Advancing CAR T-cell therapy for chronic lymphocytic leukemia: exploring resistance mechanisms and the innovative strategies to overcome them

Chimeric antigen receptor (CAR) T -cell therapy has ushered in substantial advancements in the management of various B -cell malignancies. However, its integration into chronic lymphocytic leukemia (CLL) treatment has been challenging, attributed largely to the development of very effective chemo-free alternatives. Additionally, CAR T -cell responses in CLL have not been as high as in other B -cell lymphomas or leukemias. However, a critical void exists in therapeutic options for patients with high -risk diseases who are resistant to the current CLL therapies, underscoring the urgency for adoptive immunotherapies in these patients. The diminished CAR T -cell efficacy within CLL can be traced to factors such as compromised T -cell fitness due to persistent antigenic stimulation inherent to CLL. Resistance mechanisms encompass tumor -related factors like antigen escape, CAR T -cell -intrinsic factors like T -cell exhaustion, and a suppressive tumor microenvironment (TME). New strategies to combat CAR T -cell resistance include the concurrent administration of therapies that augment CAR T -cell endurance and function, as well as the engineering of novel CAR T -cells targeting different antigens. Moreover, the concept of "armored" CAR T -cells, armed with transgenic modulators to modify both CAR T -cell function and the tumor milieu, is gaining traction. Beyond this, the development of readily available, allogeneic CAR T -cells and natural killer (NK) cells presents a promising countermeasure to innate T -cell defects in CLL patients. In this review, we explore the role of CAR T -cell therapy in CLL, the intricate tapestry of resistance mechanisms, and the pioneering methods studied to overcome resistance.