Abstract
Refractory or relapsed T cell acute lymphoblastic leukemia (r/r T-ALL) patients have poor prognoses, due to the lack of effective salvage therapies. Recently, CD7-targeting chimeric antigen receptor (CAR)-T therapies show efficacy in patients with r/r T-ALL, but relapse with CD7 loss is common. This study evaluates a CD5-gene-edited CAR-T cell therapy targeting CD5 in 19 r/r T-ALL patients, most of whom had previously failed CD7 CAR-T interventions. CAR-T products were derived from previous transplant donors (Cohort A) or newly matched donors (Cohort B). Primary endpoints were dose-limiting toxicity at 21 days and adverse events within 30 days. Secondary endpoints were responses, pharmacokinetics and severe adverse events after 30 days. A total of 16 received infusions, 10 at target dose of 1 × 106 kg−1. All encountered grade 3–4 cytopenias and one had a grade 3 infection within 30 days. All patients (100%) achieved complete remission or complete remission with incomplete blood count recovery by day 30. At a median follow-up of 14.3 months, four received transplantation; three were in remission and one died of infection. Of 12 untransplanted patients, 2 were in remission, 3 relapsed, 5 died of infection and 2 of thrombotic microangiopathy. CAR-T cells persisted and cleared CD5+ T cells. CD5− T cells, mostly CD5-gene-edited, increased but remained below normal levels. These results suggest this CD5-specific CAR-T intervention has a high remission rate for T-ALL patients. Evidence also suggests the risk of late-onset severe infection may be mitigated with consolidative transplantation. This study provides insights that could help to optimize this promising intervention. ClinicalTrials.gov registration: NCT05032599.
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Data availability
Requests for access to patient data are reviewed and approved by the ethics committee. All data provided will be anonymized to respect the privacy of patients who participated in the trial, in accordance with applicable regulations. Requests for data related to the manuscript can be made to the corresponding authors (panj@gobroadhealthcare.com or fengxiaoming@ihcams.ac.cn). Requests will be processed within 12 weeks. The paper and its Supplementary Information provide all of the data supporting the study’s findings. RNA-seq analysis and off-target prediction tool parameters were utilized human genome (v.hg38) (https://www.ncbi.nlm.nih.gov/datasets/genome/GCF_000001405.26/). TCR, DNA-seq and RNA-seq data have been deposited in the National Center for Biotechnology Information Sequence Read Archive (NCBI SRA accession number: PRJNA1132755). Source data are provided with this paper.
Code availability
No custom code was used.
References
Teachey, D. T. & Pui, C. H. Comparative features and outcomes between paediatric T-cell and B-cell acute lymphoblastic leukaemia. Lancet Oncol. 20, 142–154 (2019).
Burkhardt, B. et al. Poor outcome for children and adolescents with progressive disease or relapse of lymphoblastic lymphoma: a report from the Berlin-Frankfurt-Muenster group. J. Clin. Oncol. 27, 3363–3369 (2009).
NCCN Clinical Practice Guidelines in Oncology: Acute Lymphoblastic Leukemia (Version 1. 2020) (National Comprehensive Cancer Network, (2020); www.nccn.org/professionals/physician_gls/pdf/all.pdf
Bader, P. et al. Prognostic value of minimal residual disease quantification before allogeneic stem-cell transplantation in relapsed childhood acute lymphoblastic leukemia: the ALL-REZ BFM Study Group. J. Clin. Oncol. 27, 377–384 (2009).
Pan, J. et al. Donor-derived CD7 chimeric antigen receptor T cells for T-cell acute lymphoblastic leukemia: first-in-human, phase I trial. J. Clin. Oncol. 39, 3340–3351 (2021).
Wang, X. X. et al. Abstract CT052: clinical safety and efficacy study of TruUCAR™ GC027: the first-in-human, universal CAR-T therapy for adult relapsed/refractory T-cell acute lymphoblastic leukemia (r/r T-ALL). Cancer Res. 80, CT052 (2020).
Lu, P. et al. Naturally selected CD7 CAR-T therapy without genetic manipulations for T-ALL/LBL: first-in-human phase 1 clinical trial. Blood 140, 321–334 (2022).
Zhang, M. et al. The impact of the immunophenotyping characteristics of patients’ peripheral blood on the manufacturing and clinical outcome of CD7-targeted chimeric antigen receptor T cells. Blood 138, 3830 (2021).
Li, S. et al. Eradication of T-ALL cells by CD7-targeted universal CAR-T cells and initial test of ruxolitinib-based CRS management. Clin. Cancer Res. 27, 1242–1246 (2021).
Hill, L. C. et al. Safety and anti-tumor activity of CD5 CAR T-cells in patients with relapsed/refractory T-cell malignancies. Blood 134, 199 (2019).
Dalloul, A. CD5: a safeguard against autoimmunity and a shield for cancer cells. Autoimmun. Rev. 8, 349–353 (2009).
Mamonkin, M. et al. A T-cell-directed chimeric antigen receptor for the selective treatment of T-cell malignancies. Blood 126, 983–992 (2015).
Hill, L. C. et al. Enhanced anti-tumor activity of CD5 CAR T cells manufactured with tyrosine kinase inhibitors in patients with relapsed/refractory T-ALL. J. Clin. Oncol. 41, 7002 (2023).
Alotaibi, F. et al. CD5 blockade enhances ex vivo CD8+ T cell activation and tumour cell cytotoxicity. Eur. J. Immunol. 50, 695–704 (2020).
Chun, I. et al. CRISPR-Cas9 knock out of CD5 enhances the anti-tumor activity of chimeric antigen receptor T cells. Blood 136, 51–52 (2020).
Dai, Z. et al. The rational development of CD5-targeting biepitopic CARs with fully human heavy-chain-only antigen recognition domains. Mol. Ther. 29, 2707–2722 (2021).
Lin, R., Zhou, Y., Yan, F., Li, D. & Yuan, Y. BOIN12: Bayesian optimal interval phase I/II trial design for utility-based dose finding in immunotherapy and targeted therapies. JCO Precis. Oncol. 4, PO.20.00257 (2020).
Cook, N. et al. Early phase clinical trials to identify optimal dosing and safety. Mol. Oncol. 9, 997–1007 (2016).
Yuan, Y. & Chen, K. Novel Bayesian adaptive early phase designs to accelerate the development of CAR T-cell therapy. Hematol. Oncol. Discov. 1, 14–23 (2022).
Pan, J. et al. Sequential CD19-22 CAR T therapy induces sustained remission in children with r/r B-ALL. Blood 135, 387–391 (2020).
Liu, S. et al. Corticosteroids do not influence the efficacy and kinetics of CAR-T cells for B-cell acute lymphoblastic leukemia. Blood Cancer J. 10, 15 (2020).
Collins, R. H. et al. Donor leukocyte infusions in 140 patients with relapsed malignancy after allogeneic bone marrow transplantation. J. Clin. Oncol. 15, 433–444 (1997).
Li, Z. et al. Donor CD7 chimeric antigen receptor T cell bridging to allogeneic hematopoietic stem cell transplantation for T cell hematologic malignancy. Transplant. Cell. Ther. 29, 167–173 (2023).
Raje, N. et al. Anti-BCMA CAR T-cell therapy bb2121 in relapsed or refractory multiple myeloma. N. Engl. J. Med. 380, 1726–1737 (2019).
Shah, B. D. et al. KTE-X19 anti-CD19 CAR T-cell therapy in adult relapsed/refractory acute lymphoblastic leukemia: ZUMA-3 phase 1 results. Blood 138, 11–22 (2021).
Spiegel, J. Y. et al. CAR T cells with dual targeting of CD19 and CD22 in adult patients with recurrent or refractory B cell malignancies: a phase 1 trial. Nat. Med. 27, 1419–1431 (2021).
Meng, Y. et al. Short-interval sequential CAR-T cell infusion may enhance prior CAR-T cell expansion to augment anti-lymphoma response in B-NHL. Front. Oncol. 11, 640166 (2021).
Loren, A. W. & Porter, D. L. Donor leukocyte infusions for the treatment of relapsed acute leukemia after allogeneic stem cell transplantation. Bone. Marrow. Transplant. 41, 483–493 (2008).
Candoni, A. et al. Nelarabine as salvage therapy and bridge to allogeneic stem cell transplant in 118 adult patients with relapsed/refractory T-cell acute lymphoblastic leukemia/lymphoma. A CAMPUS ALL study. Am. J. Hematol. 95, 1466–1472 (2020).
Maude, S. L. et al. Chimeric antigen receptor T cells for sustained remissions in leukemia. N. Engl. J. Med. 371, 1507–1517 (2014).
Pan, J. et al. Frequent occurrence of CD19-negative relapse after CD19 CAR T and consolidation therapy in 14 TP53-mutated r/r B-ALL children. Leukemia 34, 3382–3387 (2020).
Verdun, N. & Marks, P. Secondary cancers after chimeric antigen receptor T-cell therapy. N. Engl. J. Med. 390, 584–586 (2024).
Jain, N. et al. Early T-cell precursor acute lymphoblastic leukemia/lymphoma (ETP-ALL/LBL) in adolescents and adults: a high-risk subtype. Blood 127, 1863–1869 (2016).
Lee, D. W. et al. ASTCT consensus grading for cytokine release syndrome and neurologic toxicity associated with immune effector cells. Biol. Blood. Marrow. Transplant. 25, 625–638 (2019).
Przepiorka, D. et al. 1994 Consensus Conference on acute GVHD grading. Bone. Marrow. Transplant. 15, 825–828 (1995).
Common Terminology Criteria for Adverse Events (CTCAE). Version 5.0 (National Cancer Institute, 2017); https://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/CTCAE_v5_Quick_Reference_8.5x11.pdf
Pan, J. et al. Sequential CD19 and CD22 chimeric antigen receptor T-cell therapy for childhood refractory or relapsed B-cell acute lymphocytic leukaemia: a single-arm, phase 2 study. Lancet Oncol. 24, 1229–1241 (2023).
Gardner, R. A. et al. Preemptive mitigation of CD19 CAR T-cell cytokine release syndrome without attenuation of antileukemic efficacy. Blood. 134, 2149–2158 (2019).
Arber, D. A. et al. The 2016 revision to the World Health Organization classification of myeloid neoplasms and acute leukemia. Blood. 127, 2391–2405 (2016).
Brown, P. A. et al. Acute lymphoblastic leukemia, version 2.2021, NCCN clinical practice guidelines in oncology. J. Natl. Compr. Canc. Netw. 19, 1079–1109 (2021).
Carreras, E. et al. (eds) The EBMT Handbook: Hematopoietic Stem Cell Transplantation and Cellular Therapies (Springer, 2019).
Liu, M. et al. High-efficient generation of natural killer cells from peripheral blood with preferable cell vitality and enhanced cytotoxicity by combination of IL-2, IL-15 and IL-18. Biochem. Biophys. Res. Commun. 534, 149–156 (2021).
Wang, K. et al. Measurements of T-cell receptor excision cycles in early stage of immune reconstitution after hematopoietic stem cell transplantation. Chin. J. Tissue Eng. Res. 22, 4643–4649 (2018).
Peng, Y. et al. Broad and strong memory CD4+ and CD8+ T cells induced by SARS-CoV-2 in UK convalescent individuals following COVID-19. Nat. Immunol. 21, 1336–1345 (2020).
Peng, Y. et al. Boosted influenza-specific T cell responses after H5N1 pandemic live attenuated influenza virus vaccination. Front. Immunol. 6, 287 (2015).
Acknowledgements
This article is in memory of late Professor Jianfeng Zhou (Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology) for his substantial contributions to the project conception. We thank the patients who participated in this study and their families. We thank T. Wu (Department of Hematopoietic Stem Cell Transplantation, Beijing Boren Hospital) for transplantation treatment of patients after CD5 CAR-T cell therapy. We also thank all physicians, nurses and other patient care providers involved in the study. We also thank J. Jin (Immunology Research Institute of Fujian Academy of Medical Sciences) and T. Yang (Department of Hematology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University) for sharing the sjTREC-RAG2 plasmid. Figure 1a and the mouse image in the Supplementary Fig. 1c were generated by Figdraw. This work was supported by the National Key R&D Program of China (2021YFA1100703, grant to X.F.), CAMS Innovation Fund for Medical Sciences (CIFMS 2021-I2M-1-017, grant to X.F.), the National Natural Science Foundation of China (32170891, grant to X.F.). The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.
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Contributions
J.P., Y.T., L.S., S.S., Y.H. and X.F. contributed to the analyses and interpretation of the clinical data. G.H. and T.T. contributed to the development of the CAR construct and provided the GMP-grade lentivirus. B.D. directed the production of CAR-T cells. J.P., Z.T., F.Y. and Y.Y. designed the clinical protocol. J.P., Z.L., J.X., J.D., Z.W. and K.W. contributed to the clinical treatments. X.Y. was responsible for immunophenotyping of leukemic cells. X.X. and Q.Z. were responsible for the next-generation sequencing and TCR sequencing assay. L.S. and Y.T. performed experiments and analyses of T cell phenotype and function, T cell reactivity to virus, and CD5 mutations in relapse samples under the supervision of X.F. J.P., Y.T., S.S., L.S. and X.F. wrote the manuscript. J.Z. provided administrative support for this study. J.P. and X.F. directed the study and had final responsibility to submit for publication. All authors read and approved the final manuscript.
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G.H. and T.T. are employees of Nanjing IASO Biotherapeutics Ltd. The other authors declare no competing interests.
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Extended data
Extended Data Fig. 1 Patient assignment per the BOIN12 design.
Shown was patient assignment per the BOIN12 design to explore the optimal biological dose (OBD) with the pre-specified target DL1 of 1 × 106 ( ± 20%) and target DL2 of 2 × 106 ( ± 20%)/kg in each cohort. Dose escalation will be performed separately for Cohorts A and B, which were separated by dotted line. Red circle indicates 10 patients (seven in Cohort A and three in Cohort B) who received DL1. Green circle indicates four patients (three in Cohort A and one in Cohort B) whose product is below DL1 cannot be used for OBD exploration, but we can still drop them to the DL-1 group and explore the safety and efficacy. Yellow circle indicates two patients (one in Cohort A and one in Cohort B) whose product is below DL-1, and the infusion still be performed at the discretion of physicians. Grey circle indicates three patients whose product did not meet the protocol-allowed minimal infusion dose of 1 × 105 (−20%)/kg, and they did not receive infusion and were out of trial. DL, dose level.
Extended Data Fig. 2 Correlation analysis related to CAR-T cell expansion, adverse events, and use of steroids and ruxolitinib.
a,The correlation of ICANS with CNS disease. b, Percentage of CD5 CAR-T cell in lymphocytes in the CSF at day 30 post-infusion by ICANS (n = 3) or no ICANS (n = 10). c, The relationship of the interval between last treatment (SCT or CD7 CAR) and CD5 CAR infusion with the severity of cytopenia, neutropenia, and lymphopenia before lymphodepletion. Left: no G3-4 cytopenia, neutropenia, lymphopenia, n = 1, 4, 3, respectively; G3-4 cytopenia, neutropenia, lymphopenia, n = 7, 4, 5, respectively. Right: no G3-4 cytopenia, neutropenia, lymphopenia, n = 0, 1, 1, respectively; G3-4 cytopenia, neutropenia, lymphopenia, n = 5, 4, 4, respectively. d, The GVHD and SAE incidence in patients who received haploidentical donor cells and matched sibling donor (MSD) cells. e,f,g, Correlation of severe infection (e), virus infection (f) and relapse (g) with steroid using for CRS (n = 10), steroid and ruxolitinib using for GVHD (n = 11). h, The peak numbers of CD5 CAR-T cells in the peripheral blood of patient subgroups according to cohort (n = 11 in A, n = 5 in B), infusion doses (n = 2 with < 5 × 105/kg, n = 4 with 5 × 105/kg, n = 10 with 1 × 106/kg), relapse (n = 3) or no relapse (n = 13), no CRS (n = 4) or CRS (n = 12), no ICANS (n = 12) or ICANS (n = 4); no GVHD (n = 5) or GVHD (n = 11), no severe infection (n = 9) or severe infection (n = 7), no steroid (n = 2) or steroid (n = 14) or and no ruxolitinib (n = 13) or ruxolitinib (n = 3) use. In b-c, the black horizontal bars indicate the median values. In h, the black horizontal bars indicate the median values, the boxes indicate values that ranging from 25th to 75th percentile, the whiskers extend from the minimum to the maximum values. In a and d-g, P values were determined by Fisher’s two-sided exact test for two group comparisons and by Chi-square test with Yates’ correction for three groups. Two-sided Mann-Whitney U test was used to determine the P value in b.
Extended Data Fig. 3 Effect of coexisting CD7 CAR-T cells on CD5 CAR-T cell expansion and adverse events.
a-e, Shown are the kinetics of CD5 and CD7 CAR-T cells in peripheral blood of five individual patients, as measured by flow cytometry; data were recorded until the cut-off date or the time point that discontinued follow-up; the first point of tumor remission is indicated, the subsequent regular detection point of MRD− is not indicated. Patient E008 tumor was in mediastinum. f, The peak numbers and percentages of CD5 CAR-T cells in the lymphocytes in the peripheral blood of patients by CD7 CAR-T cells were detectable (n = 5) or undetectable (n = 11) after CD5 CAR-T cell infusion. The black horizontal bars indicate the median values, the boxes indicate values that range from 25th to 75th percentile, and the whiskers extend from the minimum to the maximum values. g, CRS, neurotoxicity and GVHD according to whether or not CD7 CAR-T cells were still detectable after CD5 CAR-T cell infusion.
Extended Data Fig. 4 The area under the curve (AUC) from day 0 to day 30 in total T, B and NK cells between cohorts, dose subgroups or whether CD7 CAR-T cells co-existed.
The black horizontal bars indicate the median values, the boxes indicate values that range from 25th to 75th percentile, and the whiskers extend from the minimum to the maximum values. Top: n = 11 patients in Cohort A, n = 5 in Cohort B. Middle: n = 2 with < 5 × 105/kg, n = 4 with 5 × 105/kg and n = 10 with 1 × 106/kg. Bottom: n = 5 pre-CD7 CAR coexists, n = 5 pre-CD7 CAR but not coexists, n = 6 no pre-CD7 CAR.
Extended Data Fig. 5 Different T cell subpopulations according to whether they had received CD7 CAR-T cells before CD5 CAR-T infusion and whether they had detectable CD7 CAR-T cells after CD5 CAR-T infusion.
Absolute numbers of CD5−CD7+, CD5−CD7−, CD5+CD7−, CD5+CD7+ T cells at different time points since CAR-T cell infusion in the peripheral blood of all individual patients, as determined by flow cytometry. CAR+ T cells were excluded in this analysis.
Extended Data Fig. 6 The percentage of EBV and CMV spot-forming T cells in individual patients.
The percentage of IFN-γ-producing spot-forming T cells among CD3+ T cells in peripheral blood mononuclear cells from post-CD5 CAR patients (n = 13), post-CD7 CAR patients (n = 5), and healthy donors (n = 9), after incubation with EBV or CMV peptides, was determined by ELISPOT assay. Solid symbols represent patients who had received post-CD5 CAR SCT or preconditioning, and ELISPOT was not performed after SCT in them. Dashed blue squares indicate patients whose non-CAR-T cells were mostly CD5−CD7− post-CD5 CAR infusion. EBV, Epstein-Barr virus; CMV, cytomegalovirus.
Supplementary information
Supplementary Information
Supplementary Methods, Tables 1–8, Figs. 1–14, Protocol and SAP.
Supplementary Data 1
Source data for Supplementary Figs. 1, 5, 7–11 and 14.
Supplementary Data 2
Sequences of sgRNA and primers.
Source data
Source Data Figs. 2–5 and Extended Data Figs. 1–6
Statistical source data for Figs. 2–5 and Extended Data Figs. 1–6.
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Pan, J., Tan, Y., Shan, L. et al. Allogeneic CD5-specific CAR-T therapy for relapsed/refractory T-ALL: a phase 1 trial. Nat Med (2024). https://doi.org/10.1038/s41591-024-03282-2
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DOI: https://doi.org/10.1038/s41591-024-03282-2
