The Chimeric Antigen Receptor (CAR) T-Cell Immunotherapy is based on genetically engineered T cell receptors, which give the specificity of a monoclonal antibody to a T cell. Autologous T cells are transduced with a CAR using a retroviral vector.

The T cells of a patient are removed and modified, so that they express receptors specific to the cancer. The CAR-modified T cells, which can now attack the cancer cells, are then reinfused back into the patient (adoptive cell transfer).

The steps for CART therapy are usually 7:
  1 - Leukapheresis
  2 - T cells are enriched from the mononuclear cells (using magnetic or mechanical techniques)
  3 - T cells are stimulated in vitro (using beads, cytokines, or other Ag-presenting cells)
  4 - The CAR gene is transduced into the T cells
  5 - T cells are expanded in cultures over several days/weeks
  6 - Chemotherapy to patient (to induce lymphodepletion)
  7 - Infusion of the CART cells


Chimeric Antigen Receptor T Cells against CD19 for Multiple Myeloma.
N Engl J Med. 2015 Sep 10;373(11):1040-7.
Garfall AL, Maus MV, Hwang WT, Lacey SF, Mahnke YD, Melenhorst JJ, Zheng Z, Vogl DT, Cohen AD, Weiss BM, Dengel K, Kerr ND, Bagg A, Levine BL, June CH, Stadtmauer EA.

This is a case report of a patient with refractory myeloma who achieved a sustained complete response after treatment with autologous stem cell transplant followed by an infusion of CTL019 cells. Autologous T cells were transduced with an anti-CD19 chimeric antigen receptor using a lentiviral vector. The mechanism of action is not fully elucidated, because malignant plasma cells are generally negative for CD19.

Clinical responses with T lymphocytes targeting malignancy-associated κ light chains.
J Clin Invest. 2016 Jul 1;126(7):2588-96.
Ramos CA, Savoldo B, Torrano V, Ballard B, Zhang H, Dakhova O, Liu E, Carrum G, Kamble RT, Gee AP, Mei Z, Wu MF, Liu H, Grilley B, Rooney CM, Brenner MK, Heslop HE, Dotti G.
In this study, 7 patients with myeloma were treated with a CAR specific for the kappa light chain. This was done with the intent of minimizing the depletion of the normal B cells and the consequent hypogammaglobulinemia. This stratagem allowed sparing of the lambda-restricted B lymphocytes. Of the 7 patients, 4 had stable disease, lasting from 2 to 17 months.






Since the alloreactive lymphocytes mediating the graft-vs-disease effect can occasionally induce cure in myeloma patients after allogeneic stem cell transplant, the hope of cellular immunotherapy in myeloma is to produce the same effect without the high mortality risk associated with the allogeneic transplant. However, as of 2010, vaccines in multiple myeloma did not meet the expectations. Vaccines for myeloma do not have any role in standard clinical practice, and they are only investigated in the context of clinical trials.




Immunotherapy of multiple myeloma: the start of a long and tortuous journey.
Expert Rev Anticancer Ther. 2006 Dec;6(12):1769-85.
Harrison SJ, Cook G, Nibbs RJ, Prince HM.

Cellular immunotherapy for multiple myeloma.
Best Pract Res Clin Haematol. 2008 Sep;21(3):559-77.
Rosenblatt J, Avigan D.

Cancer/testis genes in multiple myeloma: expression patterns and prognosis value determined by microarray analysis.
J Immunol. 2007 Mar 1;178(5):3307-15.
Condomines M, Hose D, Raynaud P, Hundemer M, De Vos J, Baudard M, Moehler T, Pantesco V, Moos M, Schved JF, Rossi JF, Rème T, Goldschmidt H, Klein B.

Prognostic impact of cancer/testis antigen expression in advanced stage multiple myeloma patients.
Cancer Immun. 2008 Feb 1;8:2.
Andrade VC, Vettore AL, Felix RS, Almeida MS, Carvalho F, Oliveira JS, Chauffaille ML, Andriolo A, Caballero OL, Zago MA, Colleoni GW.

Practical blood dendritic cell vaccination for immunotherapy of multiple myeloma.
Br J Haematol. 2008 Nov;143(3):374-7.
Vari F, Munster DJ, Hsu JL, Rossetti TR, Mahler SM, Gray PP, Turtle CJ, Prue RL, Hart DN.



In idiotype vaccination, the unique antigenic determinants of the immunoglobulin secreted by the MM cells serve as a tumor-specific antigen.

Idiotype vaccination in multiple myeloma induced a reduction of circulating clonal tumor B cells.
Blood. 2003 Jun 1;101(11):4607-10.
Rasmussen T, Hansson L, Osterborg A, Johnsen HE, Mellstedt H.
No significant reduction of the serum M component was noted in 6 patients with stage I IgG myeloma after idiotype vaccination.

Long-term follow-up of idiotype vaccination in human myeloma as a maintenance therapy after high-dose chemotherapy.
Leukemia. 2004 Jan;18(1):139-45.
Coscia M, Mariani S, Battaglio S, Di Bello C, Fiore F, Foglietta M, Pileri A, Boccadoro M, Massaia M.
15 patients with multiple myeloma treated with autologous stem cell transplantation received idiotype vaccination. The idiotype vaccination did not improve the degree of disease response. The median progression-free survival was 40 months, and the overall survival was 82 months, results that were similar to those seen in patients treated with interferon-alpha.

Tumor antigen immunization of sibling stem cell transplant donors in multiple myeloma.
Bone Marrow Transplant. 2005 Aug;36(4):315-23.
Neelapu SS, Munshi NC, Jagannath S, Watson TM, Pennington R, Reynolds C, Barlogie B, Kwak LW.
These authors induced tumor-specific T-cells in transplant donors, in the attempt to enhance the graft-vs-myeloma effect. They vaccinated 5 HLA-matched sibling donors with myeloma idiotype proteins from the patients, and gave booster immunizations after the transplant. Outcome:
  - 2 patients died within 30 days from transplant-related complications.
  - 1 patient died after 5.5 years while in complete remission
  - 2 patients were in disease remission 7 years and 8 years after the transplant

Long-term effects of idiotype vaccination on the specific T-cell response in peripheral blood and bone marrow of multiple myeloma patients.
Eur J Haematol. 2007 Nov;79(5):371-81.
Abdalla AO, Hansson L, Eriksson I, Näsman-Glaser B, Mellstedt H, Osterborg A.

Idiotype vaccination in patients with myeloma reduced circulating myeloma cells (CMC).
Ann Oncol. 2008 Jun;19(6):1172-9.
Abdalla AO, Kokhaei P, Hansson L, Mellstedt H, Osterborg A.
11 patients with multiple myeloma were immunized with the autologous idiotype expressed by circulating myeloma cells. No responses were observed.

Idiotype-pulsed antigen-presenting cells following autologous transplantation for multiple myeloma may be associated with prolonged survival.
Am J Hematol. 2009 Dec;84(12):799-802.
Lacy MQ, Mandrekar S, Dispenzieri A, Hayman S, Kumar S, Buadi F, Dingli D, Litzow M, Wettstein P, Padley D, Kabat B, Gastineau D, Rajkumar SV, Gertz MA.
This is a phase II trial of an idiotype vaccine, given after autologous SCT in 27 patients with multiple myeloma. The median overall survival was 5.3 years, better than that seen in a control group who underwent the transplant but did not receive the vaccine (3.4 years).



Immunization with a recombinant MAGE-A3 protein after high-dose therapy for myeloma.
J Immunother. 2007 Nov-Dec;30(8):847-54.
Szmania S, Gnjatic S, Tricot G, et al.
A healthy donor was immunized with MAGE-A3 protein in order to transfer immunity to her identical twin with MAGE-A3+ myeloma. After a syngeneic stem cell transplant, patient received primed donor cells collected after immunizations, then repeated immmunizations. Patient remained in remission for at least 2.5 years.

MAGE-C1/CT7 is the dominant cancer-testis antigen targeted by humoral immune responses in patients with multiple myeloma.
Leukemia. 2008 Aug;22(8):1646-8.
Curioni-Fontecedro A, Knights AJ, Tinguely M, et al.

Differential pattern of CD4+ and CD8+ T-cell immunity to MAGE-A1/A2/A3 in patients with monoclonal gammopathy of undetermined significance (MGUS) and multiple myeloma.
Blood. 2008 Oct 15;112(8):3362-72.
Goodyear OC, Pratt G, McLarnon A, Cook M, Piper K, Moss P.



NY-ESO-1 is a cancer testis antigen. Cancer testis antigens are expressed in many neoplasms, but their expression in normal tissues is usually restricted to immunoprivileged tissues, such as the testis. NY-ESO-1 was discovered in New York, in a patient with esophageal cancer. Its function has not been defined. The NY-ESO-1 gene encodes for several peptides that bind to HLA-I and HLA-II proteins.

NY-ESO-1 is highly expressed in poor-prognosis multiple myeloma and induces spontaneous humoral and cellular immune responses.
Blood. 2005 May 15;105(10):3939-44.
van Rhee F, Szmania SM, Zhan F, Gupta SK, Pomtree M, Lin P, Batchu RB, Moreno A, Spagnoli G, Shaughnessy J, Tricot G.
This study shows that NY-ESO-1 is frequently expressed in MM with cytogenetic abnormalities, and it is capable of eliciting spontaneous humoral and T-cell immunity. MM patients with cytogenetic abnormality have increased expression of NY-ESO-1 compared to patients with normal cytogenetics (60% vs 31%). NY-ESO-1 is highly expressed in patients with relapsing disease (61%), especially when they have cytogenetic abnormalities (100%). Spontaneous NY-ESO-1-specific antibodies were detected in 33% of patients with NY-ESO-1+ MM, but not in NY-ESO-1-negative MM. Spontaneous NY-ESO-1-specific T cells were also found, and, when expanded, they were able to kill primary MM cells.

NY-ESO-1 immunotherapy for multiple myeloma.
Leuk Lymphoma. 2006 Oct;47(10):2037-48.
Szmania S, Tricot G, van Rhee F.

NY-ESO-1-specific TCR-engineered T cells mediate sustained antigen-specific antitumor effects in myeloma.
Nat Med. 2015 Aug;21(8):914-21.
Rapoport AP, Stadtmauer EA, Binder-Scholl GK, Goloubeva O, Vogl DT, Lacey SF, Badros AZ, Garfall A, Weiss B, Finklestein J, Kulikovskaya I, Sinha SK, Kronsberg S, Gupta M, Bond S, Melchiori L, Brewer JE, Bennett AD, Gerry AB, Pumphrey NJ, Williams D, Tayton-Martin HK, Ribeiro L, Holdich T, Yanovich S, Hardy N, Yared J, Kerr N, Philip S, Westphal S, Siegel DL, Levine BL, Jakobsen BK, Kalos M, June CH.
In this phase I/II trial, 20 patients with advanced myeloma were treated with engineered T cells 2 days after an autologous stem cell transplant. The engineered T cells expressed a T cell receptor (TCR) that recognized a peptide shared by the cancer-testis antigens NY-ESO-1 and LAGE-1. Clinical responses were observed in 16 patients (80%), and median progression-free survival was 19.1 months.



RHAMM-R3 peptide vaccination in patients with acute myeloid leukemia, myelodysplastic syndrome, and multiple myeloma elicits immunologic and clinical responses.
Blood. 2008 Feb 1;111(3):1357-65.
Schmitt M, Schmitt A, Rojewski MT, Chen J, Giannopoulos K, Fei F, Yu Y, Götz M, Heyduk M, Ritter G, Speiser DE, Gnjatic S, Guillaume P, Ringhoffer M, Schlenk RF, Liebisch P, Bunjes D, Shiku H, Dohner H, Greiner J.
RHAMM-R3 peptide vaccination induced a reduction of serum free light chains levels in 2 of 4 myeloma patients. RHAMM (receptor for hyaluronic acid-mediated motility) is an antigen that elicits both humoral and cellular immune responses in multiple myeloma and other malignancies.

Autologous antitumor activity by NK cells expanded from myeloma patients using GMP-compliant components.
Blood. 2008 Mar 15;111(6):3155-62.
Alici E, Sutlu T, Björkstrand B, Gilljam M, Stellan B, Nahi H, Quezada HC, Gahrton G, Ljunggren HG, Dilber MS.

Oncolytic virotherapy for multiple myeloma using a tumour-specific double-deleted vaccinia virus.
Leukemia. 2008 Dec;22(12):2261-4.
Deng H, Tang N, Stief AE, et al.

Vaccination with dendritic cell/tumor fusion cells results in cellular and humoral antitumor immune responses in patients with multiple myeloma.
Blood. 2011 Jan 13;117(2):393-402.
Rosenblatt J, Vasir B, Uhl L, Blotta S, Macnamara C, Somaiya P, Wu Z, Joyce R, Levine JD, Dombagoda D, Yuan YE, Francoeur K, Fitzgerald D, Richardson P, Weller E, Anderson K, Kufe D, Munshi N, Avigan D.
15 patients with myeloma were treated with a tumor vaccine consisting of their dendritic cells chemically fused with their myeloma cells. Several patients with advanced disease experienced disease stabilization (41 months in one patient).



Giampaolo Talamo, M.D.