International Journal of Hematology

, Volume 104, Issue 1, pp 42–72

Current status of ex vivo gene therapy for hematological disorders: a review of clinical trials in Japan around the world

Progress in Hematology Current Gene therapy for hematological disorders

DOI: 10.1007/s12185-016-2030-2

Cite this article as:
Tani, K. Int J Hematol (2016) 104: 42. doi:10.1007/s12185-016-2030-2

Abstract

Gene therapies are classified into two major categories, namely, in vivo and ex vivo. Clinical trials of human gene therapy began with the ex vivo techniques. Based on the initial successes of gene-therapy clinical trials, these approaches have spread worldwide. The number of gene therapy trials approved worldwide increased gradually starting in 1989, reaching 116 protocols per year in 1999, and a total of 2210 protocols had been approved by 2015. Accumulating clinical evidence has demonstrated the safety and benefits of several types of gene therapy, with the exception of serious adverse events in several clinical trials. These painful experiences were translated backward to basic science, resulting in the development of several new technologies that have influenced the recent development of ex vivo gene therapy in this field. To date, six gene therapies have been approved in a limited number of countries worldwide. In Japan, clinical trials of gene therapy have developed under the strong influence of trials in the US and Europe. Since the initial stages, 50 clinical trials have been approved by the Japanese government. In this review, the history and current status of clinical trials of ex vivo gene therapy for hematological disorders are introduced and discussed.

Keywords

Severe combined immune deficiency Adenosine deaminase deficiency Chronic granulomatous disease Wiskott-Aldrich syndrome Leukemia cell vaccine 

Introduction

Clinical trials of human gene therapy initially began with ex vivo techniques. The earliest efforts included a gene-marking study of transfusion of autologous tumor-infiltrating lymphocytes, modified by retroviral transduction of a neomycin resistance gene, in advanced melanoma patients, starting in 1989, and a clinical trial of transfusion of peripheral autologous lymphocytes modified by retroviral transduction of the adenosine deaminase (ADA) cDNA, for treatment of patients with severe combined immunodeficiency (SCID) with ADA deficiency, starting in 1990 [1, 2]. The results of these studies demonstrated the feasibility and safety of retroviral transduction of target genes into peripheral T cells. In addition, the second study showed that transfusion of ADA gene-transduced T cells could confer clinical benefits and save the lives of ADA-SCID patients, who are at high risk of infectious disease.

Based on the initial successes of gene-therapy clinical trials, these new therapeutic approaches have spread worldwide. The number of gene therapy trials approved worldwide increased gradually starting in 1989, reaching 116 protocols per year in 1999, and, essentially, maintaining this rate thereafter. By 2015, a total of 2210 protocols had been approved. Accumulating clinical evidence has demonstrated the safety and benefits of several types of gene therapy. Currently, 78.1 % of 2210 protocols are at phase I or I/II (http://www.wiley.com/legacy/wileychi/genmed/clinical/), but six gene therapy drugs have been approved in a limited number of countries [3, 4, 5, 6, 7].

However, progress has decelerated due to the occurrence of serious adverse events in several clinical trials, including a fatal systemic inflammatory response syndrome in an ornithine transcarbamylase-deficient patient following intrahepatic arterial injection of adenoviral vector; acute lymphoid malignancy in four patients with X-linked severe combined immunodeficiency; and myelodysplasia with monosomy 7 in 2 patients with X-linked chronic granulomatous disease following peripheral-blood transplantation of retrovirally transduced autologous peripheral stem cells [8, 9, 10]. These painful experiences were translated backward to basic science. With the goal of preventing similar outcomes in the future, subsequent trials adopted new gene-transfer technologies, selection of appropriate patients, and close monitoring of patients after gene therapy [11, 12, 13, 14].

In Japan, clinical trials of gene therapy have developed under the strong influence of trials in the US and Europe. Fifty clinical trials have been approved by the Japanese government, since the initial stages: gene therapy for an ADA deficiency patient was approved in 1995, and cancer gene therapies using GM-CSF and p53 genes were approved in 1998 [15, 16, 17]. There have been no remarkable adverse events reported in Japan. Of the 58 trials to date, 37 were for malignancies and 21 were for congenital or acquired non-malignant diseases (http://www.nihs.go.jp/mtgt/section-1/prtcl/prtcl-jn.html). These clinical trials have also been strongly supported by the Japan Society of Cell and Gene Therapy, which was established in 1995 (http://jsgt.jp/ABOUT-JSGT/about-jsgt1.html).

Gene therapies can be classified into two major categories, namely, in vivo and ex vivo [18]. Historically, ex vivo gene therapy has been the most widely adopted, because investigators can preliminarily check the safety and predict the efficacy of the gene-transduced target cells in vitro before administration of the therapeutic agents to patients. However, because serious adverse events have been reported, the long-term in vivo toxicity of ex vivo gene therapy must also be carefully considered [9, 10]. Ex vivo gene therapy can successfully treat many hematological disorders, including hematological malignancies. Therefore, in this review, we summarize the current status of ex vivo gene therapy for hematological disorders in Japan and around the world.

Ex vivo gene therapy clinical trials in Japan and around the world

Essentially, all congenital monogenic hematological and immunological disorders can be targeted by gene therapy. Historically, however, several hematological disorders have received the closest attention as target diseases for gene therapy clinical trials, largely because we have a great deal of biochemical information about their pathogenesis. In this review, clinical trials of gene therapy for congenital hematological and immunological disorders are introduced and discussed. Data from “Gene Therapy Clinical Trials Worldwide,” provided by the Journal of Gene Medicine (http://www.wiley.com/legacy/wileychi/genmed/clinical/), were used to generate Tables 1 and 2. Data from “List of Gene Therapy Clinical Study Protocols Approved in Japan” provided by the National Institute of Health Sciences, Japan (http://www.nihs.go.jp/mtgt/section-1/english/prtcl-e/prtcl-e.html), http://www.nihs.go.jp/mtgt/section-1/prtcl/prtcl-jn.html were used to generate Table 3.
Table 1

Ex vivo gene therapy for hematological congenital diseases

Disease

Trial ID

Country

Clinical phase

Approved year

Genes

Vector

Target cells/route

Principle investigator

ADA-SCID

FR-0006

France

I/II

 

Adenosine deaminase (ADA)

Retrovirus

CD34+ bone marrow cell/bone marrow transplantation

Alain Fischer

IL-0004

Israel

I

2006

Adenosine deaminase (ADA)

  

Shimon Slavin

IT-0001

Italy

I/II

1992

ADA

Retrovirus

Autologous PBL, BMC/intravenous

Claudio Bordignon

IT-0008

Italy

I/II

2000

ADA

Retrovirus

Autologous CD34+ bone marrow cells /intravenous after Busulfan

A. Aiuti

IT-0016

Italy

I/II

2002

ADA

Retrovirus

Autologous CD34+ cells/intravenous

Maria Grazia Roncarolo

JP-0002

Japan

I/II

1995/2/1

ADA

Retrovirus

Autologous PBL/intravenous

Yukio Sakiyama

JP-0012

Japan

I

2002/6/17

ADA

Retrovirus

Autologous CD34+ cells/intravenous

Tadashi Ariga

NL-0001

The Netherlands

I/II

 

Multi-drug resistance-1

Retrovirus

Autologous CD34+BMC/BMT

Pieter Hoogerbrugge

NL-0006

The Netherlands

I/II

 

ADA

Retrovirus

Autologous CD34+BMC/BMT

Dinko Valerio

UK-0012

UK

I/II

1993/1

ADA

Retrovirus

CD34+ bone marrow cell/bone marrow transplantation

Roland Levinsky

UK-0199

UK

I/II

2011/11

ADA

Lentivirus

CD34+ bone marrow cell/bone marrow transplantation

Bobby Gasper

US-0002

USA

I

1990/9/6

ADA neomycin resistance

Retrovirus

PBC, CD34+ PBC, cord blood, placenta cells

Michael Blaese

US-0337

USA

I

1999

ADA

Retrovirus

CD34+ Cells from Cord Blood or Bone

Marrow intravenous

Donald B. Kohn

US-1006

USA

I/II

2009/10

ADA

EFS lentivirus

CD34+ bone marrow cell/intravenous

Donald B. Kohn

X1-SCID

FR-0014

France

i

2002

Gamma c common chain receptor

Retrovirus

Autologous CD34+ cells/intravenous

Alain Fischer

FR-0046

France

I/II

2010/12

Gamma c common chain receptor

Retrovirus

CD34+ hematopoietic stem cells

Alain Fischer

IT-0024

Italy

I

 

IL-2 receptor gamma

Genome editing

Hamatopoietic stem cells

Pietro gienovese

UK-0061

UK

I

2001/1

Gamma c common chain receptor

Retrovirus

 

Adrian Thrasher

UK-0101

UK

I

2003/2

Gamma c common chain receptor

Retrovirus

 

Inst.Child Health London

UK-0154

UK

I

2007

Gamma c common chain receptor

Retrovirus

 

Great Ormond Street Hospital London

US-0152

USA

I

1996

Gamma c common chain receptor

Retrovirus

CD34+ BMC, CD34+ umbilical cord blood cells/intravenous

Kenneth I. Weinberg

US-0494

USA

I

2001

Gamma c common chain receptor

Retrovirus

CD34+ cord blood or BMC

Kenneth I. Weinberg

US-0516

USA

I/II

2002

Gamma c common chain receptor

Retrovirus

CD34+ cells from peripheral blood/intravenous

Harry L. Malech

US-0950

USA

I

2008/10

Gamma c common chain receptor

Retrovirus

CD34+ cells from BM/intravenous

Luigi Notarangelo

US-0963

USA

I

2009/1

Gamma c common chain receptor

Lenti (SIN)

Autologous CD34+ cells/intravenous

Brian P. Sorrentino

US-0964

USA

I

2009/1

Gamma c common chain receptor

Lenti

Autologous CD34+ cells/intravenous

Suk See DeRavin

Chronic granulomatous disease

CH-0041

Switzerland

I

2005/4

gp91phox

Retrovirus

 

Reinhard Segar

CH-0048

Switzerland

I/II

2009/6

SF71-gp91phox

Retrovirus

 

Reinhard Segar

DE-0035

Germany

I

2002/3

gp91phoxl_NGFR

Retrovirus

Autologous peripheral CD34+/intravenous

Dueter Hoelzer

DE-0085

Germany

I/II

2013/1

gp91phox

Retrovirus

Autologous peripheral CD34+/intravenous

 

FR-0067

Multi-country; France, UK, Germany

I/II

2015/4

gp91 phox

Lentivirus

Autologous peripheral CD34+/intravenous

 

KR-0009

South Korea

I/II

2007/1/2

gp91(MT91)

Retrovirus

Autologous hematopoitic stem cells

 

UK-0062

UK

I

2000/12

gp91phox

Retrovirus

 

Adrian Thrasher

UK-0198

UK

I/II

2011/11

gp91phox

Lentivirus

CD34+ cells

Adrian Thrasher

US-0104

USA

I/II

1995/4/15

p47phox

Retrovirus

CD34+ PBC/intravenous

Harry L. Malech

US-0196

USA

I

1997

gp91phox

Retrovirus

CD34+ PBC/intravenous

Franklin O. Smith

US-0231

USA

I/II

1998

p47phox gp91phox

Retrovirus

Autologous CD34+ PBC/intravenous

Harry L. Malech

US-1223

USA

I/II

2013/4

gp91phox

Lentivirus

Autologous CD34+ BMC/intravenous

Donald Kohn

XX-0025

Multi-country: UK, Switzerland, Germany, France

I/II,

2013/2

gp91phox

Lentivirus

Autologous CD34+ cells/intravenous

Adrian Thrasher

XX-0029

Multi-country: UK, Germany, France

I/II

2013/10

gp91 phox (codon optimized)

G1XCGD lentivirus

Autologous CD34+ BMC/intravenous

 

Homophilia

CN-0001

China

I/II

1995/6

Factor IX

Retrovirus

Autologous skin fibroblasts/subcutaneous

J. L. Hsueh

FR-0038

France

I

2002

Factor VIII

Adenovirus(MaxAdFVIII Vector)

 

Genstar/France

US-0247

USA

I

1998

Factor VIII

Naked/plasmid DNA

Autologous fibroblasts/intraperitoneal

David A. Roth

US-1112

USA

I

2011/6

Factor VIII

Lentivirus

Autologous CD34+ cells/intravenous

Christopher Doering

Wiskott–Aldrich Syndrome

DE-0053

Germany

I/II

2006/3

Wiskott Aldrich protein

Retrovirus

Autologous hematopoietic stem cells

Chistophe Klein

FR-0047

Multi-Country: France, UK

I/II

2011/5

Wiskott Aldrich protein

Lentivirus

Hematopoietic stem cells

Alain Fischer

FR-0062

Multi-Country: France, UK

I/II

2014/10

Wiskott Aldrich protein

Lentivirus

Autologous CD34+ cells

Marina Cavazzana

IT-0020

Italy

I/II

2010/5

Wiskott Aldrich protein

 

Hematopoietic stem cells

Alessandro Aiuti

UK-0168

UK

I/II

2008/2

Wiskott Aldrich protein

Lentivirus

Hematopoietic stem cells

Great Ormond Street Hospital London

US-1052

USA

I

2010/7

Wiskott Aldrich protein

Lentivirus

CD34+ cells from BM/intravenous

Sung-Yun Pai

Mucopolysaccharidosis type I (Hurlers syndrome)

FR-0005

France

I

 

Alpha-1-iduronidase (IDUA)

Retrovirus

Autologous fibroblast/intraperitoneal

Alain Fischer

 Type I (Hurlers syndrome)

UK-0011

UK

I/II

1997/8/1

IDUA

Retrovirus

Autologous BMC/BMT

L. S. Lashford

 Type I (Hurlers syndrome)

UK-0043

UK

I

1997/5

pLX

Retrovirus

Autologous BMC/BMT

Galpin

 Type II (Hunter disease)

US-0087

USA

I

1995/8/20

Iduronate-2-Surfatase (lDS)

Retrovirus

Autologous lymphocytes

Chester B. Whitley

 Type VII

US-0758

USA

I

2006/2

Beta-glucuronidase

Lentivirus

Autologous CD34+ cells/intravenous

Mark S. Sands

Cerebral adrenoleukodystrophy

FR-0028

France

I/II

2005

ALD

Lentivirus

Autologous CD34+ cells/intravenous

Cartier N.

FR-0042

France

III

2009/11

ALD (ABCD-1 gene)

Lentivirus

Hematopoietic stem cells

P. Aubourg

FR-0066

Multi-Country: France, UK

II/III

2013/9

ALD (ABCD-1 gene)

Lentivirus

Autologous CD34+ cells/intravenous

 

Childhood

US-1073

USA

II/III

2010/10

ALD (ABCD-1 gene)

Lentivirus

Autologous CD34+ cells/intravenous

David Williams

Sickle cell anaemia, thalassemia

FR-0029

France

I/II

2006

Human globin (A-T87Q-globin (LentiGlobin)) vec

Lentivirus

Autologous CD34+ cells/intravenous

Genetix-France

Hemoglobinopathies (Sickle Cell Anemia and Thalassemia Major)

FR-0055

France

I/II

2013/1

A-T87Q Globin

Lentivirus

Autologous CD34+ stem cells

 

Beta thalassemia

IT-0026

Italy

I/II

2015/5

Beta globin

Lentivirus

Autologous hematopoietic stem cells

Alessandro Aiuti

US-0852

USA

I

2007/4

Human globin

Lentivirus

Autologous CD34+ cells/intravenous

Farid Boulad

 

US-1067

USA

I

2010/10

gamma globin

Lentivirus(SIN)

Autologous CD34+ cells/intravenous

Derek Persons

Beta thalassemia major

US-1164

USA

I

2012/4

A-T87Q-Globin

Lentivirus

Autologous CD34+ cells/intravenous

Donald Kohn

Thalassemia

US-1304

USA

I

2014/4

mRNA or engineered zinc finger nucleases targeting human BCL11A

 

Autologous CD34+ cells/intravenous

Mark Walters

Sickle cell disease

US-1023

USA

I/II

2010/1

Beta globin with gamma globin exons gene

Lentivirus

Autologous CD34+ cells/intravenous

Malik Punam

 

US-1187

USA

I/II

2012/10

Beta globin

AS3-FB Lentivirus

Autologous CD34+ cells/intravenous

Garry Schiller

 

US-1254

USA

I

2013/10

Beta globin

BB305 lentivirus

Autologous CD34+ cells/intravenous

John F. Tisdale

Metachromatic Leukodystrophy

IT-0019

Italy

I/II

2010/5

Arylsulfatase A

Lentivirus

Hematopoietic stem cells/intravenous

Alessandra Biffi

Familial hypercholesterolemia

US-0012

USA

I

1991/11

LDLR

Retrovirus

Autologous hepatoxyte/intrahepatic

James M.Wilson

Gaucher disease

US-0046

USA

I

1993/9/3

Glucocerebrosidase

Retrovirus

Autologous CD34+ PBC/BMT

John A. Barranger

 

US-0047

USA

I/II

1993/9/3

Glucocerebrosidase

Retrovirus

Autologous CD34+ PBC/BMT

Stefan Karlsson

 

US-0061

USA

I

1994/11/15

Glucocerebrosidase

Retrovirus

Autologous G-CSF mobilized CD34+ PBC/intravenous

Friedrich G..Schuening

Fanconi anemia

US-0078

USA

I/II

1995/2/12

Fanconi Anemia Complementation Group C

Retrovirus

Autologous hematopoietic progenitor/intravenous

Johnson M.Liu

 

US-0291

USA

I/II

1999

Complementation Group A

Retrovirus

Autologous hematopoietic progenitor/intravenous

Christopher E. Walsh

 

US-0370

USA

I

2000

Complementation Group A& C

Retrovirus

Autologous CD34+ PBC/intravenous

James M. Croop

 

US-0520

USA

I

2002

herpes simplex virus thymidine kinase

Retrovirus

Allogeneic T lymphocytes/intravenous

Paul J. Orchard

 

US-0895

USA

I

2008/1

Complementation Group A

Lentivirus

Autologous CD34+ PBC/intravenous

Pamela S. Becker

 

US-1105

USA

I

2011/4

Complementation Group A

Lentivirus

Autologous CD34+ cells/intravenous

W.Scott Goebel

 

XX-0020

Multi-country: Spain, France, UK

I/II

2012/10/8

FANCA gene

Lentivirus

Filgrastime and Mozobil

 

Purine nucleoside phosphorylase deficiency

US-0111

USA

I/II

1995/7

Purine Nucleoside Phosphorylase

Retrovirus

Autologous PBC/intravenous

R. Scott Mclvor

Leukocyte adherence deficiency

US-0204

USA

I

1997

CD18(beta 2 integrin)

Retrovirus

  

Gyrate atrophy

US-0295

USA

I

1999

Ornithine aminotrasferase

Retrovirus

Autologous keratinocytes/skin patch administration

Robert B. Nussenblatt

JAK3 Deficiency

US-0446

USA

I

2001

JAK-3

Retrovirus

Autologous CD34+ hematopoietic stem cells

Rebecca H. Buckley

Inherited autosomal recessive/junctional epidermolysis bullosa

US-0423

USA

I/II

2000

Laminin 5-beta3

Retrovirus

Skin patch adminstration

Alexa Kimball

Recessive dystrophic epidermolysis bullosa (RDEB)

US-0827

USA

I/II

2007/1

Human collagen type 7 A1

Retrovirus

Autologous keratinocytes/skin patch administration

Albert T Lane

 

US-1370

USA

I/II

2015/1

Human collagen type 7 A1

Lentivirus

Autologous dermal fibroblast/intradermal

M. Peter Marinkovich

BMC bone marrow cells, BMT bone marrow transplantation, PBC peripheral blood cells, ADA adenosine deaminase, IL interleukin, EFS short form elongation factor-1α promoter

Table 2

Ex vivo gene therapy for hematological malignancies

Catogory

Disease

Trail ID

Country

Clinical phase

Approved Year

Genes

Vector

Target cells/route

Principle investigator

Leukemia

Acute leukemia

AU-0006

Australia

I/II

1997/3

Interleukin-2 PG1-B7-1

Adenovirus + retrovirus

Autologous leukemia cells

 

Acute leukemia,myelodysplastic syndrome or chronic myeloid leukemia

AU-0032

Australia

I

2014/5

icasp-9

Retrovirus

T cells/intravenous

Siok Tey

Acute lymphoblastic leukemia

CN-0037

China

I

2014/I0

CD28 CAR CD137 CAR

Lentivirus

T cells/intravenous

Hongkui Deng

Acute leukemia, Chronic myelogenous leukemia

DE-0018

Germany

I

2002/6

Herpes simplex virus thymidine kinase (HSV-TK) deltaLNGFR

Retrovirus

Allogeneic lymphocytes/intravenous

Bernd Hertenstein

Acute and chronic leukaemia, plasmacytoma

DE-0034

Germany

I/II

2001/9

Herpes simplex virus thymidine kinase (HSV-TK)

Retrovirus

Allogeneic T cells/intravenous

Axel Rolf Zander

Acute leukemia

DE-0084

Germany

III

2012/11

Herpes simplex virus thymidine kinase (HSV-TK)deltaLNGFR

Retrovirus

Allogeneic lymphocytes/intravenous

 

Leukemia, lymphomia (GVHD risk after allogeneic BMT)

FR-0011

France

I/II

 

Herpes simplex virus thymidine kinase (HSV-TK)

Retrovirus

Allogeneic CD3+ PBC/intravenous

Pierre Tiberghien

Hematological malignancies

FR-0043

France

I/II

2010/3

Herpes simplex virus thymidine kinase

Retrovirus

 

Sebastien Maury

Malignant hemopathies

IL-0001

Israel

I

1997/10

Herpes simplex virus thymidine kinase

Retrovirus

Allogeneic PBL, T cells/intravenous

Shimon Slavin

Hematological malignancies

IT-0017

Multi-country:ltaly,

Germany

I/II

2002

Herpes simplex virus thymidine kinase

Retrovirus

Allogeneic PBL, T cells/intravenous

Fabio Ciceri

 

Leukemia

IT-0018

Italy

III

2008

Herpes simplex virus thymidine kinase

Retrovirus

Haploidentical donor PBL/intravenous

 

Acute leukemia

IT-0021

Italy

III

2009/6

Herpes simplex virus thymidine kinase

Retrovirus

Haploidentical donor PBL/intravenous

Fabio Ciceri

Leukemia

IT-0023

Italy

I/II

2014/4

Inducible Caspase 9 Suicide Gene/AP1903

Retrovirus

/Intravenous

Franco Locatelli

Leukemia

JP-0015

Japan

I/II

 

Herpes simplex virus thymidine kinase

Naked/plasmid DNA

Allogeneic donor PBL/intravenous

Masafumi Onodera

Leukemia

JP-0018

Japan

I

2008

Herpes simplex virus thymidine kinase

Retrovirus

Allogeneic donor PBL/intravenous

National Cancer Center

Hematological malignancies

JP-0020

Japan

I

2008/10

Herpes simplex virus thymidine kinase

Retrovirus

Alloneic donor PBL/intravenous

 

Acute myelogeneous leukemia and myelodysplastic syndrome

JP-0027

Japan

I

2013/8

MS3-WT1-siT cell receptor

Retrovirus

Autologous T cells/intravenous

Shinichi Kageyama

Refractory or relapsed hematological malignancies

NL-0028

The Netherlands

I

2011/7

T Cell Receptor alpha and beta Chain

Retrovirus

  
 

Chronic myelogenous leukemia

UK-0060

UK

I

2000/10

Herpes simplex virus thymidine kinase

Retrovirus

Allogeneic donor PBL/intravenous

 

Acute myelogenous leukemia

UK-0119

UK

I

2004

lnterleukin-2, B7.1 (CD80)

Lentivirus

Allogeneic donor PBL/intravenous

 

CD 19+ B-lymphoid malignancies

UK-0126

UK

I

2005/6

CD19-specific chimeric T cell receptor

Retrovirus

Autologous T cells/intravenous

Christie Research centre Manchester

Leukemia

UK-0150

UK

I

2006/12

T cell receptor specific for Wilms’ tumour antigen 1

Retrovirus

Autologous T cells/intravenous

Royal Free Hospital

Acute lymphoblastic leukemia

UK-0169

UK

I

2008/2

CD19-specific T cell receptor

Retrovirus

Allogeneic T cells/intravenous

Great Ormond Street Hospital

Leukemia, lymphoma, multiple myeloma

US-0146

USA

I

1996

Herpes simplex virus thymidine kinase

Retrovirus

Allogeneic PBC/intravenous

Charles L. Link

Chronic myelogenous leukemia

US-0188

USA

I

1997

Antisense BCR/ABL Dihydrofolate reductase

Retrovirus

Autologous CD34+ PBC/BMT

Catherine Verfaillie

Chronic myelogenous leukemia

US-0206

USA

I

1997

Herpes simplex virus thymidine kinase Hygromycin phosphotransferase

Retrovirus

Allogeneic CD4+ T cells, CD8+ T cells

Mary E. D. Flowers

Chronic myelogenous leukemia (CML), multiple myeloma,

non-Hodgkin’s lymphoma, chronic lymphocytic leukemia (CLL)

US-0241

USA

I/II

1998

Herpes simplex virus thymidine kinase

Retrovirus

Alloneic donor PBL/intravenous

William I. Bensinger

Chronic lymphocytic leukaemia

US-0242

USA

I

1998

CD154 (CD40-ligand)

Adenovirus

Leukemic cells/intravenous

Thomas J. Kipps

Leukemia

US-0308

USA

I

1999

Herpes simplex virus thymidine kinase

Retrovirus

Allogeneic CD8+ cells/intravenous

Edus Warren

Acute leukemia

US-0319

USA

I

1999

lnterleukin-2 (IL-2) CD154 (CD40Higand)

Adenovirus

Autologous fibroblasts/subcutaneous

Malcolm K. Brenner

Myelodyplasia or acute myelogenous leukemia

US-0369

USA

I

2000

Granulocyte-macrophage colony stimulating factor

Adenovirus

Autologous leukemia cells/intradermal + subcutaneous

Daniel J. DeAngelo

 

Chronic lymphocytic leukaemia

US-0401

USA

II

2000

CD154 (CD40-ligand)

Adenovirus

Autologous leukemia cells/intravenous

William G. Wierda

Acute or chronic myelogenous leukemia

US-0433

USA

I

2000

Neomycin resistance(neoR)

Retrovirus

Allogeneic bone marrow cells/BMT

Malcolm K. Brenner

Leukemia, Multiple Myeloma

US-0435

USA

I/II

2000

Granulocyte-macrophage colony stimulating factor(GM-CSF)

Naked/plasmid DNA

Autologous tumor cells with an allogeneic GM-CSF producing bystander cell line/intradermal

Ivan Borrello

Chronic lymphocytic leukaemia

US-0460

USA

I

2001

lnterleukin-2 (IL-2) CD154 (CD40-ligand)

Adenovirus

Autologous leukemia cells/subcutaneous

Malcolm K. Brenner

Acute myelogenous leukemia

US-0479

USA

I/II

2001

Granulocyte-macrophage colony stimulating factor(GM-CSF)

Naked/plasmid DNA

Autologous tumor cells with an allogeneic GM-CSF producing bystander cell line/intradermal

Ivan Borrello

Acute lymphoblastic leukemia

US-0535

USA

I

2002

CD19-specific chimeric T cell receptor Hygromycin phosphotransferase Herpes simplex virus thymidine kinase

Naked/plasmid DNA

Autologous cytolytic T cell clone/intravenous

Laurence J. N. Cooper

Chronic lymphocytic leukaemia

US-0553

USA

I

2002

Interleukin-2 (IL-2) CD154 (CD40-ligand)

Naked/plasmid DNA

Autologous leukemia cells/subcutaneous

Malcolm K. Brenner

Chronic myelogenous leukemia

US-0602

USA

I

2003

Granulocyte-macrophage colony stimulating factor(GM-CSF)

Naked/plasmid DNA

Allogeneic K562 cells/intradermal

Hyam I. Levitsky

Chronic myelogenous leukemia (CML),

acute myelogenous leukemia (AML),

myelodysplasia, Graft-vs-Host Disease (GVHD)

US-0605

USA

I

2003

Herpes simplex virus thymidine kinase (HSV-TK)

Retrovirus

Allogeneic T cells/intravenous

Steven Kornblau

Myelodysplasia (MDS) or refractory acute myeloid leukemia(AML)

US-0621

USA

I

2004

Granulocyte-macrophage colony stimulating factor (GM-CSF)

Adenovirus

Autologous leukemia cells/subcutaneous

Vincent T. Ho

Chronic myelogenous leukemia (CML)

US-0670

USA

I

2004

Granulocyte-macrophage colony stimulating factor (GM-CSF)

Lipofection

Allogeneic K562 cells/intradermal+subcutaneous

Catherine Wu

Hematological malignancies

US-0712

USA

I

2005/5

Human telomerase reverse transcriptase (hTERT)

RNA transfer

Autologous dendritic cells/intradermal

David Rizzieri

Chronic lymphocytic leukaemia

US-0717

USA

I

2005/7

lnterleukin-2 (IL-2) CD154 (CD40-ligand)

Adenovirus

Autologous leukemia cells/subcutaneous

George Carrum

Chranic lymphocytic leukaemia (CLL)

US-0721

USA

I

2005/7

CD19 antigen specific-zeta T cell receptor

Retrovirus

Autologous T cell/intravenous

Renier Brentjens

 

Chronic lymphocytic leukaemia

US-0744

USA

I

2005/11

Granulocyte-macrophage colony stimulating factor (GM-CSF)

Naked/plasmid DNA

Allogeneic K562 cells/intradermal

Ian W. Flinn

Chronic lymphocytic leukaemia

US-0757

USA

I

2006/1

CD154 (CD40-ligand)

Adenovirus

Autologous leukemia cells/intravenous

William Wierda

Chronic myelogenous leukemia

US-0761

USA

I

2006/2

Granulocyte-macrophage colony stimulating factor

Naked/plasmid DNA

Allogeneic K562 cells/intradermal

B. Douglas Smith

Chronic myelogenous leukemia

US-0763

USA

I

2006/3

Granulocyte-macrophage colony stimulating factor

Naked/plasmid DNA

Allogeneic K562 cells/intradermal

B. Douglas Smith

Hematological malignancies

US-0766

USA

I/II

2006/4

Herpes simplex virus thymidine kinase (HSV-TK)

Retrovirus

Allogeneic T cells/intravenous

Steven M. Kornblau

EBV+ Hodikin's or non-Hodgkin’s lymphoma

US-0771

USA

I

2006/4

LMP2A and L MP1

Adenovirus

Autologous cytolytic T cells/intravenous

Stephen Gottschalk

Acute myelogenous leukemia

US-0789

USA

I/II

2006/7

Human telomerase reverse transcriptase

RNA transfer

Autologous dendritic cells/intradermal

John DiPersio

B-cell chronic lymphocytic leukemia

US-0800

USA

I

2006/7

Interleukin-2 (IL-2) CD154 (CD40-ligand)

Adenovirus

Autologous leukemia cells/subcutaneous

Malcolm K. Brenner

Hematological malignancies

US-0803

USA

I

2006/9

Granulocyte-macrophage colony stimulating factor

Naked/plasmid DNA

Allogeneic K562 cells/intradermal

Carol Ann Huff

B-cell acute lymphocytic leukemia

US-0813

USA

I

2006/10

Anti-CD 19-41 BB-Cdzeta

Retrovirus

Haploidentical natural killer cell/intravenous

Dario Campana

Chronic lymphocytic leukaemia

US-0817

USA

I

2006/10

Granulocyte-macrophage colony stimulating factor

Lipofection

Allogeneic K562 cells/intradermal+subcutaneous

Catherine J. Wu

Myelodysplastic Syndrpmc (MDS)

US-0907

USA

I

2008/3

Granulocyte-macrophage colony stimulating factor CD154 (CD40-ligand)

Naked/plasmid DNA

Allogeneic K562 cells/intradermal

Javier Pinilla

CD 19+ B-lymphoid malignancies

US-0922

USA

I

2008/4

CD19 antigen specific-zeta T cell receptor

Sleeping Beauty transposon

Autologous T cells/intravenous

Partow Kebriaei

MDS, AML

US-0937

USA

I

2008/8

Granulocyte-macrophage colony stimulating factor

Lipofection

Allogeneic K562 cells/intradermal+subcutaneous

Vincent T. Ho

B-cell malignancies

US-0940

USA

I

2008/9

CD19 antigen specific-zeta T cell receptor

Retrovirus

Autologous T cells/intravenous

Steven A. Rosenberg

Chronic lymphocytic leukaemia (CLL), B-Cell lymphoma

US-0941

USA

I

2008/9

Chimeric antigen receptor-Kappa-CD28 endodomain

Retrovirus

Autologous T cells/intravenous

Malcolm K. Brenner

 

Acute lymphoblastic leukemia (ALL)

US-0945

USA

I

2008/10

CD19 antigen specific-zeta T cell receptor

Retrovirus

Autologous T cells/intravenous

Robert Krance

Chronic lymphocytic leukaemia (CLL)

US-0952

USA

I

2008/10

CD154 (CD40-ligand)

Adenovirus

Autologous leukemia cells/intravenous

Januario E. Castro

Acute lymphoblastic leukemia (ALL)

US-0985

USA

I

2009/7

CD19 antigen specific-zeta T cell receptor

Retrovirus

Autologous T cells/intravenous

RenierBrentjens

B-cell malignancies

US-0998

USA

I

2009/9

CD19 antigen specific-zeta T cell receptor

Retrovirus

Allogeneic T cells/intravenous

Michael Bishop

B-cell malignancies

US-1003

USA

I

2009/10

CD19 antigen specific-zeta T cell receptor

Sleeping Beauty transposon

Allogeneic HLA matched T cells/intravenous

Laurence J. N. Cooper

B-cell malignancies

US-1022

USA

I

2010/1

CD19 antigen specific-zeta T cell receptor

Sleeping Beauty transposon

Allogeneic umbilical cord blood derived lymphocytes/intravenous

Laurence Cooper

CD 19+ B-lymphoid malignancies

US-1025

USA

I

2010/1

CD19 antigen specific-zeta T cell receptor

Lentivirus

Autologous CD3+ T cells/intravenous

David Porter

Leukemia, elimination of graft vs. host disease

US-1054

USA

I

2010

Herpes simplex virus thymidine kinase (HSV-TK)

Nerve growth factor receptor

Retrovirus

Allogeneic T cells/intravenous

Jayesh Mehta

Unmutated IgVH chronic lymphocytic leukemia

US-1059

USA

I

2010/7

CD19 antigen specific-zeta T cell receptor

Retrovirus

Autologous CD3+ T cells/intravenous

Renier Brentjens

Acute lymphoblastic leukemia (ALL)

US-1091

USA

I

2011/2

CD19 antigen specific-zeta T cell receptor

Retrovirus

Allogeneic Epstein Bar virus-specific T cells/intravenous

Nancy A. Kernan

 

CD 19+ B-lymphoid malignancies

US-1161

USA

I

2012/4

CD19 antigen specific-zeta T cell receptor

Lentivirus

Autologous T cells/intravenous

Rebecca Gardner

 

Acute myeloid leukemia (AML), myelodysplastic syndrome (MDS), and chronic myeloid leukemia (CML)

US-1169

USA

I/II

2012/6

Alpha and beta chains of Wilms’ tumor antigen 1 (WT1) T cell receptor

Lentivirus

Allogeneic T cells/intravenous

Merav Bar

 

MDS/AML

US-1185

USA

II

2012/9

Granulocyte-macrophage colony stimulating factor

Adenovirus

Autologous leukemia cells/lntradermal + subcutaneous

Glenn Dranoff

 

B-cell chronic lymphocytic leukemia

US-1192

USA

I

2012/10

CD19 antigen specific-zeta T cell receptor

Sleeping Beauty transposon

Autologous CD4+ and CD8+ T cells/intravenous

William Wierda

 

B cell non-Hodgkin lymphoma

US-1196

USA

I

2012/10

CD19 antigen specific-zeta T cell receptor

Retrovirus

Autologous T cells/intravenous

Craig Sauter

 

CD19+ leukemia and lymphoma

US-1197

USA

II

2012/12

CD19 antigen specific-zeta T cell receptor

Lentivirus

Autologous T cells/intravenous

Noelle Frey

 

Acute lymphoblastic leukemia

US-1201

USA

I

2013/1

CD19 antigen specific-zeta T cell receptor

Retrovirus

Autologous T cells/intravenous

Kevin J. Curran

 

B-cell chronic lymphocytic leukemia

US-1203

USA

I

2013/1

CD19 antigen specific chimeric antigen receptor (CAR) CD3 zeta and CD137 signaling

Sleeping beauty transposon

Autologous CD4+ and CD8+ T cells/intravenous

Chitra Hosing

 

Advanced CD19+ B cell malignancies

US-1213

USA

I/II

2013/3

CD19 antigen specific chimeric antigen receptor (CAR) epidermal growth factor receptor

Lentivirus

Autologous central memory T cells/intravenous

Cameron Turtle

 

B-cell chronic lymphocytic leukemia

US-1225

USA

I

2013/4

CD19 antigen specific-zeta T cell receptor

Sleeping beauty transposon

Autologous CD4+ and CD8+ T cells/intravenous

Laurence J. N. Cooper

 

Pediatric acute lymphoblastic leukemia

US-1233

USA

I/II

2013/6

CD19-specific chimeric antigen receptor

truncated tpidermal growth factor receptor (EGFRt)

lentivirus

Autologous T cells/intravenous

Rebecca Gardner

 

B-lineage malignancies

US-1236

USA

I

2013/7

CD19 antigen specfic-zeta T cell receptor

Sleeping beauty transposon

Allogeneic umbilical cord blood derived lymphocytes/intravenous

Partow Kebriaei

 

Chemotherapy resistant or refractory acute lymphoblastic leukemia

US-1259

USA

II

2013/10

CD19 antigen specific-zeta T cell receptor/TCR and 4-1BB signaling domains

Lentivirus

Autologous T cells/intravenous

Noelle Frey

 

Relapsed or refractory acute myeloid leukemia

US-1287

USA

I

2014/1

CD133 specific chimeric antigen receptor (CAR) epidermal growth factor receptor

Lentivirus

Autologous T cells/intravenous

L. Elizabeth Budde

 

CD 19+ leukemia or lymphoma

US-1291

USA

I

2014/1

Humanized CD19 antigen specific-zeta T cell receptor/TCR and 4-IBB signaling domains

Lentivirus

Autologous T cells/intravenous

Shannon L. Maude

 

CD19 B cell lymphoproliferative neoplasms

US-1292

USA

I

2014/2

CD19 antigen specfic chimeric antigen receptor (CAR) epidermal growth factor receptor

Lentivirus

Autologous central memory T lympnocytes (Tcm)/intravenous

Tanya Siddiqi

 

Relapsed/refractory ALL, relapsed ALL post allogeneic SCT

US-1299

USA

II

2014

CD19 chimeric antigen receptors

Expressing tandem TCR and 4-1BB costimulatory domains

Lentivirus

Autologous T cells/intravenous

Noelle Frey

 

Relapsed/refractory ALL, relapsed ALL post allogeneic SCT

US-1300

USA

II

2014/4

CD19 chimeric antigen receptors

Expressmg tandem TCR and 4-1BB costimulatory domains

Lentivirus

Autologous T cells/intravenous

Stephen Grupp

 

Acute myeloid leukemia, advanced myelodysplastic syndrome and multiple myeloma

US-1319

USA

I

2014/6

NKG2DL chimeric antigen receptor (CAR)/CD3/DAP10/human NKG2D cDNA

Retrovirus

Autologous T cells/intravenous

Susan Baumeister

 

B cell malignancies: ALL or lymphoma

US-1320

USA

I

2014/6

CD22 chimeric antigen receptors

Lentivirus

Autologous T cells expressing CD22 chimeric antigen receptors/intravenous

Terry J. Fry

 

Elimination of graft versus host disease

US-1325

USA

I/II

2014/7

Inducible caspase 9 suicide gene/AP1903

Retrovirus

AlIogeneicT cells/intravenous

Helen Heslop

 

Relapsed-refractory ALL, relapsed ALL post allogeneic SCT

US-1351

USA

II

2014/10

CD19 chimeric antigen receptors expressing tandem TCR and 4-1BB costimulatory domains

Lentivirus

Autologous T cells/intravenous

Paul L. Martin

 

B-lineage malignancies

US-1353

USA

I

2014/10

CD19 antigen specific-zeta T cell receptor interleukin-15 (IL-15)

Sleeping beauty transposon

Autologous primary CD3+ T cells/intravenous

Partow Kebriaei

 

Acute myelogenous leukemia

XX-0012

Multi-country: Italy, UK, lsrael

I/II

2001/8

Herpes simplex virus thymidine kinase (HSV-TK)

Retrovirus

Allogeneic lymphocytes/intravenous

Fabio Ciceri

Myeloma

Mutiple myelomoa

CA-0011

Canada

I

 

Intereukin-12, B7.1

Adenovirus

Autologous myeoma cells, BMT

A. K. Stewart

 

Multiple myeloma

CA-0012

Canada

I

 

Intereukin-2

Adenovirus

Autologous myeloma cells

A. K. Stewart

 

Recurrent or persistent multiple myeloma

US-0107

USA

I

1995/7

Herpes simplex virus thymidine kinase

Retrovirus

Allogeneic T cells/intravenous

Nikhil C. Munshi

 

Multiple myeloma

US-0997

USA

II

2009/8

Granulocyte-macrophage colony stimulating factor (GM-CSF)

 

Alogeneic K562 cells/intravenous

Ivan Borrello

 

Multiple myeloma

US-1056

USA

I

2010/7

High affinity T cell receptor specific for MAGE-A3 or NY-ESO-1

Lentivirus

Autologous T cells/intravenous

Aaron Rapoport

 

Multiple Myeloma

US-1208

USA

I

2013/1

Chimeric antigen receptors

Expressing tandem TCR and 4-1BB constimulatory domains

 

Autologous T cells expressing CD19/intravenous

Edward Stadtmauer

 

Multiple myeloma

US-1303

USA

I

2014/4

BCMA (B cell maturation antigen) chimeric antigen receptors expressing tandem TCR and CD28 costimulatory domains

 

Autologous T cells/intravenous

James N. Kochenderfer

Hodgkin Ddsease

EBV + Hodgkin disease

US-0473

USA

I

2001

LMP2A neomycin resistance (NeoR)

Adenovirus + retrovirus

Cytotoxic T lymphocytes/intravenous

Benedikt Gahn

 

EBV+ Hodgkin’s or non-Hodgkin’s lymphoma

US-0608

USA

I

2003

Latent membrane protein 2A (LMP2A)

Adenovirus

LMP2A specific cytotoxic T cells/intravenous

 
 

Hodgkin’s Lymphoma

US-0698

USA

I

2005

Granulocyte-macrophage colony stimulating factor (GM-CSF)

Naked/plasmid DNA

Allogeneic K562 cells/intradermal

Richard Ambinder

 

Hodgkin’s Lymphoma

US-0823

USA

I

2007/1

Granulocyte-macrophage colony stimulating factor (GM-CSF)

Naked/plasmid DNA

Allogeneic K562 cells/intradermal

Yvette Leslie Kasamon

 

Hodgkin’s lymphoma/non-Hodgkin’s lymphoma

US-1034

USA

I

2010/4

CD30 antigen specific-zeta T cell receptor

Retrovirus

Autologous Epstein Barr Virus cytotoxic T Lymphocytes/intravenous

Helen Heslop

 

Hodgkin’s lymphoma/non-Hodgkin’s lymphoma

US-1066

USA

I

2010/9

CD30 antigen specific-zeta T cell receptor

Retrovirus

Autologous or synergeneic activated T cells/intravenous

Helen Heslop

 

Refractory or relapsed Hodgkin lymphoma

US-1346

USA

I

2014/8

Anti-CD 19 TCR 4-1BB

mRNA electroporation

Autologous T cells/intravenous

Susan R. Rheingold

 

Refractory or relapsed Hodgkin lymphoma

US-1349

USA

I

2014/9

Anti-CD 19 TCR 4-1BB

mRNA electroporation

Autologous T cells/intravenous

Jakub Svoboda

Lymphoma

Lymphoma

CN-0042

China

I/II

2014/10

Anti-CD30 CAR

Lentivirus

Autologous T cells/intravenous

Jun Zhu

 

B cell lymphoma

CN-0043

China

I/II

2014/9

Anti-CD19 CAR

Lentivirus

Autologous T cells/intravenous

Jun Zhu

 

Relapse or refractory CD30 posiive lymphoma

CN-0048

China

I/II

2014/10

Anti-CD30 CAR (4th generation)

Lentvirus

Autologous T cells/intravenous

Jun Zhu

 

B cell lymphoma

CN-0049

China

I/II

2014/9

Anti-CD19 CAR (4th generation)

Lentivirus

Autologous T cells/intravenous

Jun Zhu

 

Lymphoma, malignant melanoma, renal, colon cancer

DE-0007

Germany

I

 

Interleukin-7, interleukin-2

Naked/plasmid DNA

Autologous tumor cells/subcutaneous

Ingo Schmidt-Wolf

 

AIDS related lymphoma

DE-0078

Germany

l/II

2008/10

Membrane anchored C46

Retrovirus

Gene-modified stem cells

Axel R. Zander

 

B-cell non-Hodgkin lymphoma

JP-0030

Japan

I/II

2014/5

Anti-CD19 CAR

Retrovirus

Autologous T cells/intravenous

Keiya Ozawa

 

Refractory B cell malignancy

SE-0011

Sweden

I/II

2014/4

Anti-CD19 CAR

Retrovirus

Autologous T cells/intravenous

Gunilla Enblad

 

Lymphoma

UK-0002

UK

I/II

1994/12

Multi-drug resistance-I

Retrovirus

Autologous CD34+ PBC/BMT

Devereux

 

Cutaneous T-cell lymphoma, malignant melanoma, breast, head and neck cancer

US-0199

USA

I

1997

Interleukin-12

Retrovirus

Autologous fibroblasts/intratumoral

Chan H. Park

 

CD20+ B-lymphoid malignancies

US-0330

USA

I

1990

scFvFc-zeta T cell receptor against CD30

Naked/plasmid DNA

Autologous CD8+ T ceIIs/intravenous

Michael Jensen

 

Non-Hodgkin B-cell lymphoma

US-0376

USA

I

2000

Dihydrofolate reductase (DHFR) cytidine deaminase

Retrovirus

Autologous CD34+ PBC/intravenous

Joseph Bertino

 

Lymphoma

US-0400

USA

I

2000

Multi-drug resistance-I

Retrovirus

Autologous CD34+ PBC/intravenous

Pamela S. Becker

 

Follicular non-Hodgkin’s lymphoma

US-0491

USA

I

2001

CE7R-specific scFvFc-zeta T cell receptor

Naked/plasmid DNA

Autologous CD8+ T ceIIs/intravenous

Oliver W. Press

 

Epstein–Barr virus lymphoma, elimination of graft versus host disease

US-0627

USA

I/ll

2004

Herpes simplex virus thymidine kinase (HSV-TK)

Dicistronic retroviral vector, termed NIT, encoding a mutant human nerve growth factor receptor (mLNGFR) and herps simplex virus thymidine kinase (HSV-TK)

Allogeneic T cells/intravenous

Richard J. O’Reily

 

Lymphoma

US-0713

USA

I

2005/6

Granulocyte-macrophage colony stimulating factor (GM-CSF) humanized Escherichia coli beta-galactosidase

Vaccinia virus

Cytokine-lnduced killer (CIK) Cells/intravenous

Robert S. Negrin

 

EBV+ lymphoma

US-0724

USA

I

2005/7

LMP2A dominant negative TGF-beta receptor II (DNRII)

Adenovirus+retrovirus

Autologous dendritic cells/intravenous

Catherine Bollard

 

Non-Hodgkin B-cell lymphoma, chronic lymphocytic leukemia

US-0776

USA

I

2006/4

CD19 antigen specific-zeta T cell receptor

Retrovirus

Autologous T cells/intravenous

Rammurti T. Kamble

 

CD19+ B-lymphoid malignancies

US-0793

USA

I

2006/7

CD19 antigen specific-zeta T cell receptor

Lentivirus

Autologous T cells/intravenous

David L. Porter

 

Follicular lymphoma

US-0832

USA

I

2007/2

Granulocyte-macrophage colony stimulating factor

Naked/plasmid DNA

Alogeneic K563 cells/intradermal+subcutaneous

Eric D. Jacobson

 

Mantle cell and indolent B cell lymphoma

US-0863

USA

I

2007/7

CD20-spcific scFvFc-zeta T cell recepter

Naked/plasmid DNA

Autologous T cells/intravenous

Oliver W. Press

 

Non-Hodgkin’s lymphoma

US-0892

USA

I

2008/1

CD19 antigen specific chimeric antigen receptor

Lentivirus

Autologous T cells/intravenous

Lesie Popplewell

 

Non-Hodgkin’s lymphoma, chronic lymphocytic leukemia

US-0915

USA

I

2008/4

CD19 antigen specific-zeta T cell receptor

Retrovirus

Autologous T cells/intravenous

Caros A. Ramos

 

Non-Hodgkin’s lymphoma

US-1062

USA

I/II

2010/8

CD19 antigen specific chimeric antigen receptor

Lentivirus

Autologous T cells/intravenous

Lesie Popplewell

 

Non-Hodgkin’s lymphoma

US-1183

USA

I

2012/9

CD19 antigen specific chimeric antigen receptor

Lentivirus

Autologous central memory T cells/intravenous

Lesie Popplewell

 

Non-Hodgkin’s lymphoma, chronic lymphocytic leukemia

US-1191

USA

I

2012/10

CD19 antigen specific-zeta T cell receptor

Retrovirus

Autologous T cells/intravenous

Caros A. Ramos

 

Non-Hodgkin’s lymphoma

US-1250

USA

I

2013/8

CD19 antigen specific chimeric antigen receptor epidermal growth factor receptor

Lentivirus

Autologous central memory T cells/intravenous

Leslie Popplewell

 

CD19+ oymphoma

US-1258

USA

II

2013/10

CD19 antigen specific-zeta T cell receptor/TCR and ±IBB signaling domains

Lentivirus

Autologous T cells/intravenous

Stephen Schuster

 

Non-Hodgkin’s lymphoma, chronic lymphocytic leukemia

US-1276

USA

I

2013/11

CD19 antigen specific zeta T cell recepter

Retrovirus

Autologous T cells/intravenous

Malcolm K. Brenner

 

Lymphoma

US-1279

USA

I

2013/11

Epidermal growth factor receptor

Lentivirus

Autologous centralmemory T lymphocytes (Tcm)/intravenous

Samer K. Khaled

 

Non-Hodgkin lymphoma

US-1339

USA

I/II

20I4/7

CD19 antigen specific-zeta T cell receptor KTE-C19)

Retrovirus

Autologous T cells/intravenous

Steven Rosenberg

 

Mantle cell lymphoma

US-1376

USA

II

2015/1

CD19 antigen specific-zeta T cell receptor

Retrovirus

Autologous T cells/intravenous

Michael Wang

 

Mantle cell lymphoma

CN-0036

China

I/III

2014/3

CD19CAR

retrovirus

Autologous T cells/intravenous

Vu Zhao

 

Mantle cell lymphoma

US-0654

USA

II

2004

Granulocyte-macrophage colony stimulating factor (GM-CSF) CD15+ (CD+0-ligand)

Naked/plasmid DNA

Allogeneic K562 cells/intradermal

Sophie Dessureault

 

Hematological malignancies

DE-0079

Multi-country: Germany, Itay

I/II

2002

Herpes simplex virus thymidine kinase (HSV-TK)

  

B. Hertenstein

Graft-versus-host disease

Graft-versus-host disease

US-0849

USA

I

2007/4

Inducible caspase 9 suicide gene

Retrovirus

Allogeneic T cells/intravenous

Malcolm K. Brenner

Graft-versus-host disease

US-1092

USA

I

2011/3

Inducible caspase 9 suicide gene

Retrovirus

Haploidentical donor T cells/intravenous

Malcolm K.Brenner

Graft-versus-host disease

US-1158

USA

I/II

20I2/4

Inducible caspase 9 suicide gene/API903

Retrovirus

Allogeneic (partially mismatched, related donor) T cells/intravenous

Hillard Lazarus

Graft-versus-host disease

US-1159

USA

I/II

20I2/4

Inducible caspase 9 suicide gene/API903

Retrovirus

Allogeneic T cells/intravenous

Richard E. Champlin

CAR chimeric antigen receptor, PBL peripheral blood lymphocytes, PBC peripheral blood cells, BMT bone marrow transplantation

Table 3

Ex vivo gene therapy for hematological disorders in Japan

Approved year

Affiliation

Disease

Gene

Vector

Status (cases)

(1) 1995

Hokkaido Univ.

ADA def

ADA

Retro

Finished (1)

(2) 2002

Cancer Inst.

Breast Ca

MDR1

Retro

Finished (3)

(3) 2002

Tsukuba Univ.

Leukemia (relapse)

HSV-TKΔLNGFR

Retro

Under way (10)

(4) 2002

Hokkaido Univ.

ADA def

ADA

Retro

Under way (2/4)

(5) 2002

Tohoku Univ.

X-SCID

Common γ-chain

Retro

Not started

(6) 2007

Takara Bio

Leukemia (relapse)

HSV-TKΔLNGFR

Retro

Under way (9)

(7) 2009

N.C.C.

Leukemia (relapse)

HSV-TKΔLNGFR

Retro

Under way

(8) 2012

N.C.C.H.D

X-CGD

hCYBB

Retro

Under way

(9) 2013

Multiple Univ.

Leukemia and MDS

WT-1 TCRα&β

Retro

Under way (9)

(10) 2014

Jichi Univ.

B cell lymphoma

CD19 CAR

Retro

Under way

NCC National Cancer Center, NCCHD National Center for Child Health and Development, ADA def adenosine deaminase deficiency, retro retroviral vector, ex ex vivo gene therapy, Ca cancer, X-SCID X linked severe combined immune deficiency, X-CGD X-linked chronic granulomatous disease, MDS myelodysplastic syndrome, MDR1 multidrug resistance protein 1, HSV herpes simplex virus, TCR T cell receptor, CAR chimeric antigen receptor

Ex vivo gene therapy clinical trials for congenital hematological disorders in Japan and around the world

Since the first gene therapy of a monogenic disease, severe combined immunodeficiency due to ADA deficiency (ADA-SCID) was conducted safely and with clinical benefits [2]; 209 clinical protocols for monogenic diseases have been approved as of July 2015. Almost half of the approved trials involve ex vivo gene therapy. The target diseases include ADA-SCID, X-linked severe combined immunodeficiency (SCID-X1), X-linked chronic granulomatous disease (X-CGD), hemophilia, Wiskott–Aldrich syndrome (WAS), mucopolysaccharidosis, cerebral adrenoleukodystrophy, sickle cell disease, thalassemia, metachromatic leukodystrophy, familial hypercholesterolemia, Gaucher disease, Fanconi anemia, purine nucleoside phosphorylase deficiency, leukocyte adherence deficiency, gyrate atrophy, JAK3 deficiency, and epidermolysis bullosa. In Table 1, the outlines of clinical trials of primary immunodeficiencies (PIDs) and hemoglobinopathies are presented.

PIDs are a heterogeneous group of monogenic conditions caused by altered innate and/or adaptive immune responses. More than 260 disorders involving more than 300 gene mutations have been reported, and these numbers continue to increase due to improved diagnostic modalities for immune system, the introduction of genome-wide association studies, and the next-generation sequencing technologies. Patients’ phenotypes range from asymptomatic to manifestation of life-threatening conditions, including various forms of severe combined immunodeficiency (SCID) [19, 20]. Below, the results of clinical trials for ADA-SCID, SCID-X1, CGD, and Wiskott–Aldrich syndrome are introduced and discussed.

Severe combined immunodeficiency due to ADA deficiency (ADA-SCID)

Inherited ADA deficiency causes a range of phenotypes, the most severe of which is SCID presenting in infancy, usually resulting in early death. Ten-to-fifteen percent of patients have a delayed clinical onset starting at 6–24 months of age, and a smaller percentage of patients have later onset, diagnosed between the age of 4 years and adulthood. The latter patients exhibit less severe infections and more gradual immunologic deterioration. ADA deficiency accounts for approximately 15 % of all SCID cases and one-third of cases of autosomal recessive SCID. ADA is an enzyme that catalyzes the irreversible deamination of adenosine and deoxyadenosine in the purine catabolic pathway (http://www.omim.org/) [20]. Enzyme activity is highest in lymphoid tissues, particularly the thymus. The lack of ADA results in accumulation of toxic purine metabolites, causing lymphocytes to undergo apoptosis during differentiation and selection. Enzyme replacement therapy (ERT) with polyethylene glycol-modified bovine ADA is clinically useful but non-curative. To achieve a definitive cure, hematopoietic stem cell transplantation (HSCT) from an unaffected, matched sibling donor is the treatment of choice. For those without well-matched donors, ex vivo gene therapy with autologous peripheral T cells is considered to be the treatment of choice. The first clinical trial of gene therapy for ADA-SCID, involving two children, started in 1990. Infusions of retrovirally ADA gene-transduced T cells were achieved safely, and normalized blood T cells (including many cellular and humoral immune responses) and integrated vector and ADA gene expression in T cells persisted after the discontinuation of therapy. The usefulness of T-cell-directed gene transfer in the treatment of ADA-SCID was also demonstrated by another clinical trial; however, the effects required multiple rounds of T-cell infusions and were not sufficient to alleviate the requirement for ERT, although the dose could be reduced [2, 22]. To develop a longer lasting source of ADA-expressing T cells, the ADA gene was retrovirally transduced into hematopoietic stem cells, including bone marrow cells, BM CD34+ cells, and umbilical cord blood CD34+ cells, and infused into patients. These results demonstrated the feasibility of hematopoietic cell gene therapy using a gamma retrovirus vector. The level of ADA expression, however, was not sufficient to confer significant clinical benefits [21, 22, 23, 24]. Several strategies were adopted to overcome these problems: optimization of gene transduction methods, non-myeloablative preconditioning with busulfan or melphalan to create space in the bone marrow, and discontinuation of ERT around the time of reinfusion of gene-modified stem cells [19, 21]. Nine out of ten ADA-SCID patients treated with gene therapy after non-myeloablative preconditioning with busulfan maintained lasting immune reconstitution, and eight and five of the ten were able to discontinue ERT or intravenous immune globulin, respectively, emphasizing the importance of non-myeloablative preconditioning for discontinuation of ERT [25, 26, 27].

More than 40 ADA-SCID patients have been with gamma-retroviral ADA gene therapy in the US and Europe, and 100 % of these patients survived. Furthermore, unlike other PIDs, such as X-SCID, X-CGD, and WAS, no severe adverse events related to insertional mutagenesis have been reported in any of these patients, despite equivalent vector design and integration profiles similar to those seen in other trials [21, 28]. Clonal analysis of long-term repopulating cell progeny in vivo revealed highly polyclonal T-cell populations and shared retroviral integration sites among multiple lineages, demonstrating the engraftment of multipotent HSCs [29]. ADA enzyme production may cross-rescue ADA-deficient lymphocytes, thus placing less replicative stress on the gene-corrected cells [21]. To achieve safer gene therapy for ADA-SCID patients, current trials have adopted self-inactivating HIV-1-based lentiviral vectors. Lentiviral vectors are pseudotyped with the vesicular stomatitis virus glycoprotein, which uses the broadly expressed low-density lipoprotein receptor for cell entry and thus achieves broad-cell tropism. At least 30 ADA-SCID patients have been treated with lentiviral vectors in the US and the UK. Excellent immune reconstitution has been achieved in these patients, with no vector-related complications [21].

In Japan, the first gene therapy for an ADA-SCID patient was initiated in 1995. The patient, a 5-year-old Japanese male, received periodic infusions of retrovirally ADA gene-transduced autologous T cells. The percentage of peripheral-blood lymphocytes carrying the transduced ADA gene remained stable at 10–20 % during the 12 months since the fourth infusion. ADA enzyme activity in the patient’s circulating T cells, which was barely detectable before gene transfer, increased to levels comparable to those of a heterozygous carrier individual, and was associated with increased T-cell counts and improvement in the patient’s immune function. In 2003–2004, two ADA-SCID patients, including one who received T-cell gene therapy, safely received retrovirally ADA gene–transduced autologous bone marrow CD34+ cells without any cytoreductive conditioning after discontinuation of ERT. Partial recovery of immunity due to moderate systemic detoxification was achieved, allowing temporary discontinuation of ERT for 6 and 10 years in patients 1 and 2, respectively. Vector integration-site analyses confirmed that hematopoiesis was reconstituted by a limited number of clones, some of which had myelo-lymphoid potential. These results emphasize that cytoreductive conditioning is important for achieving optimal benefits from SCGT [30] (Table 3).

X-linked severe combined immunodeficiency (SCID-X1)

X-linked severe combined immunodeficiency (SCID-X1) is caused by mutation in the gene encoding the gamma subunit of the interleukin-2 receptor (γc), a key subunit of the cytokine receptor complex for interleukin (IL)2, IL4, IL7, IL9, IL15, and IL21. Common γc deficiency is the most frequent genetic form of SCID, accounting for 50–60 % of cases, and is typically characterized by an absence of mature T cells and natural killer (NK) lymphocytes due to a complete blockade in their development [31]. SCID-X1 is a lethal condition that can be cured by allogeneic stem cell transplantation. Between 1999 and 2002, the first ex vivo gene therapy was conducted in France, using retrovirally common γc gene-transduced CD34+ bone marrow cells. The patients in this trial were 10 SCID-X1 boys without HLA-identical stem cell donors. Immune functions, including normalization of the numbers and phenotypes of T cells, the repertoire of T-cell receptors, and the in vitro proliferative responses of T cells to several antigens after immunization, persisted for up to 2 years after treatment [32]. Subsequently, a similar study was initiated in the UK. A total of 20 patients were enrolled and successfully treated with ex vivo-transduced CD34+ cells without any conditioning regime [33]. In the US, five older patients were treated with a similar protocol. Functional reconstitution, however, was not achieved in those patients, probably due to loss of thymic function by the time gene therapy was initiated. The promising results in France and the UK were subsequently hampered by the occurrence of lymphoid malignancies. Five patients developed acute T-cell leukemia; four entered remission after standard chemotherapy, but one died. All of the leukemias were associated with viral integration in oncogenes; in four of the cases, the integration occurred in LMO2. The enhancer activity of the viral LTR was the most likely cause of the initial aberrant expression of these oncogenes and dysregulation of the cell cycle; subsequent accumulation of additional genetic abnormalities, such as associated rearrangements in BMI1, CCND2, and NOTCH1, led to frank leukemic transformation [34]. In the French cases, transduced T cells were detected for up to 10.7 years after gene therapy. Seven patients, including three of the leukemia survivors, exhibited sustained immune reconstitution, whereas the three others required immunoglobulin-replacement therapy. Sustained thymopoiesis was established by the persistent presence of naive T cells, even after chemotherapy, in three patients. The T-cell receptor repertoire was diverse in all patients. Transduced B cells were not detected. Correction of immunodeficiency improved the patients’ health. After nearly 10 years of follow-up, gene therapy had corrected the immunodeficiency associated with SCID-X1.

Gene therapy is considered to be an option for patients who do not have an HLA-identical donor for HSCT and for whom the risks are deemed acceptable; the treatment is associated with a risk of acute leukemia [35, 36]. Patients who underwent gene therapy also demonstrated a clear advantage in terms of T-cell development relative to patients who underwent HSCT with a mismatched donor; moreover, patients treated with gene therapy exhibited faster T-cell reconstitution and better long-term thymic output. Interestingly, this advantage of gene therapy relative to haploidentical HSCT seemed to be independent of the presence of clinical graft-versus-host disease in the latter condition [37]. Parallel trials in Europe and the US evaluated treatment with a self-inactivating (SIN) γ-retrovirus vector containing deletions in viral enhancer sequences expressing γc (SIN-γc). All of the patients, nine boys with SCID-X1, received bone marrow-derived CD34+ cells transduced with the SIN-γc vector, without cytoreductive conditioning. After 12.1–38.7 months of follow-up, seven of the boys exhibited recovery of peripheral-blood T cells that were functional and led to resolution of infections. The patients remained healthy thereafter. The kinetics of CD3+ T-cell recovery was not significantly different from those observed in previous trials. Assessment of insertion sites in peripheral blood from patients in the current trial revealed significantly less clustering of insertion sites within LMO2, MECOM, and other lymphoid proto-oncogenes than in the previous trials. Thus, the modified γ-retrovirus vector is a safer method for treatment of SCID-X1 than the first-generation Moloney murine leukemia virus vector expressing γc [13].

The gamma chain of the human IL-2 receptor was originally cloned in Japan in 1992 [38]. Gene therapy using a γ-retrovirus vector expressing the gamma chain of the human IL-2 receptor was approved in Japan in 2002. The clinical trial was not started, however, because lymphoid malignancy arose in French patients in 2002.

X-linked chronic granulomatous disease (X-CGD)

Chronic granulomatous disease is a genetically heterogeneous immunodeficiency disorder resulting from an inability of phagocytes to kill microbes that they have ingested. This impairment in killing is caused by any of several defects in the phagocyte nicotinamide adenine dinucleotide phosphate (NADPH) oxidase (phox) complex, which generates the microbicidal ‘respiratory burst’, patients carrying mutations in subunits of NADPH oxidase suffer from defects in neutrophil function (http://www.omim.org/). The fully assembled NADPH oxidase, which consists of the cytosolic phox proteins (p47phox, p67phox, and p40phox, respectively, encoded by NCF1, NCF2, and NCF4), translocated to the membrane-bound flavocytochrome (gp91phox and p22phox, respectively, encoded by CYBB and CYBA), leads through a series of reactions to the production of reactive oxygen species (ROS), which are essential for phagocytic killing of invading microbes. Mutations in CYBB, which encodes gp91phox, lead to the X-linked form of this disease; these mutations account for 60–80 % of all CGD patients in most European countries, North America and Japan. The next most common form, representing about one-third of cases, is an autosomal recessive disease resulting from mutations in NCF1 (encoding p47phox) on chromosome 7. CGD patients are susceptible to recurrent and severe bacterial and fungal infections, notably Staphylococcus and Aspergillus, and are also affected by inflammatory complications in the lungs and gastrointestinal and genitourinary tracts. Conventional therapy involves a broad regimen of antifungals, antibiotics, anti-inflammatory medications, and HSCT, but its effectiveness is limited [34, 39, 40].

Initial trials of ex vivo gene therapy for X-CGD were conducted in the US in 1995 and 1998, targeting p47phox and gp91phox deficiency, respectively, using gamma-retroviral vectors to transduce granulocyte colony stimulating factor (G-CSF)-mobilized CD34+ HSCs without any cytoreductive conditioning. A total of 10 patients were involved. In both trials, only transient production of ROS-producing neutrophils was detected, and no remarkable long-term clinical benefits accrued [34, 39, 40, 41].

Subsequent clinical trials in Germany used gamma-retroviral vectors to transduce granulocyte colony stimulating factor (G-CSF)-mobilized CD34+ HSCs after a non-myeloablative conditioning regimen. Two adult patients exhibited substantial gene transfer to neutrophils, leading to a large number of functionally corrected phagocytes and notable clinical improvement. Large-scale analysis of the distribution of retroviral integration sites in both individuals revealed activating insertions in MDS1-EVI1, PRDM16, or SETBP1 that influenced regulation of long-term hematopoiesis by enhancing gene-corrected myelopoiesis 3–4-fold. Thus, gene therapy in combination with bone marrow conditioning was successfully used to treat CGD, an inherited disease affecting the myeloid compartment [42]. Subsequently, a total of 13 patients were treated in similar manner, and transient clinical benefits due to gene transfer were observed [10, 34, 43, 44, 45, 46, 47]. Three patients, including two adults, exhibited a temporary increase in gene-marked neutrophils followed by the clearance of infections. However, insertional mutagenesis occurred due to integration into the MECOM (MDS/EVI1 complex) and PRDM16 oncogene loci, and transactivation by the viral SFFV LTR was similar to that observed in SCID-X1 patients. Two adults with fatal outcomes exhibited silencing of transgene expression due to methylation of the viral promoter, and myelodysplasia with monosomy 7 due to insertional activation of ecotropic viral integration site 1 (EVI1). Forced overexpression of EVI1 in human cells disrupts normal centrosome duplication, linking EVI1 activation to the development of genomic instability, monosomy 7, and clonal progression toward myelodysplasia [34, 46]. The frequency of these adverse events highlighted the fact that only gp91phox-transduced cells with gain-of-function events could persist in patients who underwent ex vivo gene therapy using LTR-driven retrovirus vectors [18]. Moreover, ectopic expression of the gp91phox transgene and the highly activated bone marrow environment caused by X-CGD patients’ chronic infections was thought to promote the loss of gene-corrected cell engraftment. To increase the safety and efficacy of the gene therapy for X-CGD patients, subsequent trials adopted self-inactivating gamma retrovirus (SIN-γRV) and lentiviral vectors (SIN-LVs) with an internal promoter and a fully myeloablative conditioning regimen (12–16 mg/kg busulfan), prior to gene therapy. The vector currently under evaluation in multicenter trials is an SIN-LV configuration with a chimeric promoter consisting of myeloid-specific Cathepsin G and c-Fes regulatory elements; this promoter element allows preferential expression in myeloid cells and differentiated granulocytes [28, 48].

In Japan, a clinical trial for gene therapy to treat X-CGD was first performed in 2014. This trial, in a 27-year-old man, used a gp91phox gamma-retroviral vector in autologous G-CSF-mobilized CD34+ HSCs after busulfan conditioning. The patient received 3.9 × 108 CD34+ cells, including 76.8 % of gp91phox-expressing cells. Although clinical symptoms of lymphadenitis and CGD-colitis improved until day 95 of transplantation and no genotoxicity was observed, the number of gene-transduced cells was decreased to about 0.1 % of neutrophils at day 182 probably due to the reduction of gene-modified CD34+ stem cells. At present, gene therapy was considered to be useful as a short-term treatment for CGD patients who had no HLA-matched donor for HSCT [49].

Other ex vivo gene therapies for hematological and non-hematological congenital disorders

Wiskott–Aldrich syndrome (WAS) is a rare, complex, X-linked recessive PID disorder caused by mutations in the WAS gene that encodes the WAS protein (WASp). WAS is characterized by recurrent infections, microthrombocytopenia, eczema, and elevated risk of autoimmune manifestations and tumors. WASp is a key regulator of actin polymerization in hematopoietic cells, and contains domains involved in signaling, cell locomotion, and immunologic-synapse formation. The complex biological features of this disease result from multiple dysfunctions in different subgroups of leukocytes, including functional defects in T and B cells, disturbed formation of the NK-cell immunologic synapse, and impaired migratory responses in all leukocyte subgroups. Severe WAS leads to early death from infection or bleeding. Currently, the only curative therapy involves allogeneic HSCT, which is itself associated with considerable risk of death or complications related to transplantation. Therapy with WAS gene-corrected autologous HSCs, thus, represents a valid alternative approach for patients lacking a suitable donor or those who are more than 5 years old [18, 50].

The first gene therapy for WAS was conducted in Germany in 2006; the trial involved two patients. Sustained expression of WASp in HSCs, lymphoid and myeloid cells, and platelets after ex vivo gene therapy was achieved using autologous CD34+ HSCs transduced with gamma retroviral vector after non-myeloablative preconditioning. T and B cells, natural killer (NK) cells, and monocytes were functionally corrected. After treatment, the patients’ clinical condition markedly improved, with resolution of hemorrhagic diathesis, eczema, autoimmunity, and predisposition to severe infection. Comprehensive insertion-site analysis revealed vector integration that targeted multiple genes controlling growth and immunologic responses in a persistently polyclonal hematopoiesis [50]. Subsequently, 10 patients with severe WAS were treated using the HSC gene therapy. Nine of the ten patients exhibited sustained engraftment and correction of WASp expression in lymphoid and myeloid cells and platelets. Gene therapy resulted in partial or complete resolution of immunodeficiency, autoimmunity, and bleeding diathesis. Analysis of retroviral insertion sites revealed >140,000 unambiguous integration sites and a polyclonal pattern of hematopoiesis in all patients soon after gene therapy. Seven patients developed acute leukemia [one with acute myeloid leukemia (AML), four with T-cell acute lymphoblastic leukemia (T-ALL), and two with primary T-ALL with secondary AML associated with a dominant clone; vector integration occurred at LMO2 (six T-ALL), MDS1 (two AML), or MN1 (one AML) locus]. Thus, LMO2-driven leukemogenesis is not specific for X-SCID gene therapy, but is also seen in WAS gene therapy. Cytogenetic analysis revealed additional genetic alterations, including chromosomal translocations. This study showed that hematopoietic stem cell gene therapy for WAS is feasible and effective; however, the use of γ-retroviral vectors was associated with a substantial risk of leukemogenesis [51].

In 2010, three WAS patients in Italy received bone marrow-derived CD34+ cells genetically modified with an SIN lentiviral vector encoding functional WASp after a reduced-intensity conditioning regimen. All three patients exhibited stable engraftment of WASp-expressing cells and improvements in platelet counts, immune functions, and clinical scores. Vector integration analyses revealed highly polyclonal and multilineage hematopoiesis resulting from the gene-corrected HSCs. Lentiviral gene therapy did not induce selection of integrations near oncogenes, and no aberrant clonal expansion was observed after 20–32 months [52]. Between 2010 and 2014, seven WAS patients in France and England received a single infusion of CD34+ cells genetically modified with an SIN lentiviral vector. Six of the seven patients were alive at the time of last follow-up and exhibited sustained clinical benefit. One patient died 7 months after treatment due to a preexisting drug-resistant herpes virus infection. Eczema and susceptibility to infections resolved in all six patients. Autoimmunity improved in five patients. No severe bleeding episodes were recorded after treatment, and at last follow-up, all six surviving patients were free of blood product support and thrombopoietic agonists. Hospitalization days were reduced from a median of 25 days during the 2 years before treatment to a median of 0 days during the 2 years after treatment. All six surviving patients exhibited high-level, stable engraftment of functionally corrected lymphoid cells. The degree of myeloid cell engraftment and of platelet reconstitution correlated with the dose of gene-corrected cells administered [53]. No evidence of vector-related toxicity was observed either clinically or by molecular analysis in either of these clinical trials using SIN lentiviral vectors, although long-term follow-up is still required [52, 53].

Ex vivo gene therapy for congenital diseases other than PIDs has also been developed. Sickle cell disease (SCD) and β-thalassemia major (β-TM), the latter defined clinically as transfusion-dependent cases regardless of the underlying genotype, are the most common monogenic disorders worldwide, with approximately 400,000-affected conceptions or births each year. Over the past 8 years, clinical trials have evaluated gene therapy by ex vivo lentiviral transfer of a therapeutic β-globin gene derivative (β(AT87Q)-globin) into hematopoietic stem cells, driven by cis-regulatory elements that confer high, erythroid-specific expression. β(AT87Q)-globin is used as both a strong inhibitor of HbS polymerization and a biomarker. While long-term studies are underway in multiple centers in Europe and in the US, proof-of-principle of efficacy and safety has already been obtained in multiple patients with β-TM and SCD [54].

LG001 and HGB-205 were the first gene therapy studies worldwide to treat β-TM and SCD subjects, respectively, achieving the first conversion to long-term transfusion independence of a β-TM patients and the first evidence of clinical benefit in SCD [54, 55]. An SIN lentiviral vector expressing HPV569 β(AT87Q)-globin was used in the LG001 trial. Four β-TM patients were enrolled, 3 of whom were treated between 2006 and 2011. Transduced cells successfully engrafted in two of them. The HPV drug product was well tolerated, with no non-hematologic or drug product-related serious adverse events. One of the two treated patients receiving no backup cells exhibited clinical benefits as evidenced by transfusion independence for approximately 8 years. Integration-site analysis revealed the relative dominance of a clone bearing the vector in intron 3 of the HMGA2 gene, which reached a maximum representation of 30 % of transduced myeloid cells 15 months after gene therapy. The BB305 SIN lentiviral vector was the second generation of the HPV569, lacking the cHS4 insulator, and exhibited elevated vector titers and transduction efficiency. Several clinical trials using BB305 had been initiated in France, two separate international, and USA for β-TM and SCD patients [54].

The following two ex vivo gene therapies are for non-hematological diseases, but HSCs were used as therapeutic vehicle. First, X-linked adrenoleukodystrophy (ALD) is a severe brain demyelinating disease in boys that is caused by a deficiency in the ALD protein, an adenosine triphosphate-binding cassette transporter encoded by the ABCD1 gene. ALD progression can be halted by allogeneic hematopoietic cell transplantation (HCT). An ex vivo gene therapy trial for two ALD patients without any matched donors was initiated in 2005. Lentivirally ABCD1 gene-transduced autologous CD34+ cells were reinfused into the patients after fully myeloablative preconditioning. Over a span of 24–30 months of follow-up, polyclonal reconstitution was observed, suggesting successful gene transduction into HSCs. Beginning 14–16 months after infusion of the genetically corrected cells, progressive cerebral demyelination in the two patients stopped, a clinical outcome comparable to that achieved by allogeneic HCT. Thus, lentiviral-mediated gene therapy of HSCs provided clinical benefits in ALD [56].

Second, metachromatic leukodystrophy (MLD) is an inherited lysosomal storage disease caused by arylsulfatase A (ARSA) deficiency. Patients with MLD exhibit progressive motor and cognitive impairment and die within a few years of symptom onset. Three presymptomatic patients who exhibited genetic, biochemical, and neurophysiological evidence for late infantile MLD received lentivirally ARSA gene-transduced HSCs. After receiving the gene-corrected HSCs, the patients exhibited extensive and stable ARSA gene replacement, which led to high enzyme expression throughout hematopoietic lineages and in cerebrospinal fluid. Analyses of vector integrations revealed no evidence of aberrant clonal behavior. The disease did not manifest or progress in the three patients for 7–21 months beyond the predicted age of symptom onset. These findings suggested the clinical usefulness of lentiviral gene therapy for MLD patients [57].

Ex vivo gene therapy clinical trials for hematological malignancies in Japan and around the world

Ex vivo gene therapy clinical trials for hematological malignancies have been primarily performed to enhance host immune function in patients who could not receive stem-cell transplantation due to a lack of appropriate donors, who relapsed, or who were refractory to standard chemotherapies (Table 2). As recent advances in gene therapy using the receptor gene-modified T-cell therapy are excellently reviewed by Davila ML and Sadelain M in this special issue, in the following, we will discuss immune therapy using suicide gene-transduced donor lymphocytes and gene-modified tumor vaccines.

Suicide gene therapy

The most effective and established cell therapy approach is allogeneic HSCT, which is currently the only cure for patients with several high-risk hematological malignancies. Alloreactive T cells induce potent graft-versus-tumor effect (GvT) and also trigger detrimental graft-versus-host disease (GvHD). Gene therapy technology allows T cells to exert the GvT effect, while avoiding or controlling GvHD.

Herpes simplex virus thymidine kinase (HSV-TK) is the suicide gene most extensively tested in humans. Expression of HSV-TK in donor lymphocytes confers sensitivity to the anti-herpes drug ganciclovir (GCV). Progressive improvements in suicide genes, vector technology, and transduction protocols have ameliorated the toxicity of GvHD, while preserving the antitumor efficacy of allogeneic HSCT. Several clinical trials in the last 20 years documented the safety and the efficacy of the HSV-TK approach and established its important role in cellular therapy against cancer. Recently developed gene therapies have improved immune effector cell survival, homing, function, safety, and specificity using high-avidity tumor-reactive T-cell receptors (TCRs) or chimeric antigen receptors, and suicide gene therapy has been reappraised with the goal of avoiding or controlling the toxic effects induced by these innovative therapies [58].

After the successful administration and long-term detection of retrovirally gene-modified Epstein–Barr virus (EBV)-specific T cells in the US [59], eight Italian patients who relapsed or developed EBV-induced lymphoma after T-cell-depleted BMT were treated with donor lymphocytes retrovirally transduced with the HSV-TK suicide gene. The transduced lymphocytes survived for up to 12 months, and exerted antitumor activity in five patients. Three patients developed GvHD, which was effectively controlled by ganciclovir-induced elimination of the transduced cells. These data suggested that genetic manipulation of donor lymphocytes increased the efficacy and safety of allo-BMT and expanded its application to a larger number of patients [60]. Based on these initial clinical trials, several groups around the world have exploited suicide gene therapy to control T-cell reactivity in the context of allogeneic HSCT. The major advantage of this approach is that the donor T cells permanently acquire sensitivity to the prodrug GCV, allowing donor T-cell alloreactivity to be selectively eliminated without the administration of immunosuppressive drugs that might interfere with the natural process of post-transplant immune reconstitution. In the TK suicide gene/prodrug system, only alloreactive gene-modified T cells that proliferate actively during GVHD are killed by GCV, whereas resting transduced T cells and untransduced cells are spared. TK gene therapy has proven to be safe, with no documented adverse events related to the gene-transfer procedure, including appearance of replication-competent retroviruses or genotoxic effects of vector integration [61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71].

Based on these promising results, the safety and efficacy of suicide gene-modified donor T cells were tested in the more challenging condition of haploidentical HSCT. In this setting, the risk of GvHD is particularly high due to the immunological disparity between donor and host [58, 61]. In a phase I/II, multicenter, non-randomized trial of haploidentical stem-cell transplantation, and retrovirally HSV-TK-transduced donor lymphocytes (TK cells) were administered after transplantation. The primary study endpoint was immune reconstitution, defined as circulating CD3+ count ≥100 cells per μL in two consecutive observations. Fifty patients received haploidentical stem-cell transplants for high-risk leukemia. Immune reconstitution was not recorded before infusion of TK cells. Starting 28 days after transplantation, 28 patients received TK cells; and 22 patients achieved immune reconstitution (median, 75 days from transplantation and 23 days from infusion). Ten patients developed acute GVHD and one developed chronic GVHD, which were controlled by the induction of the suicide gene. Overall survival at 3 years was 49 % for 19 patients who were in remission from primary leukemia at the time of stem-cell transplantation. After TK-cell infusion, the last death due to infection was at 166 days, and this was the only infectious death after day 100. No acute or chronic adverse events related to the gene-transfer procedure were observed [72].

In candidates for haploidentical stem-cell transplantation, infusion of TK cells was considered to be effective in accelerating immune reconstitution, while controlling GVHD and protecting patients from late mortality [72]. TK cells played an active role in supporting a thymic-dependent pathway of immune reconstitution, which resulted in maturation and differentiation of donor hematopoietic precursors in the recipient thymus. This process was especially remarkable, because the cohort consisted of adults with a median age of 51, a stage of life usually characterized by low thymic output. Thus, infusion of genetically modified donor T cells after HSCT can drive recovery of thymic activity in adults, leading to immune reconstitution [61, 72, 73]. The HSV-TK strategy is currently under evaluation in a phase III clinical trial in patients undergoing haploidentical HSCT for high-risk acute leukemia. Preliminary results of this ongoing trial confirmed the potential clinical benefit of the T-cell gene-transfer technology integrated with T-cell depletion haploidentical HSCT, and highlighted the role of early immune reconstitution as a surrogate endpoint for survival outcomes and the dose-related antileukemic effects of TK [58].

An inducible T-cell safety switch based on the fusion of human caspase 9 to a modified human FK-binding protein, allowing conditional dimerization, was recently developed. When exposed to a chemical inducer of dimerization (CID), the inducible caspase 9 is activated, leading to the rapid death of cells expressing this construct [74]. Alloreplete haploidentical T cells expressing the inducible caspase 9 suicide gene could reconstitute immunity post-transplant, and administration of CID could eliminate these cells from both peripheral blood and the central nervous system (CNS), leading to rapid resolution of GVHD and GVHD-associated cytokine release syndrome [75]. The safety and efficiency of repeated CID treatments for persistent or recurring toxicity from T-cell therapies have also been demonstrated [76]. This approach was considered to be useful for the rapid and effective treatment of toxicities associated with infusion of engineered T lymphocytes [75, 76].

In Japan, clinical trials designed to examine the feasibility, safety, and efficacy of donor lymphocyte infusion (DLI) of TK cells were approved in 2002 and 2009. DLI of TK cells was safely performed in a total of eight patients. However, these TK cells disappeared rapidly, probably due to their insufficient in vivo expansion in these patients [77, 78]. A comparison of onset with remission of acute GVHD confirmed that TK cells were predominantly eliminated and that proliferative CD8(+) non-TK cells were also depleted in response to ganciclovir administration. The TCR Vβ-chain repertoire of both TK cells and non-TK cells changed markedly after administration of ganciclovir. In addition, whereas the TCR repertoire of non-TK cells returned to a normal spectratype long after transplantation, that of TK cells remained skewed. With the long-term prophylactic administration of acyclovir, TK cells expanded oligoclonally, and the frequency of splice variants of TK cells increased. Known cancer-associated genes were not evident near the oligoclonally expanded HSV-TK insertion sites [78, 79].

Gene-manipulated leukemia cell vaccines

Both autologous and allogeneic whole tumor cells were clinically developed as another form of cellular vaccine for cancer. The advantage of using the whole tumor-cell approach is that the tumor antigens do not have to be prospectively identified, and multiple antigens can be simultaneously targeted. Cytokine-expressing whole tumor cell approaches, including GM-CSF-expressing cells (GVAX), have been extensively clinically investigated in the context of solid tumors [15, 80]. Here, we briefly discuss clinical trials of GVAX for hematological malignancy.

Although allogeneic HSCT affords durable clinical benefits for many patients with hematologic malignancies, mediated via the GvL effect, patients with high-risk acute myeloid leukemia (AML) or advanced myelodysplasia (MDS) often relapse, underscoring the need to intensify tumor immunity within this cohort. In a phase I clinical trial, high-risk AML or MDS patients were immunized with irradiated, autologous, GM-CSF gene-transduced cells early after allogeneic, and non-myeloablative HSCT. Despite the administration of a calcineurin inhibitor as prophylaxis against GVHD, vaccination elicited local and systemic reactions that were qualitatively similar to those previously observed in non-transplanted, immunized solid-tumor patients. While the frequencies of acute and chronic GVHD were not elevated, nine of ten who completed vaccination achieved durable complete remissions, with a median follow-up of 26 months. Six long-term responders exhibited marked reductions in the levels of soluble NKG2D ligands, and three exhibited normalization of cytotoxic lymphocyte NKG2D expression as a function of treatment. These results established the safety and immunogenicity of irradiated, autologous, GM-CSF-secreting leukemia cell vaccines early after allogeneic HSCT, and raised the possibility that this combinatorial immunotherapy might potentiate GvL effects in patients [81]. In a phase II study of immune gene therapy, autologous leukemia cells admixed with GM-CSF-secreting K562 cells were administered to adult patients with acute myeloid leukemia. “Primed” lymphocytes were collected after a single pre-transplantation dose of immunotherapy and reinfused with the stem cell graft. Fifty-four subjects were enrolled; 85 % achieved complete remission; and 52 % received pre-transplantation immunotherapy. For all patients who achieved complete remission, the 3-year relapse-free survival (RFS) rate was 47.4 %, and overall survival was 57.4 %. For the 28 immunotherapy-treated patients, the RFS and overall survival rates were 61.8 and 73.4 %, respectively. Post-treatment induction of delayed-type hypersensitivity reactions to autologous leukemia cells was associated with a higher 3-year RFS rate (100 vs 48 %). Minimal residual disease was monitored by the quantitative analysis of Wilms tumor-1 (WT1), a leukemia-associated gene. A decrease in WT1 transcripts in blood was noted in 69 % of patients after the first immunotherapy dose, and was also associated with a higher 3-year RFS (61 vs 0 %). Immunotherapy in combination with primed lymphocytes and autologous stem cell transplantation showed encouraging signs of potential activity in acute myeloid leukemia [82].

A pilot study was performed to determine whether K562/GM-CSF immunotherapy could improve clinical responses to imatinib mesylate (IM) in patients with chronic myeloid leukemia (CML) in cytogenetic but not molecular complete remission. Nineteen patients, with a median duration of previous imatinib mesylate therapy of 37 months, were vaccinated. Mean PCR measurements of BCR-ABL for the group decreased significantly following vaccination. A progressive decline in disease burden was observed in thirteen patients, of whom eight had increasing disease burdens before vaccination. Twelve patients, including seven subjects who became PCR-undetectable, achieved their lowest tumor burden measurements following vaccination. Thus, the K562/GM-CSF vaccine improved molecular responses in patients on imatinib mesylate, including achievement of complete molecular remissions, despite long durations of previous imatinib mesylate therapy [83].

Conclusion

Ex vivo gene therapies have been gradually developing, and seem to lead the gene and cell therapies. The large quantities of information obtained during the translation of preclinical findings regarding ex vivo gene therapies to clinical trials facilitated the development of new modalities for the treatment of congenital intractable diseases and hematological malignancies. Particularly for congenital diseases, newly developed gene-editing technology, excellently reviewed by Voytas and Tolar in this special issue, will unquestionably change current gene therapy approaches using autologous HSCs [84]. In the case of malignancies, the recent development of gene-modified T-cell technologies, including chimeric antigen receptors and immune checkpoint inhibitors, will change the gene therapy modality for treatment of solid tumors as well as hematological malignancies [85, 86].

In Japan, expedited approval system consisting of conditional and time-limited authorizasion based on two laws known as the “The Act on the Safety of Regenerative Medicine” and the “Pharmaceuticals, Medical Devices and Other Therapeutic Products Act” has been introduced to approve new regenerative medical products, including ex vivo gene therapy since 2014. Under the traditional approval process, long-term data collection and evaluation in clinical trials for regenerative medical products were needed. New separate approval process, however, will make it possible for the regenerative, including ex vivo gene therapy medical product obtain conditional, time-limited approval, if an exploratory clinical trial predicts likely clinical benefit [87]. This new act would accelerate the development of ex vivo gene therapy in Japan.

Needless to say, further clarifications of the pathogenesis and molecular mechanisms of intractable congenital disorders and hematological malignancies, as well as further development of gene-transfer technologies, are required to achieve our goal of ideal gene therapy.

Copyright information

© The Japanese Society of Hematology 2016

Authors and Affiliations

  1. 1.Project Division of ALA Advanced Medical Research, The Institute of Medical ScienceThe University of TokyoTokyoJapan

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