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Le Cacheux C, Couturier A, Sortais C, Houot R, Péré M, Gastinne T, Seguin A, Reignier J, Lascarrou JB, Tadié JM, Quelven Q, Canet E. Features and outcomes of patients admitted to the ICU for chimeric antigen receptor T cell-related toxicity: a French multicentre cohort. Ann Intensive Care 2024; 14:20. [PMID: 38291184 PMCID: PMC10828176 DOI: 10.1186/s13613-024-01247-9] [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: 10/12/2023] [Accepted: 01/09/2024] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND Chimeric antigen receptor T-cell (CAR-T) therapy is increasingly used in patients with refractory haematological malignancies but can induce severe adverse events. We aimed to describe the clinical features and outcomes of patients admitted to the intensive care unit (ICU) after CAR-T therapy. METHODS This retrospective observational cohort study included consecutive adults admitted to either of two French ICUs in 2018-2022 within 3 months after CAR-T therapy. RESULTS Among 238 patients given CAR-T therapy, 84 (35.3%) required ICU admission and were included in the study, a median of 5 [0-7] days after CAR-T infusion. Median SOFA and SAPSII scores were 3 [2-6] and 39 [30-48], respectively. Criteria for cytokine release syndrome were met in 80/84 (95.2%) patients, including 18/80 (22.5%) with grade 3-4 toxicity. Immune effector cell-associated neurotoxicity syndrome (ICANS) occurred in 46/84 (54.8%) patients, including 29/46 (63%) with grade 3-4 toxicity. Haemophagocytic lymphohistiocytosis was diagnosed in 15/84 (17.9%) patients. Tocilizumab was used in 73/84 (86.9%) patients, with a median of 2 [1-4] doses. Steroids were given to 55/84 (65.5%) patients, including 21/55 (38.2%) given high-dose pulse therapy. Overall, 23/84 (27.4%) patients had bacterial infections, 3/84 (3.6%) had fungal infections (1 invasive pulmonary aspergillosis and 2 Mucorales), and 2 (2.4%) had cytomegalovirus infection. Vasopressors were required in 23/84 (27.4%), invasive mechanical ventilation in 12/84 (14.3%), and dialysis in 4/84 (4.8%) patients. Four patients died in the ICU (including 2 after ICU readmission, i.e., overall mortality was 4.8% of patients). One year after CAR-T therapy, 41/84 (48.9%) patients were alive and in complete remission, 14/84 (16.7%) were alive and in relapse, and 29/84 (34.5%) had died. These outcomes were similar to those of patients never admitted to the ICU. CONCLUSION ICU admission is common after CAR-T therapy and is usually performed to manage specific toxicities. Our experience is encouraging, with low ICU mortality despite a high rate of grade 3-4 toxicities, and half of patients being alive and in complete remission at one year.
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Affiliation(s)
- Corentin Le Cacheux
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire Hôtel-Dieu, 30 Bd. Jean Monnet, 44093, Nantes Cedex 1, France.
| | - Audrey Couturier
- Clinical Haematology Department, Rennes University Hospital, Rennes University, INSERM U1236, Rennes, France
| | - Clara Sortais
- Haematology Department, Nantes University Hospital, Nantes University, Nantes, France
| | - Roch Houot
- Clinical Haematology Department, Rennes University Hospital, Rennes University, INSERM U1236, Rennes, France
| | - Morgane Péré
- Biostatistics Department, Nantes University Hospital, Nantes University, Nantes, France
| | - Thomas Gastinne
- Haematology Department, Nantes University Hospital, Nantes University, Nantes, France
| | - Amélie Seguin
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire Hôtel-Dieu, 30 Bd. Jean Monnet, 44093, Nantes Cedex 1, France
| | - Jean Reignier
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire Hôtel-Dieu, 30 Bd. Jean Monnet, 44093, Nantes Cedex 1, France
- ICU, Nantes University, Nantes University Hospital,-Interactions-Performance Research Unit (MIP, UR 4334), Nantes, France
| | - Jean-Baptiste Lascarrou
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire Hôtel-Dieu, 30 Bd. Jean Monnet, 44093, Nantes Cedex 1, France
| | - Jean-Marc Tadié
- ICU, Rennes University Hospital, Rennes University, Rennes, France
| | - Quentin Quelven
- ICU, Rennes University Hospital, Rennes University, Rennes, France
| | - Emmanuel Canet
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire Hôtel-Dieu, 30 Bd. Jean Monnet, 44093, Nantes Cedex 1, France
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Bhojwani D. Managing therapy-associated neurotoxicity in children with ALL. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:376-383. [PMID: 34889354 PMCID: PMC8791096 DOI: 10.1182/hematology.2021000269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Several chemotherapeutic agents and novel immunotherapies provide excellent control of systemic and central nervous system (CNS) leukemia but can be highly neurotoxic. The manifestations of subacute methotrexate neurotoxicity are diverse and require vigilant management; nonetheless, symptoms are transient in almost all patients. As methotrexate is a crucial drug to prevent CNS relapse, it is important to aim to resume it after full neurologic recovery. Most children tolerate methotrexate rechallenge without significant delays or prophylactic medications. Neurotoxicity is more frequent with newer immunotherapies such as CD19- chimeric antigen receptor T (CAR T) cells and blinatumomab. A uniform grading system for immune effector cell-associated neurotoxicity syndrome (ICANS) and algorithms for management based on severity have been developed. Low-grade ICANS usually resolves within a few days with supportive measures, but severe ICANS requires multispecialty care in the intensive care unit for life-threatening seizures and cerebral edema. Pharmacologic interventions include anticonvulsants for seizure control and glucocorticoids to reduce neuroinflammation. Anticytokine therapies targeted to the pathophysiology of ICANS are in development. By using illustrative patient cases, we discuss the management of neurotoxicity from methotrexate, CAR T cells, and blinatumomab in this review.
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Affiliation(s)
- Deepa Bhojwani
- Division of Hematology-Oncology, Children's Hospital Los Angeles, Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, CA
- Correspondence Deepa Bhojwani, MD, Division of Hematology-Oncology, Children’s Hospital Los Angeles, 4650 Sunset Blvd., MS 54, Los Angeles, CA 90027;
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Luo Y, Song G, Liang S, Li F, Liu K. Research advances in chimeric antigen receptor-modified T-cell therapy (Review). Exp Ther Med 2021; 21:484. [PMID: 33790993 PMCID: PMC8005741 DOI: 10.3892/etm.2021.9915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 01/26/2021] [Indexed: 12/15/2022] Open
Abstract
Chimeric antigen receptor (CAR)-modified T-cells are T-cells that have been genetically engineered to express CAR molecules to target specific surface antigens on tumor cells. CAR T-cell therapy, a novel cancer immunotherapy, has been attracting increasing attention, since it exhibited notable efficacy in the treatment of hematological tumors in clinical trials. However, for this type of therapy, challenges must be overcome in the treatment of solid tumors. Furthermore, certain side effects associated with CAR T-cell therapy, including cytokine release syndrome, immune effector cell-related neurotoxicity syndrome, tumor lysis syndrome and on-target off-tumor toxicity, must be taken into consideration. The present study provides a systematic review of the principle, clinical application, current challenges, possible solutions and future perspectives for CAR T-cell therapy.
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Affiliation(s)
- Yuxi Luo
- Institute of Tissue Engineering and Stem Cells, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, Sichuan 637000, P.R. China.,The First Clinic of Anhui Medical University, Hefei, Anhui 230032, P.R. China
| | - Guiqin Song
- Department of Biology, North Sichuan Medical College, Nanchong, Sichuan 637000, P.R. China
| | - Shichu Liang
- The First Clinic of Anhui Medical University, Hefei, Anhui 230032, P.R. China
| | - Feifei Li
- Department of Pathophysiology, Anhui Medical University, Hefei, Anhui 230032, P.R. China
| | - Kang Liu
- Institute of Tissue Engineering and Stem Cells, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, Sichuan 637000, P.R. China
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[Quality assessment of CAR T-cell activity: Recommendations of the Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC)]. Bull Cancer 2020; 107:S193-S201. [PMID: 33187683 DOI: 10.1016/j.bulcan.2020.10.001] [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: 05/27/2020] [Revised: 10/22/2020] [Accepted: 10/27/2020] [Indexed: 11/23/2022]
Abstract
CAR T-cells are anti-cancer immunocellular therapy drugs that involve reprogramming the patient's T-cells using a transgene encoding a chimeric antigen receptor (CAR). Although CAR T-cells are cellular therapies, the organization for manufacturing and delivering these medicinal products is in many ways different from the one for hematopoietic cell grafts or donor lymphocyte infusions. The implementation of this innovative therapy is recent and requires close coordination between clinical teams, the therapeutic apheresis unit, the cell therapy unit, the pharmaceutical laboratory, and pharmacy. Apart from the regulatory texts, which are regularly modified, and the specific requirements of each pharmaceutical laboratory, there is currently no guide to help the centers initiating their activity and there is no specific indicator to assess the quality of the CAR T-cell activity in each center. The purpose of the current harmonization workshop is to clarify the regulatory prerequisites warranted for a center to have a CAR T-cell activity and to propose recommendations for implementing quality tools, in particular indicators, and allowing their sharing.
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Yakoub-Agha I, Chabannon C, Bader P, Basak GW, Bonig H, Ciceri F, Corbacioglu S, Duarte RF, Einsele H, Hudecek M, Kersten MJ, Köhl U, Kuball J, Mielke S, Mohty M, Murray J, Nagler A, Robinson S, Saccardi R, Sanchez-Guijo F, Snowden JA, Srour M, Styczynski J, Urbano-Ispizua A, Hayden PJ, Kröger N. Management of adults and children undergoing chimeric antigen receptor T-cell therapy: best practice recommendations of the European Society for Blood and Marrow Transplantation (EBMT) and the Joint Accreditation Committee of ISCT and EBMT (JACIE). Haematologica 2020; 105:297-316. [PMID: 31753925 PMCID: PMC7012497 DOI: 10.3324/haematol.2019.229781] [Citation(s) in RCA: 202] [Impact Index Per Article: 50.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Accepted: 11/19/2019] [Indexed: 12/22/2022] Open
Abstract
Chimeric antigen receptor (CAR) T cells are a novel class of anti-cancer therapy in which autologous or allogeneic T cells are engineered to express a CAR targeting a membrane antigen. In Europe, tisagenlecleucel (Kymriah™) is approved for the treatment of refractory/relapsed acute lymphoblastic leukemia in children and young adults as well as relapsed/refractory diffuse large B-cell lymphoma, while axicabtagene ciloleucel (Yescarta™) is approved for the treatment of relapsed/refractory high-grade B-cell lymphoma and primary mediastinal B-cell lymphoma. Both agents are genetically engineered autologous T cells targeting CD19. These practical recommendations, prepared under the auspices of the European Society of Blood and Marrow Transplantation, relate to patient care and supply chain management under the following headings: patient eligibility, screening laboratory tests and imaging and work-up prior to leukapheresis, how to perform leukapheresis, bridging therapy, lymphodepleting conditioning, product receipt and thawing, infusion of CAR T cells, short-term complications including cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome, antibiotic prophylaxis, medium-term complications including cytopenias and B-cell aplasia, nursing and psychological support for patients, long-term follow-up, post-authorization safety surveillance, and regulatory issues. These recommendations are not prescriptive and are intended as guidance in the use of this novel therapeutic class.
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Affiliation(s)
| | - Christian Chabannon
- Institut Paoli-Calmettes & Module Biothérapies, INSERM CBT-1409, Centre d'Investigations Cliniques de Marseille, Marseille, France
| | - Peter Bader
- Clinic for Children and Adolescents, University Children's Hospital, Frankfurt, Germany
| | - Grzegorz W Basak
- Department of Hematology, Oncology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Halvard Bonig
- Institute for Transfusion Medicine and Immunohematology of Goethe University and German Red Cross Blood Service, Frankfurt, Germany
| | - Fabio Ciceri
- Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Selim Corbacioglu
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, University Hospital of Regensburg, Regensburg, Germany
| | - Rafael F Duarte
- Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Hermann Einsele
- Medizinische Klinikund Poliklinik II, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Michael Hudecek
- Medizinische Klinikund Poliklinik II, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Marie José Kersten
- Department of Hematology, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam and LYMMCARE, Amsterdam, the Netherlands
| | - Ulrike Köhl
- Fraunhofer Institute for Cellular Therapeutics and Immunology (IZI) and Institute of Clinical Immunology, University of Leipzig, Leipzig as well as Institute for Cellular Therapeutics, Hannover Medical School, Hannover, Germany
| | - Jürgen Kuball
- Department of Hematology and Laboratory of Translational Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Stephan Mielke
- Department of Laboratory Medicine/Department of Cell Therapy and Allogeneic Stem Cell Transplantation (CAST), Karolinska Institutet and University Hospital, Stockholm, Sweden
| | - Mohamad Mohty
- Hôpital Saint-Antoine, AP-HP, Sorbonne Université, INSERM UMRS 938, Paris, France
| | | | - Arnon Nagler
- The Chaim Sheba Medical Center, Tel-Hashomer, Affiliated with the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | | | | | - Fermin Sanchez-Guijo
- IBSAL-Hospital Universitario de Salamanca, CIC, Universidad de Salamanca, Salamanca, Spain
| | - John A Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Micha Srour
- Service des Maladies du Sang, CHU de Lille, Lille, France
| | - Jan Styczynski
- Department of Pediatric Hematology and Oncology, Collegium Medicum, Nicolaus Copernicus University Torun, Bydgoszcz, Poland
| | | | - Patrick J Hayden
- Department. of Hematology, Trinity College Dublin, St. James's Hospital, Dublin, Ireland
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg, Hamburg, Germany
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