351
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Abstract
BACKGROUND Pediatric patients with relapsed and refractory acute lymphoblastic leukemia are more often being treated with chimeric antigen receptor (CAR) T-cell therapy. As with any new therapy, the management of this patient population has a unique set of challenges. The side effects of this therapy can range from mild to severe, with cytokine release syndrome being the most common reason for hospitalization.
. OBJECTIVES This article presents common side effects, treatments, and challenges of caring for hospitalized patients who have received CAR T-cell therapy.
. METHODS A case study is used to illustrate a patient's inpatient hospitalization course after receiving CAR T-cell therapy, including the management of treatment-related toxicities.
. FINDINGS As treatments emerge, nurses will be challenged with learning the associated side effects and toxicities. CAR T-cell therapy can result in a unique trajectory of potential symptoms and the potential for complete resolution of disease.
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352
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Khoury A, Parihar V, O'steen L, Cherabuddi K. Pertuzumab and trastuzumab infusion related cytokine release syndrome in a chemotherapy naive patient with metastatic breast cancer. Breast J 2017; 24:383-384. [PMID: 29027290 DOI: 10.1111/tbj.12943] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 05/10/2017] [Accepted: 05/12/2017] [Indexed: 11/29/2022]
Abstract
Pertuzumab is a monoclonal antibody that targets and down regulates HER-2/neu expression in ductal breast tumors. Other HER-2/neu monoclonal antibodies, particularly trastuzumab, have been implicated to induce infusion related reactions such as cytokine release syndrome (CRS). Here, we report a case of pertuzumab associated CRS prior to infusion of trastuzumab which warranted hospitalization for symptom management.
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Affiliation(s)
- Adonice Khoury
- College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Vikas Parihar
- Department of Anesthesia, Faculty of Health Sciences, McMaster University, Hamilton, ON, USA
| | - Lillie O'steen
- College of Medicine, University of Florida, Gainesville, FL, USA
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353
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Rassy EE, Assi T, Rizkallah J, Kattan J. Diffuse edema suggestive of cytokine release syndrome in a metastatic lung carcinoma patient treated with pembrolizumab. Immunotherapy 2017; 9:309-311. [PMID: 28303768 DOI: 10.2217/imt-2016-0134] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) are actually being indicated more commonly in the management of chemoresistant cancer patients in view of their favorable toxicity profile in comparison to cytotoxic chemotherapy. In this paper, we report, to our knowledge, the first case suggestive of cytokine release syndrome secondary to pembrolizumab in a patient with metastatic lung squamous cell carcinoma. In view of the quick approvals of ICI and the absence of sufficient knowledge of the corresponding toxicity profile, the occurrence of any clinical or biological sign or symptom in patients receiving ICI requires further investigation.
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Affiliation(s)
- Elie El Rassy
- Department of Hematology-Oncology, Hotel Dieu de France University Hospital, Faculty of Medicine, Saint Joseph University, Lebanon
| | - Tarek Assi
- Department of Hematology-Oncology, Hotel Dieu de France University Hospital, Faculty of Medicine, Saint Joseph University, Lebanon
| | - Jamale Rizkallah
- Department of Nephrology, Hotel Dieu de France University Hospital, Faculty of Medicine, Saint Joseph University, Lebanon
| | - Joseph Kattan
- Department of Hematology-Oncology, Hotel Dieu de France University Hospital, Faculty of Medicine, Saint Joseph University, Lebanon
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354
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Singh N, Hofmann TJ, Gershenson Z, Levine BL, Grupp SA, Teachey DT, Barrett DM. Monocyte lineage-derived IL-6 does not affect chimeric antigen receptor T-cell function. Cytotherapy 2017; 19:867-880. [PMID: 28506444 DOI: 10.1016/j.jcyt.2017.04.001] [Citation(s) in RCA: 106] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 02/20/2017] [Accepted: 04/03/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND AIMS Chimeric antigen receptor (CAR) T-cell therapy targeting CD19 has demonstrated remarkable success in targeting B-cell malignancies but is often complicated by serious systemic toxicity in the form of cytokine release syndrome (CRS). CRS symptoms are primarily mediated by interleukin 6 (IL-6), and clinical management has focused on inhibition of IL-6 signaling. The cellular source and function of IL-6 in CRS remain unknown. METHODS Using co-culture assays and data from patients on our clinical CAR T-cell trials, we investigated the cellular source of IL-6, as well as other CRS-associated cytokines, during CAR T-cell activation. We also explored the effect that IL-6 has on T-cell function. RESULTS We demonstrated that IL-6 is secreted by monocyte-lineage cells in response to CAR T-cell activation in a contact-independent mechanism upon T-cell engagement of target leukemia. We observed that the presence of antigen-presenting cell-derived IL-6 has no impact on CAR T-cell transcriptional profiles or cytotoxicity. Finally, we confirm that CAR T cells do not secrete IL-6 in vivo during clinical CRS. DISCUSSION These findings suggest that IL-6 blockade will not affect CD19 CAR T-cell-driven anti-leukemic cytotoxicity, permitting enhanced control of CRS while maintaining CAR T-cell efficacy.
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Affiliation(s)
- Nathan Singh
- Division of Hematology and Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Ted J Hofmann
- Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia, Pennsylvania, USA
| | - Zachary Gershenson
- Department of Cellular and Molecular Biology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Bruce L Levine
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Stephan A Grupp
- Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia, Pennsylvania, USA; Department of Pathology, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - David T Teachey
- Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia, Pennsylvania, USA
| | - David M Barrett
- Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia, Pennsylvania, USA
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355
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Abstract
Chimeric antigen receptor-engineered T cells therapy has become the hottest topic of immunotherapy, as its great successes achieved in treating refractory hematological malignancies. These successes also paved the road to novel strategies of treating various solid tumors including liver cancer. Many specific proteins can be expressed aberrantly in liver cancers; therefore, a series of experimental and clinical researches exploring chimeric antigen receptor-engineered T cells and liver cancer are in progress, acquiring obvious antitumor effect and revealing its feasibility in treating liver cancer. However, lots of challenges and obstacles are emerging simultaneously, such as low infiltration, side effects, safety of chimeric antigen receptor-engineered T cells, and limited data of studies or clinical trials. Researchers have been working out many innovative ways to directly stroke these obstacles, theoretically or practically. This review focuses more on the progress and obstacles from chimeric antigen receptor-engineered T cells therapy to treat liver cancer, summarizing new breakthroughs in shooting those obstacles, meanwhile, hoping to provide enlightenment to this promising immunotherapeutic method.
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Affiliation(s)
- Keyu Li
- 1 Key Laboratory of Hepatosplenic Surgery, Ministry of Education, Department of General Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yaliang Lan
- 1 Key Laboratory of Hepatosplenic Surgery, Ministry of Education, Department of General Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Jiabei Wang
- 1 Key Laboratory of Hepatosplenic Surgery, Ministry of Education, Department of General Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Lianxin Liu
- 1 Key Laboratory of Hepatosplenic Surgery, Ministry of Education, Department of General Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China.,2 Division of Hepatic Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
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356
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Mei H, Jiang H, Wu Y, Guo T, Xia L, Jin R, Hu Y. Neurological toxicities and coagulation disorders in the cytokine release syndrome during CAR-T therapy. Br J Haematol 2017; 181:689-692. [PMID: 28369673 DOI: 10.1111/bjh.14680] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Heng Mei
- Institute of Haematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.,Hubei clinical medical center of cell therapy for neoplastic disease, Wuhan, Hubei, China
| | - Huiwen Jiang
- Institute of Haematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.,Hubei clinical medical center of cell therapy for neoplastic disease, Wuhan, Hubei, China
| | - Yaohui Wu
- Institute of Haematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.,Hubei clinical medical center of cell therapy for neoplastic disease, Wuhan, Hubei, China
| | - Tao Guo
- Institute of Haematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.,Hubei clinical medical center of cell therapy for neoplastic disease, Wuhan, Hubei, China
| | - Linghui Xia
- Institute of Haematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.,Hubei clinical medical center of cell therapy for neoplastic disease, Wuhan, Hubei, China
| | - Runming Jin
- Institute of Haematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.,Department of pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yu Hu
- Institute of Haematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.,Hubei clinical medical center of cell therapy for neoplastic disease, Wuhan, Hubei, China
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357
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Halton E, Llerandi D, Diamonte C, Quintanilla H, Miale-Mayer D. Developing Infrastructure: Managing Patients With Cancer Undergoing CAR T-Cell Therapy
. Clin J Oncol Nurs 2017; 21:35-40. [PMID: 28315556 DOI: 10.1188/17.cjon.2.35-40] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The introduction of chimeric antigen receptor (CAR) T-cell therapy has created challenges and opportunities for nurses. Clinical nurses must be educated on new treatment modalities to recognize toxicity symptoms and to support the therapy moving forward.
. OBJECTIVES This article will discuss nursing leadership and interventions to standardize care and ensure patient safety while receiving CAR T cells.
. METHODS Using evolving experience, an interprofessional team created standards of care and identified common toxicities and best practices for their management. Electronic documentation forms were designed, which led to the development of a new research infrastructure to care for patients.
. FINDINGS The ability to safely manage patients on CAR T-cell treatments has improved. The new infrastructure supported clinicians and scientists in transforming the outcomes of diseases with bleak prognoses, which is possible only with strong nursing leadership.
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358
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Upperman JS, Lacroix J, Curley MAQ, Checchia PA, Lee DW, Cooke KR, Tamburro RF. Specific Etiologies Associated With the Multiple Organ Dysfunction Syndrome in Children: Part 1. Pediatr Crit Care Med 2017; 18:S50-S57. [PMID: 28248834 PMCID: PMC5333126 DOI: 10.1097/pcc.0000000000001048] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To describe a number of the conditions associated with multiple organ dysfunction syndrome presented as part of the Eunice Kennedy Shriver National Institute of Child Health and Human Development multiple organ dysfunction syndrome workshop (March 26-27, 2015). DATA SOURCES Literature review, research data, and expert opinion. STUDY SELECTION Not applicable. DATA EXTRACTION Moderated by an expert from the field, issues relevant to the association of multiple organ dysfunction syndrome with a variety of conditions were presented, discussed, and debated with a focus on identifying knowledge gaps and research priorities. DATA SYNTHESIS Summary of presentations and discussion supported and supplemented by the relevant literature. CONCLUSIONS There is a wide range of medical conditions associated with multiple organ dysfunction syndrome in children. Traditionally, sepsis and trauma are the two conditions most commonly associated with multiple organ dysfunction syndrome both in children and adults. However, there are a number of other pathophysiologic processes that may result in multiple organ dysfunction syndrome. In this article, we discuss conditions such as cancer, congenital heart disease, and acute respiratory distress syndrome. In addition, the relationship between multiple organ dysfunction syndrome and clinical therapies such as hematopoietic stem cell transplantation and cardiopulmonary bypass is also considered. The purpose of this article is to describe the association of multiple organ dysfunction syndrome with a variety of conditions in an attempt to identify similarities, differences, and opportunities for therapeutic intervention.
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Affiliation(s)
- Jeffrey S Upperman
- 1Division of Pediatric Surgery, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA. 2Division of Pediatric Critical Care Medicine, Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montreal, QC, Canada. 3School of Nursing, Departments of Anesthesia and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA. 4Sections of Critical Care and Cardiology, Department of Pediatrics, Baylor College of Medicine Texas Children's Hospital, Houston, TX. 5Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Virginia, Charlottesville, VA. 6Department of Oncology, Pediatric Blood and Marrow Transplantation Program, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Hospital, The Johns Hopkins University School of Medicine, Baltimore, MD. 7Pediatric Trauma and Critical Illness Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, MD
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359
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Zhu YM, Wu Z, Tan YP, Du YY, Liu Z, Ou RM, Liu S, Pu CF, Jiang J, Wang JP, Xiao L, Zhang Q. Anti-CD19 chimeric antigen receptor T-cell therapy for adult Philadelphia chromosome-positive acute lymphoblastic leukemia: Two case reports. Medicine (Baltimore) 2016; 95:e5676. [PMID: 28002337 PMCID: PMC5181821 DOI: 10.1097/md.0000000000005676] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
RATIONALE The presence of the Philadelphia chromosome (Ph) in acute lymphoblastic leukemia (ALL) has been associated with a high risk of disease relapse and a poor prognosis. Allogeneic hematopoietic stem cell transplantation (HSCT) is an established treatment for adults with Ph-positive ALL, but relapse remains the primary cause of treatment failure, and is associated with an extremely poor prognosis. The emergence of resistance to tyrosine kinase inhibitors (TKIs) poses a challenge for patients with disease relapses after initial treatment with TKI-containing regimens. PATIENT CONCERNS Two patients with TKI-resistant recurrent Ph-positive ALL. DIAGNOSES Ph-positive ALL. INTERVENTIONS Anti-CD19 CAR T-cell infusion. OUTCOMES One patient's bone marrow blasts decreased significantly, and the other reached negative minimal residual disease (MRD). However, we first recorded the development of new-onset acute graft-versus-host disease (aGVHD) after anti-CD19 CAR T-cell infusion in a patient who received allogeneic HSCT. Our 2 case reports also demonstrate the efficacy of anti-CD19 CAR T-cell therapy in the treatment of TKI-resistant Ph-positive ALL. LESSONS Our report suggests that anti-CD19 CAR T-cell therapy may be a promising option for the treatment of relapsed Ph-positive ALL after conventional chemotherapy or allogeneic HSCT. However, caution is due given the possibility of the adverse effects of cytokine release syndrome (CRS)-induced aGVHD for patients receiving allogeneic HSCT.
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Affiliation(s)
- Yang-min Zhu
- Department of Hematology, Guangdong No. 2 Provincial People's Hospital, Guangzhou
| | - Zhao Wu
- Innovative Cellular Therapeutics Co., Ltd. (Formerly SiDanSai Biotechnology Co., Ltd), Shanghai, China
| | - You-ping Tan
- Department of Hematology, Guangdong No. 2 Provincial People's Hospital, Guangzhou
| | - Yuan-yuan Du
- Department of Hematology, Guangdong No. 2 Provincial People's Hospital, Guangzhou
| | - Zhi Liu
- Department of Hematology, Guangdong No. 2 Provincial People's Hospital, Guangzhou
| | - Rui-ming Ou
- Department of Hematology, Guangdong No. 2 Provincial People's Hospital, Guangzhou
| | - Shuang Liu
- Department of Hematology, Guangdong No. 2 Provincial People's Hospital, Guangzhou
| | - Cheng-fei Pu
- Innovative Cellular Therapeutics Co., Ltd. (Formerly SiDanSai Biotechnology Co., Ltd), Shanghai, China
| | - Jing Jiang
- Innovative Cellular Therapeutics Co., Ltd. (Formerly SiDanSai Biotechnology Co., Ltd), Shanghai, China
| | - Jin-ping Wang
- Innovative Cellular Therapeutics Co., Ltd. (Formerly SiDanSai Biotechnology Co., Ltd), Shanghai, China
| | - Lei Xiao
- Innovative Cellular Therapeutics Co., Ltd. (Formerly SiDanSai Biotechnology Co., Ltd), Shanghai, China
| | - Qing Zhang
- Department of Hematology, Guangdong No. 2 Provincial People's Hospital, Guangzhou
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360
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Marini BL, Sun Y, Burke PW, Perissinotti AJ. Successful reintroduction of blinatumomab in a patient with relapsed/refractory acute lymphoblastic leukemia following grade 4 cytokine release syndrome. J Oncol Pharm Pract 2016; 24:67-73. [PMID: 27799606 DOI: 10.1177/1078155216676633] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Relapsed/refractory acute lymphoblastic leukemia poses a clinical challenge due to its poor prognosis and lack of effective treatment. Blinatumomab, a novel immunotherapy, has demonstrated excellent efficacy in relapsed/refractory acute lymphoblastic leukemia; however, life-threatening toxicities such as cytokine release syndrome have been reported in pivotal clinical trials. In this report, we describe the safe reintroduction of blinatumomab in an adult patient with relapsed Philadelphia chromosome-positive (Ph+) acute lymphoblastic leukemia after experiencing grade 4 blinatumomab-induced cytokine release syndrome using a unique dosing strategy and a very diligent monitoring approach. As blinatumomab often represents a last-line therapeutic option for many patients, such a step-wise dosing approach and diligent monitoring plan may be useful in an attempt to retrial blinatumomab in patients who require reintroduction of therapy.
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Affiliation(s)
- Bernard L Marini
- 1 Department of Pharmacy Services, University of Michigan Health System, Ann Arbor, MI, USA
| | - Yihan Sun
- 2 Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - Patrick W Burke
- 3 Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - Anthony J Perissinotti
- 1 Department of Pharmacy Services, University of Michigan Health System, Ann Arbor, MI, USA
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361
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Geyer MB, Brentjens RJ. Review: Current clinical applications of chimeric antigen receptor (CAR) modified T cells. Cytotherapy 2016; 18:1393-1409. [PMID: 27592405 DOI: 10.1016/j.jcyt.2016.07.003] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 06/27/2016] [Accepted: 07/15/2016] [Indexed: 12/19/2022]
Abstract
The past several years have been marked by extraordinary advances in clinical applications of immunotherapy. In particular, adoptive cellular therapy utilizing chimeric antigen receptor (CAR)-modified T cells targeted to CD19 has demonstrated substantial clinical efficacy in children and adults with relapsed or refractory B-cell acute lymphoblastic leukemia (B-ALL) and durable clinical benefit in a smaller subset of patients with relapsed or refractory chronic lymphocytic leukemia (CLL) or B-cell non-Hodgkin lymphoma (B-NHL). Early-phase clinical trials are currently assessing CAR T-cell safety and efficacy in additional malignancies. Here, we discuss clinical results from the largest series to date investigating CD19-targeted CAR T cells in B-ALL, CLL, and B-NHL, including discussion of differences in CAR T-cell design and production and treatment approach, as well as clinical efficacy, nature of severe cytokine release syndrome and neurologic toxicities, and CAR T-cell expansion and persistence. We additionally review the current and forthcoming use of CAR T cells in multiple myeloma and several solid tumors and highlight challenges and opportunities afforded by the current state of CAR T-cell therapies, including strategies to overcome inhibitory aspects of the tumor microenvironment and enhance antitumor efficacy.
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Affiliation(s)
- Mark B Geyer
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Renier J Brentjens
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Center for Cell Engineering, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Molecular Pharmacology and Chemistry Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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362
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Wang L, Ma N, Okamoto S, Amaishi Y, Sato E, Seo N, Mineno J, Takesako K, Kato T, Shiku H. Efficient tumor regression by adoptively transferred CEA-specific CAR-T cells associated with symptoms of mild cytokine release syndrome. Oncoimmunology 2016; 5:e1211218. [PMID: 27757303 PMCID: PMC5048773 DOI: 10.1080/2162402x.2016.1211218] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 06/29/2016] [Accepted: 07/03/2016] [Indexed: 01/01/2023] Open
Abstract
Carcinoembryonic antigen (CEA) is a cell surface antigen highly expressed in various cancer cell types and in healthy tissues. It has the potential to be a target for chimeric antigen receptor (CAR)-modified T-cell therapy; however, the safety of this approach in terms of on-target/off-tumor effects needs to be determined. To address this issue in a clinically relevant model, we used a mouse model in which the T cells expressing CEA-specific CAR were transferred into tumor-bearing CEA-transgenic (Tg) mice that physiologically expressed CEA as a self-antigen. The adoptive transfer in conjunction with lymphodepleting and myeloablative preconditioning mediated significant tumor regression but caused weight loss in CEA-Tg, but not in wild-type mice. The weight loss was not associated with overt inflammation in the CEA-expressing gastrointestinal tract but was associated with malnutrition, reflected in elevated systemic levels of cytokines linked to anorexia, which could be controlled by the administration of an anti-IL-6 receptor monoclonal antibody without compromising efficacy. The apparent relationship between lymphodepleting and myeloablative preconditioning, efficacy, and off-tumor toxicity of CAR-T cells would necessitate the development of CEA-specific CAR-T cells with improved signaling domains that require less stringent preconditioning for their efficacy. Taken together, these results suggest that CEA-specific CAR-based adoptive T-cell therapy may be effective for patients with CEA+ solid tumors. Distinguishing the fine line between therapeutic efficacy and off-tumor toxicity would involve further modifications of CAR-T cells and preconditioning regimens.
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Affiliation(s)
- Linan Wang
- Department of Immuno-Gene Therapy, Mie University Graduate School of Medicine , Tsu, Mie, Japan
| | - Ning Ma
- Faculty of Nursing Science, Suzuka Medical Science University , Suzuka, Mie, Japan
| | | | | | - Eiichi Sato
- Department of Pathology, Institute of Medical Science, Medical Research Center, Tokyo Medical University , Tokyo, Japan
| | - Naohiro Seo
- Department of Immuno-Gene Therapy, Mie University Graduate School of Medicine , Tsu, Mie, Japan
| | | | - Kazutoh Takesako
- Department of Pathology, Institute of Medical Science, Medical Research Center, Tokyo Medical University , Tokyo, Japan
| | - Takuma Kato
- Department of Cellular and Molecular Immunology, Mie University Graduate School of Medicine, Tsu, Mie, Japan; Center for Comprehensive Cancer Immunotherapy, Mie University, Tsu, Mie, Japan
| | - Hiroshi Shiku
- Department of Immuno-Gene Therapy, Mie University Graduate School of Medicine, Tsu, Mie, Japan; Center for Comprehensive Cancer Immunotherapy, Mie University, Tsu, Mie, Japan
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363
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Snowden A, Hayden I, Dixon J, Gregory G. Prevention and management of obinutuzumab-associated toxicities: Australian experience. Int J Nurs Pract 2016; 21 Suppl 3:15-27. [PMID: 26681665 DOI: 10.1111/ijn.12412] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Patients with chronic lymphocytic leukaemia (CLL) are typically diagnosed at an advanced age and may have multiple co-existing conditions, augmenting the challenges of treating their CLL. Aggressive cytotoxic therapies are often poorly tolerated in this patient population. Obinutuzumab is a glycoengineered type II anti-CD20 monoclonal antibody indicated in combination with chlorambucil for previously untreated CLL. The approval of this drug was based on the pivotal CLL11 trial, which demonstrated longer progression-free survival vs. rituximab/chlorambucil and chlorambucil alone in patients with significant co-existing medical conditions and/or poor renal function. However, a higher risk of infusion-related reactions (IRRs) was demonstrated with obinutuzumab-based therapy. We highlight important nursing care considerations to help prevent and successfully manage IRRs and other important adverse events, to improve the treatment experience of patients receiving obinutuzumab infusions and to enable them to complete their treatment and receive optimal benefit. Premedication, drug handling, dosing, administration, monitoring and documentation are discussed.
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Affiliation(s)
| | | | - Joanna Dixon
- Roche Products Pty. Ltd, Dee Why, NSW, Australia
| | - Gareth Gregory
- Monash Haematology, Monash Health, Clayton, Victoria, Australia
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364
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Affiliation(s)
- Manjusha Namuduri
- a Department of Pediatrics , Memorial Sloan Kettering Cancer Center , New York , NY , USA
| | - Renier J Brentjens
- b Department of Medicine , Memorial Sloan Kettering Cancer Center , New York , NY , USA.,c Center for Cell Engineering, Memorial Sloan Kettering Cancer Center , New York , NY , USA.,d Molecular Pharmacology & Chemistry Program , Memorial Sloan Kettering Cancer Center , New York , NY , USA
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365
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Abstract
INTRODUCTION Alvocidib, which has orphan drug designation in chronic lymphocytic leukemia (CLL) from the FDA and the EMA, is a plant-derived semisynthetic flavone that acts as a cyclin-dependent kinase inhibitor. It induces apoptosis in CLL cells in vitro and was introduced into clinical trials in CLL as an intravenous infusion in 1997, which proved disappointing. Since the drug avidly binds to plasma proteins, higher serum concentrations were required for clinical antileukemia activity than those suggested by in vitro studies. Subsequent studies utilizing bolus plus infusional doses revealed significant activity against CLL, even in patients with unfavorable characteristics. However, significant toxicity including high rates of major tumor lysis syndrome, cytokine release syndrome and secretory diarrhea were also observed. AREAS COVERED The chemistry, pharmacodynamics, pharmacokinetics and metabolism of alvocidib are briefly discussed and phase I-II studies in CLL are discussed in detail. To date, no phase III studies in CLL have been reported. EXPERT OPINION A number of much less toxic drugs with similar efficacy against CLL both with and without unfavorable cytogenetics have come to market. Furthermore, enthusiasm for the development of alvocidib as a single agent for the treatment of CLL has waned, primarily due to its toxicity.
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366
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Ma JSY, Kim JY, Kazane SA, Choi SH, Yun HY, Kim MS, Rodgers DT, Pugh HM, Singer O, Sun SB, Fonslow BR, Kochenderfer JN, Wright TM, Schultz PG, Young TS, Kim CH, Cao Y. Versatile strategy for controlling the specificity and activity of engineered T cells. Proc Natl Acad Sci U S A 2016; 113:E450-E458. [PMID: 26759368 DOI: 10.1073/pnas.1524193113/suppl_file/pnas.1524193113.sapp.pdf] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
The adoptive transfer of autologous T cells engineered to express a chimeric antigen receptor (CAR) has emerged as a promising cancer therapy. Despite impressive clinical efficacy, the general application of current CAR-T--cell therapy is limited by serious treatment-related toxicities. One approach to improve the safety of CAR-T cells involves making their activation and proliferation dependent upon adaptor molecules that mediate formation of the immunological synapse between the target cancer cell and T-cell. Here, we describe the design and synthesis of structurally defined semisynthetic adaptors we refer to as "switch" molecules, in which anti-CD19 and anti-CD22 antibody fragments are site-specifically modified with FITC using genetically encoded noncanonical amino acids. This approach allows the precise control over the geometry and stoichiometry of complex formation between CD19- or CD22-expressing cancer cells and a "universal" anti-FITC-directed CAR-T cell. Optimization of this CAR-switch combination results in potent, dose-dependent in vivo antitumor activity in xenograft models. The advantage of being able to titrate CAR-T-cell in vivo activity was further evidenced by reduced in vivo toxicity and the elimination of persistent B-cell aplasia in immune-competent mice. The ability to control CAR-T cell and cancer cell interactions using intermediate switch molecules may expand the scope of engineered T-cell therapy to solid tumors, as well as indications beyond cancer therapy.
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MESH Headings
- Animals
- Antigens, CD19/immunology
- Antigens, Neoplasm/immunology
- Azides
- B-Lymphocytes/immunology
- B-Lymphocytes/pathology
- Cell Line, Tumor
- Cytotoxicity, Immunologic
- Female
- Fluorescein-5-isothiocyanate
- Genetic Vectors
- Humans
- Immunotherapy, Adoptive/adverse effects
- Immunotherapy, Adoptive/methods
- Lentivirus/genetics
- Leukemia, B-Cell/therapy
- Lymphocyte Activation
- Lymphopenia/etiology
- Lymphopenia/prevention & control
- Mice
- Mice, Inbred C57BL
- Mice, Inbred NOD
- Mice, SCID
- Models, Molecular
- Phenylalanine/analogs & derivatives
- Protein Conformation
- Protein Engineering/methods
- Receptors, Antigen, T-Cell/genetics
- Receptors, Antigen, T-Cell/immunology
- Recombinant Fusion Proteins/immunology
- Sialic Acid Binding Ig-like Lectin 2/immunology
- Single-Chain Antibodies/genetics
- Single-Chain Antibodies/immunology
- T-Cell Antigen Receptor Specificity
- T-Lymphocytes/immunology
- T-Lymphocytes/transplantation
- Transduction, Genetic
- Xenograft Model Antitumor Assays
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Affiliation(s)
- Jennifer S Y Ma
- Department of Biology, California Institute for Biomedical Research, La Jolla, CA 92037
| | - Ji Young Kim
- Department of Biology, California Institute for Biomedical Research, La Jolla, CA 92037
| | - Stephanie A Kazane
- Department of Biology, California Institute for Biomedical Research, La Jolla, CA 92037
| | - Sei-Hyun Choi
- Department of Chemistry and The Skaggs Institute for Chemical Biology, The Scripps Research Institute, La Jolla, CA 92037
| | - Hwa Young Yun
- Department of Chemistry and The Skaggs Institute for Chemical Biology, The Scripps Research Institute, La Jolla, CA 92037
| | - Min Soo Kim
- Department of Biology, California Institute for Biomedical Research, La Jolla, CA 92037
| | - David T Rodgers
- Department of Biology, California Institute for Biomedical Research, La Jolla, CA 92037
| | - Holly M Pugh
- Department of Biology, California Institute for Biomedical Research, La Jolla, CA 92037
| | - Oded Singer
- Department of Biology, California Institute for Biomedical Research, La Jolla, CA 92037
| | - Sophie B Sun
- Department of Biology, California Institute for Biomedical Research, La Jolla, CA 92037
| | - Bryan R Fonslow
- Department of Chemical Physiology, The Scripps Research Institute, La Jolla, CA 92037; SCIEX Separations, Brea, CA 92821
| | - James N Kochenderfer
- Experimental Transplantation and Immunology Branch, National Institutes of Health, National Cancer Institute, Bethesda, MD 20892
| | - Timothy M Wright
- Department of Biology, California Institute for Biomedical Research, La Jolla, CA 92037
| | - Peter G Schultz
- Department of Biology, California Institute for Biomedical Research, La Jolla, CA 92037; Department of Chemistry and The Skaggs Institute for Chemical Biology, The Scripps Research Institute, La Jolla, CA 92037;
| | - Travis S Young
- Department of Biology, California Institute for Biomedical Research, La Jolla, CA 92037;
| | - Chan Hyuk Kim
- Department of Biology, California Institute for Biomedical Research, La Jolla, CA 92037;
| | - Yu Cao
- Department of Chemistry and The Skaggs Institute for Chemical Biology, The Scripps Research Institute, La Jolla, CA 92037
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367
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Ma JS, Kim JY, Kazane SA, Choi SH, Yun HY, Kim MS, Rodgers DT, Pugh HM, Singer O, Sun SB, Fonslow BR, Kochenderfer JN, Wright TM, Schultz PG, Young TS, Kim CH, Cao Y. Versatile strategy for controlling the specificity and activity of engineered T cells. Proc Natl Acad Sci U S A 2016; 113:E450-8. [PMID: 26759368 DOI: 10.1073/pnas.1524193113] [Citation(s) in RCA: 203] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The adoptive transfer of autologous T cells engineered to express a chimeric antigen receptor (CAR) has emerged as a promising cancer therapy. Despite impressive clinical efficacy, the general application of current CAR-T--cell therapy is limited by serious treatment-related toxicities. One approach to improve the safety of CAR-T cells involves making their activation and proliferation dependent upon adaptor molecules that mediate formation of the immunological synapse between the target cancer cell and T-cell. Here, we describe the design and synthesis of structurally defined semisynthetic adaptors we refer to as "switch" molecules, in which anti-CD19 and anti-CD22 antibody fragments are site-specifically modified with FITC using genetically encoded noncanonical amino acids. This approach allows the precise control over the geometry and stoichiometry of complex formation between CD19- or CD22-expressing cancer cells and a "universal" anti-FITC-directed CAR-T cell. Optimization of this CAR-switch combination results in potent, dose-dependent in vivo antitumor activity in xenograft models. The advantage of being able to titrate CAR-T-cell in vivo activity was further evidenced by reduced in vivo toxicity and the elimination of persistent B-cell aplasia in immune-competent mice. The ability to control CAR-T cell and cancer cell interactions using intermediate switch molecules may expand the scope of engineered T-cell therapy to solid tumors, as well as indications beyond cancer therapy.
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368
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Hellwig Y, Yoo YE, Reß ML, Andres O, Braun M, Schlegel PG, Wölfl M. Fulminant skin GvHD with a cytokine pattern resemblant of cytokine release syndrome successfully treated with multimodal immunosuppression including tocilizumab. Pediatr Blood Cancer 2015; 62:2033-5. [PMID: 26153219 DOI: 10.1002/pbc.25595] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Accepted: 04/20/2015] [Indexed: 12/22/2022]
Abstract
Acute Graft-versus-Host-Disease (GvHD) is a potentially life-threatening complication after allogeneic stem cell transplantation. If not treated early and adequately, the complex immunological mechanisms may lead to a self-perpetuating cycle of alloreactivity, which is then associated with a high mortality. Here we assessed the cytokine profile on a daily basis in a patient with grade 4 skin GvHD, demonstrating a signature resembling cytokine-release-syndrome. After multimodal immunosuppressive intervention, including treatment with the IL6 receptor-blocking antibody tocilizumab, the severe clinical symptoms unexpectedly resolved within 48 hr.
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Affiliation(s)
- Yuliya Hellwig
- University Hospital of Würzburg, Children's Hospital, Pediatric Stem Cell Transplantation, Josef-Schneider-Strasse 2, 97080, Würzburg, Germany
| | - Young E Yoo
- University Hospital of Würzburg, Children's Hospital, Pediatric Stem Cell Transplantation, Josef-Schneider-Strasse 2, 97080, Würzburg, Germany
| | - Marie L Reß
- University Hospital of Würzburg, Children's Hospital, Pediatric Stem Cell Transplantation, Josef-Schneider-Strasse 2, 97080, Würzburg, Germany
| | - Oliver Andres
- University Hospital of Würzburg, Children's Hospital, Pediatric Stem Cell Transplantation, Josef-Schneider-Strasse 2, 97080, Würzburg, Germany
| | - Matthias Braun
- University Hospital of Würzburg, Children's Hospital, Pediatric Stem Cell Transplantation, Josef-Schneider-Strasse 2, 97080, Würzburg, Germany
| | - Paul G Schlegel
- University Hospital of Würzburg, Children's Hospital, Pediatric Stem Cell Transplantation, Josef-Schneider-Strasse 2, 97080, Würzburg, Germany
| | - Matthias Wölfl
- University Hospital of Würzburg, Children's Hospital, Pediatric Stem Cell Transplantation, Josef-Schneider-Strasse 2, 97080, Würzburg, Germany
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369
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Tasian SK, Gardner RA. CD19-redirected chimeric antigen receptor-modified T cells: a promising immunotherapy for children and adults with B-cell acute lymphoblastic leukemia (ALL). Ther Adv Hematol 2015; 6:228-41. [PMID: 26425336 DOI: 10.1177/2040620715588916] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Relapsed and chemotherapy-refractory B-cell acute lymphoblastic leukemia (B-ALL) remain significant causes of cancer-associated morbidity and mortality for children and adults. Development of new molecularly targeted treatment strategies for patients with high-risk B-ALL is thus a major preclinical and clinical priority. Adoptive cellular therapy with patient-derived human T cells genetically engineered to express CD19 redirected chimeric antigen receptors (CD19 CAR T cells) is one immunotherapeutic modality that has recently demonstrated remarkable efficacy in re-inducing remission in patients with multiply relapsed B-ALL. Investigative teams at several major cancer centers are currently conducting phase I clinical trials in children and/or adults with relapsed/refractory B-ALL to assess the safety and to identify the maximally tolerated dose of each group's CD19 CAR T-cell product. All groups have reported major clinical toxicities associated with CD19 CAR T-cell treatment, including cytokine release syndrome (CRS) and macrophage activation syndrome, neurologic dysfunction and aplasia of normal B lymphocytes, while CD19 CAR T cells persist in vivo. Toxicities have generally been transient or manageable with supportive care measures. Some patients with life-threatening CD19 CAR T-cell induced sequelae have received anti-cytokine receptor antibody treatment to diminish CRS symptoms and/or corticosteroids to terminate CAR T-cell proliferation. Remarkably, 67-90% of children and adults with B-ALL treated with CD19 CAR T cells in these trials have achieved morphologic leukemia remission with many patients also in molecular remission. The duration of CD19 CAR T cell persistence in vivo has varied appreciably among treated patients and likely reflects differences in the CD19 CAR constructs utilized at each institution. CD19-positive and CD19-negative B-ALL relapses after CD19 CAR T-cell treatment have occurred in some patients. Phase II trials to assess the efficacy of CD19 CAR T-cell immunotherapy in larger cohorts of patients with relapsed/refractory B-ALL are ongoing or planned.
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Affiliation(s)
- Sarah K Tasian
- Children's Hospital of Philadelphia, Division of Oncology and Center for Childhood Cancer Research; University of Pennsylvania Perelman School of Medicine, Department of Pediatrics and Abramson Cancer Center; 3501 Civic Center Boulevard, CTRB 3010, Philadelphia, PA 19104, USA
| | - Rebecca A Gardner
- Division of Hematology/Oncology and Ben Towne Center for Childhood Cancer Research/Seattle Children's Research Institute, Seattle Children's Hospital, Seattle, WA, USA and University of Washington School of Medicine, Seattle, WA, USA
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370
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Abstract
Over the past 30 years, the world of pharmaceutical toxicology has seen an explosion in the area of cytokines. An overview of the many aspects of cytokine safety evaluation currently in progress and evolving strategies for evaluating these important entities was presented at this symposium. Cytokines play a broad role to help the immune system respond to diseases, and drugs which modulate their effect have led to some amazing therapies. Cytokines may be "good" when stimulating the immune system to fight a foreign pathogen or attack tumors. Other "good" cytokine effects include reduction of an immune response, for example interferon β reduction of neuron inflammation in patients with multiple sclerosis. They may be "bad" when their expression causes inflammatory diseases, such as the role of tumor necrosis factor α in rheumatoid arthritis or asthma and Crohn's disease. Therapeutic modulation of cytokine expression can help the "good" cytokines to generate or quench the immune system and block the "bad" cytokines to prevent damaging inflammatory events. However, care must be exercised, as some antibody therapeutics can cause "ugly" cytokine release which can be deadly. Well-designed toxicology studies should incorporate careful assessment of cytokine modulation that will allow effective therapies to treat unmet needs. This symposium discussed lessons learned in cytokine toxicology using case studies and suggested future directions.
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371
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Abstract
Evaluation of: Davila ML, Riviere I, Wang X et al. Efficacy and toxicity management of 19-28z CAR T cell therapy in B cell acute lymphoblastic leukemia. Sci. Transl. Med. 6(224), 224ra25 (2014). Recently, chimeric antigen receptor (CAR) T-cell immunotherapy has entered clinical trials in patients with relapsed or refractory B-cell acute lymphoblastic leukemia. 19-28z CAR T cells express a fusion protein comprised of an anti-CD19 mAb fused with CD28 costimulatory and CD3-zeta-chain signaling domains. The current paper demonstrates that administration of 19-28z CAR T cells in patients with relapsed or refractory B-ALL in a Phase I clinical trial has led to 88% of patients undergoing complete remission. Despite the benefits, CAR T-cell therapy is associated with cytokine release syndrome toxicities. The authors demonstrated criteria to diagnose severe cytokine release syndrome (sCRS) and treated sCRS with either high-dose steroids or with tocilizumab, an IL-6 receptor-specific mAb. Although both alleviated sCRS, steroid treatment negated the beneficial effects of CAR T-cell therapy, whereas tocilizumab did not. Taken together, CAR T-cell immunotherapy can be used as a safe and effective approach against tumors with known tumor-associated antigens.
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Affiliation(s)
- Jaina M Patel
- Department of Pathology & Laboratory Medicine, Emory University School of Medicine, Atlanta, GA 30322, USA
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372
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Denny JT, Burr AT, Balzer F, Tse JT, Denny JE, Chyu D. Methylene blue treatment for cytokine release syndrome-associated vasoplegia following a renal transplant with rATG infusion: A case report and literature review. Exp Ther Med 2015; 9:1915-1920. [PMID: 26136914 DOI: 10.3892/etm.2015.2349] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 03/03/2015] [Indexed: 12/29/2022] Open
Abstract
Rabbit anti-thymocyte globulin (rATG) is an infusion of polyclonal rabbit-derived antibodies against human thymocyte markers, which can be used to prevent and treat acute rejection following organ transplantation. However, the product monograph issued by the manufacturer (Sanofi Canada) reports that serious immune-mediated reactions have been observed following the use of rATG, consisting of anaphylaxis or severe cytokine release syndrome (CRS), which is a form of vasoplegic syndrome (VS), in which distributive shock occurs refractory to norepinephrine (NE) and vasopressin (VP). Severe infusion-associated reactions are consistent with CRS and can cause serious cardiac or respiratory problems, or in certain cases, mortality. CRS is a form of systemic inflammatory response syndrome (SIRS). In SIRS, the substantial activation of endothelial inducible nitric oxide synthase (iNOS) and smooth muscle guanylate cyclase (GC) is observed, which can produce severe hypotension that is unresponsive to conventional vasopressors. Methylene blue (MB) is a direct inhibitor of iNOS and GC and has been used as an effective treatment for VS following cardiothoracic surgery. In the present study, the successful use of MB as a rescue therapy for CRS in a patient receiving rATG following a renal transplant was reported. Following an uneventful cadaveric kidney transplant involving the intravenous (IV) administration of rATG for the induction of immunological tolerance, the patient became markedly hypotensive and tachycardic. The patient required high doses of VP and NE infusions. Following the protocol described for treating refractory VS in post-cardiac surgery patients, the decision was made to initiate the patient on an IV MB infusion. This treatment protocol was shown to improve the hemodynamic status of the patient, which enabled the withdrawal of vasopressors and suggests an important role for methylene blue in the management of refractory VS.
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Affiliation(s)
- John T Denny
- Department of Anesthesia, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ 08901, USA
| | - Andrew T Burr
- Department of Anesthesia, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ 08901, USA
| | - Fred Balzer
- Virtua Memorial Hospital, Department of Anesthesia, Mount Holly, NJ 08060, USA
| | - James T Tse
- Department of Anesthesia, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ 08901, USA
| | - Julia E Denny
- Department of Anesthesia, New York University Medical Center, New York, NY 10016, USA
| | - Darrick Chyu
- Department of Anesthesia, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ 08901, USA
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373
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374
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Abstract
CD19-directed chimeric antigen receptor T cells (CART19 or CTL019) have been used with success in pediatric and adult acute lymphocytic leukemia (ALL) and chronic lymphocytic leukemia (CLL) patients. While this therapy has caused toxicities, including cytokine release syndrome and macrophage activation syndrome, these conditions are reversible with IL-6 blockade using the monoclonal antibody tocilizumab. Furthermore, 90% of the very high-risk patients who underwent infusion with CTL019 achieved a complete response, despite the fact that they previously failed multiple therapies and/or transplant. With improved cell persistence, this immunotherapy may one day prove to be more than a bridge to transplant and may in fact be a transplant alternative.
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Affiliation(s)
- Stephan A Grupp
- Perelman School of Medicine, University of Pennsylvania, USA; Center for Childhood Cancer Research, Children's Hospital of Philadelphia, USA.
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375
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Alig SK, Dreyling M, Seppi B, Aulinger B, Witkowski L, Rieger CT. Severe cytokine release syndrome after the first dose of Brentuximab Vedotin in a patient with relapsed systemic anaplastic large cell lymphoma (sALCL): a case report and review of literature. Eur J Haematol 2014; 94:554-7. [PMID: 24913471 DOI: 10.1111/ejh.12396] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2014] [Indexed: 12/31/2022]
Abstract
Brentuximab Vedotin is an antibody - drug conjugate targeting CD30. We report a case of severe cytokine release syndrome (CRS) after administration of the first dose of Brentuximab Vedotin in a 64-yr-old patient with relapsed systemic anaplastic large cell lymphoma (sALCL). To our knowledge, this is the first case of CRS to Brentuximab Vedotin described in the literature. However, CRS to Brentuximab Vedotin might be underestimated, as the drug has not been tested in large phase III trials yet.
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Affiliation(s)
- Stefan K Alig
- Department of Medicine III, Medical Centre of the University of Munich, Munich, Germany
| | - Martin Dreyling
- Department of Medicine III, Medical Centre of the University of Munich, Munich, Germany
| | - Bettina Seppi
- Department of Medicine III, Medical Centre of the University of Munich, Munich, Germany
| | - Benedikt Aulinger
- Department of Medicine II, Medical Centre of the University of Munich, Munich, Germany
| | - Lukas Witkowski
- Department of Medicine III, Medical Centre of the University of Munich, Munich, Germany
| | - Christina T Rieger
- Department of Medicine III, Medical Centre of the University of Munich, Munich, Germany
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376
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Abstract
Chimeric antigen receptor (CAR)-modified T cells and bispecific T cell-engaging antibodies have demonstrated dramatic clinical responses in recent clinical trials. The hallmark of these novel highly active immunotherapies is nonphysiologic T cell activation, which has correlated not only with greatly increased efficacy but also with notable toxicity in some cases. We and others have observed a cytokine release syndrome (CRS), which correlates with both toxicity and efficacy in patients receiving T cell-engaging therapies. In addition to elevations in effector cytokines, such as interferon-γ, cytokines associated with hemophagocytic lymphohistiocytosis or macrophage activation syndrome, such as interleukin (IL)-10 and IL-6, may also be markedly elevated. Whereas corticosteroids may control some of these toxicities, their potential to block T cell activation and abrogate clinical benefit is a concern. Detailed studies of T cell proliferation and the resultant immune activation produced by these novel therapies have led to more targeted approaches that have the potential to provide superior toxicity control without compromising efficacy. One approach we have developed targets IL-6, a prominent cytokine in CRS, using the IL-6R antagonist tocilizumab. We will review the pathophysiology and management options for CRS associated with T cell-engaging therapies.
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Affiliation(s)
- Shannon L. Maude
- Division of Pediatric Oncology, Children’s Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - David Barrett
- Division of Pediatric Oncology, Children’s Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - David T. Teachey
- Division of Pediatric Oncology, Children’s Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Stephan A. Grupp
- Division of Pediatric Oncology, Children’s Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Pathology, Children’s Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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377
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Abstract
PURPOSE OF REVIEW Recent clinical trials using T-cell engaging immunotherapies such as bispecific antibodies which target T cells and tumor cells, as well as engineered T cells that express targeting and activation molecules known as chimeric antigen receptors, have demonstrated powerful proof of concept. These therapies result in a significant degree of immune activation in the patient, which has correlated with greatly increased efficacy but also with notable toxicity. These therapies produce nonphysiologic T-cell activation, which is the hallmark of these new, highly active treatments. RECENT FINDINGS We and others have noted cytokine activation profiles that correlate with both toxicity and efficacy in patients receiving T-cell engaging therapies. Effector cytokines such as interferon-γ are elevated, but so are cytokines that are associated with macrophage activation syndrome/hemophagocytic lymphohistiocytosis, such as interleukin (IL)-10 and IL-6. Although corticosteroids can control some of these toxicities, a targeted approach may produce superior toxicity control without interfering with efficacy. One approach we have developed targets IL-6, a key cytokine in the toxicity response, using the IL-6 receptor antagonist tocilizumab. SUMMARY Detailed studies of the T-cell activation produced by these novel therapies has led to more targeted approaches that have the potential to control toxicity while maintaining efficacy.
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Affiliation(s)
- David M Barrett
- Division of Pediatric Oncology, Children's Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, Pennsylvania, USA
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378
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Stephens DM, Ruppert AS, Maddocks K, Andritsos L, Baiocchi R, Jones J, Johnson AJ, Smith LL, Zhao Y, Ling Y, Li J, Phelps MA, Grever MR, Byrd JC, Flynn JM. Cyclophosphamide, alvocidib (flavopiridol), and rituximab, a novel feasible chemoimmunotherapy regimen for patients with high-risk chronic lymphocytic leukemia. Leuk Res 2013; 37:1195-9. [PMID: 23867058 DOI: 10.1016/j.leukres.2013.06.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Revised: 05/22/2013] [Accepted: 06/05/2013] [Indexed: 11/20/2022]
Abstract
Alvocidib has demonstrated efficacy in high-risk chronic lymphocytic leukemia (CLL) patients. In this phase I study, we combined cyclophosphamide, alvocidib and rituximab (CAR) in a schema designed to mitigate tumor lysis syndrome (TLS) seen previously with alvocidib. Nine nucleoside analog-naïve, high-risk patients received escalating doses of CAR therapy. Dose limiting toxicity was not experienced. No instances of TLS were observed. Patient responses included three complete remissions and four partial remissions. CAR was tolerable and active in high-risk CLL patients without TLS toxicity. With continued monitoring of toxicities, a phase Ib/II study of this combination as frontline therapy is warranted.
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Affiliation(s)
- Deborah M Stephens
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH 43210, United States.
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379
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Abstract
Alemtuzumab (Campath®, MabCampath®, Genzyme) is an IgG1k anti-CD52 humanized monoclonal antibody (mAb) that was first licensed in March 2001 by FDA. EMEA granted its approval in July 2001 and Health Canada in November 2005. The initial indication was limited to B-CLL previously treated and resistant to alkylating agents. Starting from 2007, alemtuzumab was approved also as first-line therapy of B-CLL. So far, it has been experienced in over 60 countries.
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