1
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Hughes AD, Teachey DT, Diorio C. Riding the storm: managing cytokine-related toxicities in CAR-T cell therapy. Semin Immunopathol 2024; 46:5. [PMID: 39012374 PMCID: PMC11252192 DOI: 10.1007/s00281-024-01013-w] [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: 12/11/2023] [Accepted: 03/18/2024] [Indexed: 07/17/2024]
Abstract
The advent of chimeric antigen receptor T cells (CAR-T) has been a paradigm shift in cancer immunotherapeutics, with remarkable outcomes reported for a growing catalog of malignancies. While CAR-T are highly effective in multiple diseases, salvaging patients who were considered incurable, they have unique toxicities which can be life-threatening. Understanding the biology and risk factors for these toxicities has led to targeted treatment approaches which can mitigate them successfully. The three toxicities of particular interest are cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), and immune effector cell-associated hemophagocytic lymphohistiocytosis (HLH)-like syndrome (IEC-HS). Each of these is characterized by cytokine storm and hyperinflammation; however, they differ mechanistically with regard to the cytokines and immune cells that drive the pathophysiology. We summarize the current state of the field of CAR-T-associated toxicities, focusing on underlying biology and how this informs toxicity management and prevention. We also highlight several emerging agents showing promise in preclinical models and the clinic. Many of these established and emerging agents do not appear to impact the anti-tumor function of CAR-T, opening the door to additional and wider CAR-T applications.
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Affiliation(s)
- Andrew D Hughes
- Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - David T Teachey
- Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Immune Dysregulation Frontier Program, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Caroline Diorio
- Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
- Immune Dysregulation Frontier Program, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
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2
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Brudno JN, Kochenderfer JN. Current understanding and management of CAR T cell-associated toxicities. Nat Rev Clin Oncol 2024; 21:501-521. [PMID: 38769449 DOI: 10.1038/s41571-024-00903-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2024] [Indexed: 05/22/2024]
Abstract
Chimeric antigen receptor (CAR) T cell therapy has revolutionized the treatment of several haematological malignancies and is being investigated in patients with various solid tumours. Characteristic CAR T cell-associated toxicities such as cytokine-release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS) are now well-recognized, and improved supportive care and management with immunosuppressive agents has made CAR T cell therapy safer and more feasible than it was when the first regulatory approvals of such treatments were granted in 2017. The increasing clinical experience with these therapies has also improved recognition of previously less well-defined toxicities, including movement disorders, immune effector cell-associated haematotoxicity (ICAHT) and immune effector cell-associated haemophagocytic lymphohistiocytosis-like syndrome (IEC-HS), as well as the substantial risk of infection in patients with persistent CAR T cell-induced B cell aplasia and hypogammaglobulinaemia. A more diverse selection of immunosuppressive and supportive-care pharmacotherapies is now being utilized for toxicity management, yet no universal algorithm for their application exists. As CAR T cell products targeting new antigens are developed, additional toxicities involving damage to non-malignant tissues expressing the target antigen are a potential hurdle. Continued prospective evaluation of toxicity management strategies and the design of less-toxic CAR T cell products are both crucial for ongoing success in this field. In this Review, we discuss the evolving understanding and clinical management of CAR T cell-associated toxicities.
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Affiliation(s)
- Jennifer N Brudno
- Surgery Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA.
| | - James N Kochenderfer
- Surgery Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
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3
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Peyrony O, Garcia-Pouton N, Chumbita M, Teijon-Lumbreras C, Aiello TF, Monzó-Gallo P, Gallardo-Pizarro A, Ortiz-Maldonado V, Martinez-Cibrian N, Delgado J, Fernandez de Larrea C, Mensa J, Puerta-Alcalde P, Soriano A, Garcia-Vidal C. Chimeric Antigen Receptor T-Cell Postinfusion Fever: Infection Profile, Clinical Parameters, and Biomarkers Trends to Assist Antibiotic Stewardship. Open Forum Infect Dis 2024; 11:ofae398. [PMID: 39070045 PMCID: PMC11273324 DOI: 10.1093/ofid/ofae398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 07/09/2024] [Indexed: 07/30/2024] Open
Abstract
Background This study aimed to describe documented infections associated with postinfusion fever after CAR T-cell therapy and to evaluate daily changes in vital signs, laboratory results, and the National Early Warning Score (NEWS) in patients with and without confirmed bacterial infections following fever onset, with the objective of assisting in antibiotic stewardship. Methods This was a retrospective, observational study including all consecutive adult patients who received CAR T-cell therapy. Documented infection in the first fever episode after infusion, and clinical and analytic trend comparison of patients with bacterial documented infections and those without documented infections, are described. Results Among 152 patients treated with CAR T-cell therapy, 87 (57.2%) had fever within 30 days of infusion, with a median time from infusion to fever of 3 (interquartile range, 2-5) days. Of these 87 patients, 82 (94.3%) received broad-spectrum antibiotics. Infection was documented in 9 (10.3%) patients and only 4 (4.6%) had bacterial infections. Clinical signs and biomarkers were similar in patients with bacterial documented infection and in those without documented infection at fever onset. Fever, tachycardia, and high C-reactive protein levels remained high during the first 3 days after CAR T-cell infusion, even when no infection was documented. Conclusions Fever is a common symptom following CAR T-cell infusion and is largely treated with broad-spectrum antibiotics. However, confirmed bacterial documented infections after the first fever post-CAR T-cell infusion are very unusual. Because clinical parameters and biomarkers are not useful for identifying infectious fever, other methods should be assessed to ensure the proper use of antibiotics.
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Affiliation(s)
- Olivier Peyrony
- Department of Infectious Diseases, Hospital Clinic of Barcelona, Barcelona, Spain
- Emergency Department, Hôpital Saint-Louis, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Nicole Garcia-Pouton
- Department of Infectious Diseases, Hospital Clinic of Barcelona, Instituto de Investigaciones Biomédicas August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Mariana Chumbita
- Department of Infectious Diseases, Hospital Clinic of Barcelona, Instituto de Investigaciones Biomédicas August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Christian Teijon-Lumbreras
- Department of Infectious Diseases, Hospital Clinic of Barcelona, Instituto de Investigaciones Biomédicas August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Tommaso Francesco Aiello
- Department of Infectious Diseases, Hospital Clinic of Barcelona, Instituto de Investigaciones Biomédicas August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Patricia Monzó-Gallo
- Department of Infectious Diseases, Hospital Clinic of Barcelona, Instituto de Investigaciones Biomédicas August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Antonio Gallardo-Pizarro
- Department of Infectious Diseases, Hospital Clinic of Barcelona, Instituto de Investigaciones Biomédicas August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Valentín Ortiz-Maldonado
- Department of Hematology, Hospital Clinic of Barcelona, Instituto de Investigaciones Biomédicas August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Núria Martinez-Cibrian
- Department of Hematology, Hospital Clinic of Barcelona, Instituto de Investigaciones Biomédicas August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Julio Delgado
- Department of Hematology, Hospital Clinic of Barcelona, Instituto de Investigaciones Biomédicas August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Carlos Fernandez de Larrea
- Department of Hematology, Hospital Clinic of Barcelona, Instituto de Investigaciones Biomédicas August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Josep Mensa
- Department of Infectious Diseases, Hospital Clinic of Barcelona, Instituto de Investigaciones Biomédicas August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Pedro Puerta-Alcalde
- Department of Infectious Diseases, Hospital Clinic of Barcelona, Instituto de Investigaciones Biomédicas August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Alex Soriano
- Department of Infectious Diseases, Hospital Clinic of Barcelona, Instituto de Investigaciones Biomédicas August Pi i Sunyer, University of Barcelona, Barcelona, Spain
- CIBERINFECT, Centro de Investigación Biomédica en Red, Instituto de Salud Carlos III, Madrid, Spain
| | - Carolina Garcia-Vidal
- Department of Infectious Diseases, Hospital Clinic of Barcelona, Instituto de Investigaciones Biomédicas August Pi i Sunyer, University of Barcelona, Barcelona, Spain
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4
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Lin MY, Nam E, Shih RM, Shafer A, Bouren A, Ayala Ceja M, Harris C, Khericha M, Vo KH, Kim M, Tseng CH, Chen YY. Self-regulating CAR-T cells modulate cytokine release syndrome in adoptive T-cell therapy. J Exp Med 2024; 221:e20221988. [PMID: 38607370 PMCID: PMC11010356 DOI: 10.1084/jem.20221988] [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: 11/18/2022] [Revised: 09/23/2023] [Accepted: 03/27/2024] [Indexed: 04/13/2024] Open
Abstract
Cytokine release syndrome (CRS) is a frequently observed side effect of chimeric antigen receptor (CAR)-T cell therapy. Here, we report self-regulating T cells that reduce CRS severity by secreting inhibitors of cytokines associated with CRS. With a humanized NSG-SGM3 mouse model, we show reduced CRS-related toxicity in mice treated with CAR-T cells secreting tocilizumab-derived single-chain variable fragment (Toci), yielding a safety profile superior to that of single-dose systemic tocilizumab administration. Unexpectedly, Toci-secreting CD19 CAR-T cells exhibit superior in vivo antitumor efficacy compared with conventional CD19 CAR-T cells. scRNA-seq analysis of immune cells recovered from tumor-bearing humanized mice revealed treatment with Toci-secreting CD19 CAR-T cells enriches for cytotoxic T cells while retaining memory T-cell phenotype, suggesting Toci secretion not only reduces toxicity but also significantly alters the overall T-cell composition. This approach of engineering T cells to self-regulate inflammatory cytokine production is a clinically compatible strategy with the potential to simultaneously enhance safety and efficacy of CAR-T cell therapy for cancer.
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Affiliation(s)
- Meng-Yin Lin
- Department of Chemical and Biomolecular Engineering, University of California, Los Angeles, Los Angeles, CA, USA
| | - Eunwoo Nam
- Department of Chemical and Biomolecular Engineering, University of California, Los Angeles, Los Angeles, CA, USA
| | - Ryan M. Shih
- Department of Molecular Biology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Amanda Shafer
- Department of Microbiology, Immunology, and Molecular Genetics, University of California, Los Angeles, Los Angeles, CA, USA
| | - Amber Bouren
- Department of Microbiology, Immunology, and Molecular Genetics, University of California, Los Angeles, Los Angeles, CA, USA
| | - Melanie Ayala Ceja
- Department of Microbiology, Immunology, and Molecular Genetics, University of California, Los Angeles, Los Angeles, CA, USA
| | - Caitlin Harris
- Department of Microbiology, Immunology, and Molecular Genetics, University of California, Los Angeles, Los Angeles, CA, USA
| | - Mobina Khericha
- Department of Microbiology, Immunology, and Molecular Genetics, University of California, Los Angeles, Los Angeles, CA, USA
| | - Kenny H. Vo
- Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Minsoo Kim
- Department of Chemical and Biomolecular Engineering, University of California, Los Angeles, Los Angeles, CA, USA
| | - Chi-Hong Tseng
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Yvonne Y. Chen
- Department of Chemical and Biomolecular Engineering, University of California, Los Angeles, Los Angeles, CA, USA
- Department of Microbiology, Immunology, and Molecular Genetics, University of California, Los Angeles, Los Angeles, CA, USA
- Parker Institute for Cancer Immunotherapy Center at UCLA, Los Angeles, CA, USA
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5
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Bellal M, Malherbe J, Damaj G, Du Cheyron D. Toxicities, intensive care management, and outcome of chimeric antigen receptor T cells in adults: an update. Crit Care 2024; 28:69. [PMID: 38444031 PMCID: PMC10916319 DOI: 10.1186/s13054-024-04851-0] [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: 12/10/2023] [Accepted: 02/27/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND Chimeric antigen receptor T cells are a promising new immunotherapy for haematological malignancies. Six CAR-T cells products are currently available for adult patients with refractory or relapsed high-grade B cell malignancies, but they are associated with severe life-threatening toxicities and side effects that may require admission to ICU. OBJECTIVE The aim of this short pragmatic review is to synthesize for intensivists the knowledge on CAR-T cell therapy with emphasis on CAR-T cell-induced toxicities and ICU management of complications according to international recommendations, outcomes and future issues.
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Affiliation(s)
- Mathieu Bellal
- Department of Medical Intensive Care, Caen University Hospital, Avenue de la côte de nacre, 14000, Caen, France.
- UNICAEN, INSERM UMRS U1237 PhIND, Normandie Univ, 14000, Caen, France.
| | - Jolan Malherbe
- Department of Medical Intensive Care, Caen University Hospital, Avenue de la côte de nacre, 14000, Caen, France
| | - Gandhi Damaj
- Hematology Institute, Caen University Hospital, 14000, Caen, France
| | - Damien Du Cheyron
- Department of Medical Intensive Care, Caen University Hospital, Avenue de la côte de nacre, 14000, Caen, France
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6
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Sales C, Anderson MA, Kuznetsova V, Rosenfeld H, Malpas CB, Roos I, Dickinson M, Harrison S, Kalincik T. Patterns of neurotoxicity among patients receiving chimeric antigen receptor T-cell therapy: A single-centre cohort study. Eur J Neurol 2024; 31:e16174. [PMID: 38085272 PMCID: PMC11235605 DOI: 10.1111/ene.16174] [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: 05/02/2023] [Revised: 09/28/2023] [Accepted: 11/23/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND AND PURPOSE Immune effector cell-associated neurotoxicity syndrome (ICANS) is an important complication of chimeric antigen receptor T-cell (CAR-T) therapy. This study aims to identify the patterns of neurotoxicity among patients with ICANS at a tertiary referral centre in Australia. METHODOLOGY This single-centre, prospective cohort study included all consecutively recruited patients who underwent CAR-T therapy for eligible haematological malignancies. All patients underwent a comprehensive neurological assessment and cognitive screening before CAR-T infusion, during the development of ICANS, and 1 month after treatment. Baseline demographic characteristics, incidence, and neurological patterns of neurotoxicity management were evaluated. RESULTS Over a 19-month period, 23% (12) of the 53 eligible patients developed neurotoxicity (10/12 [83%] being grade 1). All patients showed changes in handwriting and tremor as their initial presentation. Changes in cognition were manifested in most of the patients, with a more substantial drop noted in their Montreal Cognitive Assessment compared to immune effector cell-associated encephalopathy scores. All manifestations of neurotoxicity were short-lived and resolved within a 1-month period, with a mean duration of 8.2 days (range = 1-33). CONCLUSIONS The patterns of CAR-T-related neurotoxicity often include change in handwriting, tremor, and mild confusional state, especially early in their evolution. These may remain undetected by routine neurological surveillance. These features represent accessible clinical markers of incipient ICANS.
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Affiliation(s)
- Carmela Sales
- Neuroimmunology Centre, Department of NeurologyRoyal Melbourne HospitalMelbourneVictoriaAustralia
- Department of Clinical HaematologyPeter MacCallum Cancer Centre, Royal Melbourne HospitalMelbourneVictoriaAustralia
| | - Mary Ann Anderson
- Department of Clinical HaematologyPeter MacCallum Cancer Centre, Royal Melbourne HospitalMelbourneVictoriaAustralia
- Division of Blood Cells and Blood CancerWalter and Eliza Hall InstituteParkvilleVictoriaAustralia
| | - Valeriya Kuznetsova
- Neuroimmunology Centre, Department of NeurologyRoyal Melbourne HospitalMelbourneVictoriaAustralia
- Department of Clinical HaematologyPeter MacCallum Cancer Centre, Royal Melbourne HospitalMelbourneVictoriaAustralia
- Clinical Outcomes Research (CORe), Department of MedicineUniversity of MelbourneParkvilleVictoriaAustralia
| | - Hannah Rosenfeld
- Neuroimmunology Centre, Department of NeurologyRoyal Melbourne HospitalMelbourneVictoriaAustralia
- Department of Clinical HaematologyPeter MacCallum Cancer Centre, Royal Melbourne HospitalMelbourneVictoriaAustralia
| | - Charles B. Malpas
- Neuroimmunology Centre, Department of NeurologyRoyal Melbourne HospitalMelbourneVictoriaAustralia
- Clinical Outcomes Research (CORe), Department of MedicineUniversity of MelbourneParkvilleVictoriaAustralia
- Melbourne School of Psychological SciencesUniversity of MelbourneParkvilleVictoriaAustralia
| | - Izanne Roos
- Neuroimmunology Centre, Department of NeurologyRoyal Melbourne HospitalMelbourneVictoriaAustralia
- Clinical Outcomes Research (CORe), Department of MedicineUniversity of MelbourneParkvilleVictoriaAustralia
| | - Michael Dickinson
- Department of Clinical HaematologyPeter MacCallum Cancer Centre, Royal Melbourne HospitalMelbourneVictoriaAustralia
- Sir Peter MacCallum Department of OncologyUniversity of MelbourneParkvilleVictoriaAustralia
| | - Simon Harrison
- Department of Clinical HaematologyPeter MacCallum Cancer Centre, Royal Melbourne HospitalMelbourneVictoriaAustralia
- Sir Peter MacCallum Department of OncologyUniversity of MelbourneParkvilleVictoriaAustralia
| | - Tomas Kalincik
- Neuroimmunology Centre, Department of NeurologyRoyal Melbourne HospitalMelbourneVictoriaAustralia
- Clinical Outcomes Research (CORe), Department of MedicineUniversity of MelbourneParkvilleVictoriaAustralia
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7
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Beutel G, Liebregts T, Böll B. [With a tumor diagnosis in the intensive care unit]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2023; 64:946-954. [PMID: 37728738 DOI: 10.1007/s00108-023-01583-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/10/2023] [Indexed: 09/21/2023]
Abstract
Tumor patients nowadays show significantly improved survival rates due to advancements in modern intensive care medicine, particularly in the case of organ failure. The previous reluctance towards implementing intensive medical care measures in patients with a tumorous disease is no longer justified. For successful intensive care treatment, the timing and the mode of admission along with the specific intensive care measures and underlying organ dysfunction(s) are crucial factors for the prognosis. To ensure appropriate treatment in clinical practice and to balance between overly restrictive admission criteria and overtreatment, a triage system could be beneficial. This would consider the prognosis of the underlying malignant disease, the performance status of the patient, available treatment options and a dynamic assessment of the course of the intensive medical care. Long-term results of tumor patients show that around 80% of tumor patients who have been in the intensive care unit present physical and mental health similar to those who were never admitted. Even the majority of patients who needed ongoing cancer treatment due to tumor stage did not show any differences in treatment intensity and their remission status after 6 months. A successful intensive care medicine, the individualized definition of aims, as well as adjustment of the treatment goals, require close collaboration between hematologists, oncologists, and intensive care physicians.
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Affiliation(s)
- Gernot Beutel
- Klinik für Hämatologie, Hämostaseologie, Onkologie und Stammzelltransplantation, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
| | - Tobias Liebregts
- Klinik für Hämatologie und Stammzelltransplantation, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Deutschland
| | - Boris Böll
- Klinik I für Innere Medizin, Centrum für Integrierte Onkologie (CIO), Internistische Intensivmedizin/Hämatologie-Onkologie, Uniklinik Köln, Köln, Deutschland
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8
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Martino M, Canale FA, Porto G, Verduci C, Utano G, Policastro G, Germanò J, Alati C, Santoro L, Imbalzano L, Pitea M. Integrating CAR-T cell therapy into the management of DLBCL: what we are learning. Expert Opin Biol Ther 2023; 23:1277-1285. [PMID: 38078446 DOI: 10.1080/14712598.2023.2292634] [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: 08/23/2023] [Accepted: 12/05/2023] [Indexed: 12/29/2023]
Abstract
INTRODUCTION Chimeric Antigen Receptor ;(CAR) T cells therapies have become part of the standard of care for patients with relapsed/refractory (R/R) diffuse large B-cell lymphoma (DLBCL). The weakness of CAR-T therapies is that there are no comparative clinical trials, although many publications based on real-life data have confirmed the results obtained in pivotal studies. After several years of the commercialization of CAR-T, some points still need to be fully clarified. Healthcare professionals have questions about identifying patients who may benefit from therapy. There are aspects inherent in the accessibility of care related to improved relationships between CAR-T-delivering and referral centers. AREAS COVERED Open questions are inherent in the salvage and bridge therapy, predictive criteria for response and persistence of CAR-T after infusion. Managing toxicities remain a top priority and one of the points on which further knowledge is needed. EXPERT OPINION This review aims to describe the current landscape of CAR-T cells in DLBCL, outline their outcomes and toxicities, and explain the outstanding questions that remain to be addressed.
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Affiliation(s)
- Massimo Martino
- Stem Cell Transplantation and Cellular Therapies Unit (CTMO), Department of Hemato-Oncology and Radiotherapy Grande OspedaleMetropolitano "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Filippo Antonio Canale
- Stem Cell Transplantation and Cellular Therapies Unit (CTMO), Department of Hemato-Oncology and Radiotherapy Grande OspedaleMetropolitano "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Gaetana Porto
- Stem Cell Transplantation and Cellular Therapies Unit (CTMO), Department of Hemato-Oncology and Radiotherapy Grande OspedaleMetropolitano "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Chiara Verduci
- Stem Cell Transplantation and Cellular Therapies Unit (CTMO), Department of Hemato-Oncology and Radiotherapy Grande OspedaleMetropolitano "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Giovanna Utano
- Stem Cell Transplantation and Cellular Therapies Unit (CTMO), Department of Hemato-Oncology and Radiotherapy Grande OspedaleMetropolitano "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Giorgia Policastro
- Stem Cell Transplantation and Cellular Therapies Unit (CTMO), Department of Hemato-Oncology and Radiotherapy Grande OspedaleMetropolitano "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Jessyca Germanò
- Hematology Unit, Department of Hemato-Oncology and Radiotherapy Grande Ospedale Metropolitano "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Caterina Alati
- Hematology Unit, Department of Hemato-Oncology and Radiotherapy Grande Ospedale Metropolitano "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Ludovica Santoro
- Stem Cell Transplantation and Cellular Therapies Unit (CTMO), Department of Hemato-Oncology and Radiotherapy Grande OspedaleMetropolitano "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Lucrezia Imbalzano
- Stem Cell Transplantation and Cellular Therapies Unit (CTMO), Department of Hemato-Oncology and Radiotherapy Grande OspedaleMetropolitano "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Martina Pitea
- Stem Cell Transplantation and Cellular Therapies Unit (CTMO), Department of Hemato-Oncology and Radiotherapy Grande OspedaleMetropolitano "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
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Jain MD, Smith M, Shah NN. How I treat refractory CRS and ICANS after CAR T-cell therapy. Blood 2023; 141:2430-2442. [PMID: 36989488 PMCID: PMC10329191 DOI: 10.1182/blood.2022017414] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 03/01/2023] [Accepted: 03/01/2023] [Indexed: 03/31/2023] Open
Abstract
The clinical use of chimeric antigen receptor (CAR) T-cell therapy is growing rapidly because of the expanding indications for standard-of-care treatment and the development of new investigational products. The establishment of consensus diagnostic criteria for cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS), alongside the steady use of both tocilizumab and corticosteroids for treatment, have been essential in facilitating the widespread use. Preemptive interventions to prevent more severe toxicities have improved safety, facilitating CAR T-cell therapy in medically frail populations and in those at high risk of severe CRS/ICANS. Nonetheless, the development of persistent or progressive CRS and ICANS remains problematic because it impairs patient outcomes and is challenging to treat. In this case-based discussion, we highlight a series of cases of CRS and/or ICANS refractory to front-line interventions. We discuss our approach to managing refractory toxicities that persist or progress beyond initial tocilizumab or corticosteroid administration, delineate risk factors for severe toxicities, highlight the emerging use of anakinra, and review mitigation strategies and supportive care measures to improve outcomes in patients who develop these refractory toxicities.
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Affiliation(s)
- Michael D. Jain
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL
| | - Melody Smith
- Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Nirali N. Shah
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
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10
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Di Nardo M, MacLaren G, Schellongowski P, Azoulay E, DeZern AE, Gutierrez C, Antonelli M, Antonini MV, Beutel G, Combes A, Diaz R, Fawzy Hassan I, Fowles JA, Jeong IS, Kochanek M, Liebregts T, Lueck C, Moody K, Moore JA, Munshi L, Paden M, Pène F, Puxty K, Schmidt M, Staudacher D, Staudinger T, Stemmler J, Stephens RS, Vande Vusse L, Wohlfarth P, Lorusso R, Amodeo A, Mahadeo KM, Brodie D. Extracorporeal membrane oxygenation in adults receiving haematopoietic cell transplantation: an international expert statement. THE LANCET. RESPIRATORY MEDICINE 2023; 11:477-492. [PMID: 36924784 DOI: 10.1016/s2213-2600(22)00535-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 12/16/2022] [Accepted: 12/16/2022] [Indexed: 03/16/2023]
Abstract
Combined advances in haematopoietic cell transplantation (HCT) and intensive care management have improved the survival of patients with haematological malignancies admitted to the intensive care unit. In cases of refractory respiratory failure or refractory cardiac failure, these advances have led to a renewed interest in advanced life support therapies, such as extracorporeal membrane oxygenation (ECMO), previously considered inappropriate for these patients due to their poor prognosis. Given the scarcity of evidence-based guidelines on the use of ECMO in patients receiving HCT and the need to provide equitable and sustainable access to ECMO, the European Society of Intensive Care Medicine, the Extracorporeal Life Support Organization, and the International ECMO Network aimed to develop an expert consensus statement on the use of ECMO in adult patients receiving HCT. A steering committee with expertise in ECMO and HCT searched the literature for relevant articles on ECMO, HCT, and immune effector cell therapy, and developed opinion statements through discussions following a Quaker-based consensus approach. An international panel of experts was convened to vote on these expert opinion statements following the Research and Development/University of California, Los Angeles Appropriateness Method. The Appraisal of Guidelines for Research and Evaluation statement was followed to prepare this Position Paper. 36 statements were drafted by the steering committee, 33 of which reached strong agreement after the first voting round. The remaining three statements were discussed by all members of the steering committee and expert panel, and rephrased before an additional round of voting. At the conclusion of the process, 33 statements received strong agreement and three weak agreement. This Position Paper could help to guide intensivists and haematologists during the difficult decision-making process regarding ECMO candidacy in adult patients receiving HCT. The statements could also serve as a basis for future research focused on ECMO selection criteria and bedside management.
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Affiliation(s)
- Matteo Di Nardo
- Paediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University Health System, Singapore
| | - Peter Schellongowski
- Intensive Care Unit 13i2, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Elie Azoulay
- Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital, University of Paris, Paris, France
| | - Amy E DeZern
- Division of Hematologic Malignancies, Sidney Kimmel Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - Cristina Gutierrez
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy; Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Marta V Antonini
- Anaesthesia and Intensive Care Unit, Bufalini Hospital, AUSL della Romagna, Cesena, Italy; Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio Emilia, Modena, Italy
| | - Gernot Beutel
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Alain Combes
- Institute of Cardiometabolism and Nutrition, INSERM, UMRS_1166-ICAN, Sorbonne Université, Paris, France; Service de médecine intensive-réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France
| | | | | | - Jo-Anne Fowles
- Division of Surgery, Transplant and Anaesthetics, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - In-Seok Jeong
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
| | - Matthias Kochanek
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, Center of Integrated Oncology, Aachen-Bonn-Cologne-Dusseldorf, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - Tobias Liebregts
- Department of Hematology and Stem Cell Transplantation, West-German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Catherina Lueck
- Department of Hematology and Stem Cell Transplantation, West-German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Karen Moody
- Division of Pediatrics, Palliative and Supportive Care Section, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jessica A Moore
- Section of Integrated Ethics in Cancer Care, Department of Critical Care and Respiratory Care, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Sinai Health System/University Health Network, University of Toronto, Toronto, ON, Canada
| | - Matthew Paden
- Division of Critical Care, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Frédéric Pène
- Service de Médecine Intensive-Réanimation, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Centre & Université Paris Cité, Paris, France
| | - Kathryn Puxty
- Department of Critical Care, NHS Greater Glasgow and Clyde, Glasgow, UK; School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Matthieu Schmidt
- Institute of Cardiometabolism and Nutrition, INSERM, UMRS_1166-ICAN, Sorbonne Université, Paris, France; Service de médecine intensive-réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France
| | - Dawid Staudacher
- Interdisciplinary Medical Intensive Care (IMIT), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Thomas Staudinger
- Intensive Care Unit 13i2, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Joachim Stemmler
- Department of Hematology and Oncology, University Hospital, LMU Munich, Munich, Germany
| | - R Scott Stephens
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and Department of Oncology, Johns Hopkins University, Baltimore, MD, USA
| | - Lisa Vande Vusse
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Philipp Wohlfarth
- Stem Cell Transplantation Unit, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Antonio Amodeo
- Cardiac Surgery Unit, Department of Paediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Kris M Mahadeo
- Pediatric Transplant and Cellular Therapy, Duke University, Durham, NC, USA
| | - Daniel Brodie
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MA, USA
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11
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Fizza Haider S, Sloss R, Jhanji S, Nicholson E, Creagh-Brown B. Management of adult patients with haematological malignancies in critical care. Anaesthesia 2023. [PMID: 36658786 DOI: 10.1111/anae.15955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2022] [Indexed: 01/21/2023]
Abstract
There are a diverse range of haematological malignancies with varying clinical presentations and prognoses. Patients with haematological malignancy may require admission to critical care at the time of diagnosis or due to treatment related effects and complications. Although the prognosis for such patients requiring critical care has improved, there remain uncertainties in optimal clinical management. Identification of patients who will benefit from critical care admission is challenging and selective involvement of palliative care may help to reduce unnecessary and non-beneficial treatments. While patients with haematological malignancy can present a challenge to critical care physicians, good outcomes can be achieved. In this narrative review, we provide a brief overview of relevant haematological malignancies for the critical care physician and a summary of recent treatment advances. Subsequently, we focus on critical care management for the patient with haematological malignancy including sepsis; acute respiratory failure; prevention and treatment of tumour lysis syndrome; thrombocytopaenia; and venous thromboembolism. We also discuss immunotherapeutic-specific related complications and their management, including cytokine release syndrome and immune effector cell associated neurotoxicity syndrome associated with chimeric antigen receptor T-cell therapy. While the management of haematological malignancies is highly specialised and increasingly centralised, acutely unwell patients often present to their local hospital with complications requiring critical care expertise. The aim of this review is to provide a contemporary overview of disease and management principles for non-specialist critical care teams.
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Affiliation(s)
- S Fizza Haider
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - R Sloss
- Department of Peri-Operative Medicine (Critical Care), St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - S Jhanji
- Department of Critical Care, Royal Marsden Hospital, London, UK.,Division of Cancer Biology, Institute of Cancer Research, London, UK
| | - E Nicholson
- Department of Haematology, Royal Marsden Hospital, London, UK.,Division of Cancer Therapeutics, Institute of Cancer Research, London, UK
| | - B Creagh-Brown
- Intensive Care Unit, Royal Surrey Hospital NHS Foundation Trust, Guildford, UK.,Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
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12
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Athale J, Busch LM, O'Grady NP. Cytokine Release Syndrome and Sepsis: Analogous Clinical Syndromes with Distinct Causes and Challenges in Management. Infect Dis Clin North Am 2022; 36:735-748. [PMID: 36328633 PMCID: PMC9641544 DOI: 10.1016/j.idc.2022.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Both cytokine release syndrome (CRS) and sepsis are clinical syndromes rather than distinct diseases and share considerable overlap. It can often be challenging to distinguish between the two, but it is important given the availability of targeted treatment options. In addition, several other clinical syndromes overlap with CRS and sepsis, further making it difficult to differentiate them. This has particularly been highlighted in the recent coronavirus disease-2019 pandemic. As we start to understand the differences in the inflammatory markers and presentations in these syndromes, hopefully we will be able to enhance treatment and improve outcomes.
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Affiliation(s)
- Janhavi Athale
- Department of Critical Care Medicine, Division of Hematology and Oncology, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Lindsay M Busch
- Department of Medicine, Emory University Hospital, 550 Peachtree Street Northeast, Atlanta, GA 30308, USA
| | - Naomi P O'Grady
- Internal Medicine Services, National Institutes of Health, Room 2-2734, Bethesda, MD 20892-1662, USA.
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13
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Real time experience applying CAR T-cells for B-cell lymphoma—What we have learned so far: Acute toxicity management. MEMO - MAGAZINE OF EUROPEAN MEDICAL ONCOLOGY 2022. [DOI: 10.1007/s12254-022-00818-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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14
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Interleukin Inhibitors in Cytokine Release Syndrome and Neurotoxicity Secondary to CAR-T Therapy. Diseases 2022; 10:diseases10030041. [PMID: 35892735 PMCID: PMC9326641 DOI: 10.3390/diseases10030041] [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: 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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15
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Maron GM, Hijano DR, Epperly R, Su Y, Tang L, Hayden RT, Naik S, Karol SE, Gottschalk S, Triplett BM, Talleur AC. Infectious Complications in Pediatric, Adolescent and Young Adult Patients Undergoing CD19-CAR T Cell Therapy. Front Oncol 2022; 12:845540. [PMID: 35356197 PMCID: PMC8959860 DOI: 10.3389/fonc.2022.845540] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 02/04/2022] [Indexed: 12/20/2022] Open
Abstract
CD19-specific chimeric antigen receptor (CAR) T cell therapy has changed the treatment paradigm for pediatric, adolescent and young adult (AYA) patients with relapsed/refractory B-cell acute lymphoblastic leukemia (B-ALL). However, data on the associated infectious disease challenges in this patient population are scarce. Knowledge of infections presenting during treatment, and associated risk factors, is critical for pediatric cellular therapy and infectious disease specialists as we seek to formulate effective anti-infective prophylaxis, infection monitoring schemas, and empiric therapy regimens. In this work we describe our institutional experience in a cohort of 38 pediatric and AYA patients with CD19-positive malignancy treated with lymphodepleting chemotherapy (fludarabine/cyclophosphamide) followed by a single infusion of CD19-CAR T cells (total infusions, n=39), including tisagenlecleucel (n=19; CD19/4-1BB) or on an institutional clinical trial (n=20; CD19/4-1BB; NCT03573700). We demonstrate that infections were common in the 90 days post CAR T cells, with 19 (50%) patients experiencing a total of 35 infections. Most of these (73.7%) occurred early post infusion (day 0 to 28; infection density of 2.36 per 100 patient days-at-risk) compared to late post infusion (day 29 to 90; infection density 0.98 per 100 patient days-at-risk), respectively. Bacterial infections were more frequent early after CAR T cell therapy, with a predominance of bacterial blood stream infections. Viral infections occurred throughout the post infusion period and included primarily systemic reactivations and gastrointestinal pathogens. Fungal infections were rare. Pre-infusion disease burden, intensity of bridging chemotherapy, lymphopenia post lymphodepleting chemotherapy/CAR T cell infusion and development of CAR-associated hemophagocytic lymphohistiocytosis (carHLH) were all significantly associated with either infection density or time to first infection post CAR T cell infusion. A subset of patients (n=6) had subsequent CAR T cell reinfusion and did not appear to have increased risk of infectious complications. Our experience highlights the risk of infections after CD19-CAR T cell therapy, and the need for continued investigation of infectious outcomes as we seek to improve surveillance, prophylaxis and treatment algorithms.
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Affiliation(s)
- Gabriela M. Maron
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Diego R. Hijano
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Rebecca Epperly
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Yin Su
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Li Tang
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Randall T. Hayden
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Swati Naik
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Seth E. Karol
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Stephen Gottschalk
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Brandon M. Triplett
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Aimee C. Talleur
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children’s Research Hospital, Memphis, TN, United States
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16
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Critically Ill Patients Treated for Chimeric Antigen Receptor-Related Toxicity: A Multicenter Study. Crit Care Med 2022; 50:81-92. [PMID: 34259446 PMCID: PMC8678137 DOI: 10.1097/ccm.0000000000005149] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To report the epidemiology, treatments, and outcomes of adult patients admitted to the ICU after cytokine release syndrome or immune effector cell-associated neurotoxicity syndrome. DESIGN Retrospective cohort study. SETTING Nine centers across the U.S. part of the chimeric antigen receptor-ICU initiative. PATIENTS Adult patients treated with chimeric antigen receptor T-cell therapy who required ICU admission between November 2017 and May 2019. INTERVENTIONS Demographics, toxicities, specific interventions, and outcomes were collected. RESULTS One-hundred five patients treated with axicabtagene ciloleucel required ICU admission for cytokine release syndrome or immune effector cell-associated neurotoxicity syndrome during the study period. At the time of ICU admission, the majority of patients had grade 3-4 toxicities (66.7%); 15.2% had grade 3-4 cytokine release syndrome and 64% grade 3-4 immune effector cell-associated neurotoxicity syndrome. During ICU stay, cytokine release syndrome was observed in 77.1% patients and immune effector cell-associated neurotoxicity syndrome in 84.8% of patients; 61.9% patients experienced both toxicities. Seventy-nine percent of patients developed greater than or equal to grade 3 toxicities during ICU stay, however, need for vasopressors (18.1%), mechanical ventilation (10.5%), and dialysis (2.9%) was uncommon. Immune Effector Cell-Associated Encephalopathy score less than 3 (69.7%), seizures (20.2%), status epilepticus (5.7%), motor deficits (12.4%), and cerebral edema (7.9%) were more prevalent. ICU mortality was 8.6%, with only three deaths related to cytokine release syndrome or immune effector cell-associated neurotoxicity syndrome. Median overall survival time was 10.4 months (95% CI, 6.64-not available mo). Toxicity grade or organ support had no impact on overall survival; higher cumulative corticosteroid doses were associated to decreased overall and progression-free survival. CONCLUSIONS This is the first study to describe a multicenter cohort of patients requiring ICU admission with cytokine release syndrome or immune effector cell-associated neurotoxicity syndrome after chimeric antigen receptor T-cell therapy. Despite severe toxicities, organ support and in-hospital mortality were low in this patient population.
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17
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Shimabukuro-Vornhagen A, Böll B, Schellongowski P, Valade S, Metaxa V, Azoulay E, von Bergwelt-Baildon M. Critical care management of chimeric antigen receptor T-cell therapy recipients. CA Cancer J Clin 2022; 72:78-93. [PMID: 34613616 DOI: 10.3322/caac.21702] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 06/30/2021] [Accepted: 07/21/2021] [Indexed: 12/30/2022] Open
Abstract
Chimeric antigen receptor (CAR) T-cell therapy is a promising immunotherapeutic treatment concept that is changing the treatment approach to hematologic malignancies. The development of CAR T-cell therapy represents a prime example for the successful bench-to-bedside translation of advances in immunology and cellular therapy into clinical practice. The currently available CAR T-cell products have shown high response rates and long-term remissions in patients with relapsed/refractory acute lymphoblastic leukemia and relapsed/refractory lymphoma. However, CAR T-cell therapy can induce severe life-threatening toxicities such as cytokine release syndrome, neurotoxicity, or infection, which require rapid and aggressive medical treatment in the intensive care unit setting. In this review, the authors provide an overview of the state-of-the-art in the clinical management of severe life-threatening events in CAR T-cell recipients. Furthermore, key challenges that have to be overcome to maximize the safety of CAR T cells are discussed.
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Affiliation(s)
- Alexander Shimabukuro-Vornhagen
- Department I of Internal Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
- Intensive Care in Hematologic and Oncologic Patients (iCHOP), Cologne, Germany
| | - Boris Böll
- Department I of Internal Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
- Intensive Care in Hematologic and Oncologic Patients (iCHOP), Cologne, Germany
| | - Peter Schellongowski
- Intensive Care in Hematologic and Oncologic Patients (iCHOP), Cologne, Germany
- Department of Medicine I, Intensive Care Unit 13i2, Comprehensive Cancer Center, Center of Excellence in Medical Intensive Care (CEMIC), Medical University of Vienna, Vienna, Austria
| | - Sandrine Valade
- Medical Intensive Care Unit, St Louis Teaching Hospital, Public Assistance Hospitals of Paris, Paris, France
| | - Victoria Metaxa
- Department of Critical Care, King's College Hospital National Health Service Foundation Trust, London, United Kingdom
| | - Elie Azoulay
- Medical Intensive Care Unit, St Louis Teaching Hospital, Public Assistance Hospitals of Paris, Paris, France
| | - Michael von Bergwelt-Baildon
- Intensive Care in Hematologic and Oncologic Patients (iCHOP), Cologne, Germany
- Department of Medicine III, University Hospital, Ludwig-Maximilians University Munich, Munich, Germany
- Munich Comprehensive Cancer Center, University Hospital, Ludwig-Maximilians University Munich, Munich, Germany
- Bavarian Center for Cancer Research, Munich, Germany
- Nine-i Multinational Research Network, Service de Médecine Intensive et Réanimaton Médicale, Hôpital Saint-Louis, France
- German Cancer Consortium, Partner Site Munich, Munich, Germany
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18
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Gatto L, Franceschi E, Di Nunno V, Maggio I, Lodi R, Brandes AA. Engineered CAR-T and novel CAR-based therapies to fight the immune evasion of glioblastoma: gutta cavat lapidem. Expert Rev Anticancer Ther 2021; 21:1333-1353. [PMID: 34734551 DOI: 10.1080/14737140.2021.1997599] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The field of cancer immunotherapy has achieved great advancements through the application of genetically engineered T cells with chimeric antigen receptors (CAR), that have shown exciting success in eradicating hematologic malignancies and have proved to be safe with promising early signs of antitumoral activity in the treatment of glioblastoma (GBM). AREAS COVERED We discuss the use of CAR T cells in GBM, focusing on limitations and obstacles to advancement, mostly related to toxicities, hostile tumor microenvironment, limited CAR T cells infiltration and persistence, target antigen loss/heterogeneity and inadequate trafficking. Furthermore, we introduce the refined strategies aimed at strengthening CAR T activity and offer insights in to novel immunotherapeutic approaches, such as the potential use of CAR NK or CAR M to optimize anti-tumor effects for GBM management. EXPERT OPINION With the progressive wide use of CAR T cell therapy, significant challenges in treating solid tumors, including central nervous system (CNS) tumors, are emerging, highlighting early disease relapse and cancer cell resistance issues, owing to hostile immunosuppressive microenvironment and tumor antigen heterogeneity. In addition to CAR T cells, there is great interest in utilizing other types of CAR-based therapies, such as CAR natural killer (CAR NK) or CAR macrophages (CAR M) cells for CNS tumors.
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Affiliation(s)
- Lidia Gatto
- Medical Oncology Department, Azienda USL, Bologna, Italy
| | - Enrico Franceschi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Oncologia Medica del Sistema Nervoso, Bologna, Italy
| | | | - Ilaria Maggio
- Medical Oncology Department, Azienda USL, Bologna, Italy
| | - Raffaele Lodi
- IrcssIstituto di Scienze Neurologiche di Bologna, Bologna, Italy.,Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Alba Ariela Brandes
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Oncologia Medica del Sistema Nervoso, Bologna, Italy
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19
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Messmer AS, Que YA, Schankin C, Banz Y, Bacher U, Novak U, Pabst T. CAR T-cell therapy and critical care : A survival guide for medical emergency teams. Wien Klin Wochenschr 2021; 133:1318-1325. [PMID: 34613477 PMCID: PMC8671280 DOI: 10.1007/s00508-021-01948-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 09/01/2021] [Indexed: 12/12/2022]
Abstract
Chimeric antigen receptor (CAR) T‑cells are genetically engineered to give T‑cells the ability to attack specific cancer cells, and to improve outcome of patients with refractory/relapsed aggressive B‑cell malignancies. To date, several CAR T‑cell products are approved and additional products with similar indication or extended to other malignancies are currently being evaluated. Side effects of CAR T‑cell treatment are potentially severe or even life-threatening immune-related toxicities, specifically cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). Consequently, medical emergency teams (MET) are increasingly involved in the assessment and management of CAR T‑cell recipients. This article describes the principles of CAR T‑cell therapy and summarizes the main complications and subsequent therapeutic interventions aiming to provide a survival guide for METs with a proposed management algorithm.
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Affiliation(s)
- Anna S Messmer
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 10, 3010, Bern, Switzerland.
| | - Yok-Ai Que
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 10, 3010, Bern, Switzerland
| | - Christoph Schankin
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Yara Banz
- Institute of Pathology, University of Bern, Bern, Switzerland
| | - Ulrike Bacher
- Department of Haematology and Central Haematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Urban Novak
- Department of Medical Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Pabst
- Department of Medical Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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20
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Chimeric Antigen Receptor-Engineered Natural Killer (CAR NK) Cells in Cancer Treatment; Recent Advances and Future Prospects. Stem Cell Rev Rep 2021; 17:2081-2106. [PMID: 34472037 PMCID: PMC8410173 DOI: 10.1007/s12015-021-10246-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2021] [Indexed: 12/28/2022]
Abstract
Natural Killer (NK) cells are critical members of the innate immunity lymphocytes and have a critical role in host defense against malignant cells. Adoptive cell therapy (ACT) using chimeric antigen receptor (CAR) redirects the specificity of the immune cell against a target-specific antigen. ACT has recently created an outstanding opportunity for cancer treatment. Unlike CAR-armored T cells which hadnsome shortcomings as the CAR-receiving construct, Major histocompatibility complex (MHC)-independency, shorter lifespan, the potential to produce an off-the-shelf immune product, and potent anti-tumor properties of the NK cells has introduced NK cells as a potent alternative target for expression of CAR. Here, we aim to provide an updated overview on the current improvements in CAR NK design and immunobiology and describe the potential of CAR-modified NK cells as an alternative “off-the-shelf” carrier of CAR. We also provide lists for the sources of NK cells in the process of CAR NK cell production, different methods for transduction of the CAR genetic sequence to NK cells, the differences between CAR T and CAR NK, and CAR NK-targeted tumor antigens in current studies. Additionally, we provide data on recently published preclinical and clinical studies of CAR NK therapy and a list of finished and ongoing clinical trials. For achieving CAR NK products with higher efficacy and safety, we discuss current challenges in transduction and expansion of CAR NK cells, CAR NK therapy side effects, and challenges that limit the optimal efficacy of CAR NK cells and recommend possible solutions to enhance the persistence, function, safety, and efficacy of CAR NK cells with a special focus on solid tumors.
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21
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Shchekina AE, Galstyan GM, Gavrilina OA, Arapova NM, Bronyakina SI, Kotova ES, Troitskaya VV, Parovichnikova EN, Maschan MA, Savchenko VG. Extracorporeal cytokine removal in chimeric antigen receptor T-cell therapy associated cytokine release syndrome in patient with acute lymphoblastic leukemia. Case report. TERAPEVT ARKH 2021; 93:811-817. [DOI: 10.26442/00403660.2021.07.200931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 07/21/2021] [Indexed: 11/22/2022]
Abstract
Сytokine release syndrome is the common complication of CAR-T therapy. We report a case of patient with B-cell acute lymphoblastic leukemia developing сytokine release syndrome with shock and multiple organ failure and requiring cytokine removal and hemodiafiltration. Remission of the disease was achieved after CAR-T therapy.
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22
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Gutierrez C, McEvoy C, Reynolds D, Nates JL. Toxicity of Immunotherapeutic Agents. Crit Care Clin 2021; 37:605-624. [PMID: 34053709 DOI: 10.1016/j.ccc.2021.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
As the cancer population increases and immunotherapy becomes widely utilized, severe toxicities from these treatments will become more prevalent. In cancer patients, the most common immunotherapies that lead to critical illness are chimeric antigen receptor T cells, monoclonal antibodies, and immune checkpoint inhibitors. Awareness of their toxicities by the intensive care unit team is of extreme importance. A multidisciplinary approach for diagnosis and treatment is recommended. This article reviews the most common toxicities from immunotherapy and offers a therapy-specific and system-based approach for affected patients.
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Affiliation(s)
- Cristina Gutierrez
- Department of Critical Care, Division of Anesthesiology and Critical Care, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard. Houston, TX 77030, USA.
| | - Colleen McEvoy
- Stem Cell Transplant and Oncology Intensive Care Unit, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 4523 Clayton Ave, St Louis, MO 63110, USA
| | - Daniel Reynolds
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 4523 Clayton Ave, St Louis, MO 63110, USA
| | - Joseph L Nates
- Department of Critical Care, Division of Anesthesiology and Critical Care, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard. Houston, TX 77030, USA
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23
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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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24
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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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25
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Garcia Borrega J, Heindel K, Göreci Y, Warnke C, Onur OA, Kochanek M, Schub N, Ayuk F, Wichmann D, Böll B. [Toxicity after chimeric antigen receptor T-cell therapy : Overview and management of early and late onset side effects]. Internist (Berl) 2021; 62:611-619. [PMID: 34032877 DOI: 10.1007/s00108-021-01046-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The transfusion of chimeric antigen receptor (CAR) T‑cells has become established as a new treatment option in oncology; however, this is regularly associated with immune-mediated side effects, which can also run a severe course and necessitate a specific treatment and intensive medical treatment. MATERIAL AND METHODS A literature review was carried out on CAR T-cell therapy, toxicities and the management of side effects. RESULTS The cytokine release syndrome (CRS) and the immune effector cell-associated neurotoxicity syndrome (ICANS) regularly occur shortly after CAR T-cell treatment. The symptoms of CRS can range from mild flu-like symptoms to multiorgan failure. In addition to mild symptoms, such as disorientation and aphasia, ICANS can also lead to convulsive seizures and brain edema. The management of CRS and ICANS is based on the severity according to the grading of the American Society for Transplantation and Cellular Therapy (ASTCT). Tocilizumab and corticosteroids are recommended for CRS and corticosteroids are used for ICANS. In the further course persisting hypogammaglobulinemia and cytopenia are frequent even months after the initial treatment and promote infections even months after CAR T‑cell therapy. DISCUSSION Potentially severe complications regularly occur after CAR T-cell therapy. An interdisciplinary cooperation between intensive care physicians, hematologists, neurologists and specialists in other disciplines is of decisive importance for the optimal care of patients after CAR T‑cell therapy.
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Affiliation(s)
- Jorge Garcia Borrega
- Klinik I für Innere Medizin, Hämatologie-Onkologie und Internistische Intensivmedizin, Klinikum der Universität Köln, Kerpener Str. 62, 50937, Köln, Deutschland.,Klinik I für Innere Medizin, Centrum für Integrierte Onkologie Aachen Bonn Köln Düsseldorf (CIO ABCD), Klinikum der Universität zu Köln, Köln, Deutschland
| | - Katrin Heindel
- Klinik I für Innere Medizin, Hämatologie-Onkologie und Internistische Intensivmedizin, Klinikum der Universität Köln, Kerpener Str. 62, 50937, Köln, Deutschland.,Klinik I für Innere Medizin, Centrum für Integrierte Onkologie Aachen Bonn Köln Düsseldorf (CIO ABCD), Klinikum der Universität zu Köln, Köln, Deutschland
| | - Yasemin Göreci
- Klinik für Neurologie, Universitätsklinikum Köln, Köln, Deutschland
| | - Clemens Warnke
- Klinik für Neurologie, Universitätsklinikum Köln, Köln, Deutschland
| | - Oezguer A Onur
- Klinik für Neurologie, Universitätsklinikum Köln, Köln, Deutschland
| | - Matthias Kochanek
- Klinik I für Innere Medizin, Hämatologie-Onkologie und Internistische Intensivmedizin, Klinikum der Universität Köln, Kerpener Str. 62, 50937, Köln, Deutschland.,Klinik I für Innere Medizin, Centrum für Integrierte Onkologie Aachen Bonn Köln Düsseldorf (CIO ABCD), Klinikum der Universität zu Köln, Köln, Deutschland
| | - Natalie Schub
- Medizinische Klinik II, Universitätsklinik Schleswig-Holstein, Campus Kiel, Kiel, Deutschland
| | - Francis Ayuk
- Interdisziplinäre Klinik und Poliklinik für Stammzelltransplantation, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Dominic Wichmann
- Zentrum für Anästhesiologie und Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Boris Böll
- Klinik I für Innere Medizin, Hämatologie-Onkologie und Internistische Intensivmedizin, Klinikum der Universität Köln, Kerpener Str. 62, 50937, Köln, Deutschland. .,Klinik I für Innere Medizin, Centrum für Integrierte Onkologie Aachen Bonn Köln Düsseldorf (CIO ABCD), Klinikum der Universität zu Köln, Köln, Deutschland.
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26
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Wang LX, Yu XQ, Cao J, Lu YL, Luo M, Lei F, Tang Y, Fei XM. Bilateral anterior cerebral artery occlusion following CD19- and BCMA-targeted chimeric antigen receptor T-cell therapy for a myeloma patient. Int J Hematol 2021; 114:408-412. [PMID: 34009622 PMCID: PMC8131494 DOI: 10.1007/s12185-021-03160-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 05/06/2021] [Accepted: 05/12/2021] [Indexed: 11/30/2022]
Abstract
Chimeric antigen receptor T (CAR-T)-cell therapy is a promising treatment for relapsed/refractory multiple myeloma (RRMM). In our previous report, CD19- and BCMA-targeted CAR-T co-administration was associated with a high response rate. Although cytokine release syndrome (CRS) and neurotoxicity are frequent complications following CAR-T treatment, cerebral infarction is rarely reported as a CAR-T-related complication. We reported a 73-year-old female MM patient who received CD19- and BCMA-targeted CAR-T for refractory disease. Her disease responded to CAR-T therapy, but she developed neurological symptoms following CRS. Cranial CT and MRI demonstrated multiple cerebral infarctions and bilateral anterior cerebral artery (ACA) occlusion. We suggest that cerebral infarction other than CAR-T-related neurotoxicity is the underlying cause of abnormal neuropsychological symptoms, and diagnostic imaging tests should be actively performed to exclude ischemic cerebrovascular events.
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Affiliation(s)
- Li-Xia Wang
- Department of Hematology, Affiliated Hospital of Jiangsu University, 438 Jiefang Road, Zhenjiang, 212001, Jiangsu, China
| | - Xian-Qiu Yu
- Department of Hematology, Affiliated Hospital of Jiangsu University, 438 Jiefang Road, Zhenjiang, 212001, Jiangsu, China
| | - Jiang Cao
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Yi-Long Lu
- Department of Hematology, Affiliated Hospital of Jiangsu University, 438 Jiefang Road, Zhenjiang, 212001, Jiangsu, China
| | - Ming Luo
- Department of Hematology, Affiliated Hospital of Jiangsu University, 438 Jiefang Road, Zhenjiang, 212001, Jiangsu, China
| | - Fang Lei
- Department of Hematology, Affiliated Hospital of Jiangsu University, 438 Jiefang Road, Zhenjiang, 212001, Jiangsu, China
| | - Yu Tang
- Department of Rheumatology, Affiliated Hospital of Jiangsu University, Zhenjiang , Jiangsu, China
| | - Xiao-Ming Fei
- Department of Hematology, Affiliated Hospital of Jiangsu University, 438 Jiefang Road, Zhenjiang, 212001, Jiangsu, China.
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27
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Miao L, Zhang Z, Ren Z, Li Y. Reactions Related to CAR-T Cell Therapy. Front Immunol 2021; 12:663201. [PMID: 33995389 PMCID: PMC8113953 DOI: 10.3389/fimmu.2021.663201] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 04/13/2021] [Indexed: 12/11/2022] Open
Abstract
The application of chimeric antigen receptor (CAR) T-cell therapy as a tumor immunotherapy has received great interest in recent years. This therapeutic approach has been used to treat hematological malignancies solid tumors. However, it is associated with adverse reactions such as, cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), off-target effects, anaphylaxis, infections associated with CAR-T-cell infusion (CTI), tumor lysis syndrome (TLS), B-cell dysplasia, hemophagocytic lymphohistiocytosis (HLH)/macrophage activation syndrome (MAS) and coagulation disorders. These adverse reactions can be life-threatening, and thus they should be identified early and treated effectively. In this paper, we review the adverse reactions associated with CAR-T cells, the mechanisms driving such adverse reactions, and strategies to subvert them. This review will provide important reference data to guide clinical application of CAR-T cell therapy.
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Affiliation(s)
- Lele Miao
- Department of General Surgery, Second Hospital of Lanzhou University, Lanzhou, China.,Key Laboratory of the Digestive System Tumors of Gansu Province, Second Hospital of Lanzhou University, Lanzhou, China
| | - Zhengchao Zhang
- Department of General Surgery, Second Hospital of Lanzhou University, Lanzhou, China.,Key Laboratory of the Digestive System Tumors of Gansu Province, Second Hospital of Lanzhou University, Lanzhou, China
| | - Zhijian Ren
- Department of General Surgery, Second Hospital of Lanzhou University, Lanzhou, China.,Key Laboratory of the Digestive System Tumors of Gansu Province, Second Hospital of Lanzhou University, Lanzhou, China
| | - Yumin Li
- Department of General Surgery, Second Hospital of Lanzhou University, Lanzhou, China.,Key Laboratory of the Digestive System Tumors of Gansu Province, Second Hospital of Lanzhou University, Lanzhou, China
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28
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Brown BD, Tambaro FP, Kohorst M, Chi L, Mahadeo KM, Tewari P, Petropoulos D, Slopis JM, Sadighi Z, Khazal S. Immune Effector Cell Associated Neurotoxicity (ICANS) in Pediatric and Young Adult Patients Following Chimeric Antigen Receptor (CAR) T-Cell Therapy: Can We Optimize Early Diagnosis? Front Oncol 2021; 11:634445. [PMID: 33763368 PMCID: PMC7982581 DOI: 10.3389/fonc.2021.634445] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 02/01/2021] [Indexed: 01/03/2023] Open
Abstract
The Cornell Assessment for Pediatric Delirium (CAPD) was first proposed by the Pediatric Acute Lung Injury and Sepsis Investigators Network-Stem Cell Transplantation and Cancer Immunotherapy Subgroup and MD Anderson CARTOX joint working committees, for detection of immune effector cell associated neurotoxicity (ICANS) in pediatric patients receiving chimeric antigen receptor (CAR) T-cell therapy. It was subsequently adopted by the American Society for Transplantation and Cellular Therapy. The utility of CAPD as a screening tool for early diagnosis of ICANS has not been fully characterized. We conducted a retrospective study of pediatric and young adult patients (n=15) receiving standard-of-care CAR T-cell products. Cytokine release syndrome (CRS) and ICANS occurred in 87% and 40% of patients, respectively. ICANS was associated with significantly higher peaks of serum ferritin. A change in CAPD from a prior baseline was noted in 60% of patients with ICANS, 24–72 h prior to diagnosis of ICANS. The median change from baseline to maximum CAPD score of patients who developed ICANS versus those who did not was 13 versus 3, respectively (p=0.0004). Changes in CAPD score from baseline may be the earliest indicator of ICANS among pediatric and young adult patients which may warrant closer monitoring, with more frequent CAPD assessments.
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Affiliation(s)
- Brandon Douglas Brown
- Department of Pediatrics, Pediatric Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Children's Cancer Hospital, Houston, TX, United States
| | - Francesco Paolo Tambaro
- Department of Pediatrics, Pediatric Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Children's Cancer Hospital, Houston, TX, United States.,Bone Marrow Transplant Unit, Pediatric Oncology Department, AORN Santobono Pausilipon, Naples, Italy
| | - Mira Kohorst
- Department of Pediatrics, Pediatric Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Children's Cancer Hospital, Houston, TX, United States.,Division of Pediatric Hematology/Oncology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, United States
| | - Linda Chi
- Division of Diagnostic Imaging, Department of Neuroradiology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Kris Michael Mahadeo
- Department of Pediatrics, Pediatric Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Children's Cancer Hospital, Houston, TX, United States.,CARTOX Program, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Priti Tewari
- Department of Pediatrics, Pediatric Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Children's Cancer Hospital, Houston, TX, United States.,CARTOX Program, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Demetrios Petropoulos
- Department of Pediatrics, Pediatric Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Children's Cancer Hospital, Houston, TX, United States.,CARTOX Program, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - John M Slopis
- Department of Pediatrics, Neuro-Oncology/Neurology, Children's Cancer Hospital, The University of Texas at MD Anderson Cancer Center, Houston, TX, United States
| | - Zsila Sadighi
- Department of Pediatrics, Neuro-Oncology/Neurology, Children's Cancer Hospital, The University of Texas at MD Anderson Cancer Center, Houston, TX, United States
| | - Sajad Khazal
- Department of Pediatrics, Pediatric Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Children's Cancer Hospital, Houston, TX, United States.,CARTOX Program, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
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29
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Ragoonanan D, Khazal SJ, Abdel-Azim H, McCall D, Cuglievan B, Tambaro FP, Ahmad AH, Rowan CM, Gutierrez C, Schadler K, Li S, Di Nardo M, Chi L, Gulbis AM, Shoberu B, Mireles ME, McArthur J, Kapoor N, Miller J, Fitzgerald JC, Tewari P, Petropoulos D, Gill JB, Duncan CN, Lehmann LE, Hingorani S, Angelo JR, Swinford RD, Steiner ME, Hernandez Tejada FN, Martin PL, Auletta J, Choi SW, Bajwa R, Dailey Garnes N, Kebriaei P, Rezvani K, Wierda WG, Neelapu SS, Shpall EJ, Corbacioglu S, Mahadeo KM. Diagnosis, grading and management of toxicities from immunotherapies in children, adolescents and young adults with cancer. Nat Rev Clin Oncol 2021; 18:435-453. [PMID: 33608690 PMCID: PMC9393856 DOI: 10.1038/s41571-021-00474-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2021] [Indexed: 02/07/2023]
Abstract
Cancer immunotherapies are associated with remarkable therapeutic response rates but also with unique and severe toxicities, which potentially result in rapid deterioration in health. The number of clinical applications for novel immune effector-cell therapies, including chimeric antigen receptor (CAR)-expressing cells, and other immunotherapies, such as immune-checkpoint inhibitors, is increasing. In this Consensus Statement, members of the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network Hematopoietic Cell Transplantation-Cancer Immunotherapy (HCT-CI) Subgroup, Paediatric Diseases Working Party (PDWP) of the European Society of Blood and Marrow Transplantation (EBMT), Supportive Care Committee of the Pediatric Transplantation and Cellular Therapy Consortium (PTCTC) and MD Anderson Cancer Center CAR T Cell Therapy-Associated Toxicity (CARTOX) Program collaborated to provide updated comprehensive recommendations for the care of children, adolescents and young adults receiving cancer immunotherapies. With these recommendations, we address emerging toxicity mitigation strategies, we advocate for the characterization of baseline organ function according to age and discipline-specific criteria, we recommend early critical care assessment when indicated, with consideration of reversibility of underlying pathology (instead of organ failure scores) to guide critical care interventions, and we call for researchers, regulatory agencies and sponsors to support and facilitate early inclusion of young patients with cancer in well-designed clinical trials.
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Affiliation(s)
- Dristhi Ragoonanan
- Department of Pediatrics, CARTOX Program, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Sajad J Khazal
- Department of Pediatrics, CARTOX Program, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hisham Abdel-Azim
- Department of Pediatrics, Blood and Marrow Transplantation Program, Keck School of Medicine, University of Southern California, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - David McCall
- Department of Pediatrics, CARTOX Program, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Branko Cuglievan
- Department of Pediatrics, CARTOX Program, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Ali Haider Ahmad
- Department of Pediatrics, CARTOX Program, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Courtney M Rowan
- Department of Pediatrics, Division of Critical Care, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN, USA
| | - Cristina Gutierrez
- Department of Critical Care, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Keri Schadler
- Department of Pediatrics Research, Center for Energy Balance in Cancer Prevention and Survivorship, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shulin Li
- Department of Pediatrics Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matteo Di Nardo
- Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Linda Chi
- Division of Diagnostic Imaging, Neuroradiology Department, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alison M Gulbis
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Basirat Shoberu
- Department of Pediatrics, CARTOX Program, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maria E Mireles
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jennifer McArthur
- Department of Pediatrics, Division of Critical Care, St Jude Children's Research Hospital, Memphis, TN, USA.,Department of Pediatrics, Division of Critical Care, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Neena Kapoor
- Department of Pediatrics, Blood and Marrow Transplantation Program, Keck School of Medicine, University of Southern California, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Jeffrey Miller
- Department of Pediatrics, CARTOX Program, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Julie C Fitzgerald
- Department of Anesthesia and Critical Care, University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Priti Tewari
- Department of Pediatrics, CARTOX Program, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Demetrios Petropoulos
- Department of Pediatrics, CARTOX Program, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jonathan B Gill
- Department of Pediatrics, CARTOX Program, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christine N Duncan
- Pediatric Hematology-Oncology, Dana-Farber Cancer Institute, Harvard University, Boston, MA, USA
| | - Leslie E Lehmann
- Pediatric Hematology-Oncology, Dana-Farber Cancer Institute, Harvard University, Boston, MA, USA
| | - Sangeeta Hingorani
- Department of Pediatrics, University of Washington School of Medicine, Division of Nephrology, Seattle Childrens and the Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Joseph R Angelo
- Renal Section, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Rita D Swinford
- Department of Pediatrics, Division of Pediatric Nephrology, McGovern Medical School, The University of Texas Health Science Center, Houston, TX, USA
| | - Marie E Steiner
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Fiorela N Hernandez Tejada
- Department of Pediatrics, CARTOX Program, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paul L Martin
- Department of Pediatrics, Division of Transplant and Cellular Therapy, Duke Children's Hospital, Duke University, Durham, NC, USA
| | - Jeffery Auletta
- Division of Hematology, Oncology, Bone Marrow Transplant and Infectious Diseases, Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA
| | - Sung Won Choi
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Rajinder Bajwa
- Division of Pediatric Hematology/Oncology/Blood and Marrow Transplantation, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Natalie Dailey Garnes
- Department of Infectious Disease, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Partow Kebriaei
- Department of Stem Cell Transplantation and Cellular Therapy, CARTOX Program, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Katayoun Rezvani
- Department of Stem Cell Transplantation and Cellular Therapy, CARTOX Program, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William G Wierda
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sattva S Neelapu
- Department of Lymphoma and Myeloma, CARTOX Program, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elizabeth J Shpall
- Department of Stem Cell Transplantation and Cellular Therapy, CARTOX Program, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Selim Corbacioglu
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, University of Regensburg, Regensburg, Germany
| | - Kris M Mahadeo
- Department of Pediatrics, CARTOX Program, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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30
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Xu X, Huang S, Xiao X, Sun Q, Liang X, Chen S, Zhao Z, Huo Z, Tu S, Li Y. Challenges and Clinical Strategies of CAR T-Cell Therapy for Acute Lymphoblastic Leukemia: Overview and Developments. Front Immunol 2021; 11:569117. [PMID: 33643279 PMCID: PMC7902522 DOI: 10.3389/fimmu.2020.569117] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 12/22/2020] [Indexed: 12/12/2022] Open
Abstract
Chimeric antigen receptor (CAR) T-cell therapy exhibits desirable and robust efficacy in patients with acute lymphoblastic leukemia (ALL). Stimulated by the revolutionized progress in the use of FDA-approved CD19 CAR T cells, novel agents with CAR designs and targets are being produced in pursuit of superior performance. However, on the path from bench to bedside, new challenges emerge. Accessibility is considered the initial barrier to the transformation of this patient-specific product into a commercially available product. To ensure infusion safety, profound comprehension of adverse events and proactive intervention are required. Additionally, resistance and relapse are the most critical and intractable issues in CAR T-cell therapy for ALL, thus precluding its further development. Understanding the limitations through up-to-date insights and characterizing multiple strategies will be critical to leverage CAR T-cell therapy flexibly for use in clinical situations. Herein, we provide an overview of the application of CAR T-cell therapy in ALL, emphasizing the main challenges and potential clinical strategies in an effort to promote a standardized set of treatment paradigms for ALL.
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Affiliation(s)
- Xinjie Xu
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, China.,The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China.,State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shengkang Huang
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, China.,The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Xinyi Xiao
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, China.,The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Qihang Sun
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, China.,The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Xiaoqian Liang
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, China.,The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Sifei Chen
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, China.,The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Zijing Zhao
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, China.,The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Zhaochang Huo
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, China.,The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Sanfang Tu
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Yuhua Li
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
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31
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Garcia Borrega J, Heindel K, Kochanek M, Warnke C, Stemmler J, von Bergwelt-Baildon M, Liebregts T, Böll B. [The critically ill CAR T-cell patient : Relevant toxicities, their management and challenges in critical care]. Med Klin Intensivmed Notfmed 2021; 116:121-128. [PMID: 33564900 DOI: 10.1007/s00063-021-00780-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/07/2021] [Accepted: 01/07/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND CAR‑T cell therapy has been implemented as clinical routine treatment option during the last decade. Despite beneficial outcomes in many patients severe side effects and toxicities are seen regularly that can compromise the treatment success. METHODS Literature review: CAR T‑cell therapy, toxicities and their management RESULTS: The cytokine release syndrome (CRS) and the immune effector cell-associated neurotoxicity syndrome (ICANS) are seen regularly after CAR T‑cell treatment. CRS symptoms can range from mild flu-like symptoms to severe organ dysfunction requiring vasopressor therapy, mechanical ventilation and other intensive care support. ICANS symptoms usually develop later and can range from disorientation and aphasia to potentially life-threatening brain edema. IL‑6 is a key factor in the pathophysiology of CRS. The pathophysiology of ICANS is not fully understood. The ASTCT consensus grading is recommended to stratify patients for different management options. An interdisciplinary team including hematologist, intensivist, neurologists and other specialties is needed to optimize the treatment. DISCUSSION Severe and potentially life-threatening toxicities occur regularly after CAR T‑cell therapy. Treatment strategies for CRS and ICANS still need to be evaluated prospectively. Due to the increasing number of patients treated with CAR T‑cells the number of patients requiring temporary intensive care management due to CRS and ICANS is expected to increase during the next years.
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Affiliation(s)
- J Garcia Borrega
- Klinik I für Innere Medizin, Schwerpunkt Internistische Intensivmedizin, Klinikum der Universität Köln, Kerpener Str. 62, 50937, Köln, Deutschland.,Klinik I für Innere Medizin, Klinikum der Universität zu Köln, Centrum für Integrierte Onkologie Aachen Bonn Köln Düsseldorf (CIO ABCD), Köln, Deutschland
| | - K Heindel
- Klinik I für Innere Medizin, Schwerpunkt Internistische Intensivmedizin, Klinikum der Universität Köln, Kerpener Str. 62, 50937, Köln, Deutschland.,Klinik I für Innere Medizin, Klinikum der Universität zu Köln, Centrum für Integrierte Onkologie Aachen Bonn Köln Düsseldorf (CIO ABCD), Köln, Deutschland
| | - M Kochanek
- Klinik I für Innere Medizin, Schwerpunkt Internistische Intensivmedizin, Klinikum der Universität Köln, Kerpener Str. 62, 50937, Köln, Deutschland.,Klinik I für Innere Medizin, Klinikum der Universität zu Köln, Centrum für Integrierte Onkologie Aachen Bonn Köln Düsseldorf (CIO ABCD), Köln, Deutschland
| | - C Warnke
- Klinik für Neurologie, Klinikum der Universität Köln, Köln, Deutschland
| | - J Stemmler
- Medizinische Klinik und Poliklinik III, Klinikum der Ludwig-Maximilians-Universität München, München, Deutschland
| | - M von Bergwelt-Baildon
- Medizinische Klinik und Poliklinik III, Klinikum der Ludwig-Maximilians-Universität München, München, Deutschland
| | - T Liebregts
- Klinik für Innere Medizin V, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - B Böll
- Klinik I für Innere Medizin, Schwerpunkt Internistische Intensivmedizin, Klinikum der Universität Köln, Kerpener Str. 62, 50937, Köln, Deutschland. .,Klinik I für Innere Medizin, Klinikum der Universität zu Köln, Centrum für Integrierte Onkologie Aachen Bonn Köln Düsseldorf (CIO ABCD), Köln, Deutschland.
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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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33
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Lin CY, Gobius I, Souza-Fonseca-Guimaraes F. Natural killer cell engineering – a new hope for cancer immunotherapy. Semin Hematol 2020; 57:194-200. [DOI: 10.1053/j.seminhematol.2020.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 09/20/2020] [Accepted: 10/14/2020] [Indexed: 01/04/2023]
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34
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Clinical data, limitations and perspectives on chimeric antigen receptor T-cell therapy in multiple myeloma. Curr Opin Oncol 2020; 32:418-426. [DOI: 10.1097/cco.0000000000000667] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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