1
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Geva R, Vieito M, Ramon J, Perets R, Pedregal M, Corral E, Doger B, Calvo E, Bardina J, Garralda E, Brown RJ, Greger JG, Wu S, Steinbach D, Yao TWS, Cao Y, Lauring J, Chaudhary R, Patel J, Patel B, Moreno V. Safety and clinical activity of JNJ-78306358, a human leukocyte antigen-G (HLA-G) x CD3 bispecific antibody, for the treatment of advanced stage solid tumors. Cancer Immunol Immunother 2024; 73:205. [PMID: 39105878 PMCID: PMC11303617 DOI: 10.1007/s00262-024-03790-7] [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: 03/22/2024] [Accepted: 07/22/2024] [Indexed: 08/07/2024]
Abstract
BACKGROUND JNJ-78306358 is a bispecific antibody that redirects T cells to kill human leukocyte antigen-G (HLA-G)-expressing tumor cells. This dose escalation study evaluated the safety, pharmacokinetics, pharmacodynamics, and preliminary antitumor activity of JNJ-78306358 in patients with advanced solid tumors. METHODS Adult patients with metastatic/unresectable solid tumors with high prevalence of HLA-G expression were enrolled. Dose escalation was initiated with once-weekly subcutaneous administration with step-up dosing to mitigate cytokine release syndrome (CRS). RESULTS Overall, 39 heavily pretreated patients (colorectal cancer: n = 23, ovarian cancer: n = 10, and renal cell carcinoma: n = 6) were dosed in 7 cohorts. Most patients (94.9%) experienced ≥ 1 treatment-emergent adverse events (TEAEs); 87.2% had ≥ 1 related TEAEs. About half of the patients (48.7%) experienced CRS, which were grade 1/2. Nine patients (23.1%) received tocilizumab for CRS. No grade 3 CRS was observed. Dose-limiting toxicities (DLTs) of increased transaminases, pneumonitis and recurrent CRS requiring a dose reduction were reported in 4 patients, coinciding with CRS. No treatment-related deaths reported. No objective responses were noted, but 2 patients had stable disease > 40 weeks. JNJ-78306358 stimulated peripheral T cell activation and cytokine release. Anti-drug antibodies were observed in 45% of evaluable patients with impact on exposure. Approximately half of archival tumor samples (48%) had expression of HLA-G by immunohistochemistry. CONCLUSION JNJ-78306358 showed pharmacodynamic effects with induction of cytokines and T cell activation. JNJ-78306358 was associated with CRS-related toxicities including increased transaminases and pneumonitis which limited its dose escalation to potentially efficacious levels. Trial registration number ClinicalTrials.gov (No. NCT04991740).
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Affiliation(s)
- Ravit Geva
- Sourasky Medical Center, Tel-Aviv university, Tel-Aviv, Israel.
| | - Maria Vieito
- Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Jorge Ramon
- START Madrid-CIOCC, Centro Integral Oncológico Clara Campal, Madrid, Spain
| | - Ruth Perets
- Rambam Medical Center, and Technion-Israel Institute of Technology, Haifa, Israel
| | - Manuel Pedregal
- START Madrid-FJD, Hospital Fundacion Jimenez Diaz, Madrid, Spain
| | - Elena Corral
- START Madrid-CIOCC, Centro Integral Oncológico Clara Campal, Madrid, Spain
| | - Bernard Doger
- START Madrid-FJD, Hospital Fundacion Jimenez Diaz, Madrid, Spain
| | - Emiliano Calvo
- START Madrid-CIOCC, Centro Integral Oncológico Clara Campal, Madrid, Spain
| | - Jorge Bardina
- Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Elena Garralda
- Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | | | | | - Shujian Wu
- Janssen Research and Development, Horsham, PA, USA
| | | | | | - Yu Cao
- Janssen Research and Development, Raritan, NJ, USA
| | - Josh Lauring
- Janssen Research and Development, Spring House, PA, USA
| | | | - Jaymala Patel
- Janssen Research and Development, Spring House, PA, USA
| | - Bharvin Patel
- Janssen Research and Development, Spring House, PA, USA
| | - Victor Moreno
- START Madrid-FJD, Hospital Fundacion Jimenez Diaz, Madrid, Spain
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2
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Lin Y, Qiu L, Usmani S, Joo CW, Costa L, Derman B, Du J, Einsele H, Fernandez de Larrea C, Hajek R, Ho PJ, Kastritis E, Martinez-Lopez J, Mateos MV, Mikhael J, Moreau P, Nagarajan C, Nooka A, O'Dwyer M, Schjesvold F, Sidana S, van de Donk NW, Weisel K, Zweegman S, Raje N, Otero PR, Anderson LD, Kumar S, Martin T. Consensus guidelines and recommendations for the management and response assessment of chimeric antigen receptor T-cell therapy in clinical practice for relapsed and refractory multiple myeloma: a report from the International Myeloma Working Group Immunotherapy Committee. Lancet Oncol 2024; 25:e374-e387. [PMID: 38821074 DOI: 10.1016/s1470-2045(24)00094-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/07/2024] [Accepted: 02/12/2024] [Indexed: 06/02/2024]
Abstract
Chimeric antigen receptor (CAR) T-cell therapy has shown promise in patients with late-line refractory multiple myeloma, with response rates ranging from 73 to 98%. To date, three products have been approved: Idecabtagene vicleucel (ide-cel) and ciltacabtagene autoleucel (cilta-cel), which are approved by the US Food and Drug Administration, the European Medicines Agency, Health Canada (ide-cel only), and Brazil ANVISA (cilta-cel only); and equecabtagene autoleucel (eque-cel), which was approved by the Chinese National Medical Products Administration. CAR T-cell therapy is different from previous anti-myeloma therapeutics with unique toxic effects that require distinct mitigation strategies. Thus, a panel of experts from the International Myeloma Working Group was assembled to provide guidance for clinical use of CAR T-cell therapy in myeloma. This consensus opinion is from experts in the field of haematopoietic cell transplantation, cell therapy, and multiple myeloma therapeutics.
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Affiliation(s)
- Yi Lin
- Department of Hematology, Mayo Clinic, Rochester, MN, USA.
| | - Lugui Qiu
- National Clinical Research Center for Blood Diseases and State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Pekin Union Medical College, Tianjin, China
| | - Saad Usmani
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Chng Wee Joo
- Department of Medical Oncology, National University Cancer Institute, Singapore
| | - Luciano Costa
- Department of Hematology Oncology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Benjamin Derman
- Department of Hematology and Oncology, University of Chicago, Chicago, IL, USA
| | - Juan Du
- Department of Hematology, Myeloma and Lymphoma Center, Shanghai Changzheng Hospital, Navy Medical University, Shanghai, China
| | - Hermann Einsele
- Department of Internal Medicine II, University Hospital, Wurzburg, Germany
| | - Carlos Fernandez de Larrea
- Department of Hematology, Hospital Clinic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Roman Hajek
- Department of Hematooncology, University Hospital Ostrava, Ostrava, Czech Republic; Department of Hematooncology, Faculty of Medicine, University Ostrava, Ostrava, Czech Republic
| | - P Joy Ho
- Institute of Hematology, Royal Prince Alfred Hospital, University of Sydney, Sydney, NSW, Australia
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Joaquin Martinez-Lopez
- Hospital Universitario 12 de Octubre, Department of Medicine, Complutense University, CNIO, Madrid, Spain
| | | | - Joseph Mikhael
- Translational Genomics Research Institute, City of Hope Cancer Center, Phoenix, AZ, USA
| | - Philippe Moreau
- Department of Hematology, University Hospital of Nantes, Nantes, France
| | | | - Ajay Nooka
- Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Michael O'Dwyer
- Department of Medicine and Department of Haematology, National University of Ireland, Galway, Ireland
| | | | - Surbhi Sidana
- School of Medicine, Stanford University, San Francisco, CA, USA
| | - Niels Wcj van de Donk
- Department of Hematology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Katja Weisel
- Department of Oncology, Hematology and Bone Marrow Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sonja Zweegman
- Department of Hematology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Noopur Raje
- Department of Medicine, Harvard University, Cambridge, MA, USA
| | - Paula Rodriguez Otero
- Department of Hematology, Cancer Center Clinica Universidad de Navarra, Pamplona, Navarra, Spain
| | - Larry D Anderson
- Simmons Comprehensive Cancer Center, Dallas, TX, USA; University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Shaji Kumar
- Department of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Tom Martin
- Department of Hematology, University of California, San Francisco, CA, USA
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3
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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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4
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Arya S, Shahid Z. Overview of infectious complications among CAR T- cell therapy recipients. Front Oncol 2024; 14:1398078. [PMID: 39026972 PMCID: PMC11255439 DOI: 10.3389/fonc.2024.1398078] [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: 03/08/2024] [Accepted: 06/04/2024] [Indexed: 07/20/2024] Open
Abstract
Chimeric antigen receptor-modified T cell (CAR T-cell) therapy has revolutionized the management of hematological malignancies. In addition to impressive malignancy-related outcomes, CAR T-cell therapy has significant toxicity-related adverse events, including cytokine release syndrome (CRS), immune effector cell associated neurotoxicity syndrome (ICANS), immune effector cell-associated hematotoxicity (ICAHT), and opportunistic infections. Different CAR T-cell targets have different epidemiology and risk factors for infection, and these targets result in different long-term immunodeficiency states due to their distinct on-target and off- tumor effects. These effects are exacerbated by the use of multimodal immunosuppression in the management of CRS and ICANS. The most effective course of action for managing infectious complications involves determining screening, prophylactic, and monitoring strategies and understanding the role of immunoglobulin replacement and re-vaccination strategies. This involves considering the nature of prior immunomodulating therapies, underlying malignancy, the CAR T-cell target, and the development and management of related adverse events. In conclusion, we now have an increasing understanding of infection management for CAR T-cell recipients. As additional effector cells and CAR T-cell targets become available, infection management strategies will continue to evolve.
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Affiliation(s)
- Swarn Arya
- Infectious Disease Service, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Zainab Shahid
- Infectious Disease Service, Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Department of Medicine, Weill Cornell School of Medicine, New York, NY, United States
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5
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Korst CLBM, Groen K, Bosman PWC, van der Valk F, Verkleij CPM, Kruyswijk S, de Ruijter MEM, Heijink DM, Kuipers MT, Zweegman S, van de Donk NWCJ. Prophylactic tocilizumab reduces the incidence of cytokine release syndrome in relapsed/refractory myeloma patients treated with teclistamab: Implications for outpatient step-up dosing. Hemasphere 2024; 8:e132. [PMID: 39050549 PMCID: PMC11266829 DOI: 10.1002/hem3.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Revised: 06/25/2024] [Accepted: 07/04/2024] [Indexed: 07/27/2024] Open
Affiliation(s)
- Charlotte L. B. M. Korst
- Department of Hematology, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
- Cancer Biology and ImmunologyCancer Center AmsterdamAmsterdamThe Netherlands
| | - Kaz Groen
- Department of Hematology, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
- Cancer Biology and ImmunologyCancer Center AmsterdamAmsterdamThe Netherlands
| | - Patricia W. C. Bosman
- Department of Hematology, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
- Cancer Biology and ImmunologyCancer Center AmsterdamAmsterdamThe Netherlands
| | - Fleur van der Valk
- Department of HematologyOnze Lieve Vrouwe GasthuisAmsterdamThe Netherlands
| | - Christie P. M. Verkleij
- Department of Hematology, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
- Cancer Biology and ImmunologyCancer Center AmsterdamAmsterdamThe Netherlands
| | - Sandy Kruyswijk
- Department of Hematology, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
- Cancer Biology and ImmunologyCancer Center AmsterdamAmsterdamThe Netherlands
| | - Maaike E. M. de Ruijter
- Department of Hematology, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
- Cancer Biology and ImmunologyCancer Center AmsterdamAmsterdamThe Netherlands
| | - Dianne M. Heijink
- Department of Hematology, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
- Cancer Biology and ImmunologyCancer Center AmsterdamAmsterdamThe Netherlands
| | - Maria T. Kuipers
- Department of Hematology, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
- Cancer Biology and ImmunologyCancer Center AmsterdamAmsterdamThe Netherlands
| | - Sonja Zweegman
- Department of Hematology, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
- Cancer Biology and ImmunologyCancer Center AmsterdamAmsterdamThe Netherlands
| | - Niels W. C. J. van de Donk
- Department of Hematology, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
- Cancer Biology and ImmunologyCancer Center AmsterdamAmsterdamThe Netherlands
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6
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Asensi Cantó P, Arnao Herraiz M, de la Rubia Comos J. [Immunotherapy in multiple myeloma]. Med Clin (Barc) 2024; 162:485-493. [PMID: 38218655 DOI: 10.1016/j.medcli.2023.11.019] [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: 10/03/2023] [Revised: 11/14/2023] [Accepted: 11/15/2023] [Indexed: 01/15/2024]
Abstract
Patients with multiple myeloma who present with refractory disease or relapse after receiving the main classes of available drugs -immunomodulators, proteasome inhibitors and antibodies against CD38- do not have satisfactory therapeutic alternatives. New treatments based on the redirection of T lymphocytes to act directly against tumor cells, such as bispecific antibodies and T cells with chimeric antigen receptors, are changing this scenario. The published information confirms unprecedented antitumor activity of these agents in patients with refractory myeloma and they will certainly represent the backbone of the treatment of these patients in the immediate future. However, these therapies also present specific characteristics and medium or long-term toxicities that pose new healthcare challenges. In this review, we address the current results and future challenges of the administration of these treatments in patients with relapsed or refractory multiple myeloma.
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Affiliation(s)
- Pedro Asensi Cantó
- Servicio de Hematología y Hemoterapia, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Mario Arnao Herraiz
- Servicio de Hematología y Hemoterapia, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Javier de la Rubia Comos
- Servicio de Hematología y Hemoterapia, Hospital Universitario y Politécnico La Fe, Valencia, España; Facultad de Medicina y Odontología, Universidad Católica de Valencia, Valencia, España; Instituto de Investigación Sanitaria La Fe, Valencia, España; Ciberonc CB16/12/00284, Valencia, España.
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7
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Costa BA, Flynn J, Nishimura N, Devlin SM, Farzana T, Rajeeve S, Chung DJ, Landau HJ, Lahoud OB, Scordo M, Shah GL, Hassoun H, Maclachlan K, Hultcrantz M, Korde N, Lesokhin AM, Shah UA, Tan CR, Giralt SA, Usmani SZ, Nath K, Mailankody S. Prognostic impact of corticosteroid and tocilizumab use following chimeric antigen receptor T-cell therapy for multiple myeloma. Blood Cancer J 2024; 14:84. [PMID: 38802346 PMCID: PMC11130279 DOI: 10.1038/s41408-024-01048-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 03/22/2024] [Accepted: 03/28/2024] [Indexed: 05/29/2024] Open
Abstract
Despite being the mainstay of management for cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS), there is limited data regarding the impact of tocilizumab (TCZ) and corticosteroids (CCS) on chimeric antigen receptor (CAR) T-cell efficacy in multiple myeloma (MM). The present study aims to evaluate the prognostic impact of these immunosuppressants in recipients of BCMA- or GPRC5D-directed CAR T cells for relapsed/refractory MM. Our retrospective cohort involved patients treated with commercial or investigational autologous CAR T-cell products at a single institution from March 2017-March 2023. The primary endpoint was progression-free survival (PFS). Secondary endpoints included overall response rate (ORR), complete response rate (CRR), and overall survival (OS). In total, 101 patients (91% treated with anti-BCMA CAR T cells and 9% treated with anti-GPRC5D CAR T cells) were analyzed. Within 30 days post-infusion, 34% received CCS and 49% received TCZ for CRS/ICANS management. At a median follow-up of 27.4 months, no significant difference in PFS was observed between CCS and non-CCS groups (log-rank p = 0.35) or between TCZ and non-TCZ groups (log-rank p = 0.69). ORR, CRR, and OS were also comparable between evaluated groups. In our multivariable model, administering CCS with/without TCZ for CRS/ICANS management did not independently influence PFS (HR, 0.74; 95% CI, 0.36-1.51). These findings suggest that, among patients with relapsed/refractory MM, the timely and appropriate use of CCS or TCZ for mitigating immune-mediated toxicities does not appear to impact the antitumor activity and long-term outcomes of CAR T-cell therapy.
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Affiliation(s)
- Bruno Almeida Costa
- Department of Medicine, Cellular Therapy Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Mount Sinai Morningside and West, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jessica Flynn
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Noriko Nishimura
- Department of Medicine, Myeloma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sean M Devlin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Tasmin Farzana
- Department of Medicine, Cellular Therapy Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sridevi Rajeeve
- Department of Medicine, Cellular Therapy Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Myeloma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David J Chung
- Department of Medicine, Cellular Therapy Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Heather J Landau
- Department of Medicine, Cellular Therapy Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Oscar B Lahoud
- Department of Medicine, Cellular Therapy Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Michael Scordo
- Department of Medicine, Cellular Therapy Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Gunjan L Shah
- Department of Medicine, Cellular Therapy Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Hani Hassoun
- Department of Medicine, Myeloma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Kylee Maclachlan
- Department of Medicine, Myeloma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Malin Hultcrantz
- Department of Medicine, Myeloma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Neha Korde
- Department of Medicine, Myeloma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Alexander M Lesokhin
- Department of Medicine, Cellular Therapy Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Myeloma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Urvi A Shah
- Department of Medicine, Myeloma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Carlyn R Tan
- Department of Medicine, Myeloma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Sergio A Giralt
- Department of Medicine, Cellular Therapy Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Saad Z Usmani
- Department of Medicine, Cellular Therapy Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Myeloma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Karthik Nath
- Department of Medicine, Cellular Therapy Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Sham Mailankody
- Department of Medicine, Cellular Therapy Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Department of Medicine, Myeloma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA.
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Ferreri CJ, Bhutani M. Mechanisms and management of CAR T toxicity. Front Oncol 2024; 14:1396490. [PMID: 38835382 PMCID: PMC11148294 DOI: 10.3389/fonc.2024.1396490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 05/07/2024] [Indexed: 06/06/2024] Open
Abstract
Chimeric antigen receptor (CAR) T cell therapies have dramatically improved treatment outcomes for patients with relapsed or refractory B-cell acute lymphoblastic leukemia, large B-cell lymphoma, follicular lymphoma, mantle cell lymphoma, and multiple myeloma. Despite unprecedented efficacy, treatment with CAR T cell therapies can cause a multitude of adverse effects which require monitoring and management at specialized centers and contribute to morbidity and non-relapse mortality. Such toxicities include cytokine release syndrome, immune effector cell-associated neurotoxicity syndrome, neurotoxicity distinct from ICANS, immune effector cell-associated hemophagocytic lymphohistiocytosis-like syndrome, and immune effector cell-associated hematotoxicity that can lead to prolonged cytopenias and infectious complications. This review will discuss the current understanding of the underlying pathophysiologic mechanisms and provide guidelines for the grading and management of such toxicities.
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Affiliation(s)
- Christopher J Ferreri
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health Wake Forest University School of Medicine, Charlotte, NC, United States
| | - Manisha Bhutani
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health Wake Forest University School of Medicine, Charlotte, NC, United States
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9
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Walton ZE, Frigault MJ, Maus MV. Current and emerging pharmacotherapies for cytokine release syndrome, neurotoxicity, and hemophagocytic lymphohistiocytosis-like syndrome due to CAR T cell therapy. Expert Opin Pharmacother 2024; 25:263-279. [PMID: 38588525 DOI: 10.1080/14656566.2024.2340738] [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: 12/12/2023] [Accepted: 03/01/2024] [Indexed: 04/10/2024]
Abstract
INTRODUCTION Chimeric antigen receptor (CAR) T cells have revolutionized the treatment of multiple hematologic malignancies. Engineered cellular therapies now offer similar hope to transform the management of solid tumors and autoimmune diseases. However, toxicities can be serious and often require hospitalization. AREAS COVERED We review the two chief toxicities of CAR T therapy, cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS), and the rarer immune effector cell-associated hemophagocytic lymphohistiocytosis-like syndrome. We discuss treatment paradigms and promising future pharmacologic strategies. Literature and therapies reviewed were identified by PubMed search, cited references therein, and review of registered trials. EXPERT OPINION Management of CRS and ICANS has improved, aided by consensus definitions and guidelines that facilitate recognition and timely intervention. Further data will define optimal timing of tocilizumab and corticosteroids, current foundations of management. Pathophysiologic understanding has inspired off-label use of IL-1 receptor antagonism, IFNγ and IL-6 neutralizing antibodies, and janus kinase inhibitors, with data emerging from ongoing clinical trials. Further strategies to reduce toxicities include novel pharmacologic targets and safety features engineered into CAR T cells themselves. As these potentially curative therapies are used earlier in oncologic therapy and even in non-oncologic indications, effective accessible strategies to manage toxicities are critical.
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Affiliation(s)
- Zandra E Walton
- Cellular Immunotherapy Program, Massachusetts General Hospital Cancer Center, Boston, MA, USA
- Division of Rheumatology, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Matthew J Frigault
- Cellular Immunotherapy Program, Massachusetts General Hospital Cancer Center, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Marcela V Maus
- Cellular Immunotherapy Program, Massachusetts General Hospital Cancer Center, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
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10
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Barrett D. IL-6 Blockade in Cytokine Storm Syndromes. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1448:565-572. [PMID: 39117839 DOI: 10.1007/978-3-031-59815-9_37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
Interleukin-6 (IL-6) is a pro-inflammatory cytokine elevated in cytokine storm syndromes, including hemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS). It is also elevated in cytokine release syndrome (CRS) after immune activating cancer therapies such as chimeric antigen receptor (CAR) T-cells or bispecific T-cell engagers (BITEs) and in some patients after infection with SARS-CoV-2. The interaction of IL-6 with its receptor complex can happen in several forms, making effectively blocking this cytokine's effects clinically challenging. Fortunately, effective clinical agents targeting the IL-6 receptor (tocilizumab) and IL-6 directly (siltuximab) have been developed and are approved for use in humans. IL-6 blockade has now been used to safely and effectively treat several cytokine storm syndromes (CSS). Other methods of investigation in effective IL-6 blockade are underway.
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Affiliation(s)
- David Barrett
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA.
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11
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Zhou LL, Ye SG, Li P, Tang XC, Liang AB. [Effect of early tocilizumab intervention on patients with cytokine release syndrome following chimeric antigen receptor T cell therapy]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2023; 44:1022-1026. [PMID: 38503526 PMCID: PMC10834881 DOI: 10.3760/cma.j.issn.0253-2727.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Indexed: 03/21/2024]
Abstract
Objective: This study aimed to evaluate the effect of early tocilizumab intervention to relieve cytokine release syndrome (CRS) following chimeric antigen receptor T cell (CAR-T) therapy. Methods: Twenty-two patients with acute lymphoblastic leukemia who received tocilizumab to relieve CRS response after CAR-T cell infusion in our research center from October 2015 to July 2021 were retrospectively analyzed. According to the timing of tocilizumab intervention, patients were divided into the conventional and early intervention groups. Patients who received tocilizumab treatment after sustained high fever for 4 h were included in the early intervention group. The clinical data, CRS grade, and event-free survival (EFS) between the two groups were evaluated. Results: Compared with patients who used tocilizumab after severe CRS, no patients in the early intervention group died from CRS, and there was no increased risk of neurotoxicity. Eleven patients (84.62%) achieved complete remission with minimal residual lesions. The median EFS of patients in the early intervention and conventional groups was 2 (95% CI 0-5) and 7 (95% CI 3-11) months, respectively. Conclusion: Early tocilizumab intervention in patients with CRS reduces severe CRS and provides a more optimized therapeutic strategy for CRS caused by CAR-T cell therapy.
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Affiliation(s)
- L L Zhou
- Department of Hematology, Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
| | - S G Ye
- Department of Hematology, Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
| | - P Li
- Department of Hematology, Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
| | - X C Tang
- Department of Hematology, Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
| | - A B Liang
- Department of Hematology, Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
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Reynolds GK, Sim B, Spelman T, Thomas A, Longhitano A, Anderson MA, Thursky K, Slavin M, Teh BW. Infections in haematology patients treated with CAR-T therapies: A systematic review and meta-analysis. Crit Rev Oncol Hematol 2023; 192:104134. [PMID: 37739146 DOI: 10.1016/j.critrevonc.2023.104134] [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: 01/31/2023] [Revised: 08/21/2023] [Accepted: 09/12/2023] [Indexed: 09/24/2023] Open
Abstract
A registered (PROSPERO - CRD42022346462) systematic review and meta-analysis was conducted of all-grade infections amongst adult patients receiving CAR-T therapy for haematological malignancy. Meta-analysis of pooled incidence, using random effects model, was conducted. Cochran's Q test examined heterogeneity. 2678 patients across 33 studies were included in the primary outcome. Forty-percent of patients (95% CI: 0.33 - 0.48) experienced an infection of any grade. Twenty-five percent of infection events (95% CI: 0.16 - 0.34) were severe. Late infections were as common as early infections (IRR = 0.86, 95% CI: 0.38 - 1.98). All-grade infections, bacterial and viral infections were highest in myeloma patients at 57%, 37% and 28% respectively. Patients with NHL more commonly experienced late infections. Pooled rate of invasive candidiasis/yeast infections was 2% in studies utilizing anti-yeast prophylaxis. This review identified a high rate of all-grade infections, moderate rate of severe infections, and myeloma as a high-risk haematological group.
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Affiliation(s)
- Gemma K Reynolds
- Dpartment of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia; National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Department of Infectious Diseases, Austin Health, Melbourne, Victoria, Australia.
| | - Beatrice Sim
- Dpartment of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Tim Spelman
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Ashmitha Thomas
- Department of Infectious Diseases, Austin Health, Melbourne, Victoria, Australia
| | - Anthony Longhitano
- Department of Infectious Diseases, Barwon Health, Melbourne, Victoria, Australia
| | - Mary Ann Anderson
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Karin Thursky
- Dpartment of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia; National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Monica Slavin
- Dpartment of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia; National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Benjamin W Teh
- Dpartment of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia; National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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13
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Reynolds G, Sim B, Anderson MA, Spelman T, Teh BW, Slavin MA, Thursky KA. Predicting infections in patients with haematological malignancies treated with chimeric antigen receptor T-cell therapies: A systematic scoping review and narrative synthesis. Clin Microbiol Infect 2023; 29:1280-1288. [PMID: 37201866 DOI: 10.1016/j.cmi.2023.05.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 03/14/2023] [Accepted: 05/06/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Chimeric antigen receptor T cells (CAR-T cells) are increasingly used to treat haematological malignancies. Strategies for preventing infections in CAR-T-treated patients rely on expert opinions and consensus guidelines. OBJECTIVES This scoping review aimed to identify risk factors for infections in CAR-T-treated patients with haematological malignancies. DATA SOURCES A literature search utilized MEDLINE, EMBASE and Cochrane to identify relevant studies from conception until 30 September 2022. STUDY ELIGIBILITY CRITERIA Trials and observational studies were eligible. PARTICIPANTS Studies required ≥10 patients treated for haematological malignancy to report infection events (as defined by the study), and either (a) a descriptive, univariate or multivariate analysis of the relationship between infections event and a risk factors for infections, or (b) diagnostic performance of a biochemical/immunological marker in CAR-T-treated patients with infection. METHODS A scoping review was conducted in accordance with PRISMA guidelines. DATA SOURCES A literature search utilised MEDLINE, EMBASE and Cochrane to identify relevant studies from conception until September 30, 2022. Eligibility/Participants/Intervention: Trials and observational studies were eligible. Studies required ≥ 10 patients treated for haematological malignancy, to report infection events (as defined by the study), and either A) a descriptive, univariate or multivariate analysis of the relationship between infections event and a risk-factors for infections, or B) diagnostic performance of a biochemical/immunological marker in CAR-T treated patients with infection. ASSESSMENT OF RISK OF BIAS Bias assessment was undertaken according to Joanna Brigg's Institute criteria for observational studies. METHODS OF DATA SYNTHESIS Data were synthesized descriptively because of the heterogeneity of reporting. RESULTS A total of 1522 patients across 15 studies were identified. All-cause infections across haematological malignancies were associated with lines of prior therapy, steroid administration, immune-effector cell-associated neurotoxicity and treatment-emergent neutropenia. Procalcitonin, C-reactive protein and cytokine profiles did not reliably predict infections. Predictors of viral, bacterial and fungal infections were poorly canvassed. DISCUSSION Meta-analysis of the current literature is not possible because of significant heterogeneity in definitions of infections and risk factors, and small, underpowered cohort studies. Radical revision of how we approach reporting infections for novel therapies is required to promptly identify infection signals and associated risks in patients receiving novel therapies. Prior therapies, neutropenia, steroid administration and immune-effector cell-associated neurotoxicity remain the most associated with infections in CAR-T-treated patients.
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Affiliation(s)
- Gemma Reynolds
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia; National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Department of Infectious Diseases, Austin Health, Melbourne, Victoria, Australia.
| | - Beatrice Sim
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Mary Ann Anderson
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Tim Spelman
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Benjamin W Teh
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia; National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia; National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Karin A Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia; National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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14
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Martin TG, Mateos MV, Nooka A, Banerjee A, Kobos R, Pei L, Qi M, Verona R, Doyle M, Smit J, Sun W, Trancucci D, Uhlar C, van de Donk NWCJ, Rodriguez C. Detailed overview of incidence and management of cytokine release syndrome observed with teclistamab in the MajesTEC-1 study of patients with relapsed/refractory multiple myeloma. Cancer 2023; 129:2035-2046. [PMID: 36991547 DOI: 10.1002/cncr.34756] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 02/02/2023] [Accepted: 02/07/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND Teclistamab, a B-cell maturation antigen × CD3 bispecific antibody, demonstrated an overall response rate of 63.0% in 165 heavily pretreated patients with relapsed or refractory multiple myeloma in the phase 1/2 MajesTEC-1 study. Cytokine release syndrome (CRS), a known manifestation of T-cell redirection, was observed in 119 of 165 patients (72.1%). METHODS Patients received once-weekly teclistamab 1.5 mg/kg subcutaneously after two step-up doses (0.06 and 0.3 mg/kg). CRS was graded according to American Society for Transplantation and Cellular Therapy criteria and managed according to the study protocol, including use of tocilizumab and/or steroids. RESULTS Most cases of CRS occurred during the step-up dosing schedule of teclistamab and were grade 1 (50.3% of patients) or grade 2 (21.2% of patients); a single case of grade 3 CRS was reported in a patient with concurrent grade 3 pneumonia. All CRS cases resolved and none led to treatment discontinuation. Overall, 33.3% of patients had >1 CRS event; CRS recurrence was reduced when tocilizumab was administered for the first CRS event compared with when it was not (20.0% vs. 62.2%, respectively). Baseline characteristics such as tumor burden and cytokine levels did not appear to predict CRS incidence or severity. CONCLUSIONS Findings of this study support the need for preemptive planning and prompt management of CRS in patients treated with T-cell-engaging bispecific antibodies. Intervention with tocilizumab for CRS appears to decrease the likelihood of patients experiencing subsequent CRS events without compromising response to teclistamab. PLAIN LANGUAGE SUMMARY Cytokine release syndrome (CRS), observed in 72.1% of patients treated with teclistamab in the MajesTEC-1 study, was mostly grade 1 or 2 and manageable, without requiring treatment discontinuation. Most CRS occurred during the step-up schedule, requiring vigilance during treatment initiation. Ensure fever is resolved and patients have no signs of infection before initiating the teclistamab step-up schedule or administering the next teclistamab dose, to avoid exacerbating CRS. Tocilizumab reduced the risk of subsequent CRS in patients receiving it for their first CRS event (20.0% vs. 62.2% in those not receiving it), without affecting response to teclistamab. No baseline characteristics, including tumor burden or cytokine levels, appeared to clearly predict for CRS occurrence or severity.
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Affiliation(s)
- Thomas G Martin
- University of California, San Francisco, San Francisco, California, USA
| | | | - Ajay Nooka
- Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Arnob Banerjee
- Janssen Research and Development, Spring House, Pennsylvania, USA
| | - Rachel Kobos
- Janssen Research and Development, Raritan, New Jersey, USA
| | - Lixia Pei
- Janssen Research and Development, Raritan, New Jersey, USA
| | - Ming Qi
- Janssen Research and Development, Spring House, Pennsylvania, USA
| | - Raluca Verona
- Janssen Research and Development, Spring House, Pennsylvania, USA
| | | | - Jennifer Smit
- Janssen Research and Development, Spring House, Pennsylvania, USA
| | - Weili Sun
- Janssen Research and Development, Los Angeles, California, USA
| | | | - Clarissa Uhlar
- Janssen Research and Development, Spring House, Pennsylvania, USA
| | | | - Cesar Rodriguez
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
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15
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Reyes KR, Huang CY, Lo M, Arora S, Chung A, Wong SW, Wolf J, Olin RL, Martin T, Shah N, Banerjee R. Safety and efficacy of BCMA CAR-T cell therapy in older patients with multiple myeloma. Transplant Cell Ther 2023:S2666-6367(23)01171-5. [PMID: 36933659 DOI: 10.1016/j.jtct.2023.03.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 02/24/2023] [Accepted: 03/13/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Risks of B-cell maturation antigen (BCMA) chimeric antigen receptor T-cell (CAR-T) therapy for patients with multiple myeloma (MM) include cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), cytopenias, and infections. The efficacy and safety of BCMA CAR-T therapy in the geriatric setting, including complications such as falls and delirium which may be more prevalent in older patients, have not been fully analyzed. OBJECTIVES To analyze the efficacy and safety of BCMA CAR-T therapy among older patients (age ≥70 at infusion) versus younger patients with MM. STUDY DESIGN We analyzed all patients with MM who received any autologous BCMA CAR-T therapy over a 5-year period at our institution. Key endpoints included CRS, ICANS incidence, days to absolute neutrophil count (ANC) recovery, incidence of hypogammaglobulinemia (IgG < 400 mg/dL), infections within 6 months, progression-free survival (PFS), and overall survival (OS). RESULTS Of 83 analyzed patients (age range 33-77), 22 (27%) were aged ≥70 at infusion. The older cohort had lower creatinine clearances (median 67.3 vs 91.9 mL/min, p<0.001) and a higher proportion of patients with performance status ≥1 (59% vs 30%, p=0.02) but were otherwise similar. Rates of any-grade CRS, any-grade ICANS, and days to ANC recovery were similar between groups. Rates of baseline hypogammaglobulinemia were 36% in older patients and 30% in younger patients (p=0.60), while post-infusion hypogammaglobulinemia occurred in 82% vs 72% respectively (p=0.57). Infections occurred in 36% (n=8) of the older cohort versus 52% (n=32) of the younger cohort (p=0.22). There were no statistically significant differences between the older and younger cohorts in terms of documented falls (9% vs 15%, p=0.72) or non-ICANS delirium (5% vs 7%, p=1.0). Median PFS was 13.1 months in older patients (95% CI 9.2-not reached [NR]) vs 12.5 months in younger patients (95% CI 11.3-22.5, p=0.42. Median OS was not reached in the older cohort (95% CI: NR-NR) vs 31.4 months in the younger cohort (95% CI 24.8-NR) with p=0.04. However, age ≥70 was not a significant predictor of OS after adjusting for high-risk cytogenetics, triple-class refractoriness, extramedullary disease, and bone marrow plasma cell burden. CONCLUSIONS While limited by small sample size and unmeasured confounders, our retrospective analysis did not demonstrate significant increases in CAR-T toxicity among older patients. This included toxicities associated with geriatric populations such as falls and delirium. Our paradoxical finding of borderline better OS among patients aged ≥70, which was not significant in regression modeling, may have been due to selection bias in favor of disproportionately healthy CAR-T candidates in the geriatric population. Overall, BCMA CAR-T remains a safe and effective option for older patients with MM.
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Affiliation(s)
- Kevin R Reyes
- School of Medicine, University of California San Francisco, San Francisco, California
| | - Chiung-Yu Huang
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | - Mimi Lo
- Division of Hematology and Oncology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Shagun Arora
- Division of Hematology and Oncology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Alfred Chung
- Division of Hematology and Oncology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Sandy W Wong
- Division of Hematology and Oncology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Jeffrey Wolf
- Division of Hematology and Oncology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Rebecca L Olin
- Division of Hematology and Oncology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Thomas Martin
- Division of Hematology and Oncology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Nina Shah
- Division of Hematology and Oncology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Rahul Banerjee
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington.
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Banerjee R, Lee SS, Cowan AJ. Innovation in BCMA CAR-T therapy: Building beyond the Model T. Front Oncol 2022; 12:1070353. [PMID: 36505779 PMCID: PMC9729952 DOI: 10.3389/fonc.2022.1070353] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 11/08/2022] [Indexed: 11/25/2022] Open
Abstract
Autologous chimeric antigen receptor T-cell (CAR-T) therapies targeting B-cell maturation antigen (BCMA) have revolutionized the field of multiple myeloma in the same way that the Ford Model T revolutionized the original CAR world a century ago. However, we are only beginning to understand how to improve the efficacy and usability of these cellular therapies. In this review, we explore three automotive analogies for innovation with BCMA CAR-T therapies: stronger engines, better mileage, and hassle-free delivery. Firstly, we can build stronger engines in terms of BCMA targeting: improved antigen binding, tools to modulate antigen density, and armoring to better reach the antigen itself. Secondly, we can improve "mileage" in terms of response durability through ex vivo CAR design and in vivo immune manipulation. Thirdly, we can implement hassle-free delivery through rapid manufacturing protocols and off-the-shelf products. Just as the Model T set a benchmark for car manufacturing over 100 years ago, idecabtagene vicleucel and ciltacabtagene autoleucel have now set the starting point for BCMA CAR-T therapy with their approvals. As with any emerging technology, whether automotive or cellular, the best in innovation and optimization is yet to come.
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Affiliation(s)
- Rahul Banerjee
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA, United States
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, United States
| | - Sarah S. Lee
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA, United States
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, United States
| | - Andrew J. Cowan
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA, United States
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, United States
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Chimeric Antigen Receptor T-Cell Therapy: What We Expect Soon. Int J Mol Sci 2022; 23:ijms232113332. [PMID: 36362130 PMCID: PMC9657035 DOI: 10.3390/ijms232113332] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 10/10/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022] Open
Abstract
The treatment landscape for hematologic malignancies has changed since the recent approval of highly effective chimeric antigen receptor T-cell therapies (CAR-T). Moreover, more than 600 active trials are currently ongoing. However, early enthusiasm should be tempered since several issues are still unsolved and represent the challenges for the coming years. The lack of initial responses and early relapse are some hurdles to be tackled. Moreover, new strategies are needed to increase the safety profile or shorten the manufacturing process during CAR-T cells therapy production. Nowadays, most clinically evaluated CAR-T cells products are derived from autologous immune cells. The use of allogeneic CAR-T cells products generated using cells from healthy donors has the potential to change the scenario and overcome many of these limitations. In addition, CAR-T cells carry a high price tag, and there is an urgent need to understand how to pay for these therapies as many of today’s current payment systems do not feature the functionality to address the reimbursement gap. Finally, the clinical experience with CAR-T cells for solid tumors has been less encouraging, and development in this setting is desirable.
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Zhang Y, Zhou F, Wu Z, Li Y, Li C, Du M, Luo W, Kou H, Lu C, Mei H. Timing of Tocilizumab Administration Under the Guidance of IL-6 in CAR-T Therapy for R/R Acute Lymphoblastic Leukemia. Front Immunol 2022; 13:914959. [PMID: 35799791 PMCID: PMC9253384 DOI: 10.3389/fimmu.2022.914959] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 05/02/2022] [Indexed: 12/17/2022] Open
Abstract
Chimeric antigen receptor T (CAR-T) cells targeting CD19 have achieved great clinical responses in patients with relapsed or refractory (R/R) acute B lymphoblastic leukemia. However, severe adverse events such as cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome restrict it to further application. Tocilizumab is the corner stone for the treatment of severe CRS. It has been used to treat mild CRS in recent years, whereas some statistical supports clarifying the suitable timing of its administration are lacking. Sixty-seven patients with B-cell acute lymphoblastic leukemia (B-ALL) were treated with CD19-CART and enrolled in the study, of which 33 patients received Tocilizumab. Application of Tocilizumab in patients with grade 2 CRS in American Society for Transplantation and Cellular Therapy (ASTCT) criteria can significantly shorten the duration of CRS without affecting side effects and long-term efficacy. However, a number of patients still developed severe CRS with early use of Tocilizumab, indicating the significance of the introduction of clinical laboratories to assist medications. Statistically, patients with less than fourfold increase in IL-6 levels had a higher incidence of severe CRS after receiving Tocilizumab (37.5% versus. 0%, p=0.0125), which provided a basis for refining CRS intervention strategies under the guidance of IL-6.
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Affiliation(s)
- Yinqiang Zhang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Clinical Medical Center of Cell Therapy for Neoplastic Disease, Wuhan, China
| | - Fen Zhou
- Hubei Clinical Medical Center of Cell Therapy for Neoplastic Disease, Wuhan, China
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhuolin Wu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Clinical Medical Center of Cell Therapy for Neoplastic Disease, Wuhan, China
| | - Yingnan Li
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Clinical Medical Center of Cell Therapy for Neoplastic Disease, Wuhan, China
| | - Chenggong Li
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Clinical Medical Center of Cell Therapy for Neoplastic Disease, Wuhan, China
| | - Mengyi Du
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Clinical Medical Center of Cell Therapy for Neoplastic Disease, Wuhan, China
| | - Wenjing Luo
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Clinical Medical Center of Cell Therapy for Neoplastic Disease, Wuhan, China
| | - Haiming Kou
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Clinical Medical Center of Cell Therapy for Neoplastic Disease, Wuhan, China
| | - Cong Lu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Clinical Medical Center of Cell Therapy for Neoplastic Disease, Wuhan, China
| | - Heng Mei
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Clinical Medical Center of Cell Therapy for Neoplastic Disease, Wuhan, China
- *Correspondence: Heng Mei,
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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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