Choosing appropriate delivery system for chemotherapeutic drugs as well as arranging the time spots for adoptive cells administrations is the key to achieve efficient combined chemo-adoptive cell therapy. Tumor-homing character makes adoptive immune cells appropriate targeting delivery carriers, but they are rarely used for chemtoxic payloads considering payloads internalization during administration which impairs adoptive cells. Herein, we frame adoptive NK cells using DNA scaffold with chemotherapeutic payloads fastened exterior, and achieves time-programmed drugs release and NK cell decapsulation to minimize side effects and enhance therapeutic effect. IL-21 nanoparticles are prepared by conjugating cytokine IL-21 with a GSH cleavable linker and act as anchor points for DNA scaffold assembly. Chemotherapeutic payloads are prepared by loading DOX/verapamil drugs to PLGA nanoparticles (PLGAdrugs NPs), and connected to the exterior of DNA scaffold with a ROS cleavable linker. Porous DNA scaffold protects NK cells functions from impairing by chemotherapeutic payloads, while guarantees efficient communication of NK cells with exterior environment to keep tumor homing capability. Reactive oxygen species (ROS) in tumor microenvironment releases PLGAdrugs NPs to perform chemotherapy, which subsequently generates a reductive environment to detach DNA scaffold for NK cell and IL-21 release to achieve combined chemo-adoptive cell therapy with enhanced therapeutic efficiency.

Antibody-drug conjugates (ADCs), bispecific antibodies that engage T cells (BsAbs), and chimeric antigen receptor (CAR) T cells are widely used standard-of-care therapies that have revolutionized the treatment of lymphoid and plasma cell malignancies. With recent regulatory approvals, these therapies are poised to also revolutionize the treatment of common solid tumors and become a part of the everyday lexicon, the ABCs, of the practicing oncologist. Drawing from experience in hematology, we review the early, late, and rare toxicities of ADCs, BsAbs, and CAR T cells and provide general principles for their management.

Chimeric Antigen Receptor T-Cell (CAR-T) therapy is an effective therapy and promising frontier in the treatment of hematologic malignancies. However, this revolutionary treatment has led to new challenges for patients, caregivers, and the healthcare system. In this review article, we discuss the various difficulties patients face both in the acute and long-term period following CAR-T infusion. We highlight the various ways these difficulties are addressed, as well as further areas of research and support needed to improve patient experience. Additionally, we consider the difficulties and burdens placed on caregivers and healthcare systems, as well as barriers to accessing CAR-T therapy. Finally, we address future directions of research and intervention development to meet patient and caregiver needs and improve equitable access. We pose early integration of specialty palliative care for individuals and their caregivers undergoing CAR-T therapy as one promising strategy to help improve patient experience and meet their needs.

A substantial proportion of patients diagnosed with rheumatologic and musculoskeletal diseases (RMDs) exhibit resistance to conventional therapies or experience recurrent symptoms. These diseases, which include autoimmune disorders such as multiple sclerosis, rheumatoid arthritis, and systemic lupus erythematosus, are marked by the presence of autoreactive B cells that play a critical role in their pathogenesis. The persistence of these autoreactive B cells within lymphatic organs and inflamed tissues impairs the effectiveness of B-cell-depleting monoclonal antibodies like rituximab. A promising therapeutic approach involves using T cells genetically engineered to express chimeric antigen receptors (CARs) that target specific antigens. This strategy has demonstrated efficacy in treating B-cell malignancies by achieving long-term depletion of malignant and normal B cells. Preliminary data from patients with RMDs, particularly those with lupus erythematosus and dermatomyositis, suggest that CAR T-cells targeting CD19 can induce rapid and sustained depletion of circulating B cells, leading to complete clinical and serological responses in cases that were previously unresponsive to conventional therapies. This review will provide an overview of the current state of preclinical and clinical studies on the use of CAR T-cells and other cellular therapies for RMDs. Additionally, it will explore potential future applications of these innovative treatment modalities for managing patients with refractory and recurrent manifestations of these diseases.

Chimeric antigen receptor T cell (CAR-T) therapy has recently gained recognition as a transformative treatment of cancer, particularly of hematological malignancies. However, CAR-T manufacturing remains a major bottleneck of this treatment modality; in standard cases, it takes up to two weeks, resulting in a phenotypic shift toward terminally differentiated T-cells and a significant depletion of T-cells with naive-like phenotype (Tnlp), crucial for sustained clinical efficacy. Leveraging the current progress in microfluidic technologies, we develop and optimize a microfluidic device (MFD) for CAR-T cell production via an ultrafast protocol that integrates T-cell activation and lentiviral transduction in a single step within 24 hours. The MFD geometry allowed reaching a transduction rate of 27% (for MOI 3) compared to 17% and 8% transduction (MOI 3) in 48- and 6-well plates, respectively, used as controls. Notably, in the ultrafast protocol in our MFD, the amount of CD3+ Tnlp is approximately six times higher than that remaining after the standard 9 day protocol (18.07 ± 6.03% vs. 3.97 ± 2.37%). A similar pattern is noted for CD4+ and CD8+ Tnlp, with percentages of 11.07 ± 6.08% vs. 3.56 ± 3.52% and 29.2 ± 7.11% vs. 4.18 ± 1.69%, respectively, in the final CAR-T product. Our results highlight MFDs as a scalable platform to streamline CAR-T manufacturing, with the potential to improve clinical accessibility and outcomes by reducing the production time while preserving essential T-cell phenotypes.

During the time of chimeric antigen receptor T-cell (CAR-T) manufacturing, bridging therapy is often used to control disease. Because it often involves systemic treatment, the bridging therapies can induce responses and/or adverse events. We sought to assess bridging therapies used in CAR-T trials in a cross-sectional study. We reviewed FDA drug labels and peer-reviewed registration trial reports (including supplemental data) to evaluate the characteristics of bridging therapy used in trials testing CAR-T therapies. We looked at which bridging therapies were used, whether multiple therapies were combined, the response rates, and the reported adverse events associated with bridging therapy. Of the 11 studies testing CAR-T therapies, 10 reported the bridging therapies that were used in the study. Of those that reported the types of bridging therapies (n = 10), the most commonly used bridging therapy was dexamethasone (10/10, 100%), rituximab (6/10, 60%), gemcitabine (5/10, 50%), and etoposide (5/10, 50%). Of the trials, one of 11 (9%) clearly reported whether patients had responses to bridging therapy, six of 11 (55%) vaguely reported responses, and four of 11 (36%) trials did not report or mention any response information regarding bridging therapy. Although patients are often refractory to first-line therapies, which share considerable overlap with bridging therapies, these therapies may induce responses. Despite this possibility, the reporting of bridging therapy combinations and their subsequent response rates and adverse event rates are highly variable. These findings highlight the need for greater transparency in the reporting of bridging therapy to more reliably assess the efficacy of CAR-T therapies.

Hypogammaglobulinemia is a well-defined risk factor for infection. B-cell-directed immunotherapies given in addition to conventional chemotherapy are now core elements of effective therapy for children with B lymphoid malignancies. These therapies are associated with depletion of normal B cells and consequent hypogammaglobulinemia. This review summarizes the current state of knowledge regarding the mechanism, incidence, and clinical outcomes related to hypogammaglobulinemia in children with mature B-cell non-Hodgkin lymphoma and B-cell acute lymphoblastic leukemia, as well as provides practical guidance for laboratory monitoring and considerations for immunoglobulin replacement therapy.

Rich neural-immune interactions in the central nervous system (CNS) shape its function and create a unique immunological microenvironment for immunotherapy in CNS malignancies. Far from the now-debunked concept of CNS "immune privilege," it is now understood that unique immunological niches and constant immune surveillance of the brain contribute in multifaceted ways to brain health and robustly influence immunotherapy approaches for CNS cancers. Challenges include immune-suppressive and neurotoxicity-promoting crosstalk between brain, immune, and tumor cells. Developing effective immunotherapies for cancers of the nervous system will require a deeper understanding of these neural-immune-malignant cell interactions. Here, we review progress and challenges in immunotherapy for gliomas of the brain and spinal cord in light of these unique neural-immune interactions and highlight future work needed to optimize promising immunotherapies for gliomas.

The advent of genome-editing technologies, particularly the RNA-guided the clustered regularly interspaced short palindromic repeats (CRISPR)/CRISPR-associated system (Cas) 9, which originates from prokaryotic CRISPR/Cas adaptive immune mechanisms, has revolutionized molecular biology. Renowned for its simplicity, cost-effectiveness, and capacity for multiplexed gene editing, CRISPR/Cas9 has emerged as the most versatile and widely adopted genome-editing platform. Its applications span fundamental research, biotechnology, medicine, and therapeutics. This review highlights recent advancements in CRISPR-based technologies, focusing on CRISPR/Cas9, CRISPR/Cas12a, and CRISPR/Cas12f. It emphasizes precision editing methods like base editing and prime editing, which enable targeted nucleotide changes without double-strand breaks. The specificity of these tools, including on-target accuracy and off-target risks, is critically evaluated. Additionally, recent preclinical and clinical efforts to treat diseases such as cancer and sickle cell disease using CRISPR are summarized. Finally, the challenges and future directions of CRISPR-mediated gene therapy are discussed, emphasizing its potential to integrate with other molecular approaches to address unmet medical needs.

As the application of Chimeric Antigen Receptor T-cell (CAR-T) therapy in cancer treatment becomes increasingly widespread, associated hematologic and lymphatic system adverse events pose significant challenges to its clinical use. Therefore, we aim to comprehensively investigate and summarize the hematologic and lymphatic system AEs associated with CAR-T therapy.

We extracted CAR-T-related adverse event reports from the FDA Adverse Event Reporting System (FAERS) database for the period from August 2017 to December 2023. Disproportionality analysis using the Reporting Odds Ratio (ROR) and Information Component (IC) was performed to identify CAR-T-associated hematologic and lymphatic system AEs. We employed LASSO regression analysis to identify hematologic and lymphatic system AEs associated with mortality.

In the FAERS database, we identified 1,600 individual case safety reports of hematologic and lymphatic system AEs related to CAR-T therapy. The median age of patients was 57 years (interquartile range [IQR] 32-67), with fatal outcomes in 15.3% of cases. We identified 25 significant adverse event signals associated with CAR-T therapy. B-cell aplasia (ROR025 = 1054.56, IC025 = 4.74), cytopenia (ROR025 = 17.27, IC025 = 3.81), hypofibrinogenemia (ROR025 = 100.18, IC025 = 2.46), anemia (ROR025 = 1.87, IC025 = 0.59), febrile bone marrow aplasia (ROR025 = 55.32, IC025 = 2.70), and pancytopenia (ROR025 = 7.18, IC025 = 1.42) were the most significant hematologic and lymphatic system AEs for tisa-cel, axi-cel, brexu-cel, liso-cel, ide-cel, and cilta-cel, respectively. Most hematologic and lymphatic system AEs occurred within 10 days post-CAR-T infusion. Hematologic and lymphatic system AEs were associated with a mortality rate of 15.3%. Our analysis revealed 15 hematologic and lymphatic system AEs closely associated with mortality in CAR-T-treated patients, including splenic hemorrhage, disseminated intravascular coagulation, and pancytopenia.

Our study found that hematologic and lymphatic system AEs were more closely associated with anti-CD19 CAR-T and CAR-T containing CD28. Splenic hemorrhage, disseminated intravascular coagulation, and pancytopenia were identified as hematologic and lymphatic system AEs that, while less frequently reported clinically, were highly associated with mortality.

CD19-directed CAR T-cell therapy is a breakthrough immunotherapy for B-cell malignancies. However, CD19 loss-mediated relapsed/refractory disease continues to pose a significant challenge, highlighting the urgent need for CAR T cells targeting alternative antigens. To address this issue, we developed a CD20-directed CAR T incorporated with an additional CD30-directed binder to enhance cytotoxicity toward cancer cells. Here, we report that a patient with bulky transformed follicular lymphoma was successfully treated with CD20/CD30-directed CAR-T cells. The patient received two doses of anti-CD20/CD30-CAR-T therapy administered one month apart. Complete metabolic remission was achieved 1 month after the first infusion without evidence of cytokine release syndrome (CRS) or immune effector cell-associated neurotoxicity syndrome (ICANS). The second dose was given as a consolidation therapy with sustained disease-free survival exceeding 12 months to date. The report underscores the promising therapeutic potential and safety profile of CD20/CD30-directed CAR T-cell therapy.

https://www.clinicaltrials.gov, identifier NCT06756321.

Chimeric antigen receptor (CAR) T cells targeting CD19 have transformed the treatment of B-cell cancers, but many patients do not have long-term remission. We designed an anti-CD19 enhanced (armored) CAR T-cell product (huCART19-IL18) that secretes interleukin-18 to enhance antitumor activity.

In this study, we assessed the safety, feasibility, and preliminary efficacy of huCART19-IL18 in patients with relapsed or refractory lymphoma after previous anti-CD19 CAR T-cell therapy. Using a 3-day manufacturing process, we administered huCART19-IL18-positive cells in doses ranging from 3×106 to 3×108.

A total of 21 patients received huCART19-IL18. Cytokine release syndrome occurred in 62% of the patients (47% with grade 1 or 2), and immune effector-cell-associated neurotoxicity syndrome occurred in 14% (all grade 1 or 2). No unexpected adverse events were observed. Robust CAR T-cell expansion was detected across all dose levels. At 3 months after infusion, a complete or partial response was seen in 81% of the patients (90% confidence interval [CI], 62 to 93) and a complete response in 52% (90% CI, 33 to 71). With a median follow-up of 17.5 months (range, 3 to 34), the median duration of response was 9.6 months (90% CI, 5.5 to not reached).

In this small study, huCART19-IL18 had a safety profile consistent with other CAR T-cell treatments and showed promising efficacy at low cell doses in patients with lymphoma after the failure of previous anti-CD19 CAR T-cell therapy. (ClinicalTrials.gov number, NCT04684563.).

Chimeric antigen receptor (CAR)-T cell therapy has revolutionized cancer immunotherapy in the 21st century, providing innovative solutions and life-saving therapies for previously untreatable diseases. This approach has shown remarkable success in treating various hematological malignancies and is now expanding into clinical trials for solid tumors, such as prostate cancer and glioblastoma, as well as infectious and autoimmune diseases. CAR-T cell therapy involves harvesting a patient's T cells, genetically engineering them with viral vectors to express CARs targeting specific antigens and reinfusing the modified cells into the patient. These CAR-T cells function independently of major histocompatibility complex (MHC) antigen presentation, selectively identifying and eliminating target cells. This review highlights the key milestones in CAR-T cell evolution, from its invention to its clinical applications. It outlines the historical timeline leading to the invention of CAR-T cells, discusses the major achievements that have transformed them into a breakthrough therapy, and addresses remaining challenges, including high manufacturing costs, limited accessibility, and toxicity issues such as cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome. Additionally, the review explores future directions and advances in the field, such as developing next-generation CAR-T cells aiming to maximize efficacy, minimize toxicity, and broaden therapeutic applications.

Patients aged ≥50 years with r/r MCL had superior OS and lower nonrelapse mortality 1 year after receiving brexu-cel compared with alloHCT. However, the long-term PFS and OS are similar for both treatments. Individual risk-benefit evaluation is essential to guide optimal treatment decisions.

Mantle cell lymphoma (MCL) is an aggressive subtype of B-cell non-Hodgkin's lymphoma. The applicability of circulating tumor DNA (ctDNA) for predicting treatment response and prognosis in MCL remains underexplored.

This study included 34 MCL patients receiving first-line chemoimmunotherapy. We assessed the ability of plasma ctDNA to detect tumor-specific genetic alterations and explored its potential as a noninvasive biomarker for treatment response and prognosis in MCL.

Commonly mutated genes in MCL included CCND1 (93.5%), ATM (48.4%), KMT2D (25.8%), and TP53 (25.8%). Subgroup analysis of tissue samples showed that CDKN2A mutations (P = 0.028), along with alterations in BCR and TCR signaling (P = 0.004) and the PI3K pathway (P = 0.008), were enriched in the blastoid subtype. ATM mutations (P = 0.041) were more prevalent in MIPI-low patients, while epigenetic chromatin remodeling pathway alterations (P = 0.028) were more common in MIPI-high patients. Plasma ctDNA demonstrated high sensitivity for detecting structural variants (96.6%), followed by mutations (71.3%) and copy number variants (30.0%). 75% of patients exhibited moderate-to-high concordance in detecting genomic variants between plasma and tissue samples. Pretreatment ctDNA levels exhibited high specificity in predicting clinical efficacy but had a suboptimal sensitivity of 68.2%. Higher ctDNA levels were significantly associated with shorter progression-free survival (PFS; P = 0.002) and overall survival (OS; P = 0.009). Additional ctDNA-based genetic features associated with shorter PFS included TP53 (P = 0.002), TRAF2 (P = 0.023), and SMARCA4 (P = 0.023) mutations, while TP53 (P = 0.006) and TERT (P = 0.031) mutations predicted shorter OS. Persistent positive ctDNA in post-treatment plasma samples indicated molecular relapse and poor prognosis, whereas undetectable ctDNA defined a subset of patients with favorable survival outcomes.

This study identified plasma ctDNA as a promising biomarker that noninvasively captures tumor-derived genetic variants associated with treatment response and survival outcomes in MCL, highlighting the clinical value of ctDNA for diagnosis, recurrence prediction, and surveillance monitoring.

Chimeric antigen receptor T (CAR-T) cells have made brilliant achievements in the treatment of many kinds of malignant tumors, and six kinds of CAR-T products have been approved by the Food and Drug Administration (FDA), bringing new hope for the treatment of diseases. However, the complications associated with CAR-T cell therapy should not be ignored. Neurological complications often jeopardize patients' lives, including immune effector cell-associated neurotoxicity syndrome, cerebrovascular accidents, movement and neurocognitive treatment-emergent adverse events. The current knowledge of the mechanism and treatment of these complications is still insufficient, which is a direction that needs to be solved in the future.

Immuno-oncology (IO) is one of the fastest growing therapeutic areas within oncology. IO agents work indirectly via the host's adaptive and innate immune system to recognize and eradicate tumor cells. Despite checkpoint inhibitors being only introduced to the market since 2011, they have become the second most approved product category. Current Food and Drug Administration (FDA)-approved classes of IO agents include: immune checkpoint inhibitors (ICIs), chimeric antigen receptor T-cell therapy (CAR-T), bi-specific T-cell engager (BiTE) antibody therapy, T-cell receptor (TCR) engineered T cell therapy, tumor-infiltrating lymphocyte (TIL) therapy, cytokine therapy, cancer vaccine therapy, and oncolytic virus therapy. Cancer immunotherapy has made progress in multiple cancer types including melanoma, non-small cell lung cancer (NSCLC), renal cell carcinoma (RCC), and urothelial carcinoma; however, several cancers remain refractory to immunotherapy. Future directions of IO include exploration in the neoadjuvant/perioperative setting, combination strategies, and optimizing patient selection through improved biomarkers.

MCL remains incurable, and patients who relapse post BTK inhibitors have poor outcomes. BsAbs and CAR T cell therapy are novel strategies to treat patients with R/R MCL. These therapies exhibit favorable outcomes and side effect profiles in a previously dismal space. This review looks to detail the current data available for BsAbs and CAR T cell therapy in R/R MCL, and how are current treatment paradigm is shifting to incorporate these novel agents.

The development of chimeric antigen receptor (CAR) T-cells, engineered from peripheral T-lymphocytes of a patient with lymphoma, in order to specifically target tumor cells, has been a revolution in adoptive cell therapy (ACT). As outlined in this review, ACT was initiated by hematopoietic cell transplantation (HSCT) and re-injection of interleukin-boosted tumor-infiltrating lymphocytes (TIL). The innovative venture of genetically modifying autologous peripheral T-cells to target them to cell-surface tumoral antigens through an antibody-derived structure (i.e. independent of major histocompatibility antigen presentation, physiologically necessary for T-cell activation), and intracytoplasmic T-cell costimulatory peptides, via a novel membrane CAR, has been an outstanding breakthrough. Here, focusing on B-cell hematological malignancies and mostly non-Hodgkin lymphoma, attention is brought to the importance of providing an optimal microenvironment for such therapeutic cells to proliferate and positively develop anti-tumoral cytotoxicity. This, perhaps paradoxically, implies a pre-infusion step of deep lymphopenia and deregulation of immunosuppressive mechanisms enhanced by tumoral cells. Fludarabine and cyclophosphamide appear to be the most efficient lymphodepletive drugs in this context, dosage being of importance, as will be illustrated by a thorough literature review.

The immune-related adverse events associated with chimeric antigen receptor (CAR)-T cell therapy result in substantial morbidity as well as considerable cost to the health-care system, and can limit the use of these treatments. Current therapeutic strategies to manage immune-related adverse events include interleukin-6 receptor (IL-6R) blockade and corticosteroids. However, because these interventions do not always address the side effects, nor prevent progression to higher grades of adverse events, new approaches are needed. A deeper understanding of the cell types involved, and their associated signalling pathways, cellular metabolism and differentiation states, should provide the basis for alternative strategies. To preserve treatment efficacy, cytokine-mediated toxicity needs to be uncoupled from CAR-T cell function, expansion, long-term persistence and memory formation. This may be achieved by targeting CAR or independent cytokine signalling axes transiently, and through novel T cell engineering strategies, such as low-affinity CAR-T cells, reversible on-off switches and versatile adaptor systems. We summarize the current management of cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome, and review T cell- and myeloid cell-intrinsic druggable targets and cellular engineering strategies to develop safer CAR-T cells.

Older patients with lymphoma are typically underrepresented in clinical trials with chimeric antigen receptor T cell (CAR T) therapy. In this multicenter, observational study we aimed to assess the safety and efficacy of standard CD19 CAR T in patients 80 years of age or older. At total of 88 patients, median age 82 (range, 80-89) years, were included. Diffuse large B cell lymphoma (DLBCL) (N = 60, 68.2%) represented the most common histology. Patients were treated mostly with axicabtagene ciloleucel (N = 41, 46.6%) followed by lisocabtagene maraleucel (N = 25, 28.4%). Cytokine release syndrome (CRS) (any grade) was seen in 68 (77.3%) and 51 (58%) developed immune effector cell-associated neurotoxicity syndrome (ICANS). Incidence of grade 3-4 CRS and ICANS were 7.4% and 31.4%, respectively. For patients with DLBCL/tFL, the 1-year NRM, relapse, PFS, and OS were 11.6%, 40.8%, 47.6%, and 61.2%, respectively. We conclude that CAR T is feasible and effective in patients 80 years or older with B cell lymphomas. These patients must be provided the opportunity to be evaluated for this curative approach.

Cancer immunotherapy has transformed oncology by harnessing the immune system to specifically target cancer cells, offering reduced systemic toxicity compared to traditional therapies. This review highlights key strategies, including adoptive cell transfer (ACT), immune checkpoint inhibitors, oncolytic viral (OV) therapy, monoclonal antibodies (mAbs), and mRNA-based vaccines. ACT reinfuses enhanced immune cells like tumor-infiltrating lymphocytes (TILs) to combat refractory cancers, while checkpoint inhibitors (eg, PD-1 and CTLA-4 blockers) restore T-cell activity. OV therapy uses engineered viruses (eg, T-VEC) to selectively lyse cancer cells, and advanced mAbs improve targeting precision. mRNA vaccines introduce tumor-specific antigens to trigger robust immune responses. Despite significant progress, challenges like immune-related side effects, high costs, and immunosuppressive tumor microenvironments persist. This review underscores the need for combination strategies and precision medicine to overcome these barriers and maximize the potential of immunotherapy in personalized cancer treatment.

Tumor displays various forms of tumor heterogeneity including immune heterogeneity that allow cancer cells to survive during conventional anticancer drug interventions. Thus, there is a strong rationale for overcoming anticancer drug resistance by employing the components of immune cells. Using the immune system to target tumor cells has revolutionized treatment. Recently, significant progress has been achieved at preclinical and clinical levels to benefit cancer patients.

A review of literature from the past ten years across PubMed, Scopus, and Web of Science focused on immunotherapy strategies. These include immune checkpoint inhibitors (ICIs), tumor-infiltrating lymphocyte therapy, antibody-drug conjugates (ADCs), cancer vaccines, CAR T-cell therapy, and the role of the gut microbiome.

While immunotherapy outcomes have improved, particularly for tumor types such as melanoma and non-small cell lung cancer (NSCLC), challenges persist regarding predictive biomarker identification and better management. Ongoing research on modifiers of immune function like gut microbiome-derived metabolites, next-generation ADCs, and new classes of biologics is warranted. Overall, continued investigation toward optimizing synergistic immunotherapeutic combinations through strategic drug delivery systems is imperative for preclinical and clinical success in cancer patients.

Therapy-related myeloid neoplasms (t-MN), including myelodysplastic neoplasms (t-MDS) and acute myeloid leukemia (t-AML), have emerged as significant late complications after CAR T cell therapy. We retrospectively analyzed 539 patients with B cell lymphoma treated with CD19 directed CAR T cell therapy across four French centers. Cumulative incidences of t-MN was estimated with relapse or death treated as competing risk. Univariate and propensity score matching (PSM) analyses were conducted to assess risk factors with age and the number of prior treatments as covariates. After a median follow-up of 25 months, the cumulative incidence of t-MN was 4.5% at 2 years. T-MN occurred predominantly as t-MDS (62%) and t-AML (38%) with high cytogenetic risk. Median overall survival after t-MN diagnosis was 4.5 months. In univariate analysis, older age (p < 0.01), higher MCV (p < 0.01), and higher ICANS grade (p = 0.04) were associated with increased risk of t-MN. After PSM, MCV and ICANS grade remained significant risk factors. CAR T cell products with CD28 co-stimulatory domains trended towards higher t-MN risk (p = 0.09). NGS analysis showed that 85.7% of t-MN had pre-existing mutations, most commonly TP53. This study highlights t-MN as a severe late complication of CAR T cell therapy. MCV and ICANS grade were identified as key risk factors.

Chimeric antigen receptor (CAR) therapy has successfully treated relapsed/refractory hematological cancers. This strategy can effectively target tumor cells. However, despite positive outcomes in clinical applications, challenges remain to overcome. These hurdles pertain to the production of the drugs, solid tumor resistance, and side effects related to the treatment. Some cases have been missed during the drug preparation due to manufacturing issues, prolonged production times, and high costs. These challenges mainly arise from the in vitro manufacturing process, so reevaluating this process could minimize the number of missed patients. The immune cells are traditionally collected and sent to the laboratory; after several steps, the cells are modified to express the CAR gene before being injected back into the patient's body. During the in vivo method, the CAR gene is introduced to the immune cells inside the body. This allows for treatment to begin sooner, avoiding potential failures in drug preparation and the associated high costs. In this review, we will elaborate on the production and treatment process using in vivo CAR, examine the benefits and challenges of this approach, and ultimately present the available solutions for incorporating this treatment into clinical practice.

Multiple sclerosis (MS) is an autoimmune demyelinating disease of the central nervous system. The therapeutic landscape for MS has evolved significantly since the 1990s, with the development of more than 20 different disease-modifying therapies (DMTs). These therapies effectively manage relapses and inflammation, but most have failed to meaningfully prevent disease progression. While classically understood as a T cell-mediated condition, the most effective DMTs in slowing progression also target B cells. Novel classes of MS therapies in development, including anti-CD40L monoclonal antibodies, CD19 chimeric antigen receptor (CAR) T cells, and Bruton's tyrosine kinase (BTK) inhibitors show greater capacity to target and eliminate B cells in the brain/CNS, as well as impacting T-cell and innate immune compartments. These approaches may help tackle the disease at its immunopathological core, addressing both peripheral and central immune responses that drive MS progression. Another emerging therapeutic strategy is to use bispecific antibodies, which have the potential for dual-targeting various disease aspects such as immune activation and neurodegeneration. As such, the next generation of MS therapies may be the first to reduce both inflammatory demyelination and disease progression in a clinically meaningful way. Their ability to target specific immune cell populations while minimizing broad immune suppression could also lead to better safety profiles. Here, we explore the biological rationale, advantages, limitations, and clinical progress of these emerging immunotherapies for relapsing-remitting and progressive forms of MS.

Chimeric antigen receptor T-cell (CAR-T) therapies are standard of care for the treatment of several hematologic malignancies. Although patients receiving CAR-T therapies are frequently hospitalized given risks of cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS), there is increasing interest and evidence for the safety of their outpatient administration. We review various models of care and provide operational considerations for centers that are interested in developing outpatient CAR-T programs, with a particular emphasis on using remote patient monitoring (RPM) to facilitate outpatient care. Safe and high-quality outpatient care requires involvement of a multidisciplinary team with clinical pathways for rapid triage and evaluation for CRS and ICANS and their management and, if necessary, timely transition of patients to a higher level of acute care. RPM can facilitate scaling an outpatient program in a cost-effective manner, especially across multiple sites of care, and can reduce the time patients spend in an acute care setting. Overall minimizing hospital-based care and an outpatient approach can alleviate capacity challenges treatment centers have faced that have partly impacted access to CAR-T therapies and have the potential to positively impact patient and caregiver experience and quality of life.

Cholangiocarcinoma (CCA) is a fatal bile duct cancer with high resistance and recurrence rates, with only one fifth of patients eligible for surgical treatment. The disease resists standard chemotherapy and often relapses. Chimeric antigen receptor (CAR) T cell therapy has shown promise for hematological malignancies but faces challenges in solid tumors due to resistance mechanisms like PD-L1 expression, which tumors use to evade the immune system. To address this challenge, we developed fifth-generation CAR T cells targeting integrin αvβ6 that also secrete anti-PD-L1 single-chain variable fragment (scFv) to target both tumor cells and the PD-1/PD-L1 pathway. We examined integrin αvβ6 and PD-L1 expression in CCA cell lines and engineered T cells to express either fourth-generation CAR T cells targeting integrin αvβ6 (A20 CAR4 T cells) or fifth-generation CAR T cells with anti-PD-L1 scFv secretion (A20 CAR5 T cells). In vitro, A20 CAR5 T cells exhibited less exhaustion and superior long-term functionality compared to A20 CAR4 T cells. In 3D spheroid models of CCA, A20 CAR5 T cells demonstrated enhanced antitumor activity and better infiltration into the spheroid core. These findings suggest that A20 CAR5 T cells have significant potential and warrant further in vivo studies and clinical trials.

Cellular therapies have been cornerstones of the treatment of mantle cell lymphoma (MCL) for decades and have helped to improve the outcome of this formerly very unfavourable B-cell lymphoma considerably. Current established roles of cellular therapies include autologous hematopoietic cell transplantation (HCT) as part of first-line therapy, chimeric antigen receptor-engineered T-cells (CART) for relapsed/refractory MCL, and allogeneic HCT for settings in which CARTs have failed or are unavailable. Therapeutic innovations have recently entered the MCL treatment landscape and are moving upstream in treatment algorithms, challenging the existing management principles. The purpose of this paper is to give some guidance regarding how to best use cellular therapies in this increasingly complex environment. Due to differences in CART labels, available non-cellular treatment options, and philosophy between the American and the European health systems, we found it reasonable to contrast the American and European perspectives on defined standard scenarios, which are often overlapping but show discrepancies in some important aspects.

Although anti-CD19 chimeric antigen receptor (CAR-T) cells demonstrate high response rates in relapsed/refractory B-cell lymphomas, a considerable proportion of patients eventually encounter disease progression or relapse. The short-term and long-term outcomes of CAR-T treatment are intricately linked to the tumor microenvironment (TME), wherein macrophages with polarized characteristics can exhibit either anti-tumorigenic or pro-tumorigenic roles. Despite evidence implicating the crucial involvement of macrophages in CAR-T cell-treated lymphoma, their dynamic distribution and immune function related to lymphoma progression remain poorly understood. Immunocompetent mice were utilized to establish syngeneic A20 lymphoma/leukemia models. The distribution and polarization of macrophages were detected using immunohistochemistry (IHC) and flow cytometry techniques. We observed that CD19 CAR-T therapy exhibited significant efficacy in protecting mice against lymphoma, leading to increased infiltration of macrophages into the tumor tissue. Notably, during remission stages, M1-like macrophages (CD11b+F4/80+C206-CD80+) were predominant, whereas in relapsed mice, there was a shift towards M2-like phenotypes (CD11b+F4/80+C206+CD80+). The transition from remissive to relapsed status was accompanied by a reduction in the M1/M2 ratio and a decrease in pro-inflammatory cytokines. Furthermore, quantitative real-time polymerase chain reaction (qRT-PCR) analysis confirmed differential expression levels of CD206 and CD163 between remissive and relapsed mice, while signaling pathways involving PI3K and STAT3 may contribute to the skewing towards M2 polarization. In summary, our findings highlight the dynamic transformation of macrophage polarization during different stages of lymphoma progression and underscore its potential implications for immunotherapeutic interventions.

Chimeric antigen receptor (CAR) T and natural killer (NK) cell therapies represent a promising strategy for the treatment of cancers and other chronic diseases. Engineered CAR constructs endow immune cells with the ability to target desired antigens with high specificity, allowing for directed responses to antigen-expressing cells. CAR T and NK cells have shown marked success in the treatment of hematologic malignancies, although there remains a large population of patients with disease that fails to respond to CAR therapies, and their efficacy in solid tumors is still limited. In this review, we provide a broad overview of the development, design, and implementation of CAR therapies from bench to bedside. We discuss the building blocks of CAR constructs and how these can be manipulated to optimize CAR functionality, review the possible sources of T and NK cells for CAR therapies, and examine the limitations of both CAR T and CAR NK cells. Finally, we discuss recent breakthroughs in the CAR field and consider how these advances may affect the success of CAR therapies in the years to come.

Chimeric antigen receptor T (CART) cell therapy is an innovative form of immunotherapy that has shown remarkable and long-term responses in patients with B-cell malignancies. Over the years, the field has made significant progress in our understanding of the successes and challenges associated with CART cell therapy. In this review, we provide an overview of the current state of CART cell therapy in the clinic. We detail current challenges including patient access, CART-associated toxicity, tumor heterogeneity, CART cell trafficking, the tumor microenvironment, and different CART cell fates. With each challenge, we review lessons learned, potential solutions and outline areas for future development. Finally, we discuss how the field of engineered cell therapy is moving into the treatment of solid tumors and other diseases beyond cancer.

Chimeric antigen receptor (CAR)-T-cell therapy has been highly successful in the treatment of B-cell hematological malignancies. CARs are modular synthetic molecules that can redirect immune cells towards target cells with antibody-like specificity. Despite their modularity, CARs used in the clinic are currently composed of a limited set of domains, mostly derived from IgG, CD8α, 4-1BB, CD28 and CD3ζ. The current low throughput CAR screening workflows are labor-intensive and time-consuming, and lie at the basis of the limited toolbox of CAR building blocks available. High throughput screening methods facilitate simultaneous investigation of hundreds of thousands of CAR domain combinations, allowing discovery of novel domains and increasing our understanding of how they behave in the context of a CAR. Here we review the growing body of reports that employ these high throughput screening and computational methods to advance CAR design. We summarize and highlight the important differences between the different studies and discuss their limitations and future considerations for further improvements. In conclusion, while still in its infancy, high throughput screening of CARs has the capacity to vastly expand the CAR domain toolbox and improve our understanding of CAR design. This knowledge could be foundational for translating CAR therapy beyond hematological malignancies and push the frontiers in personalized medicine.

Despite clinical benefit with the use of chimeric antigen receptor (CAR) T cells, the need to manufacture patient-specific products limits its clinical utility. To overcome this barrier, we developed an allogeneic "off-the-shelf" CAR T-cell product using Epstein-Barr virus (EBV)-specific T cells (EBV-VSTs) genetically modified with a CD19-specific CAR (19-28z). Patients with relapsed/refractory (R/R) B-cell malignancies were stratified into 3 treatment cohorts: cohort 1 (n = 8; disease recurrence after allogeneic or autologous hematopoietic cell transplantation [HCT]), cohort 2 (n = 6; consolidative therapy after autologous HCT), or cohort 3 (n = 2; consolidative therapy after allogeneic HCT). The primary objective of this trial was to determine the safety of multiple CAR EBV-VST infusions. Most patients (n = 12/16) received multiple doses (overall median, 2.5 [range, 1-3]) with 3 × 106 T cells per kg determined to be the optimal dose enabling multiple treatments per manufactured cell line. Severe cytokine release syndrome or neurotoxicity did not occur after infusion, and no dose-limiting toxicity was observed in the trial. Median follow-up was 48 months (range, 4-135) with 4 deaths due to disease progression. Overall survival of all patients was 81% at 12 months and 75% at 36 months. Postinfusion expansion and persistence were limited, and CAR EBV-VSTs demonstrated a unique T-cell phenotype compared with autologous 19-28z CAR T cells. Our study demonstrates the feasibility and safety of an allogeneic "off-the-shelf" CAR EBV-VST product with favorable outcomes for patients with CD19+ R/R B-cell malignancies. This trial was registered at www.ClinicalTrials.gov as #NCT01430390.

Chimeric antigen receptor (CAR) cellular therapies have advanced outcomes in challenging hematologic malignancies like leukemia, lymphoma, and multiple myeloma. Plasma cell-directed CAR T-cell therapies have been particularly beneficial in multiple myeloma, suggesting that these agents may have a role in other challenging plasma cell disorders such as systemic AL amyloidosis and plasma cell leukemia. AL amyloidosis is a monoclonal plasma cell disorder resulting in the deposition of protein fibrils that compromise end-organ function. Delays in diagnosis can result in end-organ dysfunction and organ failure, making designing and completing treatment difficult. Plasma cell leukemia (PCL) is a rare and highly challenging malignancy with dismal survival outcomes despite aggressive therapy. Both diagnoses are currently treated with regimens borrowed from myeloma: a combination of novel agents and chemotherapy induction, then autologous stem cell transplantation (ASCT), with the current practice trending towards consolidation and maintenance. Unfortunately, only 20% of AL amyloidosis patients are transplant-eligible at diagnosis. Those transplant-ineligible (TIE) patients are treated with combination induction chemotherapy, which may be limited by worsening disease-related end-organ dysfunction. Plasma cell leukemia patients are still very likely to relapse after this intensive and prolonged therapy. Despite the promise of a shorter course of therapy, CAR T-cell therapies directed against plasma cells have not been rigorously investigated in patients with AL amyloidosis or PCL; most trials of MM have excluded these patients. Herein, we describe current treatment paradigms for AL amyloidosis and PCL and review the evidence for CAR T-cell therapies in these challenging plasma cell disorders. Further investigation into CAR T-cell therapies for plasma cell disorders other than multiple myeloma is warranted.

Prizloncabtagene autoleucel (prizlon-cel), a novel bispecific chimeric antigen receptor T cell, targets and eliminates CD19/CD20-positive tumor cells. This phase 1, open-label study investigated the safety and efficacy of prizlon-cel in patients with relapsed/refractory B-cell non-Hodgkin lymphoma (R/R B-NHL). Patients with CD19 and/or CD20-positive R/R B-NHL received a 3-day lymphodepletion (cyclophosphamide: 300 mg/m2 per day; fludarabine: 30 mg/m2 per day) followed by an IV dose of prizlon-cel. The primary end points were dose-limiting toxicity (DLT) and incidence and severity of treatment-emergent adverse events (TEAEs). Secondary end points included overall response rate (ORR), duration of response (DOR), progression-free survival (PFS), and overall survival (OS). Of the 48 patients infused prizlon-cel, 44 had large B-cell lymphoma (LBCL). No patient experienced DLT. Cytokine release syndrome occurred in 93.8% of the patients, with only 1 case of grade 3. Immune effector cell-associated neurotoxicity syndrome occurred in 6.3% of patients, with no grade 3 or higher events. The most common grade 3 or higher TEAEs were neutropenia (83.3%) and leukopenia (50%). The ORR and complete response (CR) rates in all patients were 91.5% and 85.1%, respectively, and in LBCL patients, ORR was 90.7% with 86.0% CR. With median follow-up of 30.0 months, median DOR, PFS, and OS were all not reached. Kaplan-Meier estimate of 2-year DOR, PFS, and OS rates were 66.0%, 62.6%, and 76.5%, respectively. Prizlon-cel had a favorable safety profile and a high and durable response in patients with R/R B-NHL, suggesting a promising treatment option for patients with R/R B-NHL. These trials were registered at www.clinicaltrials.gov as #NCT04317885, #NCT04655677, #NCT04696432, and #NCT04693676.

Despite increasing utilization of CAR T-cell therapy, data are lacking regarding long term follow up and risk of infectious complications after the early period following CAR T-cell infusion. In this study, we sought to compare epidemiology and risk factors for early (≤ 3 months) and late (3 months to 1 year) infections. Data were retrospectively collected at six time points: pre-CAR T, day of infusion, and at 3, 6, 9, and 12 months post CAR-T infusion for all consecutive adult patients treated at our institution. In this cohort, the cumulative incidence of any infection was 73.2% in the first year. Bridging therapy, CRS, neurotoxicity and steroid use were identified as contributing risk factors for early bacterial infections. After 3 months, community acquired respiratory infections were common. We characterize bacterial, viral and fungal pathogens based on time elapsed after CAR T-cell infusion.