WELCOME. I'M A STAFF CLINICIAN IN THE DEPARTMENT OF RADIOLOGY AND IMAGING SCIENCES. MY PLEASURE TO WELCOME TO CLINOPATHOLOGICAL GRANDS ROUNDS. A QUARTERLY GRAND ROUNDS INITIATIVE, MEANT TO ILLUSTRATE A COMPLEX, CALLING CLINICAL CASE INVOLVING THE CARE OF AN NIH PATIENT, INCLUDING [TECHNICAL DIFFICULTIES] IN DOING, SO THE CPC GRAND ROUNDS AIMS TO ADVANCE MEDICAL EDUCATION AND ILLUSTRATE THE CLINICAL CARE, CLINICAL AND TRANSLATIONAL RESEARCH THAT IS ONGOING HERE AT THE NIH. THE TITLE OF TODAY'S CPC GRAND ROUNDS, CARS FOR KIDS, LESS SONS LEARNED FROM TARGETING LYMPHOBLASTIC LEUKEMIA WITH JOHN EDWARDS. OUR LEAD -- GE FRANK GENETICALLY ENGINEERED. HE'LL BE PRESENTING ALONG SIDE JEFFREY RUBINS, CLINICAL FELLOW IN THE ONGOING BRANCH IN THE NCI, [LIST OF NAMES] WITH REGARD TO TODAY'S DISCLOSURES, DR. LEE WILL DISCUSS CD19 CAR T CELL THERAPY, NOT GIST WILL YET APPROVED. THERE ARE NO RELEVANT DISCLOSURES. THE OBJECTIVE ARE TO REVIEW THE CLINICAL PATHOLOGIC FINDINGS IN THIS CASE OF TREATMENT REFACTORY LYMPHOBLASTIC LEUKEMIA TREATED WITH CD19 CAR T CELL THERAPY, TO IDENTIFY OUTCOMES OF IMMUNOTHERAPY IN THE TREATMENT OF THESE PATIENTS. WE'LL ALSO REVIEW THE LESSONS LEARNED FROM THIS INDEX CASE, HOW THEY HAVE BEEN TRANSLATED TO THE CARE OF OTHER PATIENTS WITH RELEVANT MEDICAL CONDITIONS. MY PLEASURE TO WELCOME DR. JEFFREY RUBINS TO THE PODIUM TO DISCUSS THE INITIAL PRESENTATION AND MANAGEMENT. >> THE PATIENT IS A 15-YEAR OLD MALE, DIAGNOSED WITH ACUTE LYMPHOBLASTIC LEUKEMIA, ALMOST AT THE PRESENT YEARS BEFORE HE PRESENTED FOR THERAPY. INITIALLY, DIAGNOSED IN NOVEMBER, 2003, STANDARD RISK DISEASE. STARTED OB STANDARD CHEMOTHERAPY AND QUICKLY RESPONDED RESPONDED TO THE THERAPY, IN REMISSION 28 DAYS AFTER STARTING THERAPY. REMAINED IN REMISSION FOR 5.5 YEARS, 2.5 YEARS AFTER CHEMOTHERAPY CHEMOTHERAPY. UNFORTUNATELY RELAPSED IN APRIL, 2009 WITH FURTHER DISEASE. HE WAS STARTED AGAIN ON STANDARD REINDUCTION CHEMOTHERAPY AND RESPONDED AGAIN. AT THIS POINT, HE WAS ENREMISSION ABOUT 9 MONTHS BEFORE HE HAD A SECOND RELAPSE IN DECEMBER, 2011. AT THIS POINT HE WAS TREATED ON A CLINICAL PHASE 2 CLINICAL TRIAL FOR REINDUCTION. DID NOT RESPOND TO THIS THEY WEREPY, CONTINUED DO HAVE 3.5 BLAST IN HIS BONE MARROW. AT THAT POINT, HIS PHYSICIANS SWITCHED I AM TO A CHLORFAR ABEAN BASED CHEMOTHERAPY, VERY INTENSIVE THAT WAS ABLE TO GET HIM INTO THE THIRD REMISSION. FOR PATIENTS WHO HAVE DIFFICULT TO TREAT LEUKEMIA, THEN A STEM CELL TRANSPLANT. IN APRIL, 2012, HE HAD A DOUBLE UMBILICAL CORD BLOOD CELL TRANSPLANT, WITH THE GOAL OF KEEPING HIM IN REMISSION. UNFORTUNATELY, AGAIN, HE HAD A THIRD RELAPSE, FEBRUARY, 2013. AND AT THAT POINT, HIS PHYSICIANS LIKE THEY HAD EXHAUSTED ALL POSSIBLE THERAPEUTIC OPTIONS. HE WAS STARTED ON PALIATIVE CHEMOTHERAPY CHEMOTHERAPY. HIS PARENTS CONTINUED TO LOOK FOR THERAPEUTIC OPTIONS, READ A FEW CASE REPORTS ABOUT INITIAL SUCCESSES THAT THE NIH WAS HAVING WITH THERAPY, SO THEY CONTACTED US AND CAME TO THE NIH IN OCTOBER, 2013 TO PURSUE THIS THERAPY. CAR THERAPY IS A SETULAR BASED IMMUNOTHERAPY, WHERE IT TAKES THE PATIENT'S OWN T CELLS TO JOHN GENETICALLY ENGINEERED THEM. HE TWICE ENDED UP HE BE INTENSIVE CARE WITH SEPTIC SHOCK. HAD MRSA ENDOCARDDITES. HE HAD A MILD CARDIO MY OPPY, DEVELOPED PULMONARY ASPERGILLOSIS, AS WELL AS COALESCE TASIS. WHEN HE CAME TO THE NIH HE HAD GOOD ORGAN FUNCTION AT THAT POINT. HE HAD REACHED THE MAXIMUM DOSE, A CHEMOTHERAPY KNOWN TO CAUSE CARDIAC TOXICITY, HIS CARDIAC INDIMES AND ECHO CARDIUM WERE NORMAL. HE LAD CT SCANS, AND A BONE MARROW BIOPSY BEFORE STARTING ON THERAPY. HE HAD EXTENSIVE LUKE, '96% OF BONE MARROW WAS TAKEN UP BY BLASTS. SO TO START THE THERAPY, 11 DAYS BEFORE HE GOT THE T CELL INFUSION HE STARTED THE PROTOCOL, TO DRAW OFF HIS T CELLS SO THEY COULD BE MODIFIED IN THE LABORATORY WITH RETROVIRAL VECTOR TO MAKE THEM SPECIFICALLY ATTACK THE LEUKEMIA CELLS WHEN THEY WERE REINFUSED. HE RESTED FOR 7 DAYS BEFORE DEPLETING CHEMOTHERAPY DAY FOUR, BEFORE THE CHEMOTHERAPY HE WILL OBEFORE THE CELL INFUSION. WITH FLUID FLUID. RERESTED AND GOT HISTORY OWN INFUSION. IT'S LIKE A BLOOD CELL TRANSFUGS. THE CELLS ARE HUNG IN A BAG. HE WAS INFUSED ONE TIMES 10 TO THE 6th. HE HAD NO ALLERGIC REACTIONS FEW THE INFUSION. ABOUT DAY PLUS 3 HE STARTED TO DEVELOP CYTOKINE RELEASE SYNDROME. THIS IS CAUSED BY THE CD19 CAR SELLS TARGETING THEIR CELLS AND BECOMING ACTIVATED, RELEASING MASSIVE AMOUNTS OF CYTOKINES THAT LEADS TO INFLAMMATORY. BY DAY 3, HE HAD THE FIRST MANIFESTATIONWISE LOW GRADE FEVERS, FEVER ABOUT 38 DEGREES CELSIUS. DEVELOPED HEADACHES AND BACK ACHES. THE FEVERS CAME MORE PERSISTENT, HIGHER GRADE WITH TEMPERATURES UP TO ABOUT 40 DEGREES CELSIUS. AND STARTED TO DEVELOP SYMPTOMS, PHOTO PHOBIA AND VISUAL HALLUCINATIONS. THAT NIGHT HE STARTED TO DEVELOP ORGAN FAILURE OR AT LEAST INSUFFICIENCY, AS WELL. CREATININE INCREASED, HE HAD RENAL INSUFFICIENCY, AND HE DEVELOPED TO DEVELOP HYPOTENSION AS WELL AS WIDENING PULSE PRESSURES, WE POLICIED HIM WITH IV NEW MEXICO BUT HE WASN'T RESPONDING. WE FELT LIKE RENEEDED TO TRANSFER HIM TO THE CRITICAL CARE UNIT FOR FURTHER CARE. WE WILL NOW HAVE THE INTENSIVE CARE UNIT MANAGEMENT. >> SO THE MAIN ISSUE FOR US INITIALLY WAS TO TRY TO DETERMINE THE CAUSE OF HIS HYPOTENSION. HE HAD A HISTORY OF OWE CARDIOMYOPATHY. THERE WAS REASON TO BELIEVE HE MIGHT HAVE SOME CARDIAC IMPAIRMENT, SO CARDIO GENIC SHOCK WAS ONE POSSIBILITY. A LOW DISTRIBUTIVE SHOCK HAS MANY, MANY POSSIBLE CAUSES. THE MOST LIKELY CAUSES IN OUR MIND IS DISTRIBUTIVE SHOCK, CYTOKINE RELEASE SYNDROME OR STORM, OR LESS LIKELY, SEPSIS IN THIS NEW TRO PENIC PATIENT. SO THE INITIAL PLAN OF MANAGEMENT INCLUDED BLOOD CULTURES, CULTURES FROM BODY INFLUENZA. BROAD ANTIBIOTIC COVERAGE, AND PRESSERS FOR HYPOTENSION. AND FOR TWO DAYS MUCH THE PATIENT REMAINED STABLE. UNFORTUNATELY, ON THE THIRD DAY OF HIS ICU STAY, DAY 7 AFTER THE CAR CELLS WERE INTRODUCED, HE BECAME ACUTELY HYPOXIC, DEVELOPS PULSELESS ELECTRICAL ACTIVITY. SO SIMULTANEOUSLY, HE WAS INTUBATEED, UNDER WENT CHEST COMPRESSIONS AND RECEIVED ADVANCED LIFE SUPPORT DRUGS. THE PROGNOSIS FOR PULSELESS ELECTRICAL ACTIVITY CAN BE QUITE DISMAL. AND SO ONE KEY FEATURE HERE WAS TO TRY TO DETERMINE A REVERSIBLE CAUSE OF HIS ARREST. YOU CAN SEE THE -- ONE REASON WHY HE BECAME HYPOXIC HERE, THERE IS AN TIME WINDOW BETWEEN THE FIRST CHEST X-RAY, WHICH SHOWS SOME INFILTRATES IN THE LUNG FIELDS, AND THE SECOND CHEST X-RAY WHICH WAS PERFORMED JUST FOLLOWING HIS INTUBATION, WHERE HE IS VERY EXTENSIVE BILATERAL INFILTRATES. AND PROBABLY A GENIUS HEART SIZE. GENEROUS HEART SIZE. BACK TO THE CODE. SO DURING THE NEXT HOUR OR SO, HE HAD RECURRENT ARRESTS, WHICH CONSISTED OF HYPOXIA, HYPOTENSION AND BRADYCARDIA, WHICH HE REQUIRES CPR, MULTIPLE BOLUSES OF EPINEPHRIN. HE CONTINUED ON THE INFUSION. HE PAO2 WAS ONLY 5P WHICH IS, OF COURSE, VERY LOW. VENUS OXYGEN SATURDAYUATION WAS 36%. LOWER LIMIT OF NORMAL IN OUR LAB IS 70. WE WERE DESPERATELY SEARCHING FOR OTHER REVERSIBLE CAUSES OF HIS PEA, AND SO IN CONSULTATION WITH THE HOME TEAM, WE ADDED A GRAM OF SOLE YOU MED DOCTORAL, A VERY LARGE DOSE, ALSO SPECIFIC IL6 THERAPY. THERE HAD BEEN SOME PRIOR CASES OF CYTOKINES STORMS IN WHICH THIS THERAPY HAD ALLOWED THE PATIENT TO ERROR OVER A PERIOD OF MANY -- RECOVER OVER A PERIOD OF MANY HOURS. OUR HOPE WAS IF WE CONTINUED TO TREAT HIM, THAT HE WOULD RECOVER WITH TIME. UNFORTUNATELY, IF HE HAD A CYTOKINE RELIEF SYNDROME, HE ALSO HAD PROBLEMS WITH HIS HEART. THIS IS FOUR CHAMBER VIEW OF HIS HEART ON THE DAY HE CAME TO THE ICU. THIS IS THE LEFT VENTRICLE, THE RIGHT, AND THE ATTREA. THIS IS IN THE PARI ARREST PERIOD. YOU CAN SEE THAT THE WALLS AREN'T MOVING VERY WELL. AND THESE ARE SHORT AXIS VIEWS IN THE SAME TIME ON THE LOWER SCREENS. AND CLEARLY, HIS LEFT VENTRICULAR FUNCTION HAS DETERIORATED AND LEFT VENTRICLE HAS DILATED T LEFT VENTRICULAR EJECTS FRACTION ON THIS FILM, ON THESE PICTURES ON THE DAY HE ARRESTED WAS PROBABLY IN THE 20 TO 25% RANGE. SO WE CONTINUED TO RESUSCITATE HIM. AND FOR THE NEXT 3 AND A HALF HOURS EVERYBODY FIVE TO TEN MINUTES HE DEVELOPED PULSELESS ELECTRICAL ACTIVITY. AT ONE TIME HE DEVELOPED TACHYCARDIA, FOR WHICH HE WAS SHOCKED. HE HAD VERY FREQUENT CHEST COMPRESSIONS, AND EPINEPHRIN BOL HE IS. RENAMED ON NOR EPEN HE HAVE AFRICAN. BECAUSE OF CONCERN THAT CARDIO GENIC SHOT WAS A MAJOR CONTRIBUTOR, HE HAD ESCALATING DOSES OF INO TRIPS, INCLUDING EPINEPHRIN AND LATEDER [INDISCERNIBLE]. HE PROGRESSIVELY DEVELOPED SEVERE METABOLIC ACID DOSIS. WE SHOCKED HIM FINALLY, SORRY, WE PARALYZED HIM BECAUSE HE -- TO REDUCE HIS WORK OF BREATHING. WE WOULD NOT HAVE CHOSEN TO DO THIS, BECAUSE THE COMBINATION OF STEROIDS AND PAR ALYTICS IS NOT A GOOD ONE IN THE ICU, AND FREQUENTLY, LEADS TO A CRITICAL ILLNESS MYOPATHY. NOW, OVER THIS SAME TIME PERIOD, THERE WAS TOILETEDERS OF PULL -- TWO LITERS OF PULMONARY FLUID REMOVED FROM HIS TUBE. THAT MEANS THAT EVERY FIVE TO DENY MINUTES, THE THERAPISTS SUCTIONED HIS TUBE. LIKE LOOKING AT WATER RUNNING FROM A TAP. BUT IN OUR MIND, THE REAL QUESTION WAS, WAS THERE ANYTHING ELSE THAT WE COULD TO IN THIS SOMEWHAT DESPERATE SITUATION. FOR SOMEONE WHO HAD UNDERGONE RESUSCITATION FOR 3 AND A HALF HOURS. AND BY -- IN THE SAME TIME PERIOD, HIS LACTATE HAD RISEN TO 17. WHICH, AGAIN, IS NOT A GOOD SIGN. UNFORTUNATELY, HE HAD BEEN TURNED DOWN -- HE WAS NOT A CANDIDATE FOR EXTRA CORP PORIAL MECHANIC BECAME OXYGENATION, OR ECMO, BECAUSE THIS WOULD REQUIRE HIM TO BE ANTI-SYSTEMICALLY COAGOUATED FOR THE MEM RAIN, AND WOULD -- MEMBRANE, AND WOULD REQUIRE COAGO LAYINGS SUPPORT FOR PLACEETS FOR VERY LARGE LINES BY A SURGEON. IT'S QUESTIONABLE WHETHER HE COULD HAVE BEEN TRANSFERRED FOR THIS. GIVEN HIS DIRE SITUATION. THE ISSUE OF BALLOON PUMPING IS A LITTLE MORE CONTROVERSIAL. WE HAD RECEIVED AN OPINION THAT THE CHILD SHOULD NOT GET A BALLOON PUMP, BECAUSE THE AORTA IN CHILDREN IS VERY DISTENSIBLE. THE BALLOON PUMP WOULD NOT AUGMENT HIS SYSTEMATIC PRESSURE. WHAT IS PUTTING IN A BALL LOAN PUMP MEAN? IT MEANS THAT YOU HAVE TO PLACE THE PUMP IN THE FEMORAL ARTERY, AND THREAD IT INTO THE DESCEND ING AUTHOR RASIC AORTA, ATTACH IT TO THIS MACHINE, AND THEN HOPEFULLY -- THE PUMP DEFLATES -- DEFLATES AROUND INFLATES -- SUPPORTS DID I AS TOLLIC PRESSURES. THIS IS USE OF A PUMP IN A NORMAL INDIVIDUAL. OUR PATIENTS' HEART DID NOT LOOK LIKE THIS. THE LEFT VENTRICULAR EJECTS WAS WORSE, DESPITE THE UNCERTAINTY ABOUT THE USE IN CHILDREN, WE DECIDED TO PLACE A BALLOON PUMP. THAT WAS DONE LATER IN THE AFTERNOON. SO WHAT WE HOPED THE BALL LOAN PUMP WOULD DO FOR THIS PATIENT? NORMAL BALL OWN PUMP -- BALLOON PUMP FUNCTION ALIGNS DESIST TOLLIC PRESSURE DURING NORMAL FUNCTION, AS DOES THE DECEMBER TOLLIC PRESSURE. YOU WOULD NOT THINK THAT THE MEAN PRESSURE SHOULD FALL, IT RISES BECAUSE OF DIASTOLIC AUGMENTATION OF PRESSURE. AND SOMEWHAT TO OUR SURPRISE, THE SAME SORT OF THING HAPPENED IN THE PATIENT, THE SYSTOLIC PRESSURE FELL. THERE WAS NOT MUCH EFFECT ON DIASTOLIC PRESSURE, BUT THE MAIN PRESSURE ROSE BECAUSE OF DICE TOLLIC AUGMENTATION OF PRESSURE. NOW, DURING THE NEXT FEW HOURS THE PATIENT'S CONDITION STABILIZEED. AND BY THE NEXT MORNING, THE PATIENT WAS -- HAD THE BALLOON PUMP STILL IN PLACE AND HAD A SMALL DOLES OF EPINEPHRIN INFUSING, BUT THE PRESSERS, MANY OTHER DRUGS, THESE HAD BEEN WITHDRAWN. AND HE CONTINUED TO IMPROVE. THE DETERIORATION IN LIVER FUNCTION AND RENAL FUNCTION THAT IS OFTEN EXPECTED IN CONDITIONS OF HYPOTENSION, ALSO, DRAMATICALLY IMPROVED OVER THE NEXT FEW DAYS. AND THIS IS A SUMMARY OF HIS TIME IN THE ICU. WE THOUGHT THAT CONTRIBUTORS TO HIS DETERIORATION -- TO HIS PROBLEMS WERE A DEGREE OF CARDIO GENIC SHOCK AND ALSO CYTOKINE RELEASE SYNDROME. ON DAY 7, HE HAD THIS VERY SERIOUS, SOMEWHAT UNPRECEDENTED EVENT UNWHICH HE REQUIRED MORE THAN 4 HOURS OF CONSTANT CPR, AND SUCKS SUCCESSIONING AND DRUGS. HE WAS GIVEN IL6, AND HAD A BALLOON PUMP PLACED AS A BRIDGE SUPPORT HOPING HIS PROBLEMS WOULD REVERSE OWNED HE WOULD IMPROVE. THE BALLOON PUMP WAS REMOVED 3 DAYS LATER. HE WAS EXTWO BAITED 6 DAYS AFTER THIS EVENT, BUT DAY 13, AFTER THE CAR CELLS WERE GIVEN. AND ON DAY 16, HE WAS TRANSFERRED TO THE INPATIENT FLOOR. ALL OF THESE EVENTS REQUIRED TEAMWORK, REALLY, BAY THE ICU, ESPECIALLY THE NURSES AND RESPIRATORY THERAPISTS, AND VERY CLOSE COLLABORATION WITH THE PRIMARY SERVICE. SO BACK TO DR. RUBIN. >> THE PATIENT RETURNED TO THE PEAKED UNIT OF THE -- PEDIATRIC UNIT ON THE 16th DAY AFTER THE THEY WILL INFUSION. HE QUICKLY RETURNED BACK TO BASELINE. HIS ACTIVITY IMPROVED VERY QUICKLY. HE WAS STARTING TO WALK VERY LONG DISTANCES, HE WOULD BEG US TO LEAVE THE UNIT SO THAT HE COULD WANDER AROUND THE CAMPUS. AND HE INSISTED ON HAVING A STATIONERY BICYCLE IN WRIST WHOM SO HE COULD RIDE UP TO AN HOUR A DAY ON THE BICYCLE. HE STAYED IN THE HOSPITAL UNTIL DAY 27, BEFORE BEING DISCHARGED. AND BY 32, WE FELT HE WAS IN GOOD ENOUGH SHAPE TO RETURN BACK HOME. BEFORE LEAVING, ABOUT DAY 28 AFTER THE CELL INFUSION HE HAD A FURTHER EVALUATION FOR DISEASE. HE HAD A BONE MARROW BIOPSY, SHOWED NO EVIDENCE OF LYMPHOBLASTIC LEUKEMIA, HAD A PET SCAN DONE, SHOWED NO EVIDENCE OF DISEASE. AND TWO MONTHS LATER HE WAS BACK HOME AND MUCH IMPROVED QUALITY OF LIFE, HE WAS RIDING A LUGE IN OLYMPIC PARK FEELING VERY GOOD. AS I MENTIONED EARLIER, THE STANDARD THERAPY TO TREAT VERY DIFFICULT -- TO TREAT LEUKEMIA WHEN YOU GET THEM ENREMISSION, THE IDEA WOULD BE GO TO A BONE MARROW TRANSPLANT TO KEEP THEM IN REMISSION. UNFORTUNATELY, BECAUSE OF THE SIDE EFFECT THAT HE HAD SUFFERED THROUGHOUT HIS ENTIRE COURSE OF CHEMOTHERAPY, AND THROUGH THIS COURSE OF TREATMENT, HIS HOME PHYSICIAN TEAM DECIDED HE WAS MEDICALLY INELIGIBLE FOR A BONE MARROW TRANSPLANT, FEELING THAT HE POTENTIALLY WOULD NOT BE ABLE TO SURVIVE IT. HE HAD NO FURTHER THERAPY AFTER THIS COURSE. UNFORTUNATELY, MARCH, 2014, NEARLY 67 MONTHS AFTER THE INITIAL CELL INFUSION, HE DID RELAPSE WITH PARTIAL CD19 NEGATIVE LEUKEMIA BLASTS. TALK ABOUT THE BONE MARROW EVALUATION, DOCTOR. >> SO THE PATIENT'S FIRST BONE MARROW BIOPSY AT THE NIH PRIOR TO CAR THERAPY SHOWED EXTENSIVE DISEASE. THIS IS FROM THE BONE MARROW ASPIRATE. AS YOU CAN SEE, THERE IS A MARKED INCREASE IN MON NOTTIS, IMMATURE CELLS. THIS IS IRISH OF THE ASPIRATE SMEAR, AND YOU CAN SEE THESE CELLS HERE THAT ARE SO-CALLED HAND MIRROR CELLS. THESE ARE SMALL CELLS THAT HAVE A HI RATIO, FINE DISBURSED CHROME TONE, AND AGRANULAR CYTOPLASM THAT FORMS OWE SO-CALLED CYTOPLASMIC EURO POD THAT RESEMBLED THE HANDLE OF A HAND MIRROR. IN THE OLD DAYS, THIS SO-CALLED HAND MIRROR CELL MOREer MORE FOLLOWING WAS CONSISTENT WITH ACUTE LYMPHOBLASTIC LEUKEMIA, AS OPPOSED OPPOSED TO A ACUTE MILE LLOYD LEUKEMIA. THIS IS AN STAIN OF THE CORE BIOPSY. WHAT WE SEE HERE IS A LACK OF NORMAL -- REPLACEMENT OF NORAL ELEMENTS BY THESE VERY IMMATURE CELLS. HERE IS A MYTOSIS. THERE IS ANOTHER MYTOSIS HERE. THIS INDICATES THAT THESE CELLS HAVE A VERY HIGH PROLIFERATIVE RATE. THIS IS THE IMMUNOHISTOCHEMISTRY THAT WE PERFORMED ON THE CORE BIOPSY. THIS IS CD34, SHOWS THE IMMATURE CELLS ARE DEFUSSLY POSITIVE FOR CD34. CD34 IS A MARKER POSITIVE IN HEMATOPOIETIC STEM CELLS, ALSO ENDOTHELIAL CELLS, AS WELL AS, ON IMMATURE BLASTS AND ACUTE BLASTIC LEUKEMIA AND ACUTE MILE LLOYD LEUKEMIA. IN A NORMAL, WE WOULD SEE 1-2% THAT ARE POSITIVE SO THIS IS GROSSLY ABNORMAL. THESE ARE ALSO POSITIVE FOR TDT, A MARKER EXPRESSED ON VERY IMMATURE LIMP OF LYMPHOID CELLS AND CD79A, A SIMILAR MARKER TO CD19, IS POSITIVE. ADDITIONALLY, CD10 WAS POSITIVE IN THESE CELLS SO THIS IMMUNOPHENOTYPE IS DIAGNOSTIC FOR ACUTE PREB CURSER -- ACUTE LYMPHOBLASTIC LEUKEMIA. SO POST CAR THERAPY, THIS PATIENT WAS MOTORED VERY CAREFULLY, HAD A NUMBER OF BONE MARROW BIOPSIES IN THE FIRST FIVE MONTHS. REMARKABLY, ALL OF THE BIOPSIES WERE IN THE FIRST FIVE MONTHS, SHOWED NO EVIDENCE OF LEUKEMIA. HERE IS AN EXAMPLE OF TWO SMEARS. IN CONTRAST TO THE PRETREATMENT, WE NOW SEE MATURING MILE LLOYD PRECURSORS AND ERYTH RODE, AND GO INCREASE IN BLASTS. THIS IS ONE OF THE CORE BIOPSIES. NOW WE CAN SEE MEGACURIOUS SITES. THERE ARE MATURING EWRITHE RHODE ISLAND AND MILE LLOYD CELLS. WE HAVE HEMAMAT OPPOSESIS IN THE MARROW. WHEN WE LOOK AT CHESTTRY IN STRIKING CONTRAST, WE LOOK AT CD 4 , WE CAN SEE EVALUATE CAN YOU LAR ENDOTHELIUM, AND A FEW POSITIVE CELLS, LESS THAN 5%. TDT IS NEGATIVE, AS IS CD79A. BASED ON MORPHOLOGY, THESE ARE CONSISTENT WITH REMISSION MARROW. ONCE THE BLASTS FALL TO LESS THAN 2 TO 4% IN THE BONE MARROW, MORE FOLLOWING AND IMMUNOHISTOCHEMISTRY ARE NOT THE BEST METHODS GORE DEFECTING DISEASE. TO DETECT IT WE NEED A VERY SENSITIVE METHOD SUCH AS FLOW CYTOMETRY, AND THAT WILL BE DISCUSSED SHORTLY. SO THE MOST RECENT BONE MARROW BIOPSY THAT WE HAVE FOR THIS PATIENT AT THE 6 MONTH TIME POINT AFTER CAR THERAPY, SHOWED EVIDENCE OF RECURRENT DISEASE. THIS IS THE ASPIRATE SMEAR, AND WE CAN SEE BLASTS HERE. THIS IS THE CORE BIOPSY, PROBABLY DITCH TO SEE HERE BUT THERE -- DUSTOFFS -- DIFFICULT TO SEE HERE, BUT THERE ARE IMMATURE CELLS HERE. WHEN WE LOOK IN CONTRAST TO THE PREVIOUS POST TREATMENT BIOPSIES, THERE IS PRETTY SUBSTANTIAL INCREASE IN CB34 POSITIVE CELLS, APPROACHING ABOUT 50%, WHEN WE LOOK AT TDT WE SEE AN INCREASE IN POSITIVE CELLS AND CD79A, SO THIS IS CONSISTENT WITH RELAPSE AT 6 MONTHS. SO NEXT WE'LL REVIEW THE FLOW CYTOMETRY FINDINGS. >> WE RECEIVED A NUMBER OF BONE MARROW AND PREFERERAL BLOOD IN THIS PATIENT, STARTING WITH THE INITIAL BONE MARROW PRIOR TO CAR THERAPY. IF YOU LOOK -- LET ME -- OIF YOU LOOK -- LOOK AT CD45 VERSES LIGHT SCATTER. CD45 IS AN ANTIGEN EXPRESSED BY LINEAGE CELLS. AND WHEN WE LOOK AT IT ALONG WITH LIGHT SCAT MUCH CHARACTERISTICS, WE CAN DIFFERENTIATE ALL THE ELEMENTS OF A BONE MARROW. IN PINK WE HAVE GRANULACYTES. MOPO CITES. MATURE LYMPHOID CELLS. OVER HERE, PRECURSORS, AND ALSO HERE WE HAVE OUR BLAST REGION. IN THAT BLAST REGION THERE IS THIS BIG POPULATION OF CELLS IN RED. AND THESE ARE THE PATIENTS LYMPHOID BLASTS. IF WE LOOK AT THE RED ONES, LOOK AT CD19, YOU CAN SEE THEY'RE ALL CD19 POSITIVE. WHEN WE LOOK AT CD10 VERSES CD34, TWO ANTIGENS EXPRESSED IMMATURE LYMPHOBLASTS, YOU CAN SEE THEY ARE ALL CD10, AND CD19 -- CD10 AND CD34 POSITIVE. AND THESE RED CELLS, EACH DOT REPRESENTS A SINGLE CELL. LOOKING AT CD38 VERSES CD58, TWO OTHER ANTIGENS EXPRESSED, YOU CAN SEE CD58 POSITIVE AND THERE IS CD38 POSITIVE, ALTHOUGH THIS IS A LITTLE DIM FOR NORMAL B CELL EMPLOYEE ACCUSERS. SO -- PRECURSORS. SO POST CAR THERAPY. WHEN WE LOOK AT THE BONE MARROW ASPIRATED. IT NORMALLY CONTAINS IMMATURE B CELLS, WHERE THEY'RE DEVELOPED AND MATURE. SO WHEN WE LOOK AT THIS PATIENT'S BONE MARROW POST THERAPY, WE LOOK AT CD45 VERSES SIDE SCATTER. THE GRANUILOUS SITES, THERE ARE A LOT MORE. YOU CAN SEE THEM IN PINK, AND SEE THE MONOCYTES IN TURQUOISE. AND THE MATURE LYMPHOID CELLS, PRECURSORS. WE DON'T SEE THIS BIG RED CELL POPULATION IN THE BLAST REGION. THAT'S MISSING. IF I SUPER IMPOSE THE ALL CELLS OVER THIS NORMAL APPEARING BONE MARROW, YOU CAN SEE WHERE THEY WOULD ACURE IN RED. THEY DO NOT OCCUR HERE. IF WE JUST LOOK AT THE BLAST CELL REGION, LOOK AT CD19 VERSUS CD '4, WE HAVE SEVERAL POPULATIONS, BUT THESE ARE NORMAL MATURING B CELLS. VERY IMMATURE ONES, INTERMEDIATE, AND THE FULL CD45 BRIGHT 19 POSITIVE LYMPHOID CELLS. WE DO NOT SEE THE CELLS IN THE REGION WHERE THE A.L.L. CELLS WERE. IF WE SUPER IMPOSE THE CELLS OVER THIS, YOU CAN SEE WHERE THEY WOULD FALL. WE DO NOT SEE THEM IN THIS NORMAL BONE MARROW. WHEN WE LOOK AT CD10 VERSES CD 4 , YOU NORMALLY HAVE PRECURSORS IN BONE MARROW, NORMAL. THE MOST IMMATURE. THEN THEY LOSE CD34 AND, 34 NEGATIVE, AND THIS IS A NORMAL PATTERN. WE DO NOT SEE ANY CELLS CELLS WHERE THE A.L.L. CELLS WERE BEFORE. IF I SUPER IMPOSE THE A.L.L. BLASTS OVER THIS IN RED YOU CAN SEE WHERE THEY WOULD OCCUR. THEY'RE NOT THERE. AND THEN PERHAPS MOST USEFUL, IS LOOKING AT CD38 VERSES CD58. NORMALLY, WE SEE A SPECTRUM OF CD58 IN B CELLS AS THEY MATURE. AND THEY'RE VERY BRIGHT FOR CD38. WHEN YOU LOOK AT THE AREA OF THE A.L.L. CELLS WE SEE NO CELLS. IF I SUPER IMPOSE THE A.L.L. BLASTS OVER THIS, YOU CAN SEE THEY'RE MISSING FROM THIS NORMAL BONE MARROW. SO WE WERE ABLE TO SHOW THERE IS NO EVIDENCE OF RESIDUAL DISEASE. WE LOOKED AT THE PREFERERAL BLOOD TO LOOK AT THE CAR POSITIVE T CELLS. IF YOU LOOK AT DAY ONE OF INFUSION. THIS IS LOOKING AT THEY THEY WILLS. NONE OF THE T CELLS HAVE CAR POSITIVITY. BY DAY 11 WE HAD A DRAMATIC EXPANSION OF THE CAR POSITIVE T CELLS SO NOW 79% OF THE T CELLS ARE CAR POSITIVE. HOWEVER, BY DAY 55, WE NO LONGER HAVE THE CAR POSITIVE T CELLS. THEY HAVE BEEN ELIMINATED FROM THE PERIPHERAL BLOOD. WHAT HAPPENED TO THE B CELLS DURING THIS TIME PERIOD? IF YOU LOOK BACK AT DAY ONE, AND WE LOOK AT THE CD19 POSITIVE CELLS, YOU CAN SEE WE HAVE TWO POPULATIONS. IN RED, WE HAVE THE ACUTE LYMPHOBLASTIC LEUKEMIA CELLS 34 POSITIVE, AND 19 POSITIVE AORTA LONG THE Y AXIS. WE ALSO HAVE IN GREEN NORMAL B CELLS A FEW OF THEM, CD34 NEGATIVE AND CD19 POSITIVE. THIS IS THE DAY OF INFUSION. DAY 11 WHEN WE HAVE SEARCH A LARGE NUMBER OF CAR T CELLS YOU CAN SEE WE HAVE NO 19 POSITIVE B CELLS. THEY'RE ALL GONE. THE A.L.L. BLASTS ARE GONE, SO ARE THE NORMAL B. CELLS. BY DAY 55 IF WE LOOK, YOU CAN SEE THAT CD19 POSITIVE NORMAL B. CELLS IN GREEN HAVE RETURNED, HOWEVER, THE ACUTE LYMPHOBLASTIC LEUKEMIA CELLS HAVE NOT. SO THIS IS RETURN OF NORMAL B CELLS IN THE A.L.H. CELLS STILL NOT THERE. THE RELAPSE SPECIMEN THAT WAS RECEIVED DEMONSTRATED ACUTE LYMPHOBLASTIC LEUKEMIA. HERE WHEN WE LOOK AT CD45 VERSES LIGHT SCATTER YOU CAN AGAIN SEE IN PINK, THE NORMAL GRANULAR SITE, IN TURQUOISE, MONO SITES, BLUE. LYMPHOID CELLS, THE PRECUSTOMERS IN GREEN, AND THE AL.L. CELLS IN RED. SO THOUGH ARE THE RETURNING A.L.L. CELLS. WHEN WE LOOK AT THOSE A.L.L. CELLS THERE, WE LOOK AT CD19 AND 22, THESE ARE TWO MARKERS THAT ARE PRESENT IN NORMAL IMMATURE B CELLS IN THE BONE MARROW. THEY'RE BOTH PRESENT. SHOULD ALL BE DOUBLE POSITIVE. THEY'RE ALSO POSITIVE ON A.L.L. CELLS. THIS PATIENT, YOU CAN SEE THAT THE MAJORITY OF A.L.L. CELLS ARE 19 POSITIVE AND TWO POSITIVE. HOUR -- 22 POSITIVE. THERE IS A SUBPOPULATION THAT LOST CD19 EXPRESSION. SOME ARE CD19 NEGATIVE. WHEN WE LOOK AT CD19 VERSUS CD, SO CD19 ON THE EXAXIS, CD10 ON THE Y, A.L.L. CELLS HAVE BRIGHT CD10 EXPRESSION. WE CAN SEE WE HAVE THE EXPECTED CD19 POSITIVE, CD10 POSITIVE A.L.L. CELLS. BUT SOME OF THE BLASTS HAVE LOST CD10, RETAIN CD -- CD19, EXCUSE ME, STILL RETAIN CT10. LOOKING AT CD 4 , HERE ARE NORMAL B CELLS PRESENT, 19 POSITIVE, 34 NEGATIVE. THE MAJORITY OF THE BLASTS ARE CD19 POSITIVE, CD34 POSITIVE. BUT THERE IS, AGAIN, THIS POPULATION THAT LOST CD19 POSITIVITY. >> THANK YOU VERY MUCH. SO I'D LIKE TO TAKE A QUICK STEP BACK TO OUR PATIENT, AND ASK THE QUESTION, WE HAVE A TEENAGER WHO HAD A GREAT QUALITY OF LIFE AT THE TIME. WHY WOULD HE OR WOULD WOULD WE WANT HIM TO POTENTIALLY GO THROUGH A THERAPY THAT HAS SIDE EFFECTS WE'VE DESCRIBED HERE? IT'S IMPORTANT TO REMEMBER THAT ALTHOUGH HIS QUALITY OF LIFE WAS GOOD, HE HAD PROGRESSIVE DISEASE. AND HE HAD EXHAUSTED ALL OTHER PROVEN THERAPY. REMEMBER, THAT WHEN HE CAME TO US, HIS BONE MARROW HAD BEEN COMPLETELY REPLACED WITH BLASTS. HE HAD SIGNIFICANT AMOUNTS OF CIRCULATING BLASTS AS WELL T WRITING WAS ON THE WALL FOR HIM. AND HE KNEW IT. WITHOUT ANY ADDITIONAL INTENSIVE THERAPIES, HIS QUALITY OF LIFE WOULD BECOME POOR QUICKLY. SO HAVING EXHAUSTED ALL PROVEN CUTERIVE THERAPY, HE WAS LEFT WITH INVESTIGATIONAL THERAPIES. NOW, WHAT'S GREAT ABOUT CAR T CELLS, THIS IS NOT JUST ANOTHER DRUG. IT HAS A NOVEL MECHANISM OF ACTION. IN ADDITION WHAT WE ALLUDED TO EARLIER, THERE HAVE BEEN SEVERAL CASE REPORTS MOSTLY IN ADULTS, OF SOME IMPRESSIVE ANTI-TUMOR ACTIVITY. SO FOR THIS PATIENT, WHO IS IN DIRE STRAIGHTS FOR HIS DISEASE HE HAS FIGHTING ALL HIS LIFE IT SEEMED A REASONABLE OPTION TO TRY. RECOGNIZING THAT IT STILL HAD SIGNIFICANT POTENTIAL RISKS. TAKING A FURTHER STEP BACK, EVERYBODY THINKS THAT ACUTE LYMPHOBLASTIC LEUKEMIA IN CHILDREN, WE'VE MADE GREAT STRIDES IN THE PAST DECADES AND WE HAVE. THE VAST MAJORITY OF PATIENTS WHO ARE DIAGNOSED WITH A.L.L. AS CHILDREN, ENTER REMISSION AND WITH THE APPROPRIATE THERAPY, HAVE LIFE LONG CURES. HOWEVER, DESPITE THIS, A.L.L. STILL REMAINS THE -- A LEADING CAUSE OF DEATH DUE TO MALCY IN CHILDREN. -- MALIGNANT IN CHILDREN. THIS IS DUE TO THE PATIENTS THAT RELAPSE. SO IF FOR THOSE PATIENTS THAT RELAPSE WITHIN A YEAR-AND-A-HALF OF INITIAL DIAGNOSIS OF A.L.L., THEIR SURVIVAL, LONG TERM, IS QUITE DISMAL HERE. AND IT'S NOT MUCH BETTER FOR THOSE PATIENTS THAT RELAPSE MORE THAN 3 YEAR FROM THEIR INITIAL DIAGNOSIS. THESE URN IMPRESSIVE CURVES ARE BEING ATTAINED THROUGH THE USE OF MULTIPLE ROUNDS OF HIGHLY INTENSIVE CHEMOTHERAPY CHEMOTHERAPY, AND EVEN MYELOBLAT I HAVE TRANSPLANTATION, ALL OF WHICH CARRY WITH THEM SEVERE SIGNIFICANT ACUTE AND CHRONIC TOXICITIES. SO FOR THESE REASONS IT'S CLEAR THAT NEW THERAPIES FOUR A.L.L. ARE STILL NEEDED. AS I MENTIONED ONE SUCH POTENTIAL THERAPY ARE CAR T CELLS. HERE IN THIS CARTOON, I'VE DEMONSTRATED A CLASSIC CAR RECEPTOR HERE. IT HAS THREE MAIN COMPONENTS. THE EXTRA CELLULAR PORTION IN OUR CASE IS PART OF AN ANTIBODY THAT TARGETS THE MOLECULE, CD19 WHICH IS PRESENT ON THE TUMOR CELL. THAT INDIANA -- ANTIBODY REGULATION OCCURS THROUGH -- THE INTERN PARENTS INCLUDE TWO SIGNALING DOMAINS, CD3 ZETA AND CD328. WE KNOW THAT FOR ATHRILL TO BE FULLY ACTIVATED. IT REQUIRES TWO SIGNALS. THESE HAPPEN INDEPENDENTLY OF EACH OTHER, USUALLY. THEY REQUIRE FIRST CD3 ZETA AND THEN -- THERE ARE MANY TYPES OF THESE. WE'VE CHOSEN TO USE CD28. THIS IS ONE OF THE MAJOR ADVANTAGES OF CAR T CELL THERAPY OVER OTHER TYPES OF T CELL RECEPTOR BASED THERAPIES. THROUGH ONE SINGLE INTERACTION WITH ITS TARGET, THE CAR ACTIVATES THE T CELL COMPLETELY, PROVIDING BOTH SIGNALS 1 AND 2 SIMULTANEOUSLY. LEADING TO COMPLETE ACTIVATION. ALTHOUGH CARS NEED TO BE SPECIFIC FOR A SURFACE PROTEIN, WE DO -- THE OTHER MAJOR ADVANTAGE THAT CARS OVER -- COMPARED TO T CELL RECEPTOR ARE FREE OF THE MHC RESTRICTIONS. WE CAN USE THIS RECEPTOR IN ANY PATIENT REGARDLESS OF THEIR HLA PHENOTYPES OR GENOTYPES. FINALLY WHAT, DOES A CAR T CELL DO? WHAT DOES IT REALLY DO? WHEN IT SEES ANTIGEN IT GETS ACTIVATED. IT KILLS THE TARGET BUT DOES OTHER THINGS. THIS LEADS TO THE SIDE EFFECTS WE HAVE BEEN DISCUSSING. THEY PRODUCE SIGNIFICANT AMOUNTS OF INFLAMMATORY CYTOKINE. AND ALSO, THE CAR T CELLS THEMSELVES BEGIN TO PROLIFERATE MULTIPLE TIMES. ANOTHER DAUGHTER CELL, SINCE THE QUEEN IS STABLY INTEGRATED, ALSO CARRIES THE CAR GENE WITH THEM. SO THAT CELL, THE INITIAL CELL CAN GO ABOUT AND FIND ADDITIONAL TUMOR ANTIGENS, TUMOR TARGETS TO KILL, AS WELL AS ALL THE DAUGHTER CAR T CELLS. SO THIS SETS UP AGED FORWARD LOOP OVER TIME AND CAN LEAD TO SIGNIFICANT TOXICITY, AS WE'VE SEEN. SO IN THE PEDIATRIC ONCOLOGY BRANCH WE SKIED TO OPEN UP A PHASE ONE CLINICAL TRIAL. WE RECENTLY COMPLETED IT. PRIMARIRY ENDS POINTS WERE SAFETY, FEASIBILITY, INCLUDING CD19 CAR T CELL EXPANSION. WE WANTED TO EVALUATE THE ANTI-DO YOU MEANER RESPONSE. WE DID A DOSE ESCALATION, STARTING AT 1 MILLION CAR T CELLS PER HILO GRAM. PATIENTS WERE BETWEEN 1-30 YEARS, HAD A RELAPSED REFACTORY, POSITIVE LYMPHOBLASTIC LEUKEMIA OR NON HODGKIN'S LYMPHOMA. WE DID ALLOW AND WE WERE THE FIRST PROTOCOL TO ALLOW PATIENTS WITH PRIOR ALLOGENIC BONE MARROW TRANSPLANTATION TO BE ENROLLINGED IN THE PROTOCOL. SO ALL PATIENTS THAT WERE ENROLLED WERE TREATED WITH CAR T CELLS. THEY CAN BE INFUSED IN AS SOON AS 11 DAYS AFTER WE COLLECT THE T CELLS FROM THE PATIENT. THIS GIVE A QUICK OVERVIEW OF THE PROCESS. FIRST, THE LYMPHOCYTES ARE COLLECTED DIRECTLY FROM THE PATIENT REGARDLESS OF BONE MARROW TRANSPLANT STATUS. AFTER COLLECTION, THE T CELLS NEED TO BE ACTIVATED. THIS IS ACCOMPLISHED THROUGH THESE BEADS THAT ARE COATED WITH TWO ANTIBODIES, CD3 AND CD28. SOUNDS FAMILIAR. BOTH OF THESE DEVELOPING STORY ACTIVATE THE T CELLS. THIS HAPPENS OVER TWO DAYS. AND DURING THIS ACTIVATION PERIOD, THE T CELLS ARE MORE READILY TRANSDUCED WITH THE CHIMERIC ANTIGEN RECEPTOR. ACCOMPLISHED, EXPOSED TO THE T CELLS IN CULTURE FOR TWO DAYS. AFTER INTEGRATION, THEY'RE EXPANDED EX VIVO IN THE PRESENCE OF IL-2 FOR AN ADDITIONAL PERIOD OF TIME UNTIL THEY'RE INFUSED BACK INTO THE PATIENT. THE PATIENTS HAVE UNDERGONE A DEPLETING CHEMOTHERAPY REGIMENT. AT THE DOLES YOU SEE HERE. IT'S IMPORTANT TO NOTE THIS REGIMENT IS NOT INTENDED DO HAVE SIGNIFICANT ANTI-LEUKEMIA EFFECTS. RATHER, IT'S LIMBO DEPLETING. SO IT DEPLEATS -- THE IDEA IS TO DEPLETE THE PATIENT OF RESIDUAL T CELLS, THERE BY INCREASING THE HOMEOSTATIC CYTOKINES THAT SUPPORT T CELL EXPANSION AND GROWTH AT THE TIME WHEN WE GIVE CAR T CELLS BACK TO THE PATIENT AT DAY ZERO. SO AFTER WE INFUSE THE CELLS, THE PATIENTS ARE THEN EVALUATED AND MONITORED FOR TOXICITY. THE DISEASE STATUS ARE REEVALUATED AROUND DAY 28. SO FAR, WE HAVE ENROLLED 20 PATIENTS AND HAVE INFUSED ALL 20. 2 DATA I'LL PRESENT ARE ON THE FIRST 19. CURRENTLY AVAILABLE. MEDIUM AGE, 13 YEARS, ALMOST ALL THE PATIENTS HAD LEUKEMIA. IMPORTANTLY, WE HAD FOUR PATIENTS WHO WERE REFRACTARY PATIENTS. THAT MEANS THAT TIME OF INITIAL DIAGNOSIS, THEY RECEIVED INDUCTION CHEMOTHERAPY CHEMOTHERAPY AND DID NOT RESPOND. THEY WENT OPTO RECEIVE MULTIPLE OTHER ROUNDS OF INDUCTION CHEMOTHERAPY, WITH DIFFERENT AGENTS. AND AGAIN, THEY DID NOT RESPOND. SO THEY'VE NEVER ENTERED REMISSION. WE ALSO HAD TWO PATIENTS WITH CENTRAL NERVOUS SYSTEM INVOLVEMENT OF LUKE. AT THE TIME OF THEIR CAR T CELL INFUSION. ALL THE PATIENTS WERE HEAVILY PRETREATED WITH CHEMOTHERAPIES. NINE PATIENTS HAD ONE PRIOR BONE MARROW TRANSPLANTATION. FOUR HAD PRIOR IMMUNOTHERAPY, ONE PATIENT HAD CAR T CELL THERAPY AT A DIFFERENT INDUCE. WE FOUND OUR MANUFACTURING WAS 90% FEASIBLE. WE HAD TWO PATIENTS WHERE THE T CELLS DID NOT GROW WELL, DUE TO MULTIPLE FACTORS. IMPORTANT TO NOTE THAT EVEN THOUGH THEY DIDN'T GROW WE INFUSED BOTH THE PATIENTS WITH WHAT WE WERE ABLE DO ACHIEVE. EVEN THE DOSE WAS LESS THAN WHAT WE ASSIGNED THEM, ONE OF THOSE TWO PATIENTS HAD A COMPLETE RESPONSE. SO A BIT ON THE DEFINITIONS OF -- YOU NEEK TO LEUKEMIA. THIS TERM, MINIMAL RESIDUAL DISEASE NEGATIVE, MRD NEGATIVE. THIS INDICATES A PATIENT HAD A COMPLETE RESPONSE, NO DETECTABLE DISEASE BUT HAVE HAD NO DETECTABLE DISEASE BY THE MOST NEGATIVE TEST WE HAVE AVAILABLE TO US AT THIS TIME, WHICH IS FLOW CYTOMETRY. IN CONTRAST, THE PATIENT MRD POSITIVE IS A PATIENT WHO IS IN A MORPHOLOGIC REMISSION, BUT HAS DETECTABLE LEUKEMIA BY GLOW CYTOMETRY. WHEN WE LOOK AT THE WATER FALL PLOT OF A.L.L. PATIENTS, HAIR ON THE Y AXSIZES, WE HAVE CHANGE. SOME PATIENTS DID NOT RESPOND. SOME PATIENTS IN ORANGE HAD STABLE DISEASE, 12 PATIENTS WITH A 19A.L.L., WHO HAD COMPLETE RESPONSES. TWO OF THOSE PATIENTS SHOWN IN THE LIGHT BLUE WERE MRD POSITIVE, THE VAST MAJORITY WERE MRD NEGATIVE. THIS LEADS TO AN INTENT TO TREAT ANALYSIS OF A 63% RESPONSE RATE. IF YOU LOOK DID HE.L.L. PATIENTS, 67% OF COMPLETE RESPONSE RATE IN THOSE. OVERALL SURVIVAL, ALTHOUGH FOLLOW UP IS SHORT WITH A MEDIUM FOLLOW UP 8 MONTHS, 55%. AND MOST TRIKINGLY, IN THESE PATIENTS THAT AREVIEWED AN MRD NEGATIVE REMISSION, IF WE FOLLOWED THOUGHT PATIENTS FORELOCK LUKE-FREE SURVIVAL. -- LEUKEMIA-FREE SURVIVAL, EVERY PATIENT WHO WENT ON TO GET A BONE MARROW TRANSPORTATION, THE CALENDAR OF CARE FOR SUCH A PATIENT, IS -- REMAINED DISEASE-FREE. THERE WERE TWO PATIENTS INCLUDING THE PATIENT WE DISCUSSED TODAY, WHO WERE NOT ELIGIBLE FOR BONE MARROW TRANSPORTATION, AND UNFORTUNATELY, BOTH OF THEM HAVE RELAPSED WITH NEGATIVE DISEASE. SOPHIC YOU WANTED TO FOLLOW THE PROLIFERATION OF THE CAR T CELLS IN THESE PATIENTS. NOT A BIG SURPRISE, PATIENTS WHO RESPONDED THEY WERE MORE PEAK LEVELS OF CAR T CELLS IN THEIR CIRCULATING BLOOD THAN PATIENTS THAT DID NOT RESPOND. THESE CAR CELLS, ALSO PENETRATED INTO THE -- PENETRATED THE BLOOD BRAIN BARRIER. SO REMEMBER, WE HAD TWO PATIENTS WITH CNS LEUKEMIA, BUT IN THE TEN OUT OF 167 PATIENTS WHERE WE HAVE CFS, THERE WAS EVIDENCE OF CAR T CELLS. IN ONE WHO IS VERY HIGH. 80% OF THE T CELLS EXPRESSED IN CAR. NOT ONLY DID THEY PENETRATE THE CFS. IN THE PATIENTS THAT HAD INVOLVEMENT OF LEUKEMIA, AS YOU CAN SEE IN THE RED. WE HAVE THE BLAST COUNT. AND THE TOTAL CFS SPACE. THIS DECREASES OVER TIME. AND THE CAR T CELLS SHOWN IN BLUE ARE INFUSED AND MIGRATE TO THE CFF AND EXPAND. THIS IS EVEN MORE DRAMATIC HERE IN THIS PATIENT. THIS IS ACCOMPLISHED WITHOUT THE USE OF FURTHER CHEMOTHERAPY. SO WE DID DEFINE THE MAXIMAL TOLERATED DOSE S MILLION PERKILO GRAM. THE SIDE EFFECTS WE SAW, SOME WERE EXPECTED SUCH AS EFFECTS OF CHEMOTHERAPY LIKE CYTOPENIAS, FEVER, AND ELECTROLYTE DISTURBANCES, THE DOSE WAS THIS ENTITY CYTOKIND RELEASE SYNDROME. IT IS A SYNDROME BUT IT INVOLVED HIGH FEVER, CHILLS, MYALGIAS, CAN INVOLVE HYPOTENSION, HYPOXIA, NEUROLOGIC CHANGES OR OTHER ORGAN DYSFUNCTION. AND THE PATIENT THAT WE REVIEWED TODAY, OF COURSE, HAD GRADE 4CRS. A HIGH FEVER, LYINGERS AND CHILLS, SEVERE HYPOTENSION, AROUND THE SYMPTOMS ON THE SLIDE. SO WHAT EXACTLY IS CAUSING THIS CYTOKINE RELEASE SYNDROME? THIS A SIMPLIFIED CARTOON THAT I PUT TOGETHER. IT ACTUALLY IS RELATED TO TWO MAIN CYTOKINES WE BELIEVE AT THIS POINT. HERE IS A -- T CELL THAT HAS THE CAR IN IT, IN PROXIMITY WITH THE BLAST WITH THE CD19 ANTIGEN. ONCE THEYIORITY ACT, THE CAR T CELL KILLS THE BLAST. BECOMES ACTIVATED AS WELL. ACTIVATED CAR T CELL PROPOSEDUCE, AMONG OTHER THINGS, INTERFERON GAMMA. THIS IS ONE INFLAMMATORY CYTOKINE. INTERFERON GAMMA HAS MANY FUNCTIONS, ONE IS TO RECRUIT OTHER T CELLS BUT ALSO IMMUNOEFFECTER CELLS. IT'S THESE CELLS, THE SPECIFICS THAT I WON'T GO INTO, THAT PRODUCE THE IL6, ANOTHER INFLAMMATORY CYTOKINE. TOGETHER, THE IL6 AND INTERFERON-GAMMA ARE DRIVING THE DEVELOPMENT OF CYTOKINE RELEASE SYNDROME. THERE IS MORE TO IT. THESE ACTIVATED CAR T CELLS GO OFF AND FIND ANOTHER BLAST OR PERHAPS THEIR PROGENY IN CAR T CELLS DO, AND THEY KILL THAT BLAST, AND THEY, THEMSELVES BECOME ACTIVATED OR MORE ACTIVATED PRODUCING MORE INTERFERON-GAMMA LEADING TO THIS FEED FORWARD LOOP WE HAVE BEEN DISCUSSING, AS WELL AS CONTINUED ACTIVATION OF THE ANOTHER IMMUNE EFFECTERS, MOW PRODUCTION OF IL6, AND TOGETHER, LEAD TO EXACERBATED CRF IF LEFT UNCONTROLLED. SO I MENTIONED THESE TWO CYTOKINES. WHAT EVIDENCE DO WE HAVE? SO IN ALL OUR PATIENTS WE HAVE EVALUATED, PATIENTS WITH SEVERE CRS, GRADE 3 OR 4 HAD HIGHER CHANGES IN IL6 SHOWN ON THE TOP AND INTERFERON-GAMMA ON THE BOTTOM. PATIENTS WHO DID NOT HAVE IT OR LOW GRADE. AND WHEN WE LOOK AT THE CYTOKINE PROFILE IN OUR PATIENT WE HAVE BEEN DISCUSSING, HERE I'VE SHOWN THE CYTOKINDS PLOTTED ON THE LEFT Y AXIS, ON THE RIGHT IS THE C REACTIVE PRONE SERVING AS A SURROGATE MARK THAT ARE WE CAN EVALUATE IN REAL TIME. THESE RESULTS ARE NOT AVAILABLE. YOU CAN SEE AT THE TIME OF CAR T CELL INFUSION, THREE DAYS AFTER, INTERFERON-GAMMA AND IL6 BIN TO ROSE COINCIDING WITH THE ON SET OF FEVER. A FEW DAYS LATER THEY SKYROCKET, WHEN A PATIENT BECOMES SEVERELY HYPOTENSIVE AND ACQUIRES TRANSFER. AT DAY 7 INDICATED BY DOTTED LINE RESTED, RECEIVED STEROIDS AND AN ANTI-IL6 MONO COLONIAL ANTIBODY FDA APPROVED. AND IMMEDIATELY AFTER -- SOON AFTER THE ADMINISTRATION OF THE DRUG IN OTHER PATIENTS, AND SOON AFTER IN THIS PATIENT, THE FEVER GOES DOWN AND THE CARDIOVASCULAR STATUS BEGINS TO IMPROVE. WE HAVE HAD 6 PATIENTS WITH GRADE 3 OR 4CRS IN TOTAL. HAD TO TREAT FOR OF THEM WITH DRUGS AND TWO OF THOSE TREATED WITH STEROIDS. SO THIS REALLY, THIS HIGH LIGHTS THE FACT THAT T CELLS ARE QUITE POWERFUL. BUT THIS IS NOT A NEW PHENOMENON. BACK IN 2006, THERE WAS A PHASE 1 STUDY OF THIS COMPOUND WHICH IS A MONO COLONIAL ANTIBODY AGAINST THE CD28 MOLECULAR. NOT JUST AN ANTIBODY, IT'S A SUPER AGONIST OF THAT SIGNALING PATHWAY. THE INVESTIGATORS IN THE STUDY INFUSED 6 HEALTHY, COMPLETELY HEALTHY MEN, TEN MINUTES APART WITH A MINUSCULE AMOUNT OF THIS ANTIBODY. EVERY SINGLE ONE OF THOSE HEALTHY MEN, WITHIN AN HOUR OF RECEIVING THE INFUSION, HAD MULTIPLE ORGAN FAILURE REQUIRING ICU ADMISSION AND MONTHS OF RECOVERY. ALL THE THRALLS WERE ACTIVATED SIMULTANEOUSLY. NOW, IN THE CAR T CELL WORLD HAVE NOT SEEN SUCH DRAMATIC OWNED QUICK CRS TOITATE, HOWEVER, THERE HAVE BEEN SOME PROBLEMS. ENTIRE TO THE PATIENT WE HAVE DISCUSSED HERE, EXTRAMURAL SITES HAVE EXPERIENCED AS MUCH AS 3 DEATHS, TWO IN APRIL. OTHER PATIENTS HAVE HAD INTRACTABLE SEIZURES, ONE INSTITUTION THERE IS A 25% REPORTED OR PAEDIATRIC INTUBATION RATE. AND WHEN YOU LOOK DOWN THE ROAD, THERE ALREADY ARE MULTIPLE -- MANY CAR T CELLS PROTOCOLS OPEN ACROSS THE WORLD. LOOKING DOWN THE ROAD, THERE ARE MANY, MANY MORE THAT ARE BEING DEVELOPED, FOR MANY DIFFERENT MALLCIES -- MALIGNANCYIES, PEDIATRIC AND ADULT. EVEN THOUGH THIS IS POTENTIALLY DANGEROUS, WHAT'S IMPORTANT TO REALIZE IS THAT THIS IS -- THIS A HAS THE BENEFIT FOR GREAT BENEFIT. AND MIGHT BE BIASED BUT THE EDITORS OF SCIENCE GOT IT RIGHT WHEN THEY SAUD CANCER IMMUNOTHERAPY OR T CELLS MORE SPECIFICALLY ARE THE BREAK THROUGH OF THE YEAR. IF WE HARNESS THIS POWER WE NEED TO DO IT RESPONSIBLY, SO A STANDARDIZED APPROACH TO GRADING AND MANAGEMENT OF CRS IS NECESSARY. SO THE ONCOLOGY BRANCH IS A MEMBER OF THIS CONSORTIUM OF INSTITUTIONS ACROSS THE U.S. AND CANADA THAT YOU SEE HERE, AS PART OF THIS STAND UP TO CANCER, AS BART OF THIS DREAM TEAM. THE GOAL OF THE TEAM IS TO USE THE INFRASTRUCTURE AVAILABLE CURRENTLY TO RAPIDLY DEVELOP NEW IMMUNOTHERAPEUTICS LIKE CAR T CELLS AND OTHER ANTIBODY CONJUGATES. BUT A GROUP OF US, WHO HAVE OPEN CAR C19 TRIALS GOT TOGETHER AND RECOGNIZED THIS PROBLEM WITH CRS. THAT THIS COULD POTENTIALLY BE THE BIG THREAT TO THIS THERAPY MOVING FORWARD. SO ACTUALLY, JUST LAST WEEK, WE PUBLISH OWED PAPER IN BLOOD HOW WE TREAT CYTOKINE RELEASE SYNDROME IN AN EFFORT TO ESTABLISH A SYSTEMATIC BREATHING SYSTEM AND TREATMENT ALGORITHM. I'LL BRIEFLY DESCRIBE IT HERE. OUR CRS GOES FROM GRADE ONE TO FIVE. AND JUST ALL PATIENTS, WHO HAVE CRS, HAVE FEVER, FIRST OF ALL. IF YOU'RE GRADE ONE, YOU HAVE FEVER. AS YOU PROGRESS IN THE GRADE 2 YOU START TO HAVE ORGAN DYSFUNCTION. OR YOU BEGIN TO HAVE HYPOTENSION. AND THIS IS USUALLY EASILY MANAGED, WITH IV FLUIDS ALONE OR LOW DOSE PRESSERS, AS PATIENTS PROGRESS TO GRADE 3, THEY HAVE MORE SEVERE ORGAN DYSFUNCTION, AND THEIR PLOP IS MORE DIFFICULT TO CONTROL. YOU HAVE END ORGAN FAILURE OR DYSFUNCTION, AND THEN GRADE 5, DEATH. SO THIS IS IMPORTANT BECAUSE NOW WE HAVE A GRADING SYSTEM THAT'S UNIFORM, BUT IT ALSO HELPS TO INFORM WHEN -- AS THIS THERAPY IS EXPORTED, WHEN SHOULD THERAPY BE IMPLEMENTED? ALL PATIENTS WITH CRS REGARDLESS OF GRADE SHOULD RECEIVE VIGILANT SUPPORTED CARE AND CLOSE MONITORING. THIS CAN CHANGE QUICKLY. FOR PATIENTS WHO RISE TO A GRADE 3, THEY SHOULD HAVE ANTIOXIDANT CYTOKINE THERAPY IMPLEMENTED. SO DESPITE ALL THESE ISSUES I THINK THE FUTURE OF CAR T CELLS AT LEAST IN THE PEDIATRIC BRANCH IS BRIGHT. WE DO RECOGNIZE THAT SEVERE CRS IS MORE LIKELY IN PATIENTS THAT HAVE HIGHER DISEASE BURDENS. I DID NOT SHOW THAT DATA HERE. SO ON THE NEW VERSION OF OUR COMPREHENSIVE AMENDMENT TO THIS PROTOCOL WE'RE GOING TO IMPLEMENT THIS ALGORITHM THAT I'VE DESCRIBED, WITH THE GOAL OF ACHIEVING A GREAT FOUR CRS, LESS OR EQUAL TO TEN PERCENT. BECAUSE OF PATIENTS WITH HIGH DISEASE BURDEN ARE MORE LIKELY TO HAVE CRS, WE AIM TO TREAT THOSE PATIENTS WITH CHEMOTHERAPY. SO THAT WE CAN ACTUALLY DECREASE THEIR DISEASE BURDEN TO A LEVEL WHERE ITEMING MIGHT REDUCE THE RISK OF GRADE 4CRS, AFTER CAR T CELL INFUSION. WE BELIEVE THAT THIS WILL INCREASE THE LIKELIHOOD OF A RESPONSE, AND IT WILL BE A STEP TOWARD INCORPORATING CARS IN UP FRONT THERAPIES. IN ADDITION, A CD22 PROLL IS OPENING, THIS SUMMER. ALREADY ENROLLIS, THERE IS A CAR T CELL PROTOCOL FOR SARCOMA. SO TO SUMMARIZE, I THINK WE'VE ILLUSTRATED THAT THE POTENTIAL FOR TOXICITY, USING CAR T CELLS, CD19, AS ILLUSTRATIVE EXAMPLE, OUR PATIENT WE HAVE DISCUSSED HAS INFORMED MODIFICATIONS AND IMPROVED THE SAFETY FOR FUTURE PATIENTS. BUT HE AND OTHERS HAVE ALSO TAUGHT US THAT CRS CAN BE REVERSIBLE IF IT'S MANAGED APPROPRIATELY, AND MAY BE AVOIDABLE IF MANAGED EARLY. AND FINALLY, CD19 CAR T CELL EXPERIENCE PROVIDED PROOF OF PRINCIPAL THAT MODERN THERAPY IS COMING INTO ITS OWN, THAT AT LEAST FOR A.L.L., PROBABLY WILL OATHER FUTURE LEEK TREATMENT PARADIGMS. AND HOPEFULLY, THROUGH THAT, MITIGATE THE CHRONIC TOXICITY ASSOCIATED WITH YEARS AND YEARS OF CHRONIC CHEMOTHERAPY. THERE ARE MANY, MANY TO THANK. I HEIGHT A FEW HEAR. -- HIGHLIGHT A FEW HERE T CLINICALIC FELLOWS AND NURSING STAFF ARE ON THE FRONT LINES. THE ICU TEAM, I'LL SAY IT PHENOMENON, WAS ABSOLUTELY PHENOMENAL IN THIS CASE. NEVER SEEN A BETTER RUN RESUSCITATION IN MY CAREER. AND I THINK THOSE COMMENTS CAME FROM MANY OTHER PEOPLE AS WELL. THE ICU LED THE RESUSCITATION. THIS WAS EXCELLENT FELLOWS, NURSING, SUPPORTIVE STAFF, RESPIRATORY THERAPISTS WHO REALLY STEPPED UP AND IT'S BECAUSE OF THEM, AND SOME EARLY INTERVENTION WITH ANTI-CYTOKINE THERAPY, THAT THE PATIENT IS STILL ALIVE TODAY. DR. LETTERMAN PLACED INTERARORITYIC BALLOON PUMP. HE'S OUT OF TOWN TODAY. AND CELL PROCESSING SECTION. THE FLOW CYTOMETRY LAB, INSTRUMENTAL IN PROVIDING US VALUABLE INFORMATION ON A PROLIFERATION OF OUR CAR T CELLS, ASSISTED BY OTHER STAFF. AND OF COURSE WE GET OUR T CELLS FROM THE DOUBLELING CLIPIC -- DOWLING CLINIC. RETROVIRAL VECTOR WAS SUPPLIED FOR US, AND THANK YOU TO STAND UP FOR CANCER FOR THEIR ONGOING SUPPORT. >> THANK YOU VERY MUCH. FOR THAT EXCELLENT PRESENTATION. BEFORE WE OPEN THIS PRESENTATION UP FOR QUESTIONS, I WOULD LIKE TO REITERATE THE ROLL OF OUR CPC, WHICH IS REALLY TO LOOK AT PATIENTS, THEIR DISEASE PROCESSES AND OUTCOMES GLOBALLY AND PUBLICLY, TO GET INPUT FROM COLLEAGUES IN THE CARE OF THESE COMPLEX PATIENTS. ALSO URGE THOSE PRESENT TODAY TO GET IN TOUCH WITH ME TO SUBMIT POTENTIAL CANDIDATE CASES FOR FUTURE CPP GRAND ROUND TO BE REVIEWED BY OUR PLANNING CHITTY AND AORTA LOU US TO CONTINUE THIS IMPORTANT EDUCATIONAL EFFORT. THANK YOU FOR YOUR TIME AND ATTENTION.