- Case report
- Open Access
A good response of refractory mantel cell lymphoma to haploidentical CAR T cell therapy after failure of autologous CAR T cell therapy
- Tongjuan Li†1,
- Yuanyuan Zhang†1,
- Dan Peng2,
- Xia Mao1,
- Xiaoxi Zhou1Email authorView ORCID ID profile and
- Jianfeng Zhou1Email author
© The Author(s). 2019
- Received: 20 September 2018
- Accepted: 6 February 2019
- Published: 21 February 2019
The aggressive form of Mantle cell non-hodgkin B cell lymphoma (MCL) has a dismal prognosis. Dual targeting BTK and BCL2 with ibrutinib and venetoclax has improved outcomes in MCL patients who were predicted not to respond to conventional therapy, but it is unlikely to be curative. Chimeric antigen receptor-modified T (CAR T) cells exhibit very effective function in elimination of relapsed/refractory B-cell lymphoid malignancies, we investigated their use in a patient with relapsed MCL.
Here, we report a case of a refractory MCL in a patient who had relapsed after conventional chemotherapy and autologous CAR T cell therapy. The patient received multiple molecularly targeted therapies, including targeting BTK and BCL2, and haplo-identical CAR T (haplo-CAR T) cells from her daughter without previous allo-hematopoietic stem cell transplantation. Haplo-CAR T cells could effectively proliferate in vivo and had a clinically significant antitumor activity without serious side effects. The patient achieved a partial remission, with minimal residual disease.
This case suggests that haplo-CAR T cell therapy can be effective in controlling lymphoma that failed to respond to autologous CAR T cell therapy and overcome limitation of autologous CAR T cells, thus may be one possible regimen before the era of off-the-shelf “universal” CAR T cell therapy.
- Haplo-identical CAR T cell therapy
- Mantel cell lymphoma
Mantle cell lymphoma (MCL) is a type of non-Hodgkin B cell lymphoma with a distinctive molecular marker cyclin D1 that is constitutively overexpressed in almost all cases. MCL can be both indolent or aggressive, in either case it responds poorly to chemotherapy and consequently the aggressive form has a dismal prognosis assessed by incorporating Ki-67 proliferation index and Mantle Cell International Prognostic Index scores. An orally administered, irreversible inhibitor of Bruton’s tyrosine kinase (BTK), ibrutinib, is effective at arresting the progression of MCL  as is a highly selective BCL2 inhibitor, venetoclax (ABT-199, Venclexta™) . Dual targeting BTK and BCL2 with ibrutinib and venetoclax has increased complete response rate compared with ibrutinib monotherapy in MCL patients but it is unlikely that this combination therapy will lead to a long term cure of the disease . Chimeric antigen receptor-modified T (CAR T) cells are highly effective in the treatment of common pre-B cell acute lymphoblastic leukemia and are currently under assessment for the treatment of relapsed/refractory B-cell lymphoid malignancies, such as diffuse large-B-cell lymphoma (DLBCL) , follicular lymphoma . In MCL, their use has had missed results . Here, we report a case of a refractory MCL receiving multiple molecularly targeted therapies and haplo-identical CAR T cells from her daughter and achieving a partial remission with only minimal residual disease.
The medical history
A 40-year-old female patient had been diagnosed as classical Mantle cell lymphoma (MCL) at stage IV B with deletion of TP53 gene by lymph node biopsy in local hospital at September, 2017. The immumohistochemical staining results were as follows: CD20(+), PAX5(+), CD79a(+/−), CD5(+), CD21(+), CD23(+), CycIin-D1(+), Ki-67(30%), CD43(mild+), BCL-2(+), BCL-6(+), SOX11(partial +), and molecules including CD2, CD3, CD7, CD10, TIA1, GrB and TdT were negative. EBV was undetectable by in situ hybridization. She had received first and second line chemotherapy including R-CHOP, R-DHAP and R-VCOP, but had progressive disease. Only the combination of ibrutinib and rituximab (IR) resulted in a transient partial remission. In March 2018, she came to our hospital for CAR T cell therapy, a clinical trial of sequential infusion of CART19 (or CART20) and CART22 expressing murine scFv of anti-CD19, anti-CD20 and anti-CD22 in combination with CD28 and 4-1BB costimulatory domains, and CD3ζ signaling domain (ClinicalTrials.gov number ChiCTR-OPN- 16008526; ChiCTR1800019385 and ChiCTR1800019449).
When she was admitted to our hospital, she had a fever, severe dyspnea, and hypoxemia with the lowest SpO2 of 80%. Systemic edema, superficial lymphadenopathy and splenomegaly (reaching her pelvic cavity) were found by physical examination. The lymph nodes were about 3 cm in diameter, like beads-on-string. The number of leukocytes was 71.97*10^9/L in the peripheral blood, and the level of serum lactate dehydrogenase (LDH) was elevated (up to 1619 U/L). Follow-up FDG-PET/CT (Positron Emission Tomography-Computed Tomography) showed swollen lymph nodes throughout the body with increased metabolism, the maximum standard uptake value was 5.7. The maximum standard uptake value of splenomegaly was 6.2. The bone metabolism was hyperactive, and the maximum standard uptake value was 7.5. Furthermore, the lungs and bilateral adrenal were also infiltrated by lymphoma (max Deauville score 5) (Fig. 3a). 66 and 63% of lymphoblasts could be found in the peripheral blood and bone marrow smear, respectively. Her complex karyotype was 43, X, −X, − 9,-10,t(11;14)(q13;q32), del(13)(q12q22). A deletion of exon 7 of TP53 gene that induces frameshift (c.756delC,p.R253Pfs*92), and a nonsense mutation of the exon 34 of NOTCH2 gene (c.7242C > A, p.Y2414*;C.7176 T > G,p.Y2392*) were found by next-generation sequencing (NGS). The patient was high risk evaluated by MIPI.
Autologous CAR T cell therapy
Haplo-identical CAR T cell therapy
Here, we present a patient with primary progressive MCL that failed to respond to a combination of autologous CAR T cell therapies. In desperation we repeated the therapy using halpo-identical CART cell therapy that was able to induce a near complete remission with minimal residual disease. This is the first report demonstrating the anti-lymphoma efficacy of haplo-CAR T cell therapy in the absence of previous allo-HSCT. Although the patient became profoundly sick with multi-organ failure associated with a significantly elevated IL-6 consistent with a cytokine release syndrome, we did not see any clinical evidence of graft versus host disease or rejection of the host bone marrow by the donor CART cells. Furthermore, her symptoms were successfully controlled using cortico-steroids.
The different response to auto- and haplo-CAR T cell therapies may be due to several factors. First, we used slightly different targets as the original auto-CAR T cells were directed against CD19 and CD22 and the haplo-CAR T cells were directed against CD20 and CD22. The change in strategy was in part chosen by the relatively good response to rituximab. However, it is of note that all three targeted antigens were all expressed both before and after CAR T cell therapies (Additional file 1: Figure S1), and this is unlikely to be a significant reason for the difference.
The second important difference between auto- and haplo-CAR T cell therapies was the patient’s tumor burden before infusions. The total number of lymphocytes and monocytes in peripheral blood, used to assess tumor burden, were 8.9*10^8/L and 6*10^7/L before auto- and haplo-CAR T cell infusion, respectively. Ten times higher tumor burden might have stronger immune suppressive effects by releasing inhibitory cytokines TGF-β and IL-10 to hamper cytotoxic function of auto-CAR T cells and inducing differentiation of regulatory T cells (Tregs) . Our results showed that the ratio of CD4+/CD8+ T cells (including CAR T cells) in peripheral blood was higher after auto-CAR T cell therapy, but the ratio was lower after haplo-CAR T cell therapy(Fig.1h and 2h). It is possible that more infused auto-CAR T cells in such an inhibitory microenvironment of higher tumor burden differentiated into CD4+ Tregs, but expansion of CD8+ cytotoxic T cells was suppressed, unlike infused haplo-CAR T cells where the CD8+ T cell was a main proliferated subpopulation. Therefore, before CAR T cell therapy, we should minimize the tumor burden and raise the ratio of CAR T cells to tumor burden, increasing effector/target ratio and efficacy of CAR T cell therapy.
The third difference is the source of T cells. An obvious advantage of haplo-CAR T cells is T cells from healthy donor, which can ensure their quality and quantity, in contrast to autologous CAR T cells which are often insufficient in number by impaired ex vivo expansion and poor quality [8, 9]. Consistently, our results showed that the copy number of haplo-CAR T cells was significantly higher than the auto-CAR T cells. Other groups have reported that the clinical response of CLL to CAR T cell therapy is influenced by T cell–intrinsic attributes . CAR T cells from complete-responding patients with CLL were enriched in memory-related genes, including IL-6/STAT3 signatures, whereas T cells from non-responders upregulated programs involved in effector differentiation, glycolysis, exhaustion and apoptosis. T cells from leukemia-bearing mice presented increased expression of inhibitory co-receptors including programmed cell death protein 1 (PD1), Tim3 and LAG3, and introduction of a CAR into these T cells failed to fully reverse poor in vivo function . However, T cells from a haplo-source of healthy donor were not affected by leukemia before infusion and may express lower levels of the inhibitory molecules than T cells from the lymphoma patient. In addition, T cells from healthy donor have normal functions and may contain less regulatory T cells than T cells from the tumor patient.
One of factors influencing the efficacy of CAR T cell therapy is multiple molecular targeted therapies including rituximab, ibrutinib and venetoclax. As the patient had significant but transient response to rituximab, we used rituximab to control tumor burden during preparation of CAR T cells. Although residual serum rituximab may compete with CART20 for binding to CD20, it has been reported that the activity of CD20-targeted CAR T cells is preserved in vivo at clinically relevant levels of rituximab . Ibrutinib, a small molecule drug that binds permanently to a protein-Bruton's tyrosine kinase (BTK), was used until the infusion of haplo-CAR T cells. A previous research in vitro and in a mouse xenograft MCL model found that addition of ibrutinib to CAR T cells improves responses against MCL . Fraietta, J.A., et al.  found that ibrutinib improved the expansion and function of CAR T cells ex vivo and in vivo, and decreased expression of the immunosuppressive molecule PD1 on T cells and on tumor cells. Venetoclax, targeting BCL2, was used after the failure of auto-CAR T cell therapy. The previous studies have revealed that small-molecule inhibitors of the BCL2 family potentiate the efficacy of CAR T cells by sensitizing tumor cells to apoptosis . Importantly, venetoclax induces apoptosis in a TP53-independent manner  and is suggested as an optimal partner with ibrutinib by pharmacological and protein profiling . This was also the possible reason for the success of haplo-CART therapy. These targeted therapies not only controlled disease progression, but also did not affect the function of CAR T cells, suggesting a potential synergistic benefit. Combining CAR T cell therapy and such supplementary tactics represents a promising two-pronged therapeutic strategy in patients with MCL or other types of B-cell lymphoma.
Finally, tumor cells have the ability to escape the immune surveillance through genetic or epigenetic changes and become tolerant to the cytotoxic activity of their own T cells . But the donor T cells can eliminate tumor cells by recognizing tumor-specific or recipient-specific antigens . According to our data, of haplo-CAR T cells administered to the patient, 41.4% of T lymphocytes were her daughter’s non-CAR-transduced T cells that may exert graft-versus- lymphoma activity. This is also the possible reason for the success of haplo-CAR T cell therapy. This case suggests that haplo-identical CAR T cell therapy can be effective in controlling lymphoma that failed to respond to autologous CAR T cell therapy and help overcome limitation of autologous CAR T cells, thus may be one possible regimen before the era of off-the-shelf “universal” CAR T cell therapy.
The authors would like to thank all members of the study team, the patient, and their family. We would also like to thank the wonderful work of Bio-Raid Company, especially in the preparation of CAR T cells. We also gratefully acknowledge Dr. Arian Laurence (University of Oxford) for his helping with revision of our manuscript.
This work was supported by the National Science Foundation of China (Grant No. 81670150).
Availability of data and materials
The datasets supporting the conclusions of this article are included within the article and additional files.
JZ and XZ analyzed and interpreted the data; XM conducted the experiments of flow cytometry; DP analyzed PET/CT results; TL and YZ managed patient and wrote the manuscript. All authors read and approved the final manuscript.
Ethics approval and consent to participate
This study was approved by the Medical ethics committee of Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (TJ-IRB20160310). The patient and donor gave their written informed consent in accordance with the Declaration of Helsinki. This study is registered at www.chictr.org.cn as ChiCTR-OPN-16008526, ChiCTR1800019385 and ChiCTR1800019449.
Consent for publication
The authors have obtained consent to publish from the participant to report individual patient data.
The authors declare that they have no competing interests.
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