGCUGUGGCCguuuuagagcuagaaauagcaaguuaa unmodified
aauaaggcuaguccguuaucaacuugaaaaaguggcaccgagucggugcUUUU 19 TRAC sgRNA
spacer AGAGCAACAGUGCUGUGGCC unmodified 20 B2M sgRNA
GCUACUCUCUCUUUCUGGCCguuuuagagcuagaaauagcaaguuaaa unmodified
auaaggcuaguccguuaucaacuugaaaaaguggcaccgagucggugcUUUU 21 B2M sgRNA
spacer GCUACUCUCUCUUUCUGGCC unmodified 22 TRAC sgRNA (TA-1)
A*G*A*GCAACAGUGCUGUGGCCguuuuagagcuagaaauagcaagu modified
uaaaauaaggcuaguccguuaucaacuugaaaaaguggcaccgagucggugcU*U* *:
2'-O-methyl U*U phosphorothioate residue 23 TRAC sgRNA spacer
A*G*A*GCAACAGUGCUGUGGCC modified *: 2'-O-methyl phosphorothioate
residue 24 B2M sgRNA
G*C*U*ACUCUCUCUUUCUGGCCguuuuagagcuagaaauagcaagu modified
uaaaauaaggcuaguccguuaucaacuugaaaaaguggcaccgagucggugcU*U* *:
2'-O-methyl U*U phosphorothioate residue 25 B2M sgRNA spacer
G*C*U*ACUCUCUCUUUCUGGCC modified *: 2'-O-methyl phosphorothioate
residue 26 TRAC target AGAGCAACAGTGCTGTGGCC sequence 27 B2M target
sequence GCTACTCTCTCTTTCTGGCC 28 TRAC target AGAGCAACAGTGCTGTGGCC
(TGG) sequence with (PAM) 29 B2M target sequence
GCTACTCTCTCTTTCTGGCC (TGG) with (PAM) 30 signal peptide
MLLLVTSLLLCELPHPAFLLIP 31 signal peptide MALPVTALLLPLALLLHAARP 32
CD8a transmembrane IYIWAPLAGTCGVLLLSLVITLY domain 33 4-1BB
nucleotide AAACGGGGCAGAAAGAAACTCCTGTATATATTCAAACAA sequence
CCATTTATGAGACCAGTACAAACTACTCAAGAGGAAGAT
GGCTGTAGCTGCCGATTTCCAGAAGAAGAAGAAGGAGGA TGTGAACTG 34 4-1BB amino
acid KRGRKKLLYIFKQPFMRPVQTTQEEDGCSCRFPEEEEGGCEL sequence 35 CD28
nucleotide TCAAAGCGGAGTAGGTTGTTGCATTCCGATTACATGAATA sequence
TGACTCCTCGCCGGCCTGGGCCGACAAGAAAACATTACC
AACCCTATGCCCCCCCACGAGACTTCGCTGCGTACAGGTC C 36 CD28 amino acid
SKRSRLLHSDYMNMTPRRPGPTRKHYQPYAPPRDFAAYRS sequence 37 CD3-zeta
nucleotide CGAGTGAAGTTTTCCCGAAGCGCAGACGCTCCGGCATAT sequence
CAGCAAGGACAGAATCAGCTGTATAACGAACTGAATTTG
GGACGCCGCGAGGAGTATGACGTGCTTGATAAACGCCGG
GGGAGAGACCCGGAAATGGGGGGTAAACCCCGAAGAAA
GAATCCCCAAGAAGGACTCTACAATGAACTCCAGAAGGA
TAAGATGGCGGAGGCCTACTCAGAAATAGGTATGAAGGG
CGAACGACGACGGGGAAAAGGTCACGATGGCCTCTACCA
AGGGTTGAGTACGGCAACCAAAGATACGTACGATGCACT GCATATGCAGGCCCTGCCTCCCAGA
38 CD3-zeta amino acid RVKFSRSADAPAYQQGQNQLYNELNLGRREEYDVLDKRRG
sequence RDPEMGGKPRRKNPQEGLYNELQKDKMAEAYSEIGMKGER
RRGKGHDGLYQGLSTATKDTYDALHMQALPPR 39 FMC63-28Z
ATGCTTCTTTTGGTTACGTCTCTGTTGCTTTGCGAACTTCC (FMC63-CD8[tm]-
TCATCCAGCGTTCTTGCTGATCCCCGATATTCAGATGACT CD28[co-stimulatory
CAGACCACCAGTAGCTTGTCTGCCTCACTGGGAGACCGA domain]-CD3z)
GTAACAATCTCCTGCAGGGCAAGTCAAGACATTAGCAAA
TACCTCAATTGGTACCAGCAGAAGCCCGACGGAACGGTA
AAACTCCTCATCTATCATACGTCAAGGTTGCATTCCGGAG
TACCGTCACGATTTTCAGGTTCTGGGAGCGGAACTGACTA
TTCCTTGACTATTTCAAACCTCGAGCAGGAGGACATTGCG
ACATATTTTTGTCAACAAGGTAATACCCTCCCTTACACTT
TCGGAGGAGGAACCAAACTCGAAATTACCGGGTCCACCA
GTGGCTCTGGGAAGCCTGGCAGTGGAGAAGGTTCCACTA
AAGGCGAGGTGAAGCTCCAGGAGAGCGGCCCCGGTCTCG
TTGCCCCCAGTCAAAGCCTCTCTGTAACGTGCACAGTGAG
TGGTGTATCATTGCCTGATTATGGCGTCTCCTGGATAAGG
CAGCCCCCGCGAAAGGGTCTTGAATGGCTTGGGGTAATA
TGGGGCTCAGAGACAACGTATTATAACTCCGCTCTCAAA
AGTCGCTTGACGATAATAAAAGATAACTCCAAGAGTCAA
GTTTTCCTTAAAATGAACAGTTTGCAGACTGACGATACCG
CTATATATTATTGTGCTAAACATTATTACTACGGCGGTAG
TTACGCGATGGATTATTGGGGGCAGGGGACTTCTGTCAC
AGTCAGTAGTGCTGCTGCCTTTGTCCCGGTATTTCTCCCA
GCCAAACCGACCACGACTCCCGCCCCGCGCCCTCCGACA
CCCGCTCCCACCATCGCCTCTCAACCTCTTAGTCTTCGCC
CCGAGGCATGCCGACCCGCCGCCGGGGGTGCTGTTCATA
CGAGGGGCTTGGACTTCGCTTGTGATATTTACATTTGGGC
TCCGTTGGCGGGTACGTGCGGCGTCCTTTTGTTGTCACTC
GTTATTACTTTGTATTGTAATCACAGGAATCGCTCAAAGC
GGAGTAGGTTGTTGCATTCCGATTACATGAATATGACTCC
TCGCCGGCCTGGGCCGACAAGAAAACATTACCAACCCTA
TGCCCCCCCACGAGACTTCGCTGCGTACAGGTCCCGAGTG
AAGTTTTCCCGAAGCGCAGACGCTCCGGCATATCAGCAA
GGACAGAATCAGCTGTATAACGAACTGAATTTGGGACGC
CGCGAGGAGTATGACGTGCTTGATAAACGCCGGGGGAGA
GACCCGGAAATGGGGGGTAAACCCCGAAGAAAGAATCC
CCAAGAAGGACTCTACAATGAACTCCAGAAGGATAAGAT
GGCGGAGGCCTACTCAGAAATAGGTATGAAGGGCGAACG
ACGACGGGGAAAAGGTCACGATGGCCTCTACCAAGGGTT
GAGTACGGCAACCAAAGATACGTACGATGCACTGCATAT GCAGGCCCTGCCTCCCAGA 40
FMC63-28Z MLLLVTSLLLCELPHPAFLLIPDIQMTQTTSSLSASLGDRVTI
(FMC63-CD8[tm]- SCRASQDISKYLNWYQQKPDGTVKLLIYHTSRLHSGVPSRFS
CD28[co-stimulatory GSGSGTDYSLTISNLEQEDIATYFCQQGNTLPYTFGGGTKLEI
domain]-CD3z) TGSTSGSGKPGSGEGSTKGEVKLQESGPGLVAPSQSLSVTCT Amino Acid
VSGVSLPDYGVSWIRQPPRKGLEWLGVIWGSETTYYNSALK
SRLTIIKDNSKSQVFLKMNSLQTDDTAIYYCAKHYYYGGSY
AMDYWGQGTSVTVSSAAAFVPVFLPAKPTTTPAPRPPTPAP
TIASQPLSLRPEACRPAAGGAVHTRGLDFACDIYIWAPLAGT
CGVLLLSLVITLYCNHRNRSKRSRLLHSDYMNMTPRRPGPT
RKHYQPYAPPRDFAAYRSRVKFSRSADAPAYQQGQNQLYN
ELNLGRREEYDVLDKRRGRDPEMGGKPRRKNPQEGLYNEL
QKDKMAEAYSEIGMKGERRRGKGHDGLYQGLSTATKDTY DALHMQALPPR 41 TRAC-LHA
(800 bp) GAGATGTAAGGAGCTGCTGTGACTTGCTCAAGGCCTTAT
ATCGAGTAAACGGTAGTGCTGGGGCTTAGACGCAGGTGT
TCTGATTTATAGTTCAAAACCTCTATCAATGAGAGAGCAA
TCTCCTGGTAATGTGATAGATTTCCCAACTTAATGCCAAC
ATACCATAAACCTCCCATTCTGCTAATGCCCAGCCTAAGT
TGGGGAGACCACTCCAGATTCCAAGATGTACAGTTTGCTT
TGCTGGGCCTTTTTCCCATGCCTGCCTTTACTCTGCCAGA
GTTATATTGCTGGGGTTTTGAAGAAGATCCTATTAAATAA
AAGAATAAGCAGTATTATTAAGTAGCCCTGCATTTCAGGT
TTCCTTGAGTGGCAGGCCAGGCCTGGCCGTGAACGTTCAC
TGAAATCATGGCCTCTTGGCCAAGATTGATAGCTTGTGCC
TGTCCCTGAGTCCCAGTCCATCACGAGCAGCTGGTTTCTA
AGATGCTATTTCCCGTATAAAGCATGAGACCGTGACTTGC
CAGCCCCACAGAGCCCCGCCCTTGTCCATCACTGGCATCT
GGACTCCAGCCTGGGTTGGGGCAAAGAGGGAAATGAGAT
CATGTCCTAACCCTGATCCTCTTGTCCCACAGATATCCAG
AACCCTGACCCTGCCGTGTACCAGCTGAGAGACTCTAAA
TCCAGTGACAAGTCTGTCTGCCTATTCACCGATTTTGATT
CTCAAACAAATGTGTCACAAAGTAAGGATTCTGATGTGT
ATATCACAGACAAAACTGTGCTAGACATGAGGTCTATGG ACTTCA 42 TRAC-RHA (800 bp)
TGGAGCAACAAATCTGACTTTGCATGTGCAAACGCCTTCA
ACAACAGCATTATTCCAGAAGACACCTTCTTCCCCAGCCC
AGGTAAGGGCAGCTTTGGTGCCTTCGCAGGCTGTTTCCTT
GCTTCAGGAATGGCCAGGTTCTGCCCAGAGCTCTGGTCA
ATGATGTCTAAAACTCCTCTGATTGGTGGTCTCGGCCTTA
TCCATTGCCACCAAAACCCTCTTTTTACTAAGAAACAGTG
AGCCTTGTTCTGGCAGTCCAGAGAATGACACGGGAAAAA
AGCAGATGAAGAGAAGGTGGCAGGAGAGGGCACGTGGC
CCAGCCTCAGTCTCTCCAACTGAGTTCCTGCCTGCCTGCC
TTTGCTCAGACTGTTTGCCCCTTACTGCTCTTCTAGGCCTC
ATTCTAAGCCCCTTCTCCAAGTTGCCTCTCCTTATTTCTCC
CTGTCTGCCAAAAAATCTTTCCCAGCTCACTAAGTCAGTC
TCACGCAGTCACTCATTAACCCACCAATCACTGATTGTGC
CGGCACATGAATGCACCAGGTGTTGAAGTGGAGGAATTA
AAAAGTCAGATGAGGGGTGTGCCCAGAGGAAGCACCATT
CTAGTTGGGGGAGCCCATCTGTCAGCTGGGAAAAGTCCA
AATAACTTCAGATTGGAATGTGTTTTAACTCAGGGTTGAG
AAAACAGCTACCTTCAGGACAAAAGTCAGGGAAGGGCTC
TCTGAAGAAATGCTACTTGAAGATACCAGCCCTACCAAG
GGCAGGGAGAGGACCCTATAGAGGCCTGGGACAGGAGC TCAATGAGAAAGG 43 EF1a
GGCTCCGGTGCCCGTCAGTGGGCAGAGCGCACATCGCCC
ACAGTCCCCGAGAAGTTGGGGGGAGGGGTCGGCAATTGA
ACCGGTGCCTAGAGAAGGTGGCGCGGGGTAAACTGGGAA
AGTGATGTCGTGTACTGGCTCCGCCTTTTTCCCGAGGGTG
GGGGAGAACCGTATATAAGTGCAGTAGTCGCCGTGAACG
TTCTTTTTCGCAACGGGTTTGCCGCCAGAACACAGGTAAG
TGCCGTGTGTGGTTCCCGCGGGCCTGGCCTCTTTACGGGT
TATGGCCCTTGCGTGCCTTGAATTACTTCCACTGGCTGCA
GTACGTGATTCTTGATCCCGAGCTTCGGGTTGGAAGTGGG
TGGGAGAGTTCGAGGCCTTGCGCTTAAGGAGCCCCTTCG
CCTCGTGCTTGAGTTGAGGCCTGGCCTGGGCGCTGGGGCC
GCCGCGTGCGAATCTGGTGGCACCTTCGCGCCTGTCTCGC
TGCTTTCGATAAGTCTCTAGCCATTTAAAATTTTTGATGA
CCTGCTGCGACGCTTTTTTTCTGGCAAGATAGTCTTGTAA
ATGCGGGCCAAGATCTGCACACTGGTATTTCGGTTTTTGG
GGCCGCGGGCGGCGACGGGGCCCGTGCGTCCCAGCGCAC
ATGTTCGGCGAGGCGGGGCCTGCGAGCGCGGCCACCGAG
AATCGGACGGGGGTAGTCTCAAGCTGGCCGGCCTGCTCT
GGTGCCTGGCCTCGCGCCGCCGTGTATCGCCCCGCCCTGG
GCGGCAAGGCTGGCCCGGTCGGCACCAGTTGCGTGAGCG
GAAAGATGGCCGCTTCCCGGCCCTGCTGCAGGGAGCTCA
AAATGGAGGACGCGGCGCTCGGGAGAGCGGGCGGGTGA
GTCACCCACACAAAGGAAAAGGGCCTTTCCGTCCTCAGC
CGTCGCTTCATGTGACTCCACGGAGTACCGGGCGCCGTCC
AGGCACCTCGATTAGTTCTCGAGCTTTTGGAGTACGTCGT
CTTTAGGTTGGGGGGAGGGGTTTTATGCGATGGAGTTTCC
CCACACTGAGTGGGTGGAGACTGAAGTTAGGCCAGCTTG
GCACTTGATGTAATTCTCCTTGGAATTTGCCCTTTTTGAGT
TTGGATCTTGGTTCATTCTCAAGCCTCAGACAGTGGTTCA
AAGTTTTTTTCTTCCATTTCAGGTGTCGTGA 44 GM-CSF signal
ATGCTTCTTTTGGTTACGTCTCTGTTGCTTTGCGAACTTCC peptide
TCATCCAGCGTTCTTGCTGATCCCC 45 GM-CSF signal MLLLVTSLLLCELPHPAFLLIP
peptide 46 Anti-CD19 scFv GATATTCAGATGACTCAGACCACCAGTAGCTTGTCTGCCT
CACTGGGAGACCGAGTAACAATCTCCTGCAGGGCAAGTC
AAGACATTAGCAAATACCTCAATTGGTACCAGCAGAAGC
CCGACGGAACGGTAAAACTCCTCATCTATCATACGTCAA
GGTTGCATTCCGGAGTACCGTCACGATTTTCAGGTTCTGG
GAGCGGAACTGACTATTCCTTGACTATTTCAAACCTCGAG
CAGGAGGACATTGCGACATATTTTTGTCAACAAGGTAAT
ACCCTCCCTTACACTTTCGGAGGAGGAACCAAACTCGAA
ATTACCGGGTCCACCAGTGGCTCTGGGAAGCCTGGCAGT
GGAGAAGGTTCCACTAAAGGCGAGGTGAAGCTCCAGGAG
AGCGGCCCCGGTCTCGTTGCCCCCAGTCAAAGCCTCTCTG
TAACGTGCACAGTGAGTGGTGTATCATTGCCTGATTATGG
CGTCTCCTGGATAAGGCAGCCCCCGCGAAAGGGTCTTGA
ATGGCTTGGGGTAATATGGGGCTCAGAGACAACGTATTA
TAACTCCGCTCTCAAAAGTCGCTTGACGATAATAAAAGA
TAACTCCAAGAGTCAAGTTTTCCTTAAAATGAACAGTTTG
CAGACTGACGATACCGCTATATATTATTGTGCTAAACATT
ATTACTACGGCGGTAGTTACGCGATGGATTATTGGGGGC AGGGGACTTCTGTCACAGTCAGTAGT
47 CD19 scFv amino DIQMTQTTSSLSASLGDRVTISCRASQDISKYLNWYQQKPD acid
sequence GTVKLLIYHTSRLHSGVPSRFSGSGSGTDYSLTISNLEQEDIA Linker
underlined TYFCQQGNTLPYTFGGGTKLEITGSTSGSGKPGSGEGSTKGE
VKLQESGPGLVAPSQSLSVTCTVSGVSLPDYGVSWIRQPPRK
GLEWLGVIWGSETTYYNSALKSRLTIIKDNSKSQVFLKMNS
LQTDDTAIYYCAKHYYYGGSYAMDYWGQGTSVTVSS 48 CD8a extracellular +
GCTGCTGCCTTTGTCCCGGTATTTCTCCCAGCCAAACCGA CD8a transmembrane +
CCACGACTCCCGCCCCGCGCCCTCCGACACCCGCTCCCAC 5' Linker
CATCGCCTCTCAACCTCTTAGTCTTCGCCCCGAGGCATGC (underlined)
CGACCCGCCGCCGGGGGTGCTGTTCATACGAGGGGCTTG
GACTTCGCTTGTGATATTTACATTTGGGCTCCGTTGGCGG
GTACGTGCGGCGTCCTTTTGTTGTCACTCGTTATTACTTTG TATTGTAATCACAGGAATCGC 49
CD8a extracellular + TTTGTCCCGGTATTTCTCCCAGCCAAACCGACCACGACTC CD8a
transmembrane CCGCCCCGCGCCCTCCGACACCCGCTCCCACCATCGCCTC (without
linker) TCAACCTCTTAGTCTTCGCCCCGAGGCATGCCGACCCGCC
GCCGGGGGTGCTGTTCATACGAGGGGCTTGGACTTCGCTT
GTGATATTTACATTTGGGCTCCGTTGGCGGGTACGTGCGG
CGTCCTTTTGTTGTCACTCGTTATTACTTTGTATTGTAATC ACAGGAATCGC 50 CD8a
extracellular + FVPVFLPAKPTTTPAPRPPTPAPTIASQPLSLRPEACRPAAGG CD8a
transmembrane AVHTRGLDFACDIYIWAPLAGTCGVLLLSLVITLYCNHRNR 51 CD19 VH
EVKLQESGPGLVAPSQSLSVTCTVSGVSLPDYGVSWIRQPPR
KGLEWLGVIWGSETTYYNSALKSRLTIIKDNSKSQVFLKMN
SLQTDDTAIYYCAKHYYYGGSYAMDYWGQGTSVTVSS 52 CD19 VL
DIQMTQTTSSLSASLGDRVTISCRASQDISKYLNWYQQKPD
GTVKLLIYHTSRLHSGVPSRFSGSGSGTDYSLTISNLEQEDIA TYFCQQGNTLPYTFGGGTKLEIT
53 CD19 linker GSTSGSGKPGSGEGSTKG 54 LHA to RHA
GAGATGTAAGGAGCTGCTGTGACTTGCTCAAGGCCTTAT
ATCGAGTAAACGGTAGTGCTGGGGCTTAGACGCAGGTGT
TCTGATTTATAGTTCAAAACCTCTATCAATGAGAGAGCAA
TCTCCTGGTAATGTGATAGATTTCCCAACTTAATGCCAAC
ATACCATAAACCTCCCATTCTGCTAATGCCCAGCCTAAGT
TGGGGAGACCACTCCAGATTCCAAGATGTACAGTTTGCTT
TGCTGGGCCTTTTTCCCATGCCTGCCTTTACTCTGCCAGA
GTTATATTGCTGGGGTTTTGAAGAAGATCCTATTAAATAA
AAGAATAAGCAGTATTATTAAGTAGCCCTGCATTTCAGGT
TTCCTTGAGTGGCAGGCCAGGCCTGGCCGTGAACGTTCAC
TGAAATCATGGCCTCTTGGCCAAGATTGATAGCTTGTGCC
TGTCCCTGAGTCCCAGTCCATCACGAGCAGCTGGTTTCTA
AGATGCTATTTCCCGTATAAAGCATGAGACCGTGACTTGC
CAGCCCCACAGAGCCCCGCCCTTGTCCATCACTGGCATCT
GGACTCCAGCCTGGGTTGGGGCAAAGAGGGAAATGAGAT
CATGTCCTAACCCTGATCCTCTTGTCCCACAGATATCCAG
AACCCTGACCCTGCCGTGTACCAGCTGAGAGACTCTAAA
TCCAGTGACAAGTCTGTCTGCCTATTCACCGATTTTGATT
CTCAAACAAATGTGTCACAAAGTAAGGATTCTGATGTGT
ATATCACAGACAAAACTGTGCTAGACATGAGGTCTATGG
ACTTCAGGCTCCGGTGCCCGTCAGTGGGCAGAGCGCACA
TCGCCCACAGTCCCCGAGAAGTTGGGGGGAGGGGTCGGC
AATTGAACCGGTGCCTAGAGAAGGTGGCGCGGGGTAAAC
TGGGAAAGTGATGTCGTGTACTGGCTCCGCCTTTTTCCCG
AGGGTGGGGGAGAACCGTATATAAGTGCAGTAGTCGCCG
TGAACGTTCTTTTTCGCAACGGGTTTGCCGCCAGAACACA
GGTAAGTGCCGTGTGTGGTTCCCGCGGGCCTGGCCTCTTT
ACGGGTTATGGCCCTTGCGTGCCTTGAATTACTTCCACTG
GCTGCAGTACGTGATTCTTGATCCCGAGCTTCGGGTTGGA
AGTGGGTGGGAGAGTTCGAGGCCTTGCGCTTAAGGAGCC
CCTTCGCCTCGTGCTTGAGTTGAGGCCTGGCCTGGGCGCT
GGGGCCGCCGCGTGCGAATCTGGTGGCACCTTCGCGCCT
GTCTCGCTGCTTTCGATAAGTCTCTAGCCATTTAAAATTTT
TGATGACCTGCTGCGACGCTTTTTTTCTGGCAAGATAGTC
TTGTAAATGCGGGCCAAGATCTGCACACTGGTATTTCGGT
TTTTGGGGCCGCGGGCGGCGACGGGGCCCGTGCGTCCCA
GCGCACATGTTCGGCGAGGCGGGGCCTGCGAGCGCGGCC
ACCGAGAATCGGACGGGGGTAGTCTCAAGCTGGCCGGCC
TGCTCTGGTGCCTGGCCTCGCGCCGCCGTGTATCGCCCCG
CCCTGGGCGGCAAGGCTGGCCCGGTCGGCACCAGTTGCG
TGAGCGGAAAGATGGCCGCTTCCCGGCCCTGCTGCAGGG
AGCTCAAAATGGAGGACGCGGCGCTCGGGAGAGCGGGC
GGGTGAGTCACCCACACAAAGGAAAAGGGCCTTTCCGTC
CTCAGCCGTCGCTTCATGTGACTCCACGGAGTACCGGGCG
CCGTCCAGGCACCTCGATTAGTTCTCGAGCTTTTGGAGTA
CGTCGTCTTTAGGTTGGGGGGAGGGGTTTTATGCGATGGA
GTTTCCCCACACTGAGTGGGTGGAGACTGAAGTTAGGCC
AGCTTGGCACTTGATGTAATTCTCCTTGGAATTTGCCCTTT
TTGAGTTTGGATCTTGGTTCATTCTCAAGCCTCAGACAGT
GGTTCAAAGTTTTTTTCTTCCATTTCAGGTGTCGTGACCAC
CATGCTTCTTTTGGTTACGTCTCTGTTGCTTTGCGAACTTC
CTCATCCAGCGTTCTTGCTGATCCCCGATATTCAGATGAC
TCAGACCACCAGTAGCTTGTCTGCCTCACTGGGAGACCG
AGTAACAATCTCCTGCAGGGCAAGTCAAGACATTAGCAA
ATACCTCAATTGGTACCAGCAGAAGCCCGACGGAACGGT
AAAACTCCTCATCTATCATACGTCAAGGTTGCATTCCGGA
GTACCGTCACGATTTTCAGGTTCTGGGAGCGGAACTGACT
ATTCCTTGACTATTTCAAACCTCGAGCAGGAGGACATTGC
GACATATTTTTGTCAACAAGGTAATACCCTCCCTTACACT
TTCGGAGGAGGAACCAAACTCGAAATTACCGGGTCCACC
AGTGGCTCTGGGAAGCCTGGCAGTGGAGAAGGTTCCACT
AAAGGCGAGGTGAAGCTCCAGGAGAGCGGCCCCGGTCTC
GTTGCCCCCAGTCAAAGCCTCTCTGTAACGTGCACAGTGA
GTGGTGTATCATTGCCTGATTATGGCGTCTCCTGGATAAG
GCAGCCCCCGCGAAAGGGTCTTGAATGGCTTGGGGTAAT
ATGGGGCTCAGAGACAACGTATTATAACTCCGCTCTCAA
AAGTCGCTTGACGATAATAAAAGATAACTCCAAGAGTCA
AGTTTTCCTTAAAATGAACAGTTTGCAGACTGACGATACC
GCTATATATTATTGTGCTAAACATTATTACTACGGCGGTA
GTTACGCGATGGATTATTGGGGGCAGGGGACTTCTGTCA
CAGTCAGTAGTGCTGCTGCCTTTGTCCCGGTATTTCTCCC
AGCCAAACCGACCACGACTCCCGCCCCGCGCCCTCCGAC
ACCCGCTCCCACCATCGCCTCTCAACCTCTTAGTCTTCGC
CCCGAGGCATGCCGACCCGCCGCCGGGGGTGCTGTTCAT
ACGAGGGGCTTGGACTTCGCTTGTGATATTTACATTTGGG
CTCCGTTGGCGGGTACGTGCGGCGTCCTTTTGTTGTCACT
CGTTATTACTTTGTATTGTAATCACAGGAATCGCTCAAAG
CGGAGTAGGTTGTTGCATTCCGATTACATGAATATGACTC
CTCGCCGGCCTGGGCCGACAAGAAAACATTACCAACCCT
ATGCCCCCCCACGAGACTTCGCTGCGTACAGGTCCCGAGT
GAAGTTTTCCCGAAGCGCAGACGCTCCGGCATATCAGCA
AGGACAGAATCAGCTGTATAACGAACTGAATTTGGGACG
CCGCGAGGAGTATGACGTGCTTGATAAACGCCGGGGGAG
AGACCCGGAAATGGGGGGTAAACCCCGAAGAAAGAATC
CCCAAGAAGGACTCTACAATGAACTCCAGAAGGATAAGA
TGGCGGAGGCCTACTCAGAAATAGGTATGAAGGGCGAAC
GACGACGGGGAAAAGGTCACGATGGCCTCTACCAAGGGT
TGAGTACGGCAACCAAAGATACGTACGATGCACTGCATA
TGCAGGCCCTGCCTCCCAGATAATAATAAAATCGCTATCC
ATCGAAGATGGATGTGTGTTGGTTTTTTGTGTGTGGAGCA
ACAAATCTGACTTTGCATGTGCAAACGCCTTCAACAACA
GCATTATTCCAGAAGACACCTTCTTCCCCAGCCCAGGTAA
GGGCAGCTTTGGTGCCTTCGCAGGCTGTTTCCTTGCTTCA
GGAATGGCCAGGTTCTGCCCAGAGCTCTGGTCAATGATG
TCTAAAACTCCTCTGATTGGTGGTCTCGGCCTTATCCATT
GCCACCAAAACCCTCTTTTTACTAAGAAACAGTGAGCCTT
GTTCTGGCAGTCCAGAGAATGACACGGGAAAAAAGCAGA
TGAAGAGAAGGTGGCAGGAGAGGGCACGTGGCCCAGCC
TCAGTCTCTCCAACTGAGTTCCTGCCTGCCTGCCTTTGCTC
AGACTGTTTGCCCCTTACTGCTCTTCTAGGCCTCATTCTAA
GCCCCTTCTCCAAGTTGCCTCTCCTTATTTCTCCCTGTCTG
CCAAAAAATCTTTCCCAGCTCACTAAGTCAGTCTCACGCA
GTCACTCATTAACCCACCAATCACTGATTGTGCCGGCACA
TGAATGCACCAGGTGTTGAAGTGGAGGAATTAAAAAGTC
AGATGAGGGGTGTGCCCAGAGGAAGCACCATTCTAGTTG
GGGGAGCCCATCTGTCAGCTGGGAAAAGTCCAAATAACT
TCAGATTGGAATGTGTTTTAACTCAGGGTTGAGAAAACA
GCTACCTTCAGGACAAAAGTCAGGGAAGGGCTCTCTGAA
GAAATGCTACTTGAAGATACCAGCCCTACCAAGGGCAGG
GAGAGGACCCTATAGAGGCCTGGGACAGGAGCTCAATGA GAAAGG 55 spCas9
MDKKYSIGLDIGTNSVGWAVITDEYKVPSKKFKVLGNTDR
HSIKKNLIGALLFDSGETAEATRLKRTARRRYTRRKNRICYL
QEIFSNEMAKVDDSFFHRLEESFLVEEDKKHERHPIFGNIVD
EVAYHEKYPTIYHLRKKLVDSTDKADLRLIYLALAHMIKFR
GHFLIEGDLNPDNSDVDKLFIQLVQTYNQLFEENPINASGVD
AKAILSARLSKSRRLENLIAQLPGEKKNGLFGNLIALSLGLTP
NFKSNFDLAEDAKLQLSKDTYDDDLDNLLAQIGDQYADLF
LAAKNLSDAILLSDILRVNTEITKAPLSASMIKRYDEHHQDL
TLLKALVRQQLPEKYKEIFFDQSKNGYAGYIDGGASQEEFY
KFIKPILEKMDGTEELLVKLNREDLLRKQRTFDNGSIPHQIHL
GELHAILRRQEDFYPFLKDNREKIEKILTFRIPYYVGPLARGN
SRFAWMTRKSEETITPWNFEEVVDKGASAQSFIERMTNFDK
NLPNEKVLPKHSLLYEYFTVYNELTKVKYVTEGMRKPAFLS
GEQKKAIVDLLFKTNRKVTVKQLKEDYFKKIECFDSVEISGV
EDRFNASLGTYHDLLKIIKDKDFLDNEENEDILEDIVLTLTLF
EDREMIEERLKTYAHLFDDKVMKQLKRRRYTGWGRLSRKL
INGIRDKQSGKTILDFLKSDGFANRNFMQLIHDDSLTFKEDIQ
KAQVSGQGDSLHEHIANLAGSPAIKKGILQTVKVVDELVKV
MGRHKPENIVIEMARENQTTQKGQKNSRERMKRIEEGIKEL
GSQILKEHPVENTQLQNEKLYLYYLQNGRDMYVDQELDIN
RLSDYDVDHIVPQSFLKDDSIDNKVLTRSDKNRGKSDNVPS
EEVVKKMKNYWRQLLNAKLITQRKFDNLTKAERGGLSELD
KAGFIKRQLVETRQITKHVAQILDSRMNTKYDENDKLIREV
KVITLKSKLVSDFRKDFQFYKVREINNYHHAHDAYLNAVV
GTALIKKYPKLESEFVYGDYKVYDVRKMIAKSEQEIGKATA
KYFFYSNIMNFFKTEITLANGEIRKRPLIETNGETGEIVWDKG
RDFATVRKVLSMPQVNIVKKTEVQTGGFSKESILPKRNSDK LIARKKDWDPKKYGGFD
SPTVAYSVLVVAKVEKGKSKKLK SVKELLGITIMERSSFEKNPIDFLEAKGYKEVKKDLIIKLPKY
SLFELENGRKRMLASAGELQKGNELALPSKYVNFLYLASHY
EKLKGSPEDNEQKQLFVEQHKHYLDEIIEQISEFSKRVILADA
NLDKVLSAYNKHRDKPIREQAENIIHLFTLTNLGAPAAFKYF
DTTIDRKRYTSTKEVLDATLIHQSITGLYETRIDLSQLGGD 56 rAAV
CCTGCAGGCAGCTGCGCGCTCGCTCGCTCACTGAGGCCG
CCCGGGCGTCGGGCGACCTTTGGTCGCCCGGCCTCAGTG
AGCGAGCGAGCGCGCAGAGAGGGAGTGGCCAACTCCATC
ACTAGGGGTTCCTGCGGCCGCACGCGTGAGATGTAAGGA
GCTGCTGTGACTTGCTCAAGGCCTTATATCGAGTAAACGG
TAGTGCTGGGGCTTAGACGCAGGTGTTCTGATTTATAGTT
CAAAACCTCTATCAATGAGAGAGCAATCTCCTGGTAATG
TGATAGATTTCCCAACTTAATGCCAACATACCATAAACCT
CCCATTCTGCTAATGCCCAGCCTAAGTTGGGGAGACCACT
CCAGATTCCAAGATGTACAGTTTGCTTTGCTGGGCCTTTT
TCCCATGCCTGCCTTTACTCTGCCAGAGTTATATTGCTGG
GGTTTTGAAGAAGATCCTATTAAATAAAAGAATAAGCAG
TATTATTAAGTAGCCCTGCATTTCAGGTTTCCTTGAGTGG
CAGGCCAGGCCTGGCCGTGAACGTTCACTGAAATCATGG
CCTCTTGGCCAAGATTGATAGCTTGTGCCTGTCCCTGAGT
CCCAGTCCATCACGAGCAGCTGGTTTCTAAGATGCTATTT
CCCGTATAAAGCATGAGACCGTGACTTGCCAGCCCCACA
GAGCCCCGCCCTTGTCCATCACTGGCATCTGGACTCCAGC
CTGGGTTGGGGCAAAGAGGGAAATGAGATCATGTCCTAA
CCCTGATCCTCTTGTCCCACAGATATCCAGAACCCTGACC
CTGCCGTGTACCAGCTGAGAGACTCTAAATCCAGTGACA
AGTCTGTCTGCCTATTCACCGATTTTGATTCTCAAACAAA
TGTGTCACAAAGTAAGGATTCTGATGTGTATATCACAGAC
AAAACTGTGCTAGACATGAGGTCTATGGACTTCAGGCTC
CGGTGCCCGTCAGTGGGCAGAGCGCACATCGCCCACAGT
CCCCGAGAAGTTGGGGGGAGGGGTCGGCAATTGAACCGG
TGCCTAGAGAAGGTGGCGCGGGGTAAACTGGGAAAGTGA
TGTCGTGTACTGGCTCCGCCTTTTTCCCGAGGGTGGGGGA
GAACCGTATATAAGTGCAGTAGTCGCCGTGAACGTTCTTT
TTCGCAACGGGTTTGCCGCCAGAACACAGGTAAGTGCCG
TGTGTGGTTCCCGCGGGCCTGGCCTCTTTACGGGTTATGG
CCCTTGCGTGCCTTGAATTACTTCCACTGGCTGCAGTACG
TGATTCTTGATCCCGAGCTTCGGGTTGGAAGTGGGTGGGA
GAGTTCGAGGCCTTGCGCTTAAGGAGCCCCTTCGCCTCGT
GCTTGAGTTGAGGCCTGGCCTGGGCGCTGGGGCCGCCGC
GTGCGAATCTGGTGGCACCTTCGCGCCTGTCTCGCTGCTT
TCGATAAGTCTCTAGCCATTTAAAATTTTTGATGACCTGC
TGCGACGCTTTTTTTCTGGCAAGATAGTCTTGTAAATGCG
GGCCAAGATCTGCACACTGGTATTTCGGTTTTTGGGGCCG
CGGGCGGCGACGGGGCCCGTGCGTCCCAGCGCACATGTT
CGGCGAGGCGGGGCCTGCGAGCGCGGCCACCGAGAATCG
GACGGGGGTAGTCTCAAGCTGGCCGGCCTGCTCTGGTGC
CTGGCCTCGCGCCGCCGTGTATCGCCCCGCCCTGGGCGGC
AAGGCTGGCCCGGTCGGCACCAGTTGCGTGAGCGGAAAG
ATGGCCGCTTCCCGGCCCTGCTGCAGGGAGCTCAAAATG
GAGGACGCGGCGCTCGGGAGAGCGGGCGGGTGAGTCAC
CCACACAAAGGAAAAGGGCCTTTCCGTCCTCAGCCGTCG
CTTCATGTGACTCCACGGAGTACCGGGCGCCGTCCAGGC
ACCTCGATTAGTTCTCGAGCTTTTGGAGTACGTCGTCTTT
AGGTTGGGGGGAGGGGTTTTATGCGATGGAGTTTCCCCA
CACTGAGTGGGTGGAGACTGAAGTTAGGCCAGCTTGGCA
CTTGATGTAATTCTCCTTGGAATTTGCCCTTTTTGAGTTTG
GATCTTGGTTCATTCTCAAGCCTCAGACAGTGGTTCAAAG
TTTTTTTCTTCCATTTCAGGTGTCGTGACCACCATGCTTCT
TTTGGTTACGTCTCTGTTGCTTTGCGAACTTCCTCATCCAG
CGTTCTTGCTGATCCCCGATATTCAGATGACTCAGACCAC
CAGTAGCTTGTCTGCCTCACTGGGAGACCGAGTAACAAT
CTCCTGCAGGGCAAGTCAAGACATTAGCAAATACCTCAA
TTGGTACCAGCAGAAGCCCGACGGAACGGTAAAACTCCT
CATCTATCATACGTCAAGGTTGCATTCCGGAGTACCGTCA
CGATTTTCAGGTTCTGGGAGCGGAACTGACTATTCCTTGA
CTATTTCAAACCTCGAGCAGGAGGACATTGCGACATATTT
TTGTCAACAAGGTAATACCCTCCCTTACACTTTCGGAGGA
GGAACCAAACTCGAAATTACCGGGTCCACCAGTGGCTCT
GGGAAGCCTGGCAGTGGAGAAGGTTCCACTAAAGGCGAG
GTGAAGCTCCAGGAGAGCGGCCCCGGTCTCGTTGCCCCC
AGTCAAAGCCTCTCTGTAACGTGCACAGTGAGTGGTGTAT
CATTGCCTGATTATGGCGTCTCCTGGATAAGGCAGCCCCC
GCGAAAGGGTCTTGAATGGCTTGGGGTAATATGGGGCTC
AGAGACAACGTATTATAACTCCGCTCTCAAAAGTCGCTTG
ACGATAATAAAAGATAACTCCAAGAGTCAAGTTTTCCTT
AAAATGAACAGTTTGCAGACTGACGATACCGCTATATAT
TATTGTGCTAAACATTATTACTACGGCGGTAGTTACGCGA
TGGATTATTGGGGGCAGGGGACTTCTGTCACAGTCAGTA
GTGCTGCTGCCTTTGTCCCGGTATTTCTCCCAGCCAAACC
GACCACGACTCCCGCCCCGCGCCCTCCGACACCCGCTCCC
ACCATCGCCTCTCAACCTCTTAGTCTTCGCCCCGAGGCAT
GCCGACCCGCCGCCGGGGGTGCTGTTCATACGAGGGGCT
TGGACTTCGCTTGTGATATTTACATTTGGGCTCCGTTGGC
GGGTACGTGCGGCGTCCTTTTGTTGTCACTCGTTATTACTT
TGTATTGTAATCACAGGAATCGCTCAAAGCGGAGTAGGT
TGTTGCATTCCGATTACATGAATATGACTCCTCGCCGGCC
TGGGCCGACAAGAAAACATTACCAACCCTATGCCCCCCC
ACGAGACTTCGCTGCGTACAGGTCCCGAGTGAAGTTTTCC
CGAAGCGCAGACGCTCCGGCATATCAGCAAGGACAGAAT
CAGCTGTATAACGAACTGAATTTGGGACGCCGCGAGGAG
TATGACGTGCTTGATAAACGCCGGGGGAGAGACCCGGAA
ATGGGGGGTAAACCCCGAAGAAAGAATCCCCAAGAAGG
ACTCTACAATGAACTCCAGAAGGATAAGATGGCGGAGGC
CTACTCAGAAATAGGTATGAAGGGCGAACGACGACGGGG
AAAAGGTCACGATGGCCTCTACCAAGGGTTGAGTACGGC
AACCAAAGATACGTACGATGCACTGCATATGCAGGCCCT
GCCTCCCAGATAATAATAAAATCGCTATCCATCGAAGAT
GGATGTGTGTTGGTTTTTTGTGTGTGGAGCAACAAATCTG
ACTTTGCATGTGCAAACGCCTTCAACAACAGCATTATTCC
AGAAGACACCTTCTTCCCCAGCCCAGGTAAGGGCAGCTT
TGGTGCCTTCGCAGGCTGTTTCCTTGCTTCAGGAATGGCC
AGGTTCTGCCCAGAGCTCTGGTCAATGATGTCTAAAACTC
CTCTGATTGGTGGTCTCGGCCTTATCCATTGCCACCAAAA
CCCTCTTTTTACTAAGAAACAGTGAGCCTTGTTCTGGCAG
TCCAGAGAATGACACGGGAAAAAAGCAGATGAAGAGAA
GGTGGCAGGAGAGGGCACGTGGCCCAGCCTCAGTCTCTC
CAACTGAGTTCCTGCCTGCCTGCCTTTGCTCAGACTGTTT
GCCCCTTACTGCTCTTCTAGGCCTCATTCTAAGCCCCTTCT
CCAAGTTGCCTCTCCTTATTTCTCCCTGTCTGCCAAAAAA
TCTTTCCCAGCTCACTAAGTCAGTCTCACGCAGTCACTCA
TTAACCCACCAATCACTGATTGTGCCGGCACATGAATGCA
CCAGGTGTTGAAGTGGAGGAATTAAAAAGTCAGATGAGG
GGTGTGCCCAGAGGAAGCACCATTCTAGTTGGGGGAGCC
CATCTGTCAGCTGGGAAAAGTCCAAATAACTTCAGATTG
GAATGTGTTTTAACTCAGGGTTGAGAAAACAGCTACCTTC
AGGACAAAAGTCAGGGAAGGGCTCTCTGAAGAAATGCTA
CTTGAAGATACCAGCCCTACCAAGGGCAGGGAGAGGACC
CTATAGAGGCCTGGGACAGGAGCTCAATGAGAAAGGTAA
CCACGTGCGGACCGAGGCTGCAGCGTCGTCCTCCCTAGG
AACCCCTAGTGATGGAGTTGGCCACTCCCTCTCTGCGCGC
TCGCTCGCTCACTGAGGCCGGGCGACCAAAGGTCGCCCG
ACGCCCGGGCTTTGCCCGGGCGGCCTCAGTGAGCGAGCG AGCGCGCAGCTGCCTGCAGG
*indicates a nucleotide with a 2'-O-methyl phosphorothioate
modification. "n" refers to the spacer sequence at the 5' end.
OTHER EMBODIMENTS
[0413] All of the features disclosed in this specification may be
combined in any combination. Each feature disclosed in this
specification may be replaced by an alternative feature serving the
same, equivalent, or similar purpose. Thus, unless expressly stated
otherwise, each feature disclosed is only an example of a generic
series of equivalent or similar features.
[0414] From the above description, one skilled in the art can
easily ascertain the essential characteristics of the present
invention, and without departing from the spirit and scope thereof,
can make various changes and modifications of the invention to
adapt it to various usages and conditions. Thus, other embodiments
are also within the claims.
EQUIVALENTS
[0415] While several inventive embodiments have been described and
illustrated herein, those of ordinary skill in the art will readily
envision a variety of other means and/or structures for performing
the function and/or obtaining the results and/or one or more of the
advantages described herein, and each of such variations and/or
modifications is deemed to be within the scope of the inventive
embodiments described herein. More generally, those skilled in the
art will readily appreciate that all parameters, dimensions,
materials, and configurations described herein are meant to be
exemplary and that the actual parameters, dimensions, materials,
and/or configurations will depend upon the specific application or
applications for which the inventive teachings is/are used. Those
skilled in the art will recognize, or be able to ascertain using no
more than routine experimentation, many equivalents to the specific
inventive embodiments described herein. It is, therefore, to be
understood that the foregoing embodiments are presented by way of
example only and that, within the scope of the appended claims and
equivalents thereto, inventive embodiments may be practiced
otherwise than as specifically described and claimed. Inventive
embodiments of the present disclosure are directed to each
individual feature, system, article, material, kit, and/or method
described herein. In addition, any combination of two or more such
features, systems, articles, materials, kits, and/or methods, if
such features, systems, articles, materials, kits, and/or methods
are not mutually inconsistent, is included within the inventive
scope of the present disclosure.
[0416] All definitions, as defined and used herein, should be
understood to control over dictionary definitions, definitions in
documents incorporated by reference, and/or ordinary meanings of
the defined terms.
[0417] All references, patents and patent applications disclosed
herein are incorporated by reference with respect to the subject
matter for which each is cited, which in some cases may encompass
the entirety of the document.
[0418] The indefinite articles "a" and "an," as used herein in the
specification and in the claims, unless clearly indicated to the
contrary, should be understood to mean "at least one."
[0419] The phrase "and/or," as used herein in the specification and
in the claims, should be understood to mean "either or both" of the
elements so conjoined, i.e., elements that are conjunctively
present in some cases and disjunctively present in other cases.
Multiple elements listed with "and/or" should be construed in the
same fashion, i.e., "one or more" of the elements so conjoined.
Other elements may optionally be present other than the elements
specifically identified by the "and/or" clause, whether related or
unrelated to those elements specifically identified. Thus, as a
non-limiting example, a reference to "A and/or B", when used in
conjunction with open-ended language such as "comprising" can
refer, in one embodiment, to A only (optionally including elements
other than B); in another embodiment, to B only (optionally
including elements other than A); in yet another embodiment, to
both A and B (optionally including other elements); etc.
[0420] As used herein in the specification and in the claims, "or"
should be understood to have the same meaning as "and/or" as
defined above. For example, when separating items in a list, "or"
or "and/or" shall be interpreted as being inclusive, i.e., the
inclusion of at least one, but also including more than one, of a
number or list of elements, and, optionally, additional unlisted
items. Only terms clearly indicated to the contrary, such as "only
one of" or "exactly one of," or, when used in the claims,
"consisting of," will refer to the inclusion of exactly one element
of a number or list of elements. In general, the term "or" as used
herein shall only be interpreted as indicating exclusive
alternatives (i.e. "one or the other but not both") when preceded
by terms of exclusivity, such as "either," "one of," "only one of,"
or "exactly one of" "Consisting essentially of," when used in the
claims, shall have its ordinary meaning as used in the field of
patent law.
[0421] As used herein in the specification and in the claims, the
phrase "at least one," in reference to a list of one or more
elements, should be understood to mean at least one element
selected from any one or more of the elements in the list of
elements, but not necessarily including at least one of each and
every element specifically listed within the list of elements and
not excluding any combinations of elements in the list of elements.
This definition also allows that elements may optionally be present
other than the elements specifically identified within the list of
elements to which the phrase "at least one" refers, whether related
or unrelated to those elements specifically identified. Thus, as a
non-limiting example, "at least one of A and B" (or, equivalently,
"at least one of A or B," or, equivalently "at least one of A
and/or B") can refer, in one embodiment, to at least one,
optionally including more than one, A, with no B present (and
optionally including elements other than B); in another embodiment,
to at least one, optionally including more than one, B, with no A
present (and optionally including elements other than A); in yet
another embodiment, to at least one, optionally including more than
one, A, and at least one, optionally including more than one, B
(and optionally including other elements); etc.
[0422] It should also be understood that, unless clearly indicated
to the contrary, in any methods claimed herein that include more
than one step or act, the order of the steps or acts of the method
is not necessarily limited to the order in which the steps or acts
of the method are recited.
Sequence CWU 1
1
56119DNAArtificial SequenceSynthetic Polynucleotide 1aagagcaaca
aatctgact 19258DNAArtificial SequenceSynthetic Polynucleotide
2aagagcaaca gtgctgtgcc tggagcaaca aatctgacta agagcaacaa atctgact
58352DNAArtificial SequenceSynthetic Polynucleotide 3aagagcaaca
gtgctggagc aacaaatctg actaagagca acaaatctga ct 52453DNAArtificial
SequenceSynthetic Polynucleotide 4aagagcaaca gtgcctggag caacaaatct
gactaagagc aacaaatctg act 53538DNAArtificial SequenceSynthetic
Polynucleotide 5aagagcaaca gtgctgacta agagcaacaa atctgact
38660DNAArtificial SequenceSynthetic Polynucleotide 6aagagcaaca
gtgctgtggg cctggagcaa caaatctgac taagagcaac aaatctgact
60757DNAArtificial SequenceSynthetic Polynucleotide 7aagagcaaca
gtgctggcct ggagcaacaa atctgactaa gagcaacaaa tctgact
57860DNAArtificial SequenceSynthetic Polynucleotide 8aagagcaaca
gtgctgtgtg cctggagcaa caaatctgac taagagcaac aaatctgact
60979DNAArtificial SequenceSynthetic Polynucleotide 9cgtggcctta
gctgtgctcg cgctactctc tctttctgcc tggaggctat ccagcgtgag 60tctctcctac
cctcccgct 791078DNAArtificial SequenceSynthetic Polynucleotide
10cgtggcctta gctgtgctcg cgctactctc tctttcgcct ggaggctatc cagcgtgagt
60ctctcctacc ctcccgct 781175DNAArtificial SequenceSynthetic
Polynucleotide 11cgtggcctta gctgtgctcg cgctactctc tctttctgga
ggctatccag cgtgagtctc 60tcctaccctc ccgct 751284DNAArtificial
SequenceSynthetic Polynucleotide 12cgtggcctta gctgtgctcg cgctactctc
tctttctgga tagcctggag gctatccagc 60gtgagtctct cctaccctcc cgct
841355DNAArtificial SequenceSynthetic Polynucleotide 13cgtggcctta
gctgtgctcg cgctatccag cgtgagtctc tcctaccctc ccgct
551482DNAArtificial SequenceSynthetic Polynucleotide 14cgtggcctta
gctgtgctcg cgctactctc tctttctgtg gcctggaggc tatccagcgt 60gagtctctcc
taccctcccg ct 8215100RNAArtificial SequenceSynthetic
Polynucleotidemisc_feature(1)..(20)n is a, c, g, or u 15nnnnnnnnnn
nnnnnnnnnn guuuuagagc uagaaauagc aaguuaaaau aaggcuaguc 60cguuaucaac
uugaaaaagu ggcaccgagu cggugcuuuu 1001696RNAArtificial
SequenceSynthetic Polynucleotidemisc_feature(1)..(20)n is a, c, g,
or u 16nnnnnnnnnn nnnnnnnnnn guuuuagagc uagaaauagc aaguuaaaau
aaggcuaguc 60cguuaucaac uugaaaaagu ggcaccgagu cggugc
9617114RNAArtificial SequenceSynthetic
Polynucleotidemisc_feature(1)..(30)n is a, c, g, or
umisc_feature(18)..(30)n at positions 18 to 30 is
optionalmisc_feature(107)..(114)u at positions 2 to 8 is optional
17nnnnnnnnnn nnnnnnnnnn nnnnnnnnnn guuuuagagc uagaaauagc aaguuaaaau
60aaggcuaguc cguuaucaac uugaaaaagu ggcaccgagu cggugcuuuu uuuu
11418100RNAArtificial SequenceSynthetic Polynucleotide 18agagcaacag
ugcuguggcc guuuuagagc uagaaauagc aaguuaaaau aaggcuaguc 60cguuaucaac
uugaaaaagu ggcaccgagu cggugcuuuu 1001920RNAArtificial
SequenceSynthetic Polynucleotide 19agagcaacag ugcuguggcc
2020100RNAArtificial SequenceSynthetic Polynucleotide 20gcuacucucu
cuuucuggcc guuuuagagc uagaaauagc aaguuaaaau aaggcuaguc 60cguuaucaac
uugaaaaagu ggcaccgagu cggugcuuuu 1002120RNAArtificial
SequenceSynthetic Polynucleotide 21gcuacucucu cuuucuggcc
2022100RNAArtificial SequenceSynthetic
Polynucleotidemisc_feature(1)..(3)nucleotide with a 2'-O-methyl
phosphorothioate modificationmisc_feature(97)..(99)nucleotide with
a 2'-O-methyl phosphorothioate modification 22agagcaacag ugcuguggcc
guuuuagagc uagaaauagc aaguuaaaau aaggcuaguc 60cguuaucaac uugaaaaagu
ggcaccgagu cggugcuuuu 1002320RNAArtificial SequenceSynthetic
Polynucleotidemisc_feature(1)..(3)nucleotide with a 2'-O-methyl
phosphorothioate modification 23agagcaacag ugcuguggcc
2024100RNAArtificial SequenceSynthetic
Polynucleotidemisc_feature(1)..(3)nucleotide with a 2'-O-methyl
phosphorothioate modificationmisc_feature(97)..(99)nucleotide with
a 2'-O-methyl phosphorothioate modification 24gcuacucucu cuuucuggcc
guuuuagagc uagaaauagc aaguuaaaau aaggcuaguc 60cguuaucaac uugaaaaagu
ggcaccgagu cggugcuuuu 1002520RNAArtificial SequenceSynthetic
Polynucleotidemisc_feature(1)..(3)nucleotide with a 2'-O-methyl
phosphorothioate modification 25gcuacucucu cuuucuggcc
202620DNAArtificial SequenceSynthetic Polynucleotide 26agagcaacag
tgctgtggcc 202720DNAArtificial SequenceSynthetic Polynucleotide
27gctactctct ctttctggcc 202823DNAArtificial SequenceSynthetic
Polynucleotide 28agagcaacag tgctgtggcc tgg 232923DNAArtificial
SequenceSynthetic Polynucleotide 29gctactctct ctttctggcc tgg
233022PRTArtificial SequenceSynthetic Polypeptide 30Met Leu Leu Leu
Val Thr Ser Leu Leu Leu Cys Glu Leu Pro His Pro1 5 10 15Ala Phe Leu
Leu Ile Pro 203121PRTArtificial SequenceSynthetic Polypeptide 31Met
Ala Leu Pro Val Thr Ala Leu Leu Leu Pro Leu Ala Leu Leu Leu1 5 10
15His Ala Ala Arg Pro 203223PRTArtificial SequenceSynthetic
Polypeptide 32Ile Tyr Ile Trp Ala Pro Leu Ala Gly Thr Cys Gly Val
Leu Leu Leu1 5 10 15Ser Leu Val Ile Thr Leu Tyr
2033126DNAArtificial SequenceSynthetic Polynucleotide 33aaacggggca
gaaagaaact cctgtatata ttcaaacaac catttatgag accagtacaa 60actactcaag
aggaagatgg ctgtagctgc cgatttccag aagaagaaga aggaggatgt 120gaactg
1263442PRTArtificial SequenceSynthetic Polypeptide 34Lys Arg Gly
Arg Lys Lys Leu Leu Tyr Ile Phe Lys Gln Pro Phe Met1 5 10 15Arg Pro
Val Gln Thr Thr Gln Glu Glu Asp Gly Cys Ser Cys Arg Phe 20 25 30Pro
Glu Glu Glu Glu Gly Gly Cys Glu Leu 35 4035120DNAArtificial
SequenceSynthetic Polynucleotide 35tcaaagcgga gtaggttgtt gcattccgat
tacatgaata tgactcctcg ccggcctggg 60ccgacaagaa aacattacca accctatgcc
cccccacgag acttcgctgc gtacaggtcc 1203640PRTArtificial
SequenceSynthetic Polypeptide 36Ser Lys Arg Ser Arg Leu Leu His Ser
Asp Tyr Met Asn Met Thr Pro1 5 10 15Arg Arg Pro Gly Pro Thr Arg Lys
His Tyr Gln Pro Tyr Ala Pro Pro 20 25 30Arg Asp Phe Ala Ala Tyr Arg
Ser 35 4037336DNAArtificial SequenceSynthetic Polynucleotide
37cgagtgaagt tttcccgaag cgcagacgct ccggcatatc agcaaggaca gaatcagctg
60tataacgaac tgaatttggg acgccgcgag gagtatgacg tgcttgataa acgccggggg
120agagacccgg aaatgggggg taaaccccga agaaagaatc cccaagaagg
actctacaat 180gaactccaga aggataagat ggcggaggcc tactcagaaa
taggtatgaa gggcgaacga 240cgacggggaa aaggtcacga tggcctctac
caagggttga gtacggcaac caaagatacg 300tacgatgcac tgcatatgca
ggccctgcct cccaga 33638112PRTArtificial SequenceSynthetic
Polypeptide 38Arg Val Lys Phe Ser Arg Ser Ala Asp Ala Pro Ala Tyr
Gln Gln Gly1 5 10 15Gln Asn Gln Leu Tyr Asn Glu Leu Asn Leu Gly Arg
Arg Glu Glu Tyr 20 25 30Asp Val Leu Asp Lys Arg Arg Gly Arg Asp Pro
Glu Met Gly Gly Lys 35 40 45Pro Arg Arg Lys Asn Pro Gln Glu Gly Leu
Tyr Asn Glu Leu Gln Lys 50 55 60Asp Lys Met Ala Glu Ala Tyr Ser Glu
Ile Gly Met Lys Gly Glu Arg65 70 75 80Arg Arg Gly Lys Gly His Asp
Gly Leu Tyr Gln Gly Leu Ser Thr Ala 85 90 95Thr Lys Asp Thr Tyr Asp
Ala Leu His Met Gln Ala Leu Pro Pro Arg 100 105
110391518DNAArtificial SequenceSynthetic Polynucleotide
39atgcttcttt tggttacgtc tctgttgctt tgcgaacttc ctcatccagc gttcttgctg
60atccccgata ttcagatgac tcagaccacc agtagcttgt ctgcctcact gggagaccga
120gtaacaatct cctgcagggc aagtcaagac attagcaaat acctcaattg
gtaccagcag 180aagcccgacg gaacggtaaa actcctcatc tatcatacgt
caaggttgca ttccggagta 240ccgtcacgat tttcaggttc tgggagcgga
actgactatt ccttgactat ttcaaacctc 300gagcaggagg acattgcgac
atatttttgt caacaaggta ataccctccc ttacactttc 360ggaggaggaa
ccaaactcga aattaccggg tccaccagtg gctctgggaa gcctggcagt
420ggagaaggtt ccactaaagg cgaggtgaag ctccaggaga gcggccccgg
tctcgttgcc 480cccagtcaaa gcctctctgt aacgtgcaca gtgagtggtg
tatcattgcc tgattatggc 540gtctcctgga taaggcagcc cccgcgaaag
ggtcttgaat ggcttggggt aatatggggc 600tcagagacaa cgtattataa
ctccgctctc aaaagtcgct tgacgataat aaaagataac 660tccaagagtc
aagttttcct taaaatgaac agtttgcaga ctgacgatac cgctatatat
720tattgtgcta aacattatta ctacggcggt agttacgcga tggattattg
ggggcagggg 780acttctgtca cagtcagtag tgctgctgcc tttgtcccgg
tatttctccc agccaaaccg 840accacgactc ccgccccgcg ccctccgaca
cccgctccca ccatcgcctc tcaacctctt 900agtcttcgcc ccgaggcatg
ccgacccgcc gccgggggtg ctgttcatac gaggggcttg 960gacttcgctt
gtgatattta catttgggct ccgttggcgg gtacgtgcgg cgtccttttg
1020ttgtcactcg ttattacttt gtattgtaat cacaggaatc gctcaaagcg
gagtaggttg 1080ttgcattccg attacatgaa tatgactcct cgccggcctg
ggccgacaag aaaacattac 1140caaccctatg cccccccacg agacttcgct
gcgtacaggt cccgagtgaa gttttcccga 1200agcgcagacg ctccggcata
tcagcaagga cagaatcagc tgtataacga actgaatttg 1260ggacgccgcg
aggagtatga cgtgcttgat aaacgccggg ggagagaccc ggaaatgggg
1320ggtaaacccc gaagaaagaa tccccaagaa ggactctaca atgaactcca
gaaggataag 1380atggcggagg cctactcaga aataggtatg aagggcgaac
gacgacgggg aaaaggtcac 1440gatggcctct accaagggtt gagtacggca
accaaagata cgtacgatgc actgcatatg 1500caggccctgc ctcccaga
151840506PRTArtificial SequenceSynthetic Polypeptide 40Met Leu Leu
Leu Val Thr Ser Leu Leu Leu Cys Glu Leu Pro His Pro1 5 10 15Ala Phe
Leu Leu Ile Pro Asp Ile Gln Met Thr Gln Thr Thr Ser Ser 20 25 30Leu
Ser Ala Ser Leu Gly Asp Arg Val Thr Ile Ser Cys Arg Ala Ser 35 40
45Gln Asp Ile Ser Lys Tyr Leu Asn Trp Tyr Gln Gln Lys Pro Asp Gly
50 55 60Thr Val Lys Leu Leu Ile Tyr His Thr Ser Arg Leu His Ser Gly
Val65 70 75 80Pro Ser Arg Phe Ser Gly Ser Gly Ser Gly Thr Asp Tyr
Ser Leu Thr 85 90 95Ile Ser Asn Leu Glu Gln Glu Asp Ile Ala Thr Tyr
Phe Cys Gln Gln 100 105 110Gly Asn Thr Leu Pro Tyr Thr Phe Gly Gly
Gly Thr Lys Leu Glu Ile 115 120 125Thr Gly Ser Thr Ser Gly Ser Gly
Lys Pro Gly Ser Gly Glu Gly Ser 130 135 140Thr Lys Gly Glu Val Lys
Leu Gln Glu Ser Gly Pro Gly Leu Val Ala145 150 155 160Pro Ser Gln
Ser Leu Ser Val Thr Cys Thr Val Ser Gly Val Ser Leu 165 170 175Pro
Asp Tyr Gly Val Ser Trp Ile Arg Gln Pro Pro Arg Lys Gly Leu 180 185
190Glu Trp Leu Gly Val Ile Trp Gly Ser Glu Thr Thr Tyr Tyr Asn Ser
195 200 205Ala Leu Lys Ser Arg Leu Thr Ile Ile Lys Asp Asn Ser Lys
Ser Gln 210 215 220Val Phe Leu Lys Met Asn Ser Leu Gln Thr Asp Asp
Thr Ala Ile Tyr225 230 235 240Tyr Cys Ala Lys His Tyr Tyr Tyr Gly
Gly Ser Tyr Ala Met Asp Tyr 245 250 255Trp Gly Gln Gly Thr Ser Val
Thr Val Ser Ser Ala Ala Ala Phe Val 260 265 270Pro Val Phe Leu Pro
Ala Lys Pro Thr Thr Thr Pro Ala Pro Arg Pro 275 280 285Pro Thr Pro
Ala Pro Thr Ile Ala Ser Gln Pro Leu Ser Leu Arg Pro 290 295 300Glu
Ala Cys Arg Pro Ala Ala Gly Gly Ala Val His Thr Arg Gly Leu305 310
315 320Asp Phe Ala Cys Asp Ile Tyr Ile Trp Ala Pro Leu Ala Gly Thr
Cys 325 330 335Gly Val Leu Leu Leu Ser Leu Val Ile Thr Leu Tyr Cys
Asn His Arg 340 345 350Asn Arg Ser Lys Arg Ser Arg Leu Leu His Ser
Asp Tyr Met Asn Met 355 360 365Thr Pro Arg Arg Pro Gly Pro Thr Arg
Lys His Tyr Gln Pro Tyr Ala 370 375 380Pro Pro Arg Asp Phe Ala Ala
Tyr Arg Ser Arg Val Lys Phe Ser Arg385 390 395 400Ser Ala Asp Ala
Pro Ala Tyr Gln Gln Gly Gln Asn Gln Leu Tyr Asn 405 410 415Glu Leu
Asn Leu Gly Arg Arg Glu Glu Tyr Asp Val Leu Asp Lys Arg 420 425
430Arg Gly Arg Asp Pro Glu Met Gly Gly Lys Pro Arg Arg Lys Asn Pro
435 440 445Gln Glu Gly Leu Tyr Asn Glu Leu Gln Lys Asp Lys Met Ala
Glu Ala 450 455 460Tyr Ser Glu Ile Gly Met Lys Gly Glu Arg Arg Arg
Gly Lys Gly His465 470 475 480Asp Gly Leu Tyr Gln Gly Leu Ser Thr
Ala Thr Lys Asp Thr Tyr Asp 485 490 495Ala Leu His Met Gln Ala Leu
Pro Pro Arg 500 50541800DNAArtificial SequenceSynthetic
Polynucleotide 41gagatgtaag gagctgctgt gacttgctca aggccttata
tcgagtaaac ggtagtgctg 60gggcttagac gcaggtgttc tgatttatag ttcaaaacct
ctatcaatga gagagcaatc 120tcctggtaat gtgatagatt tcccaactta
atgccaacat accataaacc tcccattctg 180ctaatgccca gcctaagttg
gggagaccac tccagattcc aagatgtaca gtttgctttg 240ctgggccttt
ttcccatgcc tgcctttact ctgccagagt tatattgctg gggttttgaa
300gaagatccta ttaaataaaa gaataagcag tattattaag tagccctgca
tttcaggttt 360ccttgagtgg caggccaggc ctggccgtga acgttcactg
aaatcatggc ctcttggcca 420agattgatag cttgtgcctg tccctgagtc
ccagtccatc acgagcagct ggtttctaag 480atgctatttc ccgtataaag
catgagaccg tgacttgcca gccccacaga gccccgccct 540tgtccatcac
tggcatctgg actccagcct gggttggggc aaagagggaa atgagatcat
600gtcctaaccc tgatcctctt gtcccacaga tatccagaac cctgaccctg
ccgtgtacca 660gctgagagac tctaaatcca gtgacaagtc tgtctgccta
ttcaccgatt ttgattctca 720aacaaatgtg tcacaaagta aggattctga
tgtgtatatc acagacaaaa ctgtgctaga 780catgaggtct atggacttca
80042804DNAArtificial SequenceSynthetic Polynucleotide 42tggagcaaca
aatctgactt tgcatgtgca aacgccttca acaacagcat tattccagaa 60gacaccttct
tccccagccc aggtaagggc agctttggtg ccttcgcagg ctgtttcctt
120gcttcaggaa tggccaggtt ctgcccagag ctctggtcaa tgatgtctaa
aactcctctg 180attggtggtc tcggccttat ccattgccac caaaaccctc
tttttactaa gaaacagtga 240gccttgttct ggcagtccag agaatgacac
gggaaaaaag cagatgaaga gaaggtggca 300ggagagggca cgtggcccag
cctcagtctc tccaactgag ttcctgcctg cctgcctttg 360ctcagactgt
ttgcccctta ctgctcttct aggcctcatt ctaagcccct tctccaagtt
420gcctctcctt atttctccct gtctgccaaa aaatctttcc cagctcacta
agtcagtctc 480acgcagtcac tcattaaccc accaatcact gattgtgccg
gcacatgaat gcaccaggtg 540ttgaagtgga ggaattaaaa agtcagatga
ggggtgtgcc cagaggaagc accattctag 600ttgggggagc ccatctgtca
gctgggaaaa gtccaaataa cttcagattg gaatgtgttt 660taactcaggg
ttgagaaaac agctaccttc aggacaaaag tcagggaagg gctctctgaa
720gaaatgctac ttgaagatac cagccctacc aagggcaggg agaggaccct
atagaggcct 780gggacaggag ctcaatgaga aagg 804431178DNAArtificial
SequenceSynthetic Polynucleotide 43ggctccggtg cccgtcagtg ggcagagcgc
acatcgccca cagtccccga gaagttgggg 60ggaggggtcg gcaattgaac cggtgcctag
agaaggtggc gcggggtaaa ctgggaaagt 120gatgtcgtgt actggctccg
cctttttccc gagggtgggg gagaaccgta tataagtgca 180gtagtcgccg
tgaacgttct ttttcgcaac gggtttgccg ccagaacaca ggtaagtgcc
240gtgtgtggtt cccgcgggcc tggcctcttt acgggttatg gcccttgcgt
gccttgaatt 300acttccactg gctgcagtac gtgattcttg atcccgagct
tcgggttgga agtgggtggg 360agagttcgag gccttgcgct taaggagccc
cttcgcctcg tgcttgagtt gaggcctggc 420ctgggcgctg gggccgccgc
gtgcgaatct ggtggcacct tcgcgcctgt ctcgctgctt 480tcgataagtc
tctagccatt taaaattttt gatgacctgc tgcgacgctt tttttctggc
540aagatagtct tgtaaatgcg ggccaagatc tgcacactgg tatttcggtt
tttggggccg 600cgggcggcga cggggcccgt gcgtcccagc gcacatgttc
ggcgaggcgg ggcctgcgag 660cgcggccacc gagaatcgga cgggggtagt
ctcaagctgg ccggcctgct ctggtgcctg 720gcctcgcgcc gccgtgtatc
gccccgccct gggcggcaag gctggcccgg tcggcaccag 780ttgcgtgagc
ggaaagatgg ccgcttcccg gccctgctgc agggagctca aaatggagga
840cgcggcgctc gggagagcgg gcgggtgagt cacccacaca aaggaaaagg
gcctttccgt 900cctcagccgt
cgcttcatgt gactccacgg agtaccgggc gccgtccagg cacctcgatt
960agttctcgag cttttggagt acgtcgtctt taggttgggg ggaggggttt
tatgcgatgg 1020agtttcccca cactgagtgg gtggagactg aagttaggcc
agcttggcac ttgatgtaat 1080tctccttgga atttgccctt tttgagtttg
gatcttggtt cattctcaag cctcagacag 1140tggttcaaag tttttttctt
ccatttcagg tgtcgtga 11784466DNAArtificial SequenceSynthetic
Polynucleotide 44atgcttcttt tggttacgtc tctgttgctt tgcgaacttc
ctcatccagc gttcttgctg 60atcccc 664522PRTArtificial
SequenceSynthetic Polypeptide 45Met Leu Leu Leu Val Thr Ser Leu Leu
Leu Cys Glu Leu Pro His Pro1 5 10 15Ala Phe Leu Leu Ile Pro
2046735DNAArtificial SequenceSynthetic Polynucleotide 46gatattcaga
tgactcagac caccagtagc ttgtctgcct cactgggaga ccgagtaaca 60atctcctgca
gggcaagtca agacattagc aaatacctca attggtacca gcagaagccc
120gacggaacgg taaaactcct catctatcat acgtcaaggt tgcattccgg
agtaccgtca 180cgattttcag gttctgggag cggaactgac tattccttga
ctatttcaaa cctcgagcag 240gaggacattg cgacatattt ttgtcaacaa
ggtaataccc tcccttacac tttcggagga 300ggaaccaaac tcgaaattac
cgggtccacc agtggctctg ggaagcctgg cagtggagaa 360ggttccacta
aaggcgaggt gaagctccag gagagcggcc ccggtctcgt tgcccccagt
420caaagcctct ctgtaacgtg cacagtgagt ggtgtatcat tgcctgatta
tggcgtctcc 480tggataaggc agcccccgcg aaagggtctt gaatggcttg
gggtaatatg gggctcagag 540acaacgtatt ataactccgc tctcaaaagt
cgcttgacga taataaaaga taactccaag 600agtcaagttt tccttaaaat
gaacagtttg cagactgacg ataccgctat atattattgt 660gctaaacatt
attactacgg cggtagttac gcgatggatt attgggggca ggggacttct
720gtcacagtca gtagt 73547245PRTArtificial SequenceSynthetic
Polypeptide 47Asp Ile Gln Met Thr Gln Thr Thr Ser Ser Leu Ser Ala
Ser Leu Gly1 5 10 15Asp Arg Val Thr Ile Ser Cys Arg Ala Ser Gln Asp
Ile Ser Lys Tyr 20 25 30Leu Asn Trp Tyr Gln Gln Lys Pro Asp Gly Thr
Val Lys Leu Leu Ile 35 40 45Tyr His Thr Ser Arg Leu His Ser Gly Val
Pro Ser Arg Phe Ser Gly 50 55 60Ser Gly Ser Gly Thr Asp Tyr Ser Leu
Thr Ile Ser Asn Leu Glu Gln65 70 75 80Glu Asp Ile Ala Thr Tyr Phe
Cys Gln Gln Gly Asn Thr Leu Pro Tyr 85 90 95Thr Phe Gly Gly Gly Thr
Lys Leu Glu Ile Thr Gly Ser Thr Ser Gly 100 105 110Ser Gly Lys Pro
Gly Ser Gly Glu Gly Ser Thr Lys Gly Glu Val Lys 115 120 125Leu Gln
Glu Ser Gly Pro Gly Leu Val Ala Pro Ser Gln Ser Leu Ser 130 135
140Val Thr Cys Thr Val Ser Gly Val Ser Leu Pro Asp Tyr Gly Val
Ser145 150 155 160Trp Ile Arg Gln Pro Pro Arg Lys Gly Leu Glu Trp
Leu Gly Val Ile 165 170 175Trp Gly Ser Glu Thr Thr Tyr Tyr Asn Ser
Ala Leu Lys Ser Arg Leu 180 185 190Thr Ile Ile Lys Asp Asn Ser Lys
Ser Gln Val Phe Leu Lys Met Asn 195 200 205Ser Leu Gln Thr Asp Asp
Thr Ala Ile Tyr Tyr Cys Ala Lys His Tyr 210 215 220Tyr Tyr Gly Gly
Ser Tyr Ala Met Asp Tyr Trp Gly Gln Gly Thr Ser225 230 235 240Val
Thr Val Ser Ser 24548261DNAArtificial SequenceSynthetic
Polynucleotide 48gctgctgcct ttgtcccggt atttctccca gccaaaccga
ccacgactcc cgccccgcgc 60cctccgacac ccgctcccac catcgcctct caacctctta
gtcttcgccc cgaggcatgc 120cgacccgccg ccgggggtgc tgttcatacg
aggggcttgg acttcgcttg tgatatttac 180atttgggctc cgttggcggg
tacgtgcggc gtccttttgt tgtcactcgt tattactttg 240tattgtaatc
acaggaatcg c 26149252DNAArtificial SequenceSynthetic Polynucleotide
49tttgtcccgg tatttctccc agccaaaccg accacgactc ccgccccgcg ccctccgaca
60cccgctccca ccatcgcctc tcaacctctt agtcttcgcc ccgaggcatg ccgacccgcc
120gccgggggtg ctgttcatac gaggggcttg gacttcgctt gtgatattta
catttgggct 180ccgttggcgg gtacgtgcgg cgtccttttg ttgtcactcg
ttattacttt gtattgtaat 240cacaggaatc gc 2525084PRTArtificial
SequenceSynthetic Polypeptide 50Phe Val Pro Val Phe Leu Pro Ala Lys
Pro Thr Thr Thr Pro Ala Pro1 5 10 15Arg Pro Pro Thr Pro Ala Pro Thr
Ile Ala Ser Gln Pro Leu Ser Leu 20 25 30Arg Pro Glu Ala Cys Arg Pro
Ala Ala Gly Gly Ala Val His Thr Arg 35 40 45Gly Leu Asp Phe Ala Cys
Asp Ile Tyr Ile Trp Ala Pro Leu Ala Gly 50 55 60Thr Cys Gly Val Leu
Leu Leu Ser Leu Val Ile Thr Leu Tyr Cys Asn65 70 75 80His Arg Asn
Arg51120PRTArtificial SequenceSynthetic Polypeptide 51Glu Val Lys
Leu Gln Glu Ser Gly Pro Gly Leu Val Ala Pro Ser Gln1 5 10 15Ser Leu
Ser Val Thr Cys Thr Val Ser Gly Val Ser Leu Pro Asp Tyr 20 25 30Gly
Val Ser Trp Ile Arg Gln Pro Pro Arg Lys Gly Leu Glu Trp Leu 35 40
45Gly Val Ile Trp Gly Ser Glu Thr Thr Tyr Tyr Asn Ser Ala Leu Lys
50 55 60Ser Arg Leu Thr Ile Ile Lys Asp Asn Ser Lys Ser Gln Val Phe
Leu65 70 75 80Lys Met Asn Ser Leu Gln Thr Asp Asp Thr Ala Ile Tyr
Tyr Cys Ala 85 90 95Lys His Tyr Tyr Tyr Gly Gly Ser Tyr Ala Met Asp
Tyr Trp Gly Gln 100 105 110Gly Thr Ser Val Thr Val Ser Ser 115
12052107PRTArtificial SequenceSynthetic Polypeptide 52Asp Ile Gln
Met Thr Gln Thr Thr Ser Ser Leu Ser Ala Ser Leu Gly1 5 10 15Asp Arg
Val Thr Ile Ser Cys Arg Ala Ser Gln Asp Ile Ser Lys Tyr 20 25 30Leu
Asn Trp Tyr Gln Gln Lys Pro Asp Gly Thr Val Lys Leu Leu Ile 35 40
45Tyr His Thr Ser Arg Leu His Ser Gly Val Pro Ser Arg Phe Ser Gly
50 55 60Ser Gly Ser Gly Thr Asp Tyr Ser Leu Thr Ile Ser Asn Leu Glu
Gln65 70 75 80Glu Asp Ile Ala Thr Tyr Phe Cys Gln Gln Gly Asn Thr
Leu Pro Tyr 85 90 95Thr Phe Gly Gly Gly Thr Lys Leu Glu Ile Thr 100
1055318PRTArtificial SequenceSynthetic Polypeptide 53Gly Ser Thr
Ser Gly Ser Gly Lys Pro Gly Ser Gly Glu Gly Ser Thr1 5 10 15Lys
Gly544358DNAArtificial SequenceSynthetic Polynucleotide
54gagatgtaag gagctgctgt gacttgctca aggccttata tcgagtaaac ggtagtgctg
60gggcttagac gcaggtgttc tgatttatag ttcaaaacct ctatcaatga gagagcaatc
120tcctggtaat gtgatagatt tcccaactta atgccaacat accataaacc
tcccattctg 180ctaatgccca gcctaagttg gggagaccac tccagattcc
aagatgtaca gtttgctttg 240ctgggccttt ttcccatgcc tgcctttact
ctgccagagt tatattgctg gggttttgaa 300gaagatccta ttaaataaaa
gaataagcag tattattaag tagccctgca tttcaggttt 360ccttgagtgg
caggccaggc ctggccgtga acgttcactg aaatcatggc ctcttggcca
420agattgatag cttgtgcctg tccctgagtc ccagtccatc acgagcagct
ggtttctaag 480atgctatttc ccgtataaag catgagaccg tgacttgcca
gccccacaga gccccgccct 540tgtccatcac tggcatctgg actccagcct
gggttggggc aaagagggaa atgagatcat 600gtcctaaccc tgatcctctt
gtcccacaga tatccagaac cctgaccctg ccgtgtacca 660gctgagagac
tctaaatcca gtgacaagtc tgtctgccta ttcaccgatt ttgattctca
720aacaaatgtg tcacaaagta aggattctga tgtgtatatc acagacaaaa
ctgtgctaga 780catgaggtct atggacttca ggctccggtg cccgtcagtg
ggcagagcgc acatcgccca 840cagtccccga gaagttgggg ggaggggtcg
gcaattgaac cggtgcctag agaaggtggc 900gcggggtaaa ctgggaaagt
gatgtcgtgt actggctccg cctttttccc gagggtgggg 960gagaaccgta
tataagtgca gtagtcgccg tgaacgttct ttttcgcaac gggtttgccg
1020ccagaacaca ggtaagtgcc gtgtgtggtt cccgcgggcc tggcctcttt
acgggttatg 1080gcccttgcgt gccttgaatt acttccactg gctgcagtac
gtgattcttg atcccgagct 1140tcgggttgga agtgggtggg agagttcgag
gccttgcgct taaggagccc cttcgcctcg 1200tgcttgagtt gaggcctggc
ctgggcgctg gggccgccgc gtgcgaatct ggtggcacct 1260tcgcgcctgt
ctcgctgctt tcgataagtc tctagccatt taaaattttt gatgacctgc
1320tgcgacgctt tttttctggc aagatagtct tgtaaatgcg ggccaagatc
tgcacactgg 1380tatttcggtt tttggggccg cgggcggcga cggggcccgt
gcgtcccagc gcacatgttc 1440ggcgaggcgg ggcctgcgag cgcggccacc
gagaatcgga cgggggtagt ctcaagctgg 1500ccggcctgct ctggtgcctg
gcctcgcgcc gccgtgtatc gccccgccct gggcggcaag 1560gctggcccgg
tcggcaccag ttgcgtgagc ggaaagatgg ccgcttcccg gccctgctgc
1620agggagctca aaatggagga cgcggcgctc gggagagcgg gcgggtgagt
cacccacaca 1680aaggaaaagg gcctttccgt cctcagccgt cgcttcatgt
gactccacgg agtaccgggc 1740gccgtccagg cacctcgatt agttctcgag
cttttggagt acgtcgtctt taggttgggg 1800ggaggggttt tatgcgatgg
agtttcccca cactgagtgg gtggagactg aagttaggcc 1860agcttggcac
ttgatgtaat tctccttgga atttgccctt tttgagtttg gatcttggtt
1920cattctcaag cctcagacag tggttcaaag tttttttctt ccatttcagg
tgtcgtgacc 1980accatgcttc ttttggttac gtctctgttg ctttgcgaac
ttcctcatcc agcgttcttg 2040ctgatccccg atattcagat gactcagacc
accagtagct tgtctgcctc actgggagac 2100cgagtaacaa tctcctgcag
ggcaagtcaa gacattagca aatacctcaa ttggtaccag 2160cagaagcccg
acggaacggt aaaactcctc atctatcata cgtcaaggtt gcattccgga
2220gtaccgtcac gattttcagg ttctgggagc ggaactgact attccttgac
tatttcaaac 2280ctcgagcagg aggacattgc gacatatttt tgtcaacaag
gtaataccct cccttacact 2340ttcggaggag gaaccaaact cgaaattacc
gggtccacca gtggctctgg gaagcctggc 2400agtggagaag gttccactaa
aggcgaggtg aagctccagg agagcggccc cggtctcgtt 2460gcccccagtc
aaagcctctc tgtaacgtgc acagtgagtg gtgtatcatt gcctgattat
2520ggcgtctcct ggataaggca gcccccgcga aagggtcttg aatggcttgg
ggtaatatgg 2580ggctcagaga caacgtatta taactccgct ctcaaaagtc
gcttgacgat aataaaagat 2640aactccaaga gtcaagtttt ccttaaaatg
aacagtttgc agactgacga taccgctata 2700tattattgtg ctaaacatta
ttactacggc ggtagttacg cgatggatta ttgggggcag 2760gggacttctg
tcacagtcag tagtgctgct gcctttgtcc cggtatttct cccagccaaa
2820ccgaccacga ctcccgcccc gcgccctccg acacccgctc ccaccatcgc
ctctcaacct 2880cttagtcttc gccccgaggc atgccgaccc gccgccgggg
gtgctgttca tacgaggggc 2940ttggacttcg cttgtgatat ttacatttgg
gctccgttgg cgggtacgtg cggcgtcctt 3000ttgttgtcac tcgttattac
tttgtattgt aatcacagga atcgctcaaa gcggagtagg 3060ttgttgcatt
ccgattacat gaatatgact cctcgccggc ctgggccgac aagaaaacat
3120taccaaccct atgccccccc acgagacttc gctgcgtaca ggtcccgagt
gaagttttcc 3180cgaagcgcag acgctccggc atatcagcaa ggacagaatc
agctgtataa cgaactgaat 3240ttgggacgcc gcgaggagta tgacgtgctt
gataaacgcc gggggagaga cccggaaatg 3300gggggtaaac cccgaagaaa
gaatccccaa gaaggactct acaatgaact ccagaaggat 3360aagatggcgg
aggcctactc agaaataggt atgaagggcg aacgacgacg gggaaaaggt
3420cacgatggcc tctaccaagg gttgagtacg gcaaccaaag atacgtacga
tgcactgcat 3480atgcaggccc tgcctcccag ataataataa aatcgctatc
catcgaagat ggatgtgtgt 3540tggttttttg tgtgtggagc aacaaatctg
actttgcatg tgcaaacgcc ttcaacaaca 3600gcattattcc agaagacacc
ttcttcccca gcccaggtaa gggcagcttt ggtgccttcg 3660caggctgttt
ccttgcttca ggaatggcca ggttctgccc agagctctgg tcaatgatgt
3720ctaaaactcc tctgattggt ggtctcggcc ttatccattg ccaccaaaac
cctcttttta 3780ctaagaaaca gtgagccttg ttctggcagt ccagagaatg
acacgggaaa aaagcagatg 3840aagagaaggt ggcaggagag ggcacgtggc
ccagcctcag tctctccaac tgagttcctg 3900cctgcctgcc tttgctcaga
ctgtttgccc cttactgctc ttctaggcct cattctaagc 3960cccttctcca
agttgcctct ccttatttct ccctgtctgc caaaaaatct ttcccagctc
4020actaagtcag tctcacgcag tcactcatta acccaccaat cactgattgt
gccggcacat 4080gaatgcacca ggtgttgaag tggaggaatt aaaaagtcag
atgaggggtg tgcccagagg 4140aagcaccatt ctagttgggg gagcccatct
gtcagctggg aaaagtccaa ataacttcag 4200attggaatgt gttttaactc
agggttgaga aaacagctac cttcaggaca aaagtcaggg 4260aagggctctc
tgaagaaatg ctacttgaag ataccagccc taccaagggc agggagagga
4320ccctatagag gcctgggaca ggagctcaat gagaaagg
4358551368PRTArtificial SequenceSynthetic Polypeptide 55Met Asp Lys
Lys Tyr Ser Ile Gly Leu Asp Ile Gly Thr Asn Ser Val1 5 10 15Gly Trp
Ala Val Ile Thr Asp Glu Tyr Lys Val Pro Ser Lys Lys Phe 20 25 30Lys
Val Leu Gly Asn Thr Asp Arg His Ser Ile Lys Lys Asn Leu Ile 35 40
45Gly Ala Leu Leu Phe Asp Ser Gly Glu Thr Ala Glu Ala Thr Arg Leu
50 55 60Lys Arg Thr Ala Arg Arg Arg Tyr Thr Arg Arg Lys Asn Arg Ile
Cys65 70 75 80Tyr Leu Gln Glu Ile Phe Ser Asn Glu Met Ala Lys Val
Asp Asp Ser 85 90 95Phe Phe His Arg Leu Glu Glu Ser Phe Leu Val Glu
Glu Asp Lys Lys 100 105 110His Glu Arg His Pro Ile Phe Gly Asn Ile
Val Asp Glu Val Ala Tyr 115 120 125His Glu Lys Tyr Pro Thr Ile Tyr
His Leu Arg Lys Lys Leu Val Asp 130 135 140Ser Thr Asp Lys Ala Asp
Leu Arg Leu Ile Tyr Leu Ala Leu Ala His145 150 155 160Met Ile Lys
Phe Arg Gly His Phe Leu Ile Glu Gly Asp Leu Asn Pro 165 170 175Asp
Asn Ser Asp Val Asp Lys Leu Phe Ile Gln Leu Val Gln Thr Tyr 180 185
190Asn Gln Leu Phe Glu Glu Asn Pro Ile Asn Ala Ser Gly Val Asp Ala
195 200 205Lys Ala Ile Leu Ser Ala Arg Leu Ser Lys Ser Arg Arg Leu
Glu Asn 210 215 220Leu Ile Ala Gln Leu Pro Gly Glu Lys Lys Asn Gly
Leu Phe Gly Asn225 230 235 240Leu Ile Ala Leu Ser Leu Gly Leu Thr
Pro Asn Phe Lys Ser Asn Phe 245 250 255Asp Leu Ala Glu Asp Ala Lys
Leu Gln Leu Ser Lys Asp Thr Tyr Asp 260 265 270Asp Asp Leu Asp Asn
Leu Leu Ala Gln Ile Gly Asp Gln Tyr Ala Asp 275 280 285Leu Phe Leu
Ala Ala Lys Asn Leu Ser Asp Ala Ile Leu Leu Ser Asp 290 295 300Ile
Leu Arg Val Asn Thr Glu Ile Thr Lys Ala Pro Leu Ser Ala Ser305 310
315 320Met Ile Lys Arg Tyr Asp Glu His His Gln Asp Leu Thr Leu Leu
Lys 325 330 335Ala Leu Val Arg Gln Gln Leu Pro Glu Lys Tyr Lys Glu
Ile Phe Phe 340 345 350Asp Gln Ser Lys Asn Gly Tyr Ala Gly Tyr Ile
Asp Gly Gly Ala Ser 355 360 365Gln Glu Glu Phe Tyr Lys Phe Ile Lys
Pro Ile Leu Glu Lys Met Asp 370 375 380Gly Thr Glu Glu Leu Leu Val
Lys Leu Asn Arg Glu Asp Leu Leu Arg385 390 395 400Lys Gln Arg Thr
Phe Asp Asn Gly Ser Ile Pro His Gln Ile His Leu 405 410 415Gly Glu
Leu His Ala Ile Leu Arg Arg Gln Glu Asp Phe Tyr Pro Phe 420 425
430Leu Lys Asp Asn Arg Glu Lys Ile Glu Lys Ile Leu Thr Phe Arg Ile
435 440 445Pro Tyr Tyr Val Gly Pro Leu Ala Arg Gly Asn Ser Arg Phe
Ala Trp 450 455 460Met Thr Arg Lys Ser Glu Glu Thr Ile Thr Pro Trp
Asn Phe Glu Glu465 470 475 480Val Val Asp Lys Gly Ala Ser Ala Gln
Ser Phe Ile Glu Arg Met Thr 485 490 495Asn Phe Asp Lys Asn Leu Pro
Asn Glu Lys Val Leu Pro Lys His Ser 500 505 510Leu Leu Tyr Glu Tyr
Phe Thr Val Tyr Asn Glu Leu Thr Lys Val Lys 515 520 525Tyr Val Thr
Glu Gly Met Arg Lys Pro Ala Phe Leu Ser Gly Glu Gln 530 535 540Lys
Lys Ala Ile Val Asp Leu Leu Phe Lys Thr Asn Arg Lys Val Thr545 550
555 560Val Lys Gln Leu Lys Glu Asp Tyr Phe Lys Lys Ile Glu Cys Phe
Asp 565 570 575Ser Val Glu Ile Ser Gly Val Glu Asp Arg Phe Asn Ala
Ser Leu Gly 580 585 590Thr Tyr His Asp Leu Leu Lys Ile Ile Lys Asp
Lys Asp Phe Leu Asp 595 600 605Asn Glu Glu Asn Glu Asp Ile Leu Glu
Asp Ile Val Leu Thr Leu Thr 610 615 620Leu Phe Glu Asp Arg Glu Met
Ile Glu Glu Arg Leu Lys Thr Tyr Ala625 630 635 640His Leu Phe Asp
Asp Lys Val Met Lys Gln Leu Lys Arg Arg Arg Tyr 645 650 655Thr Gly
Trp Gly Arg Leu Ser Arg Lys Leu Ile Asn Gly Ile Arg Asp 660 665
670Lys Gln Ser Gly Lys Thr Ile Leu Asp Phe Leu Lys Ser Asp Gly Phe
675 680 685Ala Asn Arg Asn Phe Met Gln Leu Ile His Asp Asp Ser Leu
Thr Phe 690 695 700Lys Glu Asp Ile Gln Lys Ala Gln Val Ser Gly Gln
Gly Asp Ser Leu705 710 715 720His Glu His Ile Ala Asn Leu Ala Gly
Ser Pro Ala Ile Lys Lys Gly 725 730 735Ile Leu Gln Thr Val Lys Val
Val Asp Glu Leu Val Lys Val Met Gly 740 745 750Arg His Lys Pro Glu
Asn Ile Val Ile Glu Met Ala Arg Glu Asn Gln 755 760 765Thr Thr Gln
Lys Gly Gln Lys
Asn Ser Arg Glu Arg Met Lys Arg Ile 770 775 780Glu Glu Gly Ile Lys
Glu Leu Gly Ser Gln Ile Leu Lys Glu His Pro785 790 795 800Val Glu
Asn Thr Gln Leu Gln Asn Glu Lys Leu Tyr Leu Tyr Tyr Leu 805 810
815Gln Asn Gly Arg Asp Met Tyr Val Asp Gln Glu Leu Asp Ile Asn Arg
820 825 830Leu Ser Asp Tyr Asp Val Asp His Ile Val Pro Gln Ser Phe
Leu Lys 835 840 845Asp Asp Ser Ile Asp Asn Lys Val Leu Thr Arg Ser
Asp Lys Asn Arg 850 855 860Gly Lys Ser Asp Asn Val Pro Ser Glu Glu
Val Val Lys Lys Met Lys865 870 875 880Asn Tyr Trp Arg Gln Leu Leu
Asn Ala Lys Leu Ile Thr Gln Arg Lys 885 890 895Phe Asp Asn Leu Thr
Lys Ala Glu Arg Gly Gly Leu Ser Glu Leu Asp 900 905 910Lys Ala Gly
Phe Ile Lys Arg Gln Leu Val Glu Thr Arg Gln Ile Thr 915 920 925Lys
His Val Ala Gln Ile Leu Asp Ser Arg Met Asn Thr Lys Tyr Asp 930 935
940Glu Asn Asp Lys Leu Ile Arg Glu Val Lys Val Ile Thr Leu Lys
Ser945 950 955 960Lys Leu Val Ser Asp Phe Arg Lys Asp Phe Gln Phe
Tyr Lys Val Arg 965 970 975Glu Ile Asn Asn Tyr His His Ala His Asp
Ala Tyr Leu Asn Ala Val 980 985 990Val Gly Thr Ala Leu Ile Lys Lys
Tyr Pro Lys Leu Glu Ser Glu Phe 995 1000 1005Val Tyr Gly Asp Tyr
Lys Val Tyr Asp Val Arg Lys Met Ile Ala 1010 1015 1020Lys Ser Glu
Gln Glu Ile Gly Lys Ala Thr Ala Lys Tyr Phe Phe 1025 1030 1035Tyr
Ser Asn Ile Met Asn Phe Phe Lys Thr Glu Ile Thr Leu Ala 1040 1045
1050Asn Gly Glu Ile Arg Lys Arg Pro Leu Ile Glu Thr Asn Gly Glu
1055 1060 1065Thr Gly Glu Ile Val Trp Asp Lys Gly Arg Asp Phe Ala
Thr Val 1070 1075 1080Arg Lys Val Leu Ser Met Pro Gln Val Asn Ile
Val Lys Lys Thr 1085 1090 1095Glu Val Gln Thr Gly Gly Phe Ser Lys
Glu Ser Ile Leu Pro Lys 1100 1105 1110Arg Asn Ser Asp Lys Leu Ile
Ala Arg Lys Lys Asp Trp Asp Pro 1115 1120 1125Lys Lys Tyr Gly Gly
Phe Asp Ser Pro Thr Val Ala Tyr Ser Val 1130 1135 1140Leu Val Val
Ala Lys Val Glu Lys Gly Lys Ser Lys Lys Leu Lys 1145 1150 1155Ser
Val Lys Glu Leu Leu Gly Ile Thr Ile Met Glu Arg Ser Ser 1160 1165
1170Phe Glu Lys Asn Pro Ile Asp Phe Leu Glu Ala Lys Gly Tyr Lys
1175 1180 1185Glu Val Lys Lys Asp Leu Ile Ile Lys Leu Pro Lys Tyr
Ser Leu 1190 1195 1200Phe Glu Leu Glu Asn Gly Arg Lys Arg Met Leu
Ala Ser Ala Gly 1205 1210 1215Glu Leu Gln Lys Gly Asn Glu Leu Ala
Leu Pro Ser Lys Tyr Val 1220 1225 1230Asn Phe Leu Tyr Leu Ala Ser
His Tyr Glu Lys Leu Lys Gly Ser 1235 1240 1245Pro Glu Asp Asn Glu
Gln Lys Gln Leu Phe Val Glu Gln His Lys 1250 1255 1260His Tyr Leu
Asp Glu Ile Ile Glu Gln Ile Ser Glu Phe Ser Lys 1265 1270 1275Arg
Val Ile Leu Ala Asp Ala Asn Leu Asp Lys Val Leu Ser Ala 1280 1285
1290Tyr Asn Lys His Arg Asp Lys Pro Ile Arg Glu Gln Ala Glu Asn
1295 1300 1305Ile Ile His Leu Phe Thr Leu Thr Asn Leu Gly Ala Pro
Ala Ala 1310 1315 1320Phe Lys Tyr Phe Asp Thr Thr Ile Asp Arg Lys
Arg Tyr Thr Ser 1325 1330 1335Thr Lys Glu Val Leu Asp Ala Thr Leu
Ile His Gln Ser Ile Thr 1340 1345 1350Gly Leu Tyr Glu Thr Arg Ile
Asp Leu Ser Gln Leu Gly Gly Asp 1355 1360 1365564682DNAArtificial
SequenceSynthetic Polynucleotide 56cctgcaggca gctgcgcgct cgctcgctca
ctgaggccgc ccgggcgtcg ggcgaccttt 60ggtcgcccgg cctcagtgag cgagcgagcg
cgcagagagg gagtggccaa ctccatcact 120aggggttcct gcggccgcac
gcgtgagatg taaggagctg ctgtgacttg ctcaaggcct 180tatatcgagt
aaacggtagt gctggggctt agacgcaggt gttctgattt atagttcaaa
240acctctatca atgagagagc aatctcctgg taatgtgata gatttcccaa
cttaatgcca 300acataccata aacctcccat tctgctaatg cccagcctaa
gttggggaga ccactccaga 360ttccaagatg tacagtttgc tttgctgggc
ctttttccca tgcctgcctt tactctgcca 420gagttatatt gctggggttt
tgaagaagat cctattaaat aaaagaataa gcagtattat 480taagtagccc
tgcatttcag gtttccttga gtggcaggcc aggcctggcc gtgaacgttc
540actgaaatca tggcctcttg gccaagattg atagcttgtg cctgtccctg
agtcccagtc 600catcacgagc agctggtttc taagatgcta tttcccgtat
aaagcatgag accgtgactt 660gccagcccca cagagccccg cccttgtcca
tcactggcat ctggactcca gcctgggttg 720gggcaaagag ggaaatgaga
tcatgtccta accctgatcc tcttgtccca cagatatcca 780gaaccctgac
cctgccgtgt accagctgag agactctaaa tccagtgaca agtctgtctg
840cctattcacc gattttgatt ctcaaacaaa tgtgtcacaa agtaaggatt
ctgatgtgta 900tatcacagac aaaactgtgc tagacatgag gtctatggac
ttcaggctcc ggtgcccgtc 960agtgggcaga gcgcacatcg cccacagtcc
ccgagaagtt ggggggaggg gtcggcaatt 1020gaaccggtgc ctagagaagg
tggcgcgggg taaactggga aagtgatgtc gtgtactggc 1080tccgcctttt
tcccgagggt gggggagaac cgtatataag tgcagtagtc gccgtgaacg
1140ttctttttcg caacgggttt gccgccagaa cacaggtaag tgccgtgtgt
ggttcccgcg 1200ggcctggcct ctttacgggt tatggccctt gcgtgccttg
aattacttcc actggctgca 1260gtacgtgatt cttgatcccg agcttcgggt
tggaagtggg tgggagagtt cgaggccttg 1320cgcttaagga gccccttcgc
ctcgtgcttg agttgaggcc tggcctgggc gctggggccg 1380ccgcgtgcga
atctggtggc accttcgcgc ctgtctcgct gctttcgata agtctctagc
1440catttaaaat ttttgatgac ctgctgcgac gctttttttc tggcaagata
gtcttgtaaa 1500tgcgggccaa gatctgcaca ctggtatttc ggtttttggg
gccgcgggcg gcgacggggc 1560ccgtgcgtcc cagcgcacat gttcggcgag
gcggggcctg cgagcgcggc caccgagaat 1620cggacggggg tagtctcaag
ctggccggcc tgctctggtg cctggcctcg cgccgccgtg 1680tatcgccccg
ccctgggcgg caaggctggc ccggtcggca ccagttgcgt gagcggaaag
1740atggccgctt cccggccctg ctgcagggag ctcaaaatgg aggacgcggc
gctcgggaga 1800gcgggcgggt gagtcaccca cacaaaggaa aagggccttt
ccgtcctcag ccgtcgcttc 1860atgtgactcc acggagtacc gggcgccgtc
caggcacctc gattagttct cgagcttttg 1920gagtacgtcg tctttaggtt
ggggggaggg gttttatgcg atggagtttc cccacactga 1980gtgggtggag
actgaagtta ggccagcttg gcacttgatg taattctcct tggaatttgc
2040cctttttgag tttggatctt ggttcattct caagcctcag acagtggttc
aaagtttttt 2100tcttccattt caggtgtcgt gaccaccatg cttcttttgg
ttacgtctct gttgctttgc 2160gaacttcctc atccagcgtt cttgctgatc
cccgatattc agatgactca gaccaccagt 2220agcttgtctg cctcactggg
agaccgagta acaatctcct gcagggcaag tcaagacatt 2280agcaaatacc
tcaattggta ccagcagaag cccgacggaa cggtaaaact cctcatctat
2340catacgtcaa ggttgcattc cggagtaccg tcacgatttt caggttctgg
gagcggaact 2400gactattcct tgactatttc aaacctcgag caggaggaca
ttgcgacata tttttgtcaa 2460caaggtaata ccctccctta cactttcgga
ggaggaacca aactcgaaat taccgggtcc 2520accagtggct ctgggaagcc
tggcagtgga gaaggttcca ctaaaggcga ggtgaagctc 2580caggagagcg
gccccggtct cgttgccccc agtcaaagcc tctctgtaac gtgcacagtg
2640agtggtgtat cattgcctga ttatggcgtc tcctggataa ggcagccccc
gcgaaagggt 2700cttgaatggc ttggggtaat atggggctca gagacaacgt
attataactc cgctctcaaa 2760agtcgcttga cgataataaa agataactcc
aagagtcaag ttttccttaa aatgaacagt 2820ttgcagactg acgataccgc
tatatattat tgtgctaaac attattacta cggcggtagt 2880tacgcgatgg
attattgggg gcaggggact tctgtcacag tcagtagtgc tgctgccttt
2940gtcccggtat ttctcccagc caaaccgacc acgactcccg ccccgcgccc
tccgacaccc 3000gctcccacca tcgcctctca acctcttagt cttcgccccg
aggcatgccg acccgccgcc 3060gggggtgctg ttcatacgag gggcttggac
ttcgcttgtg atatttacat ttgggctccg 3120ttggcgggta cgtgcggcgt
ccttttgttg tcactcgtta ttactttgta ttgtaatcac 3180aggaatcgct
caaagcggag taggttgttg cattccgatt acatgaatat gactcctcgc
3240cggcctgggc cgacaagaaa acattaccaa ccctatgccc ccccacgaga
cttcgctgcg 3300tacaggtccc gagtgaagtt ttcccgaagc gcagacgctc
cggcatatca gcaaggacag 3360aatcagctgt ataacgaact gaatttggga
cgccgcgagg agtatgacgt gcttgataaa 3420cgccggggga gagacccgga
aatggggggt aaaccccgaa gaaagaatcc ccaagaagga 3480ctctacaatg
aactccagaa ggataagatg gcggaggcct actcagaaat aggtatgaag
3540ggcgaacgac gacggggaaa aggtcacgat ggcctctacc aagggttgag
tacggcaacc 3600aaagatacgt acgatgcact gcatatgcag gccctgcctc
ccagataata ataaaatcgc 3660tatccatcga agatggatgt gtgttggttt
tttgtgtgtg gagcaacaaa tctgactttg 3720catgtgcaaa cgccttcaac
aacagcatta ttccagaaga caccttcttc cccagcccag 3780gtaagggcag
ctttggtgcc ttcgcaggct gtttccttgc ttcaggaatg gccaggttct
3840gcccagagct ctggtcaatg atgtctaaaa ctcctctgat tggtggtctc
ggccttatcc 3900attgccacca aaaccctctt tttactaaga aacagtgagc
cttgttctgg cagtccagag 3960aatgacacgg gaaaaaagca gatgaagaga
aggtggcagg agagggcacg tggcccagcc 4020tcagtctctc caactgagtt
cctgcctgcc tgcctttgct cagactgttt gccccttact 4080gctcttctag
gcctcattct aagccccttc tccaagttgc ctctccttat ttctccctgt
4140ctgccaaaaa atctttccca gctcactaag tcagtctcac gcagtcactc
attaacccac 4200caatcactga ttgtgccggc acatgaatgc accaggtgtt
gaagtggagg aattaaaaag 4260tcagatgagg ggtgtgccca gaggaagcac
cattctagtt gggggagccc atctgtcagc 4320tgggaaaagt ccaaataact
tcagattgga atgtgtttta actcagggtt gagaaaacag 4380ctaccttcag
gacaaaagtc agggaagggc tctctgaaga aatgctactt gaagatacca
4440gccctaccaa gggcagggag aggaccctat agaggcctgg gacaggagct
caatgagaaa 4500ggtaaccacg tgcggaccga ggctgcagcg tcgtcctccc
taggaacccc tagtgatgga 4560gttggccact ccctctctgc gcgctcgctc
gctcactgag gccgggcgac caaaggtcgc 4620ccgacgcccg ggctttgccc
gggcggcctc agtgagcgag cgagcgcgca gctgcctgca 4680gg 4682
* * * * *