Engineered T cells expressing chimeric antigen receptors, known as CAR T cells, have revolutionized treatment for certain blood cancers by precisely targeting malignant cells. However, the traditional process requires extracting a patient's T cells, genetically modifying them in a lab, expanding them into billions, and reinfusing them—a complex, expensive procedure that can take weeks and is inaccessible for many. A groundbreaking study published in Nature introduces a transformative method: in vivo site-specific engineering to reprogram T cells directly inside the body, bypassing ex vivo manufacturing entirely.
Led by researchers at the University of California, San Francisco (UCSF), this US-led collaboration demonstrates the generation of functional CAR T cells in humanized mouse models, achieving complete tumor clearance in models of leukemia, multiple myeloma, and even challenging solid sarcomas. By integrating the CAR transgene into the T cell receptor alpha constant (TRAC) locus using CRISPR-Cas9, the approach ensures stable, physiological expression under the cell's own promoter, mimicking natural T cell behavior more closely than previous methods.
Background on CAR T Cell Therapy
Chimeric antigen receptor T cell (CAR T cell) therapy reprograms a patient's own cytotoxic T cells—immune cells that normally kill virus-infected or cancerous cells—to express synthetic receptors. These CARs consist of an antigen-binding domain (often from an antibody), transmembrane hinge, and intracellular signaling domains like CD3ζ and costimulatory molecules such as 4-1BB or CD28. Upon binding tumor-specific antigens like CD19 on B cell malignancies, CAR T cells activate, proliferate, and unleash cytokines and perforin/granzyme to eradicate cancer.
Since the FDA approvals of therapies like Kymriah (tisagenlecleucel) in 2017 and Yescarta (axicabtagene ciloleucel) in 2017, CAR T has achieved remission rates over 80% in relapsed/refractory B cell acute lymphoblastic leukemia (B-ALL) and large B cell lymphoma. Yet, success in solid tumors remains elusive due to antigen heterogeneity, immunosuppressive microenvironments, and poor T cell trafficking. Globally, the CAR T market is projected to grow from around $4-7 billion in 2025 to over $15 billion by 2035, driven by expanding indications, but manufacturing bottlenecks persist.
Challenges of Ex Vivo CAR T Production
Ex vivo manufacturing involves leukapheresis to collect peripheral blood mononuclear cells, isolation and activation of CD8+ and CD4+ T cells using anti-CD3/CD28 beads, lentiviral or AAV transduction for CAR insertion (often random), expansion in bioreactors for 7-14 days, quality control, cryopreservation, and infusion. This process costs $300,000-$500,000 per treatment, delays therapy for critically ill patients, and fails in up to 20% due to poor cell quality or manufacturing failures.
Random integration risks insertional mutagenesis and tonic signaling from non-physiological promoters, leading to exhaustion. Patient-to-patient variability in T cell fitness further complicates outcomes. In vivo approaches promise universal, off-the-shelf solutions, but prior efforts yielded transient expression or off-target effects.
The Breakthrough: A Dual-Vector System for Precision Editing
The innovation centers on a two-vector platform optimized for T cell tropism and homology-directed repair (HDR). First vector: Enveloped delivery vehicles (EDVs)—engineered nanoparticles pseudotyped with vesicular stomatitis virus G protein (VSV-G) or anti-CD3 single-chain variable fragment (scFv)—encapsulate CRISPR-Cas9 ribonucleoproteins (RNPs) targeting TRAC. Anti-CD3 EDVs bind CD3ε on resting T cells, triggering activation essential for HDR, which requires S/G2 cell cycle phases.
Second vector: An evolved adeno-associated virus serotype 6 variant, AAV-hT7, delivers the HDR template (HDRT)—a large ~4kb DNA payload with the CAR cassette flanked by TRAC homology arms. AAV-hT7, selected via directed evolution for human serum resistance (20,000-fold enrichment for HAPRVEE motif) and T/NK cell preference via CD7 receptor, evades neutralizing antibodies prevalent in 50-70% of adults.
Step-by-step process: 1) Intravenous or intraperitoneal injection of EDV (2.5 × 10^11 sgRNAs/mouse) and AAV (1 × 10^12 vg/mouse). 2) EDVs deliver Cas9 RNP, inducing targeted double-strand break at TRAC exon 1. 3) AAV provides HDRT; DNA-PK inhibitor (included) boosts HDR over non-homologous end joining (NHEJ). 4) Precise knock-in disrupts endogenous TCR (preventing GvHD) and drives CAR from TRAC promoter. Efficiency: Up to 40% CAR+ T cells in vitro, 3-20% in vivo spleen at day 14.
Key Innovations in Vector Design
EDV optimization via genome-wide CRISPR screens identified CD7 as critical for AAV entry, enabling T cell-specific transduction while sparing B cells. Anti-CD3 pseudotyping enhanced specificity 10-fold over VSV-G. AAV evolution overcame humoral immunity, crucial for repeat dosing.
TRAC locus choice ensures 1:1 CAR:TCR ratio, equitable CD4/CD8 distribution, central memory phenotype (TCF1+ TOX low), and reduced exhaustion. Compared to lentiviral random integration, TRAC-CAR T cells expanded 8-50-fold more, showed higher naive/stem memory markers, and uniform surface expression.
Impressive Results in Preclinical Models
In NSG mice humanized with PBMCs from four donors, a single dose cleared circulating B cells (complete aplasia), with CAR T comprising 10-20% of human CD3+ cells. In orthotopic NALM6 B-ALL (CD19+), 18/20 mice achieved complete remission by bioluminescence imaging, controlling rechallenge. OPM2 multiple myeloma: 100% CR in 8/8. Solid MES-SA sarcoma: 5/6 CR despite stromal barriers.
Reprogrammed T cells proliferated robustly (Ki-67+), adopted progenitor-exhausted state for durability, and secreted antitumor cytokines without syndrome. No off-target integrations or cytokine storms observed.
Universities and Researchers Driving the Discovery
This work stems from UCSF's Gladstone-UCSF Institute of Genomic Immunology, where corresponding author Justin Eyquem, PhD, an associate professor in Hematology-Oncology, pioneered TRAC targeting. First authors William A. Nyberg, now at Karolinska Institutet, and Pierre-Louis Bernard highlight interdisciplinary collaboration.
Contributions from Jennifer A. Doudna (UC Berkeley, CRISPR co-inventor) via Innovative Genomics Institute, Aravind Asokan (Duke University) for AAV evolution, and teams at Gladstone Institutes underscore academic synergy. For details on the study, explore the original Nature publication.
Clinical Implications and Advantages Over Existing Therapies
By eliminating leukapheresis and GMP facilities, in vivo reprogramming could slash costs 5-10-fold, enabling rapid deployment (days vs. weeks) for aggressive cancers. Uniform expression mitigates relapse from CAR-low escape variants. Potential for allogeneic use via TCR KO reduces donor matching needs.
Expert commentary in Nature News & Views praises superior in vivo-generated T cell quality—retaining 'stemness' lost in culture. Applications extend to TCR therapies for solid tumors, autoimmune regulators (e.g., IL-10 CAR T), and antivirals.
Challenges Ahead and Safety Considerations
- Immunogenicity: AAV/EDV components may elicit antibodies, though evolved capsids mitigate.
- Off-target editing: High-fidelity Cas9 and screens minimized risks.
- Human translation: Requires non-human primate studies; ongoing at Azalea Therapeutics (Eyquem co-founder).
- Solid tumor access: Local delivery or chemokine enhancements needed.
- Regulatory hurdles: FDA IND for first-in-human trials imminent.
Despite preclinical success, long-term persistence and neurotoxicity in humans warrant caution, as seen in ex vivo CAR T (CRS incidence 50-90%).
Future Outlook: Reshaping Immunotherapy Research
Building on this, universities like UCSF and Duke are scaling to primates and optimizing multi-CARs or logic-gated CARs. Integration with checkpoint inhibitors or oncolytic viruses could conquer solids. Academic labs now prioritize in vivo platforms, spawning startups and training next-gen immunologists.
Timeline: Phase 1 trials by 2028, market entry 2032+. For Swedish perspectives, see Karolinska Institutet coverage.
Opportunities in Academic Research and Careers
This advances gene editing, vectorology, and synthetic biology, fueling demand for postdocs in CRISPR immunotherapy at top institutions. Explore faculty positions bridging engineering and oncology.
