Castro, Januario E

Background: Chimeric Antigen Receptor (CAR) T-cell clinical trials are growing exponentially. Database analysis can help identify scientific trends and generate projections regarding potential approvals before the results of the studies are completed or published. This is particularly interesting in pediatric oncology, where available analyses from repository databases are scarce or not available. Because of that reason, we sought to analyze the clinical trial public records from entries related to CAR T-cell clinical studies in pediatric patients (18 years or younger) uploaded to the clinicaltrials.gov database. Methods: We query the available data from clinicaltrials.gov using the following keywords: “CAR T cell in pediatrics”, “CAR T cell and cancer”, “chimeric antigen receptor”, “CAR T AND tumor antigen”, 'CAR T cell antigens“, ”Tumor antigens targeted by CAR T cells“, ”engineered T cells“, ”modified T cell“, ”CAR T cells in Cancer“, ”CAR T cell therapy“, ”CAR T cell therapy AND Cancer“ (data cut off July-2023). The data were tabulated, and the trials that did not meet the search criteria were excluded manually. Data cleansing was performed using published scientific data, web search-based information, and patent databases. Results: We found 4297 results in the Clinicaltrials.gov platform; we excluded 3978 clinical trials that did not involve the pediatric population (<18 years) or CAR T-cell intervention. The final analysis included 319 clinical trials posted on the clinicaltrials.gov website by the cut-off date. 207 (64.9%) were conducted in China, 74 (23.2%) in the US, and 21 (6.5%) in Europe. Most CAR T-cell trials focused on hematological cancer (89%), followed by non-CNS solid tumors 8%, and CNS tumors 3%. The most frequent targets were CD19 (46%), CD7 (7%), followed by GD2, CD22, CD123, CD19 + CD22 and CD30. Most clinical trials did not report the construct generation used in their CAR T cell product (58%). Among the trials with that information, second-generation constructs (2G) were used in 32% of the studies, followed by 3G and 4G constructs (5% of studies each). Most clinical trials were in early stages of development, Phase 1 or 2 (75%). We observed a continuous increase in the number of clinical trials registered yearly, except for a small reduction in 2022 and 2021, probably related to COVID restrictions and challenges. Overall, the general trend predicts at least a 50% yearly increase in registered studies ( Figure 1). Similarly, to what is observed in adult clinical trials, the most common signaling domains are 2G CAR constructs expressing either CD28 or 4-1BB as costimulatory domains. Among those, 4-1BB being is the most popular choice. Conclusion: Our findings indicate a growing interest in the clinical development of CAR T-cell therapies applied to pediatric oncology. Most of these studies are in early phase I and II and focus primarily on hematological cancers using second-generation constructs targeting CD19. The is a steady increase in the number of studies registered each year that predicts future FDA approvals using CAR T-cell products.

Keywords: Chimeric Antigen Receptor T cell, Pharmacoeconomic, Pediatric, Clinical Trials With the success of Chimeric Antigen Receptor (CAR) T-cell therapy in the pediatric population, new clinical trials have surged worldwide. To date, no previous study has analyzed the effect of socioeconomic factors on the development of clinical trials for CAR T-cells in the pediatric population. In recent years new countries and emerging economies have contributed significantly to the development of CAR T-cell clinical trials. A better understanding of the socioeconomic factors that influenced these trends will facilitate the future development of this cellular therapy field. To assess the impact of socioeconomic factors related to the development of clinical trials on CAR T-cell therapies in the pediatric population, we analyzed data entries from clinical trials registered to the Clinicaltrials.gov database. To query the information, we used the following keywords “(leukemia OR cancer OR lymphoma OR malignancies OR tumor OR solid tumor) AND (CAR OR chimeric antigen receptor OR CAR T-cell OR adoptive immunotherapy OR immune effector OR cellular therapy) AND (Child)”. In addition, we used different filters that allowed the selection of studies that focused on patients 18 years of age and younger. Data corresponding to entries with a data cut-off of July-2023 were included. In addition, we use the World Bank country's macroeconomic database (January 1 st, 2009 to December 31 st, 2022). We found 4,297 results in the Clinicaltrials.gov platform; we excluded 3,978 clinical trials that did not involve the pediatric population (≤18 years) or CAR T-cell intervention. There were 319 clinical trials included, sponsored in 19 countries, as shown in Figure A. Of those studies, 207 (64.9%) were conducted in China, 74 (23.2%) in the U.S., and 21 (6.5%) in Europe. Not surprisingly, the number of clinical trials is strictly proportional to each country's Gross Domestic Product (GDP) and Research and Development (R&D) expenditure, as shown in Figure B. Pearsons' coefficient between GDP and the number of trials registered per country is 0.8 (p-value < 0.001); similarly, Pearsons's coefficient between R&D expenditure and the number of problems reported per country is 0.64 (p-value < 0.004). The United States and China are developing 88% of the Clinical trials, and 96% of the clinical trials occur in countries ranked in the top 10 highest GDP. Our database analysis shows a notable disparity in the countries leading cutting-edge research in CAR T-cell therapy for pediatric oncology. The primary locations for these clinical studies are countries ranked in the top 10 in terms of GDP, with China and the USA being the main contributors. Access to clinical trials plays a crucial role in improving cancer patients' outcomes, and this disparity in the development of cellular therapies is likely to impact children from middle and low-GDP countries significantly. Urgent strategies are required to address this issue and ensure more equitable access to advanced technologies and clinical trials in cellular therapy for pediatric cancers. These strategies should become a high priority for national and international health departments and organizations in the coming years. By promoting more comprehensive clinical trial access and collaboration, we can work towards reducing these disparities and providing better treatment options for all children facing pediatric cancer.

Introduction: Chimeric antigen receptor T-cell therapy (CAR-T) has revolutionized the treatment of non-Hodgkin lymphoma (NHL). Despite having an increased risk of NHL, patients with pre-existing autoimmune disease (AID) were excluded from pivotal CAR-T trials due to concerns that CAR-T may exacerbate AID. As a result, there are limited data on the safety and efficacy of CAR-T for NHL in patients with AID. Interestingly, there is also growing evidence that CAR-T can be therapeutically effective for AID, such as in the treatment of systemic lupus erythematosus (SLE). As CAR-T utilization for NHL increases, it is essential to characterize the safety and efficacy of this potentially curative therapy in patients with AID. This study aimed to evaluate the impact of AID on outcomes in patients treated with commercial CD19-targeted CAR-T for NHL. Methods: Following Institutional Review Board approval, we conducted a retrospective analysis of all patients who were treated with commercial CD19-targeted CAR-T for NHL and had a pre-existing AID across the Mayo Clinic Enterprise (Arizona, Florida, and Minnesota) between January 2018 and May 2023. Variables collected included age, gender, NHL type, AID type, and CAR-T product. Efficacy outcomes, including response rates at 6 and 12 months after CAR-T, were collected. Toxicities, including cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS), were collected and analyzed. Our chart review for AID included SLE, sarcoidosis, ulcerative colitis, celiac disease, pernicious anemia, Crohn's disease, psoriasis, Sjogren's syndrome, hypothyroidism (Hashimoto's disease), hyperthyroidism (Graves' disease), rheumatoid arthritis (RA), vasculitis, scleroderma, and mixed connective tissue disease (MCTD). Results: A total of 235 patients who received commercial CD19-targeted CAR-T for NHL across the Mayo Clinic Enterprise were identified (Table 1). Of these 235 patients, 27 had a pre-existing AID and 208 did not. The median age was 66 years (range 39-81) for patients with AID and 59 years (range 18-88) for patients without AID. Over half of the patients were male (59% of patients with AID and 51% of patients without AID). The most common NHL type was diffuse large B cell lymphoma (41% of patients with AID and 56% of patients without AID). Most patients received axicabtagene ciloleucel (85% of patients with AID and 84% of patients without AID). The most common AID was hypothyroidism (81%, n=22), although other conditions were also identified, including RA (11%, n=3), SLE (4%, n=1), pulmonary sarcoidosis (4%, n=1), psoriasis (4%, n=1), and MCTD (4%, n=1). Two patients had more than one AID. Median follow-up was 18 months (range 1-36) for patients with AID and 14 months (range 2-49) for patients without AID. Six months after CAR-T, the complete response (CR) rate was 77.2% and 45.1% in patients with AID and without AID, respectively (p=0.0042). Twelve months after CAR-T, the CR rate was 50% and 31.4% in patients with AID and without AID, respectively (p=0.0801). CRS of any grade occurred in 78% and 88% of patients with and without AID, respectively. ICANS of any grade occurred in 41% and 54% of patients with and without AID, respectively. Conclusion: AID did not appear to adversely impact the safety or efficacy of CAR-T for NHL. Limitations of our study include the small number of patients with AID and the fact that the most common AID was hypothyroidism. Larger studies are warranted to confirm these findings. Additional data are needed to characterize the impact of CAR-T for NHL on AID outcomes and to describe the effect of disease-modifying antirheumatic drugs on NHL outcomes after CAR-T.

Usually used in emergency settings, bedside sonographic measurement of optic nerve sheath diameter can aid in diagnosing elevated intracranial pressure. We report a case of a 26-year-old male hospitalized for CAR T-cell therapy with Axicabtagene Ciloleucel for treatment of relapsed diffuse large B-cell lymphoma, who developed progressive symptoms of immune effector cell-associated neurotoxicity syndrome. Fundoscopic examination suggested the presence of blurred optic disc margins. Bedside ocular ultrasound revealed wide optic nerve sheath diameters and bulging optic discs bilaterally. The patient had a ventriculostomy placed for monitoring and received treatment with steroids and mannitol, as well as tocilizumab. After 7 days in the ICU, the patient recovered with no evidence of long-term neurological deficits.