Molecular Imaging of Chimeric Antigen Receptor T Cells By ICOS-Immunopet

Introduction: Immunomonitoring of chimeric antigen receptor (CAR) T cells relies primarily on their quantification in the peripheral blood, which inadequately quantifies their biodistribution and activation status in the tissues. Non-invasive molecular imaging of CAR T cell therapy by positron emission tomography (PET) is a promising approach providing spatial, temporal and functional information. Reported strategies for PET-based monitoring of CAR T cells rely on additional manipulation of the cell product such as the incorporation of reporter transgenes or ex vivo biolabeling, which significantly limits the wider application of CAR T cell molecular imaging. In the present study, we assessed the ability of antibody-based PET (immunoPET) to non-invasively visualize CAR T cells in vivo.

Methods: For analysis of human CAR T cell activation, we analyzed publicly available RNA sequencing data (GSE136891) obtained at serial time points during in vitro culture of CD19.CD28z CAR T cells. We analyzed by mass cytometry (CyTOF) the ex vivo ICOS expression on human CD19-28z CAR T cells obtained from 31 patients receiving axicabtagene ciloleucel (Axi-cel) for relapsed/refractory diffuse large B-cell lymphoma (DLBCL). For in vivo murine experiments, CD19-expressing B-cell lymphoma A20 cells (2.5×10e5 cells) were injected by tail vein intravenously (i.v.) into sub-lethally (4.4 Gy) irradiated Thy1.2⁺ BALB/c mice. Seven days later, murine CD19.CD28z Luc⁺ Thy1.1⁺ CAR T cells (1×10e6) were i.v. injected. ICOS expression was analyzed by flow cytometry on CAR T cells recovered from spleen and bone marrow 5 days after injection. For imaging studies, anti-ICOS monoclonal antibody (mAb) specific for murine ICOS (clone:7E.17G9, BioXcell) was modified with the bifunctional chelator deferoxamine (DFO/p-SCN-Bn-Deferoxamine). The DFO-ICOS mAb conjugate was radiolabeled with 37 MBq (~1 mCi) of ⁸⁹Zr-oxalate (final specific activity 6 µCi/µg/ml and radiochemical purity of 99%). ⁸⁹Zr-DFO-ICOSmAb (45 μCi ± 3.6, 7.5 μg± 0.6) was injected i.v. 5 days post-CAR T cell administration and PET-CT imaging performed 48 hours later. Following PET-CT, mice were euthanized and radioactivity measured in dissected weighed tissues using a gamma-counter.

Results: Analysis of RNA-sequencing data from human CAR T cells identified ICOS as an activation marker whose transcription was up-regulated and sustained during in vitro culture. ICOS was preferentially expressed on CAR+ T cells recovered at day 7 from axi-cel treated patients compared with CAR- cells (p<0.001; Figure 1A). Phenotypic analysis in a murine model of B cell lymphoma infiltrating the spleen and the bone marrow confirmed preferential ICOS expression on murine CAR T cells compared to resident cells in both spleen (p=0.003) and bone marrow (p=0.008). Figure 1B shows representative volume-rendered technique (VRT) PET/CT images of ⁸⁹Zr-DFO-ICOS mAb-injected tumor-bearing mice either untreated (left panels) or that received mCD19.28z CAR T cells (right panels). ⁸⁹Zr-DFO-ICOS mAb similarly accumulated in highly vascularized organs (heart, liver and spleen) of both untreated and CAR T cell treated mice, consistent with the biodistribution and clearance of intact antibodies. We detected pronounced ⁸⁹Zr-DFO-ICOS mAb-PET signals in the bones of CAR T cell treated mice, particularly prominent in the lumbar spine, iliac bones, femur, tibia and humeral heads (Figure 1B). Region of interest analysis confirmed markedly increased radiotracer uptake in bones rich in bone marrow from CAR T treated mice compared with those of untreated mice (lumbar spine vertebrae p<0.001; iliac bones p=0.001; femur p=0.002; tibia p=0.002). Moreover we observed a slight, but statistically significant increase in radiotracer accumulation in the heart of CAR T cell-treated mice (p=0.004) while no significant differences were detected in spleen and liver. As expected, there was no significant signal difference in the muscle, considered background. Biodistribution analysis using gamma counting of tissues confirmed the PET results.

Conclusions: We describe for the first time an immunoPET approach to monitor the in vivo dynamics of CAR T cell migration, expansion, and persistence that does not require the addition of reporter genes or ex vivo labeling, being therefore applicable to the clinical setting for the study of any commercially available and investigational CAR T cell products.