CAR-T cell therapy for multiple myeloma: a practical toolkit for treatment in Brazil

ABSTRACT Introduction Chimeric antigen receptor T (CAR-T) cell therapy is an emerging treatment option for relapsed/refractory multiple myeloma (RRMM) that is a multi-step process involving various stakeholders. Appropriate education on the practical logistics is therefore paramount to ensure treatment success. Methods A group of key opinion leaders met to explore the key elements of setting up and running a CAR-T center in Brazil. For each step in the CAR-T cell therapy process, the experts agreed on basic requirements, gave their key recommendations from practical experience, and considered any remaining unanswered questions. Results This paper presents best-practice recommendations and advice on how to overcome common challenges for each step in the CAR-T cell therapy process, with a focus on the current situation in Brazil. Key themes throughout the process are collaboration within the multidisciplinary team and with the referring physician, along with communication and education for patients and their caregivers. Conclusion We believe that the expert insights presented in this paper, in particular on optimal patient selection and timing of CAR-T cell therapy, will deepen understanding of the CAR-T process and aid implementation of this novel therapy for patients with RRMM in Brazil.

Terapia com células CAR-T: reprogramação celular para o combate de neoplasias malignas / CAR-T cell therapy: cell reprogramming to combat malignant neoplasms

As células CAR-T são linfócitos geneticamente modificados para reconhecerem um espectro amplo de antígenos de superfície celulares. Além disso, atacam células tumorais malignas, que expressam esses antígenos, por meio da ativação da coestimulação citoplasmática, secreção de citocinas, citólise de células tumorais e proliferação de células T. O objetivo desse estudo é abordar a imunoterapia com células CAR-T, a fim de explicar seu conceito, processo de fabricação e papel no tratamento de neoplasias hematológicas e tumores sólidos. Foi realizada uma revisão através do portal PubMed, utilizando como descritores: "car-t cell therapy" e "neoplasms", determinados com base nos "Descritores em Ciências da Saúde". Foram obtidos, inicialmente, 10 artigos, os quais foram lidos integralmente para a confecção dessa revisão. Além disso, foram adicionados 3 ensaios clínicos atualizados sobre o tema. Na terapia com células CAR-T, as células T são coletadas do paciente, geneticamente modificadas para incluir receptores de antígeno específicos e, posteriormente, expandidas em laboratórios e transfundidas de volta para o paciente. Assim, esses receptores podem reconhecer células tumorais que expressam um antígeno associado a um tumor. A terapia com células CAR-T é mais conhecida por seu papel no tratamento de malignidades hematológicas de células B, sendo a proteína CD19 o alvo antigênico mais bem estudado até o momento. Entretanto, estudos estão sendo feitos para verificar a eficácia desse tratamento, também, em tumores sólidos. Portanto, apesar de inicialmente ser indicada apenas para um grupo seleto de pessoas, essa terapia tem demonstrado grande potencial para atuar em um espectro maior de pacientes.

The CAR-T cells are lymphocytes genetically modified to recognize a broader spectrum of cell surface antigens. In addition, they attack malignant tumor cells, which express these antigens, by activating cytoplasmic co-stimulation, cytokine secretion, tumor cell cytolysis and T cell proliferation. The aim of this study is to address immunotherapy with CAR-T cells, in order to explain its concept, manufacturing process and role in the treatment of hematological neoplasms and solid tumors. This is a literature review conducted through the PubMed portal, that uses the terms "car-t cell therapy" and "neoplasms" as descriptors, determined based on the DeCS (Descritores em Ciências da Saúde). To prepare this review, initially 10 articles were found and read in full. In addition, 3 updated clinical trials on the subject were added. For CAR-T cell therapy, T cells are collected from the patient, genetically modified to include specific antigen receptors, and later expanded in laboratories and transfused back to the patient. Thus, these receptors can recognize tumor cells that express a tumor-associated antigen. CAR-T cell therapy is best known for its role in the treatment of B cell hematological malignancies, with the CD19 protein being the most studied antigenic target to date. However, studies are being conducted to verify the effectiveness of this treatment, also, in solid tumors. Therefore, despite being formulated only for a selected group of patients, this therapy has great potential to act on a broader spectrum of patients.

Células asesinas naturales con el receptor de antígeno quimérico (CAR-NK): terapia emergente contra el cáncer / Chimeric antigen receptor-natural killer cells: novel therapy against cancer

Resumen Una de las herramientas más novedosas en inmunoterapias adoptivas contra leucemias y tumores malignos es el uso del receptor de antígeno quimérico "CAR". El receptor CAR ha sido ampliamente utilizada en células T (células CAR-T) potenciando su eficacia en el reconocimiento y eliminación de tumores, obteniéndose a la fecha terapias basadas en esta tecnología. No obstante, las células CAR-T llegan a repercutir negativamente en la salud del paciente, presentando el síndrome neurológico de efecto inmune asociado a células (ICANS) y el síndrome de lanzamiento de citocinas (SLC). Como consecuencia, el paciente necesita ser hospitalizado durante la terapia. Además, el coste de manufactura y terapia es elevado, siendo una tecnología limitada a un sector muy bajo de la población. En este trabajo, mencionamos el empleo de una terapia emergente de células asesinas naturales (NK) con el receptor CAR (CAR-NK), que cuentan con muchas ventajas por encima de las células CAR-T. Las células CAR-NK conservan su capacidad citotóxica en contra de tumores gracias a su acción dependiente de receptores activadores e inhibidores, por lo que el receptor CAR, solo estimula sus habilidades y persistencia. Sumado a esto, el coste de una terapia de células CAR-NK podría resultar redituable debido a la capacidad de las células CAR-NK de eliminar múltiples células tumorales sin generar daño colateral en el paciente. Aquí analizamos las características de los múltiples receptores CAR y los fenotipos de células NK que han sido utilizados durante múltiples ensayos (NK-92, células NK de sangre cordal y periférica, y células NK iPSC).

Abstract One of the novel and effective devices against leukemia and solid tumors in adoptive immunotherapies is the use of the chimeric antigen receptor "CAR". CAR technology has been widely used in T-cells (CAR-T cells) empowering its efficacy on the identification and elimination of tumor cells, getting today certain drugs based on this technology. Nevertheless, CAR-T cells can have a negative impact on patient health, causing in many cases immune effector cell-associated neurotoxicity syndrome (ICANS) and cytokine release syndrome (CRS). As a consequence, the patient will have to be hospitalized for the duration of therapy. Moreover, the cost of manufacture and therapy is quite expensive, limiting its use to a low range of people. On the other hand, we analyze the advantages of Natural Killer cells with the CAR receptor (CAR-NK), which have many plusses over CAR-T cells. CAR-NK cells retain their cytotoxic abilities against tumor cells due their activator/ inhibitor receptors balance. Thus, the CAR receptor technology just increases their skills and persistence. Furthermore, CAR-NK therapy could be more profitable since CAR-NK can eliminate multiple tumor cells without generating collateral damage on patient health. Here, we discuss the characteristics of the multiples CAR receptors in general and the NK types cells that have been used in trials demonstrating their viable emerging therapy (NK-92, cord and peripheral blood NK cells, and iPSC-derived NK cells).

Imunoterapia com células CAR-T como nova perspectiva de tratamento da leucemia linfoblástica aguda recidivada/refratária / Immunotherapy with CAR-T cells as a new treatment perspective for relapsed/refractory acute lymphoblastic leukemia

Introdução: O tratamento da leucemia linfoblástica aguda (LLA) atualmente baseia-se em quimioterapia e/ou transplante de células tronco hematopoiéticas; entretanto, uma nova terapia vem se tornando promissora: a imunoterapia com células T modificadas geneticamente que expressam um receptor de antígeno quimérico (CAR-T) visando antígenos específicos presente em blastos de LLA, gerando resultados promissores em crianças e adultos com doença recidivada e refratária (r/r). Objetivo: Discorrer sobre a LLA e descrever a imunoterapia com CAR-T, como inovação terapêutica no tratamento da LLA de linhagem B. Método: Foi realizada uma revisão bibliográfica por meio de publicações indexadas nas bases de dados Scielo e Pubmed, utilizando os descritores: leucemia linfoblástica aguda de células B; células CAR-T; receptores de antígeno quimérico, recidivados/refratários; imunoterapia. Resultados: As altas taxas de remissão completa (42% até 100%) e parcial (28,5%) da LLA (r/r) tratadas com CAR-T, possibilitam um aumento considerável da sobrevida geral comparado a outros tratamentos convencionais. Efeitos desfavoráveis, tais como síndrome da liberação de citocinas (CRS) (0 até 90%) e neurotoxicidade (NT) (0 até 29%) podem ser vistos, sendo manejáveis, não prejudicando o desfecho do tratamento. Conclusão: A LLA é uma doença grave, de difícil tratamento e prognóstico reservado. A imunoterapia vêm se mostrando promissora à essa enfermidade, principalmente em casos de doença r/r se mostrado uma ferramenta poderosa que permite o foco específico de células malignas por meio de engenharia de células T

Introduction: The treatment of acute lymphoblastic leukemia (ALL) is currently based on chemotherapy and/or hematopoietic stem cell transplantation; however, a new therapy is becoming promising: immunotherapy with genetically modified T cells that express a chimeric antigen receptor (CAR-T) targeting specific antigens present on ALL blasts, reaching promising results in children and adults with relapsed and refractory disease (r/r). Objective: To discuss ALL and describe immunotherapy with CAR-T as a therapeutic innovation in the treatment of B-lineage ALL. Method: A literature review was carried out through publications indexed in the Scielo and Pubmed databases, using the following descriptors: B-cell acute lymphoblastic leukemia; CAR-T cells; chimeric antigen receptors, relapsed/refractory; immunotherapy. Results: The high rates of complete (42% to 100%) and partial remission (28.5%) of ALL (r/r) treated with CAR-T allows a considerable increase in overall survival compared to other conventional treatments. Unfavorable effects such as cytokine release syndrome (CRS) (0 to 90%) and neurotoxicity (NT) (0 to 29%) can be seen, being manageable, not impairing the treatment outcome. Conclusion: ALL is a serious disease, with a difficult treatment and poor prognosis. Immunotherapy has shown benefits for this disease, especially in cases of r/r ALL, showing itself to be a powerful tool that allows the specific focus of malignant cells through T cell engineering.

Establishment of a simple and efficient platform for car-t cell generation and expansion: from lentiviral production to in vivo studies

ABSTRACT Introduction: Adoptive transfer of T cells expressing a CD19-specific chimeric antigen receptor (CAR) has shown impressive response rates for the treatment of CD19 + B-cell malignancies in numerous clinical trials. The CAR molecule, which recognizes cell-surface tumor-associated antigen independently of human leukocyte antigen (HLA), is composed by one or more signaling molecules to activate genetically modified T cells for killing, proliferation, and cytokine production. Objectives: In order to make this treatment available for a larger number of patients, we developed a simple and efficient platform to generate and expand CAR-T cells. Methods: Our approach is based on a lentiviral vector composed by a second-generation CAR that signals through a 41BB and CD3-ζ endodomain. Conclusions: In this work, we show a high-level production of the lentiviral vector, which was successfully used to generate CAR-T cells. The CAR-T cells produced were highly cytotoxic and specific against CD19+ cells in vitro and in vivo, being able to fully control disease progression in a xenograft B-cell lymphoma mouse model. Our work demonstrates the feasibility of producing CAR-T cells in an academic context and can serve as a paradigm for similar institutions. Nevertheless, the results presented may contribute favoring the translation of the research to the clinical practice.

Immunotherapy with natural killer cells: a possible approach for the treatment of Acute Myeloid Leukemia also in Brazil / Imunoterapia com células natural killer: um caminho possível para o tratamento da Leucemia Mielóide Aguda também no Brasil

SUMMARY The allogeneic hematopoietic stem cell transplantation (HSCT) can cure intermediate and high-risk acute myeloid leukemia. Even with the development of strategies to reduce HSCT toxicity, this is still a complex treatment with high morbidity and mortality. Knowledge of the graft versus leukemia effect of HSCT has prepared the way for the development of Adoptive Immunotherapy or in vitro expansion of activated lymphocytes without alloreactivity, with subsequent intravenous infusion. The infusion of genetically modified T lymphocytes and haploidentical natural killer cells has been tested as an alternative to HSCT with very interesting results worldwide and in Brazil, as we not only have the technology of in vitro expansion of clinical grade lymphocytes available, but also do it according to the Good Manufacturing Practices that have been determined internationally.

RESUMO O transplante de células-tronco hematopoéticas (TCTH) alogênico é curativo para leucemia mielóide aguda de risco intermediário e alto. Mesmo com o desenvolvimento de estratégias para minorar a toxicidade do TCTH, este ainda é um tratamento complexo com elevada morbi-mortalidade. O conhecimento sobre o efeito enxerto contra leukemia do TCTH pavimentou o caminho para o desenvolvimento da Imunoterapia Adotiva ou expansão in vitro de linfócitos ativados, sem alo-reatividade, com posterior infusão endovenosa. A infusão de Linfócitos T geneticamente modificados e de células Natural Killer haploidenticas tem sido testada como alternativa ao TCTH com resultados bastante interessantes no mundo e no Brazil já que não apenas dominamos a tecnologia de expansão in vitro de linfócitos em grau clínico, como o fazemos segundo as Boas Práticas de Manufatura determinadas internacionalmente.

Sandfly species diversity in association with human activities in the Kani tribe settlements of the Western Ghats, Thiruvananthapuram, Kerala, India

Sandfly prevalence in the Kani tribe settlements of Western Ghats in India was investigated. A total of 1,279 sandflies comprising 17 species was obtained. Sandfly abundance showed a negative correlation (r = -0.97, p = 0.003) with increase in altitudinal ranges from 0-1,000 m. When sandfly samples were grouped according to landscape characteristics of the location, the estimated Shannon-Weiner index (H) and species richness index (S) were high and species evenness index (J) was low in settlements located at 0-300 m altitudinal range. On the contrary, the values of H and J were high, while S was low at 301-600 m altitudinal range. With further increase in altitude, species diversity, S and J were low. Though the relative abundance of sandflies decreased with increase in altitude, the influence of altitudinal variation could not be attributed to determine sandfly diversity, since the number of sampling units were not uniform at all the altitudinal gradients due to nonavailability of suitable resting shelters. Sandfly species showed great aggregation at 0-300 m altitude interval, where not only the number of settlements were maximum (n = 19), but also the environmental conditions favoured sandfly abundance due to the concentration of tribal settlements, human dwellings and his activities.

Bone marrow transplantation: a historical review

Bone marrow transplantation has evolved over a period of 50 years. Laboratory observations and animal studies defined the essentials of transplantation biology. The first attempts to transfer these studies to patients met with little success. The definition of the complexities of the human leukocyte antigen (HLA) system made it possible to select compatible sibling donors and more recently unrelated donors. Transplantation of stem cells form marrow, blood, or cord blood is now the treatment of choice for a variety or hematological and genetic diseases. Transplantation using less toxic preparative regimens to induced mixed chimerism makes possible and application to autoimmune diseases. Laboratory and clinical research directed toward induction of tolerance and elimination of malignant cell point the way to a wider application of hematopoietic cell transplantation in the next decade.

Fundamentos de la inmunoterapia adoptiva con células T CD8+ en pacientes con SIDA y Sarcoma de Kaposi / Basis of the adoptive immunotherapy with T CD8+ cells in AIDS and Kaposi's sarcoma

El presente artículo resume los fundamentos científico y clínicos que conllevaron a dos ensayos clínicos de inmunoterapia adoptiva con células T CD8+ en pacientes con síndrome de inmunodeficiencia adquirida (SIDA) y sarcoma de Kaposi (KS). En el primer ensayo, pacientes con SIDA y KS o leucoplaquia vellosa oral (OHL) recibieron cinco rondas de reinfusiones de 10-10 células T CD8+ autólogas las cuales habían sido expandidas y activadas ex vivo. Se coadministró interleuquina-2 recombinante (rIL-2) sólo con la quinta infusión final. Esta intervención resultó en mejora, y en algunos casos resolución sin efectos secundarios, de OHL, KS y candidiasis. La observación de que la mejora clínica del KS era más pronunciada cuando la reinfusión de células T CD8+ era seguida por enfusión de rIL-2 conllevó a un segundo ensayo clínico, que fue diseñado para examinar el efecto sobre el KS asociado a SIDA, de infusiones repetidas de células T CD8+ autólogas con administración concomitante de rIL-2. Se observó mejora del grado de KS en cuatro de los ocho pacientes estudiados (tres con respuesta parcial y uno con respuesta total). El protocolo de inmunoterapia con células T CD8+ también proporcionó la oportunidad de estudiar comparativamente los programas genéticos asociados a células a células CD8+ en SIDA y controles sin infección. Se observó que los patrones de expresión basal de marcadores inmunes solubles y de superficie de células CD8+ provenientes de pacientes con SIDA y de controles sin infección eran predominantemente del tipo 1 y diferían principalmente a nivel cuantitativo o cinético. Otro hallazgo en los ensayos clínicos fue la disipación, con la progresión a través del protocolo, de las deficiencias en la expresión de mediadores inmunes por parte de células T CD8+ de pacientes con SIDA. Estas observaciones son analizadas en el contexto del conocimiento actual y de las implicancias terapéuticas de la función de células CD8+ en el SIDA y la neoplasia.

Moduladores de la respuesta inmune / Immune responce modulators

La estimulación del sistema inmune para mejorar el balance de fuerzas entre un organismo patógeno o célula tumoral y el húesped es uno de los retos más importantes para el inmunólogo. Se presenta una revisión de los principales métodos y substancias moduladoras de la respuesta inmune disponibles en la actualidad, analizando sus mecanismos de acción, efectos secundarios y posibles aplicaciones clínicas

Uso del factor de transferencia en el asma bronquial alérgica / Use to the transfer factor in the brochial asthma allergic

Se revisa el panorama de la terapéutica de la inmunomodulación y sus efectos en la modificación de la reacción inmunitaria. Se hace referencia particular al factor de transferencia como elemento terapéutico del asma bronquial, del que se asegura su eficacia e inocuidad

Influence of age on the induction of oral tolerance in mice and its adoptive transfer by spleen cells

Seven-week old B6D2F1 mice were highly susceptible to the induction of oral tolerance to ovalbumin (Ova), whereas 70-week old mice were totally refractory. Immune responsiveness (secondary antibody formation) to intraperitoneal immunization to Ova was the same in 7-week or 70-week old B6D2F1 mice. In B6D2F1 mice, the adoptive transfer of spleen cells from old donors into young recipients hindered, and, reciprocally, transfer of spleen cells from young donors into old recipients facilitated the induction of oral tolerance. In BALB/c mice, which are refractory to oral tolerance to Ova, the adoptive transfer of spleen cellsfrom neonate or young donors into old recipients failed to modify the lack of susceptibility to the induction of oral tolerance

Inmonopatología inducida en la rata por virus Junín / Immunopathology induced in the rat by Junin virus

La infección de la rata de 10 días de vida por vía intracerebral con la cepa XJ del virus Junín, da lugar a un cuadro encefalítico con un 100% de mortalidad. Los presentes experimentos con suero antitimocito (SAT) demuestran la participación de la respuesta celular en la patología de este grupo etario. En cuanto al tratmiento con SAT, se utilizaron tres esquemas, siendo el más efectivo el que consistió en dosis desde el día -1 hasta el día +9, y en los días +12, +14 y +16, siendo el día 0 el de la inoculación de virus. Se alcanzó un 54% de sobrevida y un retraso en el día promedio de muerte de 12 días. No hubo diferencias en el título en cerebro de los animales tratados y los controles infectados. Las ratas de 2 días de vida al recibir el virus presentan persistencia. Cuando a estos animales se les transfirieron esplenocitos de ratas infectadas a los 10 días de edad se produjo una mortalidad de 40% en los receptores. Por lo tanto puede concluirse que: a) la encefalitis en el animal de 10 días de vida es de origen inmunológico y b) la rata de 10 días presenta una población linfocitaria que al ser transferida al animal persistente, provoca enfermedad y muerte

El tratamiento del cáncer en función del conocimiento actual / Cancer treatment according to present knowledge

La cirugía, la radioterapia y la quimioterapia han llegado en el tratamiento del cáncer, al límite de su efectividad.El nuevo conocimiento de la biología del cáncer proporciona información sobre el proceso de diseminación y progreso de la neoplasia maligna, las cuales deben ser consideradas en el planeamiento de un tratamiento.La heterogenesidad celular de los tumores,el fenotipo metastásico,los modificadores de la respuesta biológica y la inmunobiología constituyen una nueva biología que debe ser conocida por el clínico.