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Guo ZY, Tang YQ, Zhang ZB, Liu J, Zhuang YX, Li T. COVID-19: from immune response to clinical intervention. PRECISION CLINICAL MEDICINE 2024; 7:pbae015. [PMID: 39139990 PMCID: PMC11319938 DOI: 10.1093/pcmedi/pbae015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Accepted: 07/11/2024] [Indexed: 08/15/2024] Open
Abstract
The coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has highlighted the pivotal role of the immune response in determining the progression and severity of viral infections. In this paper, we review the most recent studies on the complicated dynamics between SARS-CoV-2 and the host immune system, highlight the importance of understanding these dynamics in developing effective treatments and formulate potent management strategies for COVID-19. We describe the activation of the host's innate immunity and the subsequent adaptive immune response following infection with SARS-CoV-2. In addition, the review emphasizes the immune evasion strategies of the SARS-CoV-2, including inhibition of interferon production and induction of cytokine storms, along with the resulting clinical outcomes. Finally, we assess the efficacy of current treatment strategies, including antiviral drugs, monoclonal antibodies, and anti-inflammatory treatments, and discuss their role in providing immunity and preventing severe disease.
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Affiliation(s)
- Zheng-yang Guo
- State Key Laboratory of Quality Research in Chinese Medicines, Macau Institute for Applied Research in Medicine and Health, Macau University of Science and Technology, Macau 999078, China
| | - Yan-qing Tang
- State Key Laboratory of Quality Research in Chinese Medicines, Macau Institute for Applied Research in Medicine and Health, Macau University of Science and Technology, Macau 999078, China
| | - Zi-bo Zhang
- State Key Laboratory of Quality Research in Chinese Medicines, Macau Institute for Applied Research in Medicine and Health, Macau University of Science and Technology, Macau 999078, China
| | - Juan Liu
- State Key Laboratory of Quality Research in Chinese Medicines, Macau Institute for Applied Research in Medicine and Health, Macau University of Science and Technology, Macau 999078, China
| | - Yu-xin Zhuang
- State Key Laboratory of Quality Research in Chinese Medicines, Macau Institute for Applied Research in Medicine and Health, Macau University of Science and Technology, Macau 999078, China
| | - Ting Li
- State Key Laboratory of Quality Research in Chinese Medicines, Macau Institute for Applied Research in Medicine and Health, Macau University of Science and Technology, Macau 999078, China
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Mohammad Taheri M, Javan F, Poudineh M, Athari SS. Beyond CAR-T: The rise of CAR-NK cell therapy in asthma immunotherapy. J Transl Med 2024; 22:736. [PMID: 39103889 DOI: 10.1186/s12967-024-05534-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Accepted: 07/23/2024] [Indexed: 08/07/2024] Open
Abstract
Asthma poses a major public health burden. While existing asthma drugs manage symptoms for many, some patients remain resistant. The lack of a cure, especially for severe asthma, compels exploration of novel therapies. Cancer immunotherapy successes with CAR-T cells suggest its potential for asthma treatment. Researchers are exploring various approaches for allergic diseases including membrane-bound IgE, IL-5, PD-L2, and CTLA-4 for asthma, and Dectin-1 for fungal asthma. NK cells offer several advantages over T cells for CAR-based immunotherapy. They offer key benefits: (1) HLA compatibility, meaning they can be used in a wider range of patients without the need for matching tissue types. (2) Minimal side effects (CRS and GVHD) due to their limited persistence and cytokine profile. (3) Scalability for "off-the-shelf" production from various sources. Several strategies have been introduced that highlight the superiority and challenges of CAR-NK cell therapy for asthma treatment including IL-10, IFN-γ, ADCC, perforin-granzyme, FASL, KIR, NCRs (NKP46), DAP, DNAM-1, TGF-β, TNF-α, CCL, NKG2A, TF, and EGFR. Furthermore, we advocate for incorporating AI for CAR design optimization and CRISPR-Cas9 gene editing technology for precise gene manipulation to generate highly effective CAR constructs. This review will delve into the evolution and production of CAR designs, explore pre-clinical and clinical studies of CAR-based therapies in asthma, analyze strategies to optimize CAR-NK cell function, conduct a comparative analysis of CAR-T and CAR-NK cell therapy with their respective challenges, and finally present established novel CAR designs with promising potential for asthma treatment.
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Affiliation(s)
| | - Fatemeh Javan
- Student Research Committee, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Mohadeseh Poudineh
- Student Research Committee, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Seyed Shamseddin Athari
- Cancer Gene Therapy Research Center, Zanjan University of Medical Sciences, Zanjan, Iran.
- Department of Immunology, Zanjan School of Medicine, Zanjan University of Medical Sciences, 12th Street, Shahrake Karmandan, Zanjan, 45139-561111, Iran.
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Moore DC, Digiantonio N, Oxencis CJ, Taucher KD. Pharmacist perspectives on emerging T cell-engaging bispecific therapies in cancer therapeutics. Am J Health Syst Pharm 2024; 81:574-582. [PMID: 38394329 DOI: 10.1093/ajhp/zxae050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Indexed: 02/25/2024] Open
Abstract
PURPOSE To summarize the pharmacology, efficacy, safety, dosing, administration, and pharmacist perspectives related to operationalization of new and emerging bispecific therapies indicated for the treatment of various cancers. SUMMARY In recent years, there have been significant advancements in the expansion of immunotherapeutics in the treatment of various malignancies. Bispecific T cell-engaging therapies represent an emerging therapeutic drug class for the treatment of cancer. These therapies are unique antibody constructs that bind simultaneously to 2 targets, a tumor-specific antigen and CD3 on T cells, to elicit an immune response. Recently, several bispecific therapies have been approved, including epcoritamab, glofitamab, mosunetuzumab, tebentafusp, and teclistamab. Epcoritamab and glofitamab have been approved for diffuse large B cell lymphoma, while mosunetuzumab, tebentafusp, and teclistamab have been approved for follicular lymphoma, uveal melanoma, and multiple myeloma, respectively. As a result of their mechanism of action, the approved bispecific therapies have the potential to cause cytokine release syndrome, and, along with this, they all have unique and specific monitoring parameters and operational considerations that require clinician awareness when administering these therapies. Such operational challenges include within-patient dose escalations at therapy initiation, hospitalization for monitoring, and various pharmacological strategies for prophylaxis of cytokine release syndrome. CONCLUSION Bispecific therapies have continued to evolve the therapeutic landscape of cancer, primarily in hematological malignancies. Health-system pharmacists have the opportunity to play a key role in the operationalization and management of this new and emerging drug class.
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Affiliation(s)
- Donald C Moore
- Atrium Health Levine Cancer Institute, Charlotte, NC, USA
| | | | - Carolyn J Oxencis
- Froedtert and the Medical College of Wisconsin School of Pharmacy, Milwaukee, WI, USA
| | - Kate D Taucher
- Oncology & Infusion Pharmacy Services, Department of Pharmacy, UCHealth, Aurora, CO, USA
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Hu B, Korsos V, Palomba ML. Chimeric antigen receptor T-cell therapy for aggressive B-cell lymphomas. Front Oncol 2024; 14:1394057. [PMID: 39011476 PMCID: PMC11246842 DOI: 10.3389/fonc.2024.1394057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 05/21/2024] [Indexed: 07/17/2024] Open
Abstract
Chimeric antigen receptor (CAR) T-cell therapy is a revolutionary approach in the treatment of lymphoma. This review article provides an overview of the four FDA-approved CAR T-cell products for aggressive B-cell lymphoma, including diffuse large B-cell lymphoma and mantle cell lymphoma, highlighting their efficacy and toxicity as well as discussing future directions.
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Affiliation(s)
- Bei Hu
- Department of Hematologic Oncology and Blood Disorders, Atrium Health Levine Cancer Institute/Wake Forest School of Medicine, Charlotte, NC, United States
| | - Victoria Korsos
- Cellular Therapy Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - M Lia Palomba
- Cellular Therapy Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Lymphoma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States
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Qian H, Yang X, Zhang T, Zou P, Zhang Y, Tian W, Mao Z, Wei J. Improving the safety of CAR-T-cell therapy: The risk and prevention of viral infection for patients with relapsed or refractory B-cell lymphoma undergoing CAR-T-cell therapy. Am J Hematol 2024; 99:662-678. [PMID: 38197307 DOI: 10.1002/ajh.27198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 12/05/2023] [Accepted: 12/15/2023] [Indexed: 01/11/2024]
Abstract
Chimeric antigen receptor (CAR) T-cell therapy, an innovative immunotherapeutic against relapsed/refractory B-cell lymphoma, faces challenges due to frequent viral infections. Despite this, a comprehensive review addressing risk assessment, surveillance, and treatment management is notably absent. This review elucidates immune response compromises during viral infections in CAR-T recipients, collates susceptibility risk factors, and deliberates on preventive strategies. In the post-pandemic era, marked by the Omicron variant, new and severe threats to CAR-T therapy emerge, necessitating exploration of preventive and treatment measures for COVID-19. Overall, the review provides recommendations for viral infection prophylaxis and management, enhancing CAR-T product safety and recipient survival.
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Affiliation(s)
- Hu Qian
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xingcheng Yang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tingting Zhang
- Cancer Center, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
- Department of Hematology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
- Sino-German Joint Oncological Research Laboratory, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Taiyuan, China
| | - Ping Zou
- Department of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yicheng Zhang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Weiwei Tian
- Department of Hematology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
- Sino-German Joint Oncological Research Laboratory, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Taiyuan, China
| | - Zekai Mao
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jia Wei
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Hematology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
- Sino-German Joint Oncological Research Laboratory, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Taiyuan, China
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León-Román J, Iacoboni G, Bermejo S, Carpio C, Bolufer M, García-Carro C, Sánchez-Salinas M, Alonso-Martínez C, Bestard O, Barba P, Soler MJ. Transient acute kidney injury after chimeric antigen receptor T-cell therapy in patients with hematological malignancies. Clin Kidney J 2024; 17:sfae027. [PMID: 38500492 PMCID: PMC10946657 DOI: 10.1093/ckj/sfae027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Indexed: 03/20/2024] Open
Abstract
Background Acute kidney injury (AKI) occurs in 30% of patients infused with chimeric antigen receptor (CAR) T-cells. The purpose of this study was to identify risk factors and long-term outcomes after AKI in patients who received CAR T-cell therapy. Methods Medical records of 115 adult patients with R/R hematological malignancies treated with CD19-targeted CAR T-cells at Vall d'Hebron University Hospital between July 2018 and May 2021. Baseline demographic data including age, gender, ethnicity, body mass index (BMI), and co-morbidities, as well as the type of hematological neoplasia and prior lines of therapy were collected. Laboratory parameters including serum creatinine and whole blood hemoglobin were retrospectively reviewed and values were gathered for days +1, +7, +14, +21, and +28 post-infusion. Results A total of 24/115 (21%) patients developed AKI related to CAR T-cell therapy; 6/24 with AKI over chronic kidney disease (CKD). Two patients had AKI in the context of lymphodepleting (LD) chemotherapy and the other 22 after CAR T-cell infusion, starting at day+1 in 3 patients, day+7 in 13 patients, day +14 in 1 patient, day+21 in 2 patients, and day+28 in 3 patients. Renal function was recovered in 19/24 (79%) patients within the first month after infusion. Male gender, CKD, cytokine release syndrome (CRS), and immune effector cell-associated neurotoxicity syndrome (ICANS) were associated with AKI. Male gender, CKD, ICANS grade ≥3 and CRS grade ≥2 were identified as independent risk factors for AKI on multivariable analysis. In terms of the most frequent CAR T-cell related complications, CRS was observed in 95 (82%) patients and ICANS in 33 (29%) patients. Steroids were required in 34 (30%) patients and tocilizumab in 37 (32%) patients. Six (5%) patients were admitted to the intensive care unit (1 for septic shock, 4 for CRS grade ≥2 associated to ICANS grade ≥2, and 1 for CRS grade ≥3). A total of 5 (4.4%) patients died in the first 30 days after CAR T-cell infusion for reasons other than disease progression, including 4 cases of infectious complications and 1 of heart failure. Conclusion Our results suggest that AKI is a frequent but mild adverse event, with fast recovery in most patients.
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Affiliation(s)
- Juan León-Román
- Nephrology Department, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Research, CSUR National Unit of Expertise for Complex Glomerular Diseases of Spain, Barcelona, Spain
| | - Gloria Iacoboni
- Department of Hematology, Vall d'Hebron University Hospital, Experimental Hematology, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Sheila Bermejo
- Nephrology Department, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Research, CSUR National Unit of Expertise for Complex Glomerular Diseases of Spain, Barcelona, Spain
| | - Cecilia Carpio
- Department of Hematology, Vall d'Hebron University Hospital, Experimental Hematology, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron, Barcelona, Spain
| | - Mónica Bolufer
- Nephrology Department, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Research, CSUR National Unit of Expertise for Complex Glomerular Diseases of Spain, Barcelona, Spain
| | - Clara García-Carro
- Nephrology Department, San Carlos Clinical University Hospital, Madrid, Spain
| | - Mario Sánchez-Salinas
- Department of Hematology, Vall d'Hebron University Hospital, Experimental Hematology, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron, Barcelona, Spain
| | - Carla Alonso-Martínez
- Pharmacy Department, Vall d´Hebron Hospital Universitari, Vall d´Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Oriol Bestard
- Nephrology Department, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Research, CSUR National Unit of Expertise for Complex Glomerular Diseases of Spain, Barcelona, Spain
| | - Pere Barba
- Department of Hematology, Vall d'Hebron University Hospital, Experimental Hematology, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron, Barcelona, Spain
| | - María José Soler
- Nephrology Department, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Research, CSUR National Unit of Expertise for Complex Glomerular Diseases of Spain, Barcelona, Spain
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Luo Y, Gao L, Liu J, Yang L, Wang L, Lai X, Gao S, Liu L, Zhao L, Ye Y, Wang M, Shen L, Cao WW, Wang D, Li W, Zhang X, Huang H. Donor-derived Anti-CD19 CAR T cells GC007g for relapsed or refractory B-cell acute lymphoblastic leukemia after allogeneic HSCT: a phase 1 trial. EClinicalMedicine 2024; 67:102377. [PMID: 38204488 PMCID: PMC10776428 DOI: 10.1016/j.eclinm.2023.102377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/29/2023] [Accepted: 11/29/2023] [Indexed: 01/12/2024] Open
Abstract
Background Although chimeric antigen receptor-modified T cells (CAR T) cell therapy has been widely reported in improving the outcomes of B-cell acute lymphoblastic leukemia (B-ALL), less research about the feasibility and safety of donor-derived CAR T after allogeneic hematopoietic stem cell transplantation (allo-HSCT) was reported. Methods This phase 1 clinical trial aims to evaluate safety and efficacy of donor-derived anti-CD19 CAR T cells (GC007g) in B-ALL patients who relapsed after allo-HSCT. This trial is registered with ClinicalTrials.gov, NCT04516551. Findings Between 15 March 2021 and 19 May 2022, fifteen patients were screened, three patients were excluded due to withdraw of consent, donor's reason, and death, respectively. Patients received donor-derived CAR T cells infusions at 6 × 105/kg (n = 3) or 2 × 106/kg (n = 6) dose level. The median time from HSCT to relapse was 185 days (range, 81-2063). The median age of patients was 31 years (range 21-48). Seven patients (77.8%) had BCR-ABL fusion gene. CAR T cells expanded in vivo and the median time to reach Cmax was 9 days (range, 7-11). One patient had hyperbilirubinemia after GC007g infusion which was defined as a dose-limiting toxicity. All patients experienced CRS and hematological adverse events. Three patients had acute graft-versus-host-disease (grade I, n = 1; grade II, n = 1; grade IV, n = 1) and all resolved after treatment. They received CAR T cells from matched sister, haploidentical matched father and sisiter, respectively. At 28 days after infusion, all patients achieved complete remission with/without incomplete hematologic recovery (CRi/CR) with undetectable MRD. At a median follow-up of 475 days (range 322-732), seven patients remained in CR/CRi while two had CD19-negative relapse. The overall response rates (ORR) were 100% (9/9), 88.9% (8/9), and 75% (6/8) at 3 month, 6 month, and 12 month, respectively. The 1-year progression-free and overall survival were 77.8% and 85.7%, respectively. Interpretation GC007g expanded and induced durable remission in patients with B-ALL relapsed after allo-HSCT, with manageable safety profiles. Funding Gracell Biotechnologies Inc.
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Affiliation(s)
- Yi Luo
- The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
- Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Lei Gao
- Medical Center of Hematology, Xinqiao Hospital, Chongqing, China
| | - Jia Liu
- Gracell Biotechnologies Ind., Shanghai, China
| | - Luxin Yang
- The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
- Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Lu Wang
- Medical Center of Hematology, Xinqiao Hospital, Chongqing, China
| | - Xiaoyu Lai
- The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
- Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Shichun Gao
- Medical Center of Hematology, Xinqiao Hospital, Chongqing, China
| | - Lizhen Liu
- The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
- Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Lu Zhao
- Medical Center of Hematology, Xinqiao Hospital, Chongqing, China
| | - Yishan Ye
- The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
- Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
| | | | | | | | - Dongrui Wang
- The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
- Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Wenling Li
- Gracell Biotechnologies Ind., Shanghai, China
| | - Xi Zhang
- Medical Center of Hematology, Xinqiao Hospital, Chongqing, China
| | - He Huang
- The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
- Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
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Nazerian Y, Ghasemi M, Yassaghi Y, Nazerian A, Mahmoud Hashemi S. Role of SARS-CoV-2-induced Cytokine Storm in Multi-Organ Failure: Molecular Pathways and Potential Therapeutic Options. Int Immunopharmacol 2022; 113:109428. [PMCID: PMC9637536 DOI: 10.1016/j.intimp.2022.109428] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 10/19/2022] [Accepted: 11/01/2022] [Indexed: 11/09/2022]
Abstract
Coronavirus disease 2019 (COVID-19) outbreak has become a global public health emergency and has led to devastating results. Mounting evidence proposes that the disease causes severe pulmonary involvement and influences different organs, leading to a critical situation named multi-organ failure. It is yet to be fully clarified how the disease becomes so deadly in some patients. However, it is proven that a condition called “cytokine storm” is involved in the deterioration of COVID-19. Although beneficial, sustained production of cytokines and overabundance of inflammatory mediators causing cytokine storm can lead to collateral vital organ damages. Furthermore, cytokine storm can cause post-COVID-19 syndrome (PCS), an important cause of morbidity after the acute phase of COVID-19. Herein, we aim to explain the possible pathophysiology mechanisms involved in COVID-19-related cytokine storm and its association with multi-organ failure and PCS. We also discuss the latest advances in finding the potential therapeutic targets to control cytokine storm wishing to answer unmet clinical demands for treatment of COVID-19.
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Affiliation(s)
- Yasaman Nazerian
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mobina Ghasemi
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Younes Yassaghi
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Seyed Mahmoud Hashemi
- Medical nanotechnology and Tissue Engineering Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran,Department of Immunology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran,Corresponding author at: Medical nanotechnology and Tissue Engineering Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran / Department of Immunology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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9
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Novel Insights into Fungal Infections Prophylaxis and Treatment in Pediatric Patients with Cancer. Antibiotics (Basel) 2022; 11:antibiotics11101316. [PMID: 36289974 PMCID: PMC9598217 DOI: 10.3390/antibiotics11101316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/20/2022] [Accepted: 09/22/2022] [Indexed: 11/23/2022] Open
Abstract
Invasive fungal diseases (IFDs) are a relevant cause of morbidity and mortality in children with cancer. Their correct prevention and management impact patients’ outcomes. The aim of this review is to highlight the rationale and novel insights into antifungal prophylaxis and treatment in pediatric patients with oncological and hematological diseases. The literature analysis showed that IFDs represent a minority of cases in comparison to bacterial and viral infections, but their impact might be far more serious, especially when prolonged antifungal therapy or invasive surgical treatments are required to eradicate colonization. A personalized approach is recommended since pediatric patients with cancer often present with different complications and require tailored therapy. Moreover, while the Aspergillus infection rate does not seem to increase, in the near future, new therapeutic recommendations should be required in light of new epidemiological data on Candidemia due to resistant species. Finally, further studies on CAR-T treatment and other immunotherapies are needed in patients with unique needs and the risk of complications. Definitive guidelines on IFD treatment considering the evolving epidemiology of antifungal resistance, new therapeutic approaches in pediatric cancer, novel antifungal drugs and the importance of an appropriate antifungal stewardship are urgently needed.
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Cardiotoxicity of Chimeric Antigen Receptor T-Cell (CAR-T) Therapy: Pathophysiology, Clinical Implications, and Echocardiographic Assessment. Int J Mol Sci 2022; 23:ijms23158242. [PMID: 35897819 PMCID: PMC9368621 DOI: 10.3390/ijms23158242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 07/18/2022] [Accepted: 07/23/2022] [Indexed: 02/04/2023] Open
Abstract
Contemporary anticancer immunotherapy with chimeric antigen receptor T-cell (CAR-T) therapy has dramatically changed the treatment of many hematologic malignancies previously associated with poor prognosis. The clinical improvement and the survival benefit unveiled the risk of cardiotoxicity, ranging from minimal effects to severe cardiac adverse events, including death. Immunotherapy should also be proposed even in patients with pre-existing cardiovascular risk factors, thereby increasing the potential harm of cardiotoxicity. CAR-T therapy frequently results in cytokine release syndrome (CRS), and inflammatory activation is sustained by circulating cytokines that foster a positive feedback mechanism. Prompt diagnosis and treatment of CAR-T cardiotoxicity might significantly improve outcomes and reduce the burden associated with cardiovascular complications. Clinical and echocardiographic examinations are crucial to perform a tailored evaluation and follow-up during CAR-T treatment. This review aims to summarize the pathophysiology, clinical implications, and echocardiographic assessment of CAR-T-related cardiotoxicity to enlighten new avenues for future research.
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11
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Ferreros P, Trapero I. Interleukin Inhibitors in Cytokine Release Syndrome and Neurotoxicity Secondary to CAR-T Therapy. Diseases 2022; 10:41. [PMID: 35892735 PMCID: PMC9326641 DOI: 10.3390/diseases10030041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 06/29/2022] [Accepted: 07/01/2022] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Chimeric antigen receptor T-cell (CAR-T) therapy is an innovative therapeutic option for addressing certain recurrent or refractory hematological malignancies. However, CAR-T cells also cause the release of pro-inflammatory cytokines that lead to life-threatening cytokine release syndrome and neurotoxicity. OBJECTIVE To study the efficacy of interleukin inhibitors in addressing cytokine release syndrome (CRS) and neurotoxicity secondary to CAR-T therapy. METHODOLOGY The authors conducted a bibliographic review in which 10 articles were analyzed. These included cut-off studies, case reports, and clinical trials involving 11 cancer centers and up to 475 patients over 18 years of age. RESULTS Tocilizumab is the only interleukin inhibitor approved to address CRS secondary to CAR-T therapy due to its efficacy and safety. Other inhibitors, such as siltuximab and anakinra, could be useful in combination with tocilizumab for preventing severe cytokine release and neurotoxicity. In addition, the new specific inhibitors could be effective in mitigating CRS without affecting the cytotoxic efficacy of CAR-T therapy. CONCLUSION More lines of research should be opened to elucidate the true implications of these drugs in treating the side effects of CAR-T therapy.
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Affiliation(s)
- Puri Ferreros
- Nursing Department, Faculty of Nursing and Podiatry, University of Valencia, 46010 Valencia, Spain;
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12
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Kampouri E, Walti CS, Gauthier J, Hill JA. Managing Hypogammaglobulinemia in Patients Treated with CAR-T-cell Therapy: Key Points for Clinicians. Expert Rev Hematol 2022; 15:305-320. [PMID: 35385358 DOI: 10.1080/17474086.2022.2063833] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The unprecedented success of chimeric antigen receptor (CAR)-T-cell therapy in the management of B-cell malignancies comes with a price of specific side effects. Healthy B-cell depletion is an anticipated 'on-target' 'off-tumor' side effect and can contribute to severe and prolonged hypogammaglobulinemia. Evidence-based guidelines for the use of immunoglobulin replacement therapy (IGRT) for infection prevention are lacking in this population. AREAS COVERED This article reviews the mechanisms and epidemiology of hypogammaglobulinemia and antibody deficiency, association with infections, and strategies to address these issues in CD19- and BCMA-CAR-T-cell recipients. EXPERT OPINION CD19 and BCMA CAR-T-cell therapy result in unique immune deficits due to depletion of specific B-lineage cells and may require different infection prevention strategies. Hypogammaglobulinemia before and after CAR-T-cell therapy is frequent, but data on the efficacy and cost-effectiveness of IGRT are lacking. Monthly IGRT should be prioritized for patients with severe or recurrent bacterial infections. IGRT may be more broadly necessary to prevent infections in BCMA-CAR-T-cell recipients and children with severe hypogammaglobulinemia irrespective of infection history. Vaccinations are indicated to augment humoral immunity and can be immunogenic despite cytopenias; re-vaccination(s) may be required. Controlled trials are needed to better understand the role of IGRT and vaccines in this population.
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Affiliation(s)
- Eleftheria Kampouri
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Carla S Walti
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Infectious Disease and Hospital Epidemiology Division, University Hospital Basel, Basel, Switzerland
| | - Jordan Gauthier
- Department of Medicine, University of Washington, Seattle, Washington, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Joshua A Hill
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Department of Medicine, University of Washington, Seattle, Washington, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
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13
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Pan K, Farrukh H, Chittepu VCSR, Xu H, Pan CX, Zhu Z. CAR race to cancer immunotherapy: from CAR T, CAR NK to CAR macrophage therapy. J Exp Clin Cancer Res 2022; 41:119. [PMID: 35361234 PMCID: PMC8969382 DOI: 10.1186/s13046-022-02327-z] [Citation(s) in RCA: 218] [Impact Index Per Article: 109.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 12/11/2021] [Indexed: 12/13/2022] Open
Abstract
Adoptive cell therapy with chimeric antigen receptor (CAR) immunotherapy has made tremendous progress with five CAR T therapies approved by the US Food and Drug Administration for hematological malignancies. However, CAR immunotherapy in solid tumors lags significantly behind. Some of the major hurdles for CAR immunotherapy in solid tumors include CAR T cell manufacturing, lack of tumor-specific antigens, inefficient CAR T cell trafficking and infiltration into tumor sites, immunosuppressive tumor microenvironment (TME), therapy-associated toxicity, and antigen escape. CAR Natural Killer (NK) cells have several advantages over CAR T cells as the NK cells can be manufactured from pre-existing cell lines or allogeneic NK cells with unmatched major histocompatibility complex (MHC); can kill cancer cells through both CAR-dependent and CAR-independent pathways; and have less toxicity, especially cytokine-release syndrome and neurotoxicity. At least one clinical trial showed the efficacy and tolerability of CAR NK cell therapy. Macrophages can efficiently infiltrate into tumors, are major immune regulators and abundantly present in TME. The immunosuppressive M2 macrophages are at least as efficient as the proinflammatory M1 macrophages in phagocytosis of target cells; and M2 macrophages can be induced to differentiate to the M1 phenotype. Consequently, there is significant interest in developing CAR macrophages for cancer immunotherapy to overcome some major hurdles associated with CAR T/NK therapy, especially in solid tumors. Nevertheless, both CAR NK and CAR macrophages have their own limitations. This comprehensive review article will discuss the current status and the major hurdles associated with CAR T and CAR NK therapy, followed by the structure and cutting-edge research of developing CAR macrophages as cancer-specific phagocytes, antigen presenters, immunostimulators, and TME modifiers.
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Affiliation(s)
- Kevin Pan
- Vanderbilt University, 2201 West End Ave, Nashville, TN, 37235, USA
| | - Hizra Farrukh
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Huihong Xu
- Boston University, Boston, MA, USA.,VA Boston Healthcare System, West Roxbury, MA, USA
| | - Chong-Xian Pan
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. .,VA Boston Healthcare System, West Roxbury, MA, USA. .,Harvard Medical School, 1400 VFW Parkway Building 3, Room 2B-110, West Roxbury, MA, 02132, USA.
| | - Zheng Zhu
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. .,Harvard Medical School, 1400 VFW Parkway Building 3, Room 2B-110, West Roxbury, MA, 02132, USA.
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14
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Guha P, Katz SC. Strategies for manufacturing cell therapy products aligned with patient needs. Methods Cell Biol 2022; 167:203-226. [DOI: 10.1016/bs.mcb.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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15
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Santomasso BD, Nastoupil LJ, Adkins S, Lacchetti C, Schneider BJ, Anadkat M, Atkins MB, Brassil KJ, Caterino JM, Chau I, Davies MJ, Ernstoff MS, Fecher L, Funchain P, Jaiyesimi I, Mammen JS, Naidoo J, Naing A, Phillips T, Porter LD, Reichner CA, Seigel C, Song JM, Spira A, Suarez-Almazor M, Swami U, Thompson JA, Vikas P, Wang Y, Weber JS, Bollin K, Ghosh M. Management of Immune-Related Adverse Events in Patients Treated With Chimeric Antigen Receptor T-Cell Therapy: ASCO Guideline. J Clin Oncol 2021; 39:3978-3992. [PMID: 34724386 DOI: 10.1200/jco.21.01992] [Citation(s) in RCA: 136] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To increase awareness, outline strategies, and offer guidance on the recommended management of immune-related adverse events (irAEs) in patients treated with chimeric antigen receptor (CAR) T-cell therapy. METHODS A multidisciplinary panel of medical oncology, neurology, hematology, emergency medicine, nursing, trialists, and advocacy experts was convened to develop the guideline. Guideline development involved a systematic literature review and an informal consensus process. The systematic review focused on evidence published from 2017 to 2021. RESULTS The systematic review identified 35 eligible publications. Because of the paucity of high-quality evidence, recommendations are based on expert consensus. RECOMMENDATIONS The multidisciplinary team issued recommendations to aid in the recognition, workup, evaluation, and management of the most common CAR T-cell-related toxicities, including cytokine release syndrome, immune effector cell-associated neurotoxicity syndrome, B-cell aplasia, cytopenias, and infections. Management of short-term toxicities associated with CAR T cells begins with supportive care for most patients, but may require pharmacologic interventions for those without adequate response. Management of patients with prolonged or severe CAR T-cell-associated cytokine release syndrome includes treatment with tocilizumab with or without a corticosteroid. On the basis of the potential for rapid decline, patients with moderate to severe immune effector cell-associated neurotoxicity syndrome should be managed with corticosteroids and supportive care.Additional information is available at www.asco.org/supportive-care-guidelines.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Ian Chau
- Royal Marsden Hospital and Institute of Cancer Research, London and Surrey, United Kingdom
| | | | | | | | | | | | | | - Jarushka Naidoo
- Beaumont Hospital, Dublin, Ireland and Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | | | | | | | | | | | | | | | | | - Umang Swami
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - John A Thompson
- Seattle Cancer Care Alliance, University of Washington/Fred Hutchinson, Seattle, WA
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16
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Hansen DK, Dam M, Faramand RG. Toxicities associated with adoptive cellular therapies. Best Pract Res Clin Haematol 2021; 34:101287. [PMID: 34625233 DOI: 10.1016/j.beha.2021.101287] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 07/21/2021] [Indexed: 12/17/2022]
Abstract
Chimeric antigen receptor (CAR) T cell therapy is an effective strategy for the treatment of relapsed/refractory hematologic malignancies leading to the Food and Drug Administration (FDA) approval of five CAR T cell products. Despite encouraging efficacy, the widespread utilization of CAR T cell therapy is limited by unique immune mediated toxicities, primarily cytokine release syndrome (CRS) and neurologic toxicity. Data regarding late effects and long-term toxicities of CAR T cell therapy is evolving and includes prolonged cytopenias, hypogammaglobulinemia, infections and secondary malignancies. In this review, we will describe the clinical presentation, diagnosis, mechanisms and management of short- and long-term toxicities of CAR T cell therapy.
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Affiliation(s)
- Doris K Hansen
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy, 12902 USF Magnolia Drive, CSB 7th Floor, Tampa, FL, 33612, USA.
| | - Marian Dam
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy, 12902 USF Magnolia Drive, CSB 7th Floor, Tampa, FL, 33612, USA.
| | - Rawan G Faramand
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy, 12902 USF Magnolia Drive, CSB 7th Floor, Tampa, FL, 33612, USA; Department of Immunology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.
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17
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Banerjee R, Shah N, Dicker AP. Next-Generation Implementation of Chimeric Antigen Receptor T-Cell Therapy Using Digital Health. JCO Clin Cancer Inform 2021; 5:668-678. [PMID: 34110929 DOI: 10.1200/cci.21.00023] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Chimeric antigen receptor T-cell (CAR-T) therapy is a paradigm-shifting immunotherapy modality in oncology; however, unique toxicities such as cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome limit its ability to be implemented more widely in the outpatient setting or at smaller-volume centers. Three operational challenges with CAR-T therapy include the following: (1) the logistics of toxicity monitoring, ie, with frequent vital sign checks and neurologic assessments; (2) the specialized knowledge required for toxicity management, particularly with regard to CRS and immune effector cell-associated neurotoxicity syndrome; and (3) the need for high-quality symptomatic and supportive care during this intensive period. In this review, we explore potential niches for digital innovations that can improve the implementation of CAR-T therapy in each of these domains. These tools include patient-facing technologies and provider-facing platforms: for example, wearable devices and mobile health apps to screen for fevers and encephalopathy, electronic patient-reported outcome assessments-based workflows to assist with symptom management, machine learning algorithms to predict emerging CRS in real time, clinical decision support systems to assist with toxicity management, and digital coaching to help maintain wellness. Televisits, which have grown in prominence since the novel coronavirus pandemic, will continue to play a key role in the monitoring and management of CAR-T-related toxicities as well. Limitations of these strategies include the need to ensure care equity and stakeholder buy-in, both operationally and financially. Nevertheless, once developed and validated, the next-generation implementation of CAR-T therapy using these digital tools may improve both its safety and accessibility.
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Affiliation(s)
- Rahul Banerjee
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Nina Shah
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Adam P Dicker
- Department of Radiation Oncology, Jefferson University, Philadelphia, PA.,Jefferson Center for Digital Health, Jefferson University, Philadelphia, PA
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18
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Banerjee R, Fakhri B, Shah N. Toci or not toci: innovations in the diagnosis, prevention, and early management of cytokine release syndrome. Leuk Lymphoma 2021; 62:2600-2611. [PMID: 34151714 DOI: 10.1080/10428194.2021.1924370] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Cytokine release syndrome (CRS) remains a significant toxicity of chimeric antigen receptor T-cell (CAR-T) therapy for hematologic malignancies. While established guidelines exist for the management of Grade 2+ CRS with immunosuppressive agents such as tocilizumab or corticosteroids, the management of early-grade CRS (i.e. Grade 1 CRS with isolated fevers) has no such consensus beyond supportive care. In this review, we discuss early-grade CRS with an emphasis on its diagnosis, management, and prevention. Strategies to target early-grade CRS include immunosuppression preemptively (once CRS develops) or prophylactically (before CRS develops) as well as novel small-molecule inhibitors or fractionated CAR-T dosing. In the near future, next-generation CAR-T therapies may be able to target CRS precisely or obviate CRS entirely. If shown to prevent CRS-associated morbidity while maintaining therapeutic anti-neoplastic efficacy, these innovative strategies will enhance the safety of CAR-T therapy while also improving its operationalization and accessibility in the real-world setting.
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Affiliation(s)
- Rahul Banerjee
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Bita Fakhri
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Nina Shah
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
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19
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Hutchings M, Morschhauser F, Iacoboni G, Carlo-Stella C, Offner FC, Sureda A, Salles G, Martínez-Lopez J, Crump M, Thomas DN, Morcos PN, Ferlini C, Bröske AME, Belousov A, Bacac M, Dimier N, Carlile DJ, Lundberg L, Perez-Callejo D, Umaña P, Moore T, Weisser M, Dickinson MJ. Glofitamab, a Novel, Bivalent CD20-Targeting T-Cell-Engaging Bispecific Antibody, Induces Durable Complete Remissions in Relapsed or Refractory B-Cell Lymphoma: A Phase I Trial. J Clin Oncol 2021; 39:1959-1970. [PMID: 33739857 PMCID: PMC8210975 DOI: 10.1200/jco.20.03175] [Citation(s) in RCA: 246] [Impact Index Per Article: 82.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 01/23/2021] [Accepted: 02/02/2021] [Indexed: 12/18/2022] Open
Abstract
PURPOSE Glofitamab is a T-cell-engaging bispecific antibody possessing a novel 2:1 structure with bivalency for CD20 on B cells and monovalency for CD3 on T cells. This phase I study evaluated glofitamab in relapsed or refractory (R/R) B-cell non-Hodgkin lymphoma (B-NHL). Data for single-agent glofitamab, with obinutuzumab pretreatment (Gpt) to reduce toxicity, are presented. METHODS Seven days before the first dose of glofitamab (0.005-30 mg), all patients received 1,000 mg Gpt. Dose-escalation steps were determined using a Bayesian continuous reassessment method with overdose control. Primary end points were safety, pharmacokinetics, and the maximum tolerated dose of glofitamab. RESULTS Following initial single-patient cohorts, 171 patients were treated within conventional multipatient cohorts and received at least one dose of glofitamab. This trial included heavily pretreated patients with R/R B-NHL; most were refractory to prior therapy (155; 90.6%) and had received a median of three prior therapies. One hundred and twenty-seven patients (74.3%) had diffuse large B-cell lymphoma, transformed follicular lymphoma, or other aggressive histology, and the remainder had indolent lymphoma subtypes. Five (2.9%) patients withdrew from treatment because of adverse events. Cytokine release syndrome occurred in 86 of 171 (50.3%) patients (grade 3 or 4: 3.5%); two (1.2%) patients experienced grade 3, transient immune effector cell-associated neurotoxicity syndrome-like symptoms. The overall response rate was 53.8% (complete response [CR], 36.8%) among all doses and 65.7% (CR, 57.1%) in those dosed at the recommended phase II dose. Of 63 patients with CR, 53 (84.1%) have ongoing CR with a maximum of 27.4 months observation. CONCLUSION In patients with predominantly refractory, aggressive B-NHL, glofitamab showed favorable activity with frequent and durable CRs and a predictable and manageable safety profile.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Antibodies, Bispecific/administration & dosage
- Antibodies, Bispecific/immunology
- Antibodies, Bispecific/pharmacokinetics
- Antigens, CD20/immunology
- Antineoplastic Agents, Immunological/administration & dosage
- Antineoplastic Agents, Immunological/immunology
- Antineoplastic Agents, Immunological/pharmacokinetics
- Female
- Humans
- Lymphoma, B-Cell/immunology
- Lymphoma, B-Cell/therapy
- Male
- Middle Aged
- T-Lymphocytes/drug effects
- T-Lymphocytes/immunology
- Young Adult
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Affiliation(s)
- Martin Hutchings
- Department of Hematology and Phase 1 Unit, Rigshospitalet, Copenhagen, Denmark
| | - Franck Morschhauser
- Université de Lille, CHU Lille, ULR 7365 - GRITA - Groupe de Recherche sur les formes Injectables et les Technologies Associées, Lille, France
| | - Gloria Iacoboni
- Department of Hematology, Vall d'Hebron University Hospital, Experimental Hematology, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Department of Medicine, Universitat Autònoma of Barcelona, Barcelona, Spain
| | - Carmelo Carlo-Stella
- Humanitas Clinical and Research Center—IRCCS and Humanitas University, Rozzano, Italy
| | | | - Anna Sureda
- Institut Català d'Oncologia-Hospitalet, Institut d'Investigació Biomedica de Bellvitge, Universitat de Barcelona, Barcelona, Spain
| | - Gilles Salles
- Hôpital Lyon Sud, Université Claude Bernard Lyon 1, Pierre-Bénite, France
| | - Joaquín Martínez-Lopez
- Hospital 12 de Octubre, i+12, Complutense University, Centro Nacional de Investigaciones Oncológicas, CRIS Unit, Madrid, Spain
| | - Michael Crump
- Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
| | - Denise N. Thomas
- Roche Innovation Center New York, Roche Pharma Research and Early Development, New York, NY
| | - Peter N. Morcos
- Roche Innovation Center New York, Roche Pharma Research and Early Development, New York, NY
| | - Cristiano Ferlini
- Roche Innovation Center New York, Roche Pharma Research and Early Development, New York, NY
| | - Ann-Marie E. Bröske
- Roche Innovation Center Munich, Roche Pharma Research and Early Development, Penzberg, Germany
| | - Anton Belousov
- Roche Innovation Center Zurich, Roche Pharma Research and Early Development, Zurich, Switzerland
| | - Marina Bacac
- Roche Innovation Center Zurich, Roche Pharma Research and Early Development, Zurich, Switzerland
| | - Natalie Dimier
- Roche Innovation Center Welwyn, Roche Pharma Research and Early Development, Welwyn Garden City, United Kingdom
| | - David J. Carlile
- Roche Innovation Center Welwyn, Roche Pharma Research and Early Development, Welwyn Garden City, United Kingdom
| | - Linda Lundberg
- Roche Innovation Center Basel, Roche Pharma Research and Early Development, Basel, Switzerland
| | - David Perez-Callejo
- Roche Innovation Center Basel, Roche Pharma Research and Early Development, Basel, Switzerland
| | - Pablo Umaña
- Roche Innovation Center Zurich, Roche Pharma Research and Early Development, Zurich, Switzerland
| | - Tom Moore
- Roche Innovation Center Munich, Roche Pharma Research and Early Development, Penzberg, Germany
| | - Martin Weisser
- Roche Innovation Center Munich, Roche Pharma Research and Early Development, Penzberg, Germany
| | - Michael J. Dickinson
- Peter MacCallum Cancer Centre, Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia
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20
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Shalabi H, Gust J, Taraseviciute A, Wolters PL, Leahy AB, Sandi C, Laetsch TW, Wiener L, Gardner RA, Nussenblatt V, Hill JA, Curran KJ, Olson TS, Annesley C, Wang HW, Khan J, Pasquini MC, Duncan CN, Grupp SA, Pulsipher MA, Shah NN. Beyond the storm - subacute toxicities and late effects in children receiving CAR T cells. Nat Rev Clin Oncol 2021; 18:363-378. [PMID: 33495553 PMCID: PMC8335746 DOI: 10.1038/s41571-020-00456-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2020] [Indexed: 12/15/2022]
Abstract
As clinical advances with chimeric antigen receptor (CAR) T cells are increasingly described and the potential for extending their therapeutic benefit grows, optimizing the implementation of this therapeutic modality is imperative. The recognition and management of cytokine release syndrome (CRS) marked a milestone in this field; however, beyond the understanding gained in treating CRS, a host of additional toxicities and/or potential late effects of CAR T cell therapy warrant further investigation. A multicentre initiative involving experts in paediatric cell therapy, supportive care and/or study of late effects from cancer and haematopoietic stem cell transplantation was convened to facilitate the comprehensive study of extended CAR T cell-mediated toxicities and establish a framework for new systematic investigations of CAR T cell-related adverse events. Together, this group identified six key focus areas: extended monitoring of neurotoxicity and neurocognitive function, psychosocial considerations, infection and immune reconstitution, other end organ toxicities, evaluation of subsequent neoplasms, and strategies to optimize remission durability. Herein, we present the current understanding, gaps in knowledge and future directions of research addressing these CAR T cell-related outcomes. This systematic framework to study extended toxicities and optimization strategies will facilitate the translation of acquired experience and knowledge for optimal application of CAR T cell therapies.
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Affiliation(s)
- Haneen Shalabi
- Pediatric Oncology Branch, Center for Cancer Research, NCI, NIH, Bethesda, MD, USA
| | - Juliane Gust
- Seattle Children's Research Institute, Seattle, WA, USA
- Department of Pediatrics, University of Washington Seattle, Seattle, WA, USA
| | - Agne Taraseviciute
- Cancer and Blood Disease Institute, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Pamela L Wolters
- Pediatric Oncology Branch, Center for Cancer Research, NCI, NIH, Bethesda, MD, USA
| | - Allison B Leahy
- Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Carlos Sandi
- Pediatric Oncology Branch, Center for Cancer Research, NCI, NIH, Bethesda, MD, USA
- St. Baldrick's Foundation, Monrovia, CA, USA
| | - Theodore W Laetsch
- Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Pediatrics and Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA
| | - Lori Wiener
- Pediatric Oncology Branch, Center for Cancer Research, NCI, NIH, Bethesda, MD, USA
| | - Rebecca A Gardner
- Seattle Children's Research Institute, Seattle, WA, USA
- Department of Pediatrics, University of Washington Seattle, Seattle, WA, USA
| | - Veronique Nussenblatt
- National Institute of Allergy and Infectious Disease, Clinical Center, NIH, Bethesda, MD, USA
| | - Joshua A Hill
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Kevin J Curran
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Timothy S Olson
- Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Colleen Annesley
- Seattle Children's Research Institute, Seattle, WA, USA
- Department of Pediatrics, University of Washington Seattle, Seattle, WA, USA
| | - Hao-Wei Wang
- Laboratory of Pathology, NCI, NIH, Bethesda, MD, USA
| | - Javed Khan
- Oncogenomics Section, Genetics Branch, NCI, NIH, Bethesda, MD, USA
| | - Marcelo C Pasquini
- Blood and Marrow Transplant and Cellular Therapy Program, Medical College of Wisconsin, Milwaukee, WI, USA
- Center for International Blood and Marrow Transplant Research, Milwaukee, WI, USA
| | - Christine N Duncan
- Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA, USA
| | - Stephan A Grupp
- Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael A Pulsipher
- Cancer and Blood Disease Institute, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Nirali N Shah
- Pediatric Oncology Branch, Center for Cancer Research, NCI, NIH, Bethesda, MD, USA.
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21
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Schubert ML, Rohrbach R, Schmitt M, Stein-Thoeringer CK. The Potential Role of the Intestinal Micromilieu and Individual Microbes in the Immunobiology of Chimeric Antigen Receptor T-Cell Therapy. Front Immunol 2021; 12:670286. [PMID: 34135898 PMCID: PMC8200823 DOI: 10.3389/fimmu.2021.670286] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 05/04/2021] [Indexed: 12/25/2022] Open
Abstract
Cellular immunotherapy with chimeric antigen receptor (CAR)-T cells (CARTs) represents a breakthrough in the treatment of hematologic malignancies. CARTs are genetically engineered hybrid receptors that combine antigen-specificity of monoclonal antibodies with T cell function to direct patient-derived T cells to kill malignant cells expressing the target (tumor) antigen. CARTs have been introduced into clinical medicine as CD19-targeted CARTs for refractory and relapsed B cell malignancies. Despite high initial response rates, current CART therapies are limited by a long-term loss of antitumor efficacy, the occurrence of toxicities, and the lack of biomarkers for predicting therapy and toxicity outcomes. In the past decade, the gut microbiome of mammals has been extensively studied and evidence is accumulating that human health, apart from our own genome, largely depends on microbes that are living in and on the human body. The microbiome encompasses more than 1000 bacterial species who collectively encode a metagenome that guides multifaceted, bidirectional host-microbiome interactions, primarily through the action of microbial metabolites. Increasing knowledge has been accumulated on the role of the gut microbiome in T cell-driven anticancer immunotherapy. It has been shown that antibiotics, dietary components and gut microbes reciprocally affect the efficacy and toxicity of allogeneic hematopoietic cell transplantation (allo HCT) as the prototype of T cell-based immunotherapy for hematologic malignancies, and that microbiome diversity metrics can predict clinical outcomes of allo HCTs. In this review, we will provide a comprehensive overview of the principles of CD19-CART immunotherapy and major aspects of the gut microbiome and its modulators that impact antitumor T cell transfer therapies. We will outline i) the extrinsic and intrinsic variables that can contribute to the complex interaction of the gut microbiome and host in CART immunotherapy, including ii) antibiotic administration affecting loss of colonization resistance, expansion of pathobionts and disturbed mucosal and immunological homeostasis, and ii) the role of specific gut commensals and their microbial virulence factors in host immunity and inflammation. Although the role of the gut microbiome in CART immunotherapy has only been marginally explored so far, this review may open a new chapter and views on putative connections and mechanisms.
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Affiliation(s)
- Maria-Luisa Schubert
- Klinik fuer Haematologie, Onkologie und Rheumatologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Roman Rohrbach
- Research Division Microbiome and Cancer, Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Germany
| | - Michael Schmitt
- Klinik fuer Haematologie, Onkologie und Rheumatologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Christoph K Stein-Thoeringer
- Research Division Microbiome and Cancer, Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Germany.,Klinik fuer Medizinische Onkologie, Nationales Centrum für Tumorerkrankungen (NCT), Heidelberg, Germany
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22
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Infection Complications after Lymphodepletion and Dosing of Chimeric Antigen Receptor T (CAR-T) Cell Therapy in Patients with Relapsed/Refractory Acute Lymphoblastic Leukemia or B Cell Non-Hodgkin Lymphoma. Cancers (Basel) 2021; 13:cancers13071684. [PMID: 33918340 PMCID: PMC8038233 DOI: 10.3390/cancers13071684] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 03/26/2021] [Accepted: 03/29/2021] [Indexed: 12/22/2022] Open
Abstract
Chimeric antigen receptor T (CAR-T) cell therapy has proven to be very effective in patients with relapsed/refractory acute lymphoblastic leukemia (ALL) and non-Hodgkin lymphoma (NHL). However, infections-related either due to lymphodepletion or the CAR-T cell therapy itself-can result in severe and potentially life-threatening complications, while side effects such as cytokine release syndrome (CRS) might complicate differential diagnosis. Sixty-seven dosings of CAR-T cells in sixty adult patients with NHL (85%) and ALL (15%) receiving CAR-T cell therapy were assessed for infectious complications. Almost two-thirds of patients (61%) developed fever following lymphodepletion and CAR-T cell dosing. Microbiological or radiological findings were observed in 25% of all cases (bacterial 12%, viral 5%, fungal 8%). Inpatient infections were associated with more lines of therapy and more severe CRS. However, overall serious complications were rare after CAR-T therapy, with one patient dying of infection. Pathogen detection after inpatient stay was infrequent and mostly occurred in the first 90 days after dosing. Infections in CAR-T cell treated patents are common. Fast and suitable identification and treatment are crucial in these heavily pretreated and immunocompromised patients. In most cases infectious complications are manageable. Nonetheless, standardized anti-infective prophylaxis and supportive therapy are mandatory to reduce morbidity and mortality in CAR-T cell therapy.
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23
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Burns EA, Gentille C, Trachtenberg B, Pingali SR, Anand K. Cardiotoxicity Associated with Anti-CD19 Chimeric Antigen Receptor T-Cell (CAR-T) Therapy: Recognition, Risk Factors, and Management. Diseases 2021; 9:20. [PMID: 33802788 PMCID: PMC8006027 DOI: 10.3390/diseases9010020] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/04/2021] [Accepted: 03/15/2021] [Indexed: 12/12/2022] Open
Abstract
Chimeric antigen receptor T-cells (CAR-T) are improving outcomes in pediatric and adult patients with relapsed or refractory B-cell acute lymphoblastic leukemias and subtypes of non-Hodgkin Lymphoma. As this treatment is being increasingly utilized, a better understanding of the unique toxicities associated with this therapy is warranted. While there is growing knowledge on the diagnosis and treatment of cytokine release syndrome (CRS), relatively little is known about the associated cardiac events that occur with CRS that may result in prolonged length of hospital stay, admission to the intensive care unit for pressor support, or cardiac death. This review focuses on the various manifestations of cardiotoxicity, potential risk factors, real world and clinical trial data on prevalence of reported cardiotoxicity events, and treatment recommendations.
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Affiliation(s)
- Ethan A. Burns
- Houston Methodist Cancer Center, Houston Methodist Hospital, 6445 Main Street, Outpatient Center, 24th Floor, Houston, TX 77030, USA; (C.G.); (S.R.P.)
| | - Cesar Gentille
- Houston Methodist Cancer Center, Houston Methodist Hospital, 6445 Main Street, Outpatient Center, 24th Floor, Houston, TX 77030, USA; (C.G.); (S.R.P.)
| | - Barry Trachtenberg
- Houston Methodist DeBakey Heart and Vascular Center, 6565 Fannin St, Houston, TX 77030, USA;
| | - Sai Ravi Pingali
- Houston Methodist Cancer Center, Houston Methodist Hospital, 6445 Main Street, Outpatient Center, 24th Floor, Houston, TX 77030, USA; (C.G.); (S.R.P.)
| | - Kartik Anand
- Callahan Cancer Center, Great Plains Health, 601 W Leota St, North Platte, NE 69101, USA
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24
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Marzal-Alfaro MB, Escudero-Vilaplana V, Revuelta-Herrero JL, Collado-Borrell R, Herranz-Alonso A, Sanjurjo-Saez M. Chimeric Antigen Receptor T Cell Therapy Management and Safety: A Practical Tool From a Multidisciplinary Team Perspective. Front Oncol 2021; 11:636068. [PMID: 33777790 PMCID: PMC7992774 DOI: 10.3389/fonc.2021.636068] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/01/2021] [Indexed: 11/17/2022] Open
Abstract
Purpose The use process for chimeric antigen receptor T (CAR-T) cell drugs is complex and has been associated with a number of potentially severe complications, which requires management by a multidisciplinary team. Pharmacists are a key element in the team and have roles and responsibilities. Our objective was to develop a structured and practical guide that supports hospital pharmacist responsibilities and defines specific activities in a CAR-T cell therapy program, specifically in Europe. Methods A literature review was performed, and the recommendations related to pharmacy practice in CAR-T therapy programs were analyzed. A multidisciplinary team was assembled, and meetings were held to address the key tasks in the CAR-T cells’ management process and to create the guide, based on national and international recommendations and in expert’s opinions. Results The multidisciplinary team defined the following key tasks and issued recommendations to improve patient safety, treatment efficacy, and quality: patient selection and evaluation, CAR-T cell drug order to manufacturer, apheresis and material shipment, reception of CAR-T cell drug and storing, CAR-T cell drug prescription and pharmacy verification, CAR-T cell drug thawing and dispensing, CAR-T cell drug administration, patient education, pharmacovigilance and monitoring and outcomes’ record and evaluation. In each task the pharmacist’s role and how it can improve patient care are defined. A checklist was created to guarantee the compliance of standard operating procedures approved in the institution to manage CAR-T cell therapy and as a tool to collect required data for outcomes’ record and evaluation. Conclusion This article provides a consensus set of safety recommendations regarding CAR-T therapy management in clinical practice, easily implementable by other institutions in the European setting. The guide identifies key steps where the involvement of hospital pharmacists would improve the safety and quality of the process and is a support guide to standardize hospital pharmacists’ responsibilities within the multidisciplinary team.
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Affiliation(s)
- María Belen Marzal-Alfaro
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Vicente Escudero-Vilaplana
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Jose Luis Revuelta-Herrero
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Roberto Collado-Borrell
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Ana Herranz-Alonso
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Maria Sanjurjo-Saez
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
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25
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Banerjee R, Marsal J, Huang CY, Lo M, Kambhampati S, Kennedy VE, Arora S, Wolf JL, Martin TG, Wong SW, Shah N. Early Time-to-Tocilizumab after B Cell Maturation Antigen-Directed Chimeric Antigen Receptor T Cell Therapy in Myeloma. Transplant Cell Ther 2021; 27:477.e1-477.e7. [PMID: 33831353 DOI: 10.1016/j.jtct.2021.03.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/25/2021] [Accepted: 03/02/2021] [Indexed: 10/22/2022]
Abstract
Preemptive administration of tocilizumab (toci) to manage cytokine release syndrome (CRS) after chimeric antigen receptor T cell (CAR-T) therapy may reduce rates of serious CRS but conversely may worsen neurotoxicity or risk of infections. Optimal toci administration strategies for patients with relapsed/refractory multiple myeloma (RRMM) receiving B cell maturation antigen (BCMA)-directed CAR-T therapies have not been evaluated. The objective of this study was to identify whether shorter time-to-toci intervals (hours between first fever attributed to CRS and first dose of toci) have any impact on therapy-related toxicities or clinical outcomes among patients with RRMM receiving BCMA-directed CAR-T therapies. We retrospectively analyzed our institution's experience with 4 BCMA-directed CAR-T therapies (idecabtagene vicleucel, bb21217, ciltacabtagene autoleucel, and orvacabtagene autoceucel) for RRMM over a 3-year period ending in June 2020. We divided patients based on the administration of toci and median time-to-toci interval into early-toci (time-to-toci ≤50th percentile), late-toci (time-to-toci >50th percentile), and no-toci (no toci received) groups. We compared the early-toci and late-toci groups with regard to patient characteristics, weight-based CAR-T toxicities, selected toxicities (CRS, neurotoxicity, macrophage activation syndrome, or infections), and clinical outcomes. Of 50 analyzed patients with a median follow-up of 15.3 months, 76% (n = 38) received ≥1 dose of toci (range, 1 to 3) and were classified into early-toci (time-to-toci ≤12 hours) or late-toci (time-to-toci >12 hours) groups. The 2 groups (n = 19 each) had similar CRS grade distributions, hours to CRS onset, CRS-related biomarkers, and incidences of neurotoxicity or severe infections; however, weight-adjusted CAR-T cell doses were higher in the early-toci group (median 5.99 versus 3.80 × 106 cells/kg, P < 0.01). Peak CRS grades (range, 0 to 2) using American Society for Transplantation and Cellular Therapy consensus criteria, neurotoxicity rates, and rates of severe infections were similar between groups; however, the median CRS duration was 18.6 hours for the early-toci group versus 84.7 hours for the late-toci group. The median progression-free survival was 35.7 months in the early-toci group and 13.2 months in the late-toci group. While limited by small sample size and known confounders such as CAR-T cell dose, our analysis suggests that preemptive toci strategies for CRS management with BCMA-directed CAR-T therapy-specifically, toci administration within 12 hours of the first fever attributed to CRS-do not appear to increase rates of therapy-related toxicities or compromise efficacy. However, total CRS duration may be shorter with early-toci workflows. Prospective validation of our findings may lead to improved safety and cost-effectiveness profiles for CAR-T therapy in RRMM.
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Affiliation(s)
- Rahul Banerjee
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, San Francisco, California.
| | - Jeffrey Marsal
- A.T. Still University School of Osteopathic Medicine in Arizona, Mesa, Arizona
| | - Chiung-Yu Huang
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - Mimi Lo
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Swetha Kambhampati
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Vanessa E Kennedy
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Shagun Arora
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Jeffrey L Wolf
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Thomas G Martin
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Sandy W Wong
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Nina Shah
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, San Francisco, California
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26
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McFaline-Figueroa JR, Lee EQ. Neurological Complications of Targeted Therapies and Immunotherapies for Cancer. Curr Treat Options Neurol 2021. [DOI: 10.1007/s11940-021-00663-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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27
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Bupha-Intr O, Haeusler G, Chee L, Thursky K, Slavin M, Teh B. CAR-T cell therapy and infection: a review. Expert Rev Anti Infect Ther 2020; 19:749-758. [PMID: 33249873 DOI: 10.1080/14787210.2021.1855143] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Introduction: Chimeric antigen receptor T-cell therapy (CAR-T cell therapy) is a novel immunotherapy with promising results in the treatment of relapsed or refractory B cell malignancies. Patients undergoing CAR-T cell therapy are at increased risk of infection due to prior immunosuppression, lymphodepleting chemotherapy, treatment of unique toxicities with tocilizumab and/or steroids, on-target effects of hypogammaglobulinaemia, and prolonged cytopenias.Areas covered: A narrative review of infections (PubMed, August 2020) occurring in patients undergoing CAR-T cell therapy is described, and the evidence for infection prevention strategies is presented.Expert commentary: The rapid adoption of CAR-T cell therapy into clinical practice presents many challenges for the diagnosis, management, and prevention of infection. Ongoing surveillance of the spectrum of infectious complications and effectiveness of prophylaxis is required to support safe and effective patient care.
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Affiliation(s)
- Olivia Bupha-Intr
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Gabrielle Haeusler
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia.,National Centre for Infection in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia.,Murdoch Children's Research Institute, Parkville, Australia.,Department of Infectious Diseases, Royal Children's Hospital, Melbourne, Australia
| | - Lynette Chee
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and the Royal Melbourne Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Parkville, Australia
| | - Karin Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia.,National Centre for Infection in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia.,Department of Medicine, University of Melbourne, Parkville, Australia
| | - Monica Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia.,National Centre for Infection in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia.,Department of Medicine, University of Melbourne, Parkville, Australia
| | - Benjamin Teh
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia.,National Centre for Infection in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia.,Department of Medicine, University of Melbourne, Parkville, Australia
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28
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Abstract
PURPOSE OF REVIEW Tremendous advances have been made in the treatment armamentarium for acute lymphoblastic leukemia in recent years, which have substantially improved outcomes for these patients. At the same time, unique toxicities have emerged, and without early intervention, are life-threatening. This article will review the novel therapies in acute leukemias and highlight the clinically relevant supportive care advances. RECENT FINDINGS The American Society for Transplantation and Cellular Therapy (ASTCT) has put forth the most recent recommendations in managing the cytokine release syndrome and neurotoxicity after chimeric antigen receptor T cells (CAR-T) and blinatumomab. The hepatic injury incurred by inotuzumab, and the vascular toxicity of tyrosine kinase inhibitors, other relatively novel agents, require subspecialist intervention and multidisciplinary care. Asparaginase, a long-established and key element of pediatric regimens, has made a comeback in the young adult leukemia population. Updated guidelines have been outlined for management of asparaginase thrombotic complications. Lastly, although there have been few changes in the applications of growth factor, antimicrobial prophylaxis, and management of neuropathy, these encompass exceedingly important aspects of care. While the rapidly changing treatment paradigms for acute lymphoblastic leukemia have transformed leukemia-specific outcomes, treatment emergent toxicities have forced much necessary attention to better definitions of these toxicities and on improving supportive care guidelines in acute lymphoblastic leukemia.
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29
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Meleveedu KS, Miskovsky J, Meharg J, Abdelrahman A, Tandon R, Moody AE, Dasilva P, Masse G, LaPorte J, Saied Calvino A, Allen G, El-Bizri R, Roberts T, Armenio V, Katz SC. Tocilizumab for severe COVID-19 related illness - A community academic medical center experience. Cytokine X 2020; 2:100035. [PMID: 32895645 PMCID: PMC7467014 DOI: 10.1016/j.cytox.2020.100035] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/05/2020] [Accepted: 08/20/2020] [Indexed: 12/23/2022] Open
Abstract
The SARS-CoV-2 virus responsible for the COVID-19 pandemic can result in severe or fatal disease in a subset of infected patients. While the pathogenesis of severe COVID-19 disease has yet to be fully elucidated, an overexuberant and harmful immune response to the SARS-CoV-2 virus may be a pivotal aspect of critical illness in this patient population. The inflammatory cytokine, IL-6, has been found to be consistently elevated in severely ill COVID-19 patients, prompting speculation that IL-6 is an important driver of the pathologic process. The inappropriately elevated levels of inflammatory cytokines in COVID-19 patients is similar to cytokine release syndrome (CRS) observed in cell therapy patients. We sought to describe outcomes in a series of severely ill patients with COVID-19 CRS following treatment with anti-IL-6/IL-6-Receptor (anti-IL-6/IL-6-R) therapy, including tocilizumab or siltuximab. At our academic community medical center, we formed a multi-disciplinary committee for selecting severely ill COVID-19 patients for therapy with anti-IL-6 or IL-6-R agents. Key selection criteria included evidence of hyperinflammation, most notably elevated levels of C-reactive protein (CRP) and ferritin, and an increasing oxygen requirement. By the data cutoff point, we treated 31 patients with anti-IL-6/IL-6-R agents including 12 who had already been intubated. Overall, 27 (87%) patients are alive and 24 (77%) have been discharged from the hospital. Clinical responses to anti-IL-6/IL-6-R therapy were accompanied by significant decreases in temperature, oxygen requirement, CRP, IL-6, and IL-10 levels. Based on these data, we believe anti-IL-6/IL-6-R therapy can be effective in managing early CRS related to COVID-19 disease. Further study of anti-IL-6/IL-6-R therapy alone and in combination with other classes of therapeutics is warranted and trials are underway.
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Key Words
- (ALC), Absolute Lymphocyte Count
- (ARDS), Acute respiratory distress syndrome
- (BMI), Body mass index
- (CRP), C-reactive protein
- (CRS), Cytokine release syndrome
- (DNR/DNI), Do not resuscitate/do not intubate
- (ECMO), Extracorporeal membrane oxygenation
- (ESR), Erythrocyte sedimentation rate
- (IRB), Institutional review board
- (LDH), Lactate dehydrogenase
- (NIV), Noninvasive ventilation
- (PaO2/FiO2), Arterial oxygen partial pressure/fraction of inspired oxygen
- (RT-PCR), Reverse-transcriptase polymerase-chain-reaction
- (RWMC), Roger Williams Medical Center
- (SITC), Society for Immunotherapy of Cancer
- (SpO2), Peripheral capillary oxygen saturation
- (anti-IL-6/IL-6-R), Anti-IL-6/IL-6-Receptor
- C-reactive protein
- IL-6
- Infectious disease
- SARS-CoV-2
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Affiliation(s)
- Kapil S Meleveedu
- Immuno-oncology Institute, CharterCare Health Partners, Providence, RI, USA
- Department of Medicine, Roger Williams Medical Center, Providence, RI, USA
| | - John Miskovsky
- Department of Medicine, Roger Williams Medical Center, Providence, RI, USA
| | - Joseph Meharg
- Department of Medicine, Roger Williams Medical Center, Providence, RI, USA
| | - Abd Abdelrahman
- Department of Medicine, Roger Williams Medical Center, Providence, RI, USA
| | - Richa Tandon
- Department of Medicine, Roger Williams Medical Center, Providence, RI, USA
| | - Ashley E. Moody
- Immuno-oncology Institute, CharterCare Health Partners, Providence, RI, USA
| | - Priscilla Dasilva
- Immuno-oncology Institute, CharterCare Health Partners, Providence, RI, USA
- Department of Medicine, Roger Williams Medical Center, Providence, RI, USA
| | - Gabrielle Masse
- Immuno-oncology Institute, CharterCare Health Partners, Providence, RI, USA
| | - Jason LaPorte
- Immuno-oncology Institute, CharterCare Health Partners, Providence, RI, USA
| | - Abdul Saied Calvino
- Immuno-oncology Institute, CharterCare Health Partners, Providence, RI, USA
- Department of Surgery, Boston University School of Medicine, Department of Surgery, Boston, MA, USA
- Division of Surgical Oncology, Roger Williams Medical Center, Providence, RI, USA
| | - Greg Allen
- Department of Medicine, Roger Williams Medical Center, Providence, RI, USA
| | - Rabih El-Bizri
- Department of Medicine, Roger Williams Medical Center, Providence, RI, USA
| | - Todd Roberts
- Immuno-oncology Institute, CharterCare Health Partners, Providence, RI, USA
- Department of Medicine, Roger Williams Medical Center, Providence, RI, USA
| | - Vincent Armenio
- Immuno-oncology Institute, CharterCare Health Partners, Providence, RI, USA
- Department of Medicine, Roger Williams Medical Center, Providence, RI, USA
| | - Steven C. Katz
- Immuno-oncology Institute, CharterCare Health Partners, Providence, RI, USA
- Department of Medicine, Roger Williams Medical Center, Providence, RI, USA
- Department of Surgery, Boston University School of Medicine, Department of Surgery, Boston, MA, USA
- University of Rhode Island, Department of Biomedical and Pharmaceutical Sciences, Kingston, RI, USA
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30
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"Cytokine storm", not only in COVID-19 patients. Mini-review. Immunol Lett 2020; 228:38-44. [PMID: 33007369 PMCID: PMC7524442 DOI: 10.1016/j.imlet.2020.09.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 09/10/2020] [Accepted: 09/22/2020] [Indexed: 01/09/2023]
Abstract
Cytokine storm is a form of uncontrolled systemic inflammatory reaction activated by a variety of factors and leading to a harmful homeostatic process, even to patient's death. Triggers that start the reaction are infection, systemic diseases and rarely anaphylaxis. Cytokine storm is frequently mentioned in connection to medical interventions such as transplantation or administration of drugs. Presented mini-review would like to show current possibilities how to fight or even stop such a life-threatening, immune-mediated process in order to save lives, not only in COVID-19 patients. Early identification of rising state and multilevel course of treatment is imperative. The most widely used molecule for systemic treatment remains tocilizumab. Except for anti IL-6 treatment, contemporary research opens the possibilities for combination of pharmaceutical, non-pharmaceutical and adjunctive treatment in a successful fight with consequences of cytokine storm. Further work is needed to discover the exact signaling pathways that lead to cytokine storm and to determine how these effector molecules and/or combination of processes can help to resolve this frequently fatal episode of inflammation. It is a huge need for all scientists and clinicians to establish a physiological rational for new therapeutic targets that might lead to more personalized medicine approaches.
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31
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Gaut D, Tang K, Sim MS, Duong T, Young P, Sasine J. Filgrastim associations with CAR T-cell therapy. Int J Cancer 2020; 148:1192-1196. [PMID: 33091961 PMCID: PMC7894177 DOI: 10.1002/ijc.33356] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/09/2020] [Accepted: 10/13/2020] [Indexed: 01/13/2023]
Abstract
Little is known about the benefits and risks of myeloid growth factor administration after chimeric antigen receptor (CAR) T‐cell therapy for diffuse large B‐cell lymphoma (DLBCL). We present a retrospective analysis among 22 relapsed/refractory DLBCL patients who received CAR T‐cell therapy with axicabtagene ciloleucel. Filgrastim was administered by physician discretion to seven patients (31.8%), and the median duration of neutropenia after lymphodepleting therapy was significantly shorter for those patients who received filgrastim (5 vs 15 days, P = .016). Five patients (22.7%) developed infection in the 30 days post‐CAR T‐cell therapy with three patients being Grade 3 or higher. There was no difference in the incidence and severity of infection based on filgrastim use (P = .274, P = .138). Among the seven patients that received filgrastim, six patients (85.7%) and four patients (57.1%) had evidence of cytokine release syndrome (CRS) and immune effector cell‐associated neurotoxicity syndrome (ICANS), respectively. Among the 15 patients that did not receive filgrastim, 8 patients (53.3%) and 7 patients (46.7%) had evidence of CRS and ICANS, respectively. There was no significant difference in the incidence of developing CRS or ICANS between the group of patients that received filgrastim and those that did not (P = .193, P = .647). However, there was a significant increase in the severity of CRS for patients that received filgrastim compared to those that did not (P = .042). Filgrastim administration after CAR T‐cell therapy may lead to an increase in severity of CRS without decreasing infection rates. What's new Chimeric antigen receptor (CAR) T‐cell therapy in patients with relapsed/refractory diffuse large B‐cell lymphoma is limited by associated cytokine release syndrome, neurotoxicity, and cytopenias. Little is known about the benefits and risks of myeloid growth factor administration in CAR T‐cell therapy. This retrospective analysis reveals a significant increase in the severity but not the incidence of cytokine release syndrome in those patients that received filgrastim. There was no association of filgrastim use with the severity or incidence of neurotoxicity and infection rates. The findings call for caution in the use of myeloid growth factors in patients undergoing CAR T‐cell therapy.
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Affiliation(s)
- Daria Gaut
- Division of Hematology/Oncology, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, California, Los Angeles, USA
| | - Kevin Tang
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, California, Los Angeles, USA
| | - Myung Shin Sim
- Division of General Internal Medicine and Health Services Research, Department of Medicine Statistics Core, David Geffen School of Medicine, University of California Los Angeles, California, Los Angeles, USA
| | - Tuyen Duong
- Division of General Internal Medicine and Health Services Research, Department of Medicine Statistics Core, David Geffen School of Medicine, University of California Los Angeles, California, Los Angeles, USA
| | - Patricia Young
- Division of Hematology/Oncology, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, California, Los Angeles, USA
| | - Joshua Sasine
- Hematopoietic Cell Therapy Program, Division of Hematology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Samuel Oschin Cancer Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Regenerative Medicine Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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32
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Schubert ML, Schmitt M, Wang L, Ramos CA, Jordan K, Müller-Tidow C, Dreger P. Side-effect management of chimeric antigen receptor (CAR) T-cell therapy. Ann Oncol 2020; 32:34-48. [PMID: 33098993 DOI: 10.1016/j.annonc.2020.10.478] [Citation(s) in RCA: 217] [Impact Index Per Article: 54.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 10/15/2020] [Accepted: 10/15/2020] [Indexed: 12/18/2022] Open
Abstract
Chimeric antigen receptor (CAR) T cells directed against the B-cell marker CD19 are currently changing the landscape for treatment of patients with refractory and/or relapsed B-cell malignancies. Due to the nature of CAR T cells as living drugs, they display a unique toxicity profile. As CAR T-cell therapy is extending towards other diseases and being more broadly employed in hematology and oncology, optimal management strategies of side-effects associated with CAR T-cell therapy are of high relevance. Cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), and cytopenias constitute challenges in the treatment of patients with CAR T cells. This review summarizes the current understanding of CAR T-cell toxicity and its management.
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Affiliation(s)
- M-L Schubert
- Department of Medicine V, University Hospital Heidelberg, Heidelberg, Germany.
| | - M Schmitt
- Department of Medicine V, University Hospital Heidelberg, Heidelberg, Germany; National Centre for Tumor Diseases (NCT), Heidelberg, Germany
| | - L Wang
- Department of Medicine V, University Hospital Heidelberg, Heidelberg, Germany
| | - C A Ramos
- Center for Cell Gene Therapy, Baylor College of Medicine, Texas Children's Hospital and Houston Methodist Hospital, Houston, Texas, USA
| | - K Jordan
- Department of Medicine V, University Hospital Heidelberg, Heidelberg, Germany
| | - C Müller-Tidow
- Department of Medicine V, University Hospital Heidelberg, Heidelberg, Germany; National Centre for Tumor Diseases (NCT), Heidelberg, Germany
| | - P Dreger
- Department of Medicine V, University Hospital Heidelberg, Heidelberg, Germany; National Centre for Tumor Diseases (NCT), Heidelberg, Germany
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Los-Arcos I, Iacoboni G, Aguilar-Guisado M, Alsina-Manrique L, Díaz de Heredia C, Fortuny-Guasch C, García-Cadenas I, García-Vidal C, González-Vicent M, Hernani R, Kwon M, Machado M, Martínez-Gómez X, Maldonado VO, Pla CP, Piñana JL, Pomar V, Reguera-Ortega JL, Salavert M, Soler-Palacín P, Vázquez-López L, Barba P, Ruiz-Camps I. Recommendations for screening, monitoring, prevention, and prophylaxis of infections in adult and pediatric patients receiving CAR T-cell therapy: a position paper. Infection 2020; 49:215-231. [PMID: 32979154 PMCID: PMC7518951 DOI: 10.1007/s15010-020-01521-5] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 08/29/2020] [Indexed: 12/11/2022]
Abstract
Chimeric antigen receptor (CAR) T-cell therapy is one of the most promising emerging treatments for B-cell malignancies. Recently, two CAR T-cell products (axicabtagene ciloleucel and tisagenlecleucel) have been approved for patients with aggressive B-cell lymphoma and acute lymphoblastic leukemia; many other CAR-T constructs are in research for both hematological and non-hematological diseases. Most of the patients receiving CAR-T therapy will develop fever at some point after infusion, mainly due to cytokine release syndrome (CRS). The onset of CRS is often indistinguishable from an infection, which makes management of these patients challenging. In addition to the lymphodepleting chemotherapy and CAR T cells, the treatment of complications with corticosteroids and/or tocilizumab increases the risk of infection in these patients. Data regarding incidence, risk factors and prevention of infections in patients receiving CAR-T cell therapy are scarce. To assist in patient care, a multidisciplinary team from hospitals designated by the Spanish Ministry of Health to perform CAR-T therapy prepared these recommendations. We reviewed the literature on the incidence, risk factors, and management of infections in adult and pediatric patients receiving CAR-T cell treatment. Recommendations cover different areas: monitoring and treatment of hypogammaglobulinemia, prevention, prophylaxis, and management of bacterial, viral, and fungal infections as well as vaccination prior and after CAR-T cell therapy.
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Affiliation(s)
- Ibai Los-Arcos
- Infectious Diseases Department, Hospital Universitari Vall D'Hebron, Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Gloria Iacoboni
- Deparment of Hematology, Vall D'Hebron Institute of Oncology (VHIO), Hospital Universitari Vall D'Hebron, Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Manuela Aguilar-Guisado
- Department of Infectious Diseases, Microbiology and Preventive Medicine, University Hospital Virgen del Rocío/CSIC/Institute of Biomedicine of Seville (IBIS), Seville, Spain
| | - Laia Alsina-Manrique
- Clinical Immunology and Primary Immunodeficiencies Unit, Hospital Sant Joan de Deu, Barcelona, Spain
| | - Cristina Díaz de Heredia
- Paediatric Oncology and Hematology Department, Hematopoietic Stem Cell Transplantation, Hospital Universitari Vall D'Hebron, Barcelona, Spain
| | | | - Irene García-Cadenas
- Hematology Department, Hospital de La Santa Creu I Sant Pau, Sant Pau and Jose Carreras Leukemia Research Institutes, Autonomous University of Barcelona, Barcelona, Spain
| | - Carolina García-Vidal
- Department of Infectious Diseases, Hospital Clínic, IDIBAPS (Institut D'Investigacions biomèdiques Agust Pi I Sunyer), Universitat de Barcelona, Barcelona, Spain
| | - Marta González-Vicent
- Hematopoietic Stem Cell Transplantation and Cellular Therapy Unit, Hospital Infantil Universitario "Niño Jesus", Madrid, Spain
| | - Rafael Hernani
- Department of Hematology, Hospital Clínico Universitario, Institute for Research INCLIVA, Valencia, Spain
| | - Mi Kwon
- Haematology and Haemotherapy Department, Hospital General Universitario Gregorio Marañón, Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Marina Machado
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Xavier Martínez-Gómez
- Epidemiology Department, Vall D'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Valentín Ortiz Maldonado
- Department of Hematology, Hospital Clínic de Barcelona, Institut D'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), University of Barcelona, Barcelona, Spain
| | - Carolina Pinto Pla
- Infectious Diseases Unit, Hospital Clínico Universitario, Instituto de Investigación INCLIVA, Valencia, Spain
| | - José Luis Piñana
- Hematology Division, Hospital Universitario Y politécnico La Fe, Instituto de investigación sanitaria La Fe, Valencia, CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Virginia Pomar
- Infectious Disease Unit, Internal Medicine Department, Hospital de La Santa Creu I Sant Pau, Barcelona, Spain
| | - Juan Luis Reguera-Ortega
- Department of Haematology, University Hospital Virgen del Rocío/CSIC/Institute of Biomedicine of Seville (IBIS), Seville, Spain
| | - Miguel Salavert
- Infectious Diseases Unit, Área Clínica Médica, Hospital Universitario Y Politécnico La Fe, Valencia, Spain
| | - Pere Soler-Palacín
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Hospital, Universitari Vall D'Hebron, Barcelona, Spain
| | | | - Pere Barba
- Deparment of Hematology, Vall D'Hebron Institute of Oncology (VHIO), Hospital Universitari Vall D'Hebron, Barcelona, Spain. .,Department of Medicine, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain.
| | - Isabel Ruiz-Camps
- Infectious Diseases Department, Hospital Universitari Vall D'Hebron, Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
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34
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Siegler EL, Kenderian SS. Neurotoxicity and Cytokine Release Syndrome After Chimeric Antigen Receptor T Cell Therapy: Insights Into Mechanisms and Novel Therapies. Front Immunol 2020; 11:1973. [PMID: 32983132 PMCID: PMC7485001 DOI: 10.3389/fimmu.2020.01973] [Citation(s) in RCA: 149] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 07/21/2020] [Indexed: 12/11/2022] Open
Abstract
Chimeric antigen receptor T (CART) cell immunotherapy has been remarkably successful in treating certain relapsed/refractory hematological cancers. However, CART cell therapy is also associated with toxicities which present an obstacle to its wider adoption as a mainstay for cancer treatment. The primary toxicities following CART cell administration are cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). New insights into the mechanisms of these toxicities have spurred novel treatment options. In this review, we summarize the available literature on the clinical manifestations, mechanisms, and treatments of CART-associated CRS and ICANS.
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Affiliation(s)
- Elizabeth L Siegler
- T Cell Engineering, Mayo Clinic, Rochester, MN, United States.,Division of Hematology, Mayo Clinic, Rochester, MN, United States
| | - Saad S Kenderian
- T Cell Engineering, Mayo Clinic, Rochester, MN, United States.,Division of Hematology, Mayo Clinic, Rochester, MN, United States.,Department of Immunology, Mayo Clinic, Rochester, MN, United States.,Department of Molecular Medicine, Mayo Clinic, Rochester, MN, United States
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35
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Booth JP, Kusoski CL, Kennerly-Shah JM. The pharmacist's role in chimeric antigen receptor T cell therapy. J Oncol Pharm Pract 2020; 26:1725-1731. [PMID: 32819199 DOI: 10.1177/1078155220948940] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The emergence and efficacy of chimeric antigen receptor (CAR) T cell therapy in previously incurable malignancies represents a promising paradigm shift in cancer care. However, it is not without significant clinical, operational, and financial considerations. Pharmacists should be prepared to fulfill the various roles in CAR T cell therapy provision including: policy development; electronic medical record build; patient and staff education; patient selection; procurement, storage, and handling; medication administration and supportive care; management of adverse reactions; and quality tracking. Our commentary provides an overview of the opportunities for pharmacy involvement in the implementation and maintenance of a CAR T cell therapy program with an emphasis on the importance of pharmacy involvement as part of a multidisciplinary approach to care. Although some institutions have dedicated a CAR T cell pharmacist to meet the demands of emerging CAR T cell therapy, we believe that clinical pharmacists practicing in hematopoietic stem cell transplant and hematology/oncology have the skills and training to fulfill the pharmacist's role in CAR T cell therapy.
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Affiliation(s)
- Jennifer P Booth
- Department of Pharmacy, The Ohio State University Comprehensive Cancer Center - James, Columbus, OH, USA
| | - Carolyn L Kusoski
- Department of Pharmacy, The Ohio State University Comprehensive Cancer Center - James, Columbus, OH, USA
| | - Julie M Kennerly-Shah
- Department of Pharmacy, The Ohio State University Comprehensive Cancer Center - James, Columbus, OH, USA
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36
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Halford Z, Anderson MK, Bennett LL, Moody J. Tisagenlecleucel in Acute Lymphoblastic Leukemia: A Review of the Literature and Practical Considerations. Ann Pharmacother 2020; 55:466-479. [PMID: 32762363 DOI: 10.1177/1060028020948165] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE To evaluate the current literature for tisagenlecleucel in the treatment of relapsed/refractory (r/r) B-cell acute lymphoblastic leukemia (ALL). DATA SOURCES A literature search of PubMed (inception to June 18, 2020) and ClinicalTrials.gov was conducted using the following search terms: CTL019, chimeric antigen receptor, CAR-T, and tisagenlecleucel. STUDY SELECTION AND DATA EXTRACTION All trials evaluating the use of tisagenlecleucel in B-cell ALL were reviewed and considered for inclusion. DATA SYNTHESIS Tisagenlecleucel displayed overall remission rates ranging from 69% to 93% in patients who historically respond extremely poorly to salvage therapy. Remissions were durable, with 12-month relapse-free survival (RFS) rates of 55% to 59%. These promising results are tempered by the unique adverse effect profile of chimeric antigen receptor (CAR) T-cell therapy. Potentially life-threatening cytokine release syndrome (CRS) occurred in 77% to 100% of patients, and immune effector cell-associated neurotoxicity syndrome (ICANS) developed in 31% to 45% of patients receiving tisagenlecleucel. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE The successful utilization of tisagenlecleucel therapy requires meticulous planning, prudent patient selection, multidisciplinary collaboration, and expert training to ensure optimal patient care. The complex interplay of patient- and treatment-related factors creates problematic barriers that must be expertly navigated by the health care team and authorized treatment center. CONCLUSIONS As the first US Food and Drug Administration-approved gene therapy, tisagenlecleucel heralds an immunotherapeutic breakthrough for treating pediatric and young adult patients with r/r B-cell ALL. Many questions surrounding patient-specific gene and cellular therapies remain, but their transformative potential in cancer care remains promising.
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Affiliation(s)
| | | | | | - Jonathan Moody
- ProMedica Toledo Hospital/Russell J. Ebeid Children's Hospital, Toledo, OH, USA
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37
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Greenbaum U, Kebriaei P, Srour SA, Olson A, Bashir Q, Neelapu SS, Rezvani K, Shpall EJ. Chimeric antigen receptor T-cell therapy toxicities. Br J Clin Pharmacol 2020; 87:2414-2424. [PMID: 32463929 DOI: 10.1111/bcp.14403] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 05/12/2020] [Accepted: 05/15/2020] [Indexed: 12/13/2022] Open
Abstract
Cancer immunotherapy has greatly advanced in recent years, with chimeric antigen receptor (CAR) T cells emerging as an innovative technology that harnesses the immune system to fight malignant diseases. These genetically engineered T-cells have shown encouraging results for B-cell lymphoid malignancies and are now being explored for other cancer types. However, this novel adoptive cell therapy is associated with a new spectrum of immune-mediated adverse events and toxicities. As CAR T cells recognize and engage tumour cells, cytokines are secreted and activate other immune cells, frequently leading to rapid development of cytokine release syndrome, which can result in acute deterioration of the patient's clinical condition. In many patients, cytokine release syndrome is mild and easy to manage, but others experience persistent fevers accompanied by hypotension and hypoxia, which require management with immune-modulatory agents. Another deleterious effect of cytokines released by effector cells is immune effector cell-associated neurotoxicity syndrome. This syndrome, caused by a disruption of the blood-brain barrier as a consequence of the immune process, can result in rapid deterioration in cognitive function. This is often associated with subtle changes in handwriting, often progressing to loss of memory and concentration and reduced ability to name objects or follow commands. In some cases, the neurological state is further compromised by seizures and in rare instances with fulminant life-threatening cerebral oedema. In this review, we discuss these toxicities, as well as other CAR T-cell-related immune phenomenon, and address their clinical manifestations, grading, and management options.
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Affiliation(s)
- Uri Greenbaum
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Partow Kebriaei
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Samer A Srour
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Amanda Olson
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Qaiser Bashir
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sattva S Neelapu
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Katayoun Rezvani
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Elizabeth J Shpall
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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38
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Infection during the first year in patients treated with CD19 CAR T cells for diffuse large B cell lymphoma. Blood Cancer J 2020; 10:79. [PMID: 32759935 PMCID: PMC7405315 DOI: 10.1038/s41408-020-00346-7] [Citation(s) in RCA: 139] [Impact Index Per Article: 34.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/29/2020] [Accepted: 07/21/2020] [Indexed: 12/11/2022] Open
Abstract
CD19-targeted chimeric antigen receptor (CAR) T cell therapy is an effective treatment for diffuse large B cell lymphoma (DLBCL). In addition to cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity (ICANS), B cell aplasia and hypogammaglobulinemia are common toxicities predisposing these patients to infections. We analyzed 60 patients with DLBCL treated with FDA-approved CD19 CAR T cells and report the incidence, risk factors, and management of infections during the first year after treatment. A total of 101 infectious events were observed, including 25 mild, 51 moderate, 23 severe, 1 life-threatening, and 1 fatal infection. Bacteria were the most common causative pathogens. The cumulative incidence of overall, bacterial, severe bacterial, viral, and fungal infection at 1 year were 63.3%, 57.2%, 29.6%, 44.7%, and 4%, respectively. In multivariate analyses, the use of systemic corticosteroids for the management of CRS or ICANS was associated with an increased risk of infections and prolonged admission. Impaired performance status and history of infections within 30 days before CAR T cell therapy was a risk factor for severe bacterial infection. In conclusion, infections were common within the first 60 days after CAR T cell therapy, however, they were not associated with an increased risk of death.
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39
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Abstract
PURPOSE OF REVIEW With the introduction of new targeted therapies for hematological malignancies comes the challenges of both assessing the risk of developing an IFD while being treated with these agents, as well as managing the drug--drug interactions between azole antifungals and the agents. RECENT FINDINGS New targeted therapies for hematological malignancy include chimeric antigen receptor T cells (CAR T cells), Bi-specific T-cell Engager (BiTE) blinatumomab, and the antibody-drug conjugate (ADC) of calicheamicin inotuzumab ozogamicin for acute lymphoblasic leukemia (ALL) and lymphoma; the Bruton's tyrosine kinase (BTK) inhibitor ibrutinib and phosphatidylinositol 3-kinase (PI3Kδ) inhibitor idelalisib for lymphoma and graft-versus-host disease (GVHD); FMS-like tyrosine kinase 3 (FLT3) inhibitors, such as midostaurin, sorafenib and gilteritinib for acute myeloid leukemia (AML); and the BCL-2 inhibitor venetoclax for a range of hematological malignancies including lymphoma and leukemia. This review summarizes recommendations for IFD prophylaxis using these therapies and evidence for managing concomitant azole administration. SUMMARY Whilst some evidence exists to guide IFD prophylaxis using new targeted therapies for hematological malignancies, there is an overall lack of descriptive, robust studies specifically describing IFD risk and management. With the emergence of novel agents, clinical judgment must be used to assess the risk of developing an IFD. Care must also be taken when administering azoles with drug--drug interactions, often requiring dose adjustment of the cancer therapies.
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40
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Chastain DB, Stitt TM, Ly PT, Henao-Martínez AF, Franco-Paredes C, Osae SP. Countermeasures to Coronavirus Disease 2019: Are Immunomodulators Rational Treatment Options-A Critical Review of the Evidence. Open Forum Infect Dis 2020; 7:ofaa219. [PMID: 32691007 PMCID: PMC7313774 DOI: 10.1093/ofid/ofaa219] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 06/02/2020] [Indexed: 01/08/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 is associated with higher concentrations of proinflammatory cytokines that lead to lung damage, respiratory failure, and resultant increased mortality. Immunomodulatory therapy has the potential to inhibit cytokines and quell the immune dysregulation. Controversial data found improved oxygenation after treatment with tocilizumab, an interleukin-6 inhibitor, sparking a wave of interest and resultant clinical trials evaluating immunomodulatory therapies. The purpose of this article is to assess potential proinflammatory targets and review the safety and efficacy of immunomodulatory therapies in managing patients with acute respiratory distress syndrome associated with coronavirus disease 2019.
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Affiliation(s)
| | - Tia M Stitt
- University of Georgia College of Pharmacy, Albany, Georgia, USA
- Phoebe Putney Memorial Hospital, Albany, Georgia, USA
| | - Phong T Ly
- University of Georgia College of Pharmacy, Albany, Georgia, USA
- Phoebe Putney Memorial Hospital, Albany, Georgia, USA
| | - Andrés F Henao-Martínez
- Division of Infectious Diseases, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Carlos Franco-Paredes
- Division of Infectious Diseases, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
- Hospital Infantil de México, Federico Gómez, México City, México
| | - Sharmon P Osae
- University of Georgia College of Pharmacy, Albany, Georgia, USA
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41
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Sievers S, Watson G, Johncy S, Adkins S. Recognizing and Grading CAR T-Cell Toxicities: An Advanced Practitioner Perspective. Front Oncol 2020; 10:885. [PMID: 32670871 PMCID: PMC7327099 DOI: 10.3389/fonc.2020.00885] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 05/05/2020] [Indexed: 12/30/2022] Open
Abstract
Over the past decade, chimeric antigen receptor (CAR) T-cell therapy has significantly improved the outlook for many patients with relapsed and/or refractory B-cell malignancies. The use of CAR T-cell therapy and other therapeutic immune effector cells will likely continue to expand with the development of other targets and use in solid tumors. Although these therapies have shown significant promise in the treatment of some malignancies, they can be associated with unique toxicities including cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome which can be fatal if not identified early and treated appropriately. An understanding of how best to manage the toxicities associated with CAR T-cell therapy is continually evolving. Institutions providing CAR T-cell therapy have undergone changes in infrastructure and staffing models in order to safely care for patients receiving this novel therapy. As members of a multi-disciplinary health care team, advanced practice providers play significant roles in caring for this patient population and must be well-versed in the recognition, grading, and appropriate management of CAR T-cell therapy-related toxicities as these providers care for patients in multiple settings across the continuum of care.
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Affiliation(s)
- Savannah Sievers
- Department of Physician Assistant Programs, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Grace Watson
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Swapna Johncy
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Sherry Adkins
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
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42
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Ky B, Mann DL. COVID-19 Clinical Trials: A Primer for the Cardiovascular and Cardio-Oncology Communities. JACC CardioOncol 2020; 2:254-269. [PMID: 32313885 PMCID: PMC7164888 DOI: 10.1016/j.jaccao.2020.04.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 04/13/2020] [Indexed: 01/08/2023] Open
Abstract
The coronavirus disease-2019 (COVID-19) pandemic has resulted in a proliferation of clinical trials designed to slow the spread of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2). Many therapeutic agents that are being used to treat patients with COVID-19 are repurposed treatments for influenza, Ebola, or for malaria that were developed decades ago and are unlikely to be familiar to the cardiovascular and cardio-oncology communities. Here, we provide a foundation for cardiovascular and cardio-oncology physicians on the front line providing care to patients with COVID-19, so that they may better understand the emerging cardiovascular epidemiology and the biological rationale for the clinical trials that are ongoing for the treatment of patients with COVID-19.
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Key Words
- ACE, angiotensin-converting enzyme
- ACE2
- AT1R, angiotensin II type 1 receptor
- CI, confidence interval
- COVID-19
- COVID-19, coronavirus disease-2019
- CoV, coronavirus
- FDA, Food and Drug Administration
- IFN, interferon
- IL, interleukin
- IQR, interquartile range
- MERS, Middle East respiratory syndrome
- RAS, renin-angiotensin system
- RNA, ribonucleic acid
- SARS-CoV-2
- SARS-CoV-2, severe acute respiratory syndrome-coronavirus-2
- TMPRSS2, transmembrane protease serine 2
- clinical trials
- renin angiotensin system
- sACE2, soluble angiotensin-converting enzyme 2
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Affiliation(s)
- Bonnie Ky
- Department of Medicine, Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Douglas L. Mann
- Department of Medicine, Division of Cardiology, Center for Cardiovascular Research, Washington University School of Medicine, St. Louis, Missouri, USA
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43
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Ky B, Mann DL. COVID-19 Clinical Trials: A Primer for the Cardiovascular and Cardio-Oncology Communities. JACC Basic Transl Sci 2020; 5:501-517. [PMID: 32309679 PMCID: PMC7162643 DOI: 10.1016/j.jacbts.2020.04.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 04/13/2020] [Indexed: 01/08/2023]
Abstract
The coronavirus disease-2019 (COVID-19) pandemic has resulted in a proliferation of clinical trials designed to slow the spread of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2). Many therapeutic agents that are being used to treat patients with COVID-19 are repurposed treatments for influenza, Ebola, or for malaria that were developed decades ago and are unlikely to be familiar to the cardiovascular and cardio-oncology communities. Here, the authors provide a foundation for cardiovascular and cardio-oncology physicians on the front line providing care to patients with COVID-19, so that they may better understand the emerging cardiovascular epidemiology and the biological rationale for the clinical trials that are ongoing for the treatment of patients with COVID-19.
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Key Words
- ACE, angiotensin-converting enzyme
- ACE2
- AT1R, angiotensin II type 1 receptor
- CI, confidence interval
- COVID-19
- COVID-19, coronavirus disease-2019
- CoV, coronavirus
- FDA, Food and Drug Administration
- IFN, interferon
- IL, interleukin
- IQR, interquartile range
- MERS, Middle East respiratory syndrome
- RAS, renin-angiotensin system
- RNA, ribonucleic acid
- SARS-CoV-2
- SARS-CoV-2, severe acute respiratory syndrome-coronavirus-2
- TMPRSS2, transmembrane protease serine 2
- clinical trials
- renin angiotensin system
- sACE2, soluble angiotensin-converting enzyme 2
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Affiliation(s)
- Bonnie Ky
- Department of Medicine, Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Douglas L. Mann
- Department of Medicine, Division of Cardiology, Center for Cardiovascular Research, Washington University School of Medicine, St. Louis, Missouri
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Steineck A, Wiener L, Mack JW, Shah NN, Summers C, Rosenberg AR. Psychosocial care for children receiving chimeric antigen receptor (CAR) T-cell therapy. Pediatr Blood Cancer 2020; 67:e28249. [PMID: 32159278 PMCID: PMC8396063 DOI: 10.1002/pbc.28249] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 02/21/2020] [Accepted: 02/22/2020] [Indexed: 12/11/2022]
Abstract
Chimeric antigen receptor (CAR) T-cell therapy has transformed the treatment of relapsed/refractory B-cell acute lymphoblastic leukemia (ALL). However, this new paradigm has introduced unique considerations specific to the patients receiving CAR T-cell therapy, including prognostic uncertainty, symptom management, and psychosocial support. With increasing availability, there is a growing need for evidence-based recommendations that address the specific psychosocial needs of the children who receive CAR T-cell therapy and their families. To guide and standardize the psychosocial care offered for patients receiving CAR T-cell therapy, we propose the following recommendations for addressing psychosocial support.
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Affiliation(s)
- Angela Steineck
- Cancer and Blood Disorders Center, Seattle Children’s Hospital, Seattle, Washington, USA
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, Washington, USA
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - Lori Wiener
- Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Jennifer W. Mack
- Dana Farber Cancer Institute, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Nirali N. Shah
- Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Corinne Summers
- Cancer and Blood Disorders Center, Seattle Children’s Hospital, Seattle, Washington, USA
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Abby R. Rosenberg
- Cancer and Blood Disorders Center, Seattle Children’s Hospital, Seattle, Washington, USA
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, Washington, USA
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
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Paving the Way toward Successful Multiple Myeloma Treatment: Chimeric Antigen Receptor T-Cell Therapy. Cells 2020; 9:cells9040983. [PMID: 32316105 PMCID: PMC7226998 DOI: 10.3390/cells9040983] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 04/10/2020] [Accepted: 04/13/2020] [Indexed: 12/19/2022] Open
Abstract
Despite the significant progress of modern anticancer therapies, multiple myeloma (MM) is still incurable for the majority of patients. Following almost three decades of development, chimeric antigen receptor (CAR) T-cell therapy now has the opportunity to revolutionize the treatment landscape and meet the unmet clinical need. However, there are still several major hurdles to overcome. Here we discuss the recent advances of CAR T-cell therapy for MM with an emphasis on future directions and possible risks. Currently, CAR T-cell therapy for MM is at the first stage of clinical studies, and most studies have focused on CAR T cells targeting B cell maturation antigen (BCMA), but other antigens such as cluster of differentiation 138 (CD138, syndecan-1) are also being evaluated. Although this therapy is associated with side effects, such as cytokine release syndrome and neurotoxicity, and relapses have been observed, the benefit–risk balance and huge potential drive the ongoing clinical progress. To fulfill the promise of recent clinical trial success and maximize the potential of CAR T, future efforts should focus on the reduction of side effects, novel targeted antigens, combinatorial uses of different types of CAR T, and development of CAR T cells targeting more than one antigen.
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Novel CD19-targeted TriKE restores NK cell function and proliferative capacity in CLL. Blood Adv 2020; 3:897-907. [PMID: 30890546 DOI: 10.1182/bloodadvances.2018029371] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 02/10/2019] [Indexed: 01/23/2023] Open
Abstract
Chronic lymphocytic leukemia (CLL) is characterized by chronic clonal expansion of mature CD19-expressing B lymphocytes and global dysfunction of immune effectors, including natural killer (NK) cells. CLL remains incurable, and novel approaches to refractory CLL are needed. Our group has previously described trispecific killer engager (TriKE) molecules that redirect NK cell function against tumor cells. TriKE reagents simultaneously bind an activating receptor on NK cells, CD16, and a tumor antigen while also providing an NK cell expansion signal via an interleukin-15 moiety. Here we developed the novel CD19-targeting 161519 TriKE. We demonstrate that 161519 TriKE induced killing of a CD19-expressing Burkitt's lymphoma cell line and examined the impact on primary CLL targets using healthy donor and patient NK cells. 161519 TriKE induced potent healthy donor NK cell activation, proliferation, and directed killing. Furthermore, 161519 TriKE rescued the inflammatory function of NK cells obtained from CLL patient peripheral blood samples. Finally, we show that 161519 TriKE induced better directed killing of CLL in vitro when compared with rituximab. In conclusion, 161519 TriKE drives a potent activating and proliferative signal on NK cells, resulting in enhanced NK cell expansion and CLL target killing. Our findings indicate the potential immunotherapeutic value of 161519 TriKE in CLL.
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Reiser V. Beyond CAR T-Cell Therapy: Continued Monitoring and Management of Complications. J Adv Pract Oncol 2020; 11:159-167. [PMID: 33532115 PMCID: PMC7848815 DOI: 10.6004/jadpro.2020.11.2.4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Chimeric antigen receptor (CAR) T-cell therapy has recently emerged as a groundbreaking treatment for CD19-expressing hematologic malignancies and received rapid approval by the U.S. Food & Drug Administration. Tisagenlecleucel and axicabtagene ciloleucel are now widely available at CAR T-cell therapy centers around the United States. Many patients have achieved complete response or remission despite failing multiple previous lines of therapy, but some patients endure the severe risks of cytokine release syndrome, neurotoxicity, and other immunologic effects. As more patients receive this therapy, they will present to their primary oncologists in the community setting for continued follow-up. Oncology-trained advanced practitioners must then have a working knowledge of CAR T-cell therapy, its toxicities, and follow-up care. This review presents the CAR T-cell therapy development and infusion process with associated immediate management. In addition, patient assessment and disease monitoring, relevant diagnostics, unique grading systems to CAR T-cell therapy toxicities, indications for hospitalization, infection prophylaxis, and management of nonneutropenic and neutropenic fever are presented.
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Affiliation(s)
- Victoria Reiser
- University of Pittsburgh School of Nursing, University of Pittsburgh Medical Center Shadyside, Pittsburgh, Pennsylvania
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Gutgarts V, Jain T, Zheng J, Maloy MA, Ruiz JD, Pennisi M, Jaimes EA, Perales MA, Sathick J. Acute Kidney Injury after CAR-T Cell Therapy: Low Incidence and Rapid Recovery. Biol Blood Marrow Transplant 2020; 26:1071-1076. [PMID: 32088364 DOI: 10.1016/j.bbmt.2020.02.012] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 02/10/2020] [Accepted: 02/10/2020] [Indexed: 12/17/2022]
Abstract
Chimeric antigen receptor (CAR) T cell therapy using engineered cytotoxic T cells has shown promising responses in various hematologic malignancies. Cytokine release syndrome (CRS) and immune effector cell-associated neurologic syndrome (ICANS) are recognized toxicities of CAR-T, whereas kidney injury remains less well recognized. The objective of the present study was to identify the incidence of acute kidney injury (AKI) after CAR-T cell therapy, potential risk factors, and recovery of kidney function. We performed a retrospective review of 46 adult patients with non-Hodgkin lymphoma treated with CAR-T therapy between February 2018 and February 2019 at our institution. Serum creatinine values before CAR-T therapy through day 100 were used to assess AKI, as defined by the Kidney Disease Improving Global Outcomes (KDIGO) criteria: grade 1, 1.5- to <2-fold of baseline; grade 2, 2- to <3-fold of baseline; grade 3, ≥3-fold of baseline. CRS and ICANS were graded using the consensus criteria of the American Society of Transplantation and Cellular Therapy. The overall incidence of CRS was 78.3% (95% confidence interval [CI], 66% to 90.5%), of whom 13% (95% CI, 3.3% to 22.8%) developed grade 3-4 CRS, whereas the overall incidence of ICANS was lower at 45.7% (95% CI, 3.1% to 60.3%). The cumulative incidence of any grade AKI by day 100 was 30% (95% CI, 16.9% to 43.9%), with a grade 1 AKI incidence of 21.7% (95% CI, 9.7% to 33.8%) and a grade 2-3 AKI incidence of 8.7% (95% CI, .4% to 17%). No patients developed severe AKI necessitating renal replacement therapy. Patients with previous autologous or allogeneic stem cell transplantation, those requiring intensive care unit level care and with grade 3-4 CRS had a higher incidence of AKI. Most patients recovered, with kidney function returning to baseline within 30 days. We conclude that with early recognition and management of CAR-T complications, the incidence of AKI is low, the severity of injury is mild, and most patients recover kidney function within 30 days.
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Affiliation(s)
- Victoria Gutgarts
- Renal Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Tania Jain
- Division of Hematological Malignancies and Stem Cell Transplantation, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland; Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Junting Zheng
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Molly A Maloy
- Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Josel D Ruiz
- Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Martina Pennisi
- Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Edgar A Jaimes
- Renal Service, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Jaffer Sathick
- Renal Service, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York.
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Huang H, Wu HW, Hu YX. Current advances in chimeric antigen receptor T-cell therapy for refractory/relapsed multiple myeloma. J Zhejiang Univ Sci B 2020; 21:29-41. [PMID: 31898440 PMCID: PMC6964993 DOI: 10.1631/jzus.b1900351] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 08/30/2019] [Indexed: 01/07/2023]
Abstract
Multiple myeloma (MM), considered an incurable hematological malignancy, is characterized by its clonal evolution of malignant plasma cells. Although the application of autologous stem cell transplantation (ASCT) and the introduction of novel agents such as immunomodulatory drugs (IMiDs) and proteasome inhibitors (PIs) have doubled the median overall survival to eight years, relapsed and refractory diseases are still frequent events in the course of MM. To achieve a durable and deep remission, immunotherapy modalities have been developed for relapsed/refractory multiple myeloma (RRMM). Among these approaches, chimeric antigen receptor (CAR) T-cell therapy is the most promising star, based on the results of previous success in B-cell neoplasms. In this immunotherapy, autologous T cells are engineered to express an artificial receptor which targets a tumor-associated antigen and initiates the T-cell killing procedure. Tisagenlecleucel and Axicabtagene, targeting the CD19 antigen, are the two pacesetters of CAR T-cell products. They were approved by the US Food and Drug Administration (FDA) in 2017 for the treatment of acute lymphocytic leukemia (ALL) and diffuse large B-cell lymphoma (DLBCL). Their development enabled unparalleled efficacy in combating hematopoietic neoplasms. In this review article, we summarize six promising candidate antigens in MM that can be targeted by CARs and discuss some noteworthy studies of the safety profile of current CAR T-cell therapy.
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Affiliation(s)
- He Huang
- Bone Marrow Transplantation Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
- Institute of Hematology, Zhejiang University, Hangzhou 310058, China
| | - Heng-wei Wu
- Bone Marrow Transplantation Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
- Institute of Hematology, Zhejiang University, Hangzhou 310058, China
| | - Yong-xian Hu
- Bone Marrow Transplantation Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
- Institute of Hematology, Zhejiang University, Hangzhou 310058, China
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Whittington MD, McQueen RB, Campbell JD. Valuing Chimeric Antigen Receptor T-Cell Therapy: Current Evidence, Uncertainties, and Payment Implications. J Clin Oncol 2019; 38:359-366. [PMID: 31804859 DOI: 10.1200/jco.19.01558] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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