Abstract 5571: Disruption of cell-intrinsic checkpoint regulator CTLA-4 in CD19 directed CAR T cells provides clinical efficacy in CLL patients
Authors: Agarwal Sangya , Gomez Angela Aznar , Da Tong , Kuramitsu Shunichiro , Kong Weimin , Ravikumar Pranali , Gohil Mercy , Davis Megan M. , Fraietta Joseph A. , Plesa Gabriela , Porter David L. , Young Regina M. , June Carl H. 
Published: June 2022

Abstract
The field of cancer immunotherapy has led to successful treatments such as monoclonal antibodies (MAb), inhibitory receptor (IR) blockade, and adoptive cell transfer (ACT). ACT modified to express chimeric antigen receptors (CARs) can redirect T cells to tumor antigens and has shown remarkable clinical efficacy in patients with relapse and refractory leukemia and lymphoma. 90% of pediatric patients with acute lymphoblastic leukemia (ALL) respond to CD19 CAR T cell therapy (CAR T19), although only 26-35% of patients with chronic lymphocytic leukemia (CLL) show complete responses (CR). It is unclear why responses are less frequent in CLL compared to ALL. The heavy pre-treatment received by CLL patients likely contributes to lower response rates with CAR T cell therapy, and disease progression is worsened due to profound T cell defects characterized by elevated expression of IRs such as PD-1 and CTLA-4. Fraietta et. al. assessed CLL patient apheresis samples and CART19 products to show that CR was associated with elevated levels of CD27+PD1-CD8+ T memory cells whereas the non-responders (NR) showed an exhausted phenotype with high levels of multiple IRs. We studied 14 patients with advanced, heavily pretreated CLL who received at least one dose of CART19. Patients with CRs exhibited high in vivo expansion and persistence of infused CAR T cells, as opposed to NR’s. Importantly, at peak levels of in vivo CAR expansion, NR’s had elevated levels of CTLA-4 expression which correlated with poor CLL patient responses to CART19 therapy. In summary, these data suggest that eliminating CTLA-4 mediated T cell inhibition can be clinically beneficial. Thus, we tested the hypothesis that disruption of CTLA4 would improve CAR T cell efficacy in CLL based on numerous observations. Our data demonstrate that knockout (KO) of CTLA-4 in T cells from healthy donors using CRISPR Cas9 technology leads to maintenance of surface CAR expression and higher tumor clearance in a chronic re-stimulation model using CART19 cells against NALM6 tumor cells. In xenograft models of ALL, KO of CTLA-4 increases the anti-tumor efficacy of CART19 cells. We then performed CTLA4 disruption in T cells banked from CLL patients that did not respond to CAR T cell therapy to determine whether dysfunctional CAR T infusion products can be invigorated by CTLA-4 KO. In both chronic re-stimulation model and xenograft models of NALM6, CTLA-4 KO CD19 CAR T cells from CLL patients maintained surface CAR expression, exhibited enhanced tumor clearance, and higher survival rates relative to subject-matched unedited CAR T cells. Thus, suggesting that CTLA4 disrupted CAR T cell products may enhance the success rate of CAR T cell therapy for CLL patients. This technology can be feasibly expanded to other tumor indications to increase the overall efficacy of CAR T cells. These IND-enabling studies will support the translation of this therapy to the clinic.
Citation Format: Sangya Agarwal, Angela Aznar Gomez, Tong Da, Shunichiro Kuramitsu, Weimin Kong, Pranali Ravikumar, Mercy Gohil, Megan M. Davis, Joseph A. Fraietta, Gabriela Plesa, David L. Porter, Regina M. Young, Carl H. June. Disruption of cell-intrinsic checkpoint regulator CTLA-4 in CD19 directed CAR T cells provides clinical efficacy in CLL patients [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 5571.