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Gómez-Puerta JA, Ponce A, Triguero A, Fernández de Larrea C, Sanmartí R. Transient palindromic rheumatism induced by chimeric antigen receptor T-cell therapy. Rheumatology (Oxford) 2024; 63:e215-e216. [PMID: 38261627 DOI: 10.1093/rheumatology/keae046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 12/11/2023] [Accepted: 01/06/2024] [Indexed: 01/25/2024] Open
Affiliation(s)
- José A Gómez-Puerta
- Rheumatology Department, Hospital Clínic de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Andrés Ponce
- Rheumatology Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Ana Triguero
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
- Hematology Department, Amyloidosis and Myeloma Unit, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Carlos Fernández de Larrea
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
- Hematology Department, Amyloidosis and Myeloma Unit, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Raimon Sanmartí
- Rheumatology Department, Hospital Clínic de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
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2
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Bhullar PK, Motaparthi K, Zieman DP, Johnson C, Gurnani P, Sokumbi O. Toxic epidermal necrolysis-like cutaneous toxicity following chimeric antigen receptor T-cell therapy in recurrent large B-cell lymphoma. J Cutan Pathol 2024. [PMID: 38982730 DOI: 10.1111/cup.14687] [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: 02/08/2024] [Revised: 06/24/2024] [Accepted: 07/01/2024] [Indexed: 07/11/2024]
Abstract
Chimeric antigen receptor (CAR) T-cell therapy has demonstrated remarkable success in treating various B-cell malignancies, redirecting T-cell cytotoxicity toward cancer cells. Despite its efficacy, CAR-T therapy is associated with potential risks, including cytokine release syndrome (CRS) and cytopenia. We present a case of a 69-year-old man with diffuse large B-cell lymphoma treated with axicabtagene-ciloleucel CAR-T therapy, who developed a rare and severe cutaneous toxicity resembling toxic epidermal necrolysis (TEN). The patient exhibited persistent fevers, CRS, and subsequent development of a widespread erythematous macular eruption, progressing to vesiculation with bullae. Notably, allopurinol-induced TEN was considered with the patient's recent exposure to allopurinol, although the onset and minimal mucosal involvement did not align with typical presentations of allopurinol-induced cases. The cutaneous reaction, distinct from typical SJS/TEN, showed minimal mucosal involvement and coincided with the cytokine release storm, differing from allopurinol-induced TEN. Despite the absence of guidelines, the patient was managed with systemic steroids, achieving significant improvement. This case expands the spectrum of CAR-T therapy-related cutaneous toxicities, highlighting the need for early recognition of histopathology and tailored management by dermatologists. Further understanding of these reactions is crucial for optimizing the safety profile of this groundbreaking immunotherapy.
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Affiliation(s)
- Puneet K Bhullar
- Department of Dermatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Kiran Motaparthi
- Department of Dermatology, University of Florida, Gainesville, Florida, USA
| | - Daniel P Zieman
- Department of Dermatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Cassandra Johnson
- Department of Dermatology, University of Florida, Gainesville, Florida, USA
| | - Pooja Gurnani
- Department of Dermatology, University of Florida, Gainesville, Florida, USA
| | - Olayemi Sokumbi
- Department of Dermatology, Mayo Clinic, Jacksonville, Florida, USA
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3
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Storgard R, Dusza S, Shouval R, Scordo M, Markova A. Dermatologic Adverse Events Associated With Chimeric Antigen Receptor T-Cell Therapy: A Pharmacovigilance Analysis of the FDA Reporting System. Transplant Cell Ther 2024:S2666-6367(24)00486-X. [PMID: 38945480 DOI: 10.1016/j.jtct.2024.06.024] [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: 04/16/2024] [Revised: 06/06/2024] [Accepted: 06/25/2024] [Indexed: 07/02/2024]
Abstract
Chimeric antigen receptor T-cell (CAR-T) therapy, including axicabtagene ciloleucel (axi-cel) and tisagenlecleucel (tisa-cel), has demonstrated significant efficacy in treating refractory or relapsed diffuse large B-cell lymphoma and B-cell acute lymphoblastic leukemia. Though adverse events such as cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS) are well characterized, the dermatologic adverse event (DAE) profile is less thoroughly described. This study aims to provide the first comprehensive analysis of DAEs associated with axi-cel and tisa-cel using real-world data from the FDA Adverse Event Reporting System (FAERS) database. FAERS database reports citing axi-cel or tisa-cel in patients aged 16 years or older were included, excluding duplicate reports and off-label indications. Disproportionality analysis by reporting odds ratio (ROR) was utilized to detect increased reporting of drug-adverse event combinations. Of the 11,256,845 reports in the FAERS database, 5559 identified CAR-T therapy as the primary suspected drug. After exclusions, 3,666 reports were analyzed (2,168 for axi-cel and 1,498 for tisa-cel). Among these, 2.7% of axi-cel and 5.1% of tisa-cel cases reported DAEs. There was a statistically significant increased reporting of 2 DAE groups associated with CAR-T therapy: severe cutaneous eruptions (ROR 5.18, 95% CI 1.29, 20.76) and vascular cutaneous (ROR 2.91, 95% CI 1.51, 5.60). The median time to DAE onset was 3 days after CAR T-cell infusion. Death was a reported outcome in 11.9% and 13.0% of axi-cel and tisa-cel DAE cases, respectively, and in 50% and 25% of severe cutaneous eruptions and vascular cutaneous cases, respectively. This study reveals a significantly increased reporting rate of severe cutaneous eruptions and vascular cutaneous DAEs associated with CAR-T therapy, with both event groups associated with high mortality. These results emphasize the importance of monitoring dermatologic toxicities in clinical practice to ensure timely identification and management of potentially severe adverse events.
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Affiliation(s)
- Ryan Storgard
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Stephen Dusza
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Roni Shouval
- Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael Scordo
- Weill Cornell Medical College, Cornell University, New York, New York; Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alina Markova
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York.
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4
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Vafaeian A, Mahmoudi H, Daneshpazhooh M. What is novel in the clinical management of pemphigus vulgaris? Expert Rev Clin Pharmacol 2024; 17:489-503. [PMID: 38712540 DOI: 10.1080/17512433.2024.2350943] [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: 02/17/2024] [Accepted: 04/30/2024] [Indexed: 05/08/2024]
Abstract
INTRODUCTION Pemphigus, an uncommon autoimmune blistering disorder affecting the skin and mucous membranes, currently with mortality primarily attributed to adverse reactions resulting from treatment protocols. Additionally, the existing treatments exhibit a notable recurrence rate. The high incidence of relapse and the considerable adverse effects associated with treatment underscore the imperative to explore safer and more effective therapeutic approaches. Numerous potential therapeutic targets have demonstrated promising outcomes in trials or preliminary research stages. These encompass anti-CD-20 agents, anti-CD-25 agents, TNF-α inhibition, FAS Ligand Inhibition, FcRn inhibition, BAFF inhibition, Bruton's tyrosine kinase (BTK) inhibition, CAAR T Cells, JAK inhibition, mTOR inhibition, abatacept, IL-4 inhibition, IL-17 inhibition, IL-6 inhibition, polyclonal Regulatory T Cells, and autologous hematopoietic stem cell transplantation. AREAS COVERED The most significant studies regarding the impact and efficacy of the mentioned treatments on pemphigus were meticulously curated through a comprehensive search conducted on the PubMed database. Moreover, the investigations of interest cited in these studies were also integrated. EXPERT OPINION The efficacy and safety profiles of the other treatments under discussion do not exhibit the same level of robustness as anti-CD20 therapy, which is anticipated to endure as a critical element in pemphigus treatment well into the foreseeable future.
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Affiliation(s)
- Ahmad Vafaeian
- Autoimmune Bullous Diseases Research Center, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamidreza Mahmoudi
- Autoimmune Bullous Diseases Research Center, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Daneshpazhooh
- Autoimmune Bullous Diseases Research Center, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
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5
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Masucci C, Pepe S, La Rocca U, Zullino V, De Propris MS, Barberi W, Iori AP, Martelli S, Ruberto F, Martelli M, Di Rocco A. Case Report: Severe cutaneous adverse event associated with checkpoint inhibition in the setting of CAR T-cell therapy: beyond CRS. Front Oncol 2023; 13:1171031. [PMID: 37397390 PMCID: PMC10310403 DOI: 10.3389/fonc.2023.1171031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 06/05/2023] [Indexed: 07/04/2023] Open
Abstract
Anti-CD19 chimeric antigen receptor (CAR) T cell therapy actually represents the standard of care for multiple relapsed or refractory primary mediastinal B-cell lymphoma (r/r PMBCL). Checkpoint inhibitors, such as pembrolizumab, appear to be a safe and effective treatment strategy for patients who are ineligible for or resistant to autologous stem cell transplantation. Although preclinical studies suggested that checkpoint inhibitors may enhance the vitality and anti-tumor activity of CAR T cells, there are no substantial/robust clinical data about the immune-mediated toxicity of their association. We describe a case of a severe cutaneous adverse event arising immediately after Cytokine Release Syndrome (CRS) on day +6 from CAR T cells infusion in a young r/r PMBCL patient who previously received pembrolizumab. These skin lesions were interpreted as an immune mediated adverse event, considering their prompt improvement and fully recovering achieved with the addition of immunoglobulin infusion to systemic steroid therapy. This case of life-threatening cutaneous adverse event calls for further investigations about off-target immune-related adverse events deriving from the combination of CAR T cell therapy and checkpoint inhibition, whose synergic therapeutic effect is promising.
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Affiliation(s)
- Chiara Masucci
- Division of Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Sara Pepe
- Division of Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Ursula La Rocca
- Division of Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
- National Blood Centre, Italian National Institute of Health, Rome, Italy
| | - Veronica Zullino
- Department of Emergency-Acceptance, Critical Areas and Trauma, Policlinico Umberto 1 Hospital, Rome, Italy
| | - Maria Stefania De Propris
- Division of Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Walter Barberi
- Division of Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Anna Paola Iori
- Division of Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Sabina Martelli
- Department of Emergency-Acceptance, Critical Areas and Trauma, Policlinico Umberto 1 Hospital, Rome, Italy
| | - Franco Ruberto
- Department of General Surgery and Specialist, Sapienza University of Rome, Policlinico Umberto 1 Hospital, Rome, Italy
| | - Maurizio Martelli
- Division of Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Alice Di Rocco
- Division of Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
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6
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Babakoohi S, Gu SL, Ehsan H, Markova A. Dermatologic complications in transplantation and cellular therapy for acute leukemia. Best Pract Res Clin Haematol 2023; 36:101464. [PMID: 37353285 PMCID: PMC10291442 DOI: 10.1016/j.beha.2023.101464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 03/30/2023] [Indexed: 04/09/2023]
Abstract
Adoptive cellular immunotherapy, mainly hematopoietic stem cell transplant and CAR-T cell therapy have revolutionized treatment of patients with acute leukemia. Indications and inclusion criteria for these treatments have expanded in recent years. While these therapies are associated with significant improvements in disease response and overall survival, patients may experience adverse events from associated chemotherapy conditioning, engraftment, cytokine storm, supportive medications, and post-transplant maintenance targeted therapies. Supportive oncodermatology is a growing specialty to manage cutaneous toxicities resulting from the anti-cancer therapies. In this review, we summarize diagnosis and management of the common cutaneous adverse events including drug eruptions, graft-versus-host disease, neoplastic and paraneoplastic complications in patients undergoing cellular therapies.
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Affiliation(s)
- Shahab Babakoohi
- Levine Cancer Institute, Atrium Health Wake Forest Baptist, Charlotte, NC, USA.
| | - Stephanie L Gu
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY, USA
| | - Hamid Ehsan
- Levine Cancer Institute, Atrium Health Wake Forest Baptist, Charlotte, NC, USA
| | - Alina Markova
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY, USA.
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7
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Fiorillo G, Toso F, Cortese A, Piscazzi F, Bressan A, Bramanti S, Manara S, Narcisi A, Costanzo A, Valenti M. Cutaneous toxicity of CAR T-cell therapy: Case report of a bullous life-threatening reaction. J Eur Acad Dermatol Venereol 2023; 37:e729-e731. [PMID: 36662646 DOI: 10.1111/jdv.18892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 01/12/2023] [Indexed: 01/21/2023]
Affiliation(s)
- Giovanni Fiorillo
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Dermatology Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Francesco Toso
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Dermatology Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Andrea Cortese
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Dermatology Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Francesco Piscazzi
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Dermatology Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Alessandra Bressan
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Pathology Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Stefania Bramanti
- Department of Oncology and Hematology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Sofia Manara
- Pathology Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Alessandra Narcisi
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Dermatology Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Antonio Costanzo
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Dermatology Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Mario Valenti
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Dermatology Unit, IRCCS Humanitas Research Hospital, Milan, Italy
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8
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Li Y, Ming Y, Fu R, Li C, Wu Y, Jiang T, Li Z, Ni R, Li L, Su H, Liu Y. The pathogenesis, diagnosis, prevention, and treatment of CAR-T cell therapy-related adverse reactions. Front Pharmacol 2022; 13:950923. [PMID: 36313336 PMCID: PMC9616161 DOI: 10.3389/fphar.2022.950923] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 09/29/2022] [Indexed: 11/13/2022] Open
Abstract
Chimeric antigen receptor (CAR)-T cell therapy is effective in the treatment of refractory/relapsed (r/r) hematological malignancies (r/r B-cell lymphoblastic leukemia, B-cell lymphoma, and multiple myeloma). In addition, it is being explored as a treatment option for solid tumors. As of 31 March 2022, seven CAR-T therapies for hematological malignancies have been approved worldwide. Although CAR-T therapy is an effective treatment for many malignancies, it also causes adverse effects. The incidence of cytokine release syndrome (CRS), the most common adverse reaction after infusion of CAR-T cells, is as high as 93%.CRS, is the leading risk factor of immune effector cell-associated neurotoxicity syndrome (ICANS), as well as cardiovascular, hematological, hepatorenal, skin, pulmonary, and gastrointestinal toxicity. Severe adverse reactions complicated by CRS severely impede the widespread application of CAR-T therapy. The CAR-T product was initially approved in 2017; however, only limited studies have investigated the adverse reactions owing to CAR-T therapy compared to that of clinically approved drugs. Thus, we aimed to elucidate the mechanisms, risk factors, diagnostic criteria, and treatment of toxicities concurrent with CRS, thereby providing a valuable reference for the safe, effective, and widespread application of CAR-T therapy.
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9
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Cotangco K, Manrriquez EN, Salani R. Rapidly progressing vulvar soft tissue infection as a result of severe hypogammaglobulinemia following CAR T-cell therapy. Gynecol Oncol Rep 2022; 42:101016. [PMID: 35711731 PMCID: PMC9194578 DOI: 10.1016/j.gore.2022.101016] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/25/2022] [Accepted: 05/27/2022] [Indexed: 11/23/2022] Open
Abstract
•Consider immune dysfunction in rapidly progressing soft tissue infections refractory to medical or surgical management.•Vulvar ulcers may rapidly progress to severe complications in patients with immune dysfunction after CAR T-cell therapy.•As CAR T-cell therapy use expands, recognition of unique toxicities is an important consideration.
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Affiliation(s)
- Katherine Cotangco
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, David Geffen School of Medicine at UCLA, United States
| | - Erica N. Manrriquez
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, David Geffen School of Medicine at UCLA, United States
| | - Ritu Salani
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, David Geffen School of Medicine at UCLA, United States
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10
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He J, Xu N, Zhou H, Zhou Y, Wu D, Zhao R, Lin T, Xu J, Cao R, Li P, Liu Q. Case Report: Chimeric Antigen Receptor T Cells Induced Late Severe Cytokine Release Syndrome. Front Oncol 2022; 12:893928. [PMID: 35719984 PMCID: PMC9198280 DOI: 10.3389/fonc.2022.893928] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 04/27/2022] [Indexed: 12/12/2022] Open
Abstract
Background Severe cytokine release syndrome (sCRS) has emerged as an adverse complication in the early period of chimeric antigen receptor T cell (CART) therapy, while whether sCRS occurs in the late period remains unknown. Here, we reported two patients with late sCRS. Case Presentation Case 1 was a 34-year-old female with refractory Philadelphia chromosome-positive B cell acute lymphoblastic leukemia. She achieved complete remission (CR) but experienced grade III CRS and hemophagocytic lymphohistiocytosis (HLH) 41 days after CD19-targeted CART (CART19) cells and CD22-targeted CART (CART22) cells infusion. Ineffective to tocilizumab and HLH-94 protocol (dexamethasone and etoposide), she died of a cerebral hemorrhage on day 55 after CART therapy. Case 2 was a 38-year-old male with IgG kappa multiple myeloma. He received autologous BCMA-targeted CART (BCMA-CART) therapy 4 months after HLA–matched sibling (sister) donor transplantation and developed grade III CRS 163 days after CART administration, characterized by fever, hypotension, and skin lesions. Effective to methylprednisolone and tocilizumab, his clinical response persisted for over 6.0 months. Conclusion Severe CRS could occur in the late period after CART therapy as re-expansion of CART cells possessed the potential risk for late sCRS.
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Affiliation(s)
- Jinping He
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Na Xu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Hongsheng Zhou
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ya Zhou
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Di Wu
- Center for Cell Regeneration and Biotherapy, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
| | - Ruochong Zhao
- Institute of Hematology, Medical College, Jinan University, Guangzhou, China
| | - Tong Lin
- Department of Pediatric Endocrinology and Genetic Metabolism, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Ju Xu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Rui Cao
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Peng Li
- Center for Cell Regeneration and Biotherapy, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
| | - Qifa Liu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
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11
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Chhabra N, Kennedy J. A Review of Cancer Immunotherapy Toxicity II: Adoptive Cellular Therapies, Kinase Inhibitors, Monoclonal Antibodies, and Oncolytic Viruses. J Med Toxicol 2022; 18:43-55. [PMID: 33821435 PMCID: PMC8021214 DOI: 10.1007/s13181-021-00835-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 01/29/2021] [Accepted: 02/18/2021] [Indexed: 12/14/2022] Open
Abstract
Immunotherapy for cancer has undergone a rapid expansion in classes, agents, and indications. By utilizing aspects of the body's innate immune system, immunotherapy has improved life expectancy and quality of life for patients with several types of cancer. Adoptive cellular therapies, including chimeric antigen receptor T (CAR T) cell therapy, involve the genetic engineering of patient T cells to allow for targeting of neoplastic cells. Monitoring of patients during the lymphodepletion prior to therapy and following CAR T cell infusion is necessary to detect toxicity of therapy. Specific toxicities include cytokine release syndrome and neurologic toxicity, both of which may be life-threatening. Tocilizumab and/or corticosteroids should be considered for moderate to severe toxicity. Kinase inhibitor toxicity can occur as "on target" effects or "off target" effects to multiple organ systems due to shared protein epitopes. Treatments are organ-specific. Infusion reactions are common during treatment with monoclonal antibodies and treatment is largely supportive. Clinical experience with oncolytic viruses is limited, but local reactions including cellulitis as well as systemic influenza-like syndromes have been seen but are typically mild. Although clinical experience with adverse effects due to newer immunotherapy agents is growing, an up-to-date understanding of their mechanisms and potential toxicities is critical.
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Affiliation(s)
- Neeraj Chhabra
- Department of Emergency Medicine, Division of Medical Toxicology, Cook County Health, 1950 W Polk Street, 7th Floor, Chicago, IL, 60612, USA.
- Toxikon Consortium, Chicago, IL, USA.
| | - Joseph Kennedy
- Department of Emergency Medicine, Division of Medical Toxicology, Cook County Health, 1950 W Polk Street, 7th Floor, Chicago, IL, 60612, USA
- Toxikon Consortium, Chicago, IL, USA
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12
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Nusbaum KB, Dulmage B, Choi JN, Jaglowski SM, Korman AM. Cutaneous manifestations of chimeric antigen receptor T-cell therapy: An introduction for dermatologists. J Am Acad Dermatol 2021; 87:597-604. [PMID: 34293386 DOI: 10.1016/j.jaad.2021.07.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/28/2021] [Accepted: 07/13/2021] [Indexed: 11/25/2022]
Abstract
Chimeric antigen receptor T-cell therapy is an emerging immunotherapy with promising efficacy for the treatment of previously refractory or relapsed malignancies. As a personalized medicine approach, T cells are genetically engineered to express a receptor designed to bind a specific tumor antigen, leading to selective immune-mediated destruction of tumor cells. Due to the novelty of chimeric antigen receptor T-cell therapy, the safety profile continues to evolve with limited information currently available on cutaneous adverse events. Improved understanding of the spectrum of cutaneous adverse events may facilitate earlier recognition and appropriate management of these toxicities. To explore this knowledge gap, we discuss the available case reports and clinical trial results of cutaneous reactions associated with chimeric antigen receptor T-cell therapy.
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Affiliation(s)
| | - Brittany Dulmage
- Division of Dermatology, Department of Internal Medicine, The Ohio State University, Columbus, Ohio
| | - Jennifer N Choi
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Samantha M Jaglowski
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, Ohio
| | - Abraham M Korman
- Division of Dermatology, Department of Internal Medicine, The Ohio State University, Columbus, Ohio.
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13
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Hu Y, Zheng W, Qiao J, Cui Q, Zhu Y, Chang AH, Huang H. Bullous and Exanthematous Lesions Associated With Chimeric Antigen Receptor T-Cell Therapy in a Patient With Diffuse Large B-Cell Lymphoma. JAMA Dermatol 2021; 156:1026-1028. [PMID: 32432646 DOI: 10.1001/jamadermatol.2020.0636] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Yongxian Hu
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.,Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, Zhejiang, China.,Institute of Hematology, Zhejiang University, Hangzhou, Zhejiang, China
| | - Weiyan Zheng
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.,Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, Zhejiang, China.,Institute of Hematology, Zhejiang University, Hangzhou, Zhejiang, China
| | - Jianjun Qiao
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Qu Cui
- Department of Hematology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuanyuan Zhu
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.,Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, Zhejiang, China.,Institute of Hematology, Zhejiang University, Hangzhou, Zhejiang, China
| | - Alex H Chang
- Shanghai YaKe Biotechnology Ltd, Shanghai, China
| | - He Huang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.,Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, Zhejiang, China.,Institute of Hematology, Zhejiang University, Hangzhou, Zhejiang, China
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14
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Puri P, Severson KJ, Patel MH, Brumfiel CM, DiCaudo DJ, Rosenthal AC, Mangold AR. A case of B-cell lymphoblastic leukemia cutis flaring following CAR T-cell therapy in a patient with refractory acute lymphoblastic leukemia. JAAD Case Rep 2021; 8:64-66. [PMID: 33521213 PMCID: PMC7820298 DOI: 10.1016/j.jdcr.2020.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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15
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Kambhampati S, Gray L, Fakhri B, Lo M, Vu K, Arora S, Kaplan L, Ai WZ, Andreadis C. Immune-related Adverse Events Associated With Checkpoint Inhibition in the Setting of CAR T Cell Therapy: A Case Series. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2019; 20:e118-e123. [PMID: 31948859 DOI: 10.1016/j.clml.2019.12.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 12/03/2019] [Accepted: 12/14/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Swetha Kambhampati
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco Medical Center, San Francisco, CA; University of California San Francisco Helen Diller Family Comprehensive Center, San Francisco, CA.
| | - Lissa Gray
- University of California San Francisco Helen Diller Family Comprehensive Center, San Francisco, CA
| | - Bita Fakhri
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco Medical Center, San Francisco, CA; University of California San Francisco Helen Diller Family Comprehensive Center, San Francisco, CA
| | - Mimi Lo
- University of California San Francisco Helen Diller Family Comprehensive Center, San Francisco, CA; Department of Pharmacy, University of California San Francisco, San Francisco, CA
| | - Khoan Vu
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco Medical Center, San Francisco, CA; University of California San Francisco Helen Diller Family Comprehensive Center, San Francisco, CA
| | - Shagun Arora
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco Medical Center, San Francisco, CA; University of California San Francisco Helen Diller Family Comprehensive Center, San Francisco, CA
| | - Lawry Kaplan
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco Medical Center, San Francisco, CA; University of California San Francisco Helen Diller Family Comprehensive Center, San Francisco, CA
| | - Weiyun Z Ai
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco Medical Center, San Francisco, CA; University of California San Francisco Helen Diller Family Comprehensive Center, San Francisco, CA
| | - Charalambos Andreadis
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco Medical Center, San Francisco, CA; University of California San Francisco Helen Diller Family Comprehensive Center, San Francisco, CA
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16
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Yanovsky RL, McLeod M, Ahmed AR. Treatment of pemphigus vulgaris: part 2 - emerging therapies. Expert Rev Clin Immunol 2019; 15:1061-1071. [PMID: 31575295 DOI: 10.1080/1744666x.2020.1672539] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Introduction: Corticosteroids and immunosuppressive agents have been the mainstay for the treatment of pemphigus vulgaris (PV). While they have benefited patients, they have been associated with the risks of prolonged immune suppression and a high incidence of significant and catastrophic side effects. Relapses are common. Novel agents promising targeted therapies, that may provide better outcomes, are being studied. Areas covered: Recently rituximab with corticosteroids has been recommended as the first-line treatment for PV. A number of known and new therapeutic agents currently investigated are BAFF, P13K, BTK inhibitors along with the use of IVIg and CAR-T therapy. The possible role of these therapeutic targets in the pathophysiology appears to be the rationale for the treatment of this potentially fatal disease. Expert opinion: While there is significant enthusiasm for these therapies, certain concerns and consequences are being under-discussed. None of the current clinical trials in progress are specific for PV, except possibly CAR-T therapy. The major issue(s) that are unclear is whether these therapies would be successful in providing long-term clinical remissions. Will these therapies require additional agents to be effective? Will the benefits be limited in duration? The answers to many questions will determine their final place in the algorithm for the treatment of PV.
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Affiliation(s)
| | - Michael McLeod
- Department of Dermatology, Tufts Medical Center , Boston , MA , USA
| | - A Razzaque Ahmed
- Department of Dermatology, Tufts Medical Center , Boston , MA , USA.,Center for Blistering Diseases , Boston , MA , USA
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17
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Abstract
PURPOSE OF REVIEW Chimeric antigen receptor -(CAR) T-cell therapy has become a commonly used immunotherapy originally used in the treatment of B-cell leukemias but which are now applied broadly across tumor classes. Although high rates of remission are associated with CAR T-cell therapy, toxicities associated with these novel treatment regimens can be lethal if not recognized in a timely manner. RECENT FINDINGS Cytokine release syndrome and neurotoxicity are the two most common toxicities associated with CAR T-cell therapy. Cytokine release syndrome is characterized by a flu-like illness accompanied by significant hemodynamic instability; treatments include administration of tocilizumab and corticosteroids. Neurotoxicity is associated with nonpattern-specific neurological changes and can rapidly progress to a comatose state from cerebral edema and death. Other potential toxicities from CAR T-cell therapy include tumor lysis syndrome, B-cell aplasia, graft versus host disease, and dermatological eruptions. SUMMARY Clinical awareness of CAR T-cell toxicities is important because prompt treatment leads to improved survival and remission rates.
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18
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Siddiqi HF, Staser KW, Nambudiri VE. Research Techniques Made Simple: CAR T-Cell Therapy. J Invest Dermatol 2018; 138:2501-2504.e1. [PMID: 30243656 DOI: 10.1016/j.jid.2018.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 09/06/2018] [Accepted: 09/06/2018] [Indexed: 01/17/2023]
Abstract
Chimeric antigen receptor (CAR) and chimeric autoantibody receptor T-cell therapy hold great promise in the treatment of cancer and autoimmune disease, respectively. This powerful technique involves genetically engineering T lymphocytes to enable selective destruction of disease-causing cells. In the current approach, a patient's T cells are genetically engineered to express an antigen-specific antibody fragment fused to activating cytoplasmic T-cell signaling domains. After ex vivo activation and genetic modification of a patient's own T cells, the individually tailored CAR T cells are then infused into the patient for the selective destruction of cells bearing the targeted antigen. CAR T cells directed against the CD19 antigen expressed on B lymphoma cells have shown remarkable clinical efficacy in the treatment of refractory lymphoma, with two anti-CD19 CAR-T products recently gaining approval from the US Food and Drug Administration. For dermatological disease, preliminary studies have shown efficacy of CAR T cells in targeting melanoma cells and the pathogenic B cells in pemphigus vulgaris. Despite its great promise, current clinical CAR T-cell (or CAR-T) therapy carries a high risk of cytokine release syndrome, a potentially fatal systemic inflammatory response that can be manifest in cutaneous findings. For the dermatologist, the rapid clinical emergence of CAR-T therapy promises to treat and cure a variety of dermatological conditions, but it also requires an astute awareness of potential cutaneous complications in the increasing number of patients undergoing CAR-T therapy.
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Affiliation(s)
- Haziq F Siddiqi
- Brigham and Women's Hospital, Department of Dermatology, Harvard Medical School, Boston, MA
| | - Karl W Staser
- Division of Dermatology, Department of Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Vinod E Nambudiri
- Brigham and Women's Hospital, Department of Dermatology, Harvard Medical School, Boston, MA.
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19
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Affiliation(s)
- Carl H June
- From the Center for Cellular Immunotherapies, Perelman School of Medicine, Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia (C.H.J.); and the Center for Cell Engineering, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York (M.S.)
| | - Michel Sadelain
- From the Center for Cellular Immunotherapies, Perelman School of Medicine, Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia (C.H.J.); and the Center for Cell Engineering, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York (M.S.)
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