Immunotherapy is defined as the approach to treating cancer by generating or augmenting an immune response against it.

1. Immune Cell Therapy

2. Out line
• Introduction
• CAR Therapy
• CAR Generation
• Other Type Of CAR
• FDAApproved CAR
• Immune Checkpoints
• Adverse Effects
• Challenges
• Sum Up
• Assignment Questions
• References

3. Introduction

6.  Immunotherapy is defined as the approach to treating cancer by
generating or augmenting an immune response against it.
 Two types of immunotherapy have emerged as particularly effective
over the past decade:
1. immune-cell-targeted monoclonal antibody (mAb) therapy
2. adoptive cellular therapy (ACT).

7.  The goal of adoptive T-cell therapy is to generate a robust immune-
mediated antitumour response through the ex vivo manipulation of T
cells.
 This aim can be accomplished through the:
1. selection and expansion of tumour-infiltrating lymphocytes (TILs)
2. gene transfer of a synthetic TCR (sTCR)
3. chimeric antigen receptor (CAR) into T cells

10. CAR Therapy

13. CAR Generation

17. Other Type Of CAR

18.  TanCAR
 CAR-T cell therapy with CRISPR platform
 CAR modified NK cells
 CAR-Macrophage
 CAR-T Cells With PD-1 Antibody
 physiological CAR (receptor/ligand-based)
 universal CAR (biotin/avidin-based)
 VHH-based CAR
 γδ CAR-T
 etc.

19. TanCAR
 The design of a biphasic CAR (tandem CAR - TanCAR),a
single transgenic receptor which recognizes two distinct
antigens, offers synergistic killing and enhanced function.
 The recognition domains for the two different antigens are
in tandem and separated by a flexible hinge.
 This strategy enables bypassing antigen loss and tumor
escaping; if one target antigen is downregulated or mutated,
TanCAR is still functional and preserves the cytolytic ability
of T-cells

21. • The CD19/CD133 Tan-CAR triggered robust cytotoxicity against CD19+CD133+MLL leukemic cells…
• Importantly, the CD19/CD133 TanCAR retained cytotoxic activity towards CD19− MLL leukemic cells due to
their high CD133 expression levels.
• These results suggested that the TanCAR may be an effective solution for treating MLL-rearranged B-ALL,
with the additional benefit of preventing antigen escape relapse.

22.  Universal CAR-T cells can be derived from healthy donors and applied to treat
multiple patients. In this situation, we can use CRISPR technology to eliminate
the αβ T-cell receptor (TCR) on allogeneic CAR-T cells to avoid graft-versus-
host-disease (GVHD). Meanwhile, human leukocyte antigens class I (HLA-Is)
on CAR-T cells can also be removed to minimize their immunogenicity.
 Considering blocking programmed death-1 (PD-1) signaling can effectively treat
cancers via reversing immunosuppression, we are also capable of targeting PD-1
in CAR-T cells to render them nonresponsive to PD-1 signaling. Other T cell
inhibitory signaling molecules can also be modified in this way.
 Notably, these Cas9-based gene-editing techniques can also enable the disruption
of the virally targeted chemokine receptors in T cells. Thus CCR5 and CXCR4
can be eliminated from the T cells for HIV patients.
Application of CRISPR/Cas9 in CAR Therapy

23. FDAApproved CAR

24. October 18, 2017
$373,000

26. May 1, 2018
$475,000

28. The blockade of immune
checkpoints in cancer
immunotherapy

29.  T cell inhibitory receptors or signaling molecules, such as
CTLA-4, PD-1, LAG-3, and TIM-3 are naturally occurring
“off signals” to ensure proper control of T cell response.

31.  The expression of these inhibitory receptors on CAR-T cells leads to
T cell exhaustion.
 Recent studies showed tumor cells use this characteristic for immune
evasion, for example, tumor cells upregulated PD-1 ligand that
causes reduced immune responses.
 Therapeutic approaches specifically designed to target and inhibit
these inhibitory receptors by immune checkpoint related antibodies,
such as anti-PD-1, PD-L1 and CTLA-4, displayed great success.
 The reported successes of inhibiting these inhibitory signals by
related antibodies have led to the use of CRISPR/ Cas9 technology
to destroy them.

35. Adverse Effects

36.  cytokine-release-syndrome (CRS) is a constellation of
symptoms derived from the cytokines released by activated
T cells and/or activated macrophages
 managed with the administration of antibodies targeting the
IL-6 pathway

37.  Neurotoxicity occurs in approximately 40% of patients and is characterized
by aphasia, seizures, ataxia, delirium and other disturbances of the nervous
system.
 In the vast majority, the symptoms are fully reversible, but in a small
number of patients it led to cerebral oedema and death and mortality rates
are below 5%.
 CAR-T cells can induce endothelial cell activation in the central nervous
system, resulting in increased permeability and coagulopathy; a low ratio of
angiopoietin 1 (ANG1) to ANG2 then results in dysregulated endothelial
cell activation and a breakdown of the blood–brain barrier. These data raise
the prospect that approaches for normalizing the ANG1/ANG2 ratio could
prevent or reverse the syndrome.

38.  Another potential side effect of CAR T-cell therapy—an off-target
effect—is a mass die off of B cells, known as B-cell aplasia.
 CD19 is also expressed on normal B cells, which are responsible for
producing antibodies that kill pathogens. These normal B cells are also
often killed by the infused CAR T cells.
 To compensate, many patients must receive immunoglobulin therapy,
which provides them with the necessary antibodies to fight off infections.

39. Challenges

40.  Solid tumours present three unique challenges not seen in B-ALL:
Firstly, when compared with B-ALL, their microenvironment can be
considerably more immunosuppressive
Secondly, antigen selection is, in general, more difficult because the
antigen heterogeneity across the same malignancy is generally higher in
solid tumours
Thirdly, ‘on-target, off-tumour’ toxicity is more problematic because
potential target antigens in solid tumours are more likely to be expressed
in other essential organs.

42. Outlook
 The next generation of CAR technology is moving towards the
development of multifaceted smart T-cell machines that can:
(1) simultaneously target multiple antigens;
(2) be regulated either via small molecules or via intrinsic sensors;
(3) be modified by gene editing to augment potency and endow resistance to
suppressive factors present in the tumour microenvironment;
(4) Be equipped with recognition programs to discriminate between cancer
and healthy cells;
(5) have intrinsic fail-safes and/or suicide switches.
Bridging principles of immunology with recent developments in synthetic
biology and genetic engineering will drive the development of the next
generation of CAR-T therapies.

44. Assignment Questions
1. Off the shelf cell therapy
2. One way to overcoming solid tumor limitation
3. Using CAR T cell for other type of disease
4. Some other immune checkpoints
5. Combination therapy
6. The Activation Of Co-stimulatory T-cell Receptors
To Control Cancer

45. References
1. Grada Z, Hegde M, Byrd T, Shaffer DR, Ghazi A, Brawley VS, et al. TanCAR:
A Novel Bispecific Chimeric Antigen Receptor for Cancer Immunotherapy.
Mol Ther Nucleic Acids. 2013;2:e105.
2. June CH, Sadelain M. Chimeric Antigen Receptor Therapy. N Engl J Med.
2018;379(1):64-73.
3. Khalil DN, Smith EL, Brentjens RJ, Wolchok JD. The future of cancer
treatment: immunomodulation, CARs and combination immunotherapy. Nat
Rev Clin Oncol. 2016;13(5):273-90.
4. Miliotou AN, Papadopoulou LC. CAR T-cell Therapy: A New Era in Cancer
Immunotherapy. Curr Pharm Biotechnol. 2018;19(1):5-18.
5. Mollanoori H, Shahraki H, Rahmati Y, Teimourian S. CRISPR/Cas9 and CAR-
T cell, collaboration of two revolutionary technologies in cancer
immunotherapy, an instruction for successful cancer treatment. Hum Immunol.
2018;79(12):876-82.
6. Zhang C, Liu J, Zhong JF, Zhang X. Engineering CAR-T cells. Biomark Res.
2017;5:22.