Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review Article
  • Published:

Overcoming on-target, off-tumour toxicity of CAR T cell therapy for solid tumours

Nature Reviews Clinical Oncology volume 20, pages 49–62 (2023)Cite this article

Subjects

Abstract

Therapies with genetically modified T cells that express chimeric antigen receptors (CARs) specific for CD19 or B cell maturation antigen (BCMA) are approved to treat certain B cell malignancies. However, translating these successes into treatments for patients with solid tumours presents various challenges, including the risk of clinically serious on-target, off-tumour toxicity (OTOT) owing to CAR T cell-mediated cytotoxicity against non-malignant tissues expressing the target antigen. Indeed, severe OTOT has been observed in various CAR T cell clinical trials involving patients with solid tumours, highlighting the importance of establishing strategies to predict, mitigate and control the onset of this effect. In this Review, we summarize current clinical evidence of OTOT with CAR T cells in the treatment of solid tumours and discuss the utility of preclinical mouse models in predicting clinical OTOT. We then describe novel strategies being developed to improve the specificity of CAR T cells in solid tumours, particularly the role of affinity tuning of target binders, logic circuits and synthetic biology. Furthermore, we highlight control strategies that can be used to mitigate clinical OTOT following cell infusion such as regulating or eliminating CAR T cell activity, exogenous control of CAR expression, and local administration of CAR T cells.

Key points

  • Chimeric antigen receptor (CAR) T cell therapies have led to on-target, off-tumour toxicity (OTOT) in clinical trials involving patients with solid tumours.

  • Preclinical mouse models might provide inaccurate predictions of OTOT in patients, reflecting the need for better models to perform preclinical safety assessments.

  • Logic-gating circuits and synthetic biology approaches to CAR T cell engineering have demonstrated specificity in mice, although many of these approaches remain untested in clinical studies.

  • Methods of controlling CAR T cell activity and responding to unexpected OTOT have the potential to improve safety after infusion.

  • We advocate for robust preclinical analyses of the risks of OTOT and the implementation of control strategies capable of regulating CAR T cell activity in patients.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on SpringerLink
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Fig. 1: CAR architecture.
Fig. 2: CAR T cell cytolytic mechanisms and paracrine effects.
Fig. 3: Publicly available protein expression densities of selected solid tumour TAAs on non-malignant tissues.
Fig. 4: Principles of Boolean logic-gating to circumvent OTOT.
Fig. 5: Examples of logic-gating strategies tested in CAR T cells.
Fig. 6: Control switches in CAR T cells.
Fig. 7: Regional restriction of CAR T cell activity.

Similar content being viewed by others

References

  1. June, C. H. & Sadelain, M. Chimeric antigen receptor therapy. N. Engl. J. Med. 379, 64–73 (2018).

    Article  CAS  Google Scholar 

  2. Larson, R. C. & Maus, M. V. Recent advances and discoveries in the mechanisms and functions of CAR T cells. Nat. Rev. Cancer 21, 145–161 (2021).

    Article  CAS  Google Scholar 

  3. FDA. ABECMA (idecabtagene vicleucel). https://www.fda.gov/vaccines-blood-biologics/abecma-idecabtagene-vicleucel (2021).

  4. FDA. BREYANZI (lisocabtagene maraleucel). https://www.fda.gov/vaccines-blood-biologics/cellular-gene-therapy-products/breyanzi-lisocabtagene-maraleucel (2021).

  5. FDA. KYMRIAH (tisagenlecleucel). https://www.fda.gov/vaccines-blood-biologics/cellular-gene-therapy-products/kymriah-tisagenlecleucel (2021).

  6. FDA. TECARTUS (brexucabtagene autoleucel). https://www.fda.gov/vaccines-blood-biologics/cellular-gene-therapy-products/tecartus-brexucabtagene-autoleucel (2021).

  7. FDA. YESCARTA (axicabtagene ciloleucel). https://www.fda.gov/vaccines-blood-biologics/cellular-gene-therapy-products/yescarta-axicabtagene-ciloleucel (2021).

  8. FDA. CARVYKTI (ciltacabtagene autoleucel). https://www.fda.gov/vaccines-blood-biologics/carvykti (2022).

  9. Amini, L. et al. Preparing for CAR T cell therapy: patient selection, bridging therapies and lymphodepletion. Nat. Rev. Clin. Oncol. 19, 342–355 (2022).

    Article  Google Scholar 

  10. Logue, J. M. et al. Immune reconstitution and associated infections following axicabtagene ciloleucel in relapsed or refractory large B-cell lymphoma. Haematologica 106, 978–986 (2021).

    Article  CAS  Google Scholar 

  11. Uy, N. F. et al. Hypogammaglobulinemia and infection risk in chronic lymphocytic leukemia (CLL) patients treated with CD19-directed chimeric antigen receptor T (CAR-T) cells. Blood 136, 30–32 (2020).

    Article  Google Scholar 

  12. Schubert, M. L. et al. Side-effect management of chimeric antigen receptor (CAR) T-cell therapy. Ann. Oncol. 32, 34–48 (2021).

    Article  CAS  Google Scholar 

  13. Srivastava, S. et al. Logic-gated ROR1 chimeric antigen receptor expression rescues T cell-mediated toxicity to normal tissues and enables selective tumor targeting. Cancer Cell 35, 489–503.e8 (2019).

    Article  CAS  Google Scholar 

  14. Castellarin, M. et al. A rational mouse model to detect on-target, off-tumor CAR T cell toxicity. JCI Insight 5, e136012 (2020).

    Article  Google Scholar 

  15. Smith, J. B. et al. Tumor regression and delayed onset toxicity following B7-H4 CAR T cell therapy. Mol. Ther. 24, 1987–1999 (2016).

    Article  CAS  Google Scholar 

  16. Labanieh, L. et al. Enhanced safety and efficacy of protease-regulated CAR-T cell receptors. Cell 185, 1745–1763 (2022).

    Article  CAS  Google Scholar 

  17. Lamers, C. H. et al. Treatment of metastatic renal cell carcinoma with autologous T-lymphocytes genetically retargeted against carbonic anhydrase IX: first clinical experience. J. Clin. Oncol. 24, e20–e22 (2006).

    Article  Google Scholar 

  18. Lamers, C. H. J. et al. Treatment of metastatic renal cell carcinoma (mRCC) with CAIX CAR-engineered T-cells–a completed study overview. Biochem. Soc. Trans. 44, 951–959 (2016).

    Article  CAS  Google Scholar 

  19. Feng, K.-C. et al. Cocktail treatment with EGFR-specific and CD133-specific chimeric antigen receptor-modified T cells in a patient with advanced cholangiocarcinoma. J. Hematol. Oncol. 10, 4 (2017).

    Article  Google Scholar 

  20. Guo, Y. et al. Phase I study of chimeric antigen receptor-modified T cells in patients with EGFR-positive advanced biliary tract cancers. Clin. Cancer Res. 24, 1277–1286 (2018).

    Article  CAS  Google Scholar 

  21. Liu, Y. et al. Anti-EGFR chimeric antigen receptor-modified T cells in metastatic pancreatic carcinoma: a phase I clinical trial. Cytotherapy 22, 573–580 (2020).

    Article  Google Scholar 

  22. Feng, K. et al. Phase I study of chimeric antigen receptor modified T cells in treating HER2-positive advanced biliary tract cancers and pancreatic cancers. Protein Cell 9, 838–847 (2018).

    Article  CAS  Google Scholar 

  23. Thistlethwaite, F. C. et al. The clinical efficacy of first-generation carcinoembryonic antigen (CEACAM5)-specific CAR T cells is limited by poor persistence and transient pre-conditioning-dependent respiratory toxicity. Cancer Immunol. Immunother. 66, 1425–1436 (2017).

    Article  CAS  Google Scholar 

  24. Qi, C. et al. Claudin18.2-specific CAR T cells in gastrointestinal cancers: phase 1 trial interim results. Nat. Med. 28, 1189–1198 (2022).

    Article  CAS  Google Scholar 

  25. Zhang, Y. et al. Phase I clinical trial of EGFR-specific CAR-T cells generated by the piggyBac transposon system in advanced relapsed/refractory non-small cell lung cancer patients. J. Cancer Res. Clin. Oncol. 147, 3725–3734 (2021).

    Article  CAS  Google Scholar 

  26. Richman, S. A. et al. High-affinity GD2-specific CAR T cells induce fatal encephalitis in a preclinical neuroblastoma model. Cancer Immunol. Res. 6, 36–46 (2018).

    Article  CAS  Google Scholar 

  27. Davenport, A. J. et al. Chimeric antigen receptor T cells form nonclassical and potent immune synapses driving rapid cytotoxicity. Proc. Natl Acad. Sci. USA 115, E2068–E2076 (2018).

    Article  CAS  Google Scholar 

  28. Meiraz, A., Garber, O. G., Harari, S., Hassin, D. & Berke, G. Switch from perforin-expressing to perforin-deficient CD8+ T cells accounts for two distinct types of effector cytotoxic T lymphocytes in vivo. Immunology 128, 69–82 (2009).

    Article  CAS  Google Scholar 

  29. Hong, L. K. et al. CD30-redirected chimeric antigen receptor T cells target CD30+ and CD30- embryonal carcinoma via antigen-dependent and Fas/FasL interactions. Cancer Immunol. Res. 6, 1274–1287 (2018).

    Article  CAS  Google Scholar 

  30. Benmebarek, M.-R. et al. Killing mechanisms of chimeric antigen receptor (CAR) T cells. Int. J. Mol. Sci. 20, 1283 (2019).

    Article  CAS  Google Scholar 

  31. Dufva, O. et al. Integrated drug profiling and CRISPR screening identify essential pathways for CAR T-cell cytotoxicity. Blood 135, 597–609 (2020).

    Article  Google Scholar 

  32. Schietinger, A. et al. A mutant chaperone converts a wild-type protein into a tumor-specific antigen. Science 314, 304–308 (2006).

    Article  CAS  Google Scholar 

  33. Wong, A. J. et al. Structural alterations of the epidermal growth factor receptor gene in human gliomas. Proc. Natl Acad. Sci. USA 89, 2965–2969 (1992).

    Article  CAS  Google Scholar 

  34. Posey, A. D. Jr et al. Engineered CAR T cells targeting the cancer-associated Tn-glycoform of the membrane mucin MUC1 control adenocarcinoma. Immunity 44, 1444–1454 (2016).

    Article  CAS  Google Scholar 

  35. Heitzeneder, S. et al. GPC2-CAR T cells tuned for low antigen density mediate potent activity against neuroblastoma without toxicity. Cancer Cell 40, 53–69.e9 (2021).

    Article  Google Scholar 

  36. Bosse, K. R. et al. Identification of GPC2 as an oncoprotein and candidate immunotherapeutic target in high-risk neuroblastoma. Cancer Cell 32, 295–309.e12 (2017).

    Article  CAS  Google Scholar 

  37. Smith, C. C. et al. Alternative tumour-specific antigens. Nat. Rev. Cancer 19, 465–478 (2019).

    Article  CAS  Google Scholar 

  38. Schumacher, T. N. & Schreiber, R. D. Neoantigens in cancer immunotherapy. Science 348, 69–74 (2015).

    Article  CAS  Google Scholar 

  39. Li, G. & Wong, A. J. EGF receptor variant III as a target antigen for tumor immunotherapy. Expert Rev. Vaccines 7, 977–985 (2008).

    Article  Google Scholar 

  40. O’Rourke, D. M. et al. A single dose of peripherally infused EGFRvIII-directed CAR T cells mediates antigen loss and induces adaptive resistance in patients with recurrent glioblastoma. Sci. Transl. Med. 9, eaaa0984 (2017).

    Article  Google Scholar 

  41. Vitanza, N. A. et al. Locoregional infusion of HER2-specific CAR T cells in children and young adults with recurrent or refractory CNS tumors: an interim analysis. Nat. Med. 27, 1544–1552 (2021).

    Article  CAS  Google Scholar 

  42. Ahmed, N. et al. Autologous HER2 CMV bispecific CAR T cells are safe and demonstrate clinical benefit for glioblastoma in a Phase I trial. J. ImmunoTher. Cancer 3, O11 (2015).

    Article  Google Scholar 

  43. Hegde, M. et al. Tumor response and endogenous immune reactivity after administration of HER2 CAR T cells in a child with metastatic rhabdomyosarcoma. Nat. Commun. 11, 3549 (2020).

    Article  CAS  Google Scholar 

  44. Morgan, R. A. et al. Case report of a serious adverse event following the administration of T cells transduced with a chimeric antigen receptor recognizing ERBB2. Mol. Ther. 18, 843–851 (2010).

    Article  CAS  Google Scholar 

  45. Ivanov, S. et al. Expression of hypoxia-inducible cell-surface transmembrane carbonic anhydrases in human cancer. Am. J. Pathol. 158, 905–919 (2001).

    Article  CAS  Google Scholar 

  46. Moghimi, B. et al. Preclinical assessment of the efficacy and specificity of GD2-B7H3 SynNotch CAR-T in metastatic neuroblastoma. Nat. Commun. 12, 511 (2021).

    Article  CAS  Google Scholar 

  47. Du, H. et al. Antitumor responses in the absence of toxicity in solid tumors by targeting B7-H3 via chimeric antigen receptor T cells. Cancer Cell 35, 221–237.e8 (2019).

    Article  CAS  Google Scholar 

  48. Beatty, G. L. et al. Activity of mesothelin-specific chimeric antigen receptor T cells against pancreatic carcinoma metastases in a phase 1 trial. Gastroenterology 155, 29–32 (2018).

    Article  CAS  Google Scholar 

  49. Haas, A. R. et al. Phase I study of lentiviral-transduced chimeric antigen receptor-modified T cells recognizing mesothelin in advanced solid cancers. Mol. Ther. 27, 1919–1929 (2019).

    Article  CAS  Google Scholar 

  50. Maus, M. V. et al. T cells expressing chimeric antigen receptors can cause anaphylaxis in humans. Cancer Immunol. Res. 1, 26–31 (2013).

    Article  CAS  Google Scholar 

  51. Beatty, G. L. et al. Mesothelin-specific chimeric antigen receptor mRNA-engineered T cells induce anti-tumor activity in solid malignancies. Cancer Immunol. Res. 2, 112–120 (2014).

    Article  CAS  Google Scholar 

  52. Heczey, A. et al. CAR T cells administered in combination with lymphodepletion and PD-1 inhibition to patients with neuroblastoma. Mol. Ther. 25, 2214–2224 (2017).

    Article  CAS  Google Scholar 

  53. Straathof, K. et al. Antitumor activity without on-target off-tumor toxicity of GD2–chimeric antigen receptor T cells in patients with neuroblastoma. Sci. Transl. Med. 12, eabd6169 (2020).

    Article  CAS  Google Scholar 

  54. Pule, M. A. et al. Virus-specific T cells engineered to coexpress tumor-specific receptors: persistence and antitumor activity in individuals with neuroblastoma. Nat. Med. 14, 1264–1270 (2008).

    Article  CAS  Google Scholar 

  55. Louis, C. U. et al. Antitumor activity and long-term fate of chimeric antigen receptor-positive T cells in patients with neuroblastoma. Blood 118, 6050–6056 (2011).

    Article  CAS  Google Scholar 

  56. Gargett, T. et al. GD2-specific CAR T cells undergo potent activation and deletion following antigen encounter but can be protected from activation-induced cell death by PD-1 blockade. Mol. Ther. 24, 1135–1149 (2016).

    Article  CAS  Google Scholar 

  57. Lamers, C. H. et al. Treatment of metastatic renal cell carcinoma with CAIX CAR-engineered T cells: clinical evaluation and management of on-target toxicity. Mol. Ther. 21, 904–912 (2013).

    Article  CAS  Google Scholar 

  58. Uhlén, M. et al. Tissue-based map of the human proteome. Science 347, 1260419 (2015).

    Article  Google Scholar 

  59. Ahmed, N. et al. Human epidermal growth factor receptor 2 (HER2) -specific chimeric antigen receptor-modified T cells for the immunotherapy of HER2-positive sarcoma. J. Clin. Oncol. 33, 1688–1696 (2015).

    Article  CAS  Google Scholar 

  60. Ahmed, N. et al. HER2-specific chimeric antigen receptor–modified virus-specific T cells for progressive glioblastoma: a phase 1 dose-escalation trial. JAMA Oncol. 3, 1094–1101 (2017).

    Article  Google Scholar 

  61. Brown, C. E. et al. Bioactivity and safety of IL13Rα2-redirected chimeric antigen receptor CD8+ T cells in patients with recurrent glioblastoma. Clin. Cancer Res. 21, 4062–4072 (2015).

    Article  CAS  Google Scholar 

  62. Parker, K. R. et al. Single-cell analyses identify brain mural cells expressing CD19 as potential off-tumor targets for CAR-T immunotherapies. Cell 183, 126–142.e17 (2020).

    Article  CAS  Google Scholar 

  63. Van Oekelen, O. et al. Neurocognitive and hypokinetic movement disorder with features of parkinsonism after BCMA-targeting CAR-T cell therapy. Nat. Med. 27, 2099–2103 (2021).

    Article  Google Scholar 

  64. Mount, C. W. et al. Potent antitumor efficacy of anti-GD2 CAR T cells in H3-K27M+ diffuse midline gliomas. Nat. Med. 24, 572–579 (2018).

    Article  CAS  Google Scholar 

  65. Park, S. et al. Micromolar affinity CAR T cells to ICAM-1 achieves rapid tumor elimination while avoiding systemic toxicity. Sci. Rep. 7, 14366 (2017).

    Article  Google Scholar 

  66. Kosti, P. et al. Hypoxia-sensing CAR T cells provide safety and efficacy in treating solid tumors. Cell Rep. Med. 2, 100227 (2021).

    Article  CAS  Google Scholar 

  67. Majzner, R. G., Weber, E. W., Lynn, R. C., Xu, P. & Mackall, C. L. Neurotoxicity associated with a high-affinity GD2 CAR-letter. Cancer Immunol. Res. 6, 494–495 (2018).

    Article  Google Scholar 

  68. Majzner, R. G. et al. GD2-CAR T cell therapy for H3K27M-mutated diffuse midline gliomas. Nature 603, 934–941 (2022).

    Article  CAS  Google Scholar 

  69. Kato, D. et al. GPC1 specific CAR-T cells eradicate established solid tumor without adverse effects and synergize with anti-PD-1 Ab. eLlife 9, e49392 (2020).

    Article  CAS  Google Scholar 

  70. Fedorov, V. D., Themeli, M. & Sadelain, M. PD-1- and CTLA-4-based inhibitory chimeric antigen receptors (iCARs) divert off-target immunotherapy responses. Sci. Transl. Med. 5, 215ra172 (2013).

    Article  Google Scholar 

  71. Caruso, H. G. et al. Tuning sensitivity of CAR to EGFR density limits recognition of normal tissue while maintaining potent antitumor activity. Cancer Res. 75, 3505–3518 (2015).

    Article  CAS  Google Scholar 

  72. Hernandez-Lopez, R. A. et al. T cell circuits that sense antigen density with an ultrasensitive threshold. Science 371, 1166–1171 (2021).

    Article  CAS  Google Scholar 

  73. Cui, X. et al. Dissecting the immunosuppressive tumor microenvironments in Glioblastoma-on-a-Chip for optimized PD-1 immunotherapy. eLlife 9, e52253 (2020).

    Article  CAS  Google Scholar 

  74. Ingber, D. E. Human organs-on-chips for disease modelling, drug development and personalized medicine. Nat. Rev. Genet. 23, 467–491 (2022).

    Article  CAS  Google Scholar 

  75. Liu, X. et al. Affinity-tuned ErbB2 or EGFR chimeric antigen receptor T cells exhibit an increased therapeutic index against tumors in mice. Cancer Res. 75, 3596–3607 (2015).

    Article  CAS  Google Scholar 

  76. Watanabe, K. et al. Excessively high-affinity single-chain fragment variable region in a chimeric antigen receptor can counteract T-cell proliferation. Blood 124, 4799 (2014).

    Article  Google Scholar 

  77. Majzner, R. G. & Mackall, C. L. Tumor antigen escape from CAR T-cell therapy. Cancer Discov. 8, 1219–1226 (2018).

    Article  CAS  Google Scholar 

  78. Hegde, M. et al. Tandem CAR T cells targeting HER2 and IL13Rα2 mitigate tumor antigen escape. J. Clin. Invest. 126, 3036–3052 (2016).

    Article  Google Scholar 

  79. Fry, T. J. et al. CD22-targeted CAR T cells induce remission in B-ALL that is naive or resistant to CD19-targeted CAR immunotherapy. Nat. Med. 24, 20–28 (2018).

    Article  CAS  Google Scholar 

  80. Alabanza, L. et al. Function of Novel anti-CD19 chimeric antigen receptors with human variable regions is affected by hinge and transmembrane domains. Mol. Ther. 25, 2452–2465 (2017).

    Article  CAS  Google Scholar 

  81. Majzner, R. G. et al. Tuning the antigen density requirement for CAR T-cell activity. Cancer Discov. 10, 702–723 (2020).

    Article  CAS  Google Scholar 

  82. Feucht, J. et al. Calibration of CAR activation potential directs alternative T cell fates and therapeutic potency. Nat. Med. 25, 82–88 (2019).

    Article  CAS  Google Scholar 

  83. Wilkie, S. et al. Dual targeting of ErbB2 and MUC1 in breast cancer using chimeric antigen receptors engineered to provide complementary signaling. J. Clin. Immunol. 32, 1059–1070 (2012).

    Article  CAS  Google Scholar 

  84. Kloss, C. C., Condomines, M., Cartellieri, M., Bachmann, M. & Sadelain, M. Combinatorial antigen recognition with balanced signaling promotes selective tumor eradication by engineered T cells. Nat. Biotechnol. 31, 71–75 (2013).

    Article  CAS  Google Scholar 

  85. Zhang, E. et al. Recombination of a dual-CAR-modified T lymphocyte to accurately eliminate pancreatic malignancy. J. Hematol. Oncol. 11, 102 (2018).

    Article  Google Scholar 

  86. Sukumaran, S. et al. Enhancing the potency and specificity of engineered T cells for cancer treatment. Cancer Discov. 8, 972–987 (2018).

    Article  CAS  Google Scholar 

  87. Zhang, W. et al. Abstract PO074: Logic-gating HER2 CAR-T to the tumor microenvironment mitigates on-target, off-tumor toxicity without compromising cytotoxicity against HER2-over-expressing tumors. Cancer Immunol. Res. 9, PO074 (2021).

    Article  Google Scholar 

  88. Vaupel, P. & Multhoff, G. Revisiting the Warburg effect: historical dogma versus current understanding. J. Physiol. 599, 1745–1757 (2021).

    Article  CAS  Google Scholar 

  89. Juillerat, A. et al. An oxygen sensitive self-decision making engineered CAR T-cell. Sci. Rep. 7, 39833 (2017).

    Article  CAS  Google Scholar 

  90. Han, X. et al. Masked chimeric antigen receptor for tumor-specific activation. Mol. Ther. 25, 274–284 (2017).

    Article  CAS  Google Scholar 

  91. Liu, C., Sun, C., Huang, H., Janda, K. & Edgington, T. Overexpression of legumain in tumors is significant for invasion/metastasis and a candidate enzymatic target for prodrug therapy. Cancer Res. 63, 2957–2964 (2003).

    CAS  Google Scholar 

  92. Liu, G., Shuman, M. A. & Cohen, R. L. Co-expression of urokinase, urokinase receptor and PAI-1 is necessary for optimum invasiveness of cultured lung cancer cells. Int. J. Cancer 60, 501–506 (1995).

    Article  CAS  Google Scholar 

  93. Singhal, R. & Shah, Y. M. Oxygen battle in the gut: Hypoxia and hypoxia-inducible factors in metabolic and inflammatory responses in the intestine. J. Biol. Chem. 295, 10493–10505 (2020).

    Article  CAS  Google Scholar 

  94. Zhang, J. L. et al. Measurement of renal tissue oxygenation with blood oxygen level-dependent MRI and oxygen transit modeling. Am. J. Physiol. Ren. Physiol. 306, F579–F587 (2014).

    Article  CAS  Google Scholar 

  95. Dumas, S. J. et al. Phenotypic diversity and metabolic specialization of renal endothelial cells. Nat. Rev. Nephrol. 17, 441–464 (2021).

    Article  CAS  Google Scholar 

  96. Roybal, K. T. et al. Engineering T cells with customized therapeutic response programs using synthetic notch receptors. Cell 167, 419–432.e416 (2016).

    Article  CAS  Google Scholar 

  97. Roybal, K. T. et al. Precision tumor recognition by T cells with combinatorial antigen-sensing circuits. Cell 164, 770–779 (2016).

    Article  CAS  Google Scholar 

  98. Morsut, L. et al. Engineering customized cell sensing and response behaviors using synthetic notch receptors. Cell 164, 780–791 (2016).

    Article  CAS  Google Scholar 

  99. Hyrenius-Wittsten, A. et al. SynNotch CAR circuits enhance solid tumor recognition and promote persistent antitumor activity in mouse models. Sci. Transl. Med. 13, eabd8836 (2021).

    Article  CAS  Google Scholar 

  100. Choe, J. H. et al. SynNotch-CAR T cells overcome challenges of specificity, heterogeneity, and persistence in treating glioblastoma. Sci. Transl. Med. 13, eabe7378 (2021).

    Article  CAS  Google Scholar 

  101. Williams, J. Z. et al. Precise T cell recognition programs designed by transcriptionally linking multiple receptors. Science 370, 1099–1104 (2020).

    Article  CAS  Google Scholar 

  102. Wagner, D. L. et al. Immunogenicity of CAR T cells in cancer therapy. Nat. Rev. Clin. Oncol. 18, 379–393 (2021).

    Article  Google Scholar 

  103. Zhu, I. et al. Modular design of synthetic receptors for programmed gene regulation in cell therapies. Cell 185, 1431–1443 (2022).

    Article  CAS  Google Scholar 

  104. Feldmann, A. et al. Retargeting of T lymphocytes to PSCA- or PSMA positive prostate cancer cells using the novel modular chimeric antigen receptor platform technology “UniCAR”. Oncotarget 8, 31368–31385 (2017).

    Article  Google Scholar 

  105. Albert, S. et al. A novel nanobody-based target module for retargeting of T lymphocytes to EGFR-expressing cancer cells via the modular UniCAR platform. Oncoimmunology 6, e1287246 (2017).

    Article  Google Scholar 

  106. Mitwasi, N. et al. Development of novel target modules for retargeting of UniCAR T cells to GD2 positive tumor cells. Oncotarget 8, 108584–108603 (2017).

    Article  Google Scholar 

  107. Jureczek, J. et al. Highly efficient targeting of EGFR-expressing tumor cells with UniCAR T cells via target modules based on cetuximab(®). OncoTargets Ther. 13, 5515–5527 (2020).

    Article  CAS  Google Scholar 

  108. Cho, J. H., Collins, J. J. & Wong, W. W. Universal chimeric antigen receptors for multiplexed and logical control of T cell responses. Cell 173, 1426–1438.e11 (2018).

    Article  CAS  Google Scholar 

  109. Salzer, B. et al. Engineering AvidCARs for combinatorial antigen recognition and reversible control of CAR function. Nat. Commun. 11, 4166 (2020).

    Article  CAS  Google Scholar 

  110. Carmeliet, P. VEGF as a key mediator of angiogenesis in cancer. Oncology 69, 4–10 (2005).

    Article  CAS  Google Scholar 

  111. Richards, R. M. et al. NOT-Gated CD93 CAR T cells effectively target AML with minimized endothelial cross-reactivity. Blood Cancer Discov. 2, 648–665 (2021).

    Article  CAS  Google Scholar 

  112. Sandberg, M. L. et al. A carcinoembryonic antigen-specific cell therapy selectively targets tumor cells with HLA loss of heterozygosity in vitro and in vivo. Sci. Transl. Med. 14, eabm0306 (2022).

    Article  CAS  Google Scholar 

  113. McGranahan, N. et al. Allele-specific HLA loss and immune escape in lung cancer evolution. Cell 171, 1259–1271.e11 (2017).

    Article  CAS  Google Scholar 

  114. De Mattos-Arruda, L. et al. The genomic and immune landscapes of lethal metastatic breast cancer. Cell Rep. 27, 2690–2708.e10 (2019).

    Article  Google Scholar 

  115. Dong, L.-Q. et al. Heterogeneous immunogenomic features and distinct escape mechanisms in multifocal hepatocellular carcinoma. J. Hepatol. 72, 896–908 (2020).

    Article  CAS  Google Scholar 

  116. Hamburger, A. E. et al. Engineered T cells directed at tumors with defined allelic loss. Mol. Immunol. 128, 298–310 (2020).

    Article  CAS  Google Scholar 

  117. Tokatlian, T. et al. Mesothelin-specific CAR-T cell therapy that incorporates an HLA-gated safety mechanism selectively kills tumor cells. J. Immunother. Cancer 10, e003826 (2022).

    Article  Google Scholar 

  118. Hwang, M. S. et al. Targeting loss of heterozygosity for cancer-specific immunotherapy. Proc. Natl Acad. Sci. USA 118, e2022410118 (2021).

    Article  CAS  Google Scholar 

  119. Lajoie, M. J. et al. Designed protein logic to target cells with precise combinations of surface antigens. Science 369, 1637–1643 (2020).

    Article  CAS  Google Scholar 

  120. Brudno, J. N. & Kochenderfer, J. N. Toxicities of chimeric antigen receptor T cells: recognition and management. Blood 127, 3321–3330 (2016).

    Article  CAS  Google Scholar 

  121. Thompson, J. A. New NCCN guidelines: recognition and management of immunotherapy-related toxicity. J. Natl Compr. Canc. Netw. 16, 594–596 (2018).

    Article  Google Scholar 

  122. Weber, E. W. et al. Pharmacologic control of CAR-T cell function using dasatinib. Blood Adv. 3, 711–717 (2019).

    Article  CAS  Google Scholar 

  123. Mestermann, K. et al. The tyrosine kinase inhibitor dasatinib acts as a pharmacologic on/off switch for CAR T cells. Sci. Transl. Med. 11, eaau5907 (2019).

    Article  Google Scholar 

  124. Weber, E. W. et al. Transient rest restores functionality in exhausted CAR-T cells through epigenetic remodeling. Science 372, eaba1786 (2021).

    Article  CAS  Google Scholar 

  125. Porkka, K. et al. Dasatinib crosses the blood-brain barrier and is an efficient therapy for central nervous system Philadelphia chromosome-positive leukemia. Blood 112, 1005–1012 (2008).

    Article  CAS  Google Scholar 

  126. Straathof, K. C. et al. An inducible caspase 9 safety switch for T-cell therapy. Blood 105, 4247–4254 (2005).

    Article  CAS  Google Scholar 

  127. Stavrou, M. et al. A rapamycin-activated Caspase 9-based suicide gene. Mol. Ther. 26, 1266–1276 (2018).

    Article  CAS  Google Scholar 

  128. Duong, M. T. et al. Two-dimensional regulation of CAR-T cell therapy with orthogonal switches. Mol. Ther. Oncolytics 12, 124–137 (2019).

    Article  Google Scholar 

  129. Philip, B. et al. A highly compact epitope-based marker/suicide gene for easier and safer T-cell therapy. Blood 124, 1277–1287 (2014).

    Article  CAS  Google Scholar 

  130. Wang, X. et al. A transgene-encoded cell surface polypeptide for selection, in vivo tracking, and ablation of engineered cells. Blood 118, 1255–1263 (2011).

    Article  CAS  Google Scholar 

  131. Di Stasi, A. et al. Inducible apoptosis as a safety switch for adoptive cell therapy. N. Engl. J. Med. 365, 1673–1683 (2011).

    Article  Google Scholar 

  132. de Witte, M. A. et al. An inducible caspase 9 safety switch can halt cell therapy-induced autoimmune disease. J. Immunol. 180, 6365–6373 (2008).

    Article  Google Scholar 

  133. Foster, M. C. et al. Utility of a safety switch to abrogate CD19.CAR T-cell-associated neurotoxicity. Blood 137, 3306–3309 (2021).

    Article  CAS  Google Scholar 

  134. Paszkiewicz, P. J. et al. Targeted antibody-mediated depletion of murine CD19 CAR T cells permanently reverses B cell aplasia. J. Clin. Invest. 126, 4262–4272 (2016).

    Article  Google Scholar 

  135. Villaseñor, R. et al. Trafficking of endogenous immunoglobulins by endothelial cells at the blood-brain barrier. Sci. Rep. 6, 25658 (2016).

    Article  Google Scholar 

  136. Wehler, T. C. et al. Cetuximab-induced skin exanthema: prophylactic and reactive skin therapy are equally effective. J. Cancer Res. Clin. Oncol. 139, 1667–1672 (2013).

    Article  CAS  Google Scholar 

  137. Koristka, S. et al. Anti-CAR-engineered T cells for epitope-based elimination of autologous CAR T cells. Cancer Immunol. Immunother. 68, 1401–1415 (2019).

    Article  CAS  Google Scholar 

  138. Juillerat, A. et al. Modulation of chimeric antigen receptor surface expression by a small molecule switch. BMC Biotechnol. 19, 44–44 (2019).

    Article  Google Scholar 

  139. Sahillioglu, A. C., Toebes, M., Apriamashvili, G., Gomez, R. & Schumacher, T. N. CRASH-IT switch enables reversible and dose-dependent control of TCR and CAR T-cell function. Cancer Immunol. Res. 9, 999–1007 (2021).

    Article  CAS  Google Scholar 

  140. Li, H. S. et al. High-performance multiplex drug-gated CAR circuits. Cancer Cell https://doi.org/10.1016/j.ccell.2022.08.008 (2022).

    Article  Google Scholar 

  141. Jan, M. et al. Reversible ON- and OFF-switch chimeric antigen receptors controlled by lenalidomide. Sci. Transl. Med. 13, eabb6295 (2021).

    Article  CAS  Google Scholar 

  142. Wu, C. Y., Roybal, K. T., Puchner, E. M., Onuffer, J. & Lim, W. A. Remote control of therapeutic T cells through a small molecule-gated chimeric receptor. Science 350, aab4077 (2015).

    Article  Google Scholar 

  143. Lohmueller, J. et al. Post-translational covalent assembly of CAR and synNotch receptors for programmable antigen targeting. Preprint at https://doi.org/10.1101/2020.01.17.909895 (2020).

  144. Mata, M. et al. Inducible activation of MyD88 and CD40 in CAR T cells results in controllable and potent antitumor activity in preclinical solid tumor models. Cancer Discov. 7, 1306–1319 (2017).

    Article  CAS  Google Scholar 

  145. Kotter, B. et al. Titratable pharmacological regulation of CAR T cells using zinc finger-based transcription factors. Cancers 13, 4741 (2021).

    Article  CAS  Google Scholar 

  146. Hotblack, A. et al. Tunable control of CAR T cell activity through tetracycline mediated disruption of protein-protein interaction. Sci. Rep. 11, 21902 (2021).

    Article  CAS  Google Scholar 

  147. Richman, S. A. et al. Ligand-induced degradation of a CAR permits reversible remote control of CAR T cell activity in vitro and in vivo. Mol. Ther. 28, 1600–1613 (2020).

    Article  CAS  Google Scholar 

  148. Zajc, C. U. et al. A conformation-specific ON-switch for controlling CAR T cells with an orally available drug. Proc. Natl Acad. Sci. USA 117, 14926 (2020).

    Article  CAS  Google Scholar 

  149. Leung, W.-H. et al. Sensitive and adaptable pharmacological control of CAR T cells through extracellular receptor dimerization. JCI Insight 5, e124430 (2019).

    Article  Google Scholar 

  150. Monteys, A. M. et al. Regulated control of gene therapies by drug-induced splicing. Nature 596, 291–295 (2021).

    Article  CAS  Google Scholar 

  151. Pan, Y. et al. Mechanogenetics for the remote and noninvasive control of cancer immunotherapy. Proc. Natl Acad. Sci. USA 115, 992–997 (2018).

    Article  CAS  Google Scholar 

  152. Wu, Y. et al. Control of the activity of CAR-T cells within tumours via focused ultrasound. Nat. Biomed. Eng. 5, 1336–1347 (2021).

    Article  CAS  Google Scholar 

  153. Huang, Z. et al. Engineering light-controllable CAR T cells for cancer immunotherapy. Sci. Adv. 6, eaay9209 (2020).

    Article  CAS  Google Scholar 

  154. Kobayashi, A. et al. Light-controllable binary switch activation of CAR T cells. ChemMedChem 17, e202100722 (2022).

    CAS  Google Scholar 

  155. Priceman, S. J. et al. Regional delivery of chimeric antigen receptor-engineered T cells effectively targets HER2+ breast cancer metastasis to the brain. Clin. Cancer Res. 24, 95–105 (2018).

    Article  CAS  Google Scholar 

  156. Tchou, J. et al. Safety and efficacy of intratumoral injections of chimeric antigen receptor (CAR) T cells in metastatic breast cancer. Cancer Immunol. Res. 5, 1152–1161 (2017).

    Article  CAS  Google Scholar 

  157. Hiltbrunner, S. et al. Local delivery of CAR T cells targeting fibroblast activation protein is safe in patients with pleural mesothelioma: first report of FAPME, a phase I clinical trial. Ann. Oncol. 32, 120–121 (2021).

    Article  CAS  Google Scholar 

  158. Donovan, L. K. et al. Locoregional delivery of CAR T cells to the cerebrospinal fluid for treatment of metastatic medulloblastoma and ependymoma. Nat. Med. 26, 720–731 (2020).

    Article  CAS  Google Scholar 

  159. Nellan, A. et al. Durable regression of Medulloblastoma after regional and intravenous delivery of anti-HER2 chimeric antigen receptor T cells. J. Immunother. Cancer 6, 30 (2018).

    Article  Google Scholar 

  160. Brown, C. E. et al. Regression of glioblastoma after chimeric antigen receptor T-cell therapy. N. Engl. J. Med. 375, 2561–2569 (2016).

    Article  CAS  Google Scholar 

  161. Theruvath, J. et al. Locoregionally administered B7-H3-targeted CAR T cells for treatment of atypical teratoid/rhabdoid tumors. Nat. Med. 26, 712–719 (2020).

    Article  CAS  Google Scholar 

  162. Adusumilli, P. S. et al. A phase I trial of regional mesothelin-targeted CAR T-cell therapy in patients with malignant pleural disease, in combination with the anti-PD-1 agent pembrolizumab. Cancer Discov. 11, 2748–2763 (2021).

    Article  CAS  Google Scholar 

  163. Haydar, D. et al. Cell-surface antigen profiling of pediatric brain tumors: B7-H3 is consistently expressed and can be targeted via local or systemic CAR T-cell delivery. NeuroOncology 23, 999–1011 (2021).

    CAS  Google Scholar 

  164. Srivastava, S. & Riddell, S. R. Chimeric antigen receptor T cell therapy: challenges to bench-to-bedside efficacy. J. Immunol. 200, 459–468 (2018).

    Article  CAS  Google Scholar 

  165. Savoldo, B. et al. CD28 costimulation improves expansion and persistence of chimeric antigen receptor-modified T cells in lymphoma patients. J. Clin. Invest. 121, 1822–1826 (2011).

    Article  CAS  Google Scholar 

  166. Imai, C. et al. Chimeric receptors with 4-1BB signaling capacity provoke potent cytotoxicity against acute lymphoblastic leukemia. Leukemia 4, 676-84 (2004).

    Article  Google Scholar 

  167. Xiao, Q. et al. Size-dependent activation of CAR-T cells. Sci. Immunol. 7, eabl3995 (2022).

    Article  CAS  Google Scholar 

  168. Alizadeh, D. et al. IFNγ is critical for CAR T cell-mediated myeloid activation and induction of endogenous immunity. Cancer Discov. 11, 2248–2265 (2021).

    Article  CAS  Google Scholar 

  169. Chmielewski, M., Kopecky, C., Hombach, A. A. & Abken, H. IL-12 release by engineered T cells expressing chimeric antigen receptors can effectively Muster an antigen-independent macrophage response on tumor cells that have shut down tumor antigen expression. Cancer Res. 71, 5697–5706 (2011).

    Article  CAS  Google Scholar 

  170. Zhang, L. et al. Improving adoptive T cell therapy by targeting and controlling IL-12 expression to the tumor environment. Mol. Ther. 19, 751–759 (2011).

    Article  CAS  Google Scholar 

  171. Uhlen, M. et al. Towards a knowledge-based human protein atlas. Nat. Biotechnol. 28, 1248–1250 (2010).

    Article  CAS  Google Scholar 

  172. Nagata, Y. et al. Expression cloning of beta 1,4 N-acetylgalactosaminyltransferase cDNAs that determine the expression of GM2 and GD2 gangliosides. J. Biol. Chem. 267, 12082–12089 (1992).

    Article  CAS  Google Scholar 

Download references

Acknowledgements

The authors thank K. T. Roybal (University of California, San Francisco, USA) for his helpful comments on an earlier draft of the manuscript. They thank A. Cadinanos-Garai (University of Southern California, USA) for her critical review of the manuscript and figures. The work of G.K. is supported by R01NS121249 from NINDS and the Assisi Foundation of Memphis. The work of M.A. is supported, in part, by award P30CA014089 from the US NIH National Cancer Institute (NCI).

Author information

Author notes

  1. These authors contributed equally: Dimitrios L. Wagner and Mohamed Abou-el-Enein.

Authors and Affiliations

  1. Division of Medical Oncology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA

    Christian L. Flugel & Mohamed Abou-el-Enein

  2. BIH Center for Regenerative Therapies (BCRT), Berlin Institute of Health (BIH) at Charité–Universitätsmedizin Berlin, Berlin, Germany

    Christian L. Flugel & Dimitrios L. Wagner

  3. Department of Paediatrics, Stanford University School of Medicine, Stanford, CA, USA

    Robbie G. Majzner

  4. Stanford Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA, USA

    Robbie G. Majzner

  5. Department of Bone Marrow Transplantation and Cellular Therapy, St Jude Children’s Research Hospital, Memphis, TN, USA

    Giedre Krenciute

  6. Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

    Gianpietro Dotti

  7. Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

    Gianpietro Dotti

  8. Fred Hutchinson Cancer Research Center, Seattle, WA, USA

    Stanley R. Riddell

  9. Department of Medicine University of Washington, Seattle, WA, USA

    Stanley R. Riddell

  10. Berlin Center for Advanced Therapies (BeCAT), Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany

    Dimitrios L. Wagner

  11. Department of Stem Cell Biology and Regenerative Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA

    Mohamed Abou-el-Enein

  12. USC/CHLA Cell Therapy Program, University of Southern California, and Children’s Hospital Los Angeles, Los Angeles, CA, USA

    Mohamed Abou-el-Enein

Authors
  1. Christian L. Flugel
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Robbie G. Majzner
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Giedre Krenciute
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Gianpietro Dotti
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Stanley R. Riddell
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Dimitrios L. Wagner
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Mohamed Abou-el-Enein
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

C.L.F, D.L.W. and M.A. researched data for the manuscript, all authors made a substantial contribution to discussions of content. C.L.F., D.L.W. and M.A. wrote the manuscript, and all authors reviewed and/or edited the manuscript prior to submission.

Corresponding author

Correspondence to Mohamed Abou-el-Enein.

Ethics declarations

Competing interests

R.G.M. has acted as an adviser and/or consultant of Aptorum Group, Arovella Therapeutics, Immunai, Innervate Radiopharmaceuticals, Link Cell Therapies, Lyell Immunopharma, NKarta, Syncopation Life Sciences, and Zai lab and is a co-founder of and holds equity in Syncopation Life Sciences and Link Cell Therapies. G.K. has patent applications in the field of immunotherapy. G.D. has acted as a scientific adviser and/or consultant of Bellicum Pharmaceutical and Catamaran and Tessa Therapeutics and holds patents in the field of CAR T cells. S.R.R. has acted as a scientific adviser of Adaptive Biotechnologies and Juno Therapeutics, is a co-founder of and has intellectual property licensed to Lyell Immunopharma and Juno Therapeutics, and holds shares in and has received research funding from Lyell Immunopharma. C.L.F., D.L.W. and M.A. declare no competing interests.

Peer review

Peer review information

Nature Reviews Clinical Oncology thanks L. Shen, M. Maus, and the other, anonymous, reviewer(s), for their contribution to the peer review of this work.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Flugel, C.L., Majzner, R.G., Krenciute, G. et al. Overcoming on-target, off-tumour toxicity of CAR T cell therapy for solid tumours. Nat Rev Clin Oncol 20, 49–62 (2023). https://doi.org/10.1038/s41571-022-00704-3

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/s41571-022-00704-3

This article is cited by

Search

Advanced search

Quick links

Nature Briefing: Cancer

Sign up for the Nature Briefing: Cancer newsletter — what matters in cancer research, free to your inbox weekly.

Get what matters in cancer research, free to your inbox weekly. Sign up for Nature Briefing: Cancer