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Géraud A, Hueso T, Laparra A, Bige N, Ouali K, Cauquil C, Stoclin A, Danlos FX, Hollebecque A, Ribrag V, Gazzah A, Goldschmidt V, Baldini C, Suzzoni S, Bahleda R, Besse B, Barlesi F, Lambotte O, Massard C, Marabelle A, Castilla-Llorente C, Champiat S, Michot JM. Reactions and adverse events induced by T-cell engagers as anti-cancer immunotherapies, a comprehensive review. Eur J Cancer 2024; 205:114075. [PMID: 38733717 DOI: 10.1016/j.ejca.2024.114075] [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: 03/01/2024] [Revised: 04/14/2024] [Accepted: 04/17/2024] [Indexed: 05/13/2024]
Abstract
T-cell engagers (TCE) are cancer immunotherapies that have recently demonstrated meaningful benefit for patients with hematological malignancies and solid tumors. The anticipated widespread use of T cell engagers poses implementation challenges and highlights the need for guidance to anticipate, mitigate, and manage adverse events. By mobilizing T-cells directly at the contact of tumor cells, TCE mount an obligatory and immediate anti-tumor immune response that could result in diverse reactions and adverse events. Cytokine release syndrome (CRS) is the most common reaction and is largely confined to the first drug administrations during step-up dosage. Cytokine release syndrome should be distinguished from infusion related reaction by clinical symptoms, timing to occurrence, pathophysiological aspects, and clinical management. Other common reactions and adverse events with TCE are immune effector Cell-Associated Neurotoxicity Syndrome (ICANS), infections, tumor flare reaction and cytopenias. The toxicity profiles of TCE and CAR-T cells have commonalities and distinctions that we sum-up in this review. As compared with CAR-T cells, TCE are responsible for less frequently severe CRS or ICANS. This review recapitulates terminology, pathophysiology, severity grading system and management of reactions and adverse events related to TCE.
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Affiliation(s)
- Arthur Géraud
- Gustave Roussy, Département d'Innovation Thérapeutique et d'Essais Précoces, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Thomas Hueso
- Gustave Roussy, Département d'Innovation Thérapeutique et d'Essais Précoces, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Ariane Laparra
- Gustave Roussy, Departement Interdisciplinaire d'Organisation des Parcours Patients, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Naike Bige
- Gustave Roussy, Service de réanimation et de soins intensifs, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Kaissa Ouali
- Gustave Roussy, Département d'Innovation Thérapeutique et d'Essais Précoces, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Cécile Cauquil
- Hôpital Universitaire du Kremlin Bicêtre, Service de Neurologie, 94270 Le Kremlin-Bicêtre, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Annabelle Stoclin
- Gustave Roussy, Service de réanimation et de soins intensifs, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - François-Xavier Danlos
- Gustave Roussy, Département d'Innovation Thérapeutique et d'Essais Précoces, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Antoine Hollebecque
- Gustave Roussy, Département d'Innovation Thérapeutique et d'Essais Précoces, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Vincent Ribrag
- Gustave Roussy, Department Hématologie, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Anas Gazzah
- Gustave Roussy, Département d'Innovation Thérapeutique et d'Essais Précoces, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Vincent Goldschmidt
- Gustave Roussy, Département d'Innovation Thérapeutique et d'Essais Précoces, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Capucine Baldini
- Gustave Roussy, Département d'Innovation Thérapeutique et d'Essais Précoces, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Steve Suzzoni
- Gustave Roussy, Department of Pharmacy, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Rastislav Bahleda
- Gustave Roussy, Département d'Innovation Thérapeutique et d'Essais Précoces, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Benjamin Besse
- Gustave Roussy, Department de Médecine Oncologique, 94805 Villejuif, France; Université Paris-Saclay, Gustave Roussy, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Fabrice Barlesi
- Gustave Roussy, Department de Médecine Oncologique, 94805 Villejuif, France; Université Paris-Saclay, Gustave Roussy, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Olivier Lambotte
- Université Paris-Saclay, Gustave Roussy, 94805 Villejuif, France; Hôpital Universitaire du Kremlin Bicêtre, Service de Médecine Interne, 94270 Le Kremlin-Bicêtre, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Christophe Massard
- Gustave Roussy, Département d'Innovation Thérapeutique et d'Essais Précoces, 94805 Villejuif, France; Université Paris-Saclay, Gustave Roussy, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Aurélien Marabelle
- Gustave Roussy, Département d'Innovation Thérapeutique et d'Essais Précoces, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Cristina Castilla-Llorente
- Gustave Roussy, Department Hématologie, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Stéphane Champiat
- Gustave Roussy, Département d'Innovation Thérapeutique et d'Essais Précoces, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Jean-Marie Michot
- Gustave Roussy, Département d'Innovation Thérapeutique et d'Essais Précoces, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France.
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2
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Hamilton MP, Craig E, Gentille Sanchez C, Mina A, Tamaresis J, Kirmani N, Ehlinger Z, Syal S, Good Z, Sworder B, Schroers-Martin J, Lu Y, Muffly L, Negrin RS, Arai S, Lowsky R, Meyer E, Rezvani AR, Shizuru J, Weng WK, Shiraz P, Sidana S, Bharadwaj S, Smith M, Dahiya S, Sahaf B, Kurtz DM, Mackall CL, Tibshirani R, Alizadeh AA, Frank MJ, Miklos DB. CAR19 monitoring by peripheral blood immunophenotyping reveals histology-specific expansion and toxicity. Blood Adv 2024; 8:3314-3326. [PMID: 38498731 DOI: 10.1182/bloodadvances.2024012637] [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: 01/11/2024] [Revised: 03/04/2024] [Accepted: 03/07/2024] [Indexed: 03/20/2024] Open
Abstract
ABSTRACT Chimeric antigen receptor (CAR) T cells directed against CD19 (CAR19) are a revolutionary treatment for B-cell lymphomas (BCLs). CAR19 cell expansion is necessary for CAR19 function but is also associated with toxicity. To define the impact of CAR19 expansion on patient outcomes, we prospectively followed a cohort of 236 patients treated with CAR19 (brexucabtagene autoleucel or axicabtagene ciloleucel) for mantle cell lymphoma (MCL), follicular lymphoma, and large BCL (LBCL) over the course of 5 years and obtained CAR19 expansion data using peripheral blood immunophenotyping for 188 of these patients. CAR19 expansion was higher in patients with MCL than other lymphoma histologic subtypes. Notably, patients with MCL had increased toxicity and required fourfold higher cumulative steroid doses than patients with LBCL. CAR19 expansion was associated with the development of cytokine release syndrome, immune effector cell-associated neurotoxicity syndrome, and the requirement for granulocyte colony-stimulating factor 14 days after infusion. Younger patients and those with elevated lactate dehydrogenase (LDH) had significantly higher CAR19 expansion. In general, no association between CAR19 expansion and LBCL treatment response was observed. However, when controlling for tumor burden, we found that lower CAR19 expansion in conjunction with low LDH was associated with improved outcomes in LBCL. In sum, this study finds CAR19 expansion principally associates with CAR-related toxicity. Additionally, CAR19 expansion as measured by peripheral blood immunophenotyping may be dispensable to favorable outcomes in LBCL.
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Affiliation(s)
- Mark P Hamilton
- Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
- Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University School of Medicine, Stanford, CA
- Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Erin Craig
- Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, CA
| | - Cesar Gentille Sanchez
- Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
| | - Alain Mina
- Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
| | - John Tamaresis
- Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, CA
| | - Nadia Kirmani
- Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
| | - Zachary Ehlinger
- Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
| | - Shriya Syal
- Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
| | - Zinaida Good
- Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
- Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, CA
| | - Brian Sworder
- Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Joseph Schroers-Martin
- Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Ying Lu
- Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, CA
| | - Lori Muffly
- Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
- Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Robert S Negrin
- Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
- Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Sally Arai
- Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
- Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Robert Lowsky
- Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
- Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Everett Meyer
- Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
- Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Andrew R Rezvani
- Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
- Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Judith Shizuru
- Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
- Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Wen-Kai Weng
- Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
- Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Parveen Shiraz
- Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
- Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Surbhi Sidana
- Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
- Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Sushma Bharadwaj
- Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
- Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Melody Smith
- Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
- Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Saurabh Dahiya
- Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
- Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Bita Sahaf
- Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
| | - David M Kurtz
- Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Crystal L Mackall
- Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
- Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Robert Tibshirani
- Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, CA
| | - Ash A Alizadeh
- Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, CA
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University, Stanford, CA
- Stanford Cancer Institute, Stanford University, Stanford, CA
| | - Matthew J Frank
- Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
- Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - David B Miklos
- Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
- Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University School of Medicine, Stanford, CA
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Al Hadidi S, Heslop HE, Brenner MK, Suzuki M. Bispecific antibodies and autologous chimeric antigen receptor T cell therapies for treatment of hematological malignancies. Mol Ther 2024:S1525-0016(24)00341-1. [PMID: 38822527 DOI: 10.1016/j.ymthe.2024.05.039] [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: 01/30/2024] [Revised: 05/14/2024] [Accepted: 05/29/2024] [Indexed: 06/03/2024] Open
Abstract
In recent years, the therapeutic landscape for hematological malignancies has markedly advanced, particularly since the inaugural approval of autologous chimeric antigen receptor T cell (CAR-T) therapy in 2017 for relapsed/refractory acute lymphoblastic leukemia (ALL). Autologous CAR-T therapy involves the genetic modification of a patient's T cells to specifically identify and attack cancer cells, while bispecific antibodies (BsAbs) function by binding to both cancer cells and immune cells simultaneously, thereby triggering an immune response against the tumor. The subsequent approval of various CAR-T therapies and BsAbs have revolutionized the treatment of multiple hematological malignancies, highlighting high response rates and a subset of patients achieving prolonged disease control. This review explores the mechanisms underlying autologous CAR-T therapies and BsAbs, focusing on their clinical application in multiple myeloma, ALL, and non-Hodgkin lymphoma. We provide comprehensive insights into their individual efficacy, limitations concerning broad application, and the potential of combination therapies. These upcoming strategies aim to propel the field forward, paving the way for safer and more effective therapeutic interventions in hematological malignancies.
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Affiliation(s)
- Samer Al Hadidi
- Myeloma Center, Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Helen E Heslop
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston Methodist Hospital, Texas Children's Hospital, Houston, TX, USA
| | - Malcolm K Brenner
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston Methodist Hospital, Texas Children's Hospital, Houston, TX, USA
| | - Masataka Suzuki
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston Methodist Hospital, Texas Children's Hospital, Houston, TX, USA.
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Miller A, Daum R, Wang T, Wu M, Tat C, Pfeiffer T, Navai S, Heczey A, Hegde M, Ahmed N, Whittle SB, Hill L, Martinez C, Krance R, Ramos CA, Rouce RH, Lulla P, Heslop HE, Omer B, Shekar M. Prolonged cytopenias after immune effector cell therapy and lymphodepletion in patients with leukemia, lymphoma and solid tumors. Cytotherapy 2024:S1465-3249(24)00689-3. [PMID: 38819365 DOI: 10.1016/j.jcyt.2024.04.075] [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: 08/13/2023] [Revised: 04/10/2024] [Accepted: 04/29/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND AIMS The success of chimeric antigen receptor (CAR) T-cell therapy in treating B-cell malignancies has led to the evaluation of CAR T-cells targeting a variety of other malignancies. Although the efficacy of CAR T-cells is enhanced when administered post-lymphodepleting chemotherapy, this can trigger bone marrow suppression and sustained cytopenia after CD19.CAR T-cell therapy. Additionally, systemic inflammation associated with CAR T-cell activity may contribute to myelosuppression. Cytopenias, such as neutropenia and thrombocytopenia, elevate the risk of severe infections and bleeding, respectively. However, data on the incidence of prolonged cytopenias after immune effector therapy in the solid tumor context remain limited. OBJECTIVE We compared the incidence of prolonged cytopenias after immune effector therapy including genetically modified T-cells, virus-specific T-cells (VSTs) and NKT-cells, as well non-gene-modified VSTs for leukemia, lymphoma, and solid tumors (ST) to identify associated risk factors. METHODS A retrospective analysis was conducted of 112 pediatric and adult patients with relapsed and/or refractory cancers who received lymphodepleting chemotherapy followed by immune effector therapy. Patients treated with 13 distinct immune effector cell therapies through 11 single-center clinical trials and 2 commercial products over a 6-year period were categorized into 3 types of malignancies: leukemia, lymphoma and ST. We obtained baseline patient characteristics and adverse events data for each participant, and tracked neutrophil and platelet counts following lymphodepletion. RESULTS Of 112 patients, 104 (92.9%) experienced cytopenias and 88 (79%) experienced severe cytopenias. Patients with leukemia experienced significantly longer durations of severe neutropenia (median duration of 14 days) compared with patients with lymphoma (7 days) or ST (11 days) (P = 0.002). Patients with leukemia also had a higher incidence of severe thrombocytopenia (74.1%), compared with lymphoma (46%, P = 0.03) and ST (14.3%, P < 0.0001). Prolonged cytopenias were significantly associated with disease type (63% of patients with leukemia, 44% of patients with lymphoma, and 22.9% of patients with ST, P = 0.006), prior hematopoietic stem cell transplant (HSCT) (66.7% with prior HSCT versus 38.3% without prior HSCT, P = 0.039), and development of immune effector cell-associated neurotoxicity syndrome (ICANS) (75% with ICANS versus 38% without ICANS, P = 0.027). There was no significant association between prolonged cytopenias and cytokine release syndrome. CONCLUSIONS Immune effector recipients often experience significant cytopenias due to marrow suppression following lymphodepletion regardless of disease, but prolonged severe cytopenias are significantly less common after treatment of patients with lymphoma and solid tumors.
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Affiliation(s)
- Anne Miller
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital and Houston Methodist Hospital, Houston, TX, USA
| | - Rachel Daum
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital and Houston Methodist Hospital, Houston, TX, USA; Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | - Tao Wang
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital and Houston Methodist Hospital, Houston, TX, USA; Dan L Duncan Comprehensive Cancer Center, Houston, TX, USA
| | - Mengfen Wu
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital and Houston Methodist Hospital, Houston, TX, USA; Dan L Duncan Comprehensive Cancer Center, Houston, TX, USA
| | - Candise Tat
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital and Houston Methodist Hospital, Houston, TX, USA; Department of Pediatrics, Texas Children's Hospital, Houston, TX, USA
| | - Thomas Pfeiffer
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital and Houston Methodist Hospital, Houston, TX, USA; Department of Pediatrics, Texas Children's Hospital, Houston, TX, USA; Department of Pediatrics, Division of Hematology/Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Shoba Navai
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital and Houston Methodist Hospital, Houston, TX, USA; Department of Pediatrics, Texas Children's Hospital, Houston, TX, USA
| | - Andras Heczey
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital and Houston Methodist Hospital, Houston, TX, USA; Dan L Duncan Comprehensive Cancer Center, Houston, TX, USA; Department of Pediatrics, Texas Children's Hospital, Houston, TX, USA
| | - Meenakshi Hegde
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital and Houston Methodist Hospital, Houston, TX, USA; Dan L Duncan Comprehensive Cancer Center, Houston, TX, USA; Department of Pediatrics, Texas Children's Hospital, Houston, TX, USA
| | - Nabil Ahmed
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital and Houston Methodist Hospital, Houston, TX, USA; Dan L Duncan Comprehensive Cancer Center, Houston, TX, USA; Department of Pediatrics, Texas Children's Hospital, Houston, TX, USA; Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, USA
| | - Sarah B Whittle
- Dan L Duncan Comprehensive Cancer Center, Houston, TX, USA; Department of Pediatrics, Texas Children's Hospital, Houston, TX, USA
| | - LaQuisa Hill
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital and Houston Methodist Hospital, Houston, TX, USA; Dan L Duncan Comprehensive Cancer Center, Houston, TX, USA
| | - Caridad Martinez
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital and Houston Methodist Hospital, Houston, TX, USA; Dan L Duncan Comprehensive Cancer Center, Houston, TX, USA; Department of Pediatrics, Texas Children's Hospital, Houston, TX, USA
| | - Robert Krance
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital and Houston Methodist Hospital, Houston, TX, USA; Dan L Duncan Comprehensive Cancer Center, Houston, TX, USA; Department of Pediatrics, Texas Children's Hospital, Houston, TX, USA
| | - Carlos A Ramos
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital and Houston Methodist Hospital, Houston, TX, USA; Dan L Duncan Comprehensive Cancer Center, Houston, TX, USA; Department of Pediatrics, Texas Children's Hospital, Houston, TX, USA
| | - Rayne H Rouce
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital and Houston Methodist Hospital, Houston, TX, USA; Dan L Duncan Comprehensive Cancer Center, Houston, TX, USA; Department of Pediatrics, Texas Children's Hospital, Houston, TX, USA
| | - Premal Lulla
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital and Houston Methodist Hospital, Houston, TX, USA; Dan L Duncan Comprehensive Cancer Center, Houston, TX, USA
| | - Helen E Heslop
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital and Houston Methodist Hospital, Houston, TX, USA; Dan L Duncan Comprehensive Cancer Center, Houston, TX, USA
| | - Bilal Omer
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital and Houston Methodist Hospital, Houston, TX, USA; Dan L Duncan Comprehensive Cancer Center, Houston, TX, USA; Department of Pediatrics, Texas Children's Hospital, Houston, TX, USA
| | - Meghan Shekar
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital and Houston Methodist Hospital, Houston, TX, USA; Department of Pediatrics, Texas Children's Hospital, Houston, TX, USA.
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5
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Shahid Z, Etra AM, Levine JE, Riches ML, Baluch A, Hill JA, Nakamura R, Toor AA, Ustun C, Young JAH, Perales MA, Epstein DJ, Murthy HS. Defining and Grading Infections in Clinical Trials Involving Hematopoietic Cell Transplantation: A Report From the BMT CTN Infectious Disease Technical Committee. Transplant Cell Ther 2024; 30:540.e1-540.e13. [PMID: 38458478 DOI: 10.1016/j.jtct.2024.03.001] [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: 12/07/2023] [Revised: 02/19/2024] [Accepted: 03/03/2024] [Indexed: 03/10/2024]
Abstract
The Blood and Marrow Transplant Clinical Trials Network (BMT-CTN) was established in 2001 to conduct large multi-institutional clinical trials addressing important issues towards improving the outcomes of HCT and other cellular therapies. Trials conducted by the network investigating new advances in HCT and cellular therapy not only assess efficacy but require careful capturing and severity assessment of adverse events and toxicities. Adverse infectious events in cancer clinical trials are typically graded according to the National Cancer Institute's Common Terminology Criteria for Adverse Events (CTCAE). However, there are limitations to this framework as it relates to HCT given the associated immunodeficiency and delayed immune reconstitution. The BMT-CTN Infection Grading System is a monitoring tool developed by the BMT CTN to capture and monitor infectious complications and differs from the CTCAE by its classification of infections based on their potential impact on morbidity and mortality for HCT recipients. Here we offer a report from the BMT CTN Infectious Disease Technical Committee regarding the rationale, development, and revising of BMT-CTN Infection Grading System and future directions as it applies to future clinical trials involving HCT and cellular therapy recipients.
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Affiliation(s)
- Zainab Shahid
- Department of Medicine, Infectious Disease Service, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York.
| | - Aaron M Etra
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - John E Levine
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Marcie L Riches
- Department of Medicine, Center for International Blood and Marrow Transplantation Research (CIBMTR), Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Aliyah Baluch
- Division of Infectious Diseases, Moffitt Cancer Center, Tampa, Florida
| | - Joshua A Hill
- Department of Medicine, University of Washington, WA and Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Wisconsin
| | - Ryo Nakamura
- Division of Hematology and HCT, City of Hope, Duarte, California
| | - Amir A Toor
- Lehigh Valley Health Network, Allentown, Pennsylvania
| | - Celalettin Ustun
- Division of Hematology, Oncology and Cell Therapy, Section of Bone Marrow Transplantation and Cellular Therapy, Rush Medical College, Chicago, Illinois
| | - Jo-Anne H Young
- Department of Medicine, Division of Infectious Disease and International Medicine, Program in Adult Transplant Infectious Disease, University of Minnesota, Minneapolis, Minnesota
| | - Miguel-Angel Perales
- Department of Medicine, Weill Cornell Medical College, New York, New York; Department of Medicine, Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center; Weill Cornell Medical College, New York, New York
| | - David J Epstein
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Hemant S Murthy
- Division of Hematology-Oncology, Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, Florida
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Jimkap N, El Baroudi O, Lemoine J, Pievani D, Pastoret C, Houot R. Management of immunosuppression in post-transplant lymphoproliferative disorders treated with CAR T cells. Br J Haematol 2024; 204:2112-2116. [PMID: 38411293 DOI: 10.1111/bjh.19355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/09/2024] [Accepted: 02/12/2024] [Indexed: 02/28/2024]
Affiliation(s)
- Nathacha Jimkap
- Hematology Department, Rennes University Hospital, Rennes University, Rennes, France
- Internal Medicine Department, Douala General Hospital, Douala, Cameroon
| | - Oussama El Baroudi
- Hematology Department, Rennes University Hospital, Rennes University, Rennes, France
- Hematology Department, University Hospital of Marrakech, Cadi Ayyad University, Marrakech, Morocco
| | - Jean Lemoine
- Hematology Department, AP-HP, Université Paris Cité, Paris, France
| | - Daniele Pievani
- Immunology-Hematology Department, Hôpital Saint Louis, Paris, France
| | - Cédric Pastoret
- Hematology Biology Department, Rennes University Hospital, Rennes University, Rennes, France
| | - Roch Houot
- Hematology Department, Rennes University Hospital, Rennes University, Rennes, France
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7
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Short L, Holt RA, Cullis PR, Evgin L. Direct in vivo CAR T cell engineering. Trends Pharmacol Sci 2024; 45:406-418. [PMID: 38614815 DOI: 10.1016/j.tips.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 03/15/2024] [Accepted: 03/15/2024] [Indexed: 04/15/2024]
Abstract
T cells modified to express intelligently designed chimeric antigen receptors (CARs) are exceptionally powerful therapeutic agents for relapsed and refractory blood cancers and have the potential to revolutionize therapy for many other diseases. To circumvent the complexity and cost associated with broad-scale implementation of ex vivo manufactured adoptive cell therapy products, alternative strategies to generate CAR T cells in vivo by direct infusion of nanoparticle-formulated nucleic acids or engineered viral vectors under development have received a great deal of attention in the past few years. Here, we outline the ex vivo manufacturing process as a motivating framework for direct in vivo strategies and discuss emerging data from preclinical models to highlight the potency of the in vivo approach, the applicability for new disease indications, and the remaining challenges associated with clinical readiness, including delivery specificity, long term efficacy, and safety.
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Affiliation(s)
- Lauralie Short
- Michael Smith Genome Sciences Department, BC Cancer Research Institute, Vancouver, BC, Canada; Interdisciplinary Oncology Program, University of British Columbia, Vancouver, BC, Canada
| | - Robert A Holt
- Michael Smith Genome Sciences Department, BC Cancer Research Institute, Vancouver, BC, Canada; Interdisciplinary Oncology Program, University of British Columbia, Vancouver, BC, Canada; Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada; Department of Molecular Biology and Biochemistry, Simon Fraser University, Burnaby, BC, Canada
| | - Pieter R Cullis
- Department of Biochemistry and Molecular Biology, University of British Columbia, Vancouver, BC, Canada
| | - Laura Evgin
- Michael Smith Genome Sciences Department, BC Cancer Research Institute, Vancouver, BC, Canada; Interdisciplinary Oncology Program, University of British Columbia, Vancouver, BC, Canada; Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada.
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8
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Falde SD, Fussner LA, Tazelaar HD, O'Brien EK, Lamprecht P, Konig MF, Specks U. Proteinase 3-specific antineutrophil cytoplasmic antibody-associated vasculitis. THE LANCET. RHEUMATOLOGY 2024; 6:e314-e327. [PMID: 38574742 DOI: 10.1016/s2665-9913(24)00035-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/13/2024] [Accepted: 02/06/2024] [Indexed: 04/06/2024]
Abstract
Proteinase 3 (PR3)-specific antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis is one of two major ANCA-associated vasculitis variants and is pathogenically linked to granulomatosis with polyangiitis (GPA). GPA is characterised by necrotising granulomatous inflammation that preferentially affects the respiratory tract. The small vessel vasculitis features of GPA are shared with microscopic polyangiitis. Necrotising granulomatous inflammation of GPA can lead to PR3-ANCA and small vessel vasculitis via activation of neutrophils and monocytes. B cells are central to the pathogenesis of PR3-ANCA-associated vasculitis. They are targeted successfully by remission induction and maintenance therapy with rituximab. Relapses of PR3-ANCA-associated vasculitis and toxicities associated with current standard therapy contribute substantially to remaining mortality and damage-associated morbidity. More effective and less toxic treatments are sought to address this unmet need. Advances with cellular and novel antigen-specific immunotherapies hold promise for application in autoimmune disease, including PR3-ANCA-associated vasculitis. This Series paper describes the inter-related histopathological and clinical features, pathophysiology, as well as current and future targeted treatments for PR3-ANCA-associated vasculitis.
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Affiliation(s)
- Samuel D Falde
- Division of Pulmonary & Critical Care Medicine, Mayo Clinic Rochester, Rochester, MN, USA
| | - Lynn A Fussner
- Division of Pulmonary, Critical Care Medicine, and Sleep Medicine, Ohio State University, Columbus, OH, USA
| | - Henry D Tazelaar
- Department of Anatomic Pathology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Erin K O'Brien
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic Rochester, Rochester, MN, USA
| | - Peter Lamprecht
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Maximilian F Konig
- Division of Rheumatology, Department of Medicine & Ludwig Center for Cancer Genetics and Therapeutics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ulrich Specks
- Division of Pulmonary & Critical Care Medicine, Mayo Clinic Rochester, Rochester, MN, USA.
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9
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Ahmed N, Oluwole O, Mahmoudjafari Z, Suleman N, McGuirk JP. Managing Infection Complications in the Setting of Chimeric Antigen Receptor T cell (CAR-T) Therapy. Clin Hematol Int 2024; 6:31-45. [PMID: 38817309 PMCID: PMC11086990 DOI: 10.46989/001c.115932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 01/23/2024] [Indexed: 06/01/2024] Open
Abstract
Chimeric antigen receptor T-cell (CAR T-cell) therapy has changed the paradigm of management of non-Hodgkin's lymphoma (NHL) and Multiple Myeloma. Infection complications have emerged as a concern that can arise in the setting of therapy and lead to morbidity and mortality. In this review, we classified infection complications into three categories, pre-infusion phase from the time pre- lymphodepletion (LD) up to day zero, early phase from day of infusion to day 30 post-infusion, and late phase after day 30 onwards. Infections arising in the pre-infusion phase are closely related to previous chemotherapy and bridging therapy. Infections arising in the early phase are more likely related to LD chemo and the expected brief period of grade 3-4 neutropenia. Infections arising in the late phase are particularly worrisome because they are associated with adverse risk features including prolonged neutropenia, dysregulation of humoral and adaptive immunity with lymphopenia, hypogammaglobinemia, and B cell aplasia. Bacterial, respiratory and other viral infections, protozoal and fungal infections can occur during this time . We recommend enhanced supportive care including prompt recognition and treatment of neutropenia with growth factor support, surveillance testing for specific viruses in the appropriate instance, management of hypogammaglobulinemia with repletion as appropriate and extended antimicrobial prophylaxis in those at higher risk (e.g. high dose steroid use and prolonged cytopenia). Finally, we recommend re-immunizing patients post CAR-T based on CDC and transplant guidelines.
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Affiliation(s)
- Nausheen Ahmed
- Hematologic Malignancies and Cellular TherapeuticsUniversity of Kansas Cancer Center
| | - Olalekan Oluwole
- Medicine, Hematology and OncologyVanderbilt University Medical Center
| | - Zahra Mahmoudjafari
- Hematologic Malignancies and Cellular TherapeuticsUniversity of Kansas Cancer Center
| | - Nahid Suleman
- Hematologic Malignancies and Cellular TherapeuticsUniversity of Kansas Cancer Center
| | - Joseph P McGuirk
- Hematologic Malignancies and Cellular TherapeuticsUniversity of Kansas Cancer Center
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10
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Wu X, Cao Z, Chen Z, Wang Y, He H, Xiao P, Hu S, Lu J, Li B. Infectious complications in pediatric patients undergoing CD19+CD22+ chimeric antigen receptor T-cell therapy for relapsed/refractory B-lymphoblastic leukemia. Clin Exp Med 2024; 24:87. [PMID: 38662121 PMCID: PMC11045589 DOI: 10.1007/s10238-024-01339-7] [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: 12/25/2023] [Accepted: 03/26/2024] [Indexed: 04/26/2024]
Abstract
Chimeric antigen receptor T-cell (CAR-T) therapy is effective in the treatment of relapsed/refractory acute B-lymphoblastic leukemia (R/R B-ALL); however, patients who receive CAR-T therapy are predisposed to infections, with considerable detrimental effects on long-term survival rates and the quality of life of patients. This study retrospectively analyzed infectious complications in 79 pediatric patients with R/R B-ALL treated with CAR-T cells at our institution. Overall, 53 patients developed 88 infections. Nine patients experienced nine infections during lymphodepletion chemotherapy, 35 experienced 41 infections during the early phase (days 0-+ 30 after infusion), and 29 experienced 38 infections during the late phase (day + 31-+ 90 after infusion). Pathogens were identified in 31 infections, including 23 bacteria, seven viruses, and one fungus. Four patients were admitted to the intensive care unit for infection and one died. In a univariate analysis, there were ten factors associated with infection, including tumor load, lymphodepleting chemotherapy, neutrophil deficiency and lymphocyte reduction, cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS), etc. In a multivariate analysis, CRS ≥ grade 3 was identified as a risk factor for infection (hazard ratio = 2.41, 95% confidence interval: 1.08-5.36, P = 0.031). Therefore, actively reducing the CRS grade may decrease the risk of infection and improve the long-term quality of life of these patients.
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Affiliation(s)
- Xiaochen Wu
- Department of Hematology, Children's Hospital of Soochow University, Suzhou, 215002, Jiangsu, China
| | - Zhanmeng Cao
- Department of Hematology, Children's Hospital of Soochow University, Suzhou, 215002, Jiangsu, China
| | - Zihan Chen
- Department of Hematology, Children's Hospital of Soochow University, Suzhou, 215002, Jiangsu, China
| | - Yi Wang
- Department of Hematology, Children's Hospital of Soochow University, Suzhou, 215002, Jiangsu, China
| | - Hailong He
- Department of Hematology, Children's Hospital of Soochow University, Suzhou, 215002, Jiangsu, China
| | - Peifang Xiao
- Department of Hematology, Children's Hospital of Soochow University, Suzhou, 215002, Jiangsu, China
| | - Shaoyan Hu
- Department of Hematology, Children's Hospital of Soochow University, Suzhou, 215002, Jiangsu, China.
| | - Jun Lu
- Department of Hematology, Children's Hospital of Soochow University, Suzhou, 215002, Jiangsu, China.
| | - Benshang Li
- Key Laboratory of Pediatric Hematology and Oncology, Department of Hematology and Oncology, Shanghai Children's Medical Center, Ministry of Health, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China.
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11
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Galli E, Fresa A, Bellesi S, Metafuni E, Maiolo E, Pansini I, Frioni F, Autore F, Limongiello MA, Innocenti I, Giammarco S, Chiusolo P, Zini G, Sorà F. Hematopoiesis and immune reconstitution after CD19 directed chimeric antigen receptor T-cells (CAR-T): A comprehensive review on incidence, risk factors and current management. Eur J Haematol 2024; 112:184-196. [PMID: 37491951 DOI: 10.1111/ejh.14052] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 07/10/2023] [Accepted: 07/10/2023] [Indexed: 07/27/2023]
Abstract
Impaired function of hematopoiesis after treatment with chimeric antigen T-cells (CAR-T) is a frequent finding and can interest a wide range of patients, regardless of age and underlying disease. Trilinear cytopenias, as well as hypogammaglobulinemia, B-cell aplasia, and T-cell impairment, can severely affect the infectious risk of CAR-T recipients, as well as their quality of life. In this review, we provide an overview of defects in hematopoiesis after CAR-T, starting with a summary of different definitions and thresholds. We then move to summarize the main pathogenetic mechanisms of cytopenias, and we offer insight into cytomorphological aspects, the role of clonal hematopoiesis, and the risk of secondary myeloid malignancies. Subsequently, we expose the major findings and reports on T-cell and B-cell quantitative and functional impairment after CAR-T. Finally, we provide an overview of current recommendations and leading experiences regarding the management of cytopenias and defective B- and T-cell function.
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Affiliation(s)
- Eugenio Galli
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alberto Fresa
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Silvia Bellesi
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Elisabetta Metafuni
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Elena Maiolo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Ilaria Pansini
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Filippo Frioni
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Autore
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Maria Assunta Limongiello
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Idanna Innocenti
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Sabrina Giammarco
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Patrizia Chiusolo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gina Zini
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Federica Sorà
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
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12
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Infante MS, Nemirovsky D, Devlin S, DeWolf S, Tamari R, Dahi PB, Lee YJ, Chung DJ, Politikos I, Barker J, Giralt SA, Babady NE, Ramanathan L, Papanicolaou GA, Seo S, Kamboj M, Perales MA, Shah GL. Outcomes and Management of the SARS-CoV2 Omicron Variant in Recipients of Hematopoietic Cell Transplantation and Chimeric Antigen Receptor T Cell Therapy. Transplant Cell Ther 2024; 30:116.e1-116.e12. [PMID: 37806446 DOI: 10.1016/j.jtct.2023.09.027] [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: 06/22/2023] [Revised: 09/28/2023] [Accepted: 09/29/2023] [Indexed: 10/10/2023]
Abstract
Hematopoietic cell transplantation (HCT) and chimeric antigen receptor T cell therapy (CAR-T) recipients who develop Coronavirus disease 2019 (COVID-19) can have decreased overall survival (OS), likely due to disease-inherent and therapy-related immunodeficiency. The availability of COVID-19-directed therapies and vaccines have improved COVID-19-related outcomes, but immunocompromised individuals remain vulnerable. Specifically, the effects of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variant infections, including Omicron and its sublineages, particularly in HCT recipients, remain to be defined. The aim of this study was to compare the impact of SARS-CoV-2 Omicron infections in HCT/CAR-T recipients with outcomes previously reported for ancestral SARS-CoV-2 infections early in the pandemic (March to June 2020). This was a retrospective analysis of adult HCT/CAR-T recipients diagnosed with COVID-19 at Memorial Sloan Kettering Cancer Center between July 2021 and July 2022. We identified 353 patients (172 autologous HCT recipients [49%], 152 allogeneic HCT recipients [43%], and 29 CAR-T recipients [8%]), with a median time from HCT/CAR-T to SARS-CoV-2 infection of 1010 days (interquartile range, 300 to 2046 days). Forty-one patients (12%) were diagnosed with COVID-19 during the delta wave, and 312 patients (88%) were diagnosed during the Omicron wave. Risk factors associated with increased odds of COVID-19-related hospitalization were the presence of 2 or more comorbidities (odds ratio [OR], 4.9; 95% confidence interval [CI], 2.4 to 10.7; P < .001), CAR-T therapy compared to allogeneic HCT (OR, 7.7; 95% CI, 3.0 to 20.0; P < .001), hypogammaglobulinemia (OR, 2.71; 95% CI, 1.06 to 6.40; P = .027), and age at COVID-19 diagnosis (OR, 1.03; 95% CI, 1.0 to 1.05; P = .04). In contrast, infection during the Omicron variant BA5/BA4-dominant period compared to variant BA1 (OR, .21; 95% CI, .03 to .73; P = .037) and more than 3 years from HCT/CAR-T therapy to COVID-19 diagnosis compared to early infection at <100 days (OR, .31; 95% CI, .12 to .79; P = .011) were associated with a decreased odds for hospitalization. The OS at 12 months from COVID-19 diagnosis was 89% (95% CI, 84% to 94%), with 6 of 26 deaths attributable to COVID-19. Patients with the ancestral strain of SAR-CoV-2 had a lower OS at 12 months, with 73% (95% CI, 62% to 84%) versus 89% (95% CI, 84% to 94%; P < .001) in the Omicron cohort. Specific COVID-19 treatment was administered in 62% of patients, and 84% were vaccinated with mRNA COVID-19 vaccines. Vaccinated patients had significantly better OS than unvaccinated patients (90% [95% CI, 86% to 95%] versus 82% [95% CI, 72% to 94%] at 12 months; P = .003). No significant difference in OS was observed in patients infected with the Omicron and those infected with the Delta variant (P = .4) or treated with specific COVID-19 treatments compared with those not treated (P = .2). We observed higher OS in HCT and CAR-T recipients infected with the Omicron variants compared to those infected with the ancestral strain of SARS-CoV2. The use of COVID-19 antivirals, mAbs, and vaccines might have contributed to the improved outcomes.
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Affiliation(s)
- Maria-Stefania Infante
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; University Hospital Infanta Leonor, Madrid, Spain.
| | - David Nemirovsky
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sean Devlin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Susan DeWolf
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Roni Tamari
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Parastoo B Dahi
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Yeon Joo Lee
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - David J Chung
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Ioannis Politikos
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Juliet Barker
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Sergio A Giralt
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - N Esther Babady
- Clinical Microbiology Service, Department of Laboratory Medicine, Memorial SLoan Kettering Cancer Center, New York, New York
| | - Lakshmi Ramanathan
- Clinical Chemistry Service, Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Genovefa A Papanicolaou
- Department of Medicine, Weill Cornell Medical College, New York, New York; Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Susan Seo
- Department of Medicine, Weill Cornell Medical College, New York, New York; Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mini Kamboj
- Department of Medicine, Weill Cornell Medical College, New York, New York; Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Gunjan L Shah
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
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13
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McNerney KO, Hsieh EM, Shalabi H, Epperly R, Wolters PL, Hill JA, Gardner R, Talleur AC, Shah NN, Rossoff J. INSPIRED Symposium Part 3: Prevention and Management of Pediatric Chimeric Antigen Receptor T Cell-Associated Emergent Toxicities. Transplant Cell Ther 2024; 30:38-55. [PMID: 37821079 PMCID: PMC10842156 DOI: 10.1016/j.jtct.2023.10.006] [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: 09/07/2023] [Revised: 10/06/2023] [Accepted: 10/06/2023] [Indexed: 10/13/2023]
Abstract
Chimeric antigen receptor (CAR) T cell (CAR-T) therapy has emerged as a revolutionary cancer treatment modality, particularly in children and young adults with B cell malignancies. Through clinical trials and real-world experience, much has been learned about the unique toxicity profile of CAR-T therapy. The past decade brought advances in identifying risk factors for severe inflammatory toxicities, investigating preventive measures to mitigate these toxicities, and exploring novel strategies to manage refractory and newly described toxicities, infectious risks, and delayed effects, such as cytopenias. Although much progress has been made, areas needing further improvements remain. Limited guidance exists regarding initial administration of tocilizumab with or without steroids and the management of inflammatory toxicities refractory to these treatments. There has not been widespread adoption of preventive strategies to mitigate inflammation in patients at high risk of severe toxicities, particularly children. Additionally, the majority of research related to CAR-T toxicity prevention and management has focused on adult populations, with only a few pediatric-specific studies published to date. Given that children and young adults undergoing CAR-T therapy represent a unique population with different underlying disease processes, physiology, and tolerance of toxicities than adults, it is important that studies be conducted to evaluate acute, delayed, and long-term toxicities following CAR-T therapy in this younger age group. In this pediatric-focused review, we summarize key findings on CAR-T therapy-related toxicities over the past decade, highlight emergent CAR-T toxicities, and identify areas of greatest need for ongoing research.
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Affiliation(s)
- Kevin O McNerney
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
| | - Emily M Hsieh
- Pediatric Hematology/Oncology, Cancer and Blood Disease Institute, Children's Hospital Los Angeles, Norris Comprehensive Cancer Center, Keck School of Medicine of USC, Los Angeles, California
| | - Haneen Shalabi
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Rebecca Epperly
- Department of Bone Marrow Transplant, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Pamela L Wolters
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Joshua A Hill
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Rebecca Gardner
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Aimee C Talleur
- Department of Bone Marrow Transplant, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Nirali N Shah
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Jenna Rossoff
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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14
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O'Reilly MA, Neill L, Collin SM, Stone N, Springell D, Mensah J, Cheok KPL, Jalowiec K, Benjamin R, Kuhnl A, Roddie C, Sanderson R. High pretreatment disease burden as a risk factor for infectious complications following CD19 chimeric antigen receptor T-cell therapy for large B-cell lymphoma. Hemasphere 2024; 8:e29. [PMID: 38434533 PMCID: PMC10878197 DOI: 10.1002/hem3.29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 11/22/2023] [Indexed: 03/05/2024] Open
Abstract
Infection has emerged as the chief cause of non-relapse mortality (NRM) post CD19-targeting chimeric antigen receptor T-cell therapy (CAR-T) therapy. Even though up to 50% of patients may remain infection-free, many suffer multiple severe, life-threatening, or fatal infectious events. The primary aim of this study was to explore severe and life-threatening infections post licensed CAR-T therapy in large B-cell lymphoma, with a focus on the role of disease burden and disease sites in assessing individual risk. We sought to understand the cohort of patients who experience ≥2 infections and those at the highest risk of infectious NRM. Our analysis identifies a higher disease burden after bridging therapy as associated with infection events. Those developing ≥2 infections emerged as a uniquely high-risk cohort, particularly if the second (or beyond) infection occurred during an episode of immune effector cell-associated neurotoxicity syndrome (ICANS) or while on steroids and/or anakinra for ICANS. Herein, we also describe the first reported cases of "CAR-T cold sepsis," a phenomenon characterized by the lack of an appreciable systemic inflammatory response at the time of detection of infection. We propose a risk-based strategy to encourage heightened clinician awareness of cold sepsis, with a view to reducing NRM.
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Affiliation(s)
- Maeve A. O'Reilly
- Department of HaematologyUniversity College London HospitalLondonUK
- University College London Cancer InstituteLondonUK
| | - Lorna Neill
- Department of HaematologyUniversity College London HospitalLondonUK
| | | | - Neil Stone
- Department of Infectious DiseasesUniversity College London HospitalLondonUK
| | | | - Jeremy Mensah
- Department of HaematologyKing's College London HospitalLondonUK
| | | | | | - Reuben Benjamin
- Department of HaematologyKing's College London HospitalLondonUK
| | - Andrea Kuhnl
- Department of HaematologyKing's College London HospitalLondonUK
| | - Claire Roddie
- Department of HaematologyUniversity College London HospitalLondonUK
- University College London Cancer InstituteLondonUK
| | - Robin Sanderson
- Department of HaematologyKing's College London HospitalLondonUK
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15
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Alahmdi B, Kaur A, Jacobs SE, Sullivan T, Barghash M, Taimur S. Trypanosoma cruzi Reactivation After Chimeric Antigen Receptor T-Cell Therapy. Open Forum Infect Dis 2024; 11:ofad698. [PMID: 38264096 PMCID: PMC10804802 DOI: 10.1093/ofid/ofad698] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Indexed: 01/25/2024] Open
Abstract
https://tidbitapp.io/tidbits/trypanosoma-cruzi-reactivation-post-chimeric-antigen-receptor-t-cell-therapy/update.
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Affiliation(s)
- Bayan Alahmdi
- Division of Infectious Diseases, Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Avneet Kaur
- Division of Infectious Diseases, Department of Medicine, City of Hope, Duarte, California, USA
| | - Samantha E Jacobs
- Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Timothy Sullivan
- Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Maya Barghash
- Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sarah Taimur
- Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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16
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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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17
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Hamilton MP, Miklos DB. Chimeric Antigen Receptor T-Cell Therapy in Aggressive B-Cell Lymphoma. Hematol Oncol Clin North Am 2023; 37:1053-1075. [PMID: 37349153 DOI: 10.1016/j.hoc.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Abstract
Chimeric antigen receptor (CAR) T-cell therapy is a revolutionary therapy increasingly used in the treatment of non-Hodgkin B-cell lymphoma. This review focuses on the use of CAR T-cell therapy in aggressive B-cell lymphoma including clinical indications, known short- and long-term toxicity, mechanisms of CAR T-cell efficacy and tumor resistance, and future directions in the treatment of aggressive lymphoma with CAR T-cell therapy.
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Affiliation(s)
- Mark P Hamilton
- Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA 94305, USA; Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA; Division of Hematology, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA.
| | - David B Miklos
- Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA 94305, USA; Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
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18
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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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19
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Epperly R, Giordani VM, Mikkilineni L, Shah NN. Early and Late Toxicities of Chimeric Antigen Receptor T-Cells. Hematol Oncol Clin North Am 2023; 37:1169-1188. [PMID: 37349152 PMCID: PMC10592597 DOI: 10.1016/j.hoc.2023.05.010] [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] [Indexed: 06/24/2023]
Abstract
As chimeric antigen receptor (CAR) T-cell therapy is increasingly integrated into clinical practice across a range of malignancies, identifying and treating inflammatory toxicities will be vital to success. Early experiences with CD19-targeted CAR T-cell therapy identified cytokine release syndrome and neurotoxicity as key acute toxicities and led to unified initiatives to mitigate the influence of these complications. In this section, we provide an update on the current state of CAR T-cell-related toxicities, with an emphasis on emerging acute toxicities affecting additional organ systems and considerations for delayed toxicities and late effects.
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Affiliation(s)
- Rebecca Epperly
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, 262 Danny Thomas Place, MS 1130, Memphis, TN 38105, USA
| | - Victoria M Giordani
- Pediatric Oncology Branch, Center for Cancer Research (CCR), National Cancer Institute (NCI), NIH, Building 10, Room 1W-3750, 9000 Rockville Pike MSC 1104, Bethesda, MD 20892, USA; Pediatric Hematology/Oncology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Lekha Mikkilineni
- Blood and Marrow Transplantation & Cellular Therapy, Stanford University, Palo Alto, CA, USA; Stanford School of Medicine, 300 Pasteur Drive, Room H0101, Stanford, CA 94305, USA
| | - Nirali N Shah
- Pediatric Oncology Branch, Center for Cancer Research (CCR), National Cancer Institute (NCI), NIH, Building 10, Room 1W-3750, 9000 Rockville Pike MSC 1104, Bethesda, MD 20892, USA.
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20
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Diamond Y, Gilsenan M, Wang SS, Hanna D, Conyers R, Cole T, Hughes D, Fleming J, Meyran D, Toro C, Malalasekera V, Khaw SL, Haeusler GM. Infections in children following chimeric antigen receptor T-cell therapy for B-cell acute lymphoblastic leukemia. Transpl Infect Dis 2023; 25:e14202. [PMID: 38041799 DOI: 10.1111/tid.14202] [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: 09/12/2023] [Revised: 10/17/2023] [Accepted: 11/12/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND CD19-directed chimeric antigen receptor T-cell (CAR-T) therapy is transforming care for pediatric patients with relapsed or refractory B-cell acute lymphoblastic leukemia (B-ALL). There are limited pediatric-specific data concerning the infection risks associated with CD19 CAR-T therapy and the adequacy of current antimicrobial prophylaxis guidelines for these patients. METHODS We describe the antimicrobial prophylaxis used and the types of infectious occurring in the first 100 days following CAR-T therapy for relapsed or refractory B-cell ALL in children and adolescents (≤18 years) at our centre. RESULTS Twenty-seven patients received their first CAR-T infusion (CTI) during the study period. Almost all patients (96%) had a comprehensive Infectious Diseases review prior to CTI, which informed a personalised prophylaxis or fever/sepsis plan in six (22%). Overall, six (22%) patients had one or more infections during the study period including five (19%, 0.9 per 100 days-at-risk) from days 0-30 and three (n = 20, 15%, 0.6 per 100 days-at-risk) from days 31-100. Bacterial blood stream infections were the most common type of infection encountered during both time periods, and one patient had probable pulmonary aspergillosis. There were no infection-related deaths. CONCLUSION Our study contributes important information on the spectrum of infections encountered in pediatric patients with B-ALL post CAR-T therapy. Overall, the burden of infectious complications post CAR-T therapy in our cohort is lower than previously reported in the literature. Results suggest that our prophylaxis recommendations are effective in this population.
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Affiliation(s)
- Yonatan Diamond
- Kids Cancer Centre, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - Maddie Gilsenan
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Stacie Shiqi Wang
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Diane Hanna
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Rachel Conyers
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Theresa Cole
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Victoria, Australia
| | - David Hughes
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Jacqueline Fleming
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Deborah Meyran
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Claudia Toro
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
- Paediatric Integrated Cancer Service, Victoria, Victoria, Australia
| | | | - Seong Lin Khaw
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Gabrielle M Haeusler
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
- Paediatric Integrated Cancer Service, Victoria, Victoria, Australia
- Department of Infectious Diseases, Royal Children's Hospital, Parkville, Victoria, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
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21
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Steinbach M, Zitella LJ, Florendo E, Lee E, Riccobono C, DiFilippo H, Aronson E. Nursing Care Throughout the Chimeric Antigen Receptor T-Cell Therapy Process for Multiple Myeloma. Semin Oncol Nurs 2023; 39:151505. [PMID: 37752030 DOI: 10.1016/j.soncn.2023.151505] [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: 06/02/2023] [Revised: 08/03/2023] [Accepted: 08/26/2023] [Indexed: 09/28/2023]
Abstract
OBJECTIVES Approvals of chimeric antigen receptor T-cell (CAR-T) therapies for relapsed/refractory multiple myeloma (RRMM) represent advancements in treatment options for a hard-to-treat population. Nursing care during CAR-T therapy is crucial for patients, their caregivers, and the broader CAR-T therapy care team. This manuscript provides an overview of the CAR-T therapy administration process and describes practical considerations for nursing professionals working with patients who receive CAR-T therapy. DATA SOURCES Current literature describing CAR-T therapies for RRMM and published guidelines on nursing care during CAR-T therapy administration were identified from a PubMed database search. Literature was synthesized with practical considerations from nurses and nurse practitioners with expertise in the administration of CAR-T therapy for MM. A practical overview of the role of nursing professionals throughout all stages of CAR-T therapy administration for RRMM is provided. CONCLUSION Planning, administration, and posttreatment monitoring for CAR-T therapy requires collaboration between nursing professionals and other healthcare providers as patients migrate between community oncology providers and specialized treatment centers. Nurses help with assessment of patient eligibility and patient and caregiver education before CAR-T therapy. They act in diverse roles across various settings involved in CAR-T therapy administration. Finally, nurses contribute to long-term identification and management of CAR-T-associated toxicities. IMPLICATIONS FOR NURSING PRACTICE Nurses are crucial to the CAR-T therapy process and make significant contributions to optimizing patient care and subsequent outcomes.
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Affiliation(s)
- Mary Steinbach
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Laura J Zitella
- Hematology, Blood & Marrow Transplant, and Cellular Therapies Program, University of California San Francisco, San Francisco, CA
| | | | - Erin Lee
- Janssen Pharmaceuticals, Inc, Titusville, NJ
| | | | - Heather DiFilippo
- Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, PA
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22
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Korell F, Schönland S, Schmitt A, Jansen M, Farid K, Müller-Tidow C, Dreger P, Schmitt M, Hegenbart U. First third-generation CAR T cell application targeting CD19 for the treatment of systemic IgM AL amyloidosis with underlying marginal zone lymphoma. Biomark Res 2023; 11:91. [PMID: 37838756 PMCID: PMC10576295 DOI: 10.1186/s40364-023-00532-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/06/2023] [Indexed: 10/16/2023] Open
Abstract
Light chain amyloidosis (AL) is a rare disease caused by the generalized deposition of misfolded free light chains. Patients with immunoglobulin M gammopathy (IgM) and indolent B-cell lymphoma such as marginal zone lymphoma (MZL) may in some instances develop AL amyloidosis. So far, CAR T cells for AL amyloidosis have only been reported utilizing the B cell maturation antigen as target, while CD19 has so far not been used in AL amyloidosis.We report the case of a 71-year-old male, diagnosed with systemic AL kappa amyloidosis and MZL, receiving third-generation CAR T cell therapy targeting CD19. Prior treatment included bendamustine/rituximab and cyclophosphamide/ dexamethasone with subsequent autologous stem cell transplantation. CAR T application was well tolerated despite heart and kidney amyloid manifestations, and only early low-grade procedure-specific toxicities were observed. A continuous decrease in IgM, kappa light chains and kappa-to-lambda light chain difference was observed in the patient from day + 30 on, resulting in a deep hematological response six months after treatment.In summary, we present a novel case of CAR T cell treatment with third generation CD19 directed infusion for AL amyloidosis with an underlying secretory active B cell lymphoma, showing that this is an effective treatment modality and can be applied to patients with subsequent AL amyloidosis.
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Affiliation(s)
- Felix Korell
- Department of Hematology & Oncology, Amyloidosis Center, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Stefan Schönland
- Department of Hematology & Oncology, Amyloidosis Center, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Anita Schmitt
- Department of Hematology & Oncology, Amyloidosis Center, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Madelaine Jansen
- Department of Hematology & Oncology, Amyloidosis Center, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Kiavasch Farid
- Department of Hematology & Oncology, Amyloidosis Center, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Carsten Müller-Tidow
- Department of Hematology & Oncology, Amyloidosis Center, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Peter Dreger
- Department of Hematology & Oncology, Amyloidosis Center, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Michael Schmitt
- Department of Hematology & Oncology, Amyloidosis Center, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Ute Hegenbart
- Department of Hematology & Oncology, Amyloidosis Center, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
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23
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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: 2] [Impact Index Per Article: 2.0] [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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24
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Little JS, Tandon M, Hong JS, Nadeem O, Sperling AS, Raje N, Munshi N, Frigault M, Barmettler S, Hammond SP. Respiratory infections predominate after day 100 following B-cell maturation antigen-directed CAR T-cell therapy. Blood Adv 2023; 7:5485-5495. [PMID: 37486599 PMCID: PMC10514400 DOI: 10.1182/bloodadvances.2023010524] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 06/30/2023] [Accepted: 07/06/2023] [Indexed: 07/25/2023] Open
Abstract
Infections are an important complication after B-cell maturation antigen (BCMA)-directed chimeric antigen receptor (CAR) T-cell therapy and risks may differ between the early and late periods. We evaluated infections in 99 adults who received a first BCMA-directed CAR T-cell therapy (commercial and investigational autologous BCMA CAR T-cell products at the recommended phase 2 dose) for relapsed/refractory multiple myeloma between November 2016 and May 2022. Infections were recorded until day 365, if patients experienced symptoms with a microbiologic diagnosis, or for symptomatic site-specific infections treated with antimicrobials. One-year cumulative incidence functions were calculated based on time to first respiratory infection using dates of infection-free death and receipt of additional antineoplastic therapies as competing risks. Secondary analysis evaluated risk factors for late respiratory infections using univariate and multivariable Cox regression models. Thirty-seven patients (37%) experienced 64 infectious events over the first year after BCMA-directed CAR T-cell therapy, with 42 early infectious events (days, 0-100), and 22 late infectious events (days, 101-365). Respiratory infections were the most common site-specific infection and the relative proportion of respiratory infections increased in the late period (31% of early events vs 77% of late events). On multivariable analysis, hypogammaglobulinemia (hazard ratio [HR], 6.06; P = .044) and diagnosis of an early respiratory viral infection (HR, 2.95; P = .048) were independent risk factors for late respiratory infection. Respiratory infections predominate after BCMA CAR T-cell therapy, particularly after day 100. Hypogammaglobulinemia and diagnosis of an early respiratory infection are risk factors for late respiratory infections that may be used to guide targeted preventive strategies.
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Affiliation(s)
- Jessica S. Little
- Harvard Medical School, Boston, MA
- Dana-Farber Cancer Institute, Boston, MA
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA
| | - Megha Tandon
- Harvard Medical School, Boston, MA
- Division of Allergy and Immunology, Massachusetts General Hospital, Boston, MA
| | - Joseph Seungpyo Hong
- Harvard Medical School, Boston, MA
- Division of Allergy and Immunology, Massachusetts General Hospital, Boston, MA
| | - Omar Nadeem
- Harvard Medical School, Boston, MA
- Dana-Farber Cancer Institute, Boston, MA
| | - Adam S. Sperling
- Harvard Medical School, Boston, MA
- Dana-Farber Cancer Institute, Boston, MA
- Division of Hematology, Brigham and Women’s Hospital, Boston, MA
| | - Noopur Raje
- Harvard Medical School, Boston, MA
- Massachusetts General Hospital Cancer Center, Boston, MA
| | - Nikhil Munshi
- Harvard Medical School, Boston, MA
- Dana-Farber Cancer Institute, Boston, MA
| | - Matthew Frigault
- Harvard Medical School, Boston, MA
- Massachusetts General Hospital Cancer Center, Boston, MA
| | - Sara Barmettler
- Harvard Medical School, Boston, MA
- Division of Allergy and Immunology, Massachusetts General Hospital, Boston, MA
| | - Sarah P. Hammond
- Harvard Medical School, Boston, MA
- Dana-Farber Cancer Institute, Boston, MA
- Massachusetts General Hospital Cancer Center, Boston, MA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA
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25
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Khanam R, Faiman B, Batool S, Najmuddin MM, Usman R, Kuriakose K, Ahmed A, Rehman MEU, Roksana Z, Syed Z, Anwer F, Raza S. Management of Adverse Reactions for BCMA-Directed Therapy in Relapsed Multiple Myeloma: A Focused Review. J Clin Med 2023; 12:5539. [PMID: 37685606 PMCID: PMC10487885 DOI: 10.3390/jcm12175539] [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: 06/09/2023] [Revised: 07/26/2023] [Accepted: 08/23/2023] [Indexed: 09/10/2023] Open
Abstract
Anti-B-cell maturation antigen therapies consisting of bispecific antibodies, antibody-drug conjugates, and chimeric antigen receptor T cells have shown promising results in relapsed refractory multiple myeloma (RRMM). However, the severe side effects include cytokine release syndrome, immune effector cell-associated neurotoxicity syndrome, cytopenia(s), infections, hemophagocytic lymphohistiocytosis, and organ toxicity, which could sometimes be life-threatening. This review focuses on these most common complications post-BCMA therapy. We discussed the risk factors, pathogenesis, clinical features associated with these complications, and how to prevent and treat them. We included four original studies for this focused review. All four agents (idecabtagene vicleucel, ciltacabtagene autoleucel, teclistamab, belantamab mafodotin) have received FDA approval for adult RRMM patients. We went through the FDA access data packages of the approved agents to outline stepwise management of the complications for better patient outcomes.
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Affiliation(s)
- Razwana Khanam
- Department of Hospital Medicine, Baystate Medical Center, Springfield, MA 01199, USA
| | - Beth Faiman
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH 44106, USA; (B.F.); (F.A.); (S.R.)
| | - Saba Batool
- Department of Hospital Medicine, Carle Health Methodist Hospital, Peoria, IL 61636, USA;
| | | | - Rana Usman
- University of Tennessee Health Science Center, Memphis, TN 38163, USA;
| | - Kiran Kuriakose
- Department of Hospital Medicine, UPMC Mercy Hospital, Pittsburgh, PA 15219, USA;
| | - Arooj Ahmed
- Department of Translational Hematology and Oncology, Cleveland Clinic Taussig Cancer Center, Cleveland, OH 44195, USA;
| | | | - Zinath Roksana
- Sheikh Hasina National Institute of Burn and Plastic Surgery, Dhaka 1217, Bangladesh;
| | - Zain Syed
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH 44106, USA;
| | - Faiz Anwer
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH 44106, USA; (B.F.); (F.A.); (S.R.)
| | - Shahzad Raza
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH 44106, USA; (B.F.); (F.A.); (S.R.)
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26
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Ludwig H, Terpos E, van de Donk N, Mateos MV, Moreau P, Dimopoulos MA, Delforge M, Rodriguez-Otero P, San-Miguel J, Yong K, Gay F, Einsele H, Mina R, Caers J, Driessen C, Musto P, Zweegman S, Engelhardt M, Cook G, Weisel K, Broijl A, Beksac M, Bila J, Schjesvold F, Cavo M, Hajek R, Touzeau C, Boccadoro M, Sonneveld P. Prevention and management of adverse events during treatment with bispecific antibodies and CAR T cells in multiple myeloma: a consensus report of the European Myeloma Network. Lancet Oncol 2023; 24:e255-e269. [PMID: 37269857 DOI: 10.1016/s1470-2045(23)00159-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/31/2023] [Accepted: 03/31/2023] [Indexed: 06/05/2023]
Abstract
T-cell redirecting bispecific antibodies (BsAbs) and chimeric antigen receptor T cells (CAR T cells) have revolutionised multiple myeloma therapy, but adverse events such as cytokine release syndrome, immune effector cell-associated neurotoxicity syndrome (ICANS), cytopenias, hypogammaglobulinaemia, and infections are common. This Policy Review presents a consensus from the European Myeloma Network on the prevention and management of these adverse events. Recommended measures include premedication, frequent assessing for symptoms and severity of cytokine release syndrome, step-up dosing for several BsAbs and some CAR T-cell therapies; corticosteroids; and tocilizumab in the case of cytokine release syndrome. Other anti-IL-6 drugs, high-dose corticosteroids, and anakinra might be considered in refractory cases. ICANS often arises concomitantly with cytokine release syndrome. Glucocorticosteroids in increasing doses are recommended if needed, as well as anakinra if the response is inadequate, and anticonvulsants if convulsions occur. Preventive measures against infections include antiviral and antibacterial drugs and administration of immunoglobulins. Treatment of infections and other complications is also addressed.
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Affiliation(s)
- Heinz Ludwig
- Department of Medicine, Clinic Ottakring, Wilhelminen Cancer Research Institute, Vienna, Austria.
| | - Evangelos Terpos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Niels van de Donk
- Department of Hematology, Amsterdam UMC, VU University, Amsterdam, Netherlands
| | - Maria-Victoria Mateos
- Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca, Centro de Investigación del Cancer, Salamanca, Spain
| | - Philippe Moreau
- Department of Hematology, University Hospital of Nantes, Nantes, France
| | | | - Michel Delforge
- Division of Hematology, University of Leuven, Leuven, Belgium
| | - Paula Rodriguez-Otero
- Cancer Center Clinica Universidad de Navarra, Pamplona, Spain; Centro de Investigación Medica Aplicada, Pamplona, Spain; Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain; Centro de investigación biomédica en red de Oncologia, Pamplona, Spain
| | - Jesús San-Miguel
- Cancer Center Clinica Universidad de Navarra, Pamplona, Spain; Centro de Investigación Medica Aplicada, Pamplona, Spain; Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain; Centro de investigación biomédica en red de Oncologia, Pamplona, Spain
| | - Kwee Yong
- University College London Cancer Institute, London, UK
| | - Francesca Gay
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza, Torino, Italy
| | - Hermann Einsele
- Department of Internal Medicine, University Hospital Würzburg, Germany
| | - Roberto Mina
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza, Torino, Italy
| | - Jo Caers
- Department of Hematology, CHU de Liège, Liège, Belgium
| | - Christoph Driessen
- Department of Oncology and Hematology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Pellegrino Musto
- Department of Precision and Regenerative Medicine and Ionian Area, Aldo Moro University School of Medicine, Bari, Italy; Unit of Hematology and Stem Cell Transplantation, AOUC Policlinico, Bari, Italy
| | - Sonja Zweegman
- Department of Hematology, Amsterdam UMC, VU University, Amsterdam, Netherlands
| | - Monika Engelhardt
- Department of Hematology, Oncology and Stem Cell Transplantation, Clinical Cancer Research Group, Universitätsklinikum Freiburg, Freiburg, Germany
| | - Gordon Cook
- Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trial Research, University of Leeds, Leeds, UK
| | - Katja Weisel
- Universitätsklinikum Hamburg-Eppendorf, Medizinische Klinik und Poliklinik, Hamburg, Germany
| | - Annemiek Broijl
- Erasmus MC Cancer Institute & Erasmus University of Rotterdam, Rotterdam, Netherlands
| | - Meral Beksac
- Department of Hematology, Ankara University, Ankara, Türkiye
| | - Jelena Bila
- Clinic of Hematology, University Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Fredrik Schjesvold
- Oslo Myeloma Center, Department of Hematology, Oslo University Hospital, Oslo, Norway; KG Jebsen Center for B Cell Malignancies, University of Oslo, Oslo, Norway
| | - Michele Cavo
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, SeràgnoliIstituto di Ematologia, Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Roman Hajek
- Department of Hemato-Oncology, University Hospital Ostrava & Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Cyrille Touzeau
- Department of Hematology, University Hospital of Nantes, Nantes, France
| | - Mario Boccadoro
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza, Torino, Italy
| | - Pieter Sonneveld
- Erasmus MC Cancer Institute & Erasmus University of Rotterdam, Rotterdam, Netherlands
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27
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Mucha SR, Rajendram P. Management and Prevention of Cellular-Therapy-Related Toxicity: Early and Late Complications. Curr Oncol 2023; 30:5003-5023. [PMID: 37232836 DOI: 10.3390/curroncol30050378] [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: 04/04/2023] [Revised: 04/28/2023] [Accepted: 05/02/2023] [Indexed: 05/27/2023] Open
Abstract
Chimeric Antigen Receptor T (CAR-T) cell therapy has dramatically changed prognosis and treatment of relapsed and refractory hematologic malignancies. Currently the 6 FDA approved products target various surface antigens. While CAR-T therapy achieves good response, life-threatening toxicities have been reported. Mechanistically, can be divided into two categories: (1) toxicities related to T-cell activation and release of high levels of cytokines: or (2) toxicities resulting from interaction between CAR and CAR targeted antigen expressed on non-malignant cells (i.e., on-target, off-tumor effects). Variations in conditioning therapies, co-stimulatory domains, CAR T-cell dose and anti-cytokine administration, pose a challenge in distinguishing cytokine mediated related toxicities from on-target, off-tumor toxicities. Timing, frequency, severity, as well as optimal management of CAR T-cell-related toxicities vary significantly between products and are likely to change as newer therapies become available. Currently the FDA approved CARs are targeted towards the B-cell malignancies however the future holds promise of expanding the target to solid tumor malignancies. Further highlighting the importance of early recognition and intervention for early and late onset CAR-T related toxicity. This contemporary review aims to describe presentation, grading and management of commonly encountered toxicities, short- and long-term complications, discuss preventive strategies and resource utilization.
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Affiliation(s)
- Simon R Mucha
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Prabalini Rajendram
- Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
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28
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Reinhardt B, Lee P, Sasine JP. Chimeric Antigen Receptor T-Cell Therapy and Hematopoiesis. Cells 2023; 12:531. [PMID: 36831198 PMCID: PMC9954220 DOI: 10.3390/cells12040531] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 02/02/2023] [Accepted: 02/03/2023] [Indexed: 02/11/2023] Open
Abstract
Chimeric Antigen Receptor (CAR) T-cell therapy is a promising treatment option for patients suffering from B-cell- and plasma cell-derived hematologic malignancies and is being adapted for the treatment of solid cancers. However, CAR T is associated with frequently severe toxicities such as cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), macrophage activation syndrome (MAS), and prolonged cytopenias-a reduction in the number of mature blood cells of one or more lineage. Although we understand some drivers of these toxicities, their mechanisms remain under investigation. Since the CAR T regimen is a complex, multi-step process with frequent adverse events, ways to improve the benefit-to-risk ratio are needed. In this review, we discuss a variety of potential solutions being investigated to address the limitations of CAR T. First, we discuss the incidence and characteristics of CAR T-related cytopenias and their association with reduced CAR T-cell efficacy. We review approaches to managing or mitigating cytopenias during the CAR T regimen-including the use of growth factors, allogeneic rescue, autologous hematopoietic stem cell infusion, and alternative conditioning regimens. Finally, we introduce novel methods to improve CAR T-cell-infusion products and the implications of CAR T and clonal hematopoiesis.
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Affiliation(s)
- Bryanna Reinhardt
- School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA
| | - Patrick Lee
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Joshua P. Sasine
- Department of Medicine, Division of Hematology and Cellular Therapy, Samuel Oschin Cancer Center, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
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29
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Gea-Banacloche JC. Infectious complications of chimeric antigen receptor (CAR) T-cell therapies. Semin Hematol 2023; 60:52-58. [PMID: 37080711 PMCID: PMC10119490 DOI: 10.1053/j.seminhematol.2023.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 02/23/2023] [Indexed: 03/08/2023]
Abstract
CAR T-cells have revolutionized the treatment of many hematological malignancies. Thousands of patients with lymphoma, acute lymphoblastic leukemia, and multiple myeloma have received this "living medicine" and achieved durable remissions. Their place in therapy continues to evolve, and there is ongoing development of new generation CAR constructs, CAR T-cells against solid tumors and CAR T-cells against chronic infections like human immunodeficiency virus and hepatitis B. A significant fraction of CAR T-cell recipients, unfortunately, develop infections. This is in part due to factors intrinsic to the patient, but also to the treatment, which requires lymphodepletion (LD), causes neutropenia and hypogammaglobulinemia and necessarily increases the state of immunosuppression of the patient. The goal of this review is to present the infectious complications of CAR T-cell therapy, explain their temporal course and risk factors, and provide recommendations for their prevention, diagnosis, and management.
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Affiliation(s)
- Juan C Gea-Banacloche
- Division of Clinical Research, NIAID, Bethesda, MD; NIH Clinical Center, Bethesda, MD.
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30
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Clinical Strategies for Enhancing the Efficacy of CAR T-Cell Therapy for Hematological Malignancies. Cancers (Basel) 2022; 14:cancers14184452. [PMID: 36139611 PMCID: PMC9496667 DOI: 10.3390/cancers14184452] [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: 08/11/2022] [Revised: 08/31/2022] [Accepted: 09/03/2022] [Indexed: 11/16/2022] Open
Abstract
Chimeric antigen receptor (CAR) T cells have been successfully used for hematological malignancies, especially for relapsed/refractory B-cell acute lymphoblastic leukemia and non-Hodgkin’s lymphoma. Patients who have undergone conventional chemo-immunotherapy and have relapsed can achieve complete remission for several months with the infusion of CAR T-cells. However, side effects and short duration of response are still major barriers to further CAR T-cell therapy. To improve the efficacy, multiple targets, the discovery of new target antigens, and CAR T-cell optimization have been extensively studied. Nevertheless, the fact that the determination of the efficacy of CAR T-cell therapy is inseparable from the discussion of clinical application strategies has rarely been discussed. In this review, we will discuss some clinical application strategies, including lymphodepletion regimens, dosing strategies, combination treatment, and side effect management, which are closely related to augmenting and maximizing the efficacy of CAR T-cell therapy.
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31
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Zhou J, Zhang Y, Shan M, Zong X, Geng H, Li J, Chen G, Yu L, Xu Y, Li C, Wu D. Cytopenia after chimeric antigen receptor T cell immunotherapy in relapsed or refractory lymphoma. Front Immunol 2022; 13:997589. [PMID: 36131934 PMCID: PMC9484486 DOI: 10.3389/fimmu.2022.997589] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 08/16/2022] [Indexed: 11/26/2022] Open
Abstract
Background Patients with relapsed or refractory (R/R) lymphomas have benefited from chimeric antigen receptor (CAR)-T-cell therapy. However, this treatment is linked to a high frequency of adverse events (AEs), such as cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), and hematologic toxicity. There has been increasing interest in hematological toxicity in recent years, as it can result in additional complications, such as infection or hemorrhage, which remain intractable. Methods We conducted a retrospective, single-institution study to evaluate the patterns and outcomes of cytopenia following CAR-T-cell infusion and potential associated factors. Results Overall, 133 patients with R/R lymphoma who received CAR-T-cell therapy from June, 2017 to April, 2022 were included in this analysis. Severe neutropenia, anemia and thrombocytopenia occurred frequently (71, 30 and 41%, respectively) after CAR-T-cell infusion. A total of 98% of severe neutropenia and all severe thrombocytopenia cases occurred in the early phase. Early severe cytopenia was associated with CRS incidence and severity, as well as peak inflammatory factor (IL-6, C-reactive protein (CRP), and ferritin) levels. In multivariate analysis, prior hematopoietic stem cell transplantation (HSCT), baseline hemoglobin (HB), and lymphodepleting chemotherapy were independent adverse factors associated with early severe cytopenia. In addition, 18% and 35% of patients had late neutrophil- and platelet (PLT)-related toxicity, respectively. In multivariate analysis, lower baseline PLT count was an independent factor associated with late thrombocytopenia. More severe cytopenia was associated with higher infection rates and poorer survival. Conclusions This research indicates that improved selection of patients and management of CRS may help to decrease the severity of cytopenias and associated AEs and improve survival following CAR-T-cell therapy. Clinical Trial Registration https://www.clinicaltrials.gov/ct2/show/NCT03196830, identifier NCT03196830.
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Affiliation(s)
- Jin Zhou
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Stem Cells and Biomedical Materials of Jiangsu Province and Chinese Ministry of Science and Technology, Suzhou, China
| | - Ying Zhang
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Stem Cells and Biomedical Materials of Jiangsu Province and Chinese Ministry of Science and Technology, Suzhou, China
| | - Meng Shan
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Stem Cells and Biomedical Materials of Jiangsu Province and Chinese Ministry of Science and Technology, Suzhou, China
| | - Xiangping Zong
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Stem Cells and Biomedical Materials of Jiangsu Province and Chinese Ministry of Science and Technology, Suzhou, China
| | - Hongzhi Geng
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Stem Cells and Biomedical Materials of Jiangsu Province and Chinese Ministry of Science and Technology, Suzhou, China
| | - Jiaqi Li
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Stem Cells and Biomedical Materials of Jiangsu Province and Chinese Ministry of Science and Technology, Suzhou, China
| | - Guanghua Chen
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Stem Cells and Biomedical Materials of Jiangsu Province and Chinese Ministry of Science and Technology, Suzhou, China
| | - Lei Yu
- Institute of Biomedical Engineering and Technology, Shanghai Engineering Research Center of Molecular Therapeutics and New Drug Development, School of Chemistry and Molecular Engineering, East China Normal University, Shanghai, China
| | - Yang Xu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Stem Cells and Biomedical Materials of Jiangsu Province and Chinese Ministry of Science and Technology, Suzhou, China
- *Correspondence: Depei Wu, ; Caixia Li, ; Yang Xu,
| | - Caixia Li
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Stem Cells and Biomedical Materials of Jiangsu Province and Chinese Ministry of Science and Technology, Suzhou, China
- *Correspondence: Depei Wu, ; Caixia Li, ; Yang Xu,
| | - Depei Wu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Stem Cells and Biomedical Materials of Jiangsu Province and Chinese Ministry of Science and Technology, Suzhou, China
- *Correspondence: Depei Wu, ; Caixia Li, ; Yang Xu,
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