Total Health Oncology: Best of Heme 2025 Session 1

[00:00] Welcome to the second annual hematology conference. Thank you all for joining us. My name is Jessica Richter. I am a program coordinator at Total Health. I would like to take a moment and personally thank our program chairs for this meeting. Dr. Tappan Kadiya from MD Anderson Cancer Center and Dr. Elizabeth O'Donnell from the Dannafara Center.

[00:20] cancer Institute. Thank you for all of your help and please join me in welcoming them. Here with us in Vail we have a small group of KOLs and a limited number of exhibitors that will be with us for the entire day and we have hundreds of attendees join

[00:40] joining us online. At this weekend's conference we have some of the world's leading hematology cancer experts to discuss a variety of real world cases, all while incorporating data from the major annual meetings. Before we get started I'd like to go over a few housekeeping items in front of

[01:00] at your table you will find a program guide for the meeting. In this booklet you will see the agenda, Wi-Fi information, non-CME sessions, and the CME information. Because this is a hybrid meeting we want to be include as inclusive as we can to those who are tuning in virtually. If you haven't already please go to

[01:20] your app store and search for and download the Sevan Events App. Once you have the app downloaded, please search for the 2025 Best of Hematology Conference and select the event. Once you are in the event, you will be prompted to log in using the email you registered with. Once you are logged in, you will have

[01:40] access to the agenda, slide decks, speakers, and exhibitor information. If you have any questions during these presentations, you can click on the Q&A tab within the session to submit your questions. A member from my team will also be in the back of the room with a handheld mic for any questions so we can ensure you are heard in the room. Just please raise your

[02:00] hand and look for one of our team members, we will be in black. For our in-person attendees, we also have an exhibitor bingo raffle. If you didn't get the bingo raffle form when you checked in, please see one of our team members or visit the registration desk. Those who complete the form will be entered into a raffle and chosen at random to

[02:20] win a prize. We will be announcing that prize at the end of the conference. If you need any assistance throughout the meeting, please find a team member. Again, we will be in black and happy to help you. I hope you enjoy the program and that we have a great day.

[02:40] Thank you.

[03:00] is from Augusta University and he's going to present advances in leukemia, targeted treatments, and immunotherapy. Dr. Cortes, looking forward. Thank you very much for the kind invitation to be here and to be.

[03:20] among all these distinguished speakers, what they asked me to do is to talk about targeted therapies and immunotherapy in leukemia. And well, it's a little broad and they asked me to do it in 12 minutes. Yeah, right. So this is

[03:40] decided I cannot cover the whole thing in 12 minutes, so I'm just going to talk about whatever I want. And what I want to do is to focus it in a different perspective. A lot of these things that immunotherapy and target therapies you're going to hear about from some of my colleagues that are becoming about specific diseases.

[04:00] But I want to talk about some of the lessons that we learn about targeted therapy and the lessons that we still need to know to learn about targeted therapy, how it works and how it doesn't work, and how we overcome that. So I'm going to start with a CML. And as you know, a CML is a new tyrosine kind of disease.

[04:20] inhibitor. It is the first tyrosine kinase inhibitor that specifically targets this myristorial pocket, and because it binds in a different place compared to the traditional ATP-competitive inhibitors, it's affected by different mutations. So let me remind you how this works.

[04:40] structure of the BCR abel and abel before it's mutate, before it's rearranged and comes together with BCR abel. So normal abel, it has a mechanism of autoinhibition where the end terminal

[05:00] is meristorylated and then it binds in this pocket here that inhibits the activity of normal able. It comes to this close conformation that inhibits the activity. When this is detached, then it opens up and it is an activated kinase.

[05:20] What happens is when BGR is joined to ABLE, this myristol domain is lost and then the kinase is constantly activated. When a siminib is present, then it binds into this myristol pocket and it closes

[05:40] that conformation and inactivates the kinase. So that's how it works. It replaces that autoinhibition process that is normally present with ABLE when it's not bound together to PCR. Well, what happens is that as we started using a siminib, and this is data from

[06:00] the assembled trial, the randomized study, compared to prosutinib. We had great activity. You all know about the efficacy that led to the approval in patients that had received two prior lines of therapy or beyond. But then we also looked at the mutations that emerged in patients that had resistance to asymptomosis. And one thing that I wanted to talk about is the risk of asymptotic disease. And I want to talk about the risk of asymptotic disease. And I want to talk about the risk of asymptotic disease. And I want to talk about the risk of asymptotic disease. And I want to talk about the risk of asymptotic disease. And I want to talk about the risk of asymptotic disease. And I want to talk about the risk of asymptotic disease. And I want to talk about the risk of asymptotic disease. And I want to talk about the risk of asymptotic disease. And I want to talk about the risk of asymptotic disease.

[06:20] that was interesting is that, yes, we saw a few meristoidal pocket mutations, but many of the mutations were actually not meristoidal pocket mutations. And some of the ones that stand out is this F359V, which is relatively common in resistance to asymene, and this M244V.

[06:40] So the question is why are these mutations emerging on patients treated with asymvenive when initially we thought that those would be working for asymvenive? Well, when you look at the IC50 of asymptotic against different mutations, we know for example that

[07:00] T359 needs higher concentrations. That is why we use higher doses of acinetins in these patients with T359. We use 200 mg twice daily as opposed to the 40 mg twice daily or 80 mg once daily. So five-fold higher doses because of the much higher, you see it's about 10-fold higher

[07:20] concentrations for T359. But look at F359V. It's much higher concentrations, even higher than T359, and even some other mutations that have higher concentrations, the 252, higher concentrations than T359. And yet for those

[07:40] patients, there is no specific indication of using higher doses of asymptotic disease. So really, we don't yet have explored fully what is the right dose for each particular mutation. We've done it for T359 because it's a popular mutation. It's one that caught our attention. But there are other mutations that are

[08:00] partially sensitive only to asymptotic disease. Also, I highlighted two mutations, the M244V and the F359V that cause resistance to asymptotic disease. And actually, in vitro, we've seen that they are partially or fully resistant to asymptotic disease.

[08:20] So this is the structure again, and this is the close conformation. And you can see here that that 244 residue sits in that end lobe of the, of the, of ABLE. When that is mutated, it locks the, this SH2 domain.

[08:40] It locks it in that end-log domain and keeps the kinase in an active conformation. Even in the presence of an asymptote, it just locks it activated. It's this open conformation and therefore it does not cause inhibition. Asymptote doesn't cause inhibition.

[09:00] inhibition because of that interaction of 244 with the SH2 domain. The F359 is not in the meristoidal pocket, but it sits right outside of the meristoidal pocket and very close to this SH2 domain. So what appears to be happening is that it interferes

[09:20] with the binding of a siminib, even though it's not in the meristoidal pocket, and it also helps lock that active conformation of the F359. So clearly, it goes beyond just the meristoidal pocket mutations, and we definitely need to do a lot more work to understand what really

[09:40] individual scenarios, what works and what doesn't work. Another one that's very interesting is as you know, most of the patients have a break in the ABLE gene when BCR and ABLE come together before the exon too. So you know, the typical

[10:00] pharmacophthalmic culture that we use B3A2 and B2A2 for the different rearrangements. But there's a few patients, very few, but some that have a break in a different area. In some instances, exon 2 is gone and it's, let's say, a B2A3 or B3A3 instead of B2A2. Well, those patients

[10:20] Because that affects the structure and the localization of these SH2 and SH3 domains, it prevents them from binding in the inactive conformation and it locks it in the active conformation. So if you ever have a patient that has a B2, a B3 or a B2,

[10:40] those patients do not respond to a siminif. That is another area where we know that even though it has nothing to do with the meristural pocket, we're not going to see activity of a meristural pocket inhibitor, whereas we do see activity of the

[11:00] the ATP-competitive inhibitors. What about panatony? Where panatony, we know that we've done this study looking at the different doses and we established that 45 milligrams is the most effective dose compared to 30 or 15, that's become the standard.

[11:20] at these specific mutations, it is clear that the T359 mutation in particular is where you see the biggest difference. So clearly there you definitely need the 45 milligrams, and that's what we do. But then we have all the mutations lumped together. And there is a bit of a trend, but of course it's a mix of

[11:40] a lot of different mutations. If we go back to our IC50, and here I rearrange it, so now it's gone from lowest IC50 to higher IC50, you see again the T350 night. Sure, it has a higher IC50, therefore explaining why you need higher concentrations. But look where F350 is.

[12:00] and even some of the other ones that are more in the P loop. So there are other mutations that also benefit from higher concentrations of panatenate that we need to be aware of. And there's this interesting mutation that is a meristoidal pocket mutation, A337V. You saw it also

[12:20] Also at the bottom there you see how high concentrations is for asymptophilis. That makes sense. It's a meristul pocket mutation. Why does it need so many so high concentrations for monotony? It is unclear. It's not a common mutation. You're not going to see it. After the patient has only resistance to an ATP-competitive inhibitor, but you may see it after a

[12:40] and in that instance, ponatin is not the best way to go. You may have better log with, for example, the satin. So we're still learning about how all of these works and it's not as straightforward as we sometimes make it sound. And actually you see that in this article,

[13:00] optic study, some of the mutate, you know, when we treated patients that had some mutations, some of the residual mutations after therapy are some of these that I just mentioned, F359, E255. So showing that those mutations are clinically showing the resistance to this drug.

[13:20] Interestingly enough, on patients in vitro, we had seen that monotony, by concentrations of 49 or more or higher, would prevent the emergence of mutations. Well, we've seen that in the clinic. You see very few mutations emerge. If you use low concentrations, low doses, you see emergence of T359.

[13:40] If you use the higher concentrations, rarely do you see emergence of resistant mutations. And the one that has emerged is, again, 255, one of those at the bottom. So evidently this is a lot more complex than we have made it look. So just going back to the asymmetry.

[14:00] story, keep in mind there are sensitive mutations to Aciminib, there are some that have relative sensitivity or relative insensitivity, and then some that are insensitive. And the same thing for Ponatinib. So those with relative sensitivity, perhaps a dose change is what is needed.

[14:20] not a drug change, whereas those with complete insensitivity, we need a drug change. Let me move now to AML, and I'm going to talk about the FLI3 inhibitors. You all know, FLI3 is expressed nearly in all of the AML patients and FLI3 inhibitors.

[14:40] is expressed in all the myeloid progenitors. When it binds to its ligand, it triggers activation with proliferation and inhibits differentiation and so on. When we have the mutations, either the intended amtiloduplications or the kinase domain mutations, it is constitutably

[15:00] activated regardless of the ligand and that leads to this increased proliferation and inhibition of apoptosis, inhibition of differentiation, and so on. Well that led to the development of all these three inhibitors. You know them very well. There's a type I inhibitor that works both in the active and inactive conformation.

[15:20] the type 2 inhibitors that work only in the inactive conformation. So we learned early on, and this is initially when we were starting using seraphanib, but the beginning of a quisartanib type 2 inhibitors, that these drugs were the mutations in the kinase zone.

[15:40] domain, and these gatekeeper mutation, F369L, 691L, created resistance to these type 2 inhibitors. And so we went back and looked at our patients that had been treated with serophane or with guzardinase that had an ITD at the time of the treatment.

[16:00] treatment and sure enough we saw that 20% of patients developed a kinase domain mutation as a mechanism of resistance to these type 2 inhibitors. Well then we started getting these type 1 inhibitors, Diltaritinib came about, but one thing that results very interesting is that

[16:20] If a kinase domain mutation comes together with a Fli3ITD mutation, yes, the gluteal retinibular, type I inhibitor keeps their activity. If the kinase domain inhibitor is, excuse me, the kinase domain mutation is present by itself, there are some cases where the inhibitor is present.

[16:40] Creativity is very low and that is true with Hiltoritinib or with this other drug that's still investigational, crinolony, and other type I inhibitors. So chionesome mutations by themselves are not as sensitive in the clinic to type I inhibitors. The reason for that is unclear. Of course, we also

[17:00] Now, I also know that part of the resistance to the F3 inhibitors is not related to other mutations or so on, but to the emergence of other clones that are not F3-mutated. You may fully eliminate a F3-mutated clone, but new mutations with other new clones with other mutations, IVH or RAP.

[17:20] in this case may emerge and that is an important mechanism of resistance. But I want to come back to another element that's very interesting. From the beginning of the development of quesartanil, certainly we were focused on the FLEE-3 story, but even in the phase 1 study we saw that there were some patients that were next to us.

[17:40] negative, that they're not mutated, that had some response to quizarpenib. So in the phase two, we had two cohorts, free-3 mutated, free-3 non-mutated, and sure enough, the free-3 mutated had, in first salvage or in second salvage, a very high response rate. But the non-mutated patients had a good 30 to 35% response.

[18:00] response rate, single agent, salvaged AML. That's not very common in AML. So the development went towards the free-free mutated, but there was always this question that we had, why is this happening and what can we do with these patients? Well, sure enough,

[18:20] of recently there was this randomized study from Spain, the Kiwi trial, where patients without free 3 mutations were randomized to receive, this is frontline therapy, chemotherapy alone or with quasartan. Again, these are patients without free 3 ITD mutation. And as you can see, the overall survival was significant.

[18:40] significantly better for the patients that received quisarctanide. So why is this happening in these patients that do not have an ICD mutation? And this is not unique. You may remember many years ago there was this other study from Germany, the SOR AML, where they used essentially the same concept with SOR ARP.

[19:00] Now here it included all the patients, but only 17% of patients had an ITD mutation and yet it still showed a benefit in event-free survival, in relapse-free survival, and a trend for favorable survival. So why is it working in these patients that don't have an ITD?

[19:20] CTD mutation. Well we know that quisartinib, sure enough it's a good FLEA3 inhibitor, but it also has activity against CT. Is that the mechanism? I don't know that that's the case, that's been a hypothesis, but I think that that's probably unlikely to be the case. Now there's these.

[19:40] Old story from many years ago that shows that many patients with AML have overexpression of FLEA3. It's not mutated, it's just overexpressed and it correlates with a prognosis. So could it be that just the overexpression is leading to being then making the most sensitive to

[20:00] to a flit-reinhibitor. We of course don't have the answer to that yet, and these new studies are looking at biomarkers to try to define the mechanism, but it is something that we need to understand. I'm going to close out very quickly with another targeted therapy for AML, and this is the IVH1 inhibitors. As you know,

[20:20] We've had IvoSydanib very useful for many years. Recently, a Iloetosydanib was approved, and there are some differences in the results. There's more CRs and CRHs in the Iloetosydanib compared to Iloetosydanib. The duration of response, the overall survival, is better with Iloetosydanib.

[20:40] Now, could this be just because there's two different studies, different populations? Sure, that could be a possibility. But there's also differences in the mechanism of action of these drugs. For example, the lutecerenive has two binding sites in each IVH compared to only one with Ivosereniv. It works in the context of the disease.

[21:00] of additional mutations to the IVH site, whereas Iposininib doesn't work. And it's also very specific against IVH1 mutated, whereas recently there's been some data to suggest that Iposininib can also inhibit the unmutated IVH1, and that may have some

[21:20] implications in the management of AML. So this is hypothetical, but certainly there's something more that we need to understand about this drug and all these drugs. So again, my point here is that we need to understand better our targeted therapies. It's not as simple as I have this mutation, I have this in here.

[21:40] inhibitor, we give them their work. It is a lot more complex and we need to do better. Which brings me to my closing quote from this writer that said, missing the mark is one of the ways in which we can learn to hit the target. And actually I think that those patients that are developing resistance, where things are not working, is how we're

[22:00] starting to understand how it really works. So I'll stop there. Thank you for your attention.

[22:20] discussion and for our next session we'll be talking about innovations in car T cell therapy and please join me in welcoming Dr. Nithan Jain from MD Anderson Cancer Center to the podium. Alright good morning everyone and thanks to the organizers for inviting me

[22:40] This is my first time in well, beautiful place, so. And thanks for you to coming early in the morning. So as Dr. Kodes mentioned, we have limited time. So I'm not going to cover out all the cardtherapy innovations. I'm going to focus on the trials in the disease sets I treat, namely ALL and CLL. So we're not going to talk about lymphoma per se.

[23:00] But I think there are other colleagues who may be able to address that later if need be. Just a little bit. So again as I said, I'm going to talk about two B-cell malignancies, namely ALL and CLL, and talk to you about some of the data from ASH and also maybe how the field is evolving in terms of using cartoony cell therapy from a more practical standpoint for patients.

[23:20] patients with these diseases.

[23:40] actually at NIH, then CD19 trials, to the first approval which occurred in 2017, namely for pediatric ALL and adult lymphomas. And since then, we have had so many approvals, not just for ALL, lymphomas. We have CLL, we have multiple myeloma, and this list has evolved.

[24:00] But just shows how the development occurred and really the clinical development really took off in late, you know, 20 2006 2010 and then really everyone built on that. I also find this intriguing to see this first paper ever on a CD19 car. Obviously CD19 cars are the most commonly used cars currently and the first

[24:20] clinical data ever was from the NIH group, publishing back in 2010, but the first patient ever to be infused with a CD19 car was back in May of 2009, a patient with follicle lymphoma. So again, the field has moved so rapidly that from that time to 2017, carteys were approved and now.

[24:40] CAR T have really become the standard of care for many disease subsets. Also this is a slide from CIBM TR which tells us we are increasingly using CAR T in our practice. This is number of CAR T infusions per year in the United States. The last updated data I could find from the website was from 25.

[25:00] 2022, where you can see almost 3,500 cartees were done, majority were for diffusulide B-cell lymphoma, and now increasing the number for multiple myeloma, and then you see other subsets as well. And this will, I'm sure if we have data from 2023, 2024, this will be continuing to rise exponentially.

[25:20] So now let's talk about cartis over B cell ALL, where we'll spend most of the time. So the first question you may ask, and again, if you're treating patients with B cell ALL, is that why do we need therapies? And this is a data sets, large number of patients with adults with B cell ALL, who were treated with chemotherapy in their laparophractory setting and their average survival.

[25:40] survival was less than six months. So that basically says to us that the chemotherapy is not the answer. Then you may say, okay, we have anetosumab, we have blanetosumab. Both these drugs were approved now several years ago and are really used very commonly for patients with their laparofractory B-cell ALL. Now even if you look at these.

[26:00] studies that namely the innovate study and the tower study which led to the approval of these therapies. And if you just look at the survival in this study in the experimental arm, both happen to be 7.7 months, both for anatosumab and both for blanatosumab. And you can see the curves there which, you know,

[26:20] statistically were significant, but you can also see, basically tells us that we need to do better for these patients. This is not the most idle scenario. Obviously most of the patients eventually are ending up relapsing. So this basically sets the stage of developing biothelial cell therapy for patients with adults with a relapse of Fractory B-cell LL. And this was the first product which was approved.

[26:40] which was based on a study called Zuma 3 study. This is an autologous CD19 car T-cell therapy and the product itself is called Braxosol. So this was a study, about 55 patients were treated and 71% achieved CRCRI and majority of them were MRD negative bifluosatrometri.

[27:00] So when I'm talking to the patients, I think you can think of 70% response rate for these patients and majority will be flow cytometry negative. And then when you look at the survival of these patients, and you remember I told you with the Inovid study, with the TOWER study, the survival was 7.7 months

[27:20] patients and most of them had received one prior line of therapy. In this study, most patients had received at least two prior lines of therapy, many patients had actually received an adenosumab and blood adenomab and you can see the survival, the median survival was about 23 months, so about two years. So certainly numerically better than those therapies and certainly makes a point.

[27:40] that, you know, cartoose cell therapy have really advanced the field. Now I would also say that maybe unlike the lymphoma field where we have data with Zuma1 where these DLBCL patients are doing very well, at least 40% maybe at four, five year PFS, we'll have to see how that pans out with this data set.

[28:00] I mean this dataset is still slightly, you know, less mature than the ALBCL dataset. But still I think it's going to advance for patients. And also on the right side you see a question which gets commonly asked, if I'm going to do cartease cell therapy for my patient with ALL, should I do a subsequent allotransplant? And I think it's a complicated discussion.

[28:20] with the patient, but because some data sets have shown different ways, but at least in this Zuma 3 study, the transplant did not matter. So if you do cartoose cell therapy, at least there area seem to suggest there is no need to doing an allotransplant as a consolidation after cartoose cell therapy. Also what we are increasing

[28:40] And one of the things I'm increasingly realizing is that number of prior therapies do matter a bit. Numerically it may not appear, but less of the pre-treated patients, they do better. And on the right side curve is that patients who receive prior bileanatuzumab and anatuzumab, they tend to do less well overall survival-wise. Now that's not a good question.

[29:00] clear whether it's just because they're more heavily pre-treated. They don't have future salvage therapy options because we have used the Blena, I know, earlier lines of therapy. Maybe that's contributing to it. Now, one of the things you, if you're using a Carti cell therapy, especially for ALL in your practice, you will realize that you have a lot of options.

[29:20] realize that the rates of grade 3 or 4 CRS and ICANS is about 25%. So one-fourth of the patients will have serious issues which will require, you know, steroids, dozolosome, havesopressors, ICU care. So that is something to note. Now, in the last couple of months, a new

[29:40] A new carte cell therapy has been approved in the United States. This is the second carte cell therapy for adults with a lapsarararic V-cell ALL. And this is called Obissel and the trial which led to the approval was called the Felix trial. So this was co-led by my colleague at Emory Anderson, Dr. Jibor. Now this is a unique carte.

[30:00] Where it is a CT19 carti, but what the construct is, it is what is called a fast-off carti, where the carti cell attaches to the tumor cell for a less time, I mean, actual time-wise, less time, so that it is able to kill the tumor cell without eliciting too much cytokine release.

[30:20] And they have already shown that in their mouse models and they had a nature medicine paper a few years ago. And now this is the clinical trial to really prove that, that whether this fast off will lead to less side effects. Also what they did uniquely is that most of the time, as you know, cartoose cell therapy is just one infusion on day one.

[30:40] But this, they decided to split the infusion between day 1 and day 10 based on the bone marrow blast count. So if your bone marrow blast count is low, you get smaller, higher dose first day and the remaining dose on day 10 and vice versa. So they split the dose based on the bone marrow blast count. Also, they have a novel card.

[31:00] car, which is a fast off car. They have shown this data, and this was also published as well where they showed event-free survival. This is a shorter follow-up, it's about 12 months, which is similar to the Zuma 3 study, which I showed before. And again, the transplant didn't seem to matter.

[31:20] afterwards.

[31:40] So, I mentioned to you before that with Zuma-3 with active disease, you get 25 percent risk of high grade CRS, 25 risk of high grade ICANS, and here if you see the curve on the left side, the grade 3R for CRS was only 2 percent and the grade 3R for neurotoxicity was only 7 percent. So, their preclinical data actually matched.

[32:00] clinical data. So a lot of us have started using this product, Obie's Cell, in the practice. And again, I think we'll have to see how this pans out in real world setting with the Viz Rexacel, which is already approved for the last few years. Now one of the things which is also was also exciting at AMP

[32:20] is some new concepts which are emerging of using CRT as a consolidation therapy for adults with the ALL. And we our group we have been working on a perspective as well as with respect to series which hopefully will be published soon. But this is a prospective trial from city of hope where they argued that older patients above 60 years of age, the

[32:40] they cannot tolerate chemotherapy very well. So why don't we give them some chemotherapy, some lineptomy and then just give them CAR T. And that's it. No more transplant, no more maintenance therapy, kind of just induction, consolidation for a few cycles, and then CAR T. So they have treated 14 patients, a really small number so far, median age

[33:00] 68 years, ranging from 55 to 79 years. Some of them had high-risk genomics. And as you can see at the bottom, 79 percent had received parabola in a tumor before getting the car T-cell therapy. Now this is their summary slide, which basically they are saying is that they haven't really seen much toxicity so far, and which is also our experience.

[33:20] We have treated about 50 patients in a retrospective manner with low tumor burden with very limited toxicity. And in their also analysis, so far these patients are doing well without much relapses. So again, 14 patients, small number of patients, we'll have to see how that pans out kind of down the line. But this kind of a new concept bringing CAR T in early.

[33:40] really early lines of therapy as a consolidation. They also show Cartes expand in low tumor burden setting, and we have similar data from our center as well. So very quickly, I think in Carteen, adult ELL, we are going to see it move in early lines of therapy, MRD-positive consolidation therapy.

[34:00] role of

[34:20] And I think T-cell ALL not the focus of this particular discussion, but again there are trials with CD7, some CD5 car tees for T-cell ALL, which are still emerging and I think that remains an area of unmet medical need. In the last maybe a minute I will want to very briefly touch on one last abstract, changing gears to CLL.

[34:40] disease subset which I treat patients with. This is, so CLL, there's only one carty which is approved, which is Lysosale, that's the only carty approved. And for foreseeable future, I don't think there will be any other carty coming down the line. So this is the carty which we'll be using for the labs of Fractory CLL patients. And this data was already public.

[35:00] published as a lysosil by itself. But this, what Bill Veda from our group reported was lysosil plus ibrutinib together. So BTK inhibitor plus ibrutinib plus CAR T together as a study. This is the schema, basically same thing. You give flusillum for depletion, then you give CAR T, and then you give

[35:20] BruteNib continues throughout. Five prior lines of therapy. So these are tough patient population of CLL. If you treat patients with CLL, five prior lines of therapy. These are tough patients. Many of them will have very high-resed genomics. And what they showed was that actually very high response rate, overall response rate of

[35:40] 86 percent and practically most of the patients will become MRD negative. And actually just as the lysosale alone, the response rates and the MRD rates were half of this. So ibrutinum is really adding to the responses here, which was really nice to see.

[36:00] provocation resurfable curve, which again is better than lysosale alone. So in the context of CLL, lysosale plus a brute nep seems to be against cross-toil comparison, seems to be outperforming it. So my last slide, I think just CAR T for CLL therapy, I think one question will be the data I showed you with the brute nep combination with lysosale. But can I

[36:20] use pitobrotic, can I use a chalet, can I use xanu? That remains an unanswered question. Can I use cartine early in the lines of therapy? We don't need to do five prior lines of therapy. Can I use it in second line or third line? And there has been some thoughts about pursuing car T-cell therapy and allogenic car T-cell therapy in the context of CLL because we know T-cells from

[36:40] patients with CLL are dysfunctional, you're using them as a raw material to make cars. Why not give healthy allogenic car T-cells to patients with CLL? But that development again has somewhat lag behind. With this I would like to conclude and happy to take questions.

[37:00] question from the audience, otherwise we can move on to the next speaker. Okay if there aren't any, Dr. Jain get ready for the session later on, we'll have a panel discussion and go over all the questions. I'd like to invite Dr. Rick Heggemeister to the stage from MD Anderson Cancer Center to discuss diagnostic advancements in lymphoma. So please join me in

[37:20] welcoming Dr. Heggemeister.

[37:40] and we rotated it on the inpatient service. And just to show you what the intensity is like, it was a Saturday. We had a patient who had to have a bone marrow. And Dr. Kadiya and I called in the bone marrow, the people who had processed the material. And

[38:00] Dr. Kadiya did the bone marrow as a fellow and I observed him as a faculty member and it was perfect. I mean it was just exactly as it should be done. But it was on a Saturday while we did that and success, it was a successful fellowship for him that's for sure. So what.

[38:20] What I'm going to get into today, could I have the next slide, please? I'm going to talk about some prognostic factors and I don't want to belabor the point too much but it's really difficult to do this in a short period of time. There have been so many different prognostic factors and features that have been studied.

[38:40] Next slide. This demonstrates to you the International Prognostic Factor Index on the left hand side which most people know and recognize. One of the things that we don't really pay much attention to I suppose is that the RIPI, the IPI was invented for people who had not received

[39:00] to a rituximamp. The RIPI was specifically for people who had received rituximamp. And there's a little bit of a difference there, I suppose, but not much. The NCCN IPI is very, very similar to the other that you the other two and isn't

[39:20] really much better, but you'll see that, could I, next slide please? The two red dots and then one after that, yeah. So these two dots show you that the one group is pretty good and that group is perhaps best sorted out and thought to be as an excellent prognosis.

[39:40] On the right hand side, the NCCN-IPI, with the curve that is very low, suggests that perhaps we could pick out a really bad risk group of patients that we might do something with. But more of, more or less, the NCCN-IPI has not been really studied extensively. And at the bottom, there are other, there are other,

[40:00] systems that have also been studied, including CNS IPI, which is questionable as to whether it really holds value in some series and it is originally invented in Germany and verified in Canada. And the metabolic IPI, the biologic IPI, the lab IPI or lab PI, elderly PI, specifically

[40:20] and people over 70 and the senior IPI, which is people over 80. So these are all not being currently used to any great extent and have not been widely accepted as yet, with the exception positively of the CNS IPI. There are other important prognostic factors that are clinical features or laboratory features.

[40:40] that have not been studied and are not included in any of these IPI systems, including a Q67, T53 abnormalities which are important in every malignancy, beta-2 microglobulin, which we demonstrated many years ago was important in large cell lymphoma and other lymphomas. And MIC, BCL2, and BCL3 are important.

[41:00] BCL6 rearrangements, and immunohistochemistry. Next slide. This is the diagnosis of treatment interval as being an important feature. This was demonstrated a number of years ago, and every time we look at it, I always think, gosh, if he's doing a clinical trial and a patient has to wait for three or four weeks.

[41:20] to be enrolled on that trial to be treated. How bad is that for that patient having to wait so long, but actually it indicates the patient has a good peragnosis if they have to wait for three or four weeks, because they can. Waiting for three or four weeks is a surrogate for poor molecular features. So when a patient walks in

[41:40] and has to be treated immediately, you know that patient has a bad outcome, and they are not the patients who are included in most clinical trials. So that's why a lot of clinical trials are sort of wishy-washy about whether results are better, especially in large, randomized studies where the patients have to wait three or four weeks. On the left,

[42:00] On the left hand side you will see in this collection of a large number of patients from two different prognostic subgroups that were collected. The bad risk features all favor those who are treated within 14 days, including LDH, that's high, IPI three to five, age-adjusted IPI of two to three, B-symptom,

[42:20] symptoms, which we don't always see in large cell lymphoma, and mass is greater than 10 centimeters. Those are people who are treated very quickly. On the right-hand side, you will see that if you are treated within zero to 13 days, your chances of events of free survival are quite poor, compared to if you

[42:40] if you can wait at least two weeks. In addition, at the top, on the right-hand side, you'll see it says therapy failure within 24 months. This is the opposite of failure. This is surviving. This is reaching 24 months, which is a good prognostic feature. So on the left-hand side, if you were treated

[43:00] early on, that's when the patients are treated early on and it's a high number of patients are treated early on, they actually do not achieve POD24. On the right hand side, you'll see with that yellow line, there's some patients who went 100 days without being treated and those patients all achieved.

[43:20] event-free survival at 24 months. It's really quite remarkable. And it's one of those things to think about when you look at some studies that are, I know for sure that I always ask, how long did it take to get the patient treated? Next slide. So these are the outcomes for patients in Scholar-Warner.

[43:40] on a trial or a study that was questioned when it was first published. However, it's used now as a main way to determine whether a patient really has refractory disease and is high risk. And these are 636 patients with refractory diffuse large B cellophones. This also established with the term of refractory.

[44:00] means it is relapse in less than 12 months from stem cell transplant, which has been known to be an adverse prognostia factor for a long time, refractory to initial therapy that is progressing while on treatment, or with or refractory to second-line therapy. And you can see that the relapse

[44:20] the response rate for relapse therapy is quite, is similar for all ages, refractory status, stage, and IPI on the left hand lower side. On the right hand side, you see the event free survival for these three different refractory groups are all about the same. And at the bottom on the right hand side,

[44:40] CRs do better. But notice that only 18 out of 372 patients in this prospective collection of patients had a CR. That's nothing. So obtaining a CR we know is a really important prognostic factor in patients, and this is one.

[45:00] one of those things where these patients need better therapy and should not be subjected to standard of care treatments. I'm going to go on for the next slide, please, and talk about some high-risk molecular features. First of all, next, pathology is important. This is, I picked from 2016.

[45:20] who an international classification, the consensus classification have now split off. So we have two different ways of looking at lymphomas pathologically, they're not so far off. But I'm pointing out here that primary CNS is a disease that is completely different from diffuse large B cell.

[45:40] in its presentation, but also its outcomes. Large B-cell lymphoma, primary and mediastinal, is a better risk disease and should not be carried as being a diffuse large B-cell lymphoma. And then a high grade large B-cell lymphoma, which we now recognize as being MEC and BCL2 rearrangements. BCL6 apparently doesn't play much of a role. Next.

[46:00] These are, this is an overview of what we call clusters by LymphGen, the HMRN, which is the histology group Malignancy Research Network in Cambridge, and the Harvard group. You will notice that there are certain clusters. There were five clusters that were described by Harvard, as well as the NCI LymphGen that sort of went together.

[46:20] together, and they matched up pretty well. And the modified HMRN was also found various clusters and a few others that were not located or not found in the NCI, Lymph Gen, or Harvard. However, the main genetic alterations that were described are shown here. The COO really doesn't matter.

[46:40] longer the cell of origin and we think about non-GCB or GCB when we've been doing trials but I think we are going to have to get away from that ultimately. We still use it then as a surrogate to see its cell of origin but it's not really the key element. It's the molecular features. In addition, one of the main things on this slide is though.

[47:00] on the right hand side, that there are some lymphomas that have molecular signatures that are very similar to some of these large cell lymphomas, and we think that some of these are perhaps transformed from these more indolent disorders or related in some way to them, for example, to double-hit lymphoma.

[47:20] you see on the right-hand side being related to the EZB or is the EZB make-positive subgroup. This is looking at it in a slightly different way and I'll show you why I'm doing that. It's the same subgroups with the ABC, GCB, and unclassified being split out into molecular features. In the middle are the hallmark genetic features going down the line.

[47:40] down the row. And then the overall survival's with standard ARCHOP chemotherapy in general. However, this was a, this is supposed to be able to make it so that you can target, use some of these targets for particular drugs. This was done in China and this study sort of began.

[48:00] looking at potential drug targets and drugs that could be used for each of these individual molecular abnormalities. However, a valuable CT-DNA is quite variable for the individual patients and not all patients may have discovery of these different mutations in their tissue or their blood. This was an interesting study.

[48:20] that I thought was also published also from China using that kind of theory that I just mentioned in saying let's pick a particular drug and pick a particular target in these subgroups. They didn't use LymphGen, they used a 20 gene algorithm instead of their own making. But the other point,

[48:40] point about this that's interesting is that they sort of set a kind of standard where we're now doing our chop for all the patients and then getting their molecular signatures, which takes a little bit of time, and then switching their therapy to whatever new drug we think might be of some value versus

[49:00] another combination, and that way we can make some sense out of what their molecular features are and what the impact is upon the outcomes. In this particular study, they did exactly what I was talking about where they took the individual molecular features and treated the patient with a drug that they thought would target it. They picked some funky drugs and I can't speak.

[49:20] very much about those selections. However, all the subtypes to be able to pick out one individual versus the other is underpowered. Can we lump them all as they did on the left hand side that it R-chop plus X where the CR rate was higher compared to R-chop, the progression free survival better, and as well as the overall survival. And I don't know if you can just

[49:40] lump all of these patients together who were treated with various drugs based upon their molecular features and say, this is the way to do it, because it's going to be really hard to make sense out of which of those subgroups did better to contribute to the outcomes. The dark zone lymphoma isn't yet in our regular vocabulary.

[50:00] but it should be. This dark zone molecular features were taken primarily from Burkitt lymphoma and they were applied to diffuse large B cell lymphomas. You look up at the left hand side that there is a small number, 12% of patients with diffuse large B cell morphology.

[50:20] fit this particular mid-lacular future, next slide. Next slide. Yeah, that on the, on, next slide. I'm sorry. On the left hand side, you will see that 12% of the patients will fit into this Birkett-like

[50:40] molecular analysis, which is at the bottom. The cell of origin is usually GCD and not the ABC subtype. And then the WHO diagnosis, furthermore, is the diffuse large B cell in NOS for most of these patients, but they still have the double-hit signature.

[51:00] And they may or may not have FISH available. FISH availability is, of course, with some of them, but not all of them, so they're not called the double hits. And on the right-hand side, you will see that the freedom from progression for those patients and the overall survival for those double-hit signatures, the double hits, the Ds

[51:20] The ZZ signature now, or dark zone signature, is the red curve where the fair fee survival or freedom of progression is quite poor. And the GCB NOS is almost at the top. It's almost a straight line across the top. The overall survival at the bottom is exactly the same. Next slide.

[51:40] One of the interesting things is that when you look at the progression of free survival by cell of origin with nanostring, poly-R-chip seem to be better than our CHOP. But when you look at when they have ABC subtype, when they have GCP subtype, they don't do any differently. So you might think, well, you want to pick only

[52:00] the non-GCBs were the ABC subtype and treat them with polar urchin and not with archop. But look at the right-hand side. Those double signature positives that are treated with archop compared to patients who are treated with polar urchin. Polar urchin is one of those curves at the top and not the one at the bottom.

[52:20] and the other, R-chop that is double, dark zone negative, also is one of those curves. So only if it's treated with R-chop does dark zone lymphoma do badly. So it's interesting that polar R-chip might be a therapy that we think of for this very.

[52:40] adverse BRCA-like large cell lymphoma that does not necessarily have fish. The PFS with polar chip is also numerically better for ZB and MCD groups by the lymphogen classifier. Next slide. I want to talk a little bit about the PET scan. This is the

[53:00] multivariate cox regression of factors associated with overall survival, taking total metabolic tumor volume, which is at the top part of the box, in core tiles. They separate them out and look at them in funny ways to try to tell at the very beginning if you can tell whether a patient is going to do badly or not. And in this

[53:20] The hazard ratio was very different and very high for those patients, P value quite significant for outcome for overall survival. So was cell of origin. So you know, I sort of think a little funny about that. It might be nice to be able to look at molecular features in those patients as well. And the IPI always comes out as being an important prognostic factor whenever you look at those kind of features.

[53:40] probably with molecular features as well. This was just an attempt that was published this last year from a nuclear medicine journal. Looking at different methods of analyzing the PET scan at the very beginning, different features of the PET scan.

[54:00] scan and it turned out that this IMIPI was better. You will see the C index is the highest for them for that, but they're not better really than the IPI or the RIPI. So this was an attempt to try to get different molecular features to be incorporated into the IPI and it was basically a failure.

[54:20] The klep blemier curves really don't separate out and show patients who are at very bad risk. We got to get into molecular analysis. And so this looked at the, looked at this is something you're more accustomed to seeing. This is response to PET scan, by PET scan. Next slide, please. Next slide. Sorry.

[54:40] This is a meta-analysis also looking at the PET scan in therapy of large cell lymphoma. This is the value of an early response looking at IPI, low, low intermediate, intermediate, or high risk disease. And you'll see that the curves go down, the top curves keep going down as you go across the page. However, notice

[55:00] that the curves at the bottom are for those patients who are pet-positive either at two or four cycles of therapy. The ones that are negative are the ones that are at the top. So both the PET scan negativity or positivity played an important role and so did still the IPI. They also looked at the reduction in the uptake.

[55:20] as being whether there is a sponsor or not, or not as far as reduction in the intensity. Next slide. Next slide. Thank you. So see, self-re DNA has been around a long time. It's been in studies in solitumors, in lymphomas, in leukemias.

[55:40] It's been used often to try to predict the outcomes for patients at the very beginning. And cell-free DNA is a result of apoptosis. It usually is mostly white cells that are degenerating, but it's also, if you've been out and had a couple of drinks at night, it probably includes a few brain cells. It's clumps.

[56:00] of cells that are all broken up, so the DNA is shattered in multiple different fragments. And they are, by the way, real time because there are ACEs in your blood that rapidly clear these, so they're constantly being resupplied. So the cell-free DNA varies within hours of

[56:20] obtaining a blood sample. So it's very rare in the peripheral blood because we get rid of them, and you can see the numbers that are in lymphoma are not that much higher than they are in plasma. The mass of a single haploid copy of the human genome, that means one strand of DNA, is 3%.

[56:40] 2.3 pico-grams. That's one to the minus average, ninth or something. It's considered a standard method of measurement, finally. And it's been used for a while. Normal typical cell-free DNA in the blood is 1,500 haploid gene equivalents per ml, lymphoma patient,

[57:00] CT cell-free DNA is typically 7,500. So it's more in the lymphoma patient than it is typically in a normal walk-in or round. There are PCR and next generation sequence-based platforms have been introduced to calculate CT DNA off of the cell-free DNA.

[57:20] Existing practical problems include collection and processing of samples. They have to be harmonized. They aren't. They are done usually at one center a particular way, another center another way. And I think we're finally getting to one where we can get down to 10 to the minus 6. And I'll show you that in a moment. The relationship to overall survival should be prospectively assessed.

[57:40] results should be actionable in real time. In other words, in order to make some sense out of what's going on, we need to be able to do these things quickly and we need to have a lot of money because they're expensive and the performance of these also has to be standardized. Predicting MRD. A tough thing to look at this as a physical exam doesn't get you there quite.

[58:00] and down to where you want to get to minimal disease. Pet scan is better, but DNA-based appears to be better, especially once you get down to 10 to the minus 6. But the definition of MRD is definitely a moving target and we better more sensitive methods. These are four different methods that are

[58:20] been in clinical use or investigational use, I should say. There's the Droplet Digital PCR, which is shown on the left. It was the first one that was used. You need adequate levels of cell-free DNA, however, which is a problem. There are many mutations are also at too level, too low a level to detect.

[58:40] generation sequencing has been used for clonosec and some of the studies that have been used and reported recently have involved clonosec as well as capsic. They detect low levels of rearranged Ig that is clonosec of IgG and technical error is lower than droplet digital PCR but it still depends on cell

[59:00] free DNA levels. Capsec uses a targeted panel of molecular probes and requires methods to suppress the background error rate. Whether you know it or not, as you get older, your bone marrow starts degenerating and you develop all of these mutations that are not pleasant in your blood, in your peripheral blood, and they are associated with having

[59:20] heart attacks, atherosclerotic disease, strokes, and getting older and developing leukemia. So you have to get rid of those so that they don't cause confusion. This is the sensitivity of MRD tests, which is critical, and you can see the phase at sec appears to be one of those, as if the NCI predominantly, and there are some studies I'm going to show you that use

[59:40] exactly that. This is at the end of therapy on the right hand side. Next slide. I'm sorry. On the right hand side, the phasetizac is much more sensitive. In addition, the progression-free survival is much better than PET scan. These are patients who had end of therapy PET scan that was double score 1 to 3 and then looked at CT-TNA.

[01:00:00] not detected. And I want to say this, we talk about MRD positive or negative, that's not the way to refer to it. Don't use that terminology any longer. It is MRD detected or not detected, not positive or negative. That just means you don't see it any longer. And so go back.

[01:00:20] that's a good question. So that's a good question. Next one. Next one. I'm not controlling it next. There you

[01:00:40] disease and these are people who had negative pets and then had CT DNA detected. In X-Sci, you can also tell this early on but then as you get down further down in therapy and then at the end of therapy it appears those patients who have CT DNA detected by this method all developed disease progression.

[01:01:00] and eventually have a high risk of dying. Next slide. This, it'd be nice to be able to tell what prognostia features would tell you that you have end of therapy, CTNA, that's still going to be detectable. But there doesn't appear to be a really good one.

[01:01:20] way to be able to do that. These are five different studies that were all pulled together and looked at it also at Stanford and the NCI and there's a very poor correlation with initial IPI for having a quote negative or positive MRD. The odds ratio for various IPI scores

[01:01:40] is there, but there's an overlap. However, on the left-hand side, there's a good correlation with stage. Makes sense? We've used stage forever to tell whether a patient is going to do well or not, but there was no correlation with age or gender, no correlation with initial allele frequency, variant allele frequency, and no correlation with cell of origin.

[01:02:00] doesn't make any difference at all. I get it, you get it too. Cell of origin is gonna go away. Next, we've come up at MD Anderson with a plan to try to take those patients who are PET, CMR, but endotherapy, CTNA, measurable, and try to enroll 30 patients and then treat them with the glofitamap with.

[01:02:20] Benetuzumab, which is standard method of treatment. Next slide. This is also a study that looked at the NCI at R-E-POC, with or without R-Chop and without Calibrutinib. 55 patients were studied with either large cell lymphoma or high-grade large B cell lymphoma, and they completed therapy and at the end of treatment.

[01:02:40] They looked at their PET and their CTNA evaluation. 97% of these patients who had their blood analyzed could, they could find this very specific genetic abnormality. So this is a successful method that is used, but you got to have them at the NCI right now.

[01:03:00] We're trying to develop it so that it can be standardized and used in the United States, and it is expensive. Notice that on the left hand side, the positive predictive value of the test is way high for CTDNA and the hazard ratio for PFS is way high for CTNA compared to the PET scan.

[01:03:20] see the end of therapy, CTNA, prognostic PFS is very significantly different compared to the PET scan. So I conclude that the IPI still remains an important method of predicting groups of high-risk patients. Patients with immuno-chemotherapy refractory disease have a very dismal outcome. The response by PET still remains

[01:03:40] It's an important tool for predicting outcomes, but I don't think it's going to stay. Most targeted therapy is unlikely to improve results significantly when applied in a blanket fashion. Rapid next generation sequencing may benefit choices of therapy, but it's going to be difficult to prove in small populations. And finally, military.

[01:04:00] molecular testing needs standardization may eventually play an important role in management. Thank you. Thank you so much, Dr. Hegmeister. That was a really wonderful talk. And for our next session, we'll be discussing gene therapy and hematologic disorders. And please join me in welcoming

[01:04:20] welcoming Dr. Matthew Angelos from the University of Colorado. Welcome to the stage in your home state. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you.

[01:04:40] Alrighty, thanks so much. I'd like to thank the meeting organizers for allowing me the opportunity to present to you all today. I have no disclosures. I understand I'm up against breakfast, so I'm going to try to speed through this as quick as I can here, so I'm not holding you up here. So there's really three main disease states to share gene therapy.

[01:05:00] updates from recent publications and then also data presented from this year's ASH. First, most of the active clinical use of gene editing is within the red cell space. With FDA approvals in 2024 for severe sickle cell disease and then also transfusion-dependent beta thalassemia with vertexes, exacel, and

[01:05:20] and then also Bluebird Bio's low-vacel products. This year at ASH, Vertex presented a long-term five-year follow-up for the phase 2 Climb 121 and 131 studies in sickle cell disease. And then Beam Therapeutics also introduced preliminary data that tests a new base editing approach that I'll also go over today.

[01:05:40] Second, there's also a growing interest to implement gene editing during car T-cell manufacturing. And this is mainly to circumvent obstacles in using car T-cells for diseases that were really considered to be difficult to treat, mainly T-cell neoplasms and then also acute myeloid leukemia.

[01:06:00] discuss some of those data as well today. And then lastly, very quickly, if I have time at the end, I will highlight one of the first in-human phase I studies that we ran in conjunction with Charisma Therapeutics that used a novel adenoviral delivery platform to manufacture carmacrophages in patients that had advanced solid tumor.

[01:06:20] programmers. So CRISPR base editors and then also now PRIME editors, which are the new kids on the block, are gene-editing technologies that allow for precise DNA modifications, but they really do work in a little bit of a different manner, and they have unique advantages and also limitations.

[01:06:40] Now, CRISPR has been under clinical investigation since 2017 in the United States, and the first trial ended up deleting endogenous TCR genes in order to enhance the relative expression of cancer-specific TCRs. And mechanistically, CRISPR really does work just like a molecular scissor. So it cuts the DNA.

[01:07:00] at a specific site via Cas endonucleases. It's directed by a 22-base-pair guide RNA sequence, and then it relies on the cell's own internal machinery, either non-homologous end joining and also homology-directed repair, in order to introduce these mutational changes. Now, CRISPR's

[01:07:20] Not perfect. Certainly it can lead to unintended mutations due to guide RNA off-targeting and also these double-stranded DNA breaks. But these are oftentimes identified in preclinical development and are often disclosed and addressed prior to an IND submission. Now, base editors can improve

[01:07:40] upon this by making single-letter DNA changes without cutting both strands of DNA. And so this reduces errors and it increases the rate of a precision event. However, base editing is really limited to only correcting certain types of mutations, and it can't be used for large.

[01:08:00] insertions or deletions of particular genes. Now prime editors can be more versatile. It's basically a modified CRISPR system that can directly rewrite the DNA without generating double-stranded brakes. They certainly can offer increased precision and fewer unwanted mutations. But as you can appreciate from the cartoon on the right,

[01:08:20] They're much more complex, and so it's harder to package this entire complex and get it into a cell to yield relatively high knockout efficiency in gene editing. So going back here to XSL specifically, XSL is an autologous CRISPR-Casnoffinase-type

[01:08:40] gene-edited cell therapy that disrupts the erythroid-specific BCL11A enhancer. And this is a regulatory region that's crucial for repressing hemoglobin F expression in adult erythroid cells. Now to manufacture exosale, patients first have to undergo mobilization with GCSF.

[01:09:00] And then they undergo apheresis for cell collection, only honing in on CD34-positive stem cells. These cells are then electroporated and then a non-viral CRISPR-Cas9 protein complex is introduced and this causes targeted double-stranded breaks within the BCL11A erythroid enhancer.

[01:09:20] What this essentially does is it increases the level of hemoglobin F, and this can certainly compensate for defective or even absent hemoglobin that then can prevent sickling from occurring. With XSL, patients do receive a myeloblative basulfan-based conditioning regimen, and this is intended to

[01:09:40] clear endogenous stem cells, and then also facilitate engraftment. So XS cell here was employed in two simultaneous and parallely done multi-center, single-arm trials, climb 111 and then climb 121. These refer patients with thalassemia and sickle cell disease respectively. I'm just going to focus

[01:10:00] in on here on the sickle cell trial and really both trials had similar safety and also efficacy throughout their cohorts. Patients in both these trials were aged between 12 and 35 and specifically in Climb 121 these patients had to have had severe sickle cell disease.

[01:10:20] with a history of at least greater than or equal to two severe vaso-occlusive episodes per year over at least two years prior to enrollment. The primary endpoint was the proportion of patients that had free, that were free of severe vaso-occlusive episodes for greater than one year, or VF12 for short. And then the secondary

[01:10:40] point was the proportion of patients that were also free from hospitalization from severe vaso-occlusive crises for at least a year over the span of a 16-month follow-up period. The median baseline number of invasive-occlusive episodes was 4.2 per year. And then also the median baseline inpatient hospitalization

[01:11:00] for severe vaso-occlusive episodes was 2.7. And I think what you can appreciate here in this swimmers' plot is that each of these patients that were treated as a part of the study, the gray column represents the pre-exacel period, and each of these

[01:11:20] little blue dots represents a vaso-occlusive episode. And here within the red bars, you can see this is the timeframe in which they needed transfusional support after busulfan conditioning and then also after infusion of X-cell. And you can appreciate here in the green bars, these are the total amounts or timeframe.

[01:11:40] of patients where they've been monitored for their vaso-occlusive episodes. And you can see here that 93% of patients were able to achieve a VF12 with a median duration of vaso-occlusive-free months being 31. What I'm not showing you here on this plot is that 98% of patients

[01:12:00] 12 consecutive months without hospitalization for evasive-occlusive crisis over the five-year follow-up window. Now going back here just to the safety profile of Exacel, it was argued here that this is consistent with what one would expect with myeloblative bussulfan conditioning and auto transplant.

[01:12:20] They reported no SAEs or malignancies that were related to Exacel. There was one death in this study and that was attributed here to respiratory failure that was secondary to COVID-19 infection. All patients achieved neutrophil and platelet engraftment, the mean of which was 27 and

[01:12:40] patients were able to get the vaccine. They were able to get the vaccine in 34 days respectively and the duration of neutropenia with exacel was only 17 days. The look editing was also assessed in both the marrow and the peripheral blood. And the authors demonstrated that there was very high of

[01:13:00] stable without evidence of any off-targeting. And so collectively, these high rates of sustained efficacy I think are extremely promising. And I do think it does provide a potential functional cure with a one-time treatment for patients with sickle cell, that is, if they're able to access the therapy.

[01:13:20] Now, Climb 121's positive preliminary results here led to trying to improve upon stem cell manufacturing and safe DING now by using a base editing approach. And so a new compound, which was developed, or a new gene therapy that was developed by Beam Therapeutics, Beam 101, utilizes an adenine base

[01:13:40] mechanism that permits then just specific editing in the promoter of BCLA11 and it's specific only to the erythrolyte cells. So again, functionally, this increases the amount of hemoglobin F that's present in red cells. The Beekin study was a phase I, II study that evaluated beam 101.

[01:14:00] in patients with severe vaso-occlusive events that were all related to sickle cell disease. They had patients that were treated already in a sentinel cohort, and now the study is currently ongoing in an expansion where now 11 patients have been dosed with beam 101. Key safety endpoints included a graphment.

[01:14:20] analyses, and then the key efficacy endpoints included the proportion of patients that were free from severe vaso-occlusive events for at least one year. As of ash of 2024, seven patients had been dosed. Again, the baseline mean number of reported severe vaso-occlusive episode

[01:14:40] was 10.3 in two years prior to enrollment. And what I want to highlight here from their data in terms of the engraftment criteria is that the time to neutrophil engraftment was 17.1 days, and the time to platelet engraftment was 19.1, which is substantially shorter than what was seen in the phase 2 studies with Exacel.

[01:15:00] Again, the safety was felt to be similar to what we see with busulfan conditioning. There were no therapy emergent AEs that were greater than grade 3. There was one death that was reported within this cohort. The authors had reported that this was secondary to respiratory failure, and this was favored to be

[01:15:20] be a consequence of busulfan conditioning. And in this one particular patient, this is an individual that had a history of severe acute chest syndrome and also had ongoing e-cigarette use as well, which is felt to be contributory. In terms of the efficacy here, the induction of hemoglobin F

[01:15:40] was both rapid and robust. Patients were able to achieve a hemoglobin F level that was greater than 60% as quickly as one month after dosing. And then they had resolution of anemia in five of the six patients that they treated and done these analyses for. Furthermore, it's worth mentioning that in these six patients that they analyzed, they

[01:16:00] They also found that the on-targeting A to G editing exceeded 90 percent, and this editing was persistent for at least three months after beam 101 infusion. So these results are certainly encouraging in the red cell space, and particularly it's notable with the base-edited product.

[01:16:20] and really decreasing the amounts of time that's needed to get to a good neutrophil in platelet and graftment. So in my remaining time here, I just want to switch gears and focus in on something that I actually clinically focus on, which is cellular therapies in leukemia. And these gene editing approaches really afford us an opportunity to

[01:16:40] make rationally designed cellular therapies that could really be used for diseases where it's been historically hard to treat with cellular therapies. And so I think one major opportunity that we can use these approaches in is in utilizing CAR T cells for treating T cell neoplasms. And we can really hone in on these pan T cell antigen.

[01:17:00] antigen targets that we know are universally and robustly expressed on malignant T cells. So what we went ahead to, what we did to confirm this is we did immunohistochemistry of 95 adult peripheral T cell lymphoma cases at Penn, and then we also did flow cytometry of 51 pediatric T, ALL,

[01:17:20] cases, and we found here that there was very high in uniform expression of CD2, CD3, 5, and 7, with an advantage perhaps of CD2 and 5 being more reliably expressed as compared to CD7 and T-cell lymphoma. Now certainly one of the limitations for just engineering cars based upon those targets

[01:17:40] is that you can have this issue where the CAR T cell start to attack each other because endogenous T cell antigen is still present in the CAR T product and so this can cause fratricide. When this happens you can't successfully manufacture CAR T cells, they certainly don't expand and their efficacy is severely attenuated due to intrinsic cell death.

[01:18:00] So, one of the ways that we circumvented this issue in designing an anti-CD2-CART T-cell is we utilized CRISPR-Cas9 gene editing early on during the CAR T-cell manufacturing process. This allowed us to generate anti-CD2-CART T-cells that had relatively high CD2 knockout efficiency, and then also high

[01:18:20] car transduction efficiency as well. And then we went ahead and tested this in in vivo mouse models. These mouse models were PDX models of TLL, human TLL. And we found here that CD2 knockout car T cells were able to treat mice and get them into sustained remissions, which of course resulted in a market improvement

[01:18:40] in overall survival. So this just represents one potential gene editing approach in CAR-T cells that we can utilize for T-cell leukemias and lymphomas. And we're now moving forward with this particular product in terms of an IND submission later this year. Now, beam therapeutics has also gotten on board into the CAR-T space, and they've

[01:19:00] developed their next product, which is Beam 201. This was all based upon Carolyn Diorio's work at CHOP, for which the preclinical data was published now two years ago in blood. And with this particular product, there's a multiplexed approach for gene editing, where they do base edits in

[01:19:20] four genes, CD7, CD52, one of the TCR genes, or TRAC, and then also PD1. And so the goal in utilizing this approach is to generate allogeneic anti-CD7 CAR T cells. And the thought here is that it could potentially be resistant to lymphodipleting

[01:19:40] regimens that contain allantuzumab or campath. And this could potentially be advantageous to eliminate any potential residual disease and potentially prevent a relapse and maybe even serve as a bridge to transplant. Very quickly here, they've treated four patients so far on the first phase one trial. The trial

[01:20:00] Now I'll just drug a little bit up front because they had one patient death. It was a patient with high T-A-L burden, had a grade four CRS, and they ultimately died from disease progression. But other than that, patients had tolerated this relatively okay. All patients did develop CRS. All patients did get infections, which is probably a consequential.

[01:20:20] of T-cell eplasia, but the preliminary efficacy data does suggest that three of four patients were able to get into a CR and looking at copy numbers for car, it looks like most of these responses were sustained and potentially can confer longer-term remissions. So in the interest of time,

[01:20:40] And I was going to skip, I think, the rest of what I was going to cover here, but mainly I was going to suggest that we're also using this in the myeloid disease space. I just wanted to highlight work from Sargil, who's also utilizing CRISPR and now also base edited approaches to not only modify the CAR T product itself, but also hematopoietic

[01:21:00] stem cells from donors that can also be used for allotransplant. So they just recently treated their first patient utilizing a CD33 knocked out allodoner stem cell product and then followed it up with anti-CD3-CARTE cells with the goal here to really try to mitigate AML release.

[01:21:20] So I'm going to skip the rest of this here. Just in conclusion here for these gene-edited strategies, some closing thoughts. Certainly we need to address the accessibility of these therapies. These are quite expensive and certainly these are not 100 percent covered and oftentimes patients are not able to get this unless they're part of

[01:21:40] a clinical trial. So certainly there's some additional work that needs to be done there. We have to remember that patients for these types of therapies still need to get preparative regimens and these regimens have toxicities. There's been some work in this space to have some better non-toxic preparative regimens and we're expecting some results to be reported in the near future. And then lastly of course, this is

[01:22:00] not an overnight thing. Patients have to have donor selection, they have to be collected, the product has to be manufactured. So patients' diseases have to be stable and they have to have a bridging therapy available in order to successfully implement this. And then lastly, of course, we have to better understand what this does in terms of infection risk, particularly these CAR-Ts that target T-cell neoplasms.

[01:22:20] You could speak firsthand, it's been a particular focus of the FDA and I think it's something that our field's gonna have to address moving forward in the future. So with that, breakfast, right? Yep, thank you. Okay, great. Thank you very much. Okay, great.