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CAR T-Cell Therapy: A Healthcare Professional's Guide - KTE-C19 for Acute Lymphoblastic Leukemia

Medically reviewed by Leigh Ann Anderson, PharmD. Last updated on Oct 1, 2018.

What is CAR T-Cell Therapy?

Chimeric antigen receptor (CAR) T-cell therapy is a newly approved cell therapy, the latest personalized treatment engineered to actively seek out and destroy cancer. Recently, an FDA Advisory Committee gave their stamp of approval on this marvel of biomedical engineering.

The FDA made a final approval for Kymriah (tisagenlecleucel) from Novartis on August 30, 2017 for certain pediatric and young adult patients with a form of acute lymphoblastic leukemia (ALL). In May 2018, Kymriah was also approved for relapsed or refractory large b-cell lymphoma in adults after two or more therapies.

CAR T-cell therapy is not a "drug" in the usual sense; it is considered gene therapy, some call it a "living" drug. In CAR T, a patient's T cells (white blood cells) are separated out and engineered to express a chimeric antigen receptor (CAR) to target the tumor antigen. The tumor antigen, such as C19, is a protein on the surface of B-cell lymphomas and leukemias.

The re-engineered CAR T-cell is then infused back into the patient and redirects the T cell CAR receptor to find the cancer antigen and kill the cancer cell. It sounds like science fiction, but the National Cancer Institute, pharmaceutical industry, and major research universities are all involved.

For a brief introductory review of the tumor and CAR T-cell action, see these related slideshows:

CAR T-Cell FDA Approval: Status Update

In addition to the prior approval of Kymriah, Kite Pharma/Gilead's Yescarta (axicabtagene ciloleucel) was approved on October 18, 2017 for the treatment of adult patients with relapsed or refractory large B-cell lymphoma after two or more lines of systemic therapy. Data from Kite's ZUMA-1 trial supported the new drug application (NDA).

Clinical trial results with Yescarta were remarkable in refractory leukemias and lymphomas, leading to sustained, high rates of remission in a large percentage of treated patients. In studies, the complete remission rate after treatment with Yescarta was 51 percent.

However, treatments are not without serious risks and the manufacturing process is complicated and lengthy. Side effects, which can be difficult for the patient, can be managed by physicians in most cases. But it's important to remember when thinking about risks - these patients usually have limited or no other treatment options.

Learn More: CAR T-Cell Therapy: A Healthcare Professional's Guide - Adverse Events

What is Yescarta ?

Axicabtagene ciloleucel (Yescarta) from Kite Pharma/Gilead, initially developed at the National Cancer Institute (NCI), is an anti-CD19 CAR-T therapy. Yescarta is under study or approved for various relapsed and refractory hematologic malignancies, including:

Yescarta Approval for Diffuse Large B-cell Lymphoma

Approximately 72,000 new cases of non-Hodgkin lymphoma (NHL) are diagnosed in the U.S. each year, and diffuse large B-cell lymphoma (DLBCL) represents approximately 33% of newly diagnosed cases.

Yescarta is approved for use in adult patients with large B-cell lymphoma after at least two other kinds of treatment failed. Subtypes of large B-cell lymphoma include:

  • diffuse large B-cell lymphoma (DLBCL)
  • primary mediastinal large B-cell lymphoma
  • high grade B-cell lymphoma
  • DLBCL arising from follicular lymphoma

Yescarta is not indicated for the treatment of patients with primary central nervous system lymphoma.

Diffuse large B-cell lymphoma (DLBCL) is the most common type of NHL in adults. NHLs are cancers that begin in certain cells of the immune system and can be either fast-growing (aggressive) or slow-growing.

The European Union submission of axicabtagene ciloleucel is expected in the 3rd quarter of 2017.

Learn More: KTE-C19 Studies for Advanced non-Hodgkin Lymphoma

Learn More: CAR T-Cell Therapy: A Healthcare Professional's Guide - Manufacturing

Use of Yescarta in Acute Lymphoblastic Leukemia

Yescarta (axicabtagene ciloleucel) is also under late Phase 1 research for treatment of refractory or relapsed acute lymphoblastic leukemia (r/r ALL).

ALL is a blood and bone marrow cancer that results in a multiplication of immature lymphocytes that are ineffective in fighting infections. Lymphoblasts crowd the bone marrow and prevent normal blood cells from forming. Healthy red blood cells from the bone marrow cannot be formed, leading to anemia.

There are several approaches to treatment of ALL:

  • Blood transfusions
  • Chemotherapy, targeted cancer therapy
  • Radiation treatment
  • Stem cell transplant

In patients who are refractory to these standard treatments or relapse after receiving them, CAR T-cell therapy may offer a last-chance hope for successful treatment.

ZUMA-3 and ZUMA-4 Trials

In addition to the October 2017 approval for Non-Hodgkin lymphoma, Yescarta (axicabtagene ciloleucel) has shown impressive early results in difficult-to-treat patients with ALL. As reported in December 2016, in Phase 1 of the ZUMA-3 and ZUMA-4 trials, 13 patients with r/r ALL were treated with axicabtagene ciloleucel. In ZUMA-3, adults 18 years and older are being evaluated, and in ZUMA-4 pediatric and adolescent patients (ages 2 to 21) are being enrolled.

Preliminary analysis found:

  • 9 of 11 patients (82%) achieved a complete remission or a complete remission with incomplete or partial blood count recovery.
  • All responders (100%) tested negative for minimal residual disease (MRD), meaning low or no cancer cells in circulation, and is correlated with risk of disease relapse in ALL.
  • Manufacturing of KTE-C19 was successful in all 13 patients in a period of 6 to 8 days.

Adverse events of grade 3 or higher included:

  • Cytokine release syndrome (5 of 13 patients, 38%)
  • Neurological events (5 of 13 patients, 38%), which can include events like aphasia, tremor, and seizures.

Two patients died: one in ZUMA-3 from axicabtagene ciloleucel-related cytokine release syndrome (CRS) and one in ZUMA-4 from an unrelated fungal infection. Larger Phase 2 studies in r/r ALL will be ongoing in 2017.

ZUMA-3 Update in Adults

In June 2017 an update to the ZUMA-3 trial in adults with r/r ALL was released. In the Phase 1 trial, 11 patients were treated with KTE-C19 at different target doses.

Reported results included:

  • 73% of patients achieved complete remission, including those with incomplete or partial recovery of bone marrow.
  • Ongoing complete remissions have been observed from 2 months to greater than 7.4 months.
  • No dose-limiting toxicities occurred in the trial.
  • KTE-C19 was successfully manufactured in 6 days. Vein-to-vein time has been reduced to about 17 days. The manufacturer reports this can be further improved by 2 or 3 days.

The company noted that once cell doses are optimized, pivotal Phase 2 research would commence in 2017.

Safety Update in ZUMA-3 for r/r ALL

In the adult population with r/r ALL in ZUMA-3, the safety data included:

  • Grade 3 or higher cytokine release syndrome (CRS) occurred in 3 of 11 patients (27%)
  • Grade 3 or higher neurologic events occurred in 6 of 11 patients (55%)
  • Both of these adverse events were generally reversible.

As previously reported, one patient developed fatal CRS. In order to further improve the safety profile of axicabtagene ciloleucel, ZUMA-3 is also evaluating additional patients who will receive:

  • Tocilizumab (Actemra), an interleukin-6 (IL-6) blocker, within 36 hours post-KTE-C19 infusion
  • A lower dose of cell therapy.

On August 30, 2017 the FDA approved the use of Actemra for the treatment of chimeric antigen receptor (CAR) T cell-induced severe or life-threatening cytokine release syndrome (CRS) in patients two years of age and older.

Finished: CAR T-Cell Therapy: A Healthcare Professional's Guide - KTE-C19 for Acute Lymphoblastic Leukemia

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