BCMA CAR-T Cellular Therapy for R/R Multiple Myeloma in Chinacme-utilities.com/mailshotcme/Material...
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He Huang Bone Marrow Transplant Center Zhejiang University School of Medicine Hangzhou, China 5/16/2019 BCMA CAR-T Cellular Therapy for R/R Multiple Myeloma in China
Transcript of BCMA CAR-T Cellular Therapy for R/R Multiple Myeloma in Chinacme-utilities.com/mailshotcme/Material...
He Huang
Bone Marrow Transplant Center
Zhejiang University School of Medicine
Hangzhou, China
5/16/2019
BCMA CAR-T Cellular Therapy
for R/R Multiple Myeloma in China
◆Patients with multiple myeloma will finally evolution into refractory/ relapsed
disease
Background
Blood Cancer J. 2019 Mar 7;9(3):32.
3
◆Novel agents and antibodies developed in recent years
Leukemia (2018) 32, 252–262; doi:10.1038
Background
◆ Zelig Eshhar
Introduction for CAR-T Cells
He first proposed the concept of
chimeric antigen receptor T cell
◆ Carl H. June
His work led to the development and
commercialization of tisagenlecleucel,
the first FDA-approved gene therapy
https://www.clinicaltrials.gov
World: 744
USA: 292
China: 256
Europe: 111
(up to 5/9/2019)
Immunotherapy becomes a global hot spot!
Summary of CAR-T treatment worldwide
https://www.clinicaltrials.gov
World: 56
USA: 26
China: 26
Europe: 5
(up to 5/9/2019)
Clinical trial of CAR-T for MM develops rapidly
Summary of CAR-T treatment worldwide in MM
CAR-T treatment for MM in China
◆Nanjing Legend Biotech Inc.
Zhao WH, et al. J Hematol Oncol. 2018 Dec 20;11(1):141.
Median PFS Median OS
15 months Not reached
N Age ORR CR VGPR PR
57 54(27~72) 88% 68% 5% 14%
CAR-T treatment for MM in China
◆Nanjing Legend Biotech Inc.
CAR-T treatment for MM in China
◆Nanjing Legend Biotech Inc.
Xu J, et al. Proc Natl Acad Sci U S A. 2019 Apr 15. [Epub ahead of print]
Disease r/r MM
N 17
Age 56 (35, 73)
ORR 88.2%
CR 76.5%
VGPR 11.8%
1-year PFS 52.9%
1-year OS 82.3%
CAR-T treatment for MM in China
◆Nanjing Legend Biotech Inc.
BCMA CAR-T treatment for Multiple
myeloma in our center
12
◆Patient enrollment
➢ Relapsed or refractory multiple myeloma
➢ Younger than 75 years old
➢ Normal major organ function
➢ BCMA expression rate on MM cells is higher than 50% by flow cytometry or IHC
➢ No active infection complication y eithe
◆CAR construct
BCMA scFv (murine) Transmembrane 4-1BB CD3 ζ
CAR-T treatment in our center
Unpublished data
Withdraw for severe infection
Screen (n=40)
PBMCs collection and CAR-T
Preparation (n=33)
Excluded ineligiblen=7
n=1
FC-based conditioning regimen and
CAR-T infusion (n=32)
Evaluation for efficacy and toxicity
(n=26)
CAR-T treatment in our center
◆Patient characteristicsPatient Age Sex Type Cytogenetic
abnormalityAutologousHSCT
ISS/DS No.of Prior Lines of Therapy
CAR -T dose( /Kg)
1 71 M IgG-k None N III/IIIA 4 1.28*10^6
2 61 M IgA-k None N II/III 4 1.05*10^6
3 63 M NSMM None N IA/IIIA 6 2.66*10^6
4 60 M IgD-λ t(4;14),1q21,RB1,D13S319,IGH rearrangement
N III/IIIA 2 2.83*10^6
5 55 M IgG- λ 49, XY, +15, +5, +17
N III/IIIA 5 2.64*10^6
6 55 F IgG-k RB1, IGH rearrangement, 1q21, D13S319
Y II/IIIA 4 2.73*10^6
7 58 F IgA- k None N II/IIIA 5 2.48*10^6
8 61 M IgA None N I/IIIA 3 3.06*10^6
9 49 F IgD- λ None N I/IIIA 2 3.55*10^6
10 65 M IgG- λ RB1, 1q21,IGH rearrangement, D13S319
N III/IIIA 4 3.42*10^6
11 65 M IgG-k None N I/I 2 3.77*10^6
12 65 F IgA- k 1q21, D13S319,RB1
N III/IIIA 4 2.05*10^6
13 63 F IgG-k t(4;14), del P53 Y I/II 7 4.91*10^6
14 55 F IgG-k None Y II/III 4 4.80*10^6
15 55 F IgG-k None N I/IIIA 3 5.03*10^6
Patient Age Sex Type Cytogenetic abnormality
Autologous HSCT
ISS/DS No.of Prior Lines of Therapy
CAR T dose( /Kg)
16 59 M IgA None N I/IIIA 6 4.44*10^6
17 54 M IgG-k None Y I/I 4 4.59*10^6
18 51 F λ light chain
None Y I/IIIA 3 3.93*10^6
19 50 M IgD- λ 1q21 Y III/III 5 4.27*10^6
20 65 M IgA- k None N III/IIIA 5 3.93*10^6
21 67 M λ light chain
1q21 N II/III 4 4.61*10^6
22 64 M IgG-k None N III/IIIA 6 4.40*10^6
23 62 M λ light chain
RB1,TP53 N III/IIIA 5 2.18*10^6
24 65 F IgG-k 1q21,RB1,D13S319,P53,IGH rearrangement
N III/II 4 2.19*10^6
25 71 M IgG-k None N III/IIIB 4 5.35*10^6
26 59 M NSMM TP53 N II/III 3 4.74*10^6
◆Patient characteristics
Results Prognosis
◆Clinical Efficacy after CAR-T Infusion
Overall response rate 100%, CR or VGPR rate 80.8%
◆Minimal residual disease in bone marrow by FACSPatient No. 9 Patient No. 17 Patient No. 15Before CAR-T
After CAR-T
All 26 patients achieved MRD negative in BM after CAR-T treatment!
CAR-T treatment in our center
Extramedullary lesions were eradicated after CAR-T treatment!
Before CAR-T After CAR-T
◆ Extramedullary lesions by PETCT
CAR-T treatment in our center
Results Prognosis
◆Risk factors associated with CR by multivariate analysis
The efficacy of CAR-T therapy was not associated with cytogenetics, CAR-T cell dose, extramedullary infiltration, age and disease stage.
Covariate P value
Extramedullary infiltration 0.994
Age>60 year-old 0.994
High risk cytogenetics 0.751
ISS staging 0.994
DS staging 0.995R
CAR-T cells>3*10^6/kg 0.994
◆Clinical Efficacy after CAR-T Infusion
300-day OS 76.4% 300-day PFS 57.7%
Days after CAR-T infusion Days after CAR-T infusion
OS
(%)
PFS
(%
)
Results Prognosis
Results CAR-T cell expansion in vivo
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po
rtio
n o
f C
AR
-T c
ell
In C
D3
+ L
ym
ph
oc
yte
(%
)
Days Post CAR-T cell Infusion
High proliferation of CAR-T cells in vivo!
Results CAR-T cell expansion in vivo
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tio
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f C
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-T C
ell
(%)
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po
tio
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f C
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+C
AR
-T C
ell
(%)
Days Post CAR-T Infusion
◆Change of CAR-T cell subsets in vivo
For the first 3-5 days after CAR-T infusion, most CAR-T cells are CD4+, then CAR-T cells change to CD8+ T cells implying that CD8+ CAR-T cells eradicate myeloma cells rapidly.
Results CAR-T cell expansion in vivo
◆ CRS grade
◆16 patients received Tocilizumab treatment
◆4 patients received steroid treatment
◆No patient died of CRS
Results Adverse Effect
◆Adverse Effect
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oxi
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cyto
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ugh
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sea
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art
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idn
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or
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eti
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ibri
llati
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rrh
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chd
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adac
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rpe
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utu
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ote
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rmat
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hag
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efl
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cord
ial d
istr
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uro
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lmo
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fect
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rica
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usi
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ista
xis
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hyt
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ck
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do
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ht
swe
at
Ora
lulc
er
Adverse Effect
Cas
eC
ou
nt
Results Adverse Effect
◆Renal Function and Tumor Lysis
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Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6Patient 7 Patient 8 Patient 9 Patient 10 Patient 11 Patient 12Patient 13 Patient 14 Patient 15 Patient 16 Patient 17
crea
tin
ine(μmol/
L)
Days Post CAR-T Infusion
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Patient 7 Patient 8 Patient 9 Patient 10 Patient 11 Patient 12
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uri
c ac
id(μmol/
L)
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(U/L
)
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Patient 7 Patient 8 Patient 9 Patient 10 Patient 11 Patient 12
Patient 13 Patient 14 Patient 15 Patient 16 Patient 17
Ferr
itin
(ng/
ml)
Days Post CAR-T Infusion
◆Renal Function
Before CAR-T During CAR-T
P=0.007
81.72±28.95 67.23±36.79
Cre
atin
ine
(μmol/
L)eG
FR(m
l/m
in)
78.38±41.28 133.23±123.60
P=0.010
Before CAR-T During CAR-T
BU
N (
mm
ol/
L)
Before CAR-T During CAR-T
5.78±2.39 10.80±8.84
P=0.003
Before CAR-T During CAR-T
Uri
c A
cid
(μmol/
L)
328.29±135.88 329.46±163.06
P=0.960
Only one patient needed hemodialysis support
Results Adverse Effect
◆Coagulation Dysfunction
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PT
(s)
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AP
TT(s
)
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rin
oge
n(g
/L)
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D-dim
er(μg/L)
Days Post CAR-T Infusion
Results Adverse Effect
Case 1
◆ male，71y，Multiple Myeloma for 3 years（IgG, kappa，IIIA）
2 cycles of PCD（Velcade + DXM + CTX）
Because of peripheral neurotoxicity (Grade 3), PCD discontinued
5 cycles of RCD（Lenalidomide + DXM + CTX）
6/12/2017：DECP，PD
Bendamustine + Lenalidomide + DXM
PD
Enrolled for clinical trial of BCMA CAR-T cell therapy
Treatment
Treatment
Days after CART infusion
◆ CRP ◆ Cytokine
◆ IgG ◆ CAR-T proliferation
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IL-6
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IFNγ
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Days Post CAR-T Infusion
CAR-T cell infusion
CAR-T cell infusion
Treatment
Follow-up
The patient still keeps CR 15 months
after CAR-T treatment！
Case 2
◆ 63 year-old woman with history of multiple myeloma for 6 years,
Monoclonal IgG and Kappa, t(4;14)
Vertebral internal fixation + 8 course of radiotherapy
2012-08-05 1st ASCT with MEL200
2015-11 Relapse, t(4;14), del P53, radiotherapy and 4 courses of RVd
2016-02-22 2nd ASCT with MEL200
2017-5 Relapse, Pomalidomide + Daratumumab and Dexamethasone
2018-6 Relapse
Enrolled for clinical trial of BCMA CAR-T cell therapy
Treatment
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1 3 5 7 9 11131517192123252729313335373941434547495153
Tali IL-6
Tali IL-10
Tali IFN-γ
Days after CART infusion
◆ CRP ◆ Cytokine
◆ IgG ◆ Κ chain
Treatment
Remain CR for 7 months after CAR-T treatment
Treatment
Negative
Negative
Treatment
Our basic research on BCMA CAR-T cells
Dynamics of T cell subsets during BCMA
CAR-T therapy for R/R Multiple Myeloma
Case Primary Plasma Cell Leukemia
◆ Patient 17: Primary plasma cell leukemia, refractory
Before CAR-T Day 2 CAR-T Day 3 CAR-T Day 4 CAR-T Day 5 CAR-T Day 6 CAR-T Day 7 CAR-T
CAR-T cells expanded
rapidly and eradicated
plasma cell leukemia
within 7 days.
◼ CD4 and CD8 composition of CAR-T
cell populations (by flow cytometry)
◆Dynamics of cytokines and T cell subsets during CAR-T treatment
◆Single cell RNA-seq of CAR-T cells and normal T cells
◼ scRNA-seq was performed on six samples from three time points:
◼ T cell subsets in different time point samples
Day 0 (before CAR-T infusion) Day 8 (peak CRS) Day 15 (after CRS)
CAR-T cells
Normal T cells
T-SNE plot of T cells for each sample based on the expression of highly variable genes:
Total 24 clusters
Total 29 clusters
◆Single cell RNA-seq of CAR-T cells and normal T cells
Day 8 (peak CRS) Day 15 (after CRS)
◼ T cell subsets in total samples
⚫ CAR-T cells before CAR-T infusion(Day 0) mostly are CD4+CD25+ cells.
⚫ CAR-T cells in CAR-T peak level (Day 8) are mainly CD8+LAG3+ cells.
⚫ Normal T cells grouped into a series of subsets during CAR-T
therapy.(LAG3+,TIM3+, CCR7+,CD62L+)
◆Single cell RNA-seq of CAR-T cells and normal T cells
◼ CAR-T cell proliferation at different time point
Day 0 (before CAR-T infusion)
Day 8 (peak CRS) Day 15 (after CRS)
⚫ The proliferative capacity of CAR-T cells are highest in peak CRS (Day8).
⚫ The ability of CAR-T cell proliferation decreases as the tumor cells decrease.
◆Single cell RNA-seq of CAR-T cells and normal T cells
Our basic research on BCMA CAR-T cells
The microbiome in BCMA CAR-T treatment
for R/R multiple myeloma
◆ FC0: before FC chemotherapy
◆ FC2: after FC chemotherapy and before CAR-T cell infusion
◆ CRS0: no CRS after CAR-T cell infusion
◆ CRS1: one day after CRS
◆ CRS2: CRS restoration
◆Flora samples taken at different time point:
Our basic research on BCMA CAR-T cells
◆Methods for Stool sample detection:
◆ 16S RNA
Our basic research on BCMA CAR-T cells
Shannon index
FC0 FC2 CRS0 CRS1FC2 NA NA NACRS0 NA NACRS1 * NACRS2 * **
Simpson index
FC0 FC2 CRS0 CRS1FC2 NA NA NACRS0 NA NACRS1 * ** NACRS2 * ** *
Chao index
FC0 FC2 CRS0 CRS1FC2 NA NA NA CRS0 NA NA CRS1 NA CRS2
NA: not available; *P<0.05 **P<0.01
◆Beta diversity
Beta diversityCRS0 CRS1 FC0 CRS2 FC2
CRS0 1 * **CRS1 * 1 **FC0 1 **CRS2 ** ** 1 **FC2 ** ** 1
*P<0.05 **P<0.01
◆Alpha diversity
Flora microbiome diversity
decreased in CRS stage
Flora microbiome structure
changed after CAR-T treatment
◆ Chao index of alpha diversity is significant
difference between CR and nonCR group
in CRS1 stage.
◆ Microbiome diversity is higher in CR group
than in nonCR group.
Higher diversity of microbiome might
be associated with treatment efficacy.
Our basic research on BCMA CAR-T cells
Our basic research on BCMA CAR-T cells
The dominant microbiome is different between CRS less than grade 3 group
and grade 3 CRS group.
A: CRS less than grade 3; B: Grade 3 CRS
The dominant microbiome might be associated with CRS grade！
Summary
◆ BCMA CAR-T cells for R/R MM have very good efficacy
◆ BCMA CAR-T cells for R/R MM are safe
◆ Single cell RNA sequence may provide tools to study
mechanisms of CAR-T cytotoxicity
◆ Flora microbiome might be associated with therapeutic efficacy
and CRS grade
◆ More patients enrollment and expanded follow-up time will be
needed
Acknowledgement
◆Clinical Team
➢ Yongxian Hu
➢ Jian Yu
➢ Yi Luo
➢ Jimin Shi
➢ Guoqing Wei
➢ Wenjun Wu
➢ Jie Sun
◆Hcblab LAB
➢ Huijun Xu
➢ Hao Zhang
➢ Zuyu Liang
➢ Xiujian Wang
➢ Lijuan Ding
➢ Wanmao Ni
◆Cellular
Therapeutic Lab
➢ Hongseng Zhang
➢ Lei Xiao
➢ Zhao Wu
➢ Yanlei Zhang
➢ Jinping Wang
➢ Xin Wu
Thank You!
New district of First Affiliated Hospital of Zhejiang University School of Medicine
Total Bed: 1200
Bed for HSCT: 46
