Autologous aGVHD Associated with Infusion of T-Cells with Engineered Specificity for NY-ESO-1 and Lage-1 Following High-Dose Melphalan and ASCT in Patients with Multiple Myeloma

Autologous stem cell transplantation (auto-SCT) is uncommonly associated with acute graft-versus-host disease (aGVHD)-like syndromes that are typically mild and self-limited; incidence is increased when auto-SCT is coupled with infusion of ex vivo expanded/costimulated T-cells. We describe here a gastrointestinal GVHD-like syndrome in multiple myeloma (MM) patients treated with auto-SCT and T-regulatory-cell (T_reg)-depleted, autologous T-cells genetically modified to express a T-cell receptor with engineered specificity for a HLA-A*02-restricted epitope common to cancer-testis antigens NY-ESO-1 and LAGE-1. Subjects were HLA-A2⁺ and had high-risk MM with confirmed target expression. After initial therapy, T-cells were harvested via apheresis for transduction and culture with anti-CD3/-CD28-antibody-conjugated microbeads. Stem cells were then mobilized with cyclophosphamide +/- bortezomib. Subjects received melphalan 200 mg/m² on day -2 and >2 x 10⁶ CD34⁺ cells/kg on day 0. On day +2, autologous T-cells were infused (avg. 9x10⁹, range 7-10x10⁹; gene-modified avg. 33%, range 18-38%). Of the first 3 subjects treated, all developed persistent fever and grade 3-4 diarrhea beginning between days 2-7. Abdominal imaging was obtained in 2 subjects and demonstrated marked wall thickening in the small and large bowel. Bowel biopsies from all subjects demonstrated aGVHD. The syndrome resolved spontaneously on day +37 in subject #1, but subjects #2 and #3 required immunosuppression with steroids. With recognition of this syndrome, prophylactic administration of oral budesonide and beclomethasone was implemented. The syndrome was then observed in only 1 of 7 subsequently treated subjects; in this subject, symptoms developed only after prophylactic budesonide was discontinued due to inability to administer the drug while the subject was ventilator-dependent with pneumonia. In subjects #2 and #3, bowel biopsy specimens were assayed by qPCR for the presence of the engineered cells, which were found to be present in all biopsy specimens from both subjects. Q-RT-PCR analysis of biopsy tissues showed absence of transcripts for both NY-ESO-1 and LAGE-1 antigens and accumulation. In conclusion, immunotherapy with T_reg-depleted, NY-ESO-1/LAGE-directed autologous T-cells after high-dose melphalan is associated with a steroid-responsive and preventable immune enteritis possibly mediated by infiltration of the GI tract by the engineered autologous T-cells.