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Bindal P, Patell R, Chiasakul T, Lauw MN, Ko A, Wang TF, Zwicker JI. A meta-analysis to assess the risk of bleeding and thrombosis following chimeric antigen receptor T-cell therapy: Communication from the ISTH SSC Subcommittee on Hemostasis and Malignancy. J Thromb Haemost 2024; 22:2071-2080. [PMID: 38574863 DOI: 10.1016/j.jtha.2024.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 02/26/2024] [Accepted: 03/17/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Chimeric antigen receptor T-cell (CAR T-cell) therapy is increasingly utilized for treatment of hematologic malignancies. Hematologic toxicities including thrombosis and bleeding complications have been reported. Accurate estimates for thrombotic and bleeding outcomes are lacking. OBJECTIVES We performed a systematic review and meta-analysis in patients who received CAR T-cell therapy for an underlying hematologic malignancy with the objective to: a) assess the thrombosis and bleeding risk associated with CAR T-cell therapy, b) assess the impact of CRS and ICANS on the risks of thrombosis and bleeding, and c) assess the safety of anticoagulant or antiplatelet use in the period following treatment with CAR T-cell therapy. METHODS We searched MEDLINE, EMBASE, and Cochrane CENTRAL up to February 2022 for studies reporting thrombotic or bleeding outcomes in patients receiving CAR T-cell therapy. Pooled event rates were calculated using a random-effects model. We performed subgroup analyses stratified by follow-up duration, CAR T-cell target antigen, and underlying hematologic malignancy. RESULTS We included 47 studies with a total of 7040 patients. High heterogeneity between studies precluded reporting of overall pooled rates of thrombotic and bleeding events. In studies with follow-up duration of ≤6 months, the pooled incidence of venous thrombotic events was 2.4% (95% CI, 1.4%-3.4%; I2 = 0%) per patient-month, whereas the rate was 0.1% (95% CI, 0%-0.1%; I2 = 0%) per patient-month for studies with longer follow-up periods (>6 months). The pooled incidences of any bleeding events per patient-month in studies with follow-up duration of ≤6 months and >6 months were 1.9% (95% CI, 0.6%-3.1%; I2 = 78%) and 0.3% (95% CI: 0%-0.8%, I2 = 40%), respectively. Secondary analyses by CAR T-cell target antigen, underlying malignancy, and primary outcome of the studies did not reveal significant differences in the rates of thromboembolism, any bleeding events, or major bleeding events. CONCLUSION The risk of both thrombosis and bleeding following CAR T-cell therapy appears to be highest in the initial months following infusion.
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Affiliation(s)
- Poorva Bindal
- Division of Hematologic Malignancies and Cellular Therapies, University of Massachusetts, Worcester, Massachusetts, USA
| | - Rushad Patell
- Division of Hematology and Hematologic Malignancies, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA. https://twitter.com/rushadpatell
| | - Thita Chiasakul
- Center of Excellence in Translational Hematology, Division of Hematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Mandy N Lauw
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Amica Ko
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Tzu-Fei Wang
- Department of Medicine, University of Ottawa at The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Jeffrey I Zwicker
- Department of Medicine, Hematology Service, Memorial Sloan Kettering Cancer Center, New York City, New York, USA; Weill Cornell Medical School, New York City, New York, USA.
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Galli E, Sorà F, Rossi E. Coagulopathy in CAR-T: Critical concern or mere blip? Br J Haematol 2024. [PMID: 38938123 DOI: 10.1111/bjh.19619] [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: 06/12/2024] [Accepted: 06/18/2024] [Indexed: 06/29/2024]
Abstract
Despite Peng and colleagues providing an extensive review of the clinical and laboratory aspects of CAR-T-associated coagulopathy, the current literature often lacks specificity in nomenclature and gradings, and the clinical implications of coagulopathy may remain unclear. Clear recommendations on stratification and prophylaxis are still required to standardize the clinical approach to this topic. Commentary on: Peng et al. Coagulation abnormalities associated with CAR-T therapy in hematological malignancies: A review. Br J Haematol 2024 (Online ahead of print). doi: 10.1111/bjh.19583.
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Affiliation(s)
- Eugenio Galli
- Dipartimento di Scienze di Laboratorio ed Ematologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Federica Sorà
- Dipartimento di Scienze di Laboratorio ed Ematologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Sezione di Ematologia, Rome, Italy
| | - Elena Rossi
- Dipartimento di Scienze di Laboratorio ed Ematologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Sezione di Ematologia, Rome, Italy
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Peng X, Zhang X, Zhao M, Chang D, Yang L, Mei H, Zhang R. Coagulation abnormalities associated with CAR-T-cell therapy in haematological malignancies: A review. Br J Haematol 2024. [PMID: 38887101 DOI: 10.1111/bjh.19583] [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: 12/30/2023] [Accepted: 05/27/2024] [Indexed: 06/20/2024]
Abstract
Chimeric antigen receptor (CAR)-T-cell therapy has demonstrated considerable efficacy and safety in the treatment of patients with relapsed/refractory haematological malignancies. Owing to significant advances, CAR-T-cell therapeutic modality has undergone substantial shifts in its clinical application. Coagulation abnormalities, which are prevalent complications in CAR-T-cell therapy, can range in severity from simple abnormalities in coagulation parameters to serious haemorrhage or disseminated intravascular coagulation associated with life-threatening multiorgan dysfunction. Nonetheless, there is a lack of a comprehensive overview concerning the coagulation abnormalities associated with CAR-T-cell therapy. With an aim to attract heightened clinical focus and to enhance the safety of CAR-T-cell therapy, this review presents the characteristics of the coagulation abnormalities associated with CAR-T-cell therapy, including clinical manifestations, coagulation parameters, pathogenesis, risk factors and their influence on treatment efficacy in patients receiving CAR-T-cell infusion. Due to limited data, these conclusions may undergo changes as more experience accumulates.
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Affiliation(s)
- Xiaojuan Peng
- Department of Hematology, Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, ShanXi, China
| | - Xialin Zhang
- Department of Hematology, Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, ShanXi, China
| | - Meiling Zhao
- Department of Hematology, Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, ShanXi, China
| | - Doudou Chang
- Department of Hematology, Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, ShanXi, China
| | - Linhua Yang
- Department of Hematology, The Second Hospital of Shanxi Medical University, Taiyuan, ShanXi, China
| | - Heng Mei
- Department of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Ruijuan Zhang
- Department of Hematology, Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, ShanXi, China
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Xu J, Zhang W, Tong J, Liu C, Zhang Q, Cao L, Yu J, Zhou A, Ma J. A phase I trial of autologous RAK cell immunotherapy in metastatic renal cell carcinoma. Cancer Immunol Immunother 2024; 73:107. [PMID: 38642109 PMCID: PMC11032301 DOI: 10.1007/s00262-024-03680-y] [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: 10/26/2023] [Accepted: 03/17/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND Treatment of metastatic renal cell carcinoma (mRCC) remains a challenge worldwide. Here, we introduced a phase I trial of autologous RAK cell therapy in patients with mRCC whose cancers progressed after prior systemic therapy. Although RAK cells have been used in clinic for many years, there has been no dose-escalation study to demonstrate its safety and efficacy. METHODS We conducted a phase I trial with a 3 + 3 dose-escalation design to investigate the dose-related safety and efficacy of RAK cells in patients with mRCC whose cancers have failed to response to systemic therapy (ChiCTR1900021334). RESULTS Autologous RAK cells, primarily composed of CD8+ T and NKT cells, were infused intravenously to patients at a dose of 5 × 109, 1 × 1010 or 1.5 × 1010 cells every 28 days per cycle. Our study demonstrated general safety of RAK cells in a total of 12 patients. Four patients (33.3%) showed tumor shrinkage, two of them achieved durable partial responses. Peripheral blood analysis showed a significant increase in absolute counts of CD3+ and CD8+ T cells after infusion, with a greater fold change observed in naive CD8+ T cells (CD8+CD45RA+). Higher peak values of IL-2 and IFN-γ were observed in responders after RAK infusion. CONCLUSION This study suggests that autologous RAK cell immunotherapy is safe and has clinical activity in previously treated mRCC patients. The improvement in peripheral blood immune profiling after RAK cell infusion highlights its potential as a cancer treatment. Further investigation is necessary to understand its clinical utility.
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Affiliation(s)
- Jing Xu
- Center of Biotherapy, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Wen Zhang
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100021, People's Republic of China
| | - Jinlian Tong
- Center of Biotherapy, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Caixia Liu
- Center of Biotherapy, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Qiaohui Zhang
- Clinical Department, Everbright Cell Medical Biotech Inc., Beijing, 100061, People's Republic of China
| | - Liren Cao
- Clinical Department, Everbright Cell Medical Biotech Inc., Beijing, 100061, People's Republic of China
| | - Jiangyong Yu
- Department of Medical Oncology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Aiping Zhou
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100021, People's Republic of China.
| | - Jie Ma
- Center of Biotherapy, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, China.
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Rejeski K, Subklewe M, Locke FL. Recognizing, defining, and managing CAR-T hematologic toxicities. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:198-208. [PMID: 38066881 PMCID: PMC10727074 DOI: 10.1182/hematology.2023000472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Autologous CAR-T cell therapy (CAR-T) has improved outcomes for patients with B-cell malignancies. It is associated with the well-described canonical toxicities cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS), which may be abrogated by corticosteroids and the anti-IL6 receptor antagonist tocilizumab. Practitioners and researchers should be aware of additional toxicities. Here we review current understanding and management of hematologic toxicities after CAR-T, including cytopenias, coagulopathies, bleeding and clotting events, hemophagocytic-lymphohistiocytosis, and tumor lysis syndrome. We pay particular attention to cytopenias, recently termed immune effector cell-associated hematological toxicity (ICAHT). While the "H" is silent, hematotoxicity is not: ICAHT has the highest cumulative incidence of all immune adverse events following CAR-T. Early cytopenia (day 0-30) is closely linked to lymphodepleting chemotherapy and CRS-related inflammatory stressors. Late ICAHT (after day 30) can present either with or without antecedent count recovery (e.g., "intermittent" vs "aplastic" phenotype), and requires careful evaluation and management strategies. Growth factor support is the mainstay of treatment, with recent evidence demonstrating safety and feasibility of early granulocyte colony-stimulating factor (G-CSF) (e.g., within week 1). In G-CSF refractory cases, autologous stem cell boosts represent a promising treatment avenue, if available. The CAR-HEMATOTOX scoring system, validated for use across lymphoid malignancies (B-NHL, multiple myeloma), enables pretherapeutic risk assessment and presents the potential for risk-adapted management. Recent expert panels have led to diagnostic scoring criteria, severity grading systems, and management strategies for both ICAHT and the recently termed immune effector cell-associated hemophagocytic lymphohistiocytosis-like syndrome (IEC-HS), now clarified and defined as a distinct entity from CRS.
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Affiliation(s)
- Kai Rejeski
- Department of Medicine III, University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
- Gene Center and Department of Biochemistry, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Marion Subklewe
- Department of Medicine III, University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
- Gene Center and Department of Biochemistry, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Frederick L Locke
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL
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Kawashima I, Hyuga H, Nakadate A, Matsuura M, Sakamoto Y, Suzuki J, Kumagai T, Suzuki M, Koshiishi M, Yamamoto T, Nakajima K, Tanaka M, Kirito K. Pre-exposure prophylaxis with tixagevimab/cilgavimab for coronavirus disease 2019 (COVID-19) during the Omicron BA.5 wave at a single institution in Japan. Int J Hematol 2023; 118:731-736. [PMID: 37747583 DOI: 10.1007/s12185-023-03663-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 09/01/2023] [Accepted: 09/11/2023] [Indexed: 09/26/2023]
Abstract
Pre-exposure prophylaxis with tixagevimab/cilgavimab was considered a useful strategy to protect immunocompromised patients from COVID-19 based on the phase 3 PROVENT trial conducted between November 2020 and March 2021. However, after late 2021, the dominant substrains of COVID-19 changed to Omicron substrains, which showed resistance to tixagevimab/cilgavimab. Therefore, it is important to re-evaluate the real-world efficacy of tixagevimab/cilgavimab for the prevention of COVID-19 in the Omicron era. To this end, we retrospectively evaluated the efficacy and safety of tixagevimab/cilgavimab prophylaxis for COVID-19 during the Omicron BA.5 wave in Japan. A total of 240 consecutive patients with hematologic malignancies received tixagevimab/cilgavimab at our institution from October 18, 2022, to January 31, 2023. Among them, the cumulative incidence of COVID-19 at 90 days was 6.4%. A total of 10/14 (71.4%) had mild infection, and 4/14 (28.5%) had severe infection. No patient died due to COVID-19. Adverse events consisted of deep vein thrombosis in 2 patients. Our analysis indicated that pre-exposure prophylaxis with tixagevimab/cilgavimab might have clinical effectiveness in reducing the severity of COVID-19 in Japanese HM patients, even in the Omicron BA.5 surge. It also suggested that tixagevimab/cilgavimab may be associated with cardiovascular complications.
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Affiliation(s)
- Ichiro Kawashima
- Department of Hematology and Oncology, University of Yamanashi, 1110, Shimokato, Chuo-City, Yamanashi-Ken, 409-3898, Japan
| | - Hideto Hyuga
- Department of Hematology and Oncology, University of Yamanashi, 1110, Shimokato, Chuo-City, Yamanashi-Ken, 409-3898, Japan
| | - Ayato Nakadate
- Department of Hematology and Oncology, University of Yamanashi, 1110, Shimokato, Chuo-City, Yamanashi-Ken, 409-3898, Japan
| | - Minori Matsuura
- Department of Hematology and Oncology, University of Yamanashi, 1110, Shimokato, Chuo-City, Yamanashi-Ken, 409-3898, Japan
| | - Yuma Sakamoto
- Department of Hematology and Oncology, University of Yamanashi, 1110, Shimokato, Chuo-City, Yamanashi-Ken, 409-3898, Japan
| | - Jun Suzuki
- Department of Hematology and Oncology, University of Yamanashi, 1110, Shimokato, Chuo-City, Yamanashi-Ken, 409-3898, Japan
| | - Takuma Kumagai
- Department of Hematology and Oncology, University of Yamanashi, 1110, Shimokato, Chuo-City, Yamanashi-Ken, 409-3898, Japan
| | - Megumi Suzuki
- Department of Hematology and Oncology, University of Yamanashi, 1110, Shimokato, Chuo-City, Yamanashi-Ken, 409-3898, Japan
| | - Megumi Koshiishi
- Department of Hematology and Oncology, University of Yamanashi, 1110, Shimokato, Chuo-City, Yamanashi-Ken, 409-3898, Japan
| | - Takeo Yamamoto
- Department of Hematology and Oncology, University of Yamanashi, 1110, Shimokato, Chuo-City, Yamanashi-Ken, 409-3898, Japan
| | - Kei Nakajima
- Department of Hematology and Oncology, University of Yamanashi, 1110, Shimokato, Chuo-City, Yamanashi-Ken, 409-3898, Japan
| | - Masaru Tanaka
- Department of Hematology and Oncology, University of Yamanashi, 1110, Shimokato, Chuo-City, Yamanashi-Ken, 409-3898, Japan
| | - Keita Kirito
- Department of Hematology and Oncology, University of Yamanashi, 1110, Shimokato, Chuo-City, Yamanashi-Ken, 409-3898, Japan.
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Cantrell R, Palumbo JS. Hemostasis and tumor immunity. Res Pract Thromb Haemost 2022; 6:e12728. [PMID: 35647476 PMCID: PMC9130907 DOI: 10.1002/rth2.12728] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/19/2022] [Accepted: 05/01/2022] [Indexed: 12/13/2022] Open
Abstract
Significant data have accumulated demonstrating a reciprocal relationship between cancer and the hemostatic system whereby cancer promotes life‐threatening hemostatic system dysregulation (e.g., thromboembolism, consumptive coagulopathy), and hemostatic system components directly contribute to cancer pathogenesis. The mechanistic underpinnings of this relationship continue to be defined, but it is becoming increasingly clear that many of these mechanisms involve crosstalk between the hemostatic and immune systems. This is perhaps not surprising given that there is ample evidence for bidirectional crosstalk between the hemostatic and immune systems at multiple levels that likely evolved to coordinate the response to injury, host defense, and tissue repair. Much of the data linking hemostasis and immunity in cancer biology focus on innate immune system components. However, the advent of adaptive immunity‐based cancer therapies such as immune checkpoint inhibitors has revealed that the relationship of hemostasis and immunity in cancer extends to the adaptive immune system. Adaptive immunity‐based cancer therapies appear to be associated with an increased risk of thromboembolic complications, and hemostatic system components appear to regulate adaptive immune functions through diverse mechanisms to affect tumor progression. In this review, the evidence for crosstalk between hemostatic and adaptive immune system components is discussed, and the implications of this relationship in the context of cancer therapy are reviewed. A better understanding of these relationships will likely lead to strategies to make existing adaptive immune based therapies safer by decreasing thromboembolic risk and may also lead to novel targets to improve adaptive immune‐based cancer treatments.
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Affiliation(s)
- Rachel Cantrell
- Cancer and Blood Diseases Institute Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine Cincinnati Ohio USA
| | - Joseph S. Palumbo
- Cancer and Blood Diseases Institute Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine Cincinnati Ohio USA
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