Highlights in CAR T-Cell Therapy from the 61St American Society Of

A SPECIAL MEETING REVIEW EDITION

Highlights in CAR T-Cell Therapy From the 61st American Society of Hematology Annual Meeting A Review of Selected Presentations From the 61st ASH Meeting • December 7-10, 2019 • Orlando, Florida

Special Reporting on: • CD19-Loss With Preservation of Other B-Cell Lineage Features in Patients With Large B-Cell Lymphoma Who Relapsed Post–Axi-Cel • Pivotal Safety and Efficacy Results From TRANSCEND NHL 001, a Multicenter Phase 1 Study of Lisocabtagene Maraleucel in Relapsed/Refractory Large B-Cell Lymphomas

• KTE-X19, an Anti-CD19 Chimeric Antigen Receptor T-Cell Therapy, in Patients With Relapsed/ Refractory Mantle Cell Lymphoma: Results of the Phase 2 ZUMA-2 Study • Earlier Steroid Use With Axicabtagene Ciloleucel (Axi-Cel) in Patients With Relapsed/Refractory Large B-Cell Lymphoma • Characteristics and Outcomes of Patients Receiving Bridging Therapy While Awaiting Manufacture of Standard of Care Axicabtagene Ciloleucel CD19 Chimeric Antigen Receptor (CAR) T-Cell Therapy for Relapsed/Refractory Large B-Cell Lymphoma: Results From the US Lymphoma CAR-T Consortium • Real-World Data of High-Grade Lymphoma Patients Treated With CD19 CAR-T in England • Post-Marketing Use Outcomes of an Anti-CD19 Chimeric Antigen Receptor T-Cell Therapy, Axicabtagene Ciloleucel, for the Treatment of Large B-Cell Lymphoma in the United States • Tisagenlecleucel Chimeric Antigen Receptor T-Cell Therapy for Adults With Diffuse Large B-Cell Lymphoma: Real World Experience From the Center for International Blood & Marrow Transplant Research Cellular Therapy Registry

PLUS Meeting Abstract Summaries

With Expert Commentary by: Caron A. Jacobson, MD Medical Director, Immune Effector Cell Therapy Program Dana-Farber Cancer Institute Assistant Professor of Medicine Harvard Medical School Boston, Massachusetts

ON THE WEB: hematologyandoncology.net

Indexed through the National Library of Medicine (PubMed/MEDLINE), PubMed Central (PMC), and EMBASE B:16.5” T:16.25” S:15.875”

For adult patients with relapsed/refractory large B-cell lymphoma after ≥2 lines of systemic therapy:

® 1 RELAPSE IS LIFE-CHANGING. SO, YOU CHOSE YESCARTA . COMPELLING RESPONSE RATES * ZUMA-1 was a phase 2, open-label, single-arm, multicenter pivotal Pivotal analysis with a median 11.6-month follow-up trial in 101 adults with relapsed or refractory large B-cell lymphoma. For FDA approval, efficacy was established on the basis of CR rate and 72% objective response rate (ORR) DOR, as determined by an independent review committee.1,3 – Median duration of response (DOR): 9.2 months † Overall survival (OS) was a secondary endpoint.3 OS data are 51% complete remission (CR) descriptive and should be carefully interpreted in light of the – Median DOR not reached single-arm design. OS data are not included in the Prescribing ® 100% Information for YESCARTA . Not all data continued to be captured at the 3-year follow-up; only OS, investigator-assessed response, and adverse event reporting were captured.2

SAFETY PROFILE

50% LONGER-TERM % • Cytokine release syndrome (CRS): Grade ≥3 incidence, 13%; overall 47 1 FOLLOW-UP incidence, 94% ALIVE • Neurologic toxicities: Grade ≥3 incidence, 31%; overall incidence, 87%1 2 † • At the 2-year follow-up, no new serious adverse events, and no new AT 3 YEARS * onset of CRS or neurological events, have been reported related to YESCARTA3 0 1 yr 2 yr 3 yr

BEFORE. AND AFTER. AND AFTER. LEARN MORE ABOUT YESCARTA RESULTS AT YESCARTAHCP.COM

Relapse 3 years ago 72% ORR 51% CR1 25.8-month median OS with with an 11.6-month median follow-up a 39.1-month median follow-up2*†

YESCARTA® CAR T THERAPY, MANUFACTURED RAPIDLY AND RELIABLY1 IMPORTANT SAFETY INFORMATION (continued) YESCARTA CAR T THERAPY, MANUFACTURED RAPIDLY AND RELIABLY1 must be enrolled and comply with the REMS requirements. Certified healthcare after treatment and manage using infection precautions, antibiotic prophylaxis and B:11.125” T:10.875” In the ZUMA-1 pivotal trial, Kite demonstrated 17 days turnaround time and 99% success in manufacturing T cells.‡ facilities must have on-site, immediate access to tocilizumab, and ensure that a immunoglobulin replacement. The safety of immunization with live viral vaccines S:10.5” ‡Data reflect results from the ZUMA-1 pivotal trial. The median time from leukapheresis to product delivery. minimum of 2 doses of tocilizumab are available for each patient for infusion within during or following YESCARTA treatment has not been studied. Vaccination with 2 hours after YESCARTA infusion, if needed for treatment of CRS. Certified healthcare live virus vaccines is not recommended for at least 6 weeks prior to the start of facilities must ensure that healthcare providers who prescribe, dispense or administer lymphodepleting chemotherapy, during YESCARTA treatment, and until immune INDICATION Serious events that may be associated with CRS include cardiac arrhythmias YESCARTA are trained about the management of CRS and neurologic toxicities. Further recovery following treatment. YESCARTA is a CD19-directed genetically modified autologous T cell immunotherapy (including atrial fibrillation and ventricular tachycardia), cardiac arrest, cardiac information is available at www.YESCARTAREMS.com or 1-844-454-KITE (5483). SECONDARY MALIGNANCIES: Patients may develop secondary malignancies. Monitor indicated for the treatment of adult patients with relapsed or refractory large B-cell failure, renal insufficiency, capillary leak syndrome, hypotension, hypoxia, and Allergic reactions may occur. Serious hypersensitivity life-long for secondary malignancies. In the event that a secondary malignancy lymphoma after two or more lines of systemic therapy, including diffuse large hemophagocytic lymphohistiocytosis/macrophage activation syndrome. Ensure that HYPERSENSITIVITY REACTIONS: B-cell lymphoma (DLBCL) not otherwise specified, primary mediastinal large B-cell 2 doses of tocilizumab are available prior to infusion of YESCARTA. Monitor patients reactions including anaphylaxis may be due to dimethyl sulfoxide (DMSO) or residual occurs, contact Kite at 1-844-454-KITE (5483) to obtain instructions on patient lymphoma, high grade B-cell lymphoma, and DLBCL arising from follicular lymphoma. at least daily for 7 days at the certified healthcare facility following infusion for signs gentamicin in YESCARTA. samples to collect for testing. Limitation of Use: YESCARTA is not indicated for the treatment of patients with and symptoms of CRS. Monitor patients for signs or symptoms of CRS for 4 weeks SERIOUS INFECTIONS: Severe or life-threatening infections occurred. Infections (all EFFECTS ON ABILITY TO DRIVE AND USE MACHINES: Due to the potential for primary central nervous system lymphoma. after infusion. Counsel patients to seek immediate medical attention should signs or grades) occurred in 38% of patients, and in 23% with ≥ Grade 3. Grade 3 or higher neurologic events, including altered mental status or seizures, patients are at risk symptoms of CRS occur at any time. At the first sign of CRS, institute treatment with infections with an unspecified pathogen occurred in 16% of patients, bacterial for altered or decreased consciousness or coordination in the 8 weeks following IMPORTANT SAFETY INFORMATION supportive care, tocilizumab or tocilizumab and corticosteroids as indicated. infections in 9%, and viral infections in 4%. YESCARTA should not be administered YESCARTA infusion. Advise patients to refrain from driving and engaging in hazardous BOXED WARNING: CYTOKINE RELEASE SYNDROME AND NEUROLOGIC TOXICITIES NEUROLOGIC TOXICITIES: Neurologic toxicities occurred in 87% of patients. to patients with clinically significant active systemic infections. Monitor patients occupations or activities, such as operating heavy or potentially dangerous machinery, ∙ Cytokine Release Syndrome (CRS), including fatal or life-threatening reactions, Ninety-eight percent of all neurologic toxicities occurred within the first 8 weeks, for signs and symptoms of infection before and after YESCARTA infusion and treat during this initial period. occurred in patients receiving YESCARTA. Do not administer YESCARTA to with a median time to onset of 4 days (range: 1-43 days) and a median duration of appropriately. Administer prophylactic anti-microbials according to local guidelines. ADVERSE REACTIONS: The most common adverse reactions (incidence ≥ 20%) patients with active infection or inflammatory disorders. Treat severe or life- 17 days. Grade 3 or higher occurred in 31% of patients. The most common neurologic Febrile neutropenia was observed in 36% of patients and may be concurrent with include CRS, fever, hypotension, encephalopathy, tachycardia, fatigue, headache, threatening CRS with tocilizumab or tocilizumab and corticosteroids. toxicities included encephalopathy (57%), headache (44%), tremor (31%), CRS. In the event of febrile neutropenia, evaluate for infection and manage with decreased appetite, chills, diarrhea, febrile neutropenia, infections-pathogen ∙ Neurologic toxicities, including fatal or life-threatening reactions, occurred dizziness (21%), aphasia (18%), delirium (17%), insomnia (9%) and anxiety (9%). broad spectrum antibiotics, fluids and other supportive care as medically indicated. unspecified, nausea, hypoxia, tremor, cough, vomiting, dizziness, constipation, and in patients receiving YESCARTA, including concurrently with CRS or after CRS Prolonged encephalopathy lasting up to 173 days was noted. Serious events including Hepatitis B virus (HBV) reactivation, in some cases resulting in fulminant hepatitis, cardiac arrhythmias. hepatic failure and death, can occur in patients treated with drugs directed against resolution. Monitor for neurologic toxicities after treatment with YESCARTA. leukoencephalopathy and seizures occurred with YESCARTA. Fatal and serious cases Please see Brief Summary of Prescribing Information, including BOXED WARNING and Provide supportive care and/or corticosteroids as needed. of cerebral edema have occurred in patients treated with YESCARTA. Monitor patients B cells. Perform screening for HBV, HCV, and HIV in accordance with clinical guidelines before collection of cells for manufacturing. Medication Guide, on the following pages. ∙ YESCARTA is available only through a restricted program under a Risk at least daily for 7 days at the certified healthcare facility following infusion for signs References: 1. YESCARTA [package insert]. Santa Monica, CA: Kite Pharma, Inc; 2019. 2. Data on file. Kite Evaluation and Mitigation Strategy (REMS) called the YESCARTA REMS. and symptoms of neurologic toxicities. Monitor patients for signs or symptoms of PROLONGED CYTOPENIAS: Patients may exhibit cytopenias for several weeks Pharma, Inc. 3. Locke FL, Ghobadi A, Jacobson CA, et al. Long-term safety and activity of axicabtagene ciloleucel neurologic toxicities for 4 weeks after infusion and treat promptly. following lymphodepleting chemotherapy and YESCARTA infusion. Grade 3 or higher in refractory large B-cell lymphoma (ZUMA-1): a single-arm, multicentre, phase 1-2 trial. Lancet Oncol. CYTOKINE RELEASE SYNDROME (CRS): CRS occurred in 94% of patients, including cytopenias not resolved by Day 30 following YESCARTA infusion occurred in 28% of 2019;20(1):31-42. 13% with ≥ Grade 3. Among patients who died after receiving YESCARTA, 4 had YESCARTA REMS: Because of the risk of CRS and neurologic toxicities, YESCARTA patients and included thrombocytopenia (18%), neutropenia (15%), and anemia (3%). ongoing CRS at death. The median time to onset was 2 days (range: 1-12 days) is available only through a restricted program under a Risk Evaluation and Mitigation Monitor blood counts after YESCARTA infusion. and median duration was 7 days (range: 2-58 days). Key manifestations include Strategy (REMS) called the YESCARTA REMS. The required components of the fever (78%), hypotension (41%), tachycardia (28%), hypoxia (22%), and chills (20%). YESCARTA REMS are: Healthcare facilities that dispense and administer YESCARTA HYPOGAMMAGLOBULINEMIA: B-cell aplasia and hypogammaglobulinemia can occur. Hypogammaglobulinemia occurred in 15% of patients. Monitor immunoglobulin levels

YESCARTA, the YESCARTA Logo, KITE, and the KITE Logo are trademarks of Kite Pharma, Inc. GILEAD is a trademark of Gilead Sciences, Inc. © 2019 Kite Pharma, Inc. All rights reserved. | YESP0589 12/2019 B:16.5” T:16.25” S:15.875”

For adult patients with relapsed/refractory large B-cell lymphoma after ≥2 lines of systemic therapy:

SAFETY PROFILE

BEFORE. AND AFTER. AND AFTER. LEARN MORE ABOUT YESCARTA RESULTS AT YESCARTAHCP.COM

Relapse 3 years ago 72% ORR 51% CR1 25.8-month median OS with with an 11.6-month median follow-up a 39.1-month median follow-up2*†

BRIEF SUMMARY OF PRESCRIBING INFORMATION FOR YESCARTA® replication incompetent retroviral vector. Follow universal precautions and local Table 2. Neurologic Toxicity Grading and Management Guidance at least daily for 7 days at the certified healthcare facility following infusion for signs (axicabtagene ciloleucel) suspension for intravenous infusion biosafety guidelines for handling and disposal to avoid potential transmission of and symptoms of neurologic toxicities. Monitor patients for signs or symptoms of Grading infectious diseases. Concurrent CRS No Concurrent CRS neurologic toxicities for 4 weeks after infusion and treat promptly [see Management SEE PACKAGE INSERT FOR FULL PRESCRIBING INFORMATION Assessment Monitoring: Administer YESCARTA at a certified healthcare facility. Monitor patients of Severe Adverse Reactions (2.3); Neurologic Toxicities]. WARNING: CYTOKINE RELEASE SYNDROME and NEUROLOGIC TOXICITIES at least daily for 7 days at the certified healthcare facility following infusion for signs Grade 2 Administer tocilizumab per Table 1 Administer 5.3 YESCARTA REMS: Because of the risk of CRS and neurologic toxicities, YESCARTA and symptoms of CRS and neurologic toxicities. Instruct patients to remain within for management of Grade 2 CRS. dexamethasone 10 mg • Cytokine Release Syndrome (CRS), including fatal or life-threatening is available only through a restricted program under a Risk Evaluation and Mitigation proximity of the certified healthcare facility for at least 4 weeks following infusion. If no improvement within 24 hours intravenously every Strategy (REMS) called the YESCARTA REMS [see Boxed Warning and Warnings and reactions, occurred in patients receiving YESCARTA. Do not administer 6 hours. YESCARTA to patients with active infection or inflammatory disorders. 2.3 Management of Severe Adverse Reactions after starting tocilizumab, administer Precautions (5.1 and 5.2)]. The required components of the YESCARTA REMS are: Treat severe or life-threatening CRS with tocilizumab or tocilizumab dexamethasone 10 mg intravenously Continue • Healthcare facilities that dispense and administer YESCARTA must be enrolled Cytokine Release Syndrome (CRS): Identify CRS based on clinical presentation and comply with the REMS requirements. Certified healthcare facilities must have and corticosteroids [see Dosage and Administration (2.2, 2.3), Warnings every 6 hours if not already taking dexamethasone [see Warnings and Precautions (5.1)]. Evaluate for and treat other causes of on-site, immediate access to tocilizumab, and ensure that a minimum of two and Precautions (5.1)]. other corticosteroids. Continue use until the event is fever, hypoxia, and hypotension. If CRS is suspected, manage according to the dexamethasone use until the event is Grade 1 or less, then doses of tocilizumab are available for each patient for infusion within 2 hours after • Neurologic toxicities, including fatal or life-threatening reactions, recommendations in Table 1. Patients who experience Grade 2 or higher CRS Grade 1 or less, then taper over 3 days. taper over 3 days. YESCARTA infusion, if needed for treatment of CRS. (e.g., hypotension, not responsive to fluids, or hypoxia requiring supplemental occurred in patients receiving YESCARTA, including concurrently • Certified healthcare facilities must ensure that healthcare providers who prescribe, oxygenation) should be monitored with continuous cardiac telemetry and with CRS or after CRS resolution. Monitor for neurologic toxicities dispense or administer YESCARTA are trained about the management of CRS and pulse oximetry. For patients experiencing severe CRS, consider performing an Consider non-sedating, anti-seizure medicines after treatment with YESCARTA. Provide supportive care and/or (e.g., levetiracetam) for seizure prophylaxis. neurologic toxicities. corticosteroids, as needed [see Dosage and Administration (2.2, 2.3), echocardiogram to assess cardiac function. For severe or life-threatening CRS, Further information is available at www.YescartaREMS.com or 1-844-454-KITE (5483). Warnings and Precautions (5.2)]. consider intensive care supportive therapy. Grade 3 Administer tocilizumab per Table 1 Administer • YESCARTA is available only through a restricted program under a Risk Table 1. CRS Grading and Management Guidance for management of Grade 2 CRS. dexamethasone 10 mg 5.4 Hypersensitivity Reactions: Allergic reactions may occur with the infusion of Evaluation and Mitigation Strategy (REMS) called the YESCARTA REMS intravenously every YESCARTA. Serious hypersensitivity reactions including anaphylaxis, may be due to CRS Grade (a) Tocilizumab Corticosteroids In addition, administer dimethyl sulfoxide (DMSO) or residual gentamicin in YESCARTA. [see Warnings and Precautions (5.3)]. dexamethasone 10 mg 6 hours. Grade 1 N/A N/A intravenously with the first dose of Continue 5.5 Serious Infections: Severe or life-threatening infections occurred in patients 1 INDICATIONS AND USAGE Symptoms require tocilizumab and repeat dose every dexamethasone use after YESCARTA infusion. In Study 1, infections (all grades) occurred in 38% of patients. Grade 3 or higher infections occurred in 23% of patients. Grade 3 or higher YESCARTA is a CD19-directed genetically modified autologous T cell symptomatic treatment 6 hours. Continue dexamethasone until the event is infections with an unspecified pathogen occurred in 16% of patients, bacterial immunotherapy indicated for the treatment of adult patients with relapsed or only (e.g., fever, nausea, use until the event is Grade 1 or Grade 1 or less, then infections in 9%, and viral infections in 4%. YESCARTA should not be administered refractory large B-cell lymphoma after two or more lines of systemic therapy, fatigue, headache, less, then taper over 3 days. taper over 3 days. to patients with clinically significant active systemic infections. Monitor patients including diffuse large B-cell lymphoma (DLBCL) not otherwise specified, myalgia, malaise). for signs and symptoms of infection before and after YESCARTA infusion and treat primary mediastinal large B-cell lymphoma, high grade B-cell lymphoma, Consider non-sedating, anti-seizure medicines Grade 2 Administer tocilizumab (c) Manage per Grade 3 if appropriately. Administer prophylactic anti-microbials according to local guidelines. and DLBCL arising from follicular lymphoma. (e.g., levetiracetam) for seizure prophylaxis. Symptoms require and 8 mg/kg intravenously no improvement within Febrile neutropenia was observed in 36% of patients after YESCARTA infusion Limitation of Use: YESCARTA is not indicated for the treatment of patients with respond to moderate over 1 hour (not to 24 hours after starting Grade 4 Administer tocilizumab per Table 1 Administer and may be concurrent with CRS. In the event of febrile neutropenia, evaluate for primary central nervous system lymphoma. intervention. exceed 800 mg). tocilizumab. for management of Grade 2 CRS. methylprednisolone infection and manage with broad spectrum antibiotics, fluids and other supportive 1000 mg intravenously 2 DOSAGE AND ADMINISTRATION Oxygen requirement If no clinical Administer methylprednisolone care as medically indicated. Viral Reactivation: Hepatitis B virus (HBV) reactivation, per day for 3 days; less than 40% FiO or improvement in the 1000 mg intravenously per day in some cases resulting in fulminant hepatitis, hepatic failure and death, can 2.2 Administration: YESCARTA is for autologous use only. The patient’s identity 2 if improves, then hypotension responsive signs and symptoms of with first dose of tocilizumab and occur in patients treated with drugs directed against B cells. Perform screening must match the patient identifiers on the YESCARTA cassette and infusion bag. CRS after the first dose, manage as above. for HBV, HCV, and HIV in accordance with clinical guidelines before collection of B:11.125” to fluids or low-dose of continue methylprednisolone T:10.875” Do not infuse YESCARTA if the information on the patient-specific label does not repeat tocilizumab every cells for manufacturing. S:10.5” match the intended patient [see Dosage and Administration(2.2.3)]. one vasopressor or 1000 mg intravenously per day 8 hours as needed. for 2 more days; if improves, then 5.6 Prolonged Cytopenias: Patients may exhibit cytopenias for several weeks Grade 2 organ toxicity (b). Preparing Patient for YESCARTA Infusion: Confirm availability of YESCARTA Limit to a maximum of manage as above. following lymphodepleting chemotherapy and YESCARTA infusion. In Study 1, prior to starting the lymphodepleting regimen. Pre-treatment: Administer a 3 doses in a 24-hour Grade 3 or higher cytopenias not resolved by Day 30 following YESCARTA infusion lymphodepleting chemotherapy regimen of cyclophosphamide 500 mg/m2 period; maximum total of occurred in 28% of patients and included thrombocytopenia (18%), neutropenia 2 Consider non-sedating, anti-seizure medicines intravenously and fludarabine 30 mg/m intravenously on the fifth, fourth, and third 4 doses. (e.g., levetiracetam) for seizure prophylaxis. (15%), and anemia (3%). Monitor blood counts after YESCARTA infusion. day before infusion of YESCARTA. Premedication: Administer acetaminophen 650 mg PO and diphenhydramine 12.5 mg intravenously or PO approximately 1 hour before Grade 3 Per Grade 2 Administer 5.7 Hypogammaglobulinemia: B-cell aplasia and hypogammaglobulinemia methylprednisolone can occur in patients receiving treatment with YESCARTA. In Study 1, YESCARTA infusion. Avoid prophylactic use of systemic corticosteroids, as it may Symptoms require and 4 CONTRAINDICATIONS: None. interfere with the activity of YESCARTA. respond to aggressive 1 mg/kg intravenously hypogammaglobulinemia occurred in 15% of patients. Monitor immunoglobulin intervention. twice daily or equivalent 5 WARNINGS AND PRECAUTIONS levels after treatment with YESCARTA and manage using infection precautions, Preparation of YESCARTA for Infusion: Coordinate the timing of YESCARTA dexamethasone (e.g., antibiotic prophylaxis and immunoglobulin replacement. The safety of immunization 5.1 Cytokine Release Syndrome (CRS): CRS,including fatal or life-threatening thaw and infusion. Confirm the infusion time in advance, and adjust the start time Oxygen requirement 10 mg intravenously with live viral vaccines during or following YESCARTA treatment has not been reactions, occurred following treatment with YESCARTA. In Study 1, CRS occurred of YESCARTA thaw such that it will be available for infusion when the patient is greater than or equal to every 6 hours). studied. Vaccination with live virus vaccines is not recommended for at least in 94% (101/108) of patients receiving YESCARTA, including ≥ Grade 3 (Lee grading ready. Confirm patient identity: Prior to YESCARTA preparation, match the patient’s 40% FiO2 or hypotension 6 weeks prior to the start of lymphodepleting chemotherapy, during YESCARTA Continue corticosteroids system) CRS in 13% (14/108) of patients. Among patients who died after receiving identity with the patient identifiers on the YESCARTA cassette. Do not remove the requiring high-dose or treatment, and until immune recovery following treatment with YESCARTA. YESCARTA product bag from the cassette if the information on the patient-specific multiple vasopressors or use until the event is YESCARTA, four had ongoing CRS events at the time of death. The median time to label does not match the intended patient. Once patient identification is confirmed, Grade 1 or less, then onset was 2 days (range: 1 to 12 days) and the median duration of CRS was 7 days 5.8 Secondary Malignancies: Patients treated with YESCARTA may develop Grade 3 organ toxicity or remove the YESCARTA product bag from the cassette and check that the patient taper over 3 days. (range: 2 to 58 days). Key manifestations of CRS include fever (78%), hypotension secondary malignancies. Monitor life-long for secondary malignancies. In the event Grade 4 transaminitis. information on the cassette label matches the bag label. Inspect the product bag for (41%), tachycardia (28%), hypoxia (22%), and chills (20%). Serious events that may that a secondary malignancy occurs, contact Kite at 1-844-454-KITE (5483) to obtain any breaches of container integrity such as breaks or cracks before thawing. If the Grade 4 Per Grade 2 Administer be associated with CRS include cardiac arrhythmias (including atrial fibrillation and instructions on patient samples to collect for testing. bag is compromised, follow the local guidelines (or call Kite at 1-844-454-KITE). methylprednisolone ventricular tachycardia), cardiac arrest, cardiac failure, renal insufficiency, capillary 5.9 Effects on Ability to Drive and Use Machines: Due to the potential for Life-threatening leak syndrome, hypotension, hypoxia, and hemophagocytic lymphohistiocytosis/ Place the infusion bag inside a second sterile bag per local guidelines. Thaw symptoms. 1000 mg intravenously neurologic events, including altered mental status or seizures, patients receiving YESCARTA at approximately 37°C using either a water bath or dry thaw method per day for 3 days; if macrophage activation syndrome (HLH/MAS) [see Adverse Reactions (6)]. Ensure YESCARTA are at risk for altered or decreased consciousness or coordination in until there is no visible ice in the infusion bag. Gently mix the contents of the bag to Requirements for improves, then manage that 2 doses of tocilizumab are available prior to infusion of YESCARTA. Monitor the 8 weeks following YESCARTA infusion. Advise patients to refrain from driving disperse clumps of cellular material. If visible cell clumps remain continue to gently ventilator support, as above. patients at least daily for 7 days at the certified healthcare facility following infusion and engaging in hazardous occupations or activities, such as operating heavy or mix the contents of the bag. Small clumps of cellular material should disperse with continuous veno-venous for signs and symptoms of CRS. Monitor patients for signs or symptoms of CRS for potentially dangerous machinery, during this initial period. gentle manual mixing. Do not wash, spin down, and/or re-suspend YESCARTA in new hemodialysis (CVVHD) or 4 weeks after infusion. Counsel patients to seek immediate medical attention should signs or symptoms of CRS occur at any time [see Patient Counseling Information 6 ADVERSE REACTIONS: The following adverse reactions are described in Warnings media prior to infusion. Once thawed, YESCARTA may be stored at room temperature Grade 4 organ toxicity and Precautions: Cytokine Release Syndrome, Neurologic Toxicities, Hypersensitivity (20°C to 25°C) for up to 3 hours. (excluding transaminitis). (17)]. At the first sign of CRS, institute treatment with supportive care, tocilizumab or tocilizumab and corticosteroids as indicated [See Dosage and Administration (2.3)]. Reactions, Serious Infections, Prolonged Cytopenias, Hypogammaglobulinemia. Administration: For autologous use only. Ensure that tocilizumab and emergency (a) Lee et al 2014, (b) Refer to Table 2 for management of neurologic toxicity, (c) Refer to tocilizumab 5.2 Neurologic Toxicities: Neurologic toxicities, that were fatal or life-threatening, 6.1 Clinical Trials Experience: Because clinical trials are conducted under widely equipment are available prior to infusion and during the recovery period. Do NOT Prescribing Information for details varying conditions, adverse reaction rates observed in the clinical trials of a drug use a leukodepleting filter. Central venous access is recommended for the infusion occurred following treatment with YESCARTA. Neurologic toxicities occurred in 87% Neurologic Toxicity: Monitor patients for signs and symptoms of neurologic toxicities of patients. Ninety-eight percent of all neurologic toxicities occurred within the first cannot be directly compared to rates in the clinical trials of another drug and may of YESCARTA. Confirm the patient’s identity matches the patient identifiers on the (Table 2). Rule out other causes of neurologic symptoms. Patients who experience not reflect the rates observed in practice. The safety data described in this section YESCARTA product bag. Prime the tubing with normal saline prior to infusion. Infuse 8 weeks of YESCARTA infusion, with a median time to onset of 4 days (range: 1 to Grade 2 or higher neurologic toxicities should be monitored with continuous cardiac 43 days). The median duration of neurologic toxicities was 17 days. Grade 3 or reflect exposure to YESCARTA in the clinical trial (Study 1) in which 108 patients with the entire contents of the YESCARTA bag within 30 minutes by either gravity or a telemetry and pulse oximetry. Provide intensive care supportive therapy for severe or life relapsed/refractory B-cell NHL received CAR-positive T cells based on a recommended peristaltic pump. YESCARTA is stable at room temperature for up to 3 hours after higher neurologic toxicities occurred in 31% of patients. The most common threatening neurologic toxicities. Consider non-sedating, anti-seizure medicines (e.g., neurologic toxicities included encephalopathy (57%), headache (44%), tremor (31%), dose which was weight-based [see Clinical Trials (14)] . Patients with a history of CNS thaw. Gently agitate the product bag during YESCARTA infusion to prevent cell levetiracetam) for seizure prophylaxis for any Grade 2 or higher neurologic toxicities. disorders (such as seizures or cerebrovascular ischemia) or autoimmune disease clumping. After the entire content of the product bag is infused, rinse the tubing dizziness (21%), aphasia (18%), delirium (17%), insomnia (9%) and anxiety (9%). Prolonged encephalopathy lasting up to 173 days was noted. Serious events including requiring systemic immunosuppression were ineligible. The median duration of with normal saline at the same infusion rate to ensure all product is delivered. follow up was 8.7 months. The median age of the study population was 58 years YESCARTA contains human blood cells that are genetically modified with leukoencephalopathy and seizures occurred with YESCARTA. Fatal and serious cases of cerebral edema have occurred in patients treated with YESCARTA. Monitor patients (range: 23 to 76 years); 68% were men. The baseline ECOG performance status was B:16.5” T:16.25” S:15.875”

43% with ECOG 0, and 57% with ECOG 1. The most common adverse reactions (6%), seizure (4%), dyscalculia (2%), and myoclonus (2%); respiratory, thoracic (incidence ≥ 20%) include CRS, fever, hypotension, encephalopathy, tachycardia, and mediastinal disorders: pulmonary edema (9%); skin and subcutaneous tissue fatigue, headache, decreased appetite, chills, diarrhea, febrile neutropenia, disorders: rash (9%); vascular disorders: capillary leak syndrome (3%). infections-pathogen unspecified, nausea, hypoxia, tremor, cough, vomiting, Grade 3 or 4 Laboratory Abnormalities Occurring in ≥ 10% of Patients dizziness, constipation, and cardiac arrhythmias. Serious adverse reactions in Study 1 Following Treatment with YESCARTA based on CTCAE (N=108) occurred in 52% of patients. The most common serious adverse reactions (> 2%) include encephalopathy, fever, lung infection, febrile neutropenia, cardiac Lymphopenia 100%, Leukopenia 96%, Neutropenia 93%, Anemia 66%, arrhythmia, cardiac failure, urinary tract infection, renal insufficiency, aphasia, Thrombocytopenia 58%, Hypophosphatemia 50%, Hyponatremia 19%, Uric cardiac arrest, infection, delirium, hypotension, and hypoxia. acid increased 13%, Direct Bilirubin increased 13%, Hypokalemia 10%, Alanine The most common (≥ 10%) Grade 3 or higher reactions include febrile neutropenia, Aminotransferase increased 10%. fever, CRS, encephalopathy, infections-pathogen unspecified, hypotension, hypoxia, 6.2 Immunogenicity: YESCARTA has the potential to induce anti-product antibodies. and lung infections. Forty-five percent (49/108) of patients received tocilizumab The immunogenicity of YESCARTA has been evaluated using an enzyme-linked after infusion of YESCARTA. immunosorbent assay (ELISA) for the detection of binding antibodies against FMC63, Summary of Adverse Reactions Observed in at Least 10% of the Patients the originating antibody of the anti-CD19 CAR. Three patients tested positive for Treated with YESCARTA in Study 1 pre-dose anti-FMC63 antibodies at baseline and Months 1, 3, or 6 in Study 1. There is no evidence that the kinetics of initial expansion and persistence of YESCARTA, or the Any Grade Grades 3 or Adverse Reaction safety or effectiveness of YESCARTA, was altered in these patients. (%) Higher (%) 8 USE IN SPECIFIC POPULATIONS Blood and lymphatic Febrile neutropenia 34 31 system disorders 8.1 Pregnancy: Ris Summar: There are no available data with YESCARTA use in pregnant women. No animal reproductive and developmental toxicity studies Cardiac disorders Tachycardia 57 2 have been conducted with YESCARTA to assess whether it can cause fetal harm Arrhythmia 23 7 when administered to a pregnant woman. It is not known if YESCARTA has the Gastrointestinal Diarrhea 38 4 potential to be transferred to the fetus. Based on the mechanism of action, if the disorders Nausea 34 0 transduced cells cross the placenta, they may cause fetal toxicity, including B-cell Vomiting 26 1 lymphocytopenia. Therefore, YESCARTA is not recommended for women who are Constipation 23 0 pregnant, and pregnancy after YESCARTA infusion should be discussed with the Abdominal pain 14 1 treating physician. In the U.S. general population, the estimated background risk of Dry mouth 11 0 major birth defects and miscarriage in clinically recognized pregnancies is 2% - 4% General disorders Fever 86 16 and 15% - 20%, respectively. and administration Fatigue 46 3 8.2 Lactation: Ris Summar: There is no information regarding the presence of site conditions Chills 40 0 YESCARTA in human milk, the effect on the breastfed infant, and the effects on Edema 19 1 milk production. The developmental and health benefits of breastfeeding should be Immune system Cytokine release syndrome 94 13 considered along with the mother’s clinical need for YESCARTA and any potential disorders Hypogammaglobulinemia 15 0 adverse effects on the breastfed infant from YESCARTA or from the underlying maternal condition. B:11.125” Infections and Infections-pathogen 26 16 T:10.875” S:10.5” infestations unspecified 8.3 Females and Males of Reproductive Potential: Pregnanc Testing: Pregnancy Viral infections 16 4 status of females with reproductive potential should be verified. Sexually-active Bacterial infections 13 9 females of reproductive potential should have a pregnancy test prior to starting treatment with YESCARTA. Contracetion: See the prescribing information for Investigations Decreased appetite 44 2 fludarabine and cyclophosphamide for information on the need for effective Weight decreased 16 0 contraception in patients who receive the lymphodepleting chemotherapy. There Dehydration 11 3 are insufficient exposure data to provide a recommendation concerning duration of Musculoskeletal Motor dysfunction 19 1 contraception following treatment with YESCARTA. Infertilit: There are no data on the and connective Pain in extremity 17 2 effect of YESCARTA on fertility. tissue disorders Back pain 15 1 8.4 Pediatric Use: The safety and efficacy of YESCARTA have not been established Muscle pain 14 1 in pediatric patients. Arthralgia 10 0 8.5 Geriatric Use: Clinical trials of YESCARTA did not include sufficient numbers of Nervous system Encephalopathy 57 29 patients aged 65 years and older to determine whether they respond differently or disorders Headache 45 1 have different safety outcomes as compared to younger patients. Tremor 31 2 Dizziness 21 1 17 PATIENT COUNSELING INFORMATION Aphasia 18 6 Advise the patient to read the FDA-approved patient labeling (Medication Guide). Ensure that patients understand the risk of manufacturing failure (1% in clinical Psychiatric disorders Delirium 17 6 trial). In case of a manufacturing failure, a second manufacturing of YESCARTA Respiratory, Hypoxia 32 11 may be attempted. In addition, while the patient awaits the product, additional thoracic and Cough 30 0 chemotherapy (not the lymphodepletion) may be necessary and may increase mediastinal Dyspnea 19 3 the risk of adverse events during the pre-infusion period. Advise patients to disorders Pleural effusion 13 2 seek immediate attention for any of the following: Cytokine Release Syndrome, Renal and urinary Renal insufficiency 12 5 Neurologic Toxicities, Serious Infections, Prolonged Cytopenia [see Warnings and disorders Precautions (5.1 5.2 5.3 5.5) and Adverse Reactions (6) for more information and signs and smtoms]. Advise patients for the need to: Refrain from driving or Vascular disorders Hypotension 57 15 operating heavy or potentially dangerous machinery after YESCARTA infusion until Hypertension 15 6 at least 8 weeks after infusion [see Warnings and Precautions (5.2)], Have periodic Thrombosis 10 1 monitoring of blood counts. Contact Kite at 1-844-454-KITE (5483) if they are Te folloing events ere also counted in te incidence of CRS: taccardia arrtmia fever cills diagnosed with a secondary malignancy [see Warnings and Precautions (5.)]. incidence of certain adverse reactions lease see footnote elo Tale 3 in Section 6.1 of te ull Manufactured by, Packed by, Distributed by: Kite Pharma, Inc., Santa Monica, CA 90404 Prescriing Information. US License No 2064 Other clinically important adverse reactions that occurred in less than 10% of patients treated with YESCARTA include the following: blood and lymphatic system YESCARTA is a trademark of Kite Pharma, Inc. All other trademarks referenced disorders: coagulopathy (2%); cardiac disorders: cardiac failure (6%) and cardiac herein are the property of their respective owners. arrest (4%); immune system disorders: hemophagocytic lymphohistiocytosis/ © 2019 Kite Pharma, Inc. All Rights Reserved. | YESP0589 12/2019 macrophage activation syndrome (HLH/MAS) (1%), hypersensitivity (1%); infections and infestations disorders: fungal infections (5%); nervous system disorders: ataxia HIGHLIGHTS IN CAR T-CELL THERAPY FROM THE 61ST ASH MEETING

CD19-Loss With Preservation of Other B-Cell Lineage Features in Patients With Large B-Cell Lymphoma Who Relapsed Post–Axi-Cel

he multicenter, single-arm axicabtagene ciloleucel.1 Mechanisms with IHC, and 5 paired samples with phase 1/2 ZUMA-1 study that enable relapse may include loss RNA sequencing. (Safety and Efficacy of KTE- or modification of CD19 and involve- A consistent axicabtagene ciloleu- TC19 in Adults With Refractory ment of the immune tumor environ- cel treatment effect was observed across Aggressive Non-Hodgkin Lymphoma) ment.3 To gain further insight regard- all baseline levels of CD19. Median evaluated axicabtagene ciloleucel in ing mechanisms of treatment failure baseline CD19 H-scores were 200 for patients with refractory large B-cell after axicabtagene ciloleucel infusion, the 49 patients with a CR as the best lymphoma.1,2 The phase 2 portion of a post-hoc analysis analyzed tumor tis- response, 260 for the 22 patients with the trial originally enrolled 111 patients sue obtained from patients in cohorts a partial response, and 250 for the into 2 cohorts. The 77 patients in 1 and 2 in the ZUMA-1 trial who 11 patients with stable or progressive cohort 1 had diffuse large B-cell lym- responded and subsequently relapsed.4 disease (Figure 1). The median H-score phoma (DLBCL), and the 24 patients The protein expression of markers of was 190 in 32 patients with an ongo- in cohort 2 had primary mediastinal B-cell lineage was centrally assessed ing response and 240 in 35 patients B-cell lymphoma or transformed fol- with immunohistochemistry (IHC). who had relapsed. Prior to treatment, licular lymphoma. The primary end- For select cases, IHC was followed 90% of tumor biopsies were positive point was the objective response rate by immunofluorescence staining and for CD19, and 96% were positive (ORR). After a median follow-up of confocal microscopy. Assessed markers for CD20. Expression of CD19 and/ 27.1 months, the ORR was 83%, with included CD19 (cytoplasmic domain), or CD20 was reported in 98% of a complete response (CR) rate of 58%. CD20 (cytoplasmic domain), CD22 samples. All 13 patients with CD19- The 2-year rate of progression-free sur- (surface domain), CD79a (surface positive samples had relapsed within vival (PFS) was 39%. The 2-year rate domain), and PAX5 (nuclear stain). 6 months of receiving axicabtagene of overall survival (OS) was 51%. The CD19 splice variants were evaluated ciloleucel therapy. The 5 patients with median OS was not reached. After a by RNA sequencing. Tumor samples CD19-negative samples had a more median follow-up of 39.1 months, the included 82 with pretreatment IHC, varied course, with relapses observed 3-year OS rate was 47%. 18 IHC samples from patients who ini- between approximately 2 months Approximately 60% of patients tially responded and then relapsed, 16 and 15 months. Among 18 biopsies relapse or progress after treatment with paired samples (pre- and postrelapse) taken after progression, 5 (28%) did

Figure 1. Best response according to baseline CD19 H-score in a post- 280 hoc analysis of patients treated with axicabtagene ciloleucel in the ZUMA-1 e 240 trial who responded and subsequently o r

c relapsed. CR, complete response; PD, 200 progressive disease; PR, partial response; SD, stable disease; ZUMA-1, Safety and 160 Efficacy of KTE-C19 in Adults With 120 Refractory Aggressive Non-Hodgkin Lymphoma. Adapted from Neelapu 80 SS et al. ASH abstract 203. Blood. 2019;134(suppl 1).3

aseline CD19 H- S 40 B 0

CR PR SD + PD (n=49) (n=22) (n=11)

Median 200 260 250 H-Score

Clinical Advances in Hematology & Oncology Volume 18, Issue 2, Supplement 7 February 2020 7 SPECIAL MEETING REVIEW EDITION

not express CD19; however, all of A separate study of pediatric References the samples showed at least minimal patients with acute lymphoblastic 1. Locke FL, Ghobadi A, Jacobson CA, et al. Long- expression of the other B-cell antigens. leukemia who received treatment with term safety and activity of axicabtagene ciloleucel Among the 18 postprogression biopsy chimeric antigen receptor (CAR) T-cell in refractory large B-cell lymphoma (ZUMA-1): a samples, 72% expressed CD19, 94% therapy showed that alternative splic- single-arm, multicentre, phase 1-2 trial. Lancet Oncol. 2019;20(1):31-42. expressed CD22, and 100% expressed ing of CD19 could result in expression 2. Neelapu SS, Locke FL, Bartlett NL, et al. Axicabta- CD20, CD79a, and PAX5. Among the of a truncated CD19 variant that pro- gene ciloleucel CAR T-cell therapy in refractory large 16 paired samples, 4 (25%) showed a vided some CD19 activity, but failed B-cell lymphoma. N Engl J Med. 2017;377(26):2531- 2544. loss of CD19 expression at the time to trigger killing by CD19-directed 3. Neelapu SS, Locke FL, Bartlett NL, et al. Long- 5 of relapse (Figure 2). Downregulation CAR T-cell therapy. Samples from the term follow-up ZUMA-1: a pivotal trial of axicabta- of CD19 was demonstrated by RNA ZUMA-1 study also revealed alterna- gene ciloleucel in patients with refractory aggressive non-Hodgkin lymphoma [ASH abstract 578]. Blood. sequencing in 1 patient. tive splicing, with loss of exon 2 and/ 2017;130(suppl 1). IHC showed expression of CD20 or exons 5 and 6. Alternative splicing 4. Neelapu SS, Rossi JM, Jacobson CA, et al. in all samples at relapse. A combina- events were significantly different in CD19-loss with preservation of other B cell lineage features in patients with large B cell lymphoma who tion of immunofluorescence and con- baseline samples vs those obtained relapsed post–axi-cel [ASH abstract 203]. Blood. focal microscopy showed that CD20 after relapse (P<.05). Taken together, 2019;134(suppl 1). expression was maintained on the the results suggest that the efficacy of 5. Sotillo E, Barrett DM, Black KL, et al. Convergence of acquired mutations and alternative splicing of CD19 cell membrane at progression. CD20 CD19-directed CAR T-cell therapy enables resistance to CART-19 immunotherapy. Cancer expression was of particular interest could potentially be improved by Discov. 2015;5(12):1282-1295. because patients had received previous simultaneous or sequential targeting of treatment with rituximab. CD19 plus other B-cell antigens.

Figure 2. Changes in the H-score in a post-hoc analysis of patients treated with 300 axicabtagene ciloleucel in the ZUMA-1 trial who responded and subsequently relapsed. ZUMA-1, Safety and Efficacy of KTE-C19 in Adults With Refractory 200 Aggressive Non-Hodgkin Lymphoma. CD19 H-Score (N=16) Adapted from Neelapu SS et al. ASH 3 No change n=12 abstract 203. Blood. 2019;134(suppl 1). (between 6-300) H-Score 100 Changed to n=4 negative (≤5) Changed to n=0 positive (>5) 0 Pretreatment Relapsed

Pivotal Safety and Efficacy Results From TRANSCEND NHL 001, a Multicenter Phase 1 Study of Lisocabtagene Maraleucel in Relapsed/Refractory Large B-Cell Lymphomas

isocabtagene maraleucel is a positive CAR T cells. The multicenter phoma.2 Patients in the DLBCL cohort CD19-directed CAR T-cell phase 1 TRANSCEND NHL 001 trial had relapsed or refractory DLBCL–not product that contains a 4-1BB (Study Evaluating the Safety and Phar- otherwise specified, including trans- Lcostimulatory domain to increase T-cell macokinetics of JCAR017 in B-Cell formed indolent lymphoma; high- proliferation and persistence.1 The Non-Hodgkin Lymphoma) evaluated grade B-cell lymphoma with MYC product is administered using a defined lisocabtagene maraleucel in adults with and the BCL2 and/or BCL6 rear- ratio of CD4-positive and CD8- relapsed or refractory large B-cell lym- rangements; primary mediastinal B-cell

8 Clinical Advances in Hematology & Oncology Volume 18, Issue 2, Supplement 7 February 2020 HIGHLIGHTS IN CAR T-CELL THERAPY FROM THE 61ST ASH MEETING

lymphoma; or follicular lymphoma study, lisocabtagene maraleucel was was 3 (range, 1-8). Two-thirds of of grade 3B. Patients had received at administered to 60 patients at 3 dose patients had chemotherapy-refractory least 2 prior lines of therapy and had levels: 50 × 106, 100 × 106, or 150 × disease, 44% had never achieved a an Eastern Cooperative Oncology 106. Among 344 patients who under- CR with prior treatment, and 59% Group (ECOG) performance status went leukapheresis, 294 received an received bridging therapy during the of 0 to 2. The study permitted enroll- infusion of CAR T cells. Lisocabtagene study. High-risk features associated ment of patients who had undergone maraleucel with conforming product with shortened OS were noted in prior autologous or allogeneic stem was administered to 269 patients with 89% of patients. cell transplant (SCT), as well as those large B-cell lymphoma, and 256 were After a median follow-up of 12.0 with secondary central nervous system included in the large B-cell lymphoma months (range, 11.2-16.7 months), (CNS) lymphoma. efficacy set. Forty-six patients received the ORR was 73% (95% CI, 67%- Bridging therapy was allowed dose level 1, 169 received dose level 2, 78%), with a CR rate of 53% (95% after leukapheresis; however, patients and 41 received dose level 3. CI, 47%-59%). The median time to were required to have a positive posi- Among the 269 patients treated first CR or partial response was 1.0 tron emission tomography result prior with lisocabtagene maraleucel, the months (range, 0.7-8.9 months). to lymphodepletion. Lymphodeple- median age was 63 years (range, Response durability is shown in Figure tion was accomplished with a 3-day 18-86 years). Fifty-one percent had 3. Clinically meaningful response rates regimen of fludarabine (30 mg/m2) DLBCL–not otherwise specified, and were observed across all subgroups. plus cyclophosphamide (300 mg/m2). 3% of all patients had secondary CNS Among all patients, 12-month PFS Lisocabtagene maraleucel was admin- lymphoma. Thirty-eight percent had was 44.1% (95% CI, 37.3%-50.7%) istered within a week of lymphodeple- a high disease burden, and the median and 12-month OS was 57.9% (95% tion. In the dose-finding portion of the number of prior systemic therapies CI, 51.3%-63.8%).

100 + Censored

80 Median, NR (95% CI, NR-NR)

60 CR Total

40 Median, NR (95% CI, 8.6 months-NR)

20 PR Median, 1.9 months (95% CI, 1.1-2.1) 0 Probability of Continued Response (%) of Continued Probability

0 3 6 9 12 15 18 21 24 27 30 Months CR 136 106 91 79 48 43 25 23 1 1 0 PR 50 4 2 2 2 2 0 Total 186 110 93 81 50 45 25 23 1 1 0

Figure 3. Durability of response in the phase 1 TRANSCEND NHL 001 trial, which evaluated lisocabtagene maraleucel in adults with relapsed or refractory large B-cell lymphoma. CR, complete response; NR, not reached; PR, partial response; TRANSCEND NHL 001, Study Evaluating the Safety and Pharmacokinetics of JCAR017 in B-Cell Non-Hodgkin Lymphoma. Adapted from Abramson JS et al. ASH abstract 241. Blood. 2019;134(suppl 1).2

Clinical Advances in Hematology & Oncology Volume 18, Issue 2, Supplement 7 February 2020 9 SPECIAL MEETING REVIEW EDITION

Nearly all patients (99%) devel- alveolar damage, pulmonary hemor- of at least grade 3 were reported in oped a treatment-emergent adverse rhage, multiple organ dysfunction syn- 37% of patients, and 12% had infec- event (AE) of any grade. The most com- drome, and cardiomyopathy. tions of grade 3 or higher. mon events were neutropenia (63%), There were no reports of grade 5 anemia (48%), and fatigue (44%). cytokine-release syndrome or neuro- References The most common grade 3/4 AEs were toxicity. Any-grade cytokine-release 1. Havard R, Stephens DM. Anti-CD19 chimeric anti- neutropenia (60%), anemia (38%), syndrome occurred in 42% of patients, gen receptor T cell therapies: harnessing the power of the and thrombocytopenia (27%). Grade including 1% with grade 3 and 1% immune system to fight diffuse large B cell lymphoma. Curr Hematol Malig Rep. 2018;13(6):534-542. 5 treatment-emergent AEs occurred in with grade 4. Thirty percent of patients 2. Abramson JS, Palomba L, Gordon LI, et al. Pivotal 7 patients; in 4 patients, these deaths developed a neurologic AE of any safety and efficacy results from TRANSCEND NHL 001, were considered related to lisocabtagene grade, including 9% with grade 3 and a multicenter phase 1 study of lisocabtagene maraleucel (liso-cel) in relapsed/refractory (R/R) large B cell lympho- maraleucel. They were caused by diffuse 1% with grade 4. Prolonged infections mas [ASH abstract 241]. Blood. 2019;134(suppl 1).

KTE-X19, an Anti-CD19 Chimeric Antigen Receptor T-Cell Therapy, in Patients With Relapsed/Refractory Mantle Cell Lymphoma: Results of the Phase 2 ZUMA-2 Study

atients with mantle cell lym- Conditioning chemotherapy consisted endpoint was the ORR as assessed phoma who progress after treat- of fludarabine (30 mg/m2) plus cyclo- by an independent review committee ment with a Bruton tyrosine phosphamide (500 mg/m2) on days and included the first 60 patients who Pkinase (BTK) inhibitor have a median –5, –4, and –3. The CAR T cells were received treatment.4 OS of less than 6 months.1 KTE-X19 administered at a dose of 2 × 106 KTE- Among the 74 patients enrolled is a CD19-directed CAR T-cell therapy X19 cells per kilogram of body weight in the trial, 69 received conditioning that contains a CD3ζ T-cell activation by means of a single intravenous infu- chemotherapy. The KTE-X19 product domain and a CD28-signaling domain. sion on day 0. The first tumor assess- was successfully manufactured for 71 The KTE-X19 CAR T cells are manu- ment occurred on day 28. The primary patients (96%), and 68 patients (92%) factured using a process that removes circulating tumor cells.2 The multicenter, international phase 2 ZUMA-2 ABSTRACT SUMMARY Circulating DNA for Molecular Response trial (A Phase 2 Multicenter Study Prediction, Characterization of Resistance Mechanisms and Quanti- Evaluating Subjects With Relapsed/ fication of CAR T Cells During Axicabtagene Ciloleucel Therapy Refractory Mantle Cell Lymphoma) evaluated KTE-X19 in patients with A subset of patients with relapsed/refractory DLBCL will develop progressive disease relapsed or refractory mantle cell after treatment with axicabtagene ciloleucel. A study evaluated whether cell-free 3 lymphoma. Enrolled patients had DNA analysis could characterize molecular responses and resistance mechanisms received up to 5 prior therapies, which and track CAR19 cells (Abstract 550). The study evaluated plasma samples from 35 had to include chemotherapy with an patients. Levels of pretreatment circulating tumor DNA were prognostic in patients anthracycline or bendamustine, an receiving CAR19 therapy. PFS was significantly higher among patients with low anti-CD20 monoclonal antibody, and circulating tumor DNA. Early circulating tumor DNA dynamics and day 29 levels cor- a BTK inhibitor. Patients had at least related with outcomes. Patients with undetectable early circulating tumor DNA had a 1 measurable lesion and an ECOG significantly higher PFS. The study was able to track CAR19 cells using cell-free DNA. performance status of 0 or 1. The trial Early CAR19 dynamics did not correspond to outcome. Levels of circulating tumor excluded patients who had undergone DNA were more predictive of response than levels of axicabtagene ciloleucel. The prior allogeneic SCT or had previously investigators concluded that baseline and interim circulating tumor DNA measure- received CD19-targeted therapy or ments have prognostic significance in DLBCL patients undergoing treatment with CAR T-cell therapy. After enrollment CAR19 T cells. Cell-free DNA analysis can identify emergent resistance mutations, and leukapheresis, patients could including in CD19. receive bridging therapy with dexamethasone, ibrutinib, or acalabrutinib.

10 Clinical Advances in Hematology & Oncology Volume 18, Issue 2, Supplement 7 February 2020 HIGHLIGHTS IN CAR T-CELL THERAPY FROM THE 61ST ASH MEETING

received the KTE-X19 infusion. The 0.8-3.1 months), and the median (85%), thrombocytopenia (51%), and safety analysis included all 68 patients time to a CR was 3.0 months (range, anemia (50%). The most common who received the KTE-X19 infusion. 0.9-8.3 months). Thirty-five percent treatment-emergent grade 3/4 AEs The median time from leukapheresis of patients converted from a partial were hypophosphatemia (22%, all to delivery of the KTE-X19 cells to response to a CR, and 5% converted grade 3), hypotension (19% grade 3 the study site was 16 days. The 68 from stable disease to a CR. The ORR and 3% grade 4), and hypoxia (12% patients were a median age of 65 years was consistent across most subgroups. grade 3 and 9% grade 4). Grade 5 (range, 38-79 years), 85% had stage Median PFS and median OS were not AEs included 1 case of organizing IV disease, and 56% had a Mantle Cell reached. Twelve-month PFS was 61% pneumonia on day 37 and 1 case of Lymphoma International Prognostic (95% CI, 45%-74%), and 12-month staphylococcal bacteremia on day 134. Index score indicating intermediate- or OS was 83% (95% CI, 71%-91%). Any-grade cytokine-release syn- high-risk disease. The median number The median duration of response was drome was reported in 91% of patients, of prior therapies was 3 (range, 1-5), not reached (Figure 4). Remission was including 15% with grade 3/4. No and 43% had relapsed after autolo- maintained in 57% of all patients and cases of grade 5 cytokine-release syn- gous SCT. Sixty-eight percent were 78% of patients with a CR. Among drome occurred. The median time to refractory to treatment with a BTK the first 28 patients treated, 43% onset was 2 days (range, 1-13 days). inhibitor, and 32% had relapsed after remained in continued remission Management consisted of tocilizumab treatment. To control disease progres- without additional therapy after a in 59% of patients and corticosteroids sion prior to study treatment, 37% of median follow-up of 27.0 months in 22%. Cytokine-release syndrome patients received bridging therapy. (range, 25.3-32.3 months). resolved in all patients, at a median After a median follow-up of 12.3 The most common treatment- duration of 11 days. months (range, 7.0-32.3 months), the emergent AEs of any grade included Neurologic AEs of any grade ORR was 93% (95% CI, 84%-98%) pyrexia (94%), neutropenia (87%), occurred in 63% of patients; they were and the CR rate was 67% (95% CI, and thrombocytopenia (74%). The grade 3/4 in 31%. No grade 5 neuro- 53%-78%). The median time to an most common grade 3/4 hematologic AEs occurred. The most common initial response was 1.0 month (range, logic AEs consisted of neutropenia symptoms of neurotoxicity included

100

Duration of Response (%) Duration 20

Median, not reached (95% CI, 8.6-NE) 0 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 Months Patients at risk 56 48 42 32 25 17 15 14 12 12 11 9 2 2 2 0

Figure 4. Among patients with mantle cell lymphoma treated with KTE-X19 in the phase 2 ZUMA-2 trial, the median duration of response was not reached. ZUMA-2, A Phase 2 Multicenter Study Evaluating Subjects With Relapsed/Refractory Mantle Cell Lymphoma. Adapted from Wang M et al. ASH abstract 754. Blood. 2019;134(suppl 1).3

Clinical Advances in Hematology & Oncology Volume 18, Issue 2, Supplement 7 February 2020 11 SPECIAL MEETING REVIEW EDITION

any-grade tremor (35%), encepha- syndrome and neurologic events. study [ASH abstract 754]. Blood. 2019;134(suppl 1). lopathy (31%), and confusion (21%). 4. Cheson BD, Fisher RI, Barrington SF, et al; Alliance, References Australasian Leukaemia and Lymphoma Group; Eastern Treatments of neurologic AEs included Cooperative Oncology Group; European Mantle Cell Lymphoma Consortium; Italian Lymphoma Founda- tocilizumab (26%) and corticosteroids 1. Martin P, Maddocks K, Leonard JP, et al. Postibruti- tion; European Organisation for Research; Treatment of nib outcomes in patients with mantle cell lymphoma. (38%). The median time to onset of Cancer/Dutch Hemato-Oncology Group; Grupo Espa- Blood. 2016;127(12):1559-1563. neurologic AEs was 7 days (range, 1-32 ñol de Médula Ósea; German High-Grade Lymphoma 2. Sabatino M, Hu J, Sommariva M, et al. Generation Study Group; German Hodgkin’s Study Group; Japanese days). The median duration of neuro- of clinical-grade CD19-specific CAR-modified CD8+ Lymphorra Study Group; Lymphoma Study Association; memory stem cells for the treatment of human B-cell logic AEs was 12 days, with eventual NCIC Clinical Trials Group; Nordic Lymphoma Study malignancies. Blood. 2016;128(4):519-528. resolution in 86% of patients (37/43). Group; Southwest Oncology Group; United Kingdom 3. Wang M, Munoz J, Goy A, et al. KTE-X19, an anti- National Cancer Research Institute. Recommendations Patients with more robust expansion CD19 chimeric antigen receptor (CAR) T cell therapy, for initial evaluation, staging, and response assessment in patients (pts) with relapsed/refractory (R/R) mantle of KTE-X19 cells were more likely to of Hodgkin and non-Hodgkin lymphoma: the Lugano cell lymphoma (MCL): results of the phase 2 ZUMA-2 experience high-grade cytokine-release classification.J Clin Oncol. 2014;32(27):3059-3068.

Earlier Steroid Use With Axicabtagene Ciloleucel (Axi-Cel) in Patients With Relapsed/Refractory Large B-Cell Lymphoma

xicabtagene ciloleucel is an release syndrome of grade 3 or higher effect of earlier corticosteroid use autologous CAR T-cell therapy was observed in 13% of patients, and on the rates of these AEs.4 Patients in which T cells from the neurologic events of grade 3 or higher enrolled in cohort 4 had relapsed or Apatient are genetically modified to bind occurred in 32%. refractory DLBCL, primary medias- to CD19, thus enhancing the killing of Two additional cohorts were tinal B-cell lymphoma, transformed cancer cells.1 Common AEs from CAR added to evaluate management of follicular lymphoma, or high-grade T-cell therapy include cytokine-release cytokine-release syndrome and neu- B-cell lymphoma. They had received syndrome and neurotoxicity, both of rologic AEs.4,5 Patients in cohort 3 at least 2 prior lines of therapy. which require rigorous management. received prophylactic tocilizumab After leukapheresis, patients were The phase 2 ZUMA-1 trial evaluated on day 2, which reduced the rate of allowed to receive bridging therapy, axicabtagene ciloleucel in patients with severe cytokine-release syndrome to including dexamethasone, high-dose refractory large B-cell lymphoma.2,3 3% (1/34), but did not reduce the methylprednisolone plus rituximab, Cohort 1 included 77 patients with incidence of severe neurologic AEs. or bendamustine plus rituximab. Fol- DLBCL, and cohort 2 included 24 An additional safety expansion cohort lowing 3 days of conditioning with patients with primary mediastinal was therefore added to evaluate the cyclophosphamide and fludarabine, B-cell lymphoma or transformed follicular lymphoma. Eligible patients had not responded to their most recent chemotherapy or had relapsed within ABSTRACT SUMMARY Impact of Tisagenlecleucel Chimeric Antigen 12 months after autologous SCT. Receptor T-Cell Therapy Product Attributes on Clinical Outcomes in Patients had an ECOG performance Adults With Relapsed or Refractory Diffuse Large B-Cell Lymphoma status of 0 or 1. After receipt of a The impact of key CAR T-cell attributes was evaluated in patients with relapsed or conditioning regimen consisting of refractory DLBCL from the JULIET trial who received an infusion of tisagenlecleucel low-dose cyclophosphamide (500 mg/ (Abstract 242). Tisagenlecleucel cell viability had no significant impact on 3-month 2 2 m ) and fludarabine (30 mg/m ) deliv- response, duration of response, PFS, or OS, and no impact on rates of severe cyto- ered on days –5, –4, and –3, patients kine-release syndrome or neurologic AEs. The median T-cell transfusion efficiency 6 received an infusion of 2 × 10 CD19- also had no significant impact on efficacy or safety outcomes. Interferon-γ release directed CAR T cells per kilogram of ranged from 23.7 fg to 938 fg per CAR T cell. Durable responses were observed from body weight. Among 101 evaluable CAR T-cell batches representing the entire range of interferon-γ release. Levels of patients, the median follow-up was interferon-γ release showed no correlation with the frequency or grade of cytokine- 27.1 months. The ORR was 83%, release syndrome or neurologic AEs. The median ratio of genetically modified including a CR rate of 58%. After a CD4-positive cells to CD8-positive cells was 3.70 (range, 0.26-65.3). Efficacy or safety median follow-up of 39.1 months, the outcomes did not correspond to the ratio of CD4-positive cells to CD8-positive cells. median OS was 25.8 months and the 3-year OS rate was 47%. Cytokine-

12 Clinical Advances in Hematology & Oncology Volume 18, Issue 2, Supplement 7 February 2020 HIGHLIGHTS IN CAR T-CELL THERAPY FROM THE 61ST ASH MEETING

patients received a target dose of 2 5). In cohorts 1 and 2, the rate of grade rate of 51%. The median duration of × 106 CAR T cells/kg. Patients with 3 or higher cytokine-release syndrome response was 8.87 months, and 54% grade 1 cytokine-release syndrome was 13%. The rate was reduced to of patients had an ongoing response at received tocilizumab and/or cortico- 2% in cohort 4. The rate of grade 3 the time of the report (Figure 6). steroid therapy if no improvement or higher neurologic AEs decreased was observed after 3 days. Patients from 28% in cohorts 1 and 2 to 17% References with grade 1 neurotoxicity received in cohort 4. No cases of grade 4 or 5 1. Hopfinger G, Jäger U, Worel N. CAR-T cell therapy corticosteroid therapy, and tocili- cytokine-release syndrome or neuro- in diffuse large B cell lymphoma: hype and hope. zumab was added for grade 2 or logic AEs were observed in cohort 4. Hemasphere. 2019;3(2):e185. 2. Locke FL, Ghobadi A, Jacobson CA, et al. Long- higher neurologic AEs. Compared with cohorts 1 and 2, the term safety and activity of axicabtagene ciloleucel in Among the 41 patients in cohort rates of cytokine-release syndrome and refractory large B-cell lymphoma (ZUMA-1): a single- 4 who received the axicabtagene neurologic AEs of grade 3 or higher arm, multicentre, phase 1-2 trial. Lancet Oncol. 2019; 20(1):31-42. ciloleucel infusion, 46% had stage were reduced in cohort 4 for patients 3. Neelapu SS, Locke FL, Bartlett NL, et al. Axicabtagene IV disease. Their median age was 66 with a low or high tumor burden. ciloleucel CAR T-cell therapy in refractory large B-cell years (range, 19-77 years). Thirty- The mean cumulative corti- lymphoma. N Engl J Med. 2017;377(26):2531-2544. 4. Topp MS, van Meerten T, Houot R, et al. Earlier four percent of patients had under- costeroid dose was 13 ± 156 mg in steroid use with axicabtagene ciloleucel (axi-cel) in gone a prior SCT, 37% had disease cohorts 1 and 2 vs 5235 ± 76 mg in patients with relapsed/refractory large B cell lymphoma progression after their most recent cohort 4. Peak levels of biomarkers [ASH abstract 243]. Blood. 2019;134(suppl 1). 5. Locke FL, Neelapu SS, Bartlett NL, et al. Preliminary chemotherapy, and 20% had relapsed including interferon-γ, interleukin-2, results of prophylactic tocilizumab after axicabtagene after autologous SCT. and C-reactive protein were lower in ciloleucel (axi‑cel; KTE‑C19) treatment for patients CAR T-cell expansion was similar cohort 4 vs cohorts 1 and 2. In cohort with refractory, aggressive non‑Hodgkin lymphoma [ASH abstract 1547]. Blood. 2017;130(suppl 1). in cohorts 1 and 2 vs cohort 4 (Figure 4, the ORR was 73%, with a CR

Peak AUC P=.138 P=.526 2000 18000 1250 12000 6000 500 1

μ L) 200 1500 s) 0-28 y ells/ UC ( c

150 × d a

μ L 1000 ell s ells A

100 T c (c ells/ AR T c AR C C 500 50

0 0 Cohorts 1 and 2 Cohort 4 Cohorts 1 and 2 Cohort 4

Figure 5. CAR T-cell expansion in the ZUMA-1 trial of axicabtagene ciloleucel in patients with relapsed/refractory large B-cell lymphoma. Patients in cohort 4 could receive bridging therapy, including dexamethasone, high-dose methylprednisone plus rituximab, or bendamustine plus rituximab. AUC, area under the curve; CAR, chimeric antigen receptor; ZUMA-1, Safety and Efficacy of KTE-C19 in Adults With Refractory Aggressive Non-Hodgkin Lymphoma. Adapted from Topp MS et al. ASH abstract 243. Blood. 2019;134(suppl 1).4

Clinical Advances in Hematology & Oncology Volume 18, Issue 2, Supplement 7 February 2020 13 SPECIAL MEETING REVIEW EDITION

Median, 8.87 months (95% CI, 8.87-NE) 30 28 25 22 19 15 10 9 5 1 1 0

Figure 6. Duration of response among patients in cohort 4 of the ZUMA-1 trial of axicabtagene ciloleucel in patients with relapsed/ refractory large B-cell lymphoma. Patients in this cohort could receive bridging therapy, including dexamethasone, high-dose methylprednisolone plus rituximab, or bendamustine plus rituximab. NE, not evaluable; ZUMA-1, Safety and Efficacy of KTE-C19 in Adults With Refractory Aggressive Non-Hodgkin Lymphoma. Adapted from Topp MS et al. ASH abstract 243. Blood. 2019;134(suppl 1).4

Characteristics and Outcomes of Patients Receiving Bridging Therapy While Awaiting Manufacture of Standard of Care Axicabtagene Ciloleucel CD19 Chimeric Antigen Receptor (CAR) T-Cell Therapy for Relapsed/Refractory Large B-Cell Lymphoma: Results From the US Lymphoma CAR-T Consortium

he US CAR-T Lymphoma genetics, 75% had received 3 or more Efficacy and Safety of CTL019 in Adult Consortium evaluated real- prior lines of therapy, and 43% did DLBCL Patients), and 59% of those in world outcomes in patients not meet the inclusion criteria for the the TRANSCEND NHL 001 trial.3-5 withT DLBCL, primary mediastinal ZUMA-1 trial. Bridging therapy consisted of B-cell lymphoma, or transformed fol- After a median follow-up of 13.8 chemotherapy in 54%, only cortico- licular lymphoma who received treat- months, the median PFS was 7.16 steroids in 23%, radiation therapy ment with axicabtagene ciloleucel.1,2 months. The median OS was not in 12%, and targeted therapy in The study identified 298 patients who reached. Multivariate analysis showed a 10%. Patients who received bridging underwent leukapheresis and 275 worse OS among patients who received therapy were more likely to experience who received the axicabtagene cilo- bridging therapy vs those who did not cytokine-release syndrome of at least leucel infusion. Approximately half (hazard ratio [HR], 1.8; 95% CI, 1.0- grade 3 (9% vs 5% in those who did of patients (52%) were older than 60 2.7; P=.03). Bridging therapy was used not), neurotoxicity of at least grade 3 years. ECOG performance status was by 53% (n=158 patients). In contrast, (34% vs 28%), nonrelapse mortality 2 to 4 in 20%. The International Prog- bridging chemotherapy was used by (7.1% vs 1.5%), and death after lym- nostic Index score was 3 to 5 in 54%. no patients in the ZUMA-1 trial, 92% phoma relapse (37% vs 17%). Among Twenty-three patients had triple-hit of those in the JULIET trial (Study of patients who underwent leukapheresis,

14 Clinical Advances in Hematology & Oncology Volume 18, Issue 2, Supplement 7 February 2020 HIGHLIGHTS IN CAR T-CELL THERAPY FROM THE 61ST ASH MEETING

use of bridging therapy was also associ- went leukapheresis, the median PFS 2. Nastoupil L, Jain MD, Spiegel JY, et al. Axicabtagene ated with a reduced median PFS (HR, was similar (HR, 1.2; P=.3). However, ciloleucel (axi-cel) CD19 chimeric antigen receptor (CAR) T-cell therapy for relapsed/refractory large B-cell 1.6; P=.002) and a reduced median the median OS was superior in the lymphoma: real world experience [ASH abstract 627]. OS (HR, 2.45; P<.001; Figure 7). cohort of patients who had not received Blood. 2018;132(suppl 1). The efficacy of axicabtagene cilo- bridging therapy (HR, 1.7; P=.02). 3. Neelapu SS, Locke FL, Bartlett NL, et al. Axicabtagene ciloleucel CAR T-cell therapy in refractory large B-cell leucel was similar among the 4 cohorts lymphoma. N Engl J Med. 2017;377(26):2531-2544. of different bridging strategies (P>.05). References 4. Abramson JS, Palomba L, Gordon LI, et al. Pivotal After propensity score matching, the P safety and efficacy results from TRANSCEND NHL 1. Jain MD, Jacobs MT, Nastoupil L, et al. Charac- 001, a multicenter phase 1 study of lisocabtagene mara- values ranged from 0.30 to 1.0. Out- teristics and outcomes of patients receiving bridging leucel (liso-cel) in relapsed/refractory (R/R) large B cell comes were compared between the 104 therapy while awaiting manufacture of standard of lymphomas. Blood. 2019;134(suppl 1). patients without bridging therapy who care axicabtagene ciloleucel CD19 chimeric antigen 5. Schuster SJ, Bishop MR, Tam CS, et al; JULIET receptor (CAR) T-cell therapy for relapsed/refractory Investigators. Tisagenlecleucel in adult relapsed or were matched by propensity score to large B-cell lymphoma: results from the US Lymphoma refractory diffuse large B-cell lymphoma. N Engl J Med. 104 patients who did receive bridging CAR-T Consortium [ASH abstract 245]. Blood. 2019;380(1):45-56. treatment. Among patients who under- 2019;134(suppl 1).

Figure 7. Overall survival was decreased among patients treated with bridging therapy in a real-world analysis of patients with diffuse large B-cell lymphoma, primary mediastinal B-cell lymphoma, or transformed follicular lymphoma who received treatment with axicabtagene ciloleucel. HR, hazard ratio. Adapted from Jain MD et al. ASH abstract 245. Blood. 2019;134(suppl 1).1

A. No Bridging Therapy B. Bridging Therapy HR, 2.45; P<.001

Real-World Data of High-Grade Lymphoma Patients Treated With CD19 CAR-T in England

n England, axicabtagene ciloleucel CAR-T Clinical Panel, which includes tor national capacity, assess outcomes and tisagenlecleucel are currently independent clinical experts, patient and use of resources, and build expert available through the Cancer Drugs representatives, and delegates from 7 competency. Eligibility criteria are IFund, which provides interim funding CAR T-cell treatment centers. The latter similar to those for the ZUMA-1 and for novel treatments until their clinical are located in geographically dispersed JULIET trials.2,3 Eligible patients have and cost-effectiveness can be deter- areas across England. The panel aims to progressive disease based on Response mined.1 Patients are approved to receive use a transparent and objective approval Evaluation Criteria in Solid Tumors.4 CAR T-cell therapy based on findings process to provide equitable treatment A fresh biopsy is generally required for from a weekly meeting of the National access across regions, as well as to moni- consideration of treatment.

Clinical Advances in Hematology & Oncology Volume 18, Issue 2, Supplement 7 February 2020 15 SPECIAL MEETING REVIEW EDITION

The National Health Service corticosteroids only (16%), and radio- Cytokine-release syndrome of England conducted a study to obtain therapy with or without corticoste- grade 3 or higher was observed in real-world data on CAR T-cell roids (10%). 11% of patients. Management con- therapy for the treatment of B-cell Among 56 patients who received sisted of tocilizumab in 65% and lymphoma.1 The study enrolled 125 treatment with axicabtagene ciloleu- corticosteroids in 29%. Admission to patients, of whom 116 underwent cel, 21% had a CR and 16% had a an intensive care unit was needed by leukapheresis and 91 received a CAR partial response. Early progression 34% of patients. Hematologic AEs of T-cell infusion. Sixty-two patients occurred in 59% of patients, and grade 3 or higher included neutropenia received axicabtagene ciloleucel and 4% died. Among 24 patients who (19%) and thrombocytopenia (19%). 29 received tisagenlecleucel. The received a tisagenlecleucel infusion, Treatment-related mortality was 2%. median time from approval to infu- 17% had a CR and 12% had a partial sion was 63 days (range, 41-114 response. Early progression was noted References days). Lymphoma subtypes included in 71%. After a median follow-up of 1. Kuhnl A, Roddie C, Martinez-Cibrian N, et al. Real- de novo DLBCL (71%), transformed 7.0 months, the median OS was 9.1 world data of high-grade lymphoma patients treated follicular lymphoma (18%), primary months for the overall population with CD19 CAR-T in England [ASH abstract 767]. Blood. 2019;134(suppl 1). mediastinal B-cell lymphoma (6%), of 124 evaluable patients (Figure 8). 2. Neelapu SS, Locke FL, Bartlett NL, et al. Long- and transformed marginal zone lym- Among patients who were approved term follow-up ZUMA-1: a pivotal trial of axicabta- phoma (5%). Seventy-six percent of for CAR T-cell therapy, the median gene ciloleucel in patients with refractory aggressive non-Hodgkin lymphoma [ASH abstract 578]. Blood. patients had stage III/IV disease, and OS was not reached for those who did 2017;130(suppl 1). one-third had bulky disease (≥7.5 cm). receive a CAR T-cell infusion (n=91) 3. Schuster SJ, Bishop MR, Tam CS, et al; JULIET Extranodal disease was present in 43% vs 2.3 months for patients who did not Investigators. Tisagenlecleucel in adult relapsed or refractory diffuse large B-cell lymphoma. N Engl J Med. of patients, and 43% had received at receive an infusion (n=33). The pre- 2019;380(1):45-56. least 3 prior lines of therapy. Bridging liminary analysis suggests a lower rate 4. Eisenhauer EA, Therasse P, Bogaerts J, et al. New therapies included chemotherapy with of ongoing remissions compared with response evaluation criteria in solid tumours: revised 2,3 RECIST guideline (version 1.1). Eur J Cancer. 2009; or without corticosteroids (57%), outcomes from pivotal clinical trials. 45(2):228-247.

1.0

Infused Patients (n=91) 0.8 Median OS, not reached

0.6

All Patients (N=124) 0.4 Median OS, 9.1 months

Cumulative Survival Cumulative 0.2 Median follow-up, Patients Not Infused (n=33) 7.0 months Median OS, 2.3 months 0.0 0 1 2 3 4 5 6 7 8 9 10 11 12 Months After Approval Number at risk 124 117 113 99 90 64 53 37 23 10 5 1

Figure 8. Overall survival among patients approved for CAR T-cell therapy in a real-world analysis from the National Health Service England. CAR, chimeric antigen receptor. Adapted from Kuhnl A et al. ASH abstract 767. Blood. 2019;134(suppl 1).1

16 Clinical Advances in Hematology & Oncology Volume 18, Issue 2, Supplement 7 February 2020 HIGHLIGHTS IN CAR T-CELL THERAPY FROM THE 61ST ASH MEETING

Post-Marketing Use Outcomes of an Anti-CD19 Chimeric Antigen Receptor T-Cell Therapy, Axicabtagene Ciloleucel, for the Treatment of Large B-Cell Lymphoma in the United States

n ongoing study in the United Among 750 enrolled patients, 533 the ZUMA-1 trial,2 those in the cur- States is using the infrastruc- attended a first follow-up appointment. rent study were older (median age, 61 ture created by the Center Most of these patients (63%) were vs 58 years), were more likely to have forA International Blood and Marrow younger than 65 years. There were 326 high-risk genetics (36% vs 11%), and Transplant Research (CIBMTR) to patients with at least 6 months of follow- were more likely to have undergone evaluate the real-world safety and effi- up, and 218 were younger than 65 years. autologous SCT (32% vs 25%). cacy of axicabtagene ciloleucel.1 The Among the 533 patients who The ORR was 74% among the study includes patients who received attended a first follow-up appoint- 533 patients who attended a first fol- axicabtagene ciloleucel and agreed to ment, the median age was 61 years low-up appointment. ORR was 79% share their data with the CIBMTR. (range, 19-86 years), and 66% were in patients ages 65 years or older vs Follow-up will last for 15 years as male. The ECOG performance status 71% in younger patients (P=.07). The part of a postmarketing regulatory was 0 or 1 in 80% of patients and 326 patients with at least 6 months of requirement. The study has a planned 2 or higher in 4%. (The score was follow-up had an ORR of 84% (Figure accrual of 1500 large B-cell lymphoma unknown in 15%.) The disease was 9). ORR was 92% in older patients vs patients. The objectives are to describe transformed lymphoma in 30%, 80% in younger patients (P=.02). The early safety and efficacy outcomes and double- or triple-hit lymphoma in median duration of response was simi- to analyze treatment patterns based on 36%, and chemotherapy-resistant in lar for both older and younger patients age. The study included patients with 62%. Thirty-two percent of patients (P=.170), as were the median PFS large B-cell lymphoma who received had received a prior autologous SCT. (P=.059) and median OS (P=.618). commercial axicabtagene ciloleucel The median time from diagnosis to Cytokine-release syndrome of after approval by the US Food and axicabtagene ciloleucel infusion was any-grade occurred in 80% of younger Drug Administration. 16 months. Compared with patients in patients vs 84% of older patients.

Figure 9. Overall response among patients with at least 6 months of follow-up treated with axicabtagene ciloleucel in a real-world P=.02 analysis. Adapted from Pasquini MC et 100 al. ASH abstract 764. Blood. 2019;134 92 (suppl 1).1 90 80 84 80 70 60

% 50 40 30 20 10 0 <65 years ≥65 years Total

Partial Remission Complete Remission

Clinical Advances in Hematology & Oncology Volume 18, Issue 2, Supplement 7 February 2020 17 SPECIAL MEETING REVIEW EDITION

Rates of high-grade cytokine-release grade 3 or higher neurologic toxic- References syndrome were 8% vs 10%, respec- ity was 19% in younger patients vs 1. Pasquini MC, Locke FL, Herrera AF, et al. Post-mar- tively. In both age groups, the median 22% in older patients. Neurotoxicity keting use outcomes of an anti-CD19 chimeric antigen time to cytokine-release syndrome was resolved in 89% vs 87%, respectively. receptor (CAR) T cell therapy, axicabtagene ciloleucel 3 days, and the median duration was The median time to onset was 6 days (Axi-Cel), for the treatment of large B cell lymphoma (LBCL) in the United States (US) [ASH abstract 764]. 7 days. Cytokine-release syndrome for both cohorts. The median dura- Blood. 2019;134(suppl 1). resolved in 94% of patients younger tion of neurotoxicity was 7 vs 10 days. 2. Neelapu SS, Locke FL, Bartlett NL, et al. Axicabtagene than 65 years and in 93% of patients Rates of subsequent neoplasms were ciloleucel CAR T-cell therapy in refractory large B-cell lymphoma. N Engl J Med. 2017;377(26):2531-2544. ages 65 years and older. The rate of similar for both age groups.

Tisagenlecleucel Chimeric Antigen Receptor T-Cell Therapy for Adults With Diffuse Large B-Cell Lymphoma: Real World Experience From the Center for International Blood & Marrow Transplant Research Cellular Therapy Registry registry to track long-term Forty-nine percent of patients neurologic AEs were observed in 1%, outcomes among patients developed any-grade cytokine-release 4%, and 1% of patients, respectively. treated with CAR T-cell syndrome. Grade 4 cytokine-release syn- The median time to onset of neu- therapyA was initiated in September drome occurred in 1%, and grade 5 cases rologic AEs was 8 days (range, 2-27 2018.1 The registry will follow 2500 occurred in 2%. The median time to days), and the median duration was 14 patients with lymphoma, includ- onset of cytokine-release syndrome was 4 days (range, 5-25 days). ing 1000 with acute lymphoblastic days (range, 2-14 days), and the median Efficacy and safety outcomes were leukemia, for 15 years. Cohorts will duration was 5 days (range, 4-8 days). similar for CAR T-cell preparations be analyzed based on forms of infu- Any-grade neurotoxicity occurred that had between 60% and 79% viable sion, safety, efficacy, and CAR T-cell in 16% of patients. Grade 3, 4, and 5 CAR T cells and those with a viability manufacturing. An initial cohort of 116 patients with non-Hodgkin lymphoma received the tisagen ABSTRACT SUMMARY Detectable Circulating Tumor DNA 28 Days lecleucel infusion. Patients were a After the CD19 CAR T-Cell Therapy, Axicabtagene Ciloleucel, Is median age of 65 years (range, 15-89 Associated With Poor Outcomes in Patients With Diffuse Large years). Double- or triple-hit genetics B-Cell Lymphoma was reported in 41%, and 27% had transformed lymphoma. Thirty-two Among patients treated with CAR T-cell therapies, early identification of increased percent had refractory disease, and risk of relapse may permit early intervention to improve outcomes. A multi-institu- 28% had received prior SCT. tional, prospective study used cell-free minimal residual disease (MRD) assessment The median time from diagnosis to to predict outcomes in patients with relapsed/refractory DLBCL who received axi- administration of CAR T-cell therapy cabtagene ciloleucel (Abstract 884). The analysis included 64 patients. High levels was 15 months, and the median time of circulating tumor DNA before lymphodepletion were associated with poor out- from the start of manufacturing to comes, including lower PFS. The average level of plasma cell circulating tumor DNA CAR T-cell infusion was 32 days. The before lymphodepletion was 15-fold higher in patients who developed progressive median number of viable CAR T cells disease. The average level of plasma cell circulating tumor DNA began to rise on day 8 8 was 1.7 × 10 (range, 0.4 × 10 to 6.8 28 among patients with progressive disease. Patients who were MRD positive on day 8 × 10 ). Most patients (89%) received 28 had poor clinical outcomes. The median PFS was 3.0 months among MRD-positive cyclophosphamide plus fludarabine for patients vs not reached among MRD-negative patients (P<.001). Detection of MRD lymphodepletion. predicted relapse. Day 28 assessment of MRD using circulating tumor DNA com- After a median follow-up of 4.5 pared favorably with assessments using positron emission tomography/computed months, the ORR was 58%, with a tomography. The investigators concluded that the results provide a rationale for 40% CR rate. The 3-month duration designing risk-adapted clinical trials in CAR T-cell therapy that incorporate measure- of response was 75.2%. Three-month ment of circulating tumor DNA. PFS was 61.6%, and 3-month OS was 79.6%.

18 Clinical Advances in Hematology & Oncology Volume 18, Issue 2, Supplement 7 February 2020 HIGHLIGHTS IN CAR T-CELL THERAPY FROM THE 61ST ASH MEETING

of at least 80% of cells (Figure 10). The ORR was 54% in patients who ABSTRACT SUMMARY Experience With Axicabtagene Ciloleucel in received the lower viability prepara- Patients With Secondary CNS Involvement: Results From the US tion vs 59% for those who received Lymphoma CAR T Consortium the higher viability preparation. The 3-month duration of response was 70% A real-world, retrospective study evaluated outcomes in patients with secondary vs 79%, respectively, and 3-month OS CNS involvement who received an axicabtagene ciloleucel infusion at 1 of 17 aca- was 75% vs 84%. Any-grade cytokine- demic centers associated with the US CAR-T Lymphoma Consortium (Abstract 763). release syndrome rates were 38% vs Thirteen patients had a history of CNS involvement, and 8 patients had active CNS 49%, and rates of any-grade neuro- involvement at the time of the axicabtagene ciloleucel infusion. Baseline demo- toxicity were 13% vs 17%. The ORR graphics were similar for patients with or without CNS involvement. The ORR at was numerically lower among patients 6 months was 48% for the 257 patients without CNS involvement, 44% for the 18 infused with preparations in the low- patients with CNS involvement, 50% for the 8 patients with active CNS involvement est quartile of viable CAR T cells, but at the time of the axicabtagene ciloleucel infusion, and 40% for the 10 patients with a the difference was not significant. All history of CNS involvement. Rates of event-free survival were similar for patients with of the grade 3 to 5 cytokine-release vs without CNS involvement, as determined from the time of leukapheresis (P=.14) syndrome events occurred in patients and from the time of the axicabtagene ciloleucel infusion (P=.24). who received CAR T-cell preparations in viability quartile 3 (1.69-2.26 × 108 cells). The CIBMTR registry and the rotoxicity (5% vs 11%). However, the 2 adults with diffuse large B-cell lymphoma (DLBCL): real world experience from the Center for International JULIET trial provided similar outcome trials used different grading guidelines Blood & Marrow Transplant Research (CIBMTR) cel- data, including for ORR (58% vs 52%) for cytokine-release syndrome. lular therapy (CT) registry [ASH abstract 766]. Blood. and CR rate (40% vs 38%).2 Rates of 2019;134(suppl 1). References 2. Schuster SJ, Bishop MR, Tam CS, et al; JULIET high-grade cytokine-release syndrome Investigators. Tisagenlecleucel in adult relapsed or were lower in the CIBMTR registry (4% 1. Jaglowski S, Huan Z, Zhang Y, et al. Tisagenlecleucel refractory diffuse large B-cell lymphoma. N Engl J Med. chimeric antigen receptor (CAR) T-cell therapy for vs 23%), as were rates of high-grade neu- 2019;380(1):45-56.

% 0 20 40 60 80 100 54 ORR (CR/PR) 59 Viability 60%-79% (out-of-speci cation CR 38 in the United States) 39 Viability ≥80% PR 17 (in speci cation) 20 3-month DOR 70 79

3-month PFS 67 61

3-month OS 75 84

All-grade CRS 38 49 13 All-grade neurotoxicity 17

Figure 10. Cell viability did not impact safety or outcome in a real-world analysis of patients with diffuse large B-cell lymphoma treated with tisagenlecleucel. CR, complete response; CRS, cytokine-release syndrome; DOR, duration of response; ORR, overall response rate; OS, overall survival; PFS, progression-free survival. Adapted from Jaglowski S et al. ASH abstract 766. Blood. 2019;134(suppl 1).1

Clinical Advances in Hematology & Oncology Volume 18, Issue 2, Supplement 7 February 2020 19 SPECIAL MEETING REVIEW EDITION

Highlights in CAR T-Cell Therapy From the 61st American Society of Hematology Annual Meeting: Commentary Caron A. Jacobson, MD

everal studies in chimeric antigen lymphoma, those who had undergone a potentially safer than the 2 CAR T-cell receptor (CAR) T-cell therapy prior allogeneic transplant, those with a products approved in this space, axi- presented at the 61st American creatinine clearance between 30 and 60 cabtagene ciloleucel and tisagenlecleucel, SSociety of Hematology (ASH) meet- mL/min, and those with a cardiac ejec- based on the data from clinical trials.2,3 ing provided important insights into tion fraction between 40% and 50%. The rate of grade 3 or higher cytokine- the use of this treatment. Results from The number of patients who had release syndrome (CRS) was 2%, and clinical trials were presented for liso- their cells collected was 344, but the the median time to onset of CRS was 5 cabtagene maraleucel and KTE-X19. number of patients included in the days. Therefore, fewer patients required Follow-up analyses and real-world efficacy analysis was only 256. There are admission to the intensive care unit after reports examined data for axicabtagene several reasons for this drop-off. Thirty- developing CRS. CRS typically arises 5 ciloleucel and tisagenlecleucel. three patients died after undergoing days after infusion, raising the potential leukapheresis and before receiving the for administration in the outpatient set- Clinical Trial Data infusion. An additional 17 patients ting, where patients can be monitored Dr Jeremy S. Abramson and colleagues underwent leukapheresis but did not and then hospitalized only if needed. presented results of the TRANSCEND receive the infusion, 6 owing to disease- Any-grade cytokine release syndrome NHL 001 trial,1 the third pivotal study related complications. The CAR T-cell occurred in 42% of patients, indicating of a CD19-directed CAR T-cell prod- product could not be manufactured for that many patients can avoid hospital- uct. The study evaluated lisocabtagene 2 patients. Twenty-five patients were ization. Neurologic toxicity of grade 3 maraleucel in patients with relapsed/ excluded from the efficacy analysis or higher occurred in 10% of patients, refractory large B-cell lymphoma. Liso- because the CAR T-cell product did which is a fairly low number. Any-grade cabtagene maraleucel is a 4-1BB CAR not meet the protocol specifications for neurologic toxicity was reported in 30% product, like tisagenlecleucel. A unique infusion. These patients still received of patients. aspect to lisocabtagene maraleucel is the infusion, but under a protocol such Hospitalization in the intensive that it is formulated in a 1:1 ratio of as the single-patient Investigational care unit was required by 7% of CD4 to CD8 T cells. TRANSCEND New Drug program. Lastly, 13 patients patients, despite the lower incidence of started as a nonpivotal registrational were treated but not evaluable because grade 3 or higher CRS. This observa- study. It originally had different eligibil- they had a complete response to bridg- tion underscores the data showing ity criteria compared with previous reg- ing therapy or they had not undergone that these therapies have considerable istrational studies, but was later modi- positron-emission tomography (PET). high-grade toxicity and risk, and that fied to include a core cohort that would The PET scan was required to measure patients treated with them require be used for registration purposes. Data their response to bridging therapy and access to a medical center that can were presented at the ASH meeting.1 to establish a new baseline scan against deliver high-quality, specialized man- The study evaluated different doses and which to judge their response to liso- agement in an intensive care unit. numbers of infusions in a dose-finding cabtagene maraleucel. With respect to efficacy, the rates portion. However, the study treated The overall response rate (ORR) of overall response and complete a majority of patients (n=126) at the was based on a modified intention-to- response were similar to those seen confirmed recommended phase 2 dose treat analysis that included only the with the other T-cell products.2,3 The in a single infusion. A key point of the patients who received lisocabtagene complete response rate was 53%, and study concerns the broad population. maraleucel. The rate will decrease if the ORR was 73%. The responses were It not only included the largest cohort the analysis included all patients who durable, persisting at 6 and 12 months; of patients treated with aggressive underwent leukapheresis. With CAR in a Kaplan-Meier graph, the curve for B-cell non-Hodgkin lymphoma among T-cell therapy, the efficacy and safety the duration of response appeared to the pivotal studies,2,3 it also included of an individual product are certainly plateau around that time. The presence patients who would have been excluded important concerns, but so is the pro- of high-risk disease characteristics did from the other studies, including those portion of patients who will be able to not impact response. However, other with an Eastern Cooperative Oncology receive the product after leukapheresis. clinical trials and analyses suggest that Group performance status of 2, those Dr Abramson presented the safety patients with a higher disease burden with secondary central nervous system data first.1 Lisocabtagene maraleucel is are less likely to have a complete

20 Clinical Advances in Hematology & Oncology Volume 18, Issue 2, Supplement 7 February 2020 HIGHLIGHTS IN CAR T-CELL THERAPY FROM THE 61ST ASH MEETING

response after CAR T-cell therapy.2,4,5 is approved by the US Food and Drug The side effect profile was similar The TRANSCEND trial pro- Administration (FDA). to that of axicabtagene ciloleucel in vided efficacy data according to Dr Michael Wang and colleagues large cell lymphoma. Grade 3 or higher disease histology. This study is the presented a study of KTE-X19 in CRS occurred in 15% of patients. The first in CAR T-cell therapy to show patients with mantle cell lymphoma.6 median time to onset was 2 days. The a separate response rate for patients This study is the first in CAR T-cell rate of grade 3 or higher neurologic with primary mediastinal large B-cell therapy to enroll a large series of patients toxicity was 31%. It appeared that lymphoma. These patients, along with with mantle cell lymphoma. KTE-X19 patients with better CAR T-cell expan- patients with transformed follicular is similar to axicabtagene ciloleucel in sion were more likely to respond and lymphoma, did better than patients all attributes except for one. The manu- to achieve minimal residual disease with high-grade B-cell lymphoma, dif- facturing process of KTE-X19 selects (MRD) negativity. However, increased fuse large B-cell lymphoma, and other out T cells from potential leukemia production of CARs corresponds with transformed indolent lymphomas. or lymphoma cells, thereby remov- high-grade toxicity. There has been a question regarding the circulating tumor cells before This study is the first to show ing the long-term benefits of bridging expansion and activation. The study that a CAR T-cell therapy can achieve therapy given between T-cell collection enrolled patients with fairly high-risk an impressive response rate and good and T-cell infusion on efficacy as well as disease. Patients had received previous durability of response in a high-risk, toxicity. The pivotal trials had different treatment with chemoimmunotherapy refractory population of patients with allowances for bridging therapy. In the and a Bruton tyrosine kinase (BTK) mantle cell lymphoma. This treat- TRANSCEND trial, the use of bridg- inhibitor. Their expected survival was ment has the potential to change the ing therapy did not impact outcome.1 short. Between leukapheresis and infu- natural history of the disease for many As mentioned, the TRANSCEND sion, patients could receive bridging patients. These data will likely lead to trial had a broader eligibility criteria therapy with either corticosteroids or a approval from the FDA. than previous studies, enrolling patients BTK inhibitor. The median time from with high-risk characteristics, such as leukapheresis to delivery of KTE-X19 Follow-Up Analysis comorbidities involving cardiac or renal was 16 days. Dr Sattva S. Neelapu and colleagues function, patients who had undergone The product was successfully evaluated rates of CD19 loss in a allogeneic transplant, and patients with manufactured for 96% of patients small cohort of patients who received central nervous system disease. An and administered to 92% of patients. axicabtagene ciloleucel.7 The study analysis suggested that patients without These data are similar to those in the documented a reasonably high rate comorbidities had a better outcome than ZUMA-1 trial.2 Approximately 17% of CD19 loss. Before treatment, 90% patients with comorbidities, which is of patients had a TP53 mutation, 70% of patients were CD19-positive. This an important new observation. Patients had a high Ki-67, and more than 30% rate dropped to 72% after treatment with comorbidities still did better after had blastoid or pleomorphic morphol- among the samples evaluated by CAR T-cell therapy than they would ogy. All of these characteristics predict immunohistochemistry. There seemed have with other available therapies; this for inferior outcomes with conventional to be a selection for tumor cells that finding highlights that these patients still therapies. had lower CD19 antigen expression. benefit from this treatment, although The trial showed an impressive The study also identified patients who they represent an unmet medical need ORR of 93%, including a complete had alternative splicing of CD19 that and require more effective and safer cel- response rate of 67%. The median fol- led to a loss of the epitope that the lular therapy options. low-up was approximately 12 months. CAR binds to. Importantly, the study This study demonstrates that Approximately 47% of patients had showed that nearly all of the patients lisocabtagene maraleucel is a highly at least 2 years of follow-up, and who lost CD19 still retained other active CAR T-cell therapy with a responses were durable. It is necessary B-cell antigens. This study not only potentially safer toxicity profile that to have a longer follow-up in mantle documented the rates of CD19 loss in could allow administration in the cell lymphoma compared with large large cell lymphoma after axicabtagene outpatient setting. In the clinic, it will cell lymphoma to hypothesize whether ciloleucel, but also provided rationale be important to see how many patients a therapy might offer a potential cure. for studying dual-antigen CARs that can receive treatment after leukapher- The results of this study, though, are target more than one B-cell antigen esis. If manufacturing is efficient and promising. At 12 months, 57% of simultaneously. Ongoing phase 2 mul- patients are able to receive treatment, patients were still in response. Among ticenter clinical trials are evaluating then lisocabtagene maraleucel will be an patients with a complete response, this this presently, with results expected in important addition to this field once it response was maintained in 78%. the next few years.8,9

Clinical Advances in Hematology & Oncology Volume 18, Issue 2, Supplement 7 February 2020 21 SPECIAL MEETING REVIEW EDITION

Real-World Reports This analysis evaluated data accord- decreased progression-free survival and There were several real-world reports, ing to age to allay concerns that this overall survival. When using a propen- some drawn from the Center for Inter- is a therapy that should be limited to sity score matching analysis to control national Blood & Marrow Transplant younger patients. Interestingly, in older for factors associated with worse out- Research (CIBMTR) database. A study patients, the response rates were higher, comes, bridging therapy remained by Dr Samantha Jaglowski evaluated and responses were more durable. an independent predictive factor for real-world use of tisagenlecleucel in In the real-world analysis, grade inferior overall survival. Patients treated 80 patients.10 Rates of overall response 3 or higher CRS occurred in less than with CAR T cells after bridging and complete response were similar to 10% of patients, which is lower than in therapy still have better outcomes than those in clinical trials. The follow-up is the ZUMA-1 trial.2 This decrease likely patients treated with the current stan- short at this time. However, between reflects improvements in management. dard of care, but like the patients with 60% and 70% of patients appear to However, only approximately 15% of comorbidities in the TRANSCEND maintain their response at the 3-month patients did not have CRS. The rate of study, they represent an unmet need. mark, which is predictive of durable grade 3 or higher neurologic toxicity This study also used a propensity remissions in clinical trials.2,3 was approximately 20%, which is also score matching analysis to control for The JULIET study of tisagen better than that seen in the ZUMA-1 factors that predict for higher-risk lecleucel used a different grading scale trial,2 but higher than that seen with disease. The worse rates of progression- for CRS than the other trials, and the lisocabtagene maraleucel or tisagen free survival and overall survival seen in rate of grade 3 or higher events was lecleucel.1,3 Neurologic toxicity was patients who received bridging therapy 22%.3 In the real-world analysis, 80 not increased in patients who were persisted in this analysis. All types of patients were evaluated for CRS based older than 65 years. This real-world bridging therapies were associated with on the standardized scale set forth by analysis supports the use of axicabta- the worse outcome. the American Society for Transplanta- gene ciloleucel in the older population. Like the TRANSCEND trial, tion and Cellular Therapy.11 The rate Dr Michael D. Jain and colleagues this analysis showed that outcome is of grade 3 or higher cytokine release from the US CAR T-cell consortium inferior among patients with comor- syndrome was only 3%, which is simi- evaluated bridging therapy in a real- bidities and who undergo bridging lar to the rate in the TRANSCEND world cohort of patients treated with therapy.1 Patients treated with CAR T study, which evaluated lisocabtagene axicabtagene ciloleucel. Bridging cells after bridging therapy still have maraleucel, the other 4-1BB CAR.1 therapy was used by 53% of patients.13 better outcomes than patients treated The improved rates of CRS may reflect Bridging therapy consisted of che- with the current standard of care, but both the use of a modern toxicity grad- motherapy in 54%, corticosteroids in they represent an unmet need. ing scale as well as improvements in 23%, radiation in 12%, and targeted An analysis of real-world data from treating and managing CRS. Rates of agents in 10%. Patients who received England of patients treated with CAR grade 3 or higher neurologic toxicity, bridging therapy had several poor-risk T-cell therapy found that toxicity was as assessed using an updated consensus characteristics. They were more likely better but efficacy was worse as com- scale, were also lower in the real-world to have a poor performance status, pared with data from clinical trials.2,3,14 study vs the JULIET trial. These rates advanced-stage disease, a high Inter- In England, the mechanism for identi- were 6% in the real-world series vs national Prognostic Index, and bulky fying and approving therapy for an indi- 12% in the JULIET study.3 Again, this disease. These patients probably had vidual patient involves a comprehensive may reflect improvements in toxicity worse disease, were sicker at baseline, central review process. Patients are management and treatment. In this and were less likely to respond in general. selected for treatment with CAR T-cell real-world study, efficacy was similar to There was no difference in the therapy only if they are in good physi- that in the JULIET clinical trial, but rates of CRS and neurotoxicity in cal condition. Selected patients must safety was improved. the groups that did or did not receive wait much longer to receive treatment Dr Marcelo Pasquini presented bridging therapy. However, the rate compared with patients in the United data from the CIBMTR for 533 of nonrelapse mortality and death States. It may be that the decreased effi- patients treated with axicabtagene (presumably related to treatment) was cacy in this analysis reflects this delay, ciloleucel.12 Efficacy is similar to that 7.1% in patients who received bridg- by allowing the disease to progress. in clinical trials, with an ORR of 70% ing therapy and 1.5% in patients who to 80%, and a complete response rate did not. There was also a higher rate DNA Levels and Response of approximately 50%. After at least of death related to lymphoma relapse, CAR T-cell therapy is associated with 6 months of follow-up, a complete at 37% vs 17%, respectively. Patients high response rates, but also significant response persisted in most patients. who received bridging therapy had relapse rates. It appears that approxi-

22 Clinical Advances in Hematology & Oncology Volume 18, Issue 2, Supplement 7 February 2020 HIGHLIGHTS IN CAR T-CELL THERAPY FROM THE 61ST ASH MEETING

mately 40% of patients will achieve technology is that the sequence for the lymphomas [ASH abstract 241]. Blood. 2019;134(suppl 1). 2,3 2. Neelapu SS, Locke FL, Bartlett NL, et al. Axicabtagene long-term remissions. There is inter- actual CAR can be incorporated into ciloleucel CAR T-cell therapy in refractory large B-cell est in trying to identify patients who the panel, and the CAR T cells can be lymphoma. N Engl J Med. 2017;377(26):2531-2544. may potentially relapse in order to tracked over time to measure expansion 3. Schuster SJ, Bishop MR, Tam CS, et al; JULIET Investigators. Tisagenlecleucel in adult relapsed or administer interventions that could and persistence. The study showed that refractory diffuse large B-cell lymphoma. N Engl J Med. manipulate CAR T cells or other CAR T-cell expansion did not correlate 2019;380(1):45-56. 4. Frank MJ, Hossain N, Bukhari A, et al. Detectable cir- functional T cells to continue to with outcome. The investigators evalu- culating tumor DNA 28 days after the CD19 CAR T-cell fight against the residual lymphoma. ated the mutational burden in patients therapy, axicabtagene ciloleucel, is associated with poor Two abstracts presented at the ASH before treatment. Patients who devel- outcomes in patients with diffuse large B-cell lymphoma [ASH abstract 884]. Blood. 2019;134(suppl 1). meeting evaluated MRD after use of oped progressive disease had a different 5. Sworder B, Kurtz DM, Macaulay C, et al. Circulating axicabtagene ciloleucel in a commercial disease mutation profile from those who DNA for molecular response prediction, characterization of resistance mechanisms and quantification of CAR setting. A study presented by Dr Mat- did not. These data are preliminary, but T cells during axicabtagene ciloleucel therapy [ASH thew J. Frank included a cohort of 64 they suggest how this technology might abstract 550]. Blood. 2019;134(suppl 1) 4 6. Wang M, Munoz J, Goy A, et al. KTE-X19, an anti- patients. These patients had the same be used to predict response. CD19 chimeric antigen receptor (CAR) T cell therapy, outcomes as were seen in the ZUMA-1 A study presented by Dr Veron- in patients (pts) with relapsed/refractory (R/R) mantle trial. The study followed MRD lev- ika Bachanova and colleagues evalu- cell lymphoma (MCL): results of the phase 2 ZUMA-2 study [ASH abstract 754]. Blood. 2019;134(suppl 1). els serially through month 12. The ated 115 tisagenlecleucel products 7. Neelapu SS, Rossi JM, Jacobson CA, et al. CD19- investigators assessed circulating tumor to explore two questions.15 The first loss with preservation of other B cell lineage features in patients with large B cell lymphoma who relapsed post– DNA sequences of the mutated immu- concerned viability. The FDA has set axi-cel [ASH abstract 203]. Blood. 2019;134(suppl 1). noglobulin heavy chain (IgH) gene for a viability for tisagenlecleucel to be 8. ClinicalTrials.gov. A phase 2 multicenter study of axi- patient-specific lymphoma. For this in specification of 80%,16,17 although cabtagene ciloleucel in subjects with relapsed/refractory indolent non-Hodgkin lymphoma (ZUMA-5). https:// assessment, it is necessary to sequence patients in the clinical trial had a clinicaltrials.gov/ct2/show/NCT03105336. Identifier: IgH from an original tumor biopsy T-cell viability of 70% or higher.3 The NCT03105336. Accessed February 13, 2020. 9. ClinicalTrials.gov. Efficacy and safety of axicabta- and then measure it in the blood at analysis by Dr Bachanova showed that gene ciloleucel as first-line therapy in participants with serial time points. Patients who had there was no difference in outcomes high-risk large B-cell lymphoma (ZUMA-12). https:// a high level of this gene before treat- for patients who had cells that were clinicaltrials.gov/ct2/show/NCT03761056. Identifier: NCT03761056. Accessed February 13, 2020. ment were less likely to respond. The 70% viable vs 80% viable. In the 10. Jaglowski S, Huan Z, Zhang Y, et al. Tisagenlecleu- analysis by Dr Frank showed that real world, patients who have a T-cell cel chimeric antigen receptor (CAR) T-cell therapy for adults with diffuse large B-cell lymphoma (DLBCL): patients who are MRD-negative at day viability of less than 80% receive real world experience from the Center for International 28—the typical time of the first PET treatment under an expanded access Blood & Marrow Transplant Research (CIBMTR) cellular therapy (CT) registry [ASH abstract 766]. Blood. assessment—were much more likely protocol and not under commercial 2019;134(suppl 1). to maintain a response and had better settings. However, this analysis sup- 11. Lee DW, Santomasso BD, Locke FL, et al. ASTCT progression-free survival and overall ports expansion of the FDA label to consensus grading for cytokine release syndrome and neurologic toxicity associated with immune effector cells. survival compared with patients who encompass T-cell viability of 70% or Biol Blood Marrow Transplant. 2019;25(4):625-638. were MRD-positive.4 MRD negativity greater. The analysis also examined the 12. Pasquini MC, Locke FL, Herrera AF, et al. Post-marketing use outcomes of an anti-CD19 chimeric antigen at this time was slightly superior to posi- CD4 to CD8 T-cell composition of receptor (CAR) T cell therapy, axicabtagene ciloleucel tron emission tomography in predicting the product that was infused into the (axi-cel), for the treatment of large B cell lymphoma improved long-term outcome. patients. There was no ratio that pre- (LBCL) in the United States (US) [ASH abstract 764]. Blood. 2019;134(suppl 1). A study presented by Dr Brian dicted for improved or decreased effi- 13. Jain MD, Jacobs MT, Nastoupil L, et al. Charac- Sworder used a slightly different tech- cacy. However, patients who received teristics and outcomes of patients receiving bridging therapy while awaiting manufacture of standard of nology known as cancer personalized a product with a higher proportion of care axicabtagene ciloleucel CD19 chimeric antigen profiling by deep sequencing (CAPP- CD4 CAR T cells had increased rates receptor (CAR) T-cell therapy for relapsed/refractory Seq), which measures circulating tumor of grade 3 or higher CRS. large B-cell lymphoma: results from the US Lymphoma CAR-T Consortium [ASH abstract 245]. Blood. DNA by identifying DNA sequences 2019;134(suppl 1). for a prespecified set of highly mutated Disclosure 14. Kuhnl A, Roddie C, Martinez-Cibrian N, et al. Real- 5 world data of high-grade lymphoma patients treated genes in large cell lymphoma. As Dr Jacobson is a consultant for Kite, with CD19 CAR-T in England [ASH abstract 767]. with the previous study, this analysis Novartis, Celgene, BMS, Precision Bio- Blood. 2019;134(suppl 1). sciences, Humanigen, and Nkarta. She 15. Bachanova V, Tam CS, Borchmann P, et al. Impact of showed that higher pretreatment cir- tisagenlecleucel chimeric antigen receptor T-cell therapy culating tumor DNA levels correlated has received research funding from Pfizer. product attributes on clinical outcomes in adults with with increased tumor burden and a relapsed or refractory diffuse large B-cell lymphoma [ASH abstract 242]. Blood. 2019;134(suppl 1). lower likelihood of a durable response. References 16. Yescarta [package insert]. Santa Monica, CA: Kite; Outcome was worse in patients with 1. Abramson JS, Palomba L, Gordon LI, et al. Pivotal 2019. safety and efficacy results from TRANSCEND NHL 17. Kymriah [package insert]. East Hanover, NJ: Novar- detectable circulating tumor DNA at 001, a multicenter phase 1 study of lisocabtagene mara- tis; 2018. day 28. An interesting aspect about this leucel (liso-cel) in relapsed/refractory (R/R) large B cell

Clinical Advances in Hematology & Oncology Volume 18, Issue 2, Supplement 7 February 2020 23