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case_images: Summary protocol of medication treatment and CD19CAR structure. (A) Summary protocol of the patient's treatment. (B) The schematic diagram of pCDH-CD19-CAR.
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case_images: At the same time, the patient suffered serious headache and diplopia with increasing cerebrospinal fluid pressure measuring about 300 mmH2O, and the result of cerebrospinal fluid flow cytometry revealed that 91.13% karyocytes were malignant B naive lymphocytes (Supplementary Figure S1), which indicated refractory B-ALL with central infiltration. Then, the patient received two cycles of inter-median dose cytarabine followed by VDLP regimen one course again (Figure 1A). The structural composition of CAR: CD19 scFV = anti-CD19 single chain antibody, consisting of heavy chain variable region and light chain variable region, CD28 or 4-1BB, is a cytoplasmic costimulating molecule fragment of CAR; CD3zeta = active Zeta fragment of CD3 molecule (Figure 1B).
case_images: Clinical monitoring after infusion of pCDH-CD19-CAR cells. (A) Trends of temperature during 14 days after infusion. (B) Trends of interleukin (IL)-6 and C-reactive protein (CRP) during 14 days after infusion. (C) Changes of neutrophil count and procalcitonin (PCT) during 14 days after infusion. (D) Changes of hemoglobin (Hb) and platelet (PLT) during 14 days after infusion.
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case_images: After two cycles of inter-median dose cytarabine treatment, the result of malignant lymphocytes in his cerebrospinal fluid was 42.54% and 22.48% (Supplementary Figure S2 and Supplementary Figure S3), respectively. Four days after infusion, the patient suffered tension headache (pain score is 4) accompanied by vomiting and high body temperature (Figure 2A) with increasing CRP and interlukin-6 level. CRP and interlukin-6 level upward to around 44.03 mg/L and 100.90 ng/L on next day (Figure 2B) and observed grade 1 cytokine release syndrome. Neutropenia (Figure 2C) and thrombocytopenia were observed and corrected with granulocyte colony stimulating factor but did not have significant anemia (Figure 2D).
case_images: The result of cerebrospinal fluid flow cytometry. (A) The result of cerebrospinal fluid flow cytometry before CAR-T treatment, 0.16% malignant lymphocytes detected in CSF. (B) The result of cerebrospinal fluid flow cytometry after CAR-T treatment, no leukemic cells detected in CSF.
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case_images: After two cycles of inter-median dose cytarabine treatment, the result of malignant lymphocytes in his cerebrospinal fluid was 42.54% and 22.48% (Supplementary Figure S2 and Supplementary Figure S3), respectively. CR status in bone marrow, but it was tested that about 0.16% malignant lymphocytes in the cerebrospinal fluid (Figure 3A). Considering funding difficulties, the patient who had no choice to do allo-transplantation was enrolled to our clinical trials (Clinical Trials information: NCT02349698). One month after CAR-T cell therapy, the patient achieved complete remission and no leukemic cells in bone marrow morphology and cerebrospinal fluid (Figure 3B).
case_images: Changes of total CART percent after CAR-T treatment. (A) The proportion of CAR-T cells in CD3 positive T cells was detected by flow cytometry in PB. (B) The proportion of CAR-T cells in CD3 positive T cells was detected by flow cytometry in CSF.
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case_images: Finally, the patient achieved complete remission in bone marrow, but there were still 2% malignant lymphocytes in his cerebrospinal fluid (Supplementary Figure S4). We tested the percentage of CAR-T cells in peripheral blood and cerebrospinal fluid by flow after CAR-T therapy in 1, 3, 6, 9, 12, and 18 months, respectively (Figures 4A, B).