Acknowledgement: Medical writing assistance was provided by James Gilbart of Touch Medical Media.
Support: This Insight article was supported by Miltenyi Biotec.
Chimeric antigen receptor (CAR) T cells are engineered to bind to tumour antigens and are providing us with a new option for the treatment of B cell malignancies that are non-responsive to standard therapies.1–4 Because of the science behind this versatile new technology, it may also have great potential in the treatment of a wider range of cancers. This hope is based upon the initial results seen from small studies and case reports that seem to indicate that CAR T cell treatment can also be effective in relapsed lymphoblastic leukaemia, multiple myeloma and lymphoma.5–8 Patients who had received CAR T cell therapies were found to have not only high response rates but also high rates of complete remission. CAR T cells also have potential in the treatment of solid tumours including those occurring in the breast, colon and lung cancers; although, overcoming the tumour micro-environment in such cancers is more challenging.9 The success of this treatment in patients with haematological malignancies, who would otherwise have had poor prognoses, has stimulated considerable and significant interest in the production of CAR T cells. The compelling results of early clinical trials have driven investment interest and the global CAR T cell market is currently estimated at approximately US$72 million, but is projected to increase to nearly US$350 billion in the next decade.10
Until recently, the only means for most hospitals and clinics to obtain CAR T cells was via outsourced production at a small number of specialised facilities or to build their own production facilities at a very high cost. The methods used at such centers are expensive and labour intensive involving many manual manipulations during the cell selection, washing, transfection/transduction and expansion steps under strict clean-room conditions.11 The manufacturing time is generally 5–10 days, but collection to infusion times can range from 2–4 weeks, depending on the patient’s clinical status and chemotherapy conditioning regimen.12,13
CAR T cell therapies are typically not a first-line treatment but rather a last resort after all other treatments have failed. Patients needing CAR T cell therapy tend to be very sick and the long waiting period, required to have cells prepared at a remote facility and flown back to them for treatment, can be detrimental to their condition. The high cost of currently available commercial CAR T cell therapeutic products complicates the funding of CAR T cell therapies. Kymriah® (tisagenlecleucel; Novartis Pharmaceuticals Corporation, Basel, Switzerland), a treatment for B cell acute lymphoblastic leukaemia will cost $475,000 per patient and Yescarta® (axicabtagene ciloleucel; Kite, a Gilead company, Santa Monica, CA, US), for diffuse large B-cell lymphoma treatment, will cost $373,000 per patient.14,15 Both of these therapies were recently approved by the US Food and Drug Administration (FDA) in these indications,16,17 and more recently Kymriah has been approved for the treatment of diffuse large B-cell lymphoma too.18 With such high prices, many health insurance companies are carefully considering their reimbursement plans.19,20 These costs probably restrict the availability of the treatment for many despite the fact that Centers for Medicaid and Medicare Services and other health maintenance organisations have agreed to fund some products.21 Some oncologists consider the prices to be cost effective due to the efficacy of the treatment and the savings with respect to alternative treatments and hospitalisations that would otherwise be needed.10,19 One of the main contributors to the high cost is the complex manufacturing process which requires a large manufacturing facility with sophisticated equipment and skilled technicians to operate the labour-intensive processes.
Figure 1: The production process of chimeric antigen receptor T cells in a commercially available all-in-one instrument
Reproduced with permission from: Miltenyi Biotech
Figure 2: The CliniMACS Prodigy® all-in-one instrument for the automated production of chimeric antigen receptor T cells
Reproduced with permission from: Miltenyi Biotec
The bottle-neck in CAR T cell supply has been removed or dramatically reduced with the recent development of an automated all-in-one system designed for in-house production at treatment centers. The CliniMACS Prodigy® (Miltenyi Biotec, Bergisch Gladbach, Germany) is a commercially available, fully closed, good manufacturing practice-compliant device that simplifies CAR T cell production (Figures 1 and 2), which has been used without a clean-room manufacturing facility.11,22,23 Dr Hans-Peter Kiem, an oncologist at the University of Washington, Seattle, WA, US, described this development as ‘truly transformative’. He said that this instrument reduces the space necessary for CAR T cell production from 500 ft2 to about 5 ft2 and the number of associated full time staff from between five and ten, to one or two.24 The instrument has been described as ‘an all-in-one system about the size of an espresso machine that can handle every step of the CAR T cell manufacturing process’.25
In the fully automated CAR T cell production process within the CliniMACS Prodigy instrument, donor T cells are initially enriched magnetically. These cells are then activated using a nanomatrix conjugated to recombinant humanised CD3 and CD28 agonists and then incubated with a viral vector that encodes the CAR (e.g., CD19). This process is followed by expansion in which the CAR T cells are cultured and expanded to the desired number of cells, taking from 6–10 days. Finally, the cells are washed and concentrated for use in down-stream applications. The entire process takes 7–10 days11,13,22 and is carried out in a single-use, closed, sterile tubing set. During production the products are monitored by obtaining in-process control samples using sample pouches incorporated into the tubing set. No further manual intervention is required until the CAR T cells are available for use. The entire process is standardised, eliminating user-to-user variability which is an issue with other non-automated production methods.
The CliniMACS Prodigy System provides a new and highly competitive alternative solution to outsourced CAR T cell production. This instrument is highly advanced and is the first to automate the complete CAR T cell production process. It is the only self-contained system on the market and offers manufacturers new options that had not previously existed. These options provide many significant cost-saving benefits. Other comparable systems are unlikely to emerge within the next 3–4 years. At present, several hundred instruments are in operation at treatment centers in multiple countries and with rising demand this number will increase dramatically.
Studies comparing the CliniMACS Prodigy with existing procedures found that cell purity, transduction efficiencies, phenotype and function of CAR T cells with CD19 and CD20 antigen receptors were comparable with existing procedures and T cell yields were sufficient for anticipated therapeutic dosing.11,26,27 In addition, the process was found to be robust and reproducible. The CliniMACS Prodigy has also been approved in the EU for the commercial manufacture of Zalmoxis® (MolMed, Milan, Italy), which is a licensed patient-specific cell therapy for the treatment of adults with leukaemia and other high-risk haematological conditions.28 Numerous ongoing small and medium-scale clinical studies are evaluating the use of CAR T cells in the treatment of haematological cancers, particularly leukaemia and lymphoma.2,29,30 Some of these studies are using CAR T cells produced with the CliniMACS Prodigy System. An example is a phase I/II single group study that is currently recruiting patients (planned N=18) to evaluate the use of CD19 CAR T cells (in addition to fludarabine, cyclophosphamide and tocilizumab) in the treatment of relapsed or refractory acute lymphoblastic leukaemia (NCT03467256).31 An additional example is a phase I non-randomised study (planned N=38) that aims to evaluate the use of expanded gamma delta T cell infusion following hematopoietic stem cell transplantation and post-transplant cyclophosphamide in patients with acute or chronic myeloid leukaemia, acute lymphoblastic leukaemia, or myelodysplastic syndromes (NCT03533816).32 Another example is a phase I/II single group, open-label study (planned N=35) in which adolescent and young adult patients with relapsed or refractory acute lymphoblastic leukaemia are to be treated with a lympho-depleting course of cyclophosphamide, fludarabine and Mesna followed by a single infusion of CD 19-specific CAR T cells (NCT03573700).33
The CliniMACS Prodigy System is now in use producing cells for the active treatment of patients. This is emphasised by ongoing CAR T cell studies that are adopting the CliniMACS Prodigy CAR T cell production process for the use against hematological malignancies. A preliminary finding from a small case study at the Medical College of Wisconsin reported a 52-year-old male patient with mantle cell lymphoma that kept returning despite receiving chemotherapy, stem cell transplants, medications and participating in other clinical trials. The patient received a CAR T cell dose in the clinical trial and 6 weeks later the cancer was no longer detectable. While long-term follow-up is needed, this result was described as ‘phenomenal’ by oncologist Dr Nirav Shah, the principal investigator on the trial and added that ‘there is amazing potential here for the future of cancer treatment’.34
Although CAR T cell treatment has been associated with some safety/toxicity concerns including cytokine release syndrome and neurological toxicity, the management of this therapy has improved and physicians are more aware of the need for careful monitoring of signs and treating symptoms before they become life-threatening complications.35
CAR T cell treatment is versatile and has potential use in the treatment of solid tumours and in the treatment of many other diseases including infections such as human immunodeficiency virus (HIV).13 The use of an automated CAR T cell production instrument may have the potential to ‘democratise cell therapy’36 and bring this approach within the reach of many more hospitals and clinics. In the near future, these instruments are likely to increase in numbers providing greater access to an effective treatment in unresponsive blood malignancies with the potential to substantially reduce costs and treatment delays.
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