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Two cases of severe pulmonary toxicity from highly active mesothelin-directed CAR T cells.

ABSTRACT: Multiple clinical studies have treated mesothelin (MSLN)-positive solid tumors by administering MSLN-directed chimeric antigen receptor (CAR) T cells. Although these products are generally safe, efficacy is limited. Therefore, we generated and characterized a potent, fully human anti-MSLN CAR. In a phase 1 dose-escalation study of patients with solid tumors, we observed two cases of severe pulmonary toxicity following intravenous infusion of this product in the high-dose cohort (1-3 × 10⁸ T cells per m²). Both patients demonstrated progressive hypoxemia within 48 h of infusion with clinical and laboratory findings consistent with cytokine release syndrome. One patient ultimately progressed to grade 5 respiratory failure. An autopsy revealed acute lung injury, extensive T cell infiltration, and accumulation of CAR T cells in the lungs. RNA and protein detection techniques confirmed low levels of MSLN expression by benign pulmonary epithelial cells in affected lung and lung samples obtained from other inflammatory or fibrotic conditions, indicating that pulmonary pneumocyte and not pleural expression of mesothelin may lead to dose-limiting toxicity. We suggest patient enrollment criteria and dosing regimens of MSLN-directed therapies consider the possibility of dynamic expression of mesothelin in benign lung with a special concern for patients with underlying inflammatory or fibrotic conditions.

SUBMITTER: Haas AR

PROVIDER: S-EPMC10422001 | biostudies-literature | 2023 Aug

REPOSITORIES: biostudies-literature

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Two cases of severe pulmonary toxicity from highly active mesothelin-directed CAR T cells.

Haas Andrew R AR Golden Ryan J RJ Litzky Leslie A LA Engels Boris B Zhao Linlin L Xu Fangmin F Taraszka John A JA Ramones Melissa M Granda Brian B Chang Wan-Jung WJ Jadlowsky Julie J Shea Kim-Marie KM Runkle Adam A Chew Anne A Dowd Emily E Gonzalez Vanessa V Chen Fang F Liu Xiaojun X Fang Chongyun C Jiang Shuguang S Davis Megan M MM Sheppard Neil C NC Zhao Yangbing Y Fraietta Joseph A JA Lacey Simon F SF Plesa Gabriela G Melenhorst J Joseph JJ Mansfield Keith K Brogdon Jennifer L JL Young Regina M RM Albelda Steven M SM June Carl H CH Tanyi Janos L JL

Molecular therapy : the journal of the American Society of Gene Therapy 20230612 8

Multiple clinical studies have treated mesothelin (MSLN)-positive solid tumors by administering MSLN-directed chimeric antigen receptor (CAR) T cells. Although these products are generally safe, efficacy is limited. Therefore, we generated and characterized a potent, fully human anti-MSLN CAR. In a phase 1 dose-escalation study of patients with solid tumors, we observed two cases of severe pulmonary toxicity following intravenous infusion of this product in the high-dose cohort (1-3 × 10<sup>8</ ...[more]

PMID: 37312454

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Project description:BackgroundColorectal cancer (CRC) is the third most common cancer worldwide, with highly variable prognosis and response to treatment. A large subset of patients does not respond to standard treatments or develops resistance. As an alternative, adoptive immunotherapy based on chimeric antigen receptor (CAR)-transduced immune cells has been proposed, however with significant adverse events. We therefore evaluated alternative CAR targets already tested in other tumour types and employed the natural killer cell line NK-92 for CAR transduction because of its more favourable toxicity profile.MethodsAs an alternative antigen, we considered mesothelin (MSLN), the most represented target in CAR-based clinical studies for solid tumours. MSLN RNA expression was analysed in large series of CRC tumours (n = 640) and cell lines (n = 150), to evaluate its distribution and to identify MSLN-overexpressing models. NK-92 cells were transduced with anti-MSLN CAR, and subsequently sorted and cloned. Activity of CAR-NK-92 cells against target-expressing ovarian and CRC cells was assessed in vitro and in vivo. Statistical significance of efficacy was evaluated by t-test and log-rank test.ResultsLarge-scale expression analysis highlighted that about 10% of CRCs overexpress MSLN at levels comparable to those of ovarian cancer, a typical target of MSLN-CAR-based therapy. Intriguingly, MSLN overexpression is more frequent in poor prognosis and KRAS/BRAF-mutant CRC. Lentiviral transduction of NK-92 cells with the MSLN-CAR, followed by sorting and cloning, led to the identification of one clone, MSLN.CAR.NK-92.cl45, stably expressing the CAR and retaining the NK phenotype. As expected, the clone demonstrated significant in vitro and in vivo activity against ovarian cancer cells. When repurposed against models of CRC expressing high MSLN levels, it displayed comparable efficacy, both in vitro and in vivo. Specificity of the clone was confirmed by the absence of activity on control models with low or absent MSLN.ConclusionsOur results provide preclinical evidence that a subset of colorectal cancers expressing high mesothelin levels can be effectively targeted by MSLN-CAR-based immunotherapy. The potential therapeutic impact of these findings is enhanced by the fact that frequently MSLN-overexpressing CRCs display worse prognosis and resistance to standard care.

Dataset Information

Two cases of severe pulmonary toxicity from highly active mesothelin-directed CAR T cells.

Publications

Two cases of severe pulmonary toxicity from highly active mesothelin-directed CAR T cells.

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