CD19 chimeric antigen receptor (CAR)-T cell therapy has achieved high response rates in patients with B-cell lymphoma. However, treatment failure and relapse can be attributable to CAR-T cell dysfunction and the immunosuppression of the tumor microenvironment. Combination therapy emerges as a solution strategy, and selinexor might be a potential candidate. In this study, we first established the ex vivo tumor microenvironment model by coculturing tumor cells and macrophages, followed by coculture with CAR-T cells, and identified that selinexor decreased CAR-T cell exhaustion and enhanced its cytotoxicity. Moreover, selinexor upregulated NGFR expression and boosted CAR-T cell proliferation. The ex vivo and in vivo results showed that selinexor prevented macrophages from polarizing to M2 populations. In the xenograft animal model, the sequential use of selinexor and CAR-T cells significantly reduced the tumor burden compared with selinexor or CAR-T cell monotherapies. In summary, our findings suggest that selinexor mitigates the immunosuppression of macrophages and improves CAR-T cell functionality, and the combination of selinexor and CAR-T cells may be a promising therapeutic strategy for B-cell lymphoma.

BACKGROUND:CD19-targeted chimeric antigen receptor-T cell (CART19) therapy is clinically effective in patients with relapsed or refractory B-cell lymphoma (BCL), but treatment failure and recurrence need to be overcome. Preclinical studies demonstrated that Bruton tyrosine kinase inhibitor (BTKi) improved the efficacy of CART19 therapy. METHODS:We designed this open-label, non-randomized pragmatic clinical trial. The primary end point was safety, and the secondary end point was clinical response. RESULTS:Thirty-seven patients included were assigned to CART19 monotherapy (n = 24) or CART19 combined with BTKi (n = 13) group on their own accord. Grade 1-2 and grade 3 cytokine release syndrome occurred in 43.2% and 2.7% of patients, respectively. One patient experienced grade 3 neurotoxicity. The most common severe adverse events were hematological toxicities, including neutropenia (in 97.3% of patients), thrombocytopenia (in 40.5%), and anemia (in 43.2%). The adverse effects were comparable between the two groups. The best objective response rates were 84.6% vs. 66.7% (p > 0.05) in patients with and without BTKi, and the best complete response rates were 61.5% vs. 25.0% (p < 0.05). The combination of BTKi significantly prolonged the overall survival but did not affect the progression-free survival or the duration of response. T cells of patients treated with BTKi were predisposed to early differentiation and less exhaustion 3 months after CART19 infusion. Single-cell RNA sequencing analysis demonstrated that T cells were dysfunctional at relapse. CONCLUSION:BTKi combined with CART19 induced better outcomes with good safety profiles in patients with BCL. TRIAL REGISTRATION:ClinicalTrials.gov identifier: NCT05020392.

BACKGROUND:Chimeric antigen receptor T (CAR-T) therapy has substantially revolutionized the clinical outcomes of patients with hematologic malignancies, but the cancer-intrinsic mechanisms underlying resistance to CAR-T cells remain yet to be fully understood. This study aims to explore the molecular determinants of cancer cell sensitivity to CAR-T cell-mediated killing and to provide a better understanding of the underlying mechanisms and potential modulation to improve clinical efficacy. METHODS:The human whole-genome CRISPR/Cas9-based knockout screening was conducted to identify key genes that enable cancer cells to evade CD19 CAR-T-cell-mediated killing. The in vitro cytotoxicity assays and evaluation of tumor tissue and bone marrow specimens were further conducted to confirm the role of the key genes in cancer cell susceptibility to CAR-T cells. In addition, the specific mechanisms influencing CAR-T cell-mediated cancer clearance were elucidated in mouse and cellular models. RESULTS:The CRISPR/Cas9-based knockout screening showed that the enrichment of autophagy-related genes (ATG3, BECN1, and RB1CC1) provided protection of cancer cells from CD19 CAR-T cell-mediated cytotoxicity. These findings were further validated by in vitro cytotoxicity assays in cells with genetic and pharmacological inhibition of autophagy. Notably, higher expression of the three autophagy-related proteins in tumor samples was correlated with poorer responsiveness and worse survival in patients with relapsed/refractory B-cell lymphoma after CD19 CAR-T therapy. Bulk RNA sequencing analysis of bone marrow samples from B-cell leukemia patients also suggested the clinical relevance of autophagy to the therapeutic response and relapse after CD19 CAR-T cell therapy. Pharmacological inhibition of autophagy and knockout of RB1CC1 could dramatically sensitize tumor cells to CD19 CAR-T cell-mediated killing in mouse models of both B-cell leukemia and lymphoma. Moreover, our study revealed that cancer-intrinsic autophagy mediates evasion of CAR-T cells via the TNF-α-TNFR1 axis-mediated apoptosis and STAT1/IRF1-induced chemokine signaling activation. CONCLUSIONS:These findings confirm that autophagy signaling in B-cell malignancies is essential for the effective cytotoxic function of CAR-T cells and thereby pave the way for the development of autophagy-targeting strategies to improve the clinical efficacy of CAR-T cell immunotherapy.

Treatment of multiple myeloma (MM) has evolved remarkably over the past few decades. Autologous stem cell transplantation, as well as proteasome inhibitors, immunomodulatory drugs, and monoclonal antibodies, has substantially improved the prognosis of patients with MM. Novel therapies, including chimeric antigen receptor-T cells, bispecific T-cell engagers, antibody-drug conjugates, histone deacetylase inhibitors, and nuclear export inhibitors, have provided more options. However, MM remains incurable. T cells are the principal weapons of antitumor immunity, but T cells display a broad spectrum of dysfunctional states during MM. The promising clinical results of T-cell-directed immunotherapies emphasize the significance of enhancing T-cell function in antimyeloma treatment. This review summarizes the potential effects of these antimyeloma agents on T-cell function and discusses possible optimized strategies for MM management by boosting T-cell immunity.

Multiple myeloma (MM) bears heterogeneous cells that poses a challenge for single-target immunotherapies. Here we constructed bispecific CS1-BCMA CAR-T cells aiming to augment BCMA targeting with CS1. Sixteen patients with relapsed or refractory (RR) MM received CS1-BCMA CAR-T infusion. Six patients (38%) had cytokine release syndrome, which was of grade 1–2 in 31%. No neurological toxicities were observed. The most common severe adverse events were hematological, including leukopenia (100%), neutropenia (94%), lymphopenia (100%) and thrombocytopenia (31%). Three patients with solitary extramedullary disease (sEMD) did not respond. At a median follow-up of 246 days, 13 patients (81%) had an overall response and attained minimal residual disease-negativity, and six (38%) reached a stringent complete response (sCR). Among the 13 responders, 1-year overall survival and progression-free survival were 72.73% and 56.26%, respectively. Four patients maintained sCR with a median duration of 17 months. Four patients experienced BCMA+ and CS1+ relapse or progression. One patient responded after anti-BCMA CAR-T treatment failure. Lenalidomide maintenance after CAR-T infusion and the resistance mechanism of sEMD were preliminarily explored in three patients. CAR-T cells persisted at a median of 406 days. Soluble BCMA could serve as an ideal biomarker for efficacy monitoring. CS1-BCMA CAR-T cells were clinically active with good safety profiles in patients with RRMM. Clinical trial registration: This study was registered on ClinicalTrials.gov, number NCT04662099.

Topic: 25. Gene therapy, cellular immunotherapy and vaccination - Clinical Background: Anti-CD19 chimeric antigen receptor (CAR) T-cell treatment has showed about 60-80% of response rate in relapsed or refractory (R/R) B-cell lymphoma. However, approximately 40% of patients (PTs) achieved long-term remissions and CD19 antigen target downregulation or loss has been proposed as a common mechanism. CD37, widely expressed on B cells, is involved in lymphoma pathogenesis and immune regulation. Therefore, we generated a bispecific CAR-T cell targeting CD19 and CD37. Preclinical studies found that bispecific CD19/CD37 CAR-T cells were effective against B-cell lymphoma (Cancers 2021,13, 981). Aims: An open-label single arm clinical trial (ChiCTR2100049827) was designed to explore the safety and efficacy of CAR19/37 T-cell therapy for PTs with R/R aggressive B-cell lymphoma. Methods: In this trial, bispecific CAR19/37 was comprised of a murine anti-CD19 scFv (clone FMC63) and humanized anti-CD37 scFv (based on clone 2B8D12F2D4) in loop, and a 4-1BB costimulatory molecule (Figure A). Enrolled PTs had measurable disease with CD19, CD37 or CD19/CD37 expression (Figure B) and have received ≥2 prior lines of therapy. All PTs received cyclophosphamide (500 mg/m2, d-5 to d-4) and fludarabine (30 mg/m2, d-5 to d-3) daily, followed by CAR-T cell infusion at a dose of 0.5x106, 1×106, or 2×106 cells/kg on day 0. The primary endpoint was to characterize the safety. Adverse effects (AEs) were graded using CTCAE v5.0, except that cytokine release syndrome (CRS) and neurotoxicity were graded by ASCTC criteria. Secondary endpoints were pharmacokinetics and efficacy. Lugano criteria (2014) were used for response assessment. Results: As of Feb 22, 2023, 10 PTs s received CD19/CD37 CAR-T cells with a median age of 53 (range 42-67) years old and a median of 3 (range 2-6) prior lines of therapy. Of 10 PTs, 1 was Burkitt lymphoma, 1 was chronic lymphocytic leukemia (CLL) with Ritcher’s transformation, 2 were follicular lymphoma, and the rest were diffuse large B-cell lymphoma. Besides, 6 out of PTs had high-risk cytogenetic profiles, and 2PTs were relapsed after previous CD19 CAR-T cell therapy. Most frequent AEs of grade 3-4 were neutropenia (100%), leukopenia (90%), and thrombocytopenia (30%). 4 PTs (40%) experienced CRS, of which grade 3 CRS occurred once and lasted for 8 days. No neurotoxicity was observed. With follow-up, the overall response was 70%, including 3 complete response (CR) and 4 partial response, and 3 PTs were in ongoing CR (Figure C). PT3 with double-hit lymphoma mainly in tonsil and abdominal cavity did not respond to CAR-T cell therapy and died at month 2. PT8 with two major lesions in abdominal cavity and bilateral neck relapsed from autologous stem cell therapy and further received 3 prior lines of therapy; the patient withdrew from the study at 4 month and survived up to now. PT9 who was CLL with Rither’s transformation relapsed from 6 prior lines of therapy, and the disease progressed on day 12. CAR-T cells peaked at 36766 copies/μg DNA in peripheral blood (PB) (n=9) by droplet digital PCR on day 14 after infusion and were detectable up to 7 months. CAR-T cells peaked at 71830 cells/mL in PB by flow cytometry (FCM) on day 10 after infusion (Figure D). FCM analysis showed that MDSCs and G-MDSCs population were decreased 2 months after CAR-T cells infusion (Figure E). Additionally, PTs with lower TIM-3 expression were inclined to achieve OR (Figure F). Conclusion: In our study, CD19/CD37 CAR-T cells present a good safety and efficacy profile and show immune regulation in R/R aggressive B-cell lymphoma.Keywords: CAR-T, B cell lymphoma, Bispecific

BACKGROUND AIMS:Combination therapy is being actively explored to improve the efficacy and safety of anti-CD19 chimeric antigen receptor T-cell (CART19) therapy, among which Bruton tyrosine kinase inhibitors (BTKIs) are highly expected. BTKIs may modulate T-cell function and remodel the tumor micro-environment (TME), but the exact mechanisms involved and the steps required to transform different BTKIs into clinical applications need further investigation. METHODS:We examined the impacts of BTKIs on T-cell and CART19 phenotype and functionality in vitro and further explored the mechanisms. We evaluated the efficacy and safety of CART19 concurrent with BTKIs in vitro and in vivo. Moreover, we investigated the effects of BTKIs on TME in a syngeneic lymphoma model. RESULTS:Here we identified that the three BTKIs, ibrutinib, zanubrutinib and orelabrutinib, attenuated CART19 exhaustion mediated by tonic signaling, T-cell receptor (TCR) activation and antigen stimulation. Mechanistically, BTKIs markedly suppressed CD3-ζ phosphorylation of both chimeric antigen receptor and TCR and downregulated the expression of genes associated with T-cell activation signaling pathways. Moreover, BTKIs decreased interleukin 6 and tumor necrosis factor alpha release in vitro and in vivo. In a syngeneic lymphoma model, BTKIs reprogrammed macrophages to the M1 subtype and polarized T helper (Th) cells toward the Th1 subtype. CONCLUSIONS:Our data revealed that BTKIs preserved T-cell and CART19 functionality under persistent antigen exposure and further demonstrated that BTKI administration was a potential strategy for mitigating cytokine release syndrome after CART19 treatment. Our study lays the experimental foundation for the rational application of BTKIs combined with CART19 in clinical practice.

Topic: 25. Gene therapy, cellular immunotherapy and vaccination - Clinical Background: CD19 chimeric antigen receptor (CAR) T-cell therapy has achieved remarkable efficacy in the field of treating relapsed/refractory B-cell malignancies. However, electrolyte disorders including hypoelectrolytemia during CAR T-cell therapy are also common events at incidences of 30-80% and connected to toxicity and prognosis. Aims: To investigate the relationship between electrolyte abnormalities and prognosis after CAR T-cell therapy. Methods: We retrospectively analyzed routine indicators in 71 patients with non-Hodgkin lymphoma and B-cell acute lymphoblastic leukemia (B-ALL) who received anti-CD19 CAR T-cell therapy. From baseline pre-lymphodepletion to 30 days after CAR T-cell infusion. Abnormalities of electrolytes were determined in accordance with Common Terminology Criteria for Adverse Events, version 4.03. Additionally, the assessment of cytokine release syndrome (CRS) and immune-effector cell-associated neurotoxicity syndrome (ICANS) was referred to the American Society for Transplantation and Cellular Therapy guidelines. The time from the CAR T-cell infusion to the date of disease progression, relapse, or death from any cause was considered progression-free survival (PFS), and the time from the infusion to the date of death from any cause was considered overall survival. In accordance with the 2014 Cheson criteria released, the lymphoma relapse or progression were assessed based on the CT scan or 18FDG-PET/CT results. According to NCCN guideline, minimal residual disease was used to assess leukemia relapse or progression. Results: This retrospective single-center study included 71 patients diagnosed with B-cell malignancies (NHL, n=45; B-ALL, n=26), with a median age of 45 years (range, 13–74) and 53.50% male. The incidences of hypokalemia, hypocalcemia, hypophosphatemia, hypomagnesemia, hypochloremia, and hyponatremia were, respectively, 84.51%, 83.10%, 76.06%, 73.24%, 57.75%, and 42.25%. In addition, 28.17% of patients had all six electrolyte abnormalities during treatment (Figure 1A). The electrolyte alterations were resulted from CRS independent of impaired renal function. The nadir values of electrolytes were also influenced by the severity of CRS (Figure 1B). Importantly, we found that low baseline calcium was associated with inferior PFS (P =0.003, Figure 1C) and poor response rate (P =0.016, Figure 1D), especially for patients with B-ALL (Figure 1E). Summary/Conclusion: CRS impacted the electrolyte levels independent of renal function. In addition, low baseline calcium was associated with inferior PFS and poor response rate.Keywords: Clinical outcome, Cellular therapy, Clinical data

Chimeric antigen receptor-T (CAR-T) therapy remains to be investigated in T-cell malignancies. CD7 is an ideal target for T-cell malignancies but is also expressed on normal T cells, which may cause CAR-T cell fratricide. Donor-derived anti-CD7 CAR-T cells using endoplasmic reticulum retention have shown efficacy in patients with T-cell acute lymphoblastic leukemia (ALL). Here we launched a phase I trial to explore differences between autologous and allogeneic anti-CD7 CAR-T therapies in T-cell ALL and lymphoma. Ten patients were treated and 5 received autologous CAR-T therapies. No dose-limiting toxicity or neurotoxicity was observed. Grade 1–2 cytokine release syndrome occurred in 7 patients, and grade 3 in 1 patient. Grade 1–2 graft-versus-host diseases were observed in 2 patients. Seven patients had bone marrow infiltration, and 100% of them achieved complete remission with negative minimal residual disease within one month. Two-fifths of patients achieved extramedullary or extranodular remission. The median follow-up was 6 (range, 2.7–14) months and bridging transplantation was not administrated. Patients treated with allogeneic CAR-T cells had higher remission rate, less recurrence and more durable CAR-T survival than those receiving autologous products. Allogeneic CAR-T cells appeared to be a better option for patients with T-cell malignancies.

Uncontrolled inflammation is a pathological state that underlies many diseases. Despite the development of numerous anti-inflammatory agents, the treatment of uncontrolled inflammation remains a challenging task. We developed a targeted delivery system for [5-(p-fluorophenyl)-2-ureido]thiophene-3-carboxamide (TPCA-1), a potent inhibitor of the NF-κB signaling pathway. The system comprises TPCA-1-loaded nanoparticles (NPs) functionalized with a monoclonal antibody (mAb) that specifically binds to the break point of the IgD6 region of the platelet/endothelial cell adhesion molecule-1 (PECAM-1) extracellular segment that is overexposed on the injured endothelium and activated macrophages during the pathogenesis of inflammation. In vitro binding and cellular uptake experiments revealed that the mAb modification on NPs could significantly enhance uptake by both Raw264.7 and HUVEC compared with unmodified NPs. In studies conducted at the cellular level focusing on anti-inflammatory and antioxidant effects, this formulation was found to effectively inhibit M1 polarization of macrophages, downregulate the secretion of pro-inflammatory cytokines, and reduce the production of reactive oxygen species (ROS) and nitric oxide (NO). In an animal model of vascular endothelial injury with acute inflammation, these NPs were capable of delivering TPCA-1 to inflammatory lesions in a targeted manner. Compared with the free agent-treated group, the NP-treated group exhibited reduced infiltration of inflammatory cells. In conclusion, our study demonstrates that this targeted delivery of TPCA-1-loaded NPs represents a promising strategy for improved mitigation of uncontrolled inflammation.

Chimeric antigen receptor (CAR) T-cell-associated coagulopathy can cause bleeding events. To explore risk factors for hemorrhage after CAR T-cell therapy, we retrospectively analyzed routine indicators in 56 patients with non-Hodgkin lymphoma and B-cell acute lymphoblastic leukemia who received anti-CD19 CAR T-cell therapy. Disturbance of coagulation occurred mainly within one month post infusion, especially on day 7 and 14. The cumulative incidence of bleeding events within one month was 32.8%, with the median onset of 7 (range, 0-28) days. All bleeding events were grade 1-3. Patients who experienced bleeding events within one month had longer prothrombin time, higher IL-6, higher IL-10, and lower platelets before lymphodepletion. There were also correlations among coagulation-, inflammatory-, and tumor burden-related markers. Multi-variate analysis showed IL-10 (> 7.98 pg/mL; adjusted odds ratio [OR], 13.84; 95% confidence interval [CI], 2.03-94.36; P = 0.007) and the endothelial activation and stress index (EASIX, defined as dehydrogenase [U/L] × creatinine [mg/dL] / platelets [×109 cells/L]; >7.65; adjusted OR, 7.06; 95% CI, 1.03-48.23; P = 0.046) were significant risk factors for bleeding events. IL-10 plus the EASIX defined three risk groups for bleeding events with cumulative incidence of 100% (hazard ratio [HR], 14.47; 95% CI, 2.78-75.29; P < 0.0001), 38.5% (HR, 3.68; 95% CI, 0.82-16.67; P = 0.089), and 11.8% (reference), respectively. Future studies are needed to verify the risk assessment models for bleeding events after CAR T-cell treatment in larger cohorts.

Chimeric antigen receptor T (CAR T) therapy has revolutionized clinic outcomes of patients with hematologic malignancies, but therapeutic failure due to cancer resistance and relapse remains one of the major obstacles faced by CAR T cell therapy. We herein performed an unbiased CRISPR/Cas9 loss-of-function screening, which showed that enrichment of autophagy genes (ATG3, BECN1, RB1CC1 etc.) provided protection of cancer cells from CD19 CAR T cell-mediated cytotoxicity. Bulk RNA sequencing of clinical samples also suggested the clinical relevance of autophagy to therapeutic response and relapse in patients receiving CAR T cell therapy, indicating that autophagy may promote resistance to CAR-mediated cytotoxicity of B cell malignancies. The addition of autophagy inhibitor (autophinib) during the co-culture with B cell malignancy cells significantly enhanced the killing effect of CD19 CAR T cells, whereas the addition of autophagy inducer (rapamycin) demonstrated the opposite effects. As expected, consistent results were observed upon knockout of key autophagy genes, further validating the protective role of autophagy. Pharmacological inhibition of autophagy induced caspase 8 and caspase 9 cleavage when co-cultured with CD19 CAR T cells, and the knockout of BECN1 and RB1CC1 also exhibited a substantial increase in the apoptosis. The induced apoptosis after autophagy inhibition could be obviously suppressed at the presence of TNFRSF1A knockout, which indicated that the protective effect of autophagy in the context of CAR T cell killing was mediated primarily through inhibition of TNF-α-induced apoptosis. Despite the suppressed resistance to CD19 CAR T-driven killing observed in vitro cytotoxicity assays, we also observed consistent inhibition of tumor growth with the treatment of SAR405. Mice engrafted with RB1CC1-KO Raji-luc cells demonstrated attenuated resistance to CD19 CAR T cells in vivo. Remarkably, the increased infiltration of total CD3+ T and CD19 CAR T cells into Raji-luc lymphoma tumors treated with SAR405 was further confirmed by flow cytometry and immunohistochemistry staining. The cytokine profiling data identified that CXCL10 and CXCL11 were released, at least in part, from the tumor in response to autophagy inhibition. Using existing ChIP-seq datasets in ChIP-Atlas, we found that STAT1 and IRF1 had binding peaks in the promoter region of CXCL10 and CXCL11. Additionally, autophinib and SAR405 failed to induce CXCL10 and CXCL11 mRNA and protein expression in the absence of STAT1 or IRF1. Therefore, our data further validated the role of STAT1/IRF1 induced chemokine activation by autophagy targeting in reversing tumor immune escape. In conclusion, this study offered a novel mechanism in which autophagy mediates cancer-intrinsic biology contributing to observed therapeutic failure during CAR T cell therapy, wherein both STAT1/IRF1-induced chemokine signaling activation and TNF-α induced apoptosis are involved (Figure 1). Our findings promote better understanding of the role of autophagy in cancer cell resistance to CAR T cells, which will help to identify crucial areas requiring further research to improve patient outcomes. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

近年来，细胞治疗显现出巨大的研究潜力和临床价值。嵌合抗原受体T细胞（CAR-T细胞）治疗在血液肿瘤领域已取得重大进展，CD19 CAR-T治疗B-ALL完全缓解率高达90% [1]。但CAR-T治疗仍面临诸多挑战：①自体T细胞质量不足，异体T细胞引起移植物抗宿主病（GVHD）风险；②制备耗时；③细胞因子释放综合征（CRS）和免疫效应细胞相关神经毒性综合征（ICANS）等不良反应；④复发；⑤价格高昂。CAR-自然杀伤（NK）细胞可以在一定程度上弥补CAR-T治疗的局限，是最具潜力的新一代CAR细胞治疗产品。2020年一项靶向CD19 CAR-NK治疗B系肿瘤的临床研究实现了73%的缓解率和64%的完全缓解率，并且无GVHD、CRS和ICANS发生，首次确定CAR-NK临床应用的有效性和安全性 [2]。本文我们主要对NK细胞生物学特点、CAR-NK作用机制、CAR-NK与CAR-T的比较、血液肿瘤CAR-NK研究现状、目前的优化措施进行了总结归纳。

Background: CD19-targeted chimeric antigen receptor-T (CART19) cell therapy has achieved extraordinary success in B-cell lymphoma and leukemia. However, recurrence and adverse effects, including cytokine release syndrome (CRS) and immune cell-associated neurotoxicity syndrome (ICANS), remain its obstacles. Recurrence, even resistance to CART19 cell therapy, might be attributed to CAR-T cell dysfunction and suppressor cells in the microenvironment. Cytokines required for CRS and ICANS are predominantly derived from monocytes and macrophages. Given that Bruton’s tyrosine kinase (BTK) is expressed on myeloid cells, we considered that BTK inhibitors (BTKi) could improve CAR-T cell therapy by modulating immune system. Aims: To systematically evaluate the effects of three BTKi, ibrutinib (IB), zanubrutinib (ZB) and orelabrutinib (OB), on T cells, CART19 cells and tumor microenvironment. Methods: T and CART19 cells were cultured with the three BTKi for 4 days, and the immune and differentiated phenotypes (PD1, TIM3, CTLA4, CD25, CD69 and CD28, CD45RA and CD62L) were analyzed by flow cytometry (FCM). The effects of BTKi on CART19 cytotoxicity against NALM-6 were assessed for 24-hour coculture. CART19, NALM-6 and macrophages differentiated from THP-1 upon PMA stimulation were cocultured and IL-6 in the supernatants was detected by cytometry bead assays. Lymphoma mouse models were established with BALB/c mice by subcutaneous injection of 5x106 A20 cells. IB, ZB and OB were administered to the BALB/c mice at 25, 10 and 10mg/kg respectively by oral gavage once daily for 28 days. Vehicle treatment was performed using 0.5% carboxymethylcellulose sodium. Mice in healthy controls were fed with no additional treatment. Splenocytes, bone marrow (BM) samples and tumor specimens were harvested, and single-cell suspensions were prepared to analyze immune phenotypes by FCM. Results: Compared with control T cells, IB-supplemented T cells significantly reduced the expression of PD-1 (62.28% vs 14.95%, P = 0.0024), TIM-3 (71.38% vs 7.88%, P <0.0001) and CTLA-4 (92.65% vs 15.5%, P <0.0001) following CD3/CD28 stimulation (Figure 1A). The downregulation of the suppressive markers was also observed in T cells treated with ZB, but not with OB (Figure 1A). In parallel, IB and ZB decreased activation markers expression and increased effector memory cell subsets, while decreased naïve T cells (Figure 1A and B). BTKi decreased IL-6 level in the supernatants of CART19, NALM-6 cells and macrophages (Figure 1C), and decreased CTLA-4 expression on CART19 (Figure 1D). The effects of BTKi on CART19 differentiated phenotypes were not observed (Figure E). Considering strong CD3/CD28 stimulation and tonic signaling could drive terminal differentiation and even apoptosis of CAR-T cells, we supposed BTKi could protect CART19 from excessive activation in long-term cultivation and stimulation (not shown). The three BTKi did not show synergistic effects on cytotoxicity of CART19 against NALM-6 cells (not shown). In lymphoma mice models, the three BTKi all increased the ratio of type 1 macrophages (M1) to type 2 macrophages (M2) and Th1 to Th2 in tumor, and reduced tumor-infiltrating macrophages (Figure 1F-H). BTKi induced significant decreases in exhaustion markers expression on T cells in BM tissues, but not in tumor specimens (Figure I). Image:Summary/Conclusion: Differentiation and exhaustion of CAR-T cells highly activated upon CD3/CD28 stimulation and tonic signaling can be prevented by BTKi. Moreover, BTKi can alter the tumor microenvironment and downregulate IL-6 level to improve the efficacy and safety of CART19 cell therapy.

Cancer patients are prone to infections, but the mortality of fatal infections remains unclear. Understanding the patterns of fatal infections in patients with cancer is imperative. In this study, we report the characteristics, incidence, and predictive risk factors of fatal infections among a population-based cancer cohort. A total of 8,471,051 patients diagnosed with cancer between 1975 and 2016 were retrospectively identified from the Surveillance, Epidemiology, and End Results (SEER) program. The primary outcome was dying from fatal infections. Mortality rates and standardized mortality ratios (SMRs) adjusted for age, sex, race, and calendar year were calculated to characterize the relative risks of dying from fatal infections and to compare with the general population. Furthermore, cumulative mortality rates and the Cox regression models were applied to identify predictive risk factors of fatal infections. In cancer patients, the mortality rate of fatal infections was 260.1/100,000 person-years, nearly three times that of the general population [SMR, 2.92; 95% (confidence interval) CI 2.91–2.94]. Notably, a decreasing trend in mortality rate of fatal infections was observed in recent decades. SMRs of fatal infections were highest in Kaposi sarcoma (SMR, 162.2; 95% CI 159.4–165.1), liver cancer (SMR, 30.9; 95% CI 30.0–31.8), acute lymphocytic leukemia (SMR, 19.1; 95% CI 17.0–21.4), and acute myeloid leukemia (SMR, 13.3; 95% CI 12.4–14.3). Patients aged between 20 and 39 years old exhibited a higher cumulative mortality rate in the first few years after cancer diagnosis, whereas the cumulative mortality rate of those > 80 years old was rapidly increasing and became the highest approximately 3 years post-cancer diagnosis. Predictive risk factors of dying from fatal infections in cancer patients were the age of 20–39 or > 80 years, male sex, black race, diagnosed with cancer before 2000, unmarried status, advanced cancer stage, and not receiving surgery and radiotherapy, but receiving chemotherapy. Cancer patients were at high risks of dying from infectious diseases. Certain groups of cancer patients, including those aged between 20 and 39 or > 80 years, as well as those receiving chemotherapy, should be sensitized to the risk of fatal infections.

Features of the deaths caused by COPD (chronic obstructive pulmonary disease) in cancer patients remained a controversial issue. This study aimed to characterize the demographic characteristics and mortality rates of the deaths from COPD in patients with cancer. In total, 7,846,370 cancer patients aged 40 years or older in the United States were identified from the Surveillance, Epidemiology, and End Results database (1975-2016). Mortality rates and SMRs (standardized mortality ratios) adjusted by age, race, sex, and calendar year were calculated to investigate the risk of COPD deaths in cancer survivors and to compare it with the general population. A total of 119,228 COPD deaths in patients with cancer were recorded, with a mortality rate of 261.5/100,000 person-years, nearly two-fold that of the general population (SMR, 2.17; 95% CI [confidence interval], 2.16-2.18). The proportion of cancer survivors dying from COPD increased from 0.9% in 1975 to 3.4% in 2016. Patients with lung cancer had a higher overall risk (SMR, 9.23; 95% CI, 9.12-9.35) than those with extrapulmonary malignancies. Among all extrapulmonary sites, laryngeal (SMR, 5.54; 95% CI, 5.34-5.75) and esophageal cancers (SMR, 4.33; 95% CI, 4.04-4.63) had the highest SMR. The risk of death from COPD increased with follow-up time.

BACKGROUND:Infective endocarditis (IE) continues to be associated with great challenges. Embolic events (EE) are frequent and life-threatening complications in IE patients. It remains challenging to predict and assess the embolic risk in individual patients with IE accurately.HYPOTHESIS:Accurate prediction of embolization is critical in the early identification and treatment of risky and potentially embolic lesions in patients with IE.METHODS:We searched the PubMed, Web of Science, and Google Scholar databases using a range of related search terms, and reviewed the literatures about the pathogenesis and embolic predictors of IE.RESULTS:The development of IE and its complications is widely accepted as the result of complex interactions between microorganisms, valve endothelium, and host immune responses. The predictive value of echocardiographic characteristics is the most powerful for EE. In addition, both easily obtained blood biomarkers such as C-reactive protein, mean platelet volume, neutrophil-to-lymphocyte ratio, anti-β2-glycoprotein I antibodies, D-Dimer, troponin I, matrix metalloproteinases, and several microbiological or clinical characteristics might be promising as potential predictors of EE.CONCLUSION:Our review provides a synthesis of current knowledge regarding the pathogenesis and predictors of embolism in IE along with a review of potentially emerging biomarkers.

Patients with hematological malignancies might be at high risk for renal diseases as evidenced by earlier studies. We aim to investigate the mortality and risk factors of deaths due to renal diseases in this population. A total of 831 535 patients diagnosed with hematological malignancies in the Surveillance, Epidemiology, and End Results (SEER) database in the United States from 1975 to 2016 were identified. Standardized mortality ratio (SMR) was evaluated based on the general population's mortality data gathered by the National Center for Health Statistics. The mortality rate associated with renal diseases was 94.22/100 000 person-years among patients with hematological malignancies (SMR = 3.59; 95% CI, 3.48-3.70]). The highest mortality rate of dying from renal diseases was observed among multiple myeloma (MM) patients (307.99/100 000 person-years; SMR = 7.98; 95% CI, 7.49-8.50), followed by those with chronic myeloid leukemia (142.57/100 000 person-years; SMR = 6.54; 95% CI, 5.63-7.60) and chronic lymphocytic leukemia (103.66/100 000 person-years; SMR = 2.51; 95% CI, 2.27-2.77). The SMRs increased with time and were found to be the highest 10 years after cancer diagnosis. Independent predictors associated with death from renal diseases were found to be older age, male gender, blacks, unmarried, and MM, using the Cox proportional hazards model. We call for enhanced coordinated multidisciplinary care between hematologists and nephrologists to reduce the mortality rate of renal diseases among patients with hematological malignancies.