Updates and Advances in CAR-T Cell Generation · 2020-03-02 · Advances in CAR-T Cell Generation...

Updates and Advances in CAR-T Cell GenerationNICOLE AQUI, M.D.

CHIEF, TRANSFUSION AND APHERESIS SERVICESDIVISION OF TRANSFUSION MEDICINEDEPARTMENT OF PATHOLOGY AND LABORATORY MEDICINE

UNIVERSITY OF PENNSYLVANIA

CAR-T Therapy: General Outline

https://www.cancer.gov/about-cancer/treatment/research/car-t-cell-therapy-infographic

What is a CAR T cell?

Majzner and Mackall, Nature Medicine 2019

Components of CAR-T Cells

Benmebarek et al, Int J Mol Sci 2019

Killing Mechanisms of CAR-T Cells

Benmebarek et al, Int J Mol Sci 2019

CAR-T Successes

ELIANA trial

JULIET trial

CAR-T in Solid Malignancies

Neuroblastoma Glioblastoma Colorectal Cancer Prostate Cancer Pancreatic Cancer Breast Cancer

Barriers to Success in

Solid Malignancies

• Trafficking

• Proliferation and

survival

• Tumor recognition

• Control of effects

• Immunosuppressive

microenvironment

Tokarew, British J Cancer, 2019

Trafficking, Proliferation, and Survival

Evolution of CAR-TDesign


Tumor Recognition

Types of CAR-T Cell TargetsCategory Expression pattern Advantages Disadvantages Example

TSA protein form

Uniquely expressed on malignant cells

Increased anti-tumor efficacy and safety

Antigenic heterogeneity EGFRvIII

TAA protein form

Overexpressed by cancer cells, with low expression by healthy tissues

Wide range of options for target selection

On-target/off-tumor toxicities; immunoescape

Mesothelin

Glycolipid or ganglioside antigen

Expressed on both cancerous and normal tissues

Expands the range of target candidates; reduces immunoescape; high density on cell surface

On-target/off-tumor toxicities

GD2

CASC surface antigen protein form

Mainly expressed by CASCs, with low or no expression on cancer cells

Avoids immunoescape; broadly applicable in various cancers

Severe side-effect toxicities

FAP

Adapted from Liu et al, Am J Cancer Research 2019

Control of Effects

Safety Strategies to Overcome Toxicity

Suicide switch

Endogenous switch

Exogenous switch

Yu et al., Molecular Cancer 2019


Suicide switch



Suicide switch

Endogenous switch



Suicide switch

Endogenous switch

Exogenous switch


Bispecific T cell Engager (BiTE)

Bachmann, Immunology Letters 2019

UniCARs


UniCARS – Target Molecules


Overcoming TME

Evolution of CAR-TDesign


CRISPR/Cas9 Genome Editing

Chen et al, Cancer Letters 2019

First-In-Human CRISPR Clinical Trial

Stadtmauer et al. Science 2020

Strategies to Improve CAR-T Therapy in Solid Malignancies


Beyond T Cells

Biological Functions of NK Cells

Vivier et al, Science 2011

Benefits of CAR-NK cells

ALLOGENEIC SOURCE SHORTER WAIT TIME FOR PRODUCT

UNMODIFIED NK CELLS HAVE PROVEN TRACK RECORD OF SAFETY

CAR-NK cells in Practice

Phase I/II

11 patients with relapsed/refractory CD19+ tumors

Cord-derived NK cells transduced with anti-CD19 CAR, IL-15, iCas9

E Liu et al. N Engl J Med 2020

Clinical Response to CAR-NK Therapy

SAFETY PROFILE• No CRS!• No Neurotoxicity!• No GVHD!

What does this mean for collection facilities?

NEED FOR APHERESIS WILL ONLY GROW

COLLECTION FACILITIES MUST DEVELOP PROCESSES TO

PRIORITIZE RESOURCES

INSTITUTIONAL COMMITMENT TO CELL THERAPY PROGRAMS IS

KEY

Summary

CAR-T therapy represents a breakthrough in the treatment of cancer

Despite successes in hematologic malignancies, solid tumors remain a challenge

CAR-T design is evolving to improve efficacy and safety

Allogeneic NK cells may represent an off-the-shelf solution to many issues faced by autologous T cell therapy

Acknowledgements

UPENN Transfusion Medicine Faculty

Don Siegel, MD PhD

Vijay Bhoj, MD PhD

Andrew Fesnak, MD PhD

Taku Kambayashi, MD PhD

Una O’Doherty, MD PhD

UPENN Apheresis Staff

UPENN CTT Faculty and Staff

Kristin Gray, MSN, RN

*

*Robots (2005) Blue Sky Studios

*

*Institutional*Lack of resources

Staffing

Access to information

*Cultural

*No support

*Individual* Inadequate knowledge

*Peer/Colleague resistance

*Scope of practice

*Poor interdisciplinary engagement

*

NO

I don’t know where to begin…

This is too hard…

*Look at the process*Identify interdisciplinary impact Scheduling

Orders

Billing

Documentation

Supply contracts

Educational impact

Collateral impact (i.e. Supplies, Housekeeping

*Write down possible goals or outcomes

*

*

*Stakeholders*Interested

*Interdisciplinary impact list.

*Elevator speech

*Administrative*Key to success

*Institutional goals

*Speak leadership’s language

*

Background

Significance

Relates ideas/concepts

Identify themes

Are there gaps?

Future research questions

Com-munica-

tion

Data Storage

Time-line

Create Work-flows

Educate

* Expect the unexpected

Be flexible

Revisit stakeholders

Look for areas to improve

Communicate

Celebrate success and failures

*

*Analyze data

*Met goals or outcomes

*Statistically significant

*Applicable

*Sustainable

*

*Share successes and failures

*Lessons learned

*Disseminate findings

Local

National

International

*Encourage others

References

Evidence Based Nursing. (2020, February 2). Retrieved from https://libguides.uwf.edu/c.php?g=215270&p=4439026

Ginex, P.K. (2018, April 19). Use these methods to evaluate EBP outcomes and disseminate results. Retrieved from https://voice.ons.org/news-and-views/use-these-methods-to-evaluate-ebp-outcomes-and-disseminate-results

Ginex, P.K. (2018, May 30). Overcome barriers to applying an evidence-based process for practice change. Retrieved from https://voice.ons.org/news-and-views/overcome-barriers-to-applying-an-evidence-based-process-for-practice-change

Shayan, S.J., Kiwanuka, F., & Nakaye, Z. (2019). Barriers associated with evidence-based practice among low-and middle-income countries: A systematic review, Worldviews on Evidence-Based Nursing, 16(1), 12-20.

Nursing Challenges and Outcome Measures – Chronic Red Cell

Exchange

Learning Objectives

• Discuss the barriers to and list approaches that may improve compliance

• List outcome indicators that can be used in a RBCx quality program

• Outline considerations for setting and individualizing parameters

• Identify IV access options and discuss troubleshooting techniques

• Identify areas where consensus and standard practices are needed

Psychosocial Considerations

Tips for long term success

Cautionary Tales

Standardized Practice Improvement Opportunity

[email protected]@ucsf.edu

Background: Chronic Transfusion in SCD

• 1998: STOP study shows that Transcranial Doppler is a reliable indicator of stroke risk and tx effective prevention1

• Subsequent studies inconclusive regarding duration of stroke risk and efficacy of transfusion alternatives in treatment of cerebrovascular disease. 2, 3, 4

• 2014: SIT study reveals prevalence of silent infarcts and devastating effects on IQ5

– Current standards to address cerebral vascular disease and brain injury re examined.

• Multiple studies involving tx reveal positive impact of transfusion on quality of life4,6

– Implementation of limited courses of transfusion therapy to address other indications, like frequent pain episodes.7

Chronic Transfusion = Iron Overload

Chronic Red Cell Exchange Advantages

• Isovolemic

• Allows for greater reduction in variant Hgb

• Ameliorates iron accumulation

• Does not result in higher alloimmunization rates than simple transfusion8,9

Clinical Indication

• RBCx for stroke/iron overload prophylaxis: Category I indication per ASFA guidelines

• RBCx for pain crisis: Category II 10

ASFA Guidelines for the Use of Therapeutic Apheresis 8th ed, 2019.

Pediatric Red Cell Exchange

Goals of Chronic RBCx

Goal of Chronic Tx

• Maintain the percentage of healthy red blood cells within an identified range to provide CNS or other organ protection

Added goal of Chronic Exchange

• Prevent or diminish iron overload

Raising the Hct by 3% = 1 straight unit tx

The balancing act of cRBCX

Red Cell Flow sheet‐Patient 1

Iron burden‐Patient 1

Pre and Post Hematocrit

18

20

22

24

26

28

30

Mar Apr June July August Sept Oct Nov Dec Jan Feb

Patient 1

Pre Hct Post Hct

31

32

33

34

35

36

37

38

39

40

41


Patient 2

Pre Hct Post Hct

Iron Balance

Patient 1 Patient 2

‐10

‐8

‐6

‐4

‐2

0

2

4

6

8

10


RBC Net: mL/kg

‐10

‐8

‐6

‐4

‐2

0

2

4

6

8

10


RBC Net: mL/kg

Goals of Chronic RBCX

• Maintain the percentage of healthy red blood cells within an identified range to provide CNS or other organ protection

+

• Prevent or diminish iron overload

Raising the Hct by 3% = 1 straight unit tx

=

The balancing act of cRBCX

IsovolemicHemodilution

• Decrease Blood usage

• May allow for increased procedure intervals

• Has greatest usefulness in patients who maintain a Hct greater than 27%

• Should be performed with caution

Generally Accepted Parameters

Maintain the percentage of healthy red blood cells within an identified range• Maintaining Hgb S below 30% is

the only validated method for stroke prevention.

• Post procedure Hgb S of 10% is optimal for maintaining S <30%

• Goal for Hgb S maintenance in other indications (pain reduction, leg ulcers, pulmonary HTN) is generally less than 50%

Methods and Considerations• Attenuate iron accumulation from

chronic tx• Considerations:– Current iron burden – Preservation of Cognitive Function• Minimum Hct of 27% is optimal

– Quality of lIfe – reduction of pain episodes, number of hospital days

– School performance?– Subjective perception of stamina?

UCSFB CHO Guidelines

• Post exchange HgbS 10‐15% (stroke risk)

– Generally = FCR of 30% in pre transfused patients

• Minimum Hct post exchange: 27%

• Maximum reduction in Hct of 5%

• Goals for post exchange Hct are individualized

• 4‐5 week interval

Evaluating Outcome Data

• End Hct within 3% of target

• Pre procedure Hgb S % within 5% of target • Evaluate trends

• FCR= Desired %S ÷Current %S

• Does the change in %S (or A) approximate FCR?

Cautionary tale: An inappropriate change in %S may signal line failure or thrombus.

Quality Elements

• Procedures should be evaluated against an established set of outcome parameters

• Equipment cleaning and maintenance

• Staff training and competency

• CAPA plans for adverse events and inconsistent outcomes

• Tracking of CLABSI rates

Annual competency assessment

• For each type of procedure performed

• Pediatric Procedures:

– Normal ranges of vital signs by age

– Blood prime procedures

– Knowledge of growth and development

– Understanding of effects of brain injury

IV Access

IV access Options • Peripheral

• Implanted Ports– Vortex dual lumen (Angiodynamics)

• 11.4 Fr catheter

– Powerport (Bard)• 9.6 Fr catheter (DL or SL)• Other SL options (7.5, 6.6Fr)

– Powerflow single lumen (Bard)• 9.6 Fr catheter• FDA approved for apheresis

• AV Fistula/Graft

Venous Access Challenge

• The National Kidney Foundation’s Clinical Practice Guidelines have been successful in reducing complications and improving quality of life for a patients with chronic renal disease

• Such a set of guidelines should be developed for patients with Sickle Cell Disease

– ASFA?ASH?

Peripheral

• Can be successful using angiocaths for both draw and return.

• Inlet flow determines size of angiocathneeded.

–Maximum flow rate listed on packaging

– 22Ga max flow= 38mL/min

Tips for successful PIV access

• Have patients drink LOTS of water for 3 days prior to the procedure.

• Warmth

Discourage use of antecubital veins by lab

• Developmentally appropriate preparation and ongoing dialogue with patient– Listen to, address and respect a child’s concerns, fears, and limits.16

• Use of Ultrasound where possible

Implanted Venous Access Devices

Standard Dual Lumen Port Powerflow Port

Before Using New Implaned Devices

Cautionary Tale: Wait 2 weeks before using for apheresis

– Poor healing of the tissue pocket movement of the reservoir catheter kinking \\

Cautionary Tale: Catheter tip can migrate.

– Confirm catheter tip placement prior to first use and whenever changes in function are noted.

Troubleshooting dual lumen ports

• tPA prior

• Have procedure for stopping and adding tPA– How long ?

– Flush access line

• Watch for return of plasma during procedure and monitor pre/post %SCautionary Tale:

– Both needles can be accidentally placed in same lumen.

– Thrombus or line failure can cause recirculation

Troubleshooting dual lumen ports

If dye study is indicated, accompany patient, observe if possible.

When ports are removed due to suspected malfunction, examine them, report and return to manufacturer

• Lifespan= 2000 punctures with 22Ga needle.

– Flow problems occur and needles do not sit as firmly when septum is worn out.

RBCx: A long term

investment with huge dividends

References

1. Adams RJ, McKie VC, Hsu L, et al. Prevention of a first stroke by transfusions in children with sickle cell anemia and abnormal results on transcranial Doppler ultrasonography. N Engl J Med. 1998;339(1):5‐11

2. Adams RJ, Brambilla D, Optimizing Primary Stroke Prevention in Sickle Cell Anemia Trial I. Discontinuing prophylactic transfusions used to prevent stroke in

sickle cell disease. N Engl J Med. 2005;353(26) 2769‐2778.3. Ware RE, Helms RW, Investigators SW. Stroke With Transfusions Changing to Hydroxyurea (SWiTCH). Blood. 2012;119(17):3925‐3932.4.DeBaun, Michael R, Kirkham, Fenella J, Central Nervous System Complications and Management in Sickle Cell Diesease: A Review.

Blood, Prepublished online January 12, 2016. doi: 10.1182blood‐2015‐09‐618578.

5. DeBaun MR, Gordon M, McKinstry RC, et al. Controlled trial of transfusions for silent cerebral infarcts in sickle cell anemia. N Engl J Med. 2014;371(8):699‐710.

References

6. Beverung LM, Strouse JJ, Hulbert ML, et al. Health‐related quality of life in children with sickle cell anemia: impact of blood transfusion therapy. Am J Hematol2015;90(2):139‐143.

7. Kim, H, Red Cell Exchange: Special Focus on sickle cell disease, American Society of Hematology Education Program. 2014 Dec 5;2014(1):450‐6. doi: 10.1182/asheducation‐2014.1.450. Epub 2014 Nov 18.8. Wahl SK, Garcia A, Hagar W, Gildengorin G, Quirolo K, Vichinsky E.

Lower alloimmunization rates in pediatric sickle cell patients on chronicerythrocytapheresis compared to chronic simple transfusions. Transfusion.2012;52(12):2671‐2676.

9. Michot, Jean‐marie, Driss, Corinne Guitton et al. Immunohematologic tolerance of chronich transfusion exchanges with erythrocytaphersis in sickle cell disease. Transfusion 2015;55:357‐363.

References10. Padmanabhan A, et al. Guidelines on the use of therapeutic apheresis in clinical practice—Evidence‐based approach from the Writing Committee of the American Society for Apheresis:The8th special issue. J Clin Apher 2019:34:171‐354.11. Spectra Optia® Apheresis System Essential’s Guide. Lakewood, CO:

Terumo BCT, Inc., 2010.12. Spectra Optia® Apheresis System Physician’s Ordering Guide, Terumo BCT, Inc, Lakewood CO, 2015.

13. Vichinsky, Elliott, Neumayr, Lynne et al, Neuropsychological Dysfunction and Neuroimaging Abnormalities in Neurologically Intact Adults With Sickle Cell Anemia, JAMA, May

12,2010‐vol 303, no18. 14. Steen, R. Grant, Miles, Mark A. et al, Cognitive Impairment in Children with

Hemoglobin SS Sickle Cell Disease: Relationship to MR Imaging Findings and Hematocrit. Am J Neuroradiology 24: 382‐389, March, 2003.15. National Kidney Foundation. “Kidney Dialysis Outcome Quality Initiative:Clinical Practice Recommendation 8: Vascular Access in Pediatric Patients. 2006. 16. Hockenberry M, Wilson D, eds. Wong’s nursing care of infants and children. 8th ed. St. Louis, MO: Mosby Elsevier, 2011:999‐1001.

Instrumentation

• Spectra Optia, Terumo BCT

– Currently the most common instrument used in RBCx

• Amicus, Fresinius Kabe

Assessing Instrumentation for pediatric use

• Extracorporeal Volume

• Extracorporeal Red Blood Cell Volume

• Blood or albumin prime capacity

• Type of anticoagulant recommended

• Lower limits of operation

• Anticoagulant: WB ratios, rates, total doses– Can they be attenuated?

• Concentration of anticoagulant placed in the system during prime

Optia fluid volume considerations11

• Extracorporeal Volume‐should not exceed 110‐115% of patient TBV

– 185mL

– Optia calculated and displays an alarm for ECV 10‐15% of the patient’s ECV (programmed into configs)

– TBV must be calculated manually for patients <25kg

• Intraprocedural Hematocrit

– Optia calculates and displays an alarm for ECRCV > 10‐15% of the patient’s RCV (programmed into configs)

Optia pediatric considerations

Slow Down

• Conservative AC flow rates recommended:– 0.8‐1.0mL/L TBV/min

– Exceeding 1.2mL/L TBV min causes Optia to run in caution mode.

– Achieved by decreasing inlet flow rate and/or increasing AC:WB ratio.

– Optia defaults to 13:1

– 15:1 usually adequate.

• Lower limits of operation for RBCx: – inlet rate of 5mL/min

Albumin Prime in Optia11

• Primes the circuit with albumin and the return line with PRBC’s

• RBC prime is less efficient

Cautionary Tale: Inaccurate Data Entry can lead to serious adverse events

• 3 instances of improper data entry on Optia, 2 of which necessitated phlebotomy.

• Interviews with Operators revealed that new EMR contributed to the problem.

RBCX Data entry checklist

RBCX Data Entry Checklist Patient Name:___________________Date of procedure: _______________

Patient Height: ____________ □Patient Weight: ____________ □TBV:_________________ □Current Hct: ___________ □Target Hct: _________ □Fluid Balance: ___________ □RBC unit volume: ~ ____________□Average Hct of RBC units: __________□

– # of CPDA units: ______ (Hct 75%)– # of AS units: ________ (Hct 55%)– Washed: ___________ (Hct 72%)

Data entry information was reviewed and confirmed prior to starting run by:

_______________________ ______________________Operator Signature Time

_______________________ Verified by (signature)

Phenotyping policy: C, c, E, e, K + ABO and D

More extended phenotyping in patients with an identified antibody

Updates and Advances in CAR-T Cell Generation · 2020-03-02 · Advances in CAR-T Cell Generation...

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