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679 Safe and Effective Combination of Donor-Derived, Allogeneic CD19/CD22-CAR T Cells with Myeloablative Graft-Engineered Allo-HCT for High-Risk B-ALL

Program: Oral and Poster Abstracts
Type: Oral
Session: 704. Cellular Immunotherapies: Early Phase Clinical Trials and Toxicities: B Cell-directed CAR T Cell Therapies for ALL and for Autoimmunity
Hematology Disease Topics & Pathways:
Research, Clinical trials, Lymphoid Leukemias, ALL, Adult, Clinical Research, Chimeric Antigen Receptor (CAR)-T Cell Therapies, Diseases, Treatment Considerations, Biological therapies, Lymphoid Malignancies, Young adult , Study Population, Human, Transplantation (Allogeneic and Autologous)
Sunday, December 8, 2024: 4:30 PM

Lori Muffly, MD1, Snegha Ananth, MBBS2, Lindsay Danley3*, Caroline Wagner3*, Diana Kordek3*, Kimi DeNoble4*, Ayesha Fraser3*, Emily Egeler5*, Alfonso Molina, MD, MPH6, Zachary Ehlinger, MS5*, Moksha Desai, MS5*, Hossein Daghagh3*, Ramya Tunuguntla, PhD7*, Annie K. Brown, MS8*, Raquel Ibañez9*, Anne Marijn Kramer, MD, PhD10, Zinaida Good, PhD5, Sally Arai, MD11, Laura Johnston, MD11, Robert Lowsky, MD1*, Andrew R. Rezvani11*, Judith Shizuru11*, Lekha Mikkilineni, MD, MA12, Parveen Shiraz11*, Surbhi Sidana, MD1, Wen-Kai Weng, MD, PhD12, Vanessa E. Kennedy, MD12, Sushma Bharadwaj, MD12, Saurabh Dahiya, MD13, Matthew J. Frank, MD, PhD12, Everett H. Meyer, MD, PhD1, Robert S. Negrin, MD11, Steven A. Feldman, PhD14*, Crystal L. Mackall, MD5, Bita Sahaf11*, David B. Miklos, MD, PhD15 and Melody Smith, MD, MS1

1Division of Blood and Marrow Transplantation and Cellular Therapy, Stanford University School of Medicine, Stanford, CA
2Division of Blood and Marrow Transplantation & Cellular Therapy, Stanford University, Palo Alto, CA
3Stanford University, Division of Blood and Marrow Transplant and Cellular Therapy, Stanford, CA
4Department of Bone Marrow Transplant and Cellular Therapy, Stanford University School of Medicine, Palo Alto, CA
5Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
6Department of Medicine, Division of Hematology, Stanford University School of Medicine, San Carlos, CA
7Center for Cancer Cell Therapy, Stanford University, Stanford, CA
8Stanford University, Division of Blood and Marrow Transplant and Cellular Therapy, Stanford
9Stanford University School of Medicine, Stanford, CA
10Division of Blood and Marrow Transplantation & Cellular Therapy, Stanford University School of Medicine, Menlo Park, CA
11Division of Blood and Marrow Transplantation and Cellular Therapy, Stanford University, Stanford, CA
12Division of Blood and Marrow Transplantation and Cellular Therapy, Stanford University School of Medicine, Palo Alto, CA
13Division of Blood and Marrow Transplantation & Cellular Therapy, Stanford University School of Medicine, Mountain View, CA
14Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University, Stanford, CA
15Division of Blood and Marrow Transplantation and Cellular Therapy, Stanford University, Palo Alto, CA

Background: High-risk B-cell acute lymphoblastic leukemia (B-ALL) remains incurable for many patients despite treatment with autologous CAR T cells or allogeneic hematopoietic cell transplant (allo-HCT). We previously demonstrated that CAR T cells can be safely administered following allo-HCT without causing graft-versus-host disease (GVHD) in a preclinical murine model (Ghosh A, Smith M et al. Nat Med 2017). Hence, we hypothesized that adding allogeneic CD19/CD22-CAR T cells to a myeloablative allo-HCT containing donor T regulatory (Treg) cells (Orca-T) would augment graft versus leukemia without increasing acute GVHD or graft failure. We administered a CD19/CD22-CAR that was previously administered as an autologous CAR (NCT03233854) to patients with B-ALL where it demonstrated a high objective overall response but limited durable remission (Spiegel, J et. al. Nat Med 2021). Here, we report clinical outcomes of the initial dose escalation of donor-derived, allogeneic CD19/CD22-CAR T cells with Orca-T in our novel clinical trial design (NCT05507827).

Methods: This is a single-center, phase 1, dose escalation and expansion trial of allogeneic CD19/CD22-CAR T cells in adults with high-risk B-ALL. Myeloablative conditioning with cyclophosphamide and total body irradiation precede infusion of investigational Orca-T, which consists of infusions of HSPCs and Tregs on Day 0 and an infusion of T conventional (Tcon) cells on Day 2. Allogeneic CD19/CD22-CAR-T cells are also infused on Day 2. Single agent pharmacologic GVHD prophylaxis with tacrolimus starts on Day 3. Three dose levels (DL) of allogeneic CD19/CD22-CAR T cells are being studied: DL1 (1x106), DL2 (2x106) and DL3 (3x106) CAR+ cells/kg. The primary objective is to evaluate safety and feasibility of administering allogeneic CD19/CD22-CAR T cells in combination with Orca-T. The primary endpoint is the incidence of engraftment without Grade III to IV acute GVHD at Day 42. Key secondary objectives include efficacy outcomes, CAR persistence, and immune reconstitution.

Results: To date, eight patients have been enrolled and treated: 3 on DL1, 3 on DL2, and 2 on DL3 of the dose escalation phase. The median age is 28 (range, 21-52); six (75%) patients are Hispanic. Regarding high-risk disease features, 2 patients had Ph-like ALL, 1 had TP53-mutated ALL, 7 were MRD+ post-induction, and 1 had relapsed disease. At enrollment, 3 (37%) were in an MRD- CR, 4 (50%) were in an MRD+ CR, and 1 (13%) had active disease. Seven (88%) received an HLA matched sibling donor allograft, while 1 (13%) patient received an allograft from a matched unrelated donor.

CAR T cells meeting the specified release criteria were successfully manufactured for all patients. All patients engrafted with median time to neutrophil and platelet recovery of 14 days (range, 12-20) and 15 days (range, 13-19), respectively. To date, no patients have experienced aGVHD, cGVHD, graft failure, or severe infectious complications. All patients experienced CRS (Grade 1, n= 7; Grade 2, n=1); there were no cases of ICANS.

At Day +42 post-treatment assessment, all patients demonstrated an MRD- CR as measured by flow cytometry and BCR::ABL1 PCR (Ph+ ALL), while 7/8 patients were MRD-negative by NGS (clonoSEQ). With a median follow-up of 190 days (range, 78-502, including 6 patients with >6 months of follow-up), all patients have an ongoing MRD- CR. At last assessment, whole blood and CD3 chimerism exceeds 95% in all patients.

All patients had good expansion of allogeneic CAR in the presence of immunosuppression with tacrolimus. Although the assessment of CAR T cell persistence is ongoing, 3/3 patients, all of whom were treated on DL1, have allogeneic CAR T cells detectable beyond one year. Six of the 8 patients treated will have at least one year of follow-up by the time of the meeting.

Conclusion: Here, we report very promising initial feasibility, safety and efficacy of the combination of allogeneic CD19/CD22-CAR T cells with Orca-T in patients with high-risk B-ALL. This paradigm shifting combination of allogeneic CAR T and allo-HCT resulted in 100% MRD- CR with full donor chimerism but without GVHD or severe CAR-mediated toxicity. These data, which demonstrate antigen-specific anti-tumor benefit of allogeneic CAR T cells in combination with GVHD prophylaxis mediated by Tregs and tacrolimus, have potential implications that could benefit patients with other hematologic diseases.

Disclosures: Muffly: Pfizer: Consultancy; Wugen: Research Funding; Bristol Myers Squibb: Consultancy; Kite, a Gilead Company: Consultancy, Research Funding; Astellas: Consultancy; Vor: Consultancy, Research Funding; Autolus: Consultancy; Cargo Therapeutics: Consultancy; Jasper: Research Funding; Adaptive: Research Funding. Kramer: Autolus: Patents & Royalties: obecabtagene autoleucel. Good: Kite, a Gilead Company: Research Funding; Boom Capital Ventures: Consultancy; 10x Genomics: Research Funding; Mubadala Ventures: Consultancy; Sangamo Therapeutics: Honoraria; Standard Biotools: Honoraria, Other: Travel Support. Lowsky: Orca Bio: Research Funding. Rezvani: Pharmacyclics/AbbVie: Research Funding; Nohla Therapeutics: Membership on an entity's Board of Directors or advisory committees; Kaleido: Membership on an entity's Board of Directors or advisory committees. Mikkilineni: BiolineRx: Consultancy, Other: advisory board at ASH December 2023; Legend Biotech: Consultancy, Other: advisory board at ASH December 2023. Shiraz: Kite Pharma-Gilead: Research Funding. Sidana: Kite, A Gilead company: Consultancy; BMS: Consultancy, Research Funding; Janssen: Consultancy, Research Funding; Sanofi: Consultancy; Oncopeptides: Consultancy; Takeda: Consultancy; Regeneron: Consultancy; Abbvie: Consultancy; Pfizer: Consultancy; BiolineRx: Consultancy; Legend: Consultancy; Novartis: Research Funding. Weng: Dren Bio: Other: Member of Data and Safety Monitoring Board . Kennedy: Astellas: Consultancy. Dahiya: Kite, a Gilead Company: Consultancy, Research Funding. Meyer: Orca Bio: Research Funding. Negrin: Amgen: Membership on an entity's Board of Directors or advisory committees; Garuda Therapeutics: Membership on an entity's Board of Directors or advisory committees; Apia: Membership on an entity's Board of Directors or advisory committees; Cellenkos: Membership on an entity's Board of Directors or advisory committees; Biorasi: Membership on an entity's Board of Directors or advisory committees; UpToDate: Patents & Royalties. Feldman: Samsara BioCapital: Consultancy; Obsidian: Consultancy; Gradalis: Consultancy; Lonza PerMed: Consultancy; FreshWind Bio: Membership on an entity's Board of Directors or advisory committees; Achieve Clinics: Membership on an entity's Board of Directors or advisory committees; Autolomous: Membership on an entity's Board of Directors or advisory committees; MFX: Membership on an entity's Board of Directors or advisory committees; Advanced Cell Therapy Centre (Oslo University Hospital): Membership on an entity's Board of Directors or advisory committees. Mackall: Cargo Therapeutics: Consultancy, Current equity holder in publicly-traded company, Membership on an entity's Board of Directors or advisory committees; Link Cell Therapies: Consultancy, Current equity holder in private company, Membership on an entity's Board of Directors or advisory committees; Lyell Immunopharma: Current equity holder in publicly-traded company, Research Funding; Immatics: Consultancy; Ensoma: Consultancy; Mammoth: Consultancy, Current equity holder in private company; Adaptimmune: Consultancy; Bristol Meyers Squibb: Consultancy. Miklos: Bristol Myers Squibb: Consultancy; Galapagos: Consultancy; Miltenyi: Consultancy, Research Funding; Novartis: Consultancy; Adaptive Biotechnologies: Research Funding; Allogene: Research Funding; Kite, a Gilead Company: Consultancy, Other: Travel Support, Research Funding; Janssen: Consultancy, Patents & Royalties; Juno Therapeutics: Consultancy; 2SeventyBio: Research Funding; Fosun Kite Biotechnology: Honoraria; Adicet: Research Funding. Smith: A28 Therapeutics: Current holder of stock options in a privately-held company; CVS Caremark: Consultancy.

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