CAR T-cells for acute leukemias in children: current status, challenges, and future directions.

CAR T-cells therapy is seen as one of the most promising immunotherapies for leukemias, since targeting CD19 has revolutionized the treatment of relapsed/refractory B-cell acute lymphoblastic leukemia (B-ALL) in children, adolescents, and young adults. Early phase clinical trials have shown a very high initial response rate confirmed by follow up and real-world studies. However, almost half of patients relapse with the available commercial product currently suggesting the need of a consolidative treatment after CAR T-cell infusion in well-defined cases, according to several pre- and post-CAR clinical and biological factors. This finding highlights that numerous challenges exist before the extension of CAR T-cell indications (first relapse and high-risk first line) in the field of B-ALL: to enhance persistence of CAR T-cells to avoid CD19-positive relapse and to avoid CD19-negative relapse by reducing tumor burden pre-CAR-T infusion and/or by multitargeting. Promising approaches with exciting early clinical data are emerging in the field of T-cell ALL. The use of CAR T-cells for acute myeloid leukemias remains challenging due to the lack of leukemia-specific antigens and to the immunosuppressive microenvironment.