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Potent antitumor efficacy of anti-GD2 CAR T cells in H3-K27M+ diffuse midline gliomas

Nature Medicine volume 24, pages 572–579 (2018)Cite this article

Abstract

Diffuse intrinsic pontine glioma (DIPG) and other diffuse midline gliomas (DMGs) with mutated histone H3 K27M (H3-K27M)1,2,3,4,5 are aggressive and universally fatal pediatric brain cancers6. Chimeric antigen receptor (CAR)-expressing T cells have mediated impressive clinical activity in B cell malignancies7,8,9,10, and recent results suggest benefit in central nervous system malignancies11,12,13. Here, we report that patient-derived H3-K27M-mutant glioma cell cultures exhibit uniform, high expression of the disialoganglioside GD2. Anti-GD2 CAR T cells incorporating a 4-1BBz costimulatory domain14 demonstrated robust antigen-dependent cytokine generation and killing of DMG cells in vitro. In five independent patient-derived H3-K27M+ DMG orthotopic xenograft models, systemic administration of GD2-targeted CAR T cells cleared engrafted tumors except for a small number of residual GD2lo glioma cells. To date, GD2-targeted CAR T cells have been well tolerated in clinical trials15,16,17. Although GD2-targeted CAR T cell administration was tolerated in the majority of mice bearing orthotopic xenografts, peritumoral neuroinflammation during the acute phase of antitumor activity resulted in hydrocephalus that was lethal in a fraction of animals. Given the precarious neuroanatomical location of midline gliomas, careful monitoring and aggressive neurointensive care management will be required for human translation. With a cautious multidisciplinary clinical approach, GD2-targeted CAR T cell therapy for H3-K27M+ diffuse gliomas of pons, thalamus and spinal cord could prove transformative for these lethal childhood cancers.

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Fig. 1: GD2 is a target for immunotherapy in DIPG.
Fig. 2: GD2-CAR T cells mediate a potent and lasting antitumor response in DIPG orthotopic xenografts.
Fig. 3: GD2-CAR T cell therapy improves survival in mice with DIPG orthotopic xenografts.
Fig. 4: GD2 CAR T cell therapy effectively clears other midline H3-K27M-mutant pediatric DMGs but is associated with toxicity in thalamic xenografts.

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Acknowledgements

We thank the following for generously providing cell cultures: A. Moore (University of Queensland) and C. Jones (Institute of Cancer Research) for QCTB R059, R. Seeger (Children's Hospital Los Angeles) for CHLA136, 255, C. Khanna (National Cancer Institute) for MG63-3 and L. Helman (Children's Hospital Los Angeles) for EW8 and TC32.

This work was supported by a Stand Up To Cancer–St. Baldrick’s–National Cancer Institute Pediatric Dream Team Translational Cancer Research Grant (C.L.M.). Stand Up To Cancer is a program of the Entertainment Industry Foundation administered by the American Association for Cancer Research. C.L.M is a member of the Parker Institute for Cancer Immunotherapy, which supports the Stanford University Cancer Immunotherapy Program. The authors gratefully acknowledge support from the National Institute of Neurological Disorders and Stroke (F31NS098554 to C.W.M. and R01NS092597 to M.M.), Abbie’s Army Foundation (M.M.), Unravel Pediatric Cancer (M.M.), Maiy’s Miracle Foundation (E.P.A.), Stella S. Jones Foundation (M.M.), McKenna Claire Foundation (M.M.), Alex’s Lemonade Stand Foundation (M.M.), Izzy's Infantry Foundation (M.M.), The Cure Starts Now Foundation and DIPG Collaborative (M.M.), Lyla Nsouli Foundation (M.M.), Declan Gloster Memorial Fund (M.M.), N8 Foundation (M.M.), Fly a Kite Foundation (M.M.), Liwei Wang Research Fund (M.M.), Virginia and D.K. Ludwig Fund for Cancer Research (M.M. and C.L.M.), Sam Jeffers Foundation (M.M.), Michael Mosier DEFEAT DIPG Foundation (M.M.), ChadTough Foundation (M.M.), Reller Family Research Fund, Child Health Research Institute at Stanford and SPARK program (M.M.) and the Anne T. and Robert M. Bass Endowed Faculty Scholarship in Pediatric Cancer and Blood Diseases (M.M.).

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Author notes

  1. These authors contributed equally: Christopher W. Mount and Robbie G. Majzner.

Authors and Affiliations

  1. Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA

    Christopher W. Mount, Shree Sundaresh, Evan P. Arnold, Pamelyn J. Woo, Hannes Vogel & Michelle Monje

  2. Medical Scientist Training Program, Stanford University, Stanford, CA, USA

    Christopher W. Mount

  3. Neurosciences Program, Stanford University, Stanford, CA, USA

    Christopher W. Mount

  4. Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA

    Robbie G. Majzner, Meena Kadapakkam, Samuel Haile, Louai Labanieh, Skyler P. Rietberg, Hannes Vogel, Michelle Monje & Crystal L. Mackall

  5. Department of Bioengineering, Stanford University, Stanford, CA, USA

    Louai Labanieh

  6. Department of Pediatric Oncology, VU University Medical Center, Amsterdam, The Netherlands

    Esther Hulleman

  7. Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA

    Hannes Vogel & Michelle Monje

  8. Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA

    Hannes Vogel & Michelle Monje

  9. Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA, USA

    Michelle Monje & Crystal L. Mackall

  10. Stanford Institute for Stem Cell and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, USA

    Michelle Monje

  11. Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA

    Crystal L. Mackall

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Contributions

C.W.M. and E.P.A. performed the antibody array screening. C.W.M. and M.M. identified GD2 as a target in H3-K27M+ DMGs. C.W.M. and S.S. performed immunohistochemistry and immunofluorescence microscopy on primary and xenograft tissue. L.L. and R.G.M. designed CAR constructs. R.G.M. and M.K. prepared CAR T cells for in vivo experiments. C.W.M. and P.J.W. conducted in vivo experiments. R.G.M., M.K. and S.P.R. performed in vitro T cell experiments and flow cytometry. E.H. contributed VUMC-DIPG10 and data on ganglioside synthesis pathway expression. H.V. performed neuropathological review of brain tissue. S.H. performed CRISPR–Cas9-mediated gene editing. C.W.M., R.G.M., H.V., M.M. and C.L.M. contributed to data analysis and interpretation. C.W.M., M.M., R.G.M. and C.L.M wrote the manuscript. C.W.M. and R.G.M. made the figures. M.M. and C.L.M. supervised all aspects of the work.

Corresponding authors

Correspondence to Michelle Monje or Crystal L. Mackall.

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Competing interests

C.L.M, M.M., R.G.M. and C.W.M. are inventors on a patent application for GD2-directed CAR use for H3-K27M DMG.

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Supplementary Text and Figures

Supplementary Figures 1–10 and Supplementary Tables 2 and 3

Reporting Summary

Supplementary Table 1

Surface Panel Flow Cytometry Screening Data

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Mount, C.W., Majzner, R.G., Sundaresh, S. et al. Potent antitumor efficacy of anti-GD2 CAR T cells in H3-K27M+ diffuse midline gliomas. Nat Med 24, 572–579 (2018). https://doi.org/10.1038/s41591-018-0006-x

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