DERENZO, KRENCIUTE, AND GOTTSCHALK

The Landscape of CAR T Cells Beyond Acute Lymphoblas c

Leukemia for Pediatric Solid Tumors
Christopher DeRenzo, MD, MBA, Giedre Krenciute, PhD, and Stephen Go schalk, MD

OVERVIEW
Adop ve cell therapy with gene cally modified T cells holds the promise to improve outcomes for children with recurrent/
refractory solid tumors and has the poten al to reduce treatment complica ons for all pa ents. Although T cells that ex-
press chimeric an gen receptors (CARs) specific for CD19 have had remarkable success for B-cell–derived malignancies,
which has led to their approval by the U.S. Food and Drug Administra on, CAR T cells have been less effec ve for solid
tumors and brain tumors. Lack of efficacy is most likely mul factorial, but heterogeneous an gen expression; limited mi-
gra on of T cells to tumor sites; and the immunosuppressive, hos le tumor microenvironment have emerged as major
roadblocks that must be addressed. In this review, we summarize the clinical experience with CAR T-cell therapy for pe-
diatric solid tumors, including brain tumors. In addi on, we review strategies that have been and are being developed to
enhance their an tumor ac vity.

I mmunotherapy for pediatric malignancies holds the promises

of improving outcomes and reducing treatment-related
complica ons. Among different forms of immunotherapy that
are ac vely being pursued, the adop ve transfer of T cells
that express chimeric an gen receptors (CARs) has garnered
great excitement because of the success of CAR T-cell ther-
apy for CD19-posi ve malignancies.1-11
CARs are synthe c molecules that combine the specific-
ity of monoclonal an bodies with the effector func on of
T cells.12-14 The prototypic CAR consists of an an gen bind-
ing domain encoded by a single-chain variable fragment
derived from a monoclonal an body, a hinge and trans-
membrane domain, and signaling domains derived from
the CD3.ζ chain as well as cos mulatory molecules, such
as CD28 and/or 41BB (Fig. 1A). The majority of CAR T-cell
products are generated by viral transduc on that uses rep-
lica on incompetent retroviral or len viral vectors (Fig. 1B).
Since the submission of the first inves ga onal new drug
applica on for CD19–CAR T cells, the field has moved rapidly
and culminated in 2017 with approval by the U.S. Food and
Drug Administra on (FDA) of two CD19–CAR T-cell prod-
ucts.15 The interested reader is referred to recent reviews,
which summarize the clinical results of CD19–CAR T cells
in detail.1,2 Here, we highlight only the key findings, which
must be considered as we develop and improve current CAR
T-cell therapy approaches for pediatric solid tumors.
First, lymphodeple ng chemotherapy with cyclophospha-
mide and fludarabine is cri cal to allow engra ment and
expansion of adop vely transferred CD19–CAR T cells. Sec-
ond, CD19–CAR T cells can eradicate B-cell malignancies re-
gardless of their underlying gene c altera on. Third, CD19–
CAR T cells, can eradicate B-cell malignancies, which are
refractory to chemotherapy and/or radia on, highligh ng
that T cells kill their target cells through different cytotoxic
mechanisms than conven onal therapies. Fourth, CD19-
CARs have to encode a cos mulatory signaling domain
to be effec ve. Although CD19–CAR.CD28.ζ and CD19–
CAR.41BB.ζ T cells have not been compared directly in a sin-
gle clinical study, results of published studies indicate that
CD19–CAR.41BB.ζ T cells persist longer.1-11 However, it re-
mains unclear whether this translates into improved an tu-
mor ac vity.1-11 Fi h, targe ng a single an gen can result in
an gen loss variants. Last, CD19–CAR T-cell therapy can be
associated with important clinical adverse effects, including
cytokine release syndrome (CRS) and neurotoxicity.1-11
In this educa onal review, results of early-phase clinical
studies with CAR T cells for pediatric solid tumors and brain
tumors are summarized (Table 1). In addi on, strategies to
improve their an tumor ac vity and current challenges are
discussed.
CLINICAL STUDIES WITH CAR T CELLS FOR
PEDIATRIC BRAIN AND SOLID TUMORS
Neuroblastoma
Two clinical studies have been conducted with first-
genera on CAR T cells in pa ents with neuroblastoma. In

From the Department of Bone Marrow Transplanta on and Cellular Therapy, St. Jude Children’s Research Hospital, Memphis, TN.

Disclosures of poten al conflicts of interest provided by the authors are available with the online ar cle at asco.org/edbook.

Corresponding author: Stephen Go schalk, MD, Department of Bone Marrow Transplanta on and Cellular Therapy, St Jude Children’s Research Hospital, 262 Danny Thomas Pl.,
MS321, Memphis, TN 38105; email: stephen.go schalk@stjude.org.

© 2018 American Society of Clinical Oncology

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FIGURE 1. Scheme of CAR T-Cell Genera on
A 1st Gen 2nd Gen B
Activation
Cytokines
zeta costim
Day 0
zeta
(A) CARs consist of an ectodomain, hinge and transmembrane domain, and endodomain. CARs have been designed with or without cos mulatory (cos m) signaling domains. As examples, first- and second-
genera on (Gen) CARs are shown. (B) CAR T cells are produced by ac va ng T cells in the presence of cytokines. When T cells proliferate, they are transduced with viral vectors that encode CARs. CAR T cells
subsequently are expanded with cytokines, and sufficient CAR T cells for preclinical or clinical studies are generated within 9 to 10 days of culture ini a on.
the first study, pa ents received up to 109/m2 CD8 CD171-
specific CAR T-cell clones.16 Adop ve transfer of T cells was
well tolerated, but T cells persisted for only 6 weeks, and
only one of six pa ents had a par al response. One strat-
egy to improve the persistence of adop vely transferred T
cells takes advantage of the specificity of the endogenous
αβ T-cell receptor expressed by CAR T cells. For example,
virus-specific T cells receive appropriate s mula on by viral
an gens presented by professional an gen-presen ng cells.
This concept was explored in the second clinical study, in
which inves gators expressed a first-genera on disialogan-
glioside (GD2)-specific CAR in polyclonal Epstein Barr virus
(EBV)–specific T cells. The in vivo fate of GD2–CAR EBV-
specific T cells was directly compared with ac vated T cells
that expressed the same CAR in individual patients.17,18
Although GD2–CAR EBV-specific T cells did not expand, they
persisted longer than GD2–CAR ac vated T cells. Five of 11
patients with active disease showed tumor responses or
necrosis. Three of them had complete responses.
PRACTICAL APPLICATIONS
• CAR T cells for pediatric solid tumors are safe but have
limited an tumor ac vity in early-phase clinical studies.
• Carefully designed correla ve studies will be cri cal to
understand current failures of CAR T-cell therapies and
to devise strategies to improve them.
• Rou ne, noninvasive, clinical imaging of infused CAR
T cells would provide invaluable insight into their
biodistribu on in humans.
• Addi onal gene c modifica ons have improved the
an tumor ac vity of CAR T cells in preclinical models,
but improved CAR T cells have not been tested in the
clinic.
• Costs and regulatory requirements associated with
clinical tes ng of CAR T cells have the poten al to
impede progress.
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LANDSCAPE OF CAR T CELLS BEYOND ACUTE LYMPHOBLASTIC LEUKEMIA
Viral Transduction Freeze
Cytokines
Day 1-2 Day 9-10
More recently, ac vated T cells that expressed a third-
genera on GD2–CAR with a CD28.OX40.ζ endodomain were
evaluated in pa ents with neuroblastoma.19 Three cohorts
of pa ents were infused. The first cohort (four pa ents) re-
ceived only CAR T cells; the second cohort (four pa ents) re-
ceived lymphodeple ng chemotherapy (cyclophosphamide
and fludarabine) before CAR T-cell infusion; and the third
cohort (three pa ents) received two doses of pembroli-
zumab in addi on to CAR T-cell infusion: on day −1 and day
21 rela ve to CAR T-cell infusion. Lymphodeple ng chemo-
therapy induced expansion of CAR T cells for up to 3 logs,
and expansion peaked at 1 to 2 weeks post infusion. Addi-
on of pembrolizumab did not improve T-cell expansion or
persistence further. There was a large increase in the fre-
quency of circula ng myeloid cells in the peripheral blood
with an immunosuppressive M2 phenotype a er CAR T-cell
infusion in all three cohorts. Addi onal studies are needed
to inves gate the significance of this finding.
In addi on to these published studies, several clinical
trials, including one study to evaluate second-genera on
(41BB.ζ) and third-genera on (CD28.41BB.ζ) CAR T cells that
target CD17124 in pa ents with neuroblastoma and gangli-
oneuroblastoma (NCT02311621), are in progress. In addi on,
studies con nue to explore GD2–CAR T cells for neuroblas-
toma; these include NCT02107963, NCT02761915, and
NCT03373097.
Sarcoma
T cells that express second-genera on HER2–CARs (CD28.ζ)
have been evaluated in 19 pa ents with refractory HER2-
posi ve sarcoma (16 with osteosarcoma, one with Ewing
sarcoma, one with primi ve neuroectodermal tumor, and
one with desmoplas c small round cell tumor). HER2–CAR
T-cell infusions were well tolerated and had no dose-limi ng
toxicity.20 HER2–CAR T cells persisted for at least 6 weeks in
pa ents who received greater than 1 × 106/m2 HER2–CAR
T cells and were detected at tumor sites. Of 17 evaluable
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DERENZO, KRENCIUTE, AND GOTTSCHALK

TABLE 1. Selected Completed and Future CAR T-Cell Therapy Studies for Pediatric Solid Tumors or Brain
Tumors

CAR Signaling Cell Type and Lymph Comment, NCT No., or

Disease Target Domain Vector Delivery Deple on Reference (if published)
Neuroblastoma CD171 ζ Pl ATC, IV — Park et al16
41BB.ζ or
CD171 LV ATC, IV + NCT02311621
CD28.41BB.ζ
GD2 ζ RV VST or ATC, IV — Pule et al,17 Louis et al18
GD2 CD28.OX40.ζ RV ATC, IV ± Pembrolizumab, Heczey et al19
GD2 ζ, ND RV ATC, IV + NCT03373097
GD2 ζ, ND RV ATC, IV ± NCT02761915
Second transgene: IL-15,
GD2 ζ, ND RV iNKT, IV +
NCT03294954
Neuroblastoma and
GD2 CD28.OX40.ζ RV ATC, IV + NCT02107963
sarcoma
Sarcoma Ahmed et al (2015),20 Hegde
HER2 CD28.ζ RV ATC, IV ±
et al21
GD2 CD28.OX40.ζ RV VST, IV ± VZV vaccine, NCT02932956
Hepatoblastoma and
GPC3 41BB.ζ RV ATC, IV + NCT02932956
sarcoma
Brain tumors HER2 CD28.ζ RV VST, IV — Ahmed et al (2017)22
IL-13Rα2 41BB.ζ LV ATC, IC — NCT02208362, Brown et al23

Abbrevia ons: ATC, ac vated T cells; CAR, chimeric an gen receptor; IC, intracranial; IL, interleukin; IL-13R, IL-13 receptor; iNKT, invariant NK T cells; IV, intravenous; LV, len virus; ND, not disclosed;
Pl, plasmid; RV, retrovirus; VST, virus-specific T cells.

pa ents, four had stable disease. Three of these had their However, responses were observed; these included one
tumor removed; one showed 90% or greater necrosis. Sub- par al response22 and one complete response,23 and sev-
sequently, six pa ents received lymphodeple ng chemo- eral pa ents had stable disease for a prolonged period of
therapy before HER2–CAR T-cell infusion. HER2-CAR T-cell me.22
expansion was observed without apparent toxicity, and Detailed correla ve studies performed a er infusion
one pa ent with refractory rhabdomyosarcoma, who had of EGFRvIII–CAR T cells revealed that T cells were able to
persistent bone marrow disease only, achieved a complete migrate to glioma sites a er intravenous infusion.26 Target
response for greater than 12 months.21 In addi on to HER2– an gen expression was reduced in resected gliomas, which
CAR T cells, GD2–CAR T cells are ac vely being explored was indica ve of an on-target CAR T-cell effect. In addi on,
(NCT01953900, NCT02107963) for sarcoma. In one study, a gliomas upregulated the expression of immunosuppressive
third-genera on GD2–CAR with a CD28.OX40.ζ endodomain molecules, including indoleamine 2,3 dioxygenase and IL-
is expressed in varicella zoster virus–specific T cells, and 10, which highlighted the ability of gliomas to counteract
the inves gators are evalua ng whether GD2–CAR virus- infiltra ng pro-inflammatory CAR T cells. Currently, only one
specific T cells can be boosted with an FDA-approved var- clinical study (NCT02208362) is ac vely recrui ng pa ents,
icella zoster virus vaccine a er infusion. Another clinical including children older than age 12 years, with gliomas.
study (NCT02932956) is approved by the FDA to evaluate This study is evalua ng the safety and efficacy of intracranial
the safety and efficacy of GPC3-CAR T cells25 in pa ents with injec ons of IL-13Rα2–CAR.41BB.ζ T cells.
pediatric solid tumors, including rhabdomyosarcoma. How- The ini al foray into the clinic with CAR T cells has demon-
ever, the study currently is not open for accrual. strated their safety for pediatric solid tumors and brain
tumors. However, only subsets of pa ents have benefited
Brain Tumors from this approach so far. Poten al strategies to increase
Clinical studies with CAR T cells that target HER2, EGFRvIII, the efficacy of CAR T cells are reviewed in the next sec on.
and interleukin (IL)-13 receptor α2 (IL-13Rα2) have been
conducted in pa ents with high-grade glioma.22,23,26,27 Two Strategies to Improve CAR T-Cell Therapy for Solid
studies infused only adults, whereas 10 of 17 pa ents in the Tumors
HER2–CAR T-cell therapy study were children. T cells were Lack of CAR T-cell efficacy is most likely mul factorial. Major
given either intravenously (HER2, EGFRvIII) or directly in- roadblocks include the availability of targeted an gens and
jected into the tumor and/or ventricle (IL-13Rα2). Like the their heterogeneous expression, the homing of T cells to
CAR T-cell therapy studies for solid tumors, the majority of tumor cells, and the immunosuppressive tumor microenvi-
pa ents in the brain tumor studies had progressive disease. ronment (Fig. 2).

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Expanding the Repertoire of Targetable An gens
The majority of CARs developed so far recognize cell sur-
face proteins (GD2, HER2, Glypican (GPC)3, and IL-13Rα2),
which originally were discovered as targets for monoclonal
an bodies. Efforts are underway with gene expression ar-
ray data and proteomics to iden fy new targetable cell sur-
face an gens.28 The recent iden fica on of GPC2, which is
expressed at high levels on neuroblastoma, highlights the
feasibility of this approach.29 However, it might be difficult
to discover an gens that are not expressed at low levels in
normal ssues. Although private neoan gens are present,
albeit at low frequency, in pediatric tumors,30 directly tar-
ge ng these with CAR T cells is not feasible with current
technology that uses viral vectors to generate CAR T cells.
In addi on to the large regulatory burden and cost, me is
a barrier: it takes more than 6 months to generate a clinical-
grade viral vector. However, op miza on of CAR T cells to
efficiently induce immune responses against nontargeted
an gen (i.e., an gen spreading) would be one approach to
target private neoan gens and could increase the an tumor
ac vity of CAR T cells in a manner similar to that of cancer
vaccines.31
CAR T cells are being developed to recognize an gen
pa erns. Examples include designing CARs that recognize
two an gens or engineering T cells that express mul ple
CARs.32,33 T cells that express these CARs become fully ac -
vated only in the presence of all targeted an gens. Target-
ing mul ple an gens also should offset the risk of selec ng
an gen loss variants. In addi on, so-called inhibitory CARs
that block poten al off-target T-cell responses have been
developed.34 Development of CARs that recognize pep des
in the context of major histocompa bility complex class I
molecules also might increase the poten al repertoire of
targetable an gens, because two-thirds of all expressed
proteins reside within the cell. This can be achieved with a
single-chain variable fragment derived from a T-cell receptor
to mimic a monoclonal an body as a CAR an gen-binding
domain. Examples include CARs specific for an HLA-A2–
restricted pep de derived from intracellular proteins, such
as Wilms tumor 1 protein or proteinase 3.35,36
Inducible expression systems may provide a poten al
solu on to the an gen dilemma. So-called synthe c notch
signaling receptors allow the expression of CARs only af-
ter a T cell has migrated to tumor sites, which poten ally
FIGURE 2. Roadblocks of CAR T Cells for Solid
Tumors
Antigen &
Heterogeneity
CART
Roadblocks
Tumor
environment Homing
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LANDSCAPE OF CAR T CELLS BEYOND ACUTE LYMPHOBLASTIC LEUKEMIA
enables the targe ng of an gens that are expressed in nor-
mal ssues.37,38
Enhancing Migra on of CAR T-Cells to Tumor Sites
and Within Tumors
Several preclinical studies have highlighted the mismatch
between chemokines secreted by solid tumors and chemo-
kine receptors expressed by CAR T cells. Transgenic expres-
sion of chemokine receptors has been shown to overcome
this roadblock.39 For example, neuroblastoma secretes high
levels of CCL2; however, CAR T cells lack expression of the
corresponding chemokine receptor (i.e., CCR2).40 Trans-
genic expression of CCR2b on GD2–CAR T cells resulted
in enhanced homing and an tumor ac vity in preclinical
neuroblastoma models.40 Besides migra on to tumor sites,
limited migra on within tumors might contribute to the
reduced an tumor ac vity observed in clinical studies. For
example, CAR T cells are limited in their ability to degrade
the extracellular matrix, and this limita on results in poor
tumor penetra on. However, penetra on can be improved
by expressing heparanase.41 Another approach consists of
directly targe ng cancer-associated fibroblasts, the main
producer of collagen within tumors, with CAR T cells.42
Engineering CAR T Cells to Resist the
Immunosuppressive Tumor Environment
Brain and solid tumors create a hos le tumor environment
that favors T-cell exhaus on and/or dysfunc on induced by
immunosuppressive cytokines (e.g., IL-4, IL-10, transforming
growth factor β [TGFβ]); expression of inhibitory molecules
(e.g., first apoptosis signal receptor [FAS] ligand, PD-L1); the
metabolic environment; and/or recruitment of immunosup-
pressive cells, including myeloid-derived suppressor cells,
cancer-associated fibroblasts, and/or regulatory T cells.43-45
Although this sec on is focused on engineering CAR T
cells to improve their an tumor ac vity in the tumor mi-
croenvironment, combina on therapies also are a rac ve
approaches. For example, combina on of CAR T-cell therapy
with checkpoint blockade, oncoly c viruses, chemotherapy,
radia on, and/or small molecules is being explored in pre-
clinical studies with encouraging results.46-48 Gene c engi-
neering approaches to enhance the an tumor ac vity of
CAR T cells can be divided into two broad categories: trans-
genic expression of immune s mulatory molecules and si-
lencing nega ve regulators.
Several preclinical studies have shown that transgenic ex-
pression of cytokines (e.g., IL-12, IL-15, IL-18),49-51 cons tu-
ve cytokine receptors,52 41BBL,53 or CD40L54 enhance the
an tumor ac vity of CAR T cells. A recent study also demon-
strated that transgenic expression of IL-7 in combina on
with the chemokine CCL19 not only enhances the effector
func on of CAR T cells but also enables the cells to induce
endogenous T-cell responses against the targeted tumor,
which is indica ve of an gen spreading.55
Direct blockade of inhibitory cytokines or conversion of
their signal into a T-cell s mulatory signal are other ap-
proaches that are being pursued. For example, expression
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DERENZO, KRENCIUTE, AND GOTTSCHALK
of a dominant nega ve TGFβ receptor renders T cells re-
sistant to TGFβ in preclinical as well as in clinical studies.56
In addi on, dominant nega ve receptors have been de-
veloped to provide intrinsic protec on from PD-1/PD-L1
checkpoint blockade.57 Chimeric cytokine or switch recep-
tors not only block an inhibitory signal but also convert it
into a T-cell s mulatory signal. Examples include receptors
that consist of the ectodomain of the IL-4 receptor and
the transmembrane and intracellular signaling domain of
the IL-2 or IL-7 receptor.58,59 Although siRNA approaches
were used ini ally to silence nega ve regulators, more re-
cent studies have focused on gene edi ng technologies,
such as TALENs and CRIPSR/Cas9. Per nent examples in-
clude the silencing of FAS ligand or the knockout of PD-1 in
T cells.60,61
As we enhance the effector func on of CAR T cells, it is
advisable to insert safety switches that can be ac vated if
adverse effects develop. Safety switches that have been
tested clinically include HSV thymidine kinase (HSV-tk),
which enables cell killing in the presence of ganciclovir,62 or
an inducible caspase 9,63 which can be ac vated by a chem-
ical inducer of dimeriza on. In addi on, expression of cell
surface molecules (e.g., EGFR, CD20),64,65 which can be tar-
geted with FDA-approved monoclonal an bodies, is another
suicide gene op on that has been evaluated successfully in
preclinical models.
CURRENT CHALLENGES
CAR T-Cell Genera on
The majority of clinical studies have used retroviral or len -
viral vectors to generate clinical-grade CAR T-cell products.
Genera on of clinical-grade viral vectors is me consuming
and costly, and their use is associated with a large regulatory
burden. In this regard, reducing some of the required test-
ing of CAR T-cell products, as recently advocated,66,67 would
be a step in the right direc on. Required tes ng could also
be reduced with the use of nonviral DNA delivery systems
that have been successfully used to generate CAR T cells.68-70
Closed-cell manufacturing systems71,72 and the use of off-
the-shelf CAR T-cell products73 also hold the promise to
streamline CAR T-cell produc on and/or distribu on.
What Is the Op mal T-Cell Subset to Generate CAR T
Cells?
Several studies have highlighted that CAR T cells genera on
from central memory T cells with a defined CD4:CD8 ra o
have superior effector func on compared with CAR T cells
generated from bulk T cells in preclinical models.74,75 Epigen-
e c profiling of T cells has provided novel insight76 and holds
the promise to advance our ability to select the most potent
T-cell subset for CAR T-cell genera on. Also, γδ T cells and
invariant natural killer T cells are being explored as T-cell
pla orms for CAR T-cell therapy.77,78 In this regard, a clinical
study with invariant natural killer T cells that express GD2–
CARs and IL-15 for pa ents with neuroblastoma has been
approved by the FDA (NCT03294954) but is not ac vely ac-
cruing pa ents.
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Need for Preclinical Tes ng in Range of Animal
Models
The majority of preclinical studies have relied on xenogra
models, which do not reliably recapitulate the complex tu-
mor microenvironment. Immunocompetent animal mod-
els have been adapted for CAR T-cell therapies, and these
models will be invaluable as combina on therapies are
developed.79-81 In addi on, pa ent-derived xenogra mod-
els should enable preclinical tes ng of CAR T cells against
a panel of human tumors that more closely mimic pa ent
tumors than tumor cell lines that have been propagated in
vitro. Also, large animal models hold promise to evaluate
CAR T cells in spontaneous tumor models.82
Correla ve Studies, In Vivo Tracking of Infused T
Cells, and Clinical Response Criteria
There currently is only one published CAR T-cell therapy
(noted in the Brain Tumor sec on) that has systema cally
studied tumor biopsies a er infusion.26 These types of stud-
ies will be cri cal to understand current therapeu c failures
and to devise evidence-based approaches to overcome
them. In addi on, our ability to track infused CAR T cells
in pa ents is limited unless the cells are gene cally modi-
fied with a reporter gene, such HSV thymidine kinase.83 The
ability to rou nely track CAR T cells for 48 to 72 hours a er
infusion would be a major advance that could provide in-
valuable insight into ini al biodistribu on of CAR T cells and
their ability to migrate to tumor sites. Although diagnos c
imaging immune response criteria have been implemented
for the assessment of immunotherapies for solid tumors
and brain tumors,84,85 these were developed in the cancer
vaccine era and might require addi onal fine tuning for cell-
based immunotherapies, including CAR T cells.
CONCLUSIONS
The ini al foray of CAR T cells into the clinic for pediatric
solid tumors and brain tumors demonstrated their safety but
also highlighted their limited an tumor ac vity. Addi onal
gene c modifica on of CAR T cells has greatly enhanced the
an tumor ac vity of these cells in preclinical studies, and
we hope that some of the devised strategies will translate
into improved an tumor ac vity in humans. To advance
the field, there is an urgent need to discover novel an gens
that can be targeted with CAR T cells and to improve our
ability to evaluate CAR T-cell therapies in preclinical mod-
els. The abili es to track CAR T cells noninvasively and to
perform detailed studies with pa ents enrolled in CAR T-cell
therapy should enable us to advance the field. We remain
hopeful that, within the next 5 to 10 years, pa ents with
solid tumors will benefit from CAR T-cell therapies to the
same degree that pa ents with B-cell–derived malignancies
do today.
ACKNOWLEDGMENT
This work was supported by Na onal Ins tutes of Health
Grants No. 5T32HL092332 and 1R01CA173750 and CRPIT
Grant No. RP101335.

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