On June 24, 2022, the Food and Drug Administration approved lisocabtagene maraleucel (Breyanzi, Juno Therapeutics, Inc.) for adult patients with large B-cell lymphoma (LBCL) who have refractory disease to first-line chemoimmunotherapy or relapse within 12 months of first-line chemoimmunotherapy; or refractory disease to first-line chemoimmunotherapy or relapse after first-line chemoimmunotherapy and are not eligible for hematopoietic stem cell transplantation (HSCT) due to comorbidities or age. It is not indicated for the treatment of patients with primary central nervous system lymphoma.
Efficacy was evaluated in TRANSFORM (NCT03575351), a randomized, open-label, multicenter trial in adult patients with primary refractory LBCL or relapse within 12 months of achieving complete response (CR) to first-line therapy. Patients had not yet received treatment for relapsed or refractory lymphoma and were potential candidates for autologous HSCT. A total of 184 patients were randomized 1:1 to receive a single infusion of lisocabtagene maraleucel following fludarabine and cyclophosphamide lymphodepleting chemotherapy or to receive second-line standard therapy, consisting of three cycles of chemoimmunotherapy followed by high-dose therapy and autologous HSCT in patients who attained CR or partial response (PR).
The primary efficacy measure was event-free survival (EFS) as determined by an independent review committee (IRC). EFS was significantly longer in the lisocabtagene maraleucel arm with a hazard ratio (HR) of 0.34 (95% CI:0.22, 0.52; p-value <0.0001). The estimated 1-year EFS was 45% (95% CI: 29, 59) in the lisocabtagene maraleucel arm and 24% (95% CI: 14, 35) in the standard therapy arm. The estimated median EFS was 10.1 months (95% CI: 6.1, not evaluable) and 2.3 months (95% CI: 2.2, 4.3), respectively. Of patients randomized to receive standard therapy, 47% received autologous HSCT as planned, with lack of response to chemotherapy being the most common reason for not receiving HSCT. The IRC-assessed progression-free survival was also significantly longer in the lisocabtagene maraleucel arm with a HR of 0.41 (95% CI: 0.25, 0.66; p-value 0.0001).
Efficacy was also evaluated in PILOT (NCT03483103), a single-arm, open-label, multicenter trial in transplant-ineligible patients with relapsed or refractory LBCL after one line of chemoimmunotherapy. The study enrolled patients who were ineligible for high-dose therapy and HSCT due to organ function or age, but who had adequate organ function for CAR-T cell therapy. Efficacy was based on CR rate and duration of response (DOR) as determined by an IRC. Of 74 patients who underwent leukapheresis (median age, 73 years), 61 (82%) received lisocabtagene maraleucel of whom 54% (95% CI: 41, 67) achieved CR. The median DOR was not reached (95% CI: 11.2 months, not reached) in patients who achieved CR and 2.1 months (95% CI: 1.4, 2.3) in patients with a best response of PR. Among all leukapheresed patients, the CR rate was 46% (95% CI: 34, 58).
FDA approved lisocabtagene maraleucel with a Risk Evaluation and Mitigation Strategy because of the risk of fatal or life-threatening cytokine release syndrome (CRS) and neurologic toxicities. In studies of lisocabtagene maraleucel as second-line therapy for LBCL, CRS occurred in 45% of patients (Grade 3 or higher, 1.3%), and neurologic toxicities occurred in 27% (Grade 3, 7%). Serious adverse reactions occurred in 33% to 38% of patients.
The recommended lisocabtagene maraleucel dose for second-line therapy is 90 to 110 × 106 CAR-positive T cells with a 1:1 ratio of CD4 and CD8 components.
This application was granted priority review, regenerative medicine advanced therapy designation, and breakthrough designation. A description of FDA expedited programs is in the Guidance for Industry: Expedited Programs for Serious Conditions-Drugs and Biologics. The application also received orphan drug designation.
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