血液肿瘤CAR-T细胞治疗的现状与挑战

过继性细胞免疫疗法(adoptive cellular immunotherapy,ACI)是药物开发中一种全新模式,目前已具备在肿瘤疾病中带来临床益处的明确证据。其中嵌合抗原受体修饰的T细胞(chimeric antigen receptor-modified T cells,CAR-T)疗法利用基因工程技术重编程T细胞,使其具备非主要组织相容性抗原复合物(major histocompability complex,MHC)限制性的靶向结合并杀伤肿瘤细胞的能力,并在急性B淋巴细胞性白血病(B-cell acute lymphoblastic leukemia,B-ALL)、非霍奇金淋巴瘤(non-Hodgkin's lymphoma,NHL)、多发性骨髓瘤(multiple myeloma,MM)患者中展现出显著的缓解率,为难治复发性血液肿瘤疾病提供了治愈希望,因此多项商品化CAR-T产品也获批应用于临床,开拓了肿瘤免疫治疗的新时代。然而,细胞因子释放综合征(cytokine release syndrome,CRS)、免疫效应细胞相关神经毒性综合征(immune effector cell-associated neurotoxicity syndrome,ICANS)和其他并发症的发生是其应用的安全性挑战,并且部分患者发生CAR-T治疗无效或复发,需要提出优化CAR-T细胞疗法的新策略,在不同水平强化肿瘤清除作用,以确保安全性和有效性。本文对血液肿瘤领域的CAR-T细胞疗法临床研究进展进行综述,并归纳了下一代CAR-T细胞疗法面临的主要挑战,为拓展CAR-T细胞基础研究及临床转化研究方向提供思路。

2022 Chinese expert consensus and guidelines on clinical management of toxicity in anti-CD19 chimeric antigen receptor T-cell therapy for B-cell non-Hodgkin lymphoma

Adoptive cellular immunotherapy with chimeric antigen receptor(CAR)T cells has emerged as a novel modality for treating relapsed and/or refractory B-cell non-Hodgkin lymphoma(B-NHL).With increasing approval of CAR T-cell products and advances in CAR T cell therapy,CAR T cells are expected to be used in a growing number of cases.However,CAR T-cell-associated toxicities can be severe or even fatal,thus compromising the survival benefit from this therapy.Standardizing and studying the clinical management of these toxicities are imperative.In contrast to other hematological malignancies,such as acute lymphoblastic leukemia and multiple myeloma,anti-CD19 CAR T-cell-associated toxicities in B-NHL have several distinctive features,most notably local cytokine-release syndrome(CRS).However,previously published guidelines have provided few specific recommendations for the grading and management of toxicities associated with CAR T-cell treatment for B-NHL.Consequently,we developed this consensus for the prevention,recognition,and management of these toxicities,on the basis of published literature regarding the management of anti-CD19 CAR T-cell-associated toxicities and the clinical experience of multiple Chinese institutions.This consensus refines a grading system and classification of CRS in B-NHL and corresponding measures for CRS management,and delineates comprehensive principles and exploratory recommendations for managing anti-CD19 CAR T-cell-associated toxicities in addition to CRS.

Diagnostic and Prognostic Value of Plasma Factor V Activity and Parameters in Thrombin Generation for Disseminated Intravascular Coagulation in Patients with Hematological Malignancies

In this study,we used plasma factor V activity and parameters of the thrombin generation test to discuss their diagnostic and prognostic value for disseminated intravascular coagulation (DIC) in patients with hematological malignancies.A total of 164 patients who were diagnosed with hematological malignancies in the Department of Hematology,Union Hospital,between Apr 2014 and Dec.2014 were enrolled in this study.There were 131 patients in the study group and 33 patients in the control group in terms of the laboratory results for DIC.The patients in the study group were divided into a DIC subgroup (n=59) and a non-DIC subgroup (n=72) based on the International Society of Thrombosis and Hemostasis (ISTH) Integral System,and they were divided into four subgroups [score ≤3 (n=35),score=4 (n=37),score=5 (n=47),and score >6 (n=12)] according to ISTH scores.Using 28-day mortality as the endpoint,the patients in the study group were divided into a survival subgroup (n=111) and a non-survival subgroup (n=20).The results showed that the plasma factor V activity was significantly weaker,and lag time and time to peak were significantly shorter in the study group than in the control group (P<0.01).The factor V activity,peak and endogenous thrombin potential (ETP) were significantly decreased in the DIC subgroup as compared with those in the non-DIC subgroup (P<0.01).Among factor V activity,lag time,peak,ETP,and ttPeak,only the factor V activity was significantly decreased in the nonsurvival subgroup compared with the survival subgroup (P<0.01).With the increase in ISTH score,the ETP and peak decreased gradually.The binary logistic regression analysis revealed that PLT,D-dimer,factor V activity and ETP had linear relationship with DIC diagnosed by ISTH Integral System.Using DIC diagnosed by ISTH Integral System as the endpoint,the area under curve (AUC) of factor V activity was found to be similar to that of blood platelet count (PLT) and prothrombin time (PT).In conclusion,factor V activity,ETP and peak had diagnostic value for DIC in patients with hematological malignancies,and only factor V activity had limited prognostic value.

Simvastatin Improves Outcomes of Endotoxin-induced Coagulopathy by Regulating Intestinal Microenvironment

Objective:The systemic inflammatory response is regarded as the major cause of endotoxin-induced coagulopathy,which is a strong predictor of mortality in patients with severe sepsis.Simvastatin plays an important role in reducing inflammation.In addition,the gut has long been hypothesized to be the“motor”of critical illness,driving or aggravating sepsis by the increased intestinal permeability and bacterial translocation.

Immunotherapy in hematologic malignancies:achievements,challenges and future prospects

The immune-cell origin of hematologic malignancies provides a unique avenue for the understanding of both the mechanisms of immune responsiveness and immune escape,which has accelerated the progress of immunotherapy.Several categories of immunotherapies have been developed and are being further evaluated in clinical trials for the treatment of blood cancers,including stem cell transplantation,immune checkpoint inhibitors,antigen-targeted antibodies,antibody-drug conjugates,tumor vaccines,and adoptive cell therapies.These immunotherapies have shown the potential to induce long-term remission in refractory or relapsed patients and have led to a paradigm shift in cancer treatment with great clinical success.Different immunotherapeutic approaches have their advantages but also shortcomings that need to be addressed.To provide clinicians with timely information on these revolutionary therapeutic approaches,the comprehensive review provides historical perspectives on the applications and clinical considerations of the immunotherapy.Here,we first outline the recent advances that have been made in the understanding of the various categories of immunotherapies in the treatment of hematologic malignancies.We further discuss the specific mechanisms of action,summarize the clinical trials and outcomes of immunotherapies in hematologic malignancies,as well as the adverse effects and toxicity management and then provide novel insights into challenges and future directions.

基于个体化机器学习的原发性免疫性血小板减少症危重出血预测模型:一项全国前瞻性队列研究

原发性免疫性血小板减少症(ITP)中少见但至关重要的危重出血事件,给患者的预后、生活质量和治疗决策带来严重影响。尽管有一些研究探讨了ITP中与危重出血相关的风险因素,但目前尚缺乏大样本数据、大规模多中心研究结果以及针对ITP患者致命出血事件的预测模型。本研究首次采用国际血栓与止血学会新提出的ITP致命出血标准,利用大样本数据开发了首个基于机器学习的在线应用,用于预测ITP患者的致命出血.研究中,我们使用中国各地大型多中心数据进行开发,并对全国39家医疗中心进行为期一年的外部测试,得到了较好的训练、验证和测试数据集预测能力该基于新算法的便捷网络工具能够快速识别ITP患者的出血风险,辅助临床决策,有望未来降低不良事件的发生。

Hepatitis Virus-associated Non-hodgkin Lymphoma: Pathogenesis and Treatment Strategies

Over the last decade,epidemiological studies have discovered a link between hepatitis C virus(HCV)and hepatitis B virus(HBV)infection and non-Hodgkin lymphoma(NHL).The regression of HCV-associated NHL after HCV eradication is the most compelling proof supporting HCV infection’s role in lymphoproliferative diseases.HBV infection was found to significantly enhance the incidence of NHL,according to the epidemiological data.The exact mechanism of HCV leading to NHL has not been fully clarified,and there are mainly the following possible mechanisms:(1)Indirect mechanisms:stimulation of B lymphocytes by extracellular HCV and cytokines;(2)Direct mechanisms:oncogenic effects mediated by intracellular HCV proteins;(3)hit-and-run mechanism:permanent genetic B lymphocytes damage by the transitional entry of HCV.The specific role of HBV in the occurrence of NHL is still unclear,and the research on its mechanism is less extensively explored than HCV,and there are mainly the following possible mechanisms:(1)Indirect mechanisms:stimulation of B lymphocytes by extracellular HBV;(2)Direct mechanisms:oncogenic effects mediated by intracellular HBV DNA.In fact,it is reasonable to consider direct-acting antivirals(DAAs)as first-line therapy for indolent HCV-associated BNHL patients who do not require immediate chemotherapy.Chemotherapy for NHL is affected by HBV infection and replication.At the same time,chemotherapy can also activate HBV replication.Following recent guidelines,all patients with􀀫HBsAg positive/HBV DNA≥2,000IU/mL should be treated for HBV.The data on epidemiology,interventional studies,and molecular mechanisms of HCV and HBV-associated B-NHL are systematically summarized in this review.

Chinese expert consensus on the management of chimeric antigen receptor T cell therapy-associated coagulopathy

Chimeric antigen receptor T-cell(CAR-T)therapy has greatly improved the disease remission rate and long-term survival rate of patients with relapsed/refractory hematological malignancies.[1-3]Currently,several commercial CAR-T products are available in the market and numerous CAR-T clinical trials have been conducted.Attention should be paid to the safety of CAR-T therapy.The main adverse effects of CAR-T therapy are cytokine release syndrome(CRS)and immune effector cell-associated neurotoxicity syndrome(ICANS).[4]

Carrier-free nanodrugs with efficient drug delivery and release for cancer therapy:From intrinsic physicochemical properties to external modification

The considerable development of carrier-free nanodrugs has been achieved due to their high drug-loading capability,simple preparation method,and offering“all-in-one”functional platform features.However,the native defects of carrier-free nanodrugs limit their delivery and release behavior throughout the in vivo journey,which significantly compromise the therapeutic efficacy and hinder their further development in cancer treatment.In this review,we summarized and discussed the recent strategies to enhance drug delivery and release of carrier-free nanodrugs for improved cancer therapy,including optimizing the intrinsic physicochemical properties and external modification.Finally,the corresponding challenges that carrier-free nanodrugs faced are discussed and the future perspectives for its application are presented.We hope this review will provide constructive information for the rational design of more effective carrier-free nanodrugs to advance therapeutic treatment.

“CALM”让CAR-T细胞疗法更强大

Chimeric antigen receptor(CAR)-T therapy was first described in 1989 and has revolutionized the management of hematological cancers with its great potential in reinforcing T cells against tumors[1].CAR-T therapies are mechanistically different from more traditional approaches to the treatment of hematological cancers such as surgery,chemoradiotherapy,and monoclonal antibody therapy.To date,six CAR-T products have been approved by the US Food and Drug Administration(FDA)and successfully applied to the treatment of B-cell acute lymphoblastic leukemia(B-ALL),diffuse large B cell lymphoma(DLBCL),follicular lymphoma(FL),and multiple myeloma(MM).Whilst there has been progress in the identification of new targets and related technologies for solid tumors,commercial products are not yet available.

SARS-CoV-2 infection causes immunodeficiency in recovered patients by downregulating CD19 expression in B cells via enhancing B-cell metabolism

The SARS-CoV-2 infection causes severe immune disruption.However,it is unclear if disrupted immune regulation still exists and pertains in recovered COVID-19 patients.In our study,we have characterized the immunephe no type of B cells from 15 recovered COVID-19 patients,and found that healthy controls and recovered patients had similar B-cell populations before and after BCR stimulation,but the frequencies of PBC in patients were significantly increased when compared to healthy controls before stimulation.However,the percentage of unswitched memory B cells was decreased in recovered patients but not changed in healthy controls upon BCR stimulation.Interestingly,we found that CD19 expression was significantly reduced in almost all the B-cell subsets in recovered patients.Moreover,the BCR signaling and early B-cell response were disrupted upon BCR stimulation.Mechanistically,we found that the reduced CD19 expression was caused by the dysregulation of cell metabolism.In conclusion,we found that SARS-CoV-2 infection causes immunodeficiency in recovered patients by downregulating CD19 expression in B cells via enhandng B-cell metabolism,which may provide a new intervention target to cure COVID-19.

Mitochondria-acting carrier-free nanoplatform self-assembled by a-tocopheryl succinate carrying cisplatin for combinational tumor therapy

Unsatisfactory drug loading capability,potential toxicity of the inert carrier and the limited therapeutic effect of a single chemotherapy drug are all vital inhibitory factors of carrier-assisted drug delivery systems for chemotherapy.To address the above obstacles,a series of carrier-free nanoplatforms self-assembled by dual-drug conjugates was constructed to reinforce chemotherapy against tumors by simultaneously disrupting intratumoral DNA activity and inhibiting mitochondria function.In this nanoplatform,the mitochondria-targeting small-molecular drug,a-tocopheryl succinate(TOS),firstly self-assembled into nanoparticles,which then were used as the carrier to conjugate cisplatin(CDDP).Systematic characterization results showed that this nanoplatform exhibited suitable particle size and a negative surface charge with good stability in physicochemical environments,as well as pH-sensitive drug release and efficient cellular uptake.Due to the combined effects of reactive oxygen species(ROS)generation by TOS and DNA damage by CDDP,the developed nanoplatform could induce mitochondrial dysfunction and elevated cell apoptosis,resulting in highly efficient anti-tumor outcomes in vitro.Collectively,the combined design principles adopted for carrier-free nanodrugs construction in this study aimed at targeting different intracellular organelles for facilitating ROS production and DNA disruption can be extended to other carrier-free nanodrugs-dependent therapeutic systems.

High-drug-loading capacity of redox-activated biodegradable nanoplatform for active targeted delivery of chemotherapeutic drugs

Challenges associated with low-drug-loading capacity,lack of active targeting of tumor cells and unspecific drug release of nanocarriers synchronously plague the success of cancer therapy.Herein,we constructed active-targeting,redox-activated polymeric micelles(HPGssML)selfassembled aptamer-decorated,amphiphilic biodegradable poly(benzyl malolactonate-co-e-caprolactone)copolymer with disulfide linkage and p-conjugated moieties.HPGssML with a homogenous spherical shape and nanosized diameter(-150 nm)formed a low critical micellar concentration(10^-3mg/mL),suggesting good stability of polymeric micelles.The anticancer drug,doxorubicin(DOX),can be efficiently loaded into the core of micelles with high-drug-loading content via strong π-π interaction,which was verified by a decrease in fluorescence intensity and redshift in UV adsorption of DOX in micelles.The redox sensitivity of polymeric micelles was confirmed by size change and in vitro drug release in a reducing environment.Confocal microscopy and flow cytometry assay demonstrated that conjugating aptamers could enhance specific uptake of HPGssML by cancer cells.An in vitro cytotoxicity study showed that the half-maximal inhibitory concentration(IC50)of DOX-loaded HPGssML was two times lower than that of the control group,demonstrating improved antitumor efficacy.Therefore,the multifunctional biodegradable polymeric micelles can be exploited as a desirable drug carrier for effective cancer treatment.

Targeting autophagy overcomes cancer-intrinsic resistance to CAR-T immunotherapy in B-cell malignancies

Background:Chimeric antigen receptor T(CAR-T)therapy has substantially revolutionized the clinical outcomes of patients with hematologic malignan-cies,but the cancer-intrinsic mechanisms underlying resistance to CAR-T cells remain yet to be fully understood.This study aims to explore the molecular deter-minants of cancer cell sensitivity to CAR-T cell-mediated killing and to provide a better understanding of the underlying mechanisms and potential modulation to improve clinical efficacy.Methods:The human whole-genome CRISPR/Cas9-based knockout screening was conducted to identify key genes that enable cancer cells to evade CD19 CAR-T-cell-mediated killing.The in vitro cytotoxicity assays and evaluation of tumor tissue and bone marrow specimens were further conducted to confirm the role of the key genes in cancer cell susceptibility to CAR-T cells.In addition,the specific mechanisms influencing CAR-T cell-mediated cancer clearance were elucidated in mouse and cellular models.Results:The CRISPR/Cas9-based knockout screening showed that the enrich-ment of autophagy-related genes(ATG3,BECN1,and RB1CC1)provided protec-tion of cancer cells from CD19 CAR-T cell-mediated cytotoxicity.These findings were further validated by in vitro cytotoxicity assays in cells with genetic and pharmacological inhibition of autophagy.Notably,higher expression of the three autophagy-related proteins in tumor samples was correlated with poorer respon-siveness and worse survival in patients with relapsed/refractory B-cell lymphoma after CD19 CAR-T therapy.Bulk RNA sequencing analysis of bone marrow samples from B-cell leukemia patients also suggested the clinical relevance of autophagy to the therapeutic response and relapse after CD19 CAR-T cell ther-apy.Pharmacological inhibition of autophagy and knockout of RB1CC1 could dramatically sensitize tumor cells to CD19 CAR-T cell-mediated killing in mouse models of both B-cell leukemia and lymphoma.Moreover,our study revealed that cancer-intrinsic autophagy mediates evasion of CAR-T cells via the TNF-α-TNFR1 axis-mediated apoptosis and STAT1/IRF1-induced chemokine signaling activation.Conclusions:These findings confirm that autophagy signaling in B-cell malig-nancies is essential for the effective cytotoxic function of CAR-T cells and thereby pave the way for the development of autophagy-targeting strategies to improve the clinical efficacy of CAR-T cell immunotherapy.