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Hoogland AI, Barata A, Li X, Irizarry-Arroyo N, Jain MD, Welniak T, Rodriguez Y, Oswald LB, Gudenkauf LM, Chavez JC, Khimani F, Lazaryan A, Liu HD, Nishihori T, Pinilla-Ibarz J, Shah BD, Crowder SL, Parker NH, Carson TL, Vinci CE, Pidala JA, Logue J, Locke FL, Jim HSL. Prospective Assessment of Quality of Life and Patient-Reported Toxicities Over the First Year After Chimeric Antigen Receptor T-Cell Therapy. Transplant Cell Ther 2024:S2666-6367(24)00666-3. [PMID: 39306278 DOI: 10.1016/j.jtct.2024.09.013] [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: 06/03/2024] [Revised: 09/05/2024] [Accepted: 09/14/2024] [Indexed: 09/26/2024]
Abstract
Chimeric antigen receptor (CAR) T-cell therapy has transformed survival outcomes in patients with relapsed and refractory large B-cell lymphoma (LBCL), but it is associated with a variety of side effects. This study examined changes in patient-reported quality of life (QoL) and toxicities, as well as risk factors for worse QoL and toxicities, in the first year after treatment. Patients with LBCL completed questionnaires assessing QoL and toxicity severity before infusion, and 90, 180, and 360 days after infusion. Mixed models were used to examine changes in QoL and toxicities over time, and clinical moderators of change in QoL and toxicities. Patients reported improvements in physical functioning and fatigue in the year after treatment (P values <.01), but there were no changes in pain, anxiety, or depression over time. Patients with active disease at day 90 reported more physical dysfunction at all postinfusion timepoints (Ps ≤ .01) compared to patients who responded to treatment. Similarly, patients with active disease at day 90 reported worsening depression over time, such that at day 360, depressive symptoms were worse for patients with active disease than patients without active disease (P = .02). Patients treated with 4+ lines of prior therapy reported worsening pain and anxiety over time, such that at day 360, both pain and anxiety were significantly worse for patients previously treated with 4 of more lines of therapy than patients treated with fewer lines of therapy (Ps ≤ .01). Regarding toxicities, patients reported decreasing overall toxicity burden up to day 180, with subsequent worsening at day 360 (P = .02). Most patients reported at least one or two grade 2 toxicities at each timepoint. Patients demonstrated unchanging or improved QoL after treatment with CAR T-cell therapy, but active disease and greater prior lines of therapy were associated with worse QoL outcomes over time. Toxicity severity also improved during the first 6 months post-treatment, but worsened thereafter, particularly among patients with active disease after treatment.
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Affiliation(s)
- Aasha I Hoogland
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida.
| | - Anna Barata
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Xiaoyin Li
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida
| | | | - Michael D Jain
- Department of Blood and Marrow Transplantation and Cellular Therapy, Moffitt Cancer Center, Tampa, Florida
| | - Taylor Welniak
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida
| | - Yvelise Rodriguez
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida
| | - Laura B Oswald
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida
| | - Lisa M Gudenkauf
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida
| | - Julio C Chavez
- Department of Blood and Marrow Transplantation and Cellular Therapy, Moffitt Cancer Center, Tampa, Florida
| | - Farhad Khimani
- Department of Blood and Marrow Transplantation and Cellular Therapy, Moffitt Cancer Center, Tampa, Florida
| | - Aleksandr Lazaryan
- Department of Blood and Marrow Transplantation and Cellular Therapy, Moffitt Cancer Center, Tampa, Florida
| | - Hien D Liu
- Department of Blood and Marrow Transplantation and Cellular Therapy, Moffitt Cancer Center, Tampa, Florida
| | - Taiga Nishihori
- Department of Blood and Marrow Transplantation and Cellular Therapy, Moffitt Cancer Center, Tampa, Florida
| | - Javier Pinilla-Ibarz
- Department of Blood and Marrow Transplantation and Cellular Therapy, Moffitt Cancer Center, Tampa, Florida
| | - Bijal D Shah
- Department of Blood and Marrow Transplantation and Cellular Therapy, Moffitt Cancer Center, Tampa, Florida
| | - Sylvia L Crowder
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida
| | - Nathan H Parker
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida
| | - Tiffany L Carson
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida
| | - Christine E Vinci
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida
| | - Joseph A Pidala
- Department of Blood and Marrow Transplantation and Cellular Therapy, Moffitt Cancer Center, Tampa, Florida
| | - Jennifer Logue
- Moffitt Malignant Hematology & Cellular Therapy, Memorial Healthcare System, Pembroke Pines, Florida
| | - Frederick L Locke
- Department of Blood and Marrow Transplantation and Cellular Therapy, Moffitt Cancer Center, Tampa, Florida
| | - Heather S L Jim
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida
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Cordeiro AC, Durisek G, Batista MV, Schmidt J, de Lima M, Bezerra E. Late events after anti-CD19 CAR T-cell therapy for relapsed/refractory B-cell non-Hodgkin lymphoma. Front Oncol 2024; 14:1404351. [PMID: 38919524 PMCID: PMC11196778 DOI: 10.3389/fonc.2024.1404351] [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: 03/20/2024] [Accepted: 05/27/2024] [Indexed: 06/27/2024] Open
Abstract
Background The short-term complications from chimeric antigen receptor T-cell therapy (CART) are well characterized, but the long-term complications still need to be further investigated. Therefore, herein, we will review the currently available literature published on the late adverse events following CART. Methods We reviewed published data available from pivotal trials and real-world experiences with anti-CD19 CART (CART19) for adults with lymphoma. We defined late events as occurring or persisting beyond 1 month after CART infusion. We focused our literature review on the following late-event outcomes post-CART19: cytopenia, immune reconstitution, infections, and subsequent malignancies. Results Grade 3-4 cytopenia beyond 30 days occurs in 30%-40% of patients and beyond 90 days in 3%-22% of patients and is usually managed with growth-factor and transfusion support, along with neutropenic prophylaxis. B-cell aplasia and hypogammaglobulinemia are expected on-target off-tumor effects of CART19, 44%-53% of patients have IgG < 400 mg/dL, and approximately 27%-38% of patients receive intravenous immunoglobulin (IVIG) replacement. Infections beyond the initial month from CART19 are not frequent and rarely severe, but they are more prevalent and severe when patients receive subsequent therapies post-CART19 for their underlying disease. Late neurotoxicity and neurocognitive impairment are uncommon, and other causes should be considered. T-cell lymphoma (TCL) after CART is an extremely rare event and not necessarily related to CAR transgene. Myeloid neoplasm is not rare post-CART, but unclear causality given heavily pretreated patient population is already at risk for therapy-related myeloid neoplasm. Conclusion CART19 is associated with clinically significant long-term effects such as prolonged cytopenia, hypogammaglobulinemia, and infections that warrant clinical surveillance, but they are mostly manageable with a low risk of non-relapse mortality. The risk of subsequent malignancies post-CART19 seems low, and the relationship with CART19 and/or prior therapies is unclear; but regardless of the possible causality, this should not impact the current benefit-risk ratio of CART19 for relapsed/refractory B-cell non-Hodgkin lymphoma (NHL).
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Affiliation(s)
| | - George Durisek
- College of Medicine, The Ohio State University, Columbus, OH, United States
| | | | - Jayr Schmidt
- Hematology Division, AC Camargo Cancer Center, São Paulo, SP, Brazil
| | - Marcos de Lima
- Division of Hematology, The Ohio State University, Columbus, OH, United States
| | - Evandro Bezerra
- Division of Hematology, The Ohio State University, Columbus, OH, United States
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Strongyli E, Evangelidis P, Sakellari I, Gavriilaki M, Gavriilaki E. Change in Neurocognitive Function in Patients Who Receive CAR-T Cell Therapies: A Steep Hill to Climb. Pharmaceuticals (Basel) 2024; 17:591. [PMID: 38794161 PMCID: PMC11123727 DOI: 10.3390/ph17050591] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 05/01/2024] [Accepted: 05/02/2024] [Indexed: 05/26/2024] Open
Abstract
Immunotherapy with chimeric antigen receptor T (CAR-T) cell therapies has brought substantial improvement in clinical outcomes in patients with relapsed/refractory B cell neoplasms. However, complications such as cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS) limit the therapeutic efficacy of this treatment approach. ICANS can have a broad range of clinical manifestations, while various scoring systems have been developed for its grading. Cognitive decline is prevalent in CAR-T therapy recipients including impaired attention, difficulty in item naming, and writing, agraphia, and executive dysfunction. In this review, we aim to present the diagnostic methods and tests that have been used for the recognition of cognitive impairment in these patients. Moreover, up-to-date data about the duration of cognitive impairment symptoms after the infusion are presented. More research on the risk factors, pathogenesis, preventive measures, and therapy of neurocognitive impairment is crucial for better outcomes for our patients.
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Affiliation(s)
- Evlampia Strongyli
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (E.S.); (I.S.)
| | - Paschalis Evangelidis
- Second Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece;
| | - Ioanna Sakellari
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (E.S.); (I.S.)
| | - Maria Gavriilaki
- 1st Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece;
| | - Eleni Gavriilaki
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (E.S.); (I.S.)
- Second Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece;
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Perthus A, Colin F, Charton E, Anota A, Lhomme F, Manson G, De Guibert S, Daufresne P, Bellec A, Le Bars L, De Barros S, Ysebaert L, Merceur M, Cogné M, Lamy De La Chapelle T, Houot R, Moignet A. Remission after CAR T-cell therapy: Do lymphoma patients recover a normal life? Hemasphere 2024; 8:e72. [PMID: 38803454 PMCID: PMC11129324 DOI: 10.1002/hem3.72] [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: 01/12/2024] [Revised: 03/14/2024] [Accepted: 03/28/2024] [Indexed: 05/29/2024] Open
Abstract
Chimeric antigen receptor T cells (CAR T cells) can induce prolonged remission in a substantial subset of patients with relapse/refractory lymphoma. However, little is known about patients' life after CAR T-cell therapy. We prospectively assessed the multidimensional recovery of lymphoma patients in remission, before leukapheresis, before CAR T-cell infusion, and 3, 6, and 12 months thereafter. Validated tools were used to measure lymphoma-related and global health-related quality of life (HRQoL; Functional Assessment of Cancer Therapy-Lymphoma [FACT-Lym] and EQ-5D-5L), cognitive complaint (FACT-Cognition), fatigue (FACIT-Fatigue subscale), psychological status (Hospital Anxiety and Depression Scale, Post-Traumatic Check List Scale), and sexuality (Relationship and Sexuality Scale). Beyond 12 months of remission, we also surveyed physical, professional, sexual, and general life status. At 3, 6, and 12 months, 53, 35, and 23 patients were evaluable, respectively. Improvement in lymphoma-related HRQoL was clinically relevant at 3, 6, and 12 months with a mean change from baseline of 10.9 (95% confidence interval [CI]: 5.8; 16.1), 12.2 (95% CI: 4.2; 20.1), and 11.72 (95% CI: 2.06; 21.38), respectively. Improvement in global HRQoL, fatigue, and anxiety was clinically relevant, but 20%-40% of patients experienced persistent fatigue, psychological distress, and cognitive complaints over time. Beyond 12 months after CAR T cells, 81.8% of 22 evaluable patients were satisfied with their daily life. Physical activity, professional, sexual, and global well-being had returned to prediagnosis levels in nearly half of the patients. We found an improvement in HRQoL after CAR T-cell therapy including anxiety, depression, sexual satisfaction, and general well-being. However, not all patients recover a "normal life." Further research is needed to determine which patients are at risk of quality-of-life impairment to improve recovery after CAR T-cell infusion.
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Affiliation(s)
- Alya Perthus
- Service d'Hématologie—CHU Pontchaillou, Department of HematologyUniversity Hospital of RennesRennesFrance
| | - Fanny Colin
- Service d'Hématologie—CHU Pontchaillou, Department of HematologyUniversity Hospital of RennesRennesFrance
| | - Emilie Charton
- Human and Social Sciences DepartmentLeon Berard CenterLyonFrance
| | - Amélie Anota
- Human and Social Sciences DepartmentLeon Berard CenterLyonFrance
- Department of Clinical Research and InnovationLeon Berard CenterLyonFrance
| | - Faustine Lhomme
- Service d'Hématologie—CHU Pontchaillou, Department of HematologyUniversity Hospital of RennesRennesFrance
| | - Guillaume Manson
- Service d'Hématologie—CHU Pontchaillou, Department of HematologyUniversity Hospital of RennesRennesFrance
| | - Sophie De Guibert
- Service d'Hématologie—CHU Pontchaillou, Department of HematologyUniversity Hospital of RennesRennesFrance
| | - Pierre Daufresne
- Service d'Hématologie—CHU Pontchaillou, Department of HematologyUniversity Hospital of RennesRennesFrance
| | - Adeline Bellec
- Service d'Hématologie—CHU Pontchaillou, Department of HematologyUniversity Hospital of RennesRennesFrance
| | - Laetitia Le Bars
- Service d'Hématologie—CHU Pontchaillou, Department of HematologyUniversity Hospital of RennesRennesFrance
| | - Sandra De Barros
- Department of HematologyCancer University Institute of Toulouse OncopoleToulouseFrance
| | - Loïc Ysebaert
- Department of HematologyCancer University Institute of Toulouse OncopoleToulouseFrance
| | - Marianne Merceur
- Department of Physical and Rehabilitation MedicineUniversity Hospital of RennesRennesFrance
| | - Mélanie Cogné
- Department of Physical and Rehabilitation MedicineUniversity Hospital of RennesRennesFrance
| | - Thierry Lamy De La Chapelle
- Service d'Hématologie—CHU Pontchaillou, Department of HematologyUniversity Hospital of RennesRennesFrance
- UMR U1236, INSERMUniversity of RennesRennesFrance
| | - Roch Houot
- Service d'Hématologie—CHU Pontchaillou, Department of HematologyUniversity Hospital of RennesRennesFrance
- UMR U1236, INSERMUniversity of RennesRennesFrance
| | - Aline Moignet
- Service d'Hématologie—CHU Pontchaillou, Department of HematologyUniversity Hospital of RennesRennesFrance
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5
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Knight E T, Oluwole O, Kitko C. The Implementation of Chimeric Antigen Receptor (CAR) T-cell Therapy in Pediatric Patients: Where Did We Come From, Where Are We Now, and Where are We Going? Clin Hematol Int 2024; 6:96-115. [PMID: 38817691 PMCID: PMC11108586 DOI: 10.46989/001c.94386] [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: 01/17/2024] [Accepted: 02/13/2024] [Indexed: 06/01/2024] Open
Abstract
CD19-directed Chimeric Antigen Receptor (CAR) T-cell therapy has revolutionized the treatment of patients with B-cell acute lymphoblastic leukemia (B-ALL). Somewhat uniquely among oncologic clinical trials, early clinical development occurred simultaneously in both children and adults. In subsequent years however, the larger number of adult patients with relapsed/refractory (r/r) malignancies has led to accelerated development of multiple CAR T-cell products that target a variety of malignancies, resulting in six currently FDA-approved for adult patients. By comparison, only a single CAR-T cell therapy is approved by the FDA for pediatric patients: tisagenlecleucel, which is approved for patients ≤ 25 years with refractory B-cell precursor ALL, or B-cell ALL in second or later relapse. Tisagenlecleucel is also under evaluation in pediatric patients with relapsed/refractory B-cell non-Hodgkin lymphoma, but is not yet been approved for this indication. All the other FDA-approved CD19-directed CAR-T cell therapies available for adult patients (axicabtagene ciloleucel, brexucabtagene autoleucel, and lisocabtagene maraleucel) are currently under investigations among children, with preliminary results available in some cases. As the volume and complexity of data continue to grow, so too does the necessity of rapid assimilation and implementation of those data. This is particularly true when considering "atypical" situations, e.g. those arising when patients do not precisely conform to the profile of those included in pivotal clinical trials, or when alternative treatment options (e.g. hematopoietic stem cell transplantation (HSCT) or bispecific T-cell engagers (BITEs)) are also available. We have therefore developed a relevant summary of the currently available literature pertaining to the use of CD19-directed CAR-T cell therapies in pediatric patients, and sought to provide guidance for clinicians seeking additional data about specific clinical situations.
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Affiliation(s)
| | - Olalekan Oluwole
- Medicine Hematology and Oncology, Vanderbilt University Medical Center
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6
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Puckrin R, Jamani K, Jimenez-Zepeda VH. Long-term survivorship care after CAR-T cell therapy. Eur J Haematol 2024; 112:41-50. [PMID: 37767547 DOI: 10.1111/ejh.14100] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 08/29/2023] [Indexed: 09/29/2023]
Abstract
While cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome are well-recognized acute toxicities of chimeric antigen receptor (CAR) T cell therapy, these complications have become increasingly manageable by protocolized treatment algorithms incorporating the early administration of tocilizumab and corticosteroids. As CAR-T cell therapy expands to new disease indications and the number of long-term survivors steadily increases, there is growing recognition of the need to appropriately evaluate and manage the late effects of CAR-T cell therapy, including late-onset or persistent neurotoxicity, prolonged cytopenias, delayed immune reconstitution and infections, subsequent malignancies, organ dysfunction, psychological distress, and fertility implications. In this review, we provide a practical approach to the long-term survivorship care of the CAR-T cell recipient, with a focus on the optimal strategies to address the common and challenging late complications affecting this unique population.
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Affiliation(s)
- Robert Puckrin
- Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada
| | - Kareem Jamani
- Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada
| | - Victor H Jimenez-Zepeda
- Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada
- Arnie Charbonneau Cancer Research Institute, University of Calgary, Calgary, Alberta, Canada
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Epperly R, Shah NN. Long-term follow-up of CD19-CAR T-cell therapy in children and young adults with B-ALL. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:77-83. [PMID: 38066902 PMCID: PMC10727115 DOI: 10.1182/hematology.2023000422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
The tremendous successes of CD19-directed CAR T cells in children and young adults with B-cell acute lymphoblastic leukemia (B-ALL) has led to the more widespread use of this important treatment modality. With an ability to induce remission and potentially lead to long-term survival in patients with multiply relapsed/chemotherapy refractory disease, more children are now receiving this therapy with the hope of inducing a long-term durable remission (with or without consolidative hematopoietic cell transplantation). While overcoming the acute toxicities was critical to its broad implementation, the emerging utilization requires close evaluation of subacute and delayed toxicities alongside a consideration of late effects and issues related to survivorship following CAR T cells. In this underexplored area of toxicity monitoring, this article reviews the current state of the art in relationship to delayed toxicities while highlighting areas of future research in the study of late effects in children and young adults receiving CAR T cells.
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Affiliation(s)
- Rebecca Epperly
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN
| | - Nirali N Shah
- Pediatric Oncology Branch, Center for Cancer Research (CCR), National Cancer Institute (NCI), NIH, Bethesda, MD
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8
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Liang EC, Sidana S. Managing side effects: guidance for use of immunotherapies in multiple myeloma. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:348-356. [PMID: 38066898 PMCID: PMC10727020 DOI: 10.1182/hematology.2023000435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Chimeric antigen receptor T-cell therapy and bispecific T-cell recruiting antibodies have transformed the treatment landscape for relapsed/refractory multiple myeloma, with B-cell maturation antigen being the most common target and other targets in clinical development. However, these therapies are associated with unique and severe toxicities, including cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), delayed neurotoxicity, cytopenias, and infection. In addition, immune effector cell-associated hemophagocytic lymphohistiocytosis (HLH)-like syndrome (IEC-HS), which exhibits overlap between CRS and HLH, can be challenging to diagnose and treat. In this review, we provide an overview of toxicities associated with novel immunotherapies for treatment of multiple myeloma and describe management recommendations. The pathophysiology and risk factors behind these toxicities are not yet comprehensively understood. Based on consensus recommendations, treatment for CRS consists of tocilizumab and steroids, while treatment for ICANS includes steroids and anakinra in severe cases. Management of cytopenias and infection is similar to post-hematopoietic cell transplantation principles with antimicrobial prophylaxis, growth factor support, immunoglobulin replacement, and vaccinations. In contrast, effective treatments for delayed neurotoxicity and IEC-HS are lacking, although steroids and anakinra are commonly used. Management of all these toxicities should include a broad differential and multidisciplinary collaboration with infectious diseases, neurology, and/or critical care providers.
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Affiliation(s)
- Emily C Liang
- University of Washington and Fred Hutchinson Cancer Center, Seattle, WA
| | - Surbhi Sidana
- Department of Medicine, Division of Blood and Marrow Transplantation and Cellular Therapy, Stanford University School of Medicine, Stanford, CA
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Kazzi C, Kuznetsova V, Siriratnam P, Griffith S, Wong S, Tam CS, Alpitsis R, Spencer A, O'Brien TJ, Malpas CB, Monif M. Cognition following chimeric antigen receptor T-cell therapy: A systematic review. J Autoimmun 2023; 140:103126. [PMID: 37837807 DOI: 10.1016/j.jaut.2023.103126] [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: 08/03/2023] [Revised: 09/23/2023] [Accepted: 10/04/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND This systematic review aimed to characterise the cognitive outcomes of patients who received chimeric antigen receptor T-cell therapy. METHODS A systematic search of the literature was performed using PubMed, PsycINFO, SCOPUS, EMBASE, Medline, and CINAHL (February 2023). Risk of bias was assessed using the JBI Checklist for Case Reports and the Risk of Bias Assessment Tool for Non-randomised Studies. RESULTS Twenty-two studies met inclusion criteria with a total of 1104 participants. There was considerable methodological heterogeneity with differing study designs (e.g., cohort studies, clinical trials, case studies, a qualitative interview, and a focus group), measures of cognition (e.g., self-report, neuropsychological measures, clinician assessed/neurological examinations), and longest follow-up time points (i.e., five days to five years). DISCUSSION Results of the studies were heterogenous with studies demonstrating stable, improved, or reduced cognition across differing time points. Overall, cognitive symptoms are common particularly in the acute stage (<2 weeks) post-infusion. Most deficits that arise in the acute stage resolve within one to two weeks, however, there is a subset of patients who continue to experience and self-report persistent deficits in the subacute and chronic stages. Future studies are needed to comprehensively analyse cognition using a combination of self-report and psychometric measures following chimeric antigen receptor T-cell therapy in the acute, subacute, and chronic settings.
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Affiliation(s)
- Christina Kazzi
- Department of Neurosciences, Faculty of Medicine, Nursing and Health Sciences, Central Clinical School, Monash University, Melbourne, VIC, Australia; Department of Neurology, Alfred Health, Melbourne, VIC, Australia
| | - Valeriya Kuznetsova
- Neuroimmunology Centre, Department of Neurology, Royal Melbourne Hospital, Melbourne, VIC, Australia; Department of Clinical Haematology, Peter MacCallum Cancer Centre, VIC, Australia; CORe, Department of Medicine, University of Melbourne, VIC, Australia
| | - Pakeeran Siriratnam
- Department of Neurosciences, Faculty of Medicine, Nursing and Health Sciences, Central Clinical School, Monash University, Melbourne, VIC, Australia; Department of Neurology, Alfred Health, Melbourne, VIC, Australia
| | - Sarah Griffith
- Department of Neurosciences, Faculty of Medicine, Nursing and Health Sciences, Central Clinical School, Monash University, Melbourne, VIC, Australia; Department of Neurology, Alfred Health, Melbourne, VIC, Australia
| | - Shu Wong
- Department of Haematology, Alfred Hospital, Central Clinical School, VIC, Australia
| | - Constantine S Tam
- Department of Clinical Haematology, Peter MacCallum Cancer Centre, VIC, Australia; Department of Haematology, Alfred Hospital, Central Clinical School, VIC, Australia
| | - Rubina Alpitsis
- Department of Neurosciences, Faculty of Medicine, Nursing and Health Sciences, Central Clinical School, Monash University, Melbourne, VIC, Australia; Department of Neurology, Alfred Health, Melbourne, VIC, Australia
| | - Andrew Spencer
- Department of Haematology, Alfred Hospital, Central Clinical School, VIC, Australia; Australian Centre for Blood Diseases, Monash University, VIC, Australia
| | - Terence J O'Brien
- Department of Neurosciences, Faculty of Medicine, Nursing and Health Sciences, Central Clinical School, Monash University, Melbourne, VIC, Australia; Department of Neurology, Alfred Health, Melbourne, VIC, Australia
| | - Charles B Malpas
- Department of Neurosciences, Faculty of Medicine, Nursing and Health Sciences, Central Clinical School, Monash University, Melbourne, VIC, Australia; Department of Neurology, Alfred Health, Melbourne, VIC, Australia; Neuroimmunology Centre, Department of Neurology, Royal Melbourne Hospital, Melbourne, VIC, Australia; Department of Neurology, The Royal Melbourne Hospital, Parkville, VIC, Australia; Melbourne School of Psychological Sciences, University of Melbourne, VIC, Australia
| | - Mastura Monif
- Department of Neurosciences, Faculty of Medicine, Nursing and Health Sciences, Central Clinical School, Monash University, Melbourne, VIC, Australia; Department of Neurology, Alfred Health, Melbourne, VIC, Australia; Department of Neurology, The Royal Melbourne Hospital, Parkville, VIC, Australia.
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10
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Liu J, Tang M, Zhu D, Ruan G, Zou S, Cheng Z, Zhu X, Zhu Y. The remodeling of metabolic brain pattern in patients with extracranial diffuse large B-cell lymphoma. EJNMMI Res 2023; 13:94. [PMID: 37902852 PMCID: PMC10616001 DOI: 10.1186/s13550-023-01046-6] [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: 06/28/2023] [Accepted: 10/22/2023] [Indexed: 11/01/2023] Open
Abstract
BACKGROUND Owing to the advances in diagnosis and therapy, survival or remission rates for lymphoma have improved prominently. Apart from the lymphoma- and chemotherapy-related somatic symptom burden, increasing attention has been drawn to the health-related quality of life. The application of 18F-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET/CT) has been routinely recommended for the staging and response assessment of FDG-avid lymphoma. However, up till now, only a few researches have investigated the brain metabolic impairments in patients with pre-treatment lymphoma. The determination of the lymphoma-related metabolic brain pattern would facilitate exploring the tailored therapeutic regimen to alleviate not only the physiological, but also the psychological symptoms. In this retrospective study, we aimed to establish the diffuse large B-cell lymphoma-related pattern (DLBCLRP) of metabolic brain network and investigate the correlations between DLBCLRP and several indexes of the staging and response assessment. RESULTS The established DLBCLRP was characterized by the increased metabolic activity in bilateral cerebellum, brainstem, thalamus, striatum, hippocampus, amygdala, parahippocampal gyrus and right middle temporal gyrus and by the decreased metabolic activity in bilateral occipital lobe, parietal lobe, anterior cingulate gyrus, midcingulate cortex and medial frontal gyrus. Significant difference in the baseline expression of DLBCLRP was found among complete metabolic response (CMR), partial metabolic response (PMR) and progressive metabolic disease (PMD) groups (P < 0.01). DLBCLRP expressions were also significantly or tended to be positively correlated with international prognostic index (IPI) (rs = 0.306, P < 0.05), lg(total metabolic tumor volume, TMTV) (r = 0.298, P < 0.05) and lg(total lesion glycolysis, TLG) (r = 0.233, P = 0.064). Though no significant correlation of DLBCLRP expression was found with Ann Arbor staging or tumor SUVmax (P > 0.05), the post-treatment declines of DLBCLRP expression were significantly positively correlated with Ann Arbor staging (rs = 0.284, P < 0.05) and IPI (rs = 0.297, P < 0.05). CONCLUSIONS The proposed DLBCLRP would lay the foundation for further investigating the cerebral dysfunction related to DLBCL itself and/or treatments. Besides, the expression of DLBCLRP was associated with the tumor burden of lymphoma, implying a potential biomarker for prognosis.
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Affiliation(s)
- Junyi Liu
- Department of Nuclear Medicine and PET Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Ave, Wuhan, 430030, China
| | - Ming Tang
- Department of Nuclear Medicine and PET Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Ave, Wuhan, 430030, China
| | - Dongling Zhu
- Department of Nuclear Medicine and PET Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Ave, Wuhan, 430030, China
| | - Ge Ruan
- Department of Radiology, Hospital, Hubei University, Wuhan, 430062, China
| | - Sijuan Zou
- Department of Nuclear Medicine and PET Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Ave, Wuhan, 430030, China
| | - Zhaoting Cheng
- Department of Nuclear Medicine and PET Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Ave, Wuhan, 430030, China
| | - Xiaohua Zhu
- Department of Nuclear Medicine and PET Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Ave, Wuhan, 430030, China.
| | - Yuankai Zhu
- Department of Nuclear Medicine and PET Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Ave, Wuhan, 430030, China.
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11
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Correa DD, Vachha BA, Baser RE, Koch A, Wong P, Gohel S, Giralt S, Root JC. Neuroimaging and Neurocognitive Outcomes in Older Patients with Multiple Myeloma Treated with Chemotherapy and Autologous Stem Cell Transplantation. Cancers (Basel) 2023; 15:4484. [PMID: 37760454 PMCID: PMC10526394 DOI: 10.3390/cancers15184484] [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: 07/19/2023] [Revised: 08/21/2023] [Accepted: 09/04/2023] [Indexed: 09/29/2023] Open
Abstract
There is a paucity of research on treatment-related neurotoxicity in older adults with multiple myeloma (MM) treated with high-dose chemotherapy (HDC) and autologous SCT (HDC/ASCT), despite the increasing use of this regimen. We examined resting state functional connectivity (RSFC), gray matter (GM) volume, neurocognitive function (NF), and proinflammatory cytokines (PCy) in older patients with MM pre- and post-HDC/ASCT. Eighteen patients underwent MRI, NF tests, and serum PCy measurements prior to HDC/ASCT, and fifteen patients completed a follow up five-months post-HDC/ASCT. There were significant decreases in RSFC post-HDC/ASCT in (1) the central executive network (CEN) involving the left dorsolateral prefrontal cortex and right posterior parietal cortex (p = 0.022) and (2) the CEN involving the right posterior parietal cortex and the salience network involving the right dorsal anterior cingulate cortex (p = 0.029). There were no significant changes in GM or NF, except for improvements in attention (Digit Span Backward, p = 0.03). There were significant increases in several PCy post-HDC/ASCT (p ≤ 0.05). In conclusion, RSFC decreased in frontal, parietal, and cingulate cortices post-HDC/ASCT, NF was relatively stable, and several PCy increased. These findings are congruent with other studies in cancer patients and provide supporting evidence for the vulnerability of frontoparietal regions to chemotherapy's adverse effects.
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Affiliation(s)
- Denise D. Correa
- Department of Neurology, MSKCC—Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
- Department of Neurology, Weill Cornell Medical College, New York, NY 10065, USA
| | - Behroze A. Vachha
- Department of Radiology, UMass Chan Medical School, Worcester, MA 01665, USA
| | - Raymond E. Baser
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Adrian Koch
- Department of Neurology, MSKCC—Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Phillip Wong
- Department of Immune Monitoring Facility, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Suril Gohel
- Department of Heath Informatics, Rutgers University School of Health Professions, Newark, NJ 08854, USA
| | - Sergio Giralt
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - James C. Root
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
- Departments of Psychiatry, Weill Cornell Medical College, New York, NY 10065, USA
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12
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Santomasso BD, Gust J, Perna F. How I treat unique and difficult-to-manage cases of CAR T-cell therapy-associated neurotoxicity. Blood 2023; 141:2443-2451. [PMID: 36877916 PMCID: PMC10329188 DOI: 10.1182/blood.2022017604] [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: 10/24/2022] [Revised: 02/01/2023] [Accepted: 02/17/2023] [Indexed: 03/08/2023] Open
Abstract
With growing indications for chimeric antigen receptor (CAR) T-cell therapy, toxicity profiles are evolving. There is an urgent and unmet need of approaches to optimally manage emerging adverse events that extend beyond the standard paradigm of cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome (ICANS). Although management guidelines exist for ICANS, there is little guidance on how to approach patients with neurologic comorbidities, and how to manage rare neurotoxicity presentations, such as CAR T-cell therapy-related cerebral edema, severe motor complications or late-onset neurotoxicity. In this study, we present 3 scenarios of patients treated with CAR T cells who develop unique types of neurotoxicity, and we describe an approach for the evaluation and management based on experience because objective data are limited. The goal of this study is to develop an awareness of emerging and unusual complications, discuss treatment approaches, and help institutions and health care providers establish frameworks to navigate how to best address unusual neurotoxicities to ultimately improve patient outcomes.
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Affiliation(s)
- Bianca D. Santomasso
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY
- Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Juliane Gust
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, WA
- Seattle Children's Research Institute Center for Integrative Brain Research, Seattle, WA
| | - Fabiana Perna
- Division of Hematology/Oncology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
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13
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Karschnia P, Rejeski K, Subklewe M, von Baumgarten L. Reader Response: Long-term Neurologic Safety in Patients With B-Cell Lymphoma Treated With Anti-CD19 Chimeric Antigen Receptor T-Cell Therapy. Neurology 2023; 100:687-688. [PMID: 37012062 PMCID: PMC10104609 DOI: 10.1212/wnl.0000000000207209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 02/06/2023] [Indexed: 04/05/2023] Open
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14
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Fleming B, Edison P, Kenny L. Cognitive impairment after cancer treatment: mechanisms, clinical characterization, and management. BMJ 2023; 380:e071726. [PMID: 36921926 DOI: 10.1136/bmj-2022-071726] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
Cognitive impairment is a debilitating side effect experienced by patients with cancer treated with systemically administered anticancer therapies. With around 19.3 million new cases of cancer worldwide in 2020 and the five year survival rate growing from 50% in 1970 to 67% in 2013, an urgent need exists to understand enduring side effects with severe implications for quality of life. Whereas cognitive impairment associated with chemotherapy is recognized in patients with breast cancer, researchers have started to identify cognitive impairment associated with other treatments such as immune, endocrine, and targeted therapies only recently. The underlying mechanisms are diverse and therapy specific, so further evaluation is needed to develop effective therapeutic interventions. Drug and non-drug management strategies are emerging that target mechanistic pathways or the cognitive deficits themselves, but they need to be rigorously evaluated. Clinically, consistent use of objective diagnostic tools is necessary for accurate diagnosis and clinical characterization of cognitive impairment in patients treated with anticancer therapies. This should be supplemented with clinical guidelines that could be implemented in daily practice. This review summarizes the recent advances in the mechanisms, clinical characterization, and novel management strategies of cognitive impairment associated with treatment of non-central nervous system cancers.
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Affiliation(s)
- Ben Fleming
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, London, UK
| | - Paul Edison
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, London, UK
- College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Laura Kenny
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
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15
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Tan BBJW, Chua SKK, Soh QY, Chan LL, Tan EK. Chimeric antigen receptor (CAR) T therapy and cognitive functions. J Neurol Sci 2023; 444:120495. [PMID: 36446259 DOI: 10.1016/j.jns.2022.120495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 11/10/2022] [Accepted: 11/12/2022] [Indexed: 11/17/2022]
Affiliation(s)
| | - Shaun Kai Kiat Chua
- National Neuroscience Institute, Singapore, Singapore; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Qian Ying Soh
- National Neuroscience Institute, Singapore, Singapore; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Ling-Ling Chan
- Duke-NUS Medical School, Singapore, Singapore; Singapore General Hospital, Singapore
| | - Eng-King Tan
- National Neuroscience Institute, Singapore, Singapore; Duke-NUS Medical School, Singapore, Singapore.
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16
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Nath K, Wudhikarn K, Alarcon Tomas A, Perales MA. Safety evaluation of axicabtagene ciloleucel for relapsed or refractory large B-cell lymphoma. Expert Opin Drug Saf 2023; 22:5-15. [PMID: 36737060 PMCID: PMC9975047 DOI: 10.1080/14740338.2023.2177268] [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: 08/04/2022] [Accepted: 02/02/2023] [Indexed: 02/05/2023]
Abstract
INTRODUCTION CD19-directed chimeric antigen receptor (CAR) T-cell therapy is a highly effective therapy for patients with relapsed/refractory large B-cell lymphoma (LBCL) and three CD19 CAR T-cell products (axicabtagene ciloleucel, tisagenlecleucel and lisocabtagene maraleucel) are currently approved for this indication. Despite the clinical benefit of CD19 directed CAR T-cell therapy, this treatment is associated with significant morbidity from treatment-emergent toxicities. AREAS COVERED This Review discusses the safety considerations of axicabtagene ciloleucel in patients with LBCL. This includes discussion of the frequently observed immune-mediated toxicities of cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome. Additionally, we review CAR T-cell therapy related cytopenias, infection, organ dysfunction and the more recently described hemophagocytic lymphohistiocytosis. EXPERT OPINION A thorough understanding of the toxicities associated with CD19-directed CAR T-cell therapy will facilitate the optimal selection of patients for this therapy. Furthermore, knowledge of preventative measures of CAR T-cell related complications, and early recognition and appropriate intervention will lead to the safe administration of these therapies, and ultimately improved outcomes for our patients.
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Affiliation(s)
- Karthik Nath
- Cellular Therapy Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kitsada Wudhikarn
- Division of Hematology and Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Ana Alarcon Tomas
- Division of Hematology and Hemotherapy, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
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17
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Taylor MR, Steineck A, Lahijani S, Hall AG, Jim HSL, Phelan R, Knight JM. Biobehavioral Implications of Chimeric Antigen Receptor T-cell Therapy: Current State and Future Directions. Transplant Cell Ther 2023; 29:19-26. [PMID: 36208728 DOI: 10.1016/j.jtct.2022.09.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/22/2022] [Accepted: 09/29/2022] [Indexed: 11/06/2022]
Abstract
Chimeric antigen receptor (CAR) T-cell therapy has demonstrated remarkable clinical responses in hematologic malignancies. Recent advances in CAR T-cell therapy have expanded its application into other populations including older patients and those with central nervous system and solid tumors. Although its clinical efficacy has been excellent for some malignancies, CAR T-cell therapy is associated with severe and even life-threatening immune-mediated toxicities, including cytokine release syndrome and neurotoxicity. There is a strong body of scientific evidence highlighting the connection between immune activation and neurocognitive and psychological phenomena. To date, there has been limited investigation into this relationship in the context of immunotherapy. In this review, we present a biobehavioral framework to inform current and future cellular therapy research and contribute to improving the multidimensional outcomes of patients receiving CAR T-cell therapy.
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Affiliation(s)
- Mallory R Taylor
- Division of Hematology/Oncology, Department of Pediatrics, University of Washington, Seattle, Washington; Palliative Care and Resilience Program, Seattle Children's Research Institute, Seattle, Washington
| | - Angela Steineck
- Division of Pediatric Hematology, Oncology, Blood and Marrow Transplantation, Department of Pediatrics, Medical College of Wisconsin and Children's Wisconsin, Milwaukee, Wisconsin
| | - Sheila Lahijani
- Division of Medical Psychiatry, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California
| | - Anurekha G Hall
- Division of Hematology/Oncology, Department of Pediatrics, University of Washington, Seattle, Washington
| | - Heather S L Jim
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida
| | - Rachel Phelan
- Division of Pediatric Hematology, Oncology, Blood and Marrow Transplantation, Department of Pediatrics, Medical College of Wisconsin and Children's Wisconsin, Milwaukee, Wisconsin
| | - Jennifer M Knight
- Departments of Psychiatry, Medicine, and Microbiology & Immunology, Medical College of Wisconsin, Milwaukee, Wisconsin
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18
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Evaluating the Patient with Neurotoxicity after Chimeric Antigen Receptor T-cell Therapy. Curr Treat Options Oncol 2022; 23:1845-1860. [PMID: 36525238 DOI: 10.1007/s11864-022-01035-2] [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: 10/30/2022] [Indexed: 12/23/2022]
Abstract
OPINION STATEMENT Chimeric antigen receptor (CAR) T-cells are now a well-established treatment for hematologic malignancies. Their use in clinical practice has expanded quite rapidly and hospitals have developed CAR T-cell protocols to evaluate patients for associated toxicities, and particularly for neurotoxicity. There are many variables that influence the risk for developing this complication, many of which are not fully understood. The severity can be related to a particular product. Clinical vigilance is critical to facilitate early recognition of neurotoxicity, hence the importance of pre-CAR T-cell neurological evaluation of each patient. While details of such an evaluation may slightly differ between institutions, generally a comprehensive neurological evaluation including assessment of cognitive abilities along with magnetic resonance imaging (MRI) of the brain is a gold standard. Management of neurotoxicity requires a well-orchestrated team approach with specialists from oncology, neurology, oftentimes neurosurgery and neuro-intensive care. Diagnostic work-up frequently includes detailed neurologic evaluation with comparison to the baseline assessment, imaging of the brain, electroencephalogram, and lumbar puncture. While steroids are uniformly used for treatment, many patients also receive tocilizumab for an underlying and frequently concomitant cytokine release syndrome (CRS) in addition to symptom-driven supportive care. Novel CAR T-cell constructs and other agents allowing for potentially lower risk of toxicity are being explored. While neurotoxicity is predominantly an early, and reversible, event, a growing body of literature suggests that late neurotoxicity with variable clinical presentation can also occur.
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19
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Change in Patients' Perceived Cognition Following Chimeric Antigen Receptor T-Cell Therapy for Lymphoma. Transplant Cell Ther 2022; 28:401.e1-401.e7. [PMID: 35580732 PMCID: PMC9339228 DOI: 10.1016/j.jtct.2022.05.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 04/13/2022] [Accepted: 05/10/2022] [Indexed: 12/17/2022]
Abstract
Chimeric antigen receptor (CAR) T-cell therapy can lead to durable responses in patients with relapsed/refractory hematologic malignancies. Immune effector cell-associated neurotoxicity syndrome (ICANS) and cytokine release syndrome (CRS) are common and may place patients at risk for longer-term cognitive impairment. This study examined changes in cognition in the first year after CD19-directed CAR T-cell therapy for lymphoma, as well as CAR T-cell therapy-specific risk-factors (e.g., ICANS, CRS) and nonspecific risk factors (e.g., baseline quality of life, frailty) for worsening cognition. Patients' perceived cognition was assessed at baseline and at days 90 and 360. Clinical variables were abstracted from medical records. Piecewise mixed models were used to examine acute change (i.e., within 90 days) and longer-term change (i.e., from 90 days to 360 days) in cognition, as well as to explore risk factors for worsening cognition. Among 118 participants (mean age 61, 59% male), mean levels of perceived cognition did not change from baseline to day 90 (P> .05) but worsened from day 90 to day 360 in global cognition and in the domains of memory, language, organization, and divided attention (P< .05). Although statistically significant, changes were small (d values 0.15-0.28). Greater baseline fatigue, anxiety, and depression were associated with worse global cognition at day 90 (P< .01). Patients with more severe ICANS post-CART reported worse global cognition at day 360 (P< .05), although there were no differences in perceived cognition by severity of CRS (P> .05). Other putative risk factors were not associated with acute or longer-term changes in perceived cognition (P> .05). CAR T-cell therapy recipients reported delayed deterioration in several cognitive domains, although changes were small. These findings may be useful when educating future patients on what to expect when receiving CAR T-cell therapy.
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