Marco Becilli

Background: Autoimmune hepatitis (AIH) is a rare immune-mediated disease potentially leading to liver failure, ultimately requiring liver transplantation when it fails to respond to conventional immunosuppressive therapy (IST) or when adverse effects associated with immunosuppressants necessitate their discontinuation. Therefore, novel and better tolerated options are urgently needed in these cases. Bispecific T-cell engagers (BiTEs) have recently shown efficacy for the treatment of refractory autoimmune disorders (ADs). We used blinatumomab, a CD3/CD19-targeting BiTE, to treat a 16-year-old boy with an atypical AIH, seronegative for classical AIH-specific autoantibodies, with primary sclerosing cholangitis and scleroderma-like skin and joint involvement, refractory to several lines of conventional IST, including rituximab. Case Description: Two cycles of blinatumomab were administered at a dose of 30 µg/m²/day over 28 days and 3 months apart. Ongoing immunosuppressants were tapered prior infusion to enhance T-cell effector function. Disease activity was monitored through clinical evaluation, laboratory tests, B-cell phenotyping, and liver imaging. The treatment was well tolerated, with no severe adverse events. Mild cytokine release syndrome and transient lymphopenia were observed. B-cells were promptly depleted and pre-treatment detected autoantibodies levels (anti-parietal cell antibodies), although not specific for AIH or juvenile localized scleroderma (JLS), decreased up to normalization. The patient experienced substantial improvement in morphea-like skin lesions, subcutaneous thickening and joint mobility. The alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels, temporarily increased during IST tapering before blinatumomab infusion, rapidly returned to normal values, allowing further tapering of immunosuppression, and remained normal 5 months after blinatumomab infusion. A backbone of IST, with a reduced dose of mycophenolate mofetil (MMF), was maintained. Continuous remission of the signs of cholangitis was documented at the magnetic-resonance imaging (MRI). Conclusions: These findings suggest that blinatumomab may represent a promising and safe alternative for selected cases of recalcitrant ADs, including AIH. In our patient, it allowed reduction of IST to the lowest dose ever received, sparing the patient from chronic IST-related side effects. Caution is warranted in fully attributing the observed improvements to blinatumomab, as a low dose of mofetil mycophenolate was maintained, and further studies are needed to confirm these responses and evaluate long-term outcomes.

Autologous second-generation CD7-directed chimeric antigen receptor T cells, expressing an anti-CD7 protein expression blocker to prevent self-killing fratricide, were infused in 3 pediatric/young adult patients with relapsed/refractory CD7+ acute myeloid leukemia, resulting in measurable residual disease negativity. The safety profile was favorable.

Chimeric antigen receptor (CAR) T cell therapy was recently proposed as a treatment for adults with B-cell-mediated autoimmune diseases (ADs) refractory to conventional immunomodulatory therapy. We present a case series of eight children with severe/refractory AD (four systemic lupus erythematosus, three dermatomyositis, one systemic sclerosis) treated at Ospedale Pediatrico Bambino Gesù, Rome, and University Hospital Erlangen with a single infusion of 1 × 10⁶ kg⁻¹ point-of-care manufactured autologous CD19 CAR T cells (zorpocabtagene autoleucel), in a hospital exemption (HE) program. In Europe, the HE pathway offers the opportunity to treat patients with life-threatening or seriously debilitating disorders who lack valid therapeutic options, using an advanced therapy medicinal product (ATMP) authorized on a nonroutine, single-patient basis. In contrast to the ‘compassionate use’ pathway, the ATMP does not necessarily need to have undergone clinical trials or marketing authorization applications. Manufacturing was successful in all patients, yielding several drug product bags. Once infused after lymphodepletion, zorpocabtagene autoleucel cells expanded in vivo, promoting prompt B cell clearance. Grade 1 cytokine release syndrome was reported in six patients, and grade 1 immune effector cell-associated neurotoxicity syndrome was reported in one patient. Late-hematotoxicity was limited to grade 1 in two patients. All these adverse events were manageable and no severe infections occurred. With a median follow-up of 16.5 months (range = 9–24 months), all patients experienced a clinically substantial improvement/resolution of AD, as evidenced by reduction in disease activity scores and signs of reversal of organ damage. This improvement enabled sustained discontinuation of immunomodulators, even after B cell reconstitution. The activation of formal clinical trials enrolling children and adolescents is urgently needed to confirm these preliminary results and to assess the long-term safety of this approach.

The point-of-care, automated manufacturing of CAR T cells can reduce the waiting window and increase the therapy accessibility to patients with relapsed/refractory (r/r) BCP-ALL as compared to commercially available drug products (DP). We conducted a phase I/II trial (NCT04787263) on the use of 2nd generation (4.1BB), CD19-CAR T cells, for the treatment of BCP-ALL patients with either 1st relapse and very high-risk (VHR) characteristics or >2nd relapse and rapidly progressing disease preventing access to the commercial DP. CAR-T cells were manufactured with a 12-day process using CliniMACS Prodigy®, from a fresh apheresis and infused fresh. Three dose levels were tested in the phase I, namely 1.0, 2.0 and 3.0×106 CAR+T cells/kg. Nineteen pts were enrolled, 13/19 (68%) in first VHR relapse. The designed dose was always successfully produced. No dose-limiting toxicities were observed in the phase I. Grade 1-2 cytokine release syndrome was observed in 13/19 (68%) patients. Grade 1-2 immune effector cell-associated neurotoxicity syndrome occurred in 2 patients and resolved spontaneously. All patients achieved bone marrow complete remission with negative minimal residual disease. Eight pts (42%) received hematopoietic stem cell transplantation (HSCT) consolidation. Overall, CR was maintained in 13/19 patients (68%), 7 of them having received HSCT. Importantly, all patients but one treated with 3.0x106 CAR+T cells/kg maintain CR. The 3y-EFS and OS of the whole cohort are 68% and 83%, respectively. Our data suggest that the point-of-care, manufacturing of autologous, anti-CD19 CAR T cells can successfully treat patients with BCP-ALL including those with 1st relapse and VHR characteristics. (NCT04787263)

Background: Bloodstream infections affect up to 20% of pediatric cancer patients receiving intensive care, contributing significantly to morbidity and mortality, with infection-related mortality rates reported to be as high as 16%. Methods: The identification of microorganisms directly from whole blood is difficult due to several factors, such as interference from host genomic material, low bacterial load, the endogenous components of whole blood and exogenous substances, which can interfere with the identification process. Nevertheless, rapid microbial diagnosis remains of paramount importance in these patients. Results and Conclusion: Here, we present the first case of bacterial pathogen identification directly from whole blood using MALDI-TOF mass spectrometry in an onco-hematological pediatric patient affected by sepsis and admitted to Bambino Gesù Children’s Hospital (IRCCS) in Rome, Italy.

Supplemental Figure 10. In vivo experiment of NSG mice bearing D283 Med-GFP-FF-Luc cells treated with NT or CAR.GD2 T-cells.

Supplemental Figure 5. Real-Time killing assay of CAR.GD2 T-cells vs DAOY-GFP cell line.

Supplemental Figure 13. Evaluation of GD2 expression on DAOY cells pre and post treatment with Tazemetostat.

Supplemental Figure 4. Real-Time killing assay of CAR.GD2 T-cells vs D283 Med-GFP-FF-Luc cell line.