CAR T cell

The first chimeric receptors containing portions of an antibody and the T cell receptor were described in 1987 by Yoshihisa Kuwana et al., at Fujita Health University and Kyowa Hakko Kogyo, Co. Ltd., in Japan, and independently in 1989 by Gideon Gross and Zelig Eshhar at the Weizmann Institute in Israel. Originally termed "T-bodies", these early approaches combined an antibody's ability to specifically bind to diverse targets with the constant domains of the TCR-α or TCR-β proteins. In 1991, chimeric receptors containing the intracellular signaling domain of CD3ζ were shown to activate T cell signaling by Arthur Weiss at the University of California, San Francisco. This work prompted CD3ζ intracellular domains to be added to chimeric receptors with antibody-like extracellular domains, commonly single-chain fraction variable (scFv) domains, as well as proteins such as CD4, subsequently termed first generation CARs. A first generation CAR containing a CD4 extracellular domain and a CD3ζ intracellular domain was used in the first clinical trial of chimeric antigen receptor T cells by the biotechnology company Cell Genesys in the mid 1990s, allowing adoptively transferred T cells to target HIV infected cells, although it failed to show any clinical improvement. In the early 2000s, co-stimulatory domains such as CD28 or 4-1BB were added to first generation CAR's CD3ζ intracellular domain. Termed second generation CARs, these constructs showed greater persistence and improved tumor clearance in pre-clinical models. Clinical trials in the early 2010s using second generation CARs targeting CD19, a protein expressed by normal B cells as well as B-cell leukemias and lymphomas, by investigators at the NCI, University of Pennsylvania, and Memorial Sloan Kettering Cancer Center demonstrated the clinical efficacy of CAR T cell therapies and resulted in complete remissions in many heavily pre-treated patients. == Production ==

The first step in the production of CAR T-cells is the isolation of T cells from human blood. CAR T-cells may be manufactured either from the patient's own blood, known as an autologous treatment, or from the blood of a healthy donor, known as an allogeneic treatment. The manufacturing process is the same in both cases; only the choice of initial blood donor is different. First, leukocytes are isolated using a blood cell separator in a process known as leukocyte apheresis. Peripheral blood mononuclear cells (PBMCs) are then separated and collected. The products of leukocyte apheresis are then transferred to a cell-processing center. In the cell processing center, specific T cells are stimulated so that they will actively proliferate and expand to large numbers. To drive their expansion, T cells are typically treated with the cytokine interleukin 2 (IL-2) and anti-CD3 antibodies. Anti-CD3/CD28 antibodies are also used in some protocols. The new gene editing tool CRISPR/Cas9 has recently been used instead of retroviral vectors to integrate the CAR gene into specific sites in the genome. The patient undergoes lymphodepletion chemotherapy prior to the introduction of the engineered CAR T-cells. == Delivery ==

As of March 2019, there were around 364 ongoing clinical trials happening globally involving CAR T cells. The majority of those trials target blood cancers: CAR T therapies account for more than half of all trials for hematological malignancies. followed by BCMA (commonly expressed in multiple myeloma). In 2016, studies began to explore the viability of other antigens, such as CD20. Trials for solid tumors are less dominated by CAR T, with about half of cell therapy-based trials involving other platforms such as NK cells. Adoptive transfer of T cells expressing CARs is a promising anti-cancer therapeutic, because CAR-modified T cells can be engineered to target potentially any tumor associated antigen. Early CAR T cell research has focused on blood cancers. The first approved treatments use CARs that target the antigen CD19, present in B-cell-derived cancers such as acute lymphoblastic leukemia (ALL) and diffuse large B-cell lymphoma (DLBCL). There are also efforts underway to engineer CARs targeting many other blood cancer antigens, including CD30 in refractory Hodgkin lymphoma; CD33, CD123, and FLT3 in acute myeloid leukemia (AML); and BCMA in multiple myeloma. Aside from CD19, CARs targeting the multiple myeloma antigen B-cell maturation antigen (BCMA) have achieved the most clinical success so far. CARs targeting BCMA were initially reported by Robert Carpenter and James Kochenderfer et al. Anti-BCMA CAR T cells have now been tested in many clinical trials, and anti-BCMA CAR T-cell products have been approved by the U.S. Food and Drug Administration. CAR T cells have also been found to be effective in treating glioblastoma. A single infusion is enough to show rapid tumor regression in a matter of days. Solid tumors have presented a more difficult target. Identification of good antigens has been challenging: such antigens must be highly expressed on the majority of cancer cells, but largely absent on normal tissues. A regulatory T cell outfitted with a CAR could confer tolerance to a specific antigen, which could be utilized in organ transplantation or rheumatologic diseases like lupus. It has been investigated as a treatment for ulcerative colitis and rheumatoid arthritis. Clinical trials have launched for systemic sclerosis, myositis and rheumatoid arthritis. == Approved therapies ==

There are serious side effects that result from CAR T-cells being introduced into the body, including cytokine release syndrome and neurotoxicity. Because it is a relatively new treatment, there are few data about the long-term effects of CAR T-cell therapy. There are still concerns about long-term patient survival, as well as pregnancy complications in female patients treated with CAR T-cells. Anaphylaxis may be a side effect, as the CAR is made with a foreign monoclonal antibody, and as a result provokes an immune response. On-target/off-tumor recognition occurs when the CAR T-cell recognizes the correct antigen, but the antigen is expressed on healthy, non-pathogenic tissue. This results in the CAR T-cells attacking non-tumor tissue, such as healthy B cells that express CD19 causing B-cell aplasia. The severity of this adverse effect can vary but the combination of prior immunosuppression, lymphodepleting chemotherapy and on-target effects causing hypogammaglobulinaemia and prolonged cytopenias places patients at increased risk of serious infections. Indeed, the group of Dr. Marco Ruella and others have shown that less intensive lymphodepletion strategies such us bendamustine might reduce CART-related toxicities such as neurotoxicity, cytopenias, and neutropenic fever. Comprehensive dental evaluation and treatment before CAR T-cell therapy is recommended for reducing the risk of oral and systemic infections during the neutropenic phase. There is also the unlikely possibility that the engineered CAR T-cells will themselves become transformed into cancerous cells through insertional mutagenesis, due to the viral vector inserting the CAR gene into a tumor suppressor or oncogene in the host T cell's genome. Some retroviral (RV) vectors carry a lower risk than lentiviral (LV) vectors. However, both have the potential to be oncogenic. Genomic sequencing analysis of CAR insertion sites in T cells has been established for better understanding of CAR T-cell function and persistence in vivo. CRS occurs in almost all patients treated with CAR T-cell therapy; in fact, the presence of CRS is a diagnostic marker that indicates the CAR T-cells are working as intended to kill the cancer cells. Early intervention using tocilizumab was shown to reduce the frequency of severe CRS in multiple studies without affecting the therapeutic effect of the treatment. A novel strategy aimed to ameliorate CRS is based on the simultaneous expression of an artificial non-signaling IL-6 receptor on the surface of CAR T-cells. This construct neutralizes macrophage-derived IL-6 through sequestration, thus decreasing the severity of CRS without interfering with the antitumor capability of the CAR T-cell itself. Immune effector cell-associated neurotoxicity (ICANS) Neurological toxicity is also often associated with CAR T-cell treatment. The underlying mechanism is poorly understood, and may or may not be related to CRS. Clinical manifestations include delirium, the partial loss of the ability to speak coherently while still having the ability to interpret language (expressive aphasia), lowered alertness (obtundation), and seizures. In another clinical trial sponsored by the Fred Hutchinson Cancer Research Center, there was one reported case of irreversible and fatal neurological toxicity 122 days after the administration of CAR T-cells. Hypokinetic movement disorder (parkinsonism, or movement and neurocognitive treatment emergent adverse events) has been observed with BCMA-chimeric antigen receptor (CAR) T-cell treatment for multiple myeloma. == Advantages/benefits ==

Tumor cells have the ability to evolve new mechanisms for evasion of the immune system after its initial response. Some of these methods include downregulating the expression of their Major Histocompatibility Complex, secreting immunosuppressive factors, or altering their antigen expression, limiting the ability of conventional T cells to recognize and kill them. CAR (Chimeric Antigen Receptor) T cells overcome this limitation by recognizing tumor antigens directly through their engineered receptor, therefore bypassing the need for MHC presentation. In addition, CAR T Cell Therapy offers the included advantages of: Higher response rates in refractory cancers, longer term remission because they remain in the body for years, and they are a more personalized treatment approach because they use the body's own T cells. == Chimeric antigen receptor structure ==

Chimeric antigen receptors combine many facets of normal T cell activation into a single protein. They link an extracellular antigen recognition domain to an intracellular signalling domain, which activates the T cell when an antigen is bound. CARs are composed of four regions: an antigen recognition domain, an extracellular hinge region, a transmembrane domain, and an intracellular T cell signaling domain. Antigen recognition domain The antigen recognition domain is exposed to the outside of the cell, in the ectodomain portion of the receptor. It interacts with potential target molecules and is responsible for targeting the CAR T cell to any cell expressing a matching molecule. The antigen recognition domain is typically derived from the variable regions of a monoclonal antibody linked together as a single-chain variable fragment (scFv). These VL and VH regions are selected in advance for their binding ability to the target antigen (such as CD19). The linker between the two chains consists of hydrophilic residues with stretches of glycine and serine in it for flexibility as well as stretches of glutamate and lysine for added solubility. Single domain antibodies (e.g. VH, VHH, VNAR) have been engineered and developed as antigen recognition domains in the CAR format due to their high transduction efficiency in T cells. In addition to antibody fragments, non-antibody-based approaches have also been used to direct CAR specificity, usually taking advantage of ligand/receptor pairs that normally bind to each other. Hinge sequences are often based on membrane-proximal regions from other immune molecules including IgG, CD8, and CD28. Intracellular T cell signaling domain The intracellular T cell signaling domain lies in the receptor's endodomain, inside the cell. Signaling domains from a wide variety of co-stimulatory molecules have been successfully tested, including CD28, CD27, CD134 (OX40), and CD137 (4-1BB).. Moreover, it induces T cells into an anergic state, i.e., non-functional state of lymphocytes upon stimulation with the antigen. • Second- and third-generation CARs: to improve CAR-T cell efficacy, second- and third-generation CARs, additionally including one or two co-stimulatory signaling domains respectively, were developed. In these constructs, the CD3ζ chain from TCR provides T cells with activation signal 1, while co-stimulatory domains provide activation signal 2, which are both necessary for successful activation of CAR-T cells . The incorporation of co-stimulatory domains made it possible to achieve long-term T cell proliferation and expansion, prevent T cells from AICD and anergy, and thus improved in vivo persistence . The most commonly used co-stimulatory domains are CD28 , belonging to B7 family, and CD137 (4-1BB) from TNFR family, which transmits downstream signals through different signaling pathways. As a consequence, CD28- and 4-1BB-based CARs show different signaling kinetics in terms of T cell activation. CD28-CARs promote a rapid and strong T cell expansion, but a shorter effector T cell survival, whereas 4-1BB-CARs are associated with long-term persistence and decreased T cell exhaustion . Preclinical data show the third-generation CARs exhibit improved effector functions and better in vivo persistence as compared to second-generation CARs.. For instance, IL-12 induces CAR-T cell expansion and persistence at the same time that induces a more powerful killing by recruiting other immune cells and modulating the TME . == Research ==

Antigen recognition Although the initial clinical remission rates after CAR T cell therapy in all patients are as high as 90%, long-term survival rates are much lower. The cause is typically the emergence of leukemia cells that do not express CD19 and so evade recognition by the CD19–CAR T cells, a phenomenon known as antigen escape. Multiple mechanisms can be deployed to finely regulate the activity of SUPRA CAR, which limits overactivation. In contrast to the traditional CAR design, SUPRA CAR allows targeting of multiple antigens without further genetic modification of immune cells. In 2026, CART4-34 therapy targeted B cell receptors carrying the gene IGHV4-34 — thought to be involved in immune response and which appears at high levels in tumor cells. In mice models CART4-34 therapy was as effective as CD19 CAR-T therapy at destroying tumor cells in diffuse large B-cell lymphoma. IGHV4-34 gene is rare in healthy cells. The therapy does not target CD19, reducing/eliminating immune system effects. Treatment of antigenically heterogeneous tumors can be achieved by administration of a mixture of the desired antigen-specific adaptors. CAR T function Fourth generation CARs (also known as TRUCKs or armored CARs) further add factors that enhance T cell expansion, persistence, and anti-tumoral activity. This can include cytokines, such is IL-2, IL-5, IL-12 and co-stimulatory ligands. Control mechanisms Adding a synthetic control mechanism to engineered T cells allows doctors to precisely control the persistence or activity of the T cells in the patient's body, with the goal of reducing toxic side effects. The major control techniques trigger T cell death or limit T cell activation, and often regulate the T cells via a separate drug that can be introduced or withheld as needed. ;Suicide genes: Genetically modified T cells are engineered to include one or more genes that can induce apoptosis when activated by an extracellular molecule. Herpes simplex virus thymidine kinase (HSV-TK) and inducible caspase 9 (iCasp9) are two types of suicide genes that have been integrated into CAR T cells. In the iCasp9 system, the suicide gene complex has two elements: a mutated FK506-binding protein with high specificity to the small molecule rimiducid/AP1903, and a gene encoding a pro-domain-deleted human caspase 9. Dosing the patient with rimiducid activates the suicide system, leading to rapid apoptosis of the genetically modified T cells. Although both the HSV-TK and iCasp9 systems demonstrate a noticeable function as a safety switch in clinical trials, some defects limit their application. HSV-TK is virus-derived and may be immunogenic to humans. It is also currently unclear whether the suicide gene strategies will act quickly enough in all situations to halt dangerous off-tumor cytotoxicity. ;Dual-antigen receptor: CAR T cells are engineered to express two tumor-associated antigen receptors at the same time, reducing the likelihood that the T cells will attack non-tumor cells. Dual-antigen receptor CAR T cells have been reported to have less intense side effects. An in vivo study in mice shows that dual-receptor CAR T cells effectively eradicated prostate cancer and achieved complete long-term survival. ;ON-switch and OFF-switch: In this system, CAR T cells can only function in the presence of both tumor antigen and a benign exogenous molecule. To achieve this, the CAR T cell's engineered chimeric antigen receptor is split into two separate proteins that must come together in order to function. The first receptor protein typically contains the extracellular antigen binding domain, while the second protein contains the downstream signaling elements and co-stimulatory molecules (such as CD3ζ and 4-1BB). In the presence of an exogenous molecule (such as a rapamycin analog), the binding and signaling proteins dimerize together, allowing the CAR T cells to attack the tumor. Human EGFR truncated form (hEGFRt) has been used as an OFF-switch for CAR T cells using cetuximab. The anti-CD20/CD3 bispecific molecule shows high specificity to both malignant B cells and cancer cells in mice. FITC is another bifunctional molecule used in this strategy. FITC can redirect and regulate the activity of the FITC-specific CAR T cells toward tumor cells with folate receptors. Manufacturing Due to high costs, Another approach exploits bioinstructive materials. Shortening or eliminating the activation and expansion steps is another cost reduction strategy. Alternative activating domains Recent advancements in CAR T-cell therapy have focused on alternative activating domains to enhance efficacy and overcome resistance in solid tumors. For instance, Toll-like receptor 4 (TLR4) signaling components can be incorporated into CAR constructs to modulate cytokine production and boost T-cell activation and proliferation, leading to enhanced CAR T-cell expansion and persistence. Similarly, the FYN kinase, a member of the Src family kinases involved in T-cell receptor signaling, can be integrated to improve the signaling cascade within CAR T-cells, resulting in better targeting and elimination of cancer cells. Additionally, KIR-based CARs (KIR-CAR), which use the transmembrane and intracellular domains of the activating receptor KIR2DS2 combined with the DAP-12 signaling adaptor, have shown improved T-cell proliferation and antitumor activity. These strategies, including the use of nonconventional costimulatory molecules like MyD88/CD40, highlight the innovative approaches being taken to optimize CAR T-cell therapies for more effective cancer treatments. == Economics ==

The cost of CAR T cell therapies has been criticized, with the initial costs of tisagenlecleucel and axicabtagene ciloleucel at $375,000 and $475,000, respectively. The high cost of CAR T therapies is due to complex cellular manufacturing in specialized good manufacturing practice (GMP) facilities as well as the high level of hospital care necessary after CAR T cells are administered due to risks such as cytokine release syndrome. Manufacturers of CAR T cells have developed alternative payment programs due to the high cost of CAR T therapy, such as by requiring payment only if the CAR T therapy induces a complete remission by a certain time point after treatment. Additionally, CAR T cell therapies are not available worldwide yet. CAR T cell therapies have been approved in China, Australia, Singapore, the United Kingdom, and some European countries. In February 2022 Brazil approved tisagenlecleucel (Kymriah) treatment. As a promising strategy to reduce complexity and cost of CAR T-cell therapy, in vivo CAR T-cell therapy has recently emerged. This approach entails the direct delivery of CAR-encoding genetic material into a patient's T-cells in situ, typically via functionalised viral vectors or targeted nanocarriers, eliminating the necessity for ex vivo cell harvesting, separation, modification, expansion and reinfusion. Various delivery platforms are currently under investigation, including lipid nanoparticles, exosomes, and polymer-based nanocarriers, as well as viral vectors such as lentivirus, retrovirus, and adeno-associated virus (AAV) by universities like the Columbia Initiative in Cell Engineering and Therapy or biotech companies like Interius BioTherapeutics, Umoja Biopharma, or EsoBiotec. Porentially related risks involve challenges with precise T cell targeting, off-tumour on-target (OTOT) toxicities or with sustained CAR expression. However, in vivo CAR T therapy might mitigate some of the associated risks of systemic toxicities of classic ex vivo CAR T therapy like cytokine release syndrome (CRS) or Immune effector cell-associated neurotoxicity (ICANS). Besides an estimated reduction in costs by "an order of magnitude" compared to classic ex vivo CAR therapy, the biggest potential advantage of in vivo CAR T-cell transfection is a reduction of timelines, as 20% of patients die before their CAR T-cell therapy has been produced in the USA. == See also ==