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Hernani R, Aiko M, Victorio R, Benzaquén A, Pérez A, Piñana JL, Hernández-Boluda JC, Amat P, Pastor-Galán I, Remigia MJ, Ferrer-Lores B, Micó M, Carbonell N, Ferreres J, Blasco-Cortés ML, Santonja JM, Dosdá R, Estellés R, Campos S, Martínez-Ciarpaglini C, Ferrández-Izquierdo A, Goterris R, Gómez M, Teruel A, Saus A, Ortiz A, Morello D, Martí E, Carretero C, Calabuig M, Tormo M, Terol MJ, Cases P, Solano C. EEG before chimeric antigen receptor T-cell therapy and early after onset of immune effector cell-associated neurotoxicity syndrome. Clin Neurophysiol 2024; 163:132-142. [PMID: 38733703 DOI: 10.1016/j.clinph.2024.04.014] [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: 12/17/2023] [Revised: 03/24/2024] [Accepted: 04/17/2024] [Indexed: 05/13/2024]
Abstract
BACKGROUND Immune effector cell-associated neurotoxicity syndrome (ICANS) is common after chimeric antigen receptor T-cell (CAR-T) therapy. OBJECTIVE This study aimed to assess the impact of preinfusion electroencephalography (EEG) abnormalities and EEG findings at ICANS onset for predicting ICANS risk and severity in 56 adult patients with refractory lymphoma undergoing CAR-T therapy. STUDY DESIGN EEGs were conducted at the time of lymphodepleting chemotherapy and shortly after onset of ICANS. RESULTS Twenty-eight (50%) patients developed ICANS at a median time of 6 days after CAR-T infusion. Abnormal preinfusion EEG was identified as a risk factor for severe ICANS (50% vs. 17%, P = 0.036). Following ICANS onset, EEG abnormalities were detected in 89% of patients [encephalopathy (n = 19, 70%) and/or interictal epileptiform discharges (IEDs) (n = 14, 52%)]. Importantly, IEDs seemed to be associated with rapid progression to higher grades of ICANS within 24 h. CONCLUSIONS If confirmed in a large cohort of patients, these findings could establish the basis for modifying current management guidelines, enabling the identification of patients at risk of neurotoxicity, and providing support for preemptive corticosteroid use in patients with both initial grade 1 ICANS and IEDs at neurotoxicity onset, who are at risk of neurological impairment.
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Affiliation(s)
- Rafael Hernani
- Haematology Department, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain.
| | - Mika Aiko
- Neurophysiology Department, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain
| | - Ruth Victorio
- Neurophysiology Department, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain
| | - Ana Benzaquén
- Haematology Department, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain
| | - Ariadna Pérez
- Haematology Department, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain
| | - José Luis Piñana
- Haematology Department, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain
| | - Juan Carlos Hernández-Boluda
- Haematology Department, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain; Department of Medicine, University of Valencia, Valencia, Spain
| | - Paula Amat
- Haematology Department, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain; Department of Medicine, University of Valencia, Valencia, Spain
| | - Irene Pastor-Galán
- Haematology Department, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain
| | - María José Remigia
- Haematology Department, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain
| | - Blanca Ferrer-Lores
- Haematology Department, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain
| | - Mireia Micó
- Haematology Department, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain
| | - Nieves Carbonell
- Intensive Care Unit, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain
| | - José Ferreres
- Intensive Care Unit, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain
| | | | - José Miguel Santonja
- Neurology Department, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain
| | - Rosa Dosdá
- Radiology Department, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain
| | - Rocío Estellés
- Radiology Department, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain
| | - Salvador Campos
- Radiology Department, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain
| | | | | | - Rosa Goterris
- Haematology Department, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain
| | - Montse Gómez
- Haematology Department, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain
| | - Anabel Teruel
- Haematology Department, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain; Department of Medicine, University of Valencia, Valencia, Spain
| | - Ana Saus
- Haematology Department, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain
| | - Alfonso Ortiz
- Haematology Department, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain
| | - Daniela Morello
- Haematology Department, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain
| | - Edel Martí
- Haematology Department, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain
| | - Carlos Carretero
- Haematology Department, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain
| | - Marisa Calabuig
- Haematology Department, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain
| | - Mar Tormo
- Haematology Department, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain; Department of Medicine, University of Valencia, Valencia, Spain
| | - María José Terol
- Haematology Department, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain; Department of Medicine, University of Valencia, Valencia, Spain
| | - Paula Cases
- Neurophysiology Department, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain
| | - Carlos Solano
- Haematology Department, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain; Department of Medicine, University of Valencia, Valencia, Spain
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Sales C, Anderson MA, Kuznetsova V, Rosenfeld H, Malpas CB, Roos I, Dickinson M, Harrison S, Kalincik T. Patterns of neurotoxicity among patients receiving chimeric antigen receptor T-cell therapy: A single-centre cohort study. Eur J Neurol 2024; 31:e16174. [PMID: 38085272 PMCID: PMC11235605 DOI: 10.1111/ene.16174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 09/28/2023] [Accepted: 11/23/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND AND PURPOSE Immune effector cell-associated neurotoxicity syndrome (ICANS) is an important complication of chimeric antigen receptor T-cell (CAR-T) therapy. This study aims to identify the patterns of neurotoxicity among patients with ICANS at a tertiary referral centre in Australia. METHODOLOGY This single-centre, prospective cohort study included all consecutively recruited patients who underwent CAR-T therapy for eligible haematological malignancies. All patients underwent a comprehensive neurological assessment and cognitive screening before CAR-T infusion, during the development of ICANS, and 1 month after treatment. Baseline demographic characteristics, incidence, and neurological patterns of neurotoxicity management were evaluated. RESULTS Over a 19-month period, 23% (12) of the 53 eligible patients developed neurotoxicity (10/12 [83%] being grade 1). All patients showed changes in handwriting and tremor as their initial presentation. Changes in cognition were manifested in most of the patients, with a more substantial drop noted in their Montreal Cognitive Assessment compared to immune effector cell-associated encephalopathy scores. All manifestations of neurotoxicity were short-lived and resolved within a 1-month period, with a mean duration of 8.2 days (range = 1-33). CONCLUSIONS The patterns of CAR-T-related neurotoxicity often include change in handwriting, tremor, and mild confusional state, especially early in their evolution. These may remain undetected by routine neurological surveillance. These features represent accessible clinical markers of incipient ICANS.
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Affiliation(s)
- Carmela Sales
- Neuroimmunology Centre, Department of NeurologyRoyal Melbourne HospitalMelbourneVictoriaAustralia
- Department of Clinical HaematologyPeter MacCallum Cancer Centre, Royal Melbourne HospitalMelbourneVictoriaAustralia
| | - Mary Ann Anderson
- Department of Clinical HaematologyPeter MacCallum Cancer Centre, Royal Melbourne HospitalMelbourneVictoriaAustralia
- Division of Blood Cells and Blood CancerWalter and Eliza Hall InstituteParkvilleVictoriaAustralia
| | - Valeriya Kuznetsova
- Neuroimmunology Centre, Department of NeurologyRoyal Melbourne HospitalMelbourneVictoriaAustralia
- Department of Clinical HaematologyPeter MacCallum Cancer Centre, Royal Melbourne HospitalMelbourneVictoriaAustralia
- Clinical Outcomes Research (CORe), Department of MedicineUniversity of MelbourneParkvilleVictoriaAustralia
| | - Hannah Rosenfeld
- Neuroimmunology Centre, Department of NeurologyRoyal Melbourne HospitalMelbourneVictoriaAustralia
- Department of Clinical HaematologyPeter MacCallum Cancer Centre, Royal Melbourne HospitalMelbourneVictoriaAustralia
| | - Charles B. Malpas
- Neuroimmunology Centre, Department of NeurologyRoyal Melbourne HospitalMelbourneVictoriaAustralia
- Clinical Outcomes Research (CORe), Department of MedicineUniversity of MelbourneParkvilleVictoriaAustralia
- Melbourne School of Psychological SciencesUniversity of MelbourneParkvilleVictoriaAustralia
| | - Izanne Roos
- Neuroimmunology Centre, Department of NeurologyRoyal Melbourne HospitalMelbourneVictoriaAustralia
- Clinical Outcomes Research (CORe), Department of MedicineUniversity of MelbourneParkvilleVictoriaAustralia
| | - Michael Dickinson
- Department of Clinical HaematologyPeter MacCallum Cancer Centre, Royal Melbourne HospitalMelbourneVictoriaAustralia
- Sir Peter MacCallum Department of OncologyUniversity of MelbourneParkvilleVictoriaAustralia
| | - Simon Harrison
- Department of Clinical HaematologyPeter MacCallum Cancer Centre, Royal Melbourne HospitalMelbourneVictoriaAustralia
- Sir Peter MacCallum Department of OncologyUniversity of MelbourneParkvilleVictoriaAustralia
| | - Tomas Kalincik
- Neuroimmunology Centre, Department of NeurologyRoyal Melbourne HospitalMelbourneVictoriaAustralia
- Clinical Outcomes Research (CORe), Department of MedicineUniversity of MelbourneParkvilleVictoriaAustralia
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Benedetti GM, Guerriero RM, Press CA. Review of Noninvasive Neuromonitoring Modalities in Children II: EEG, qEEG. Neurocrit Care 2023; 39:618-638. [PMID: 36949358 PMCID: PMC10033183 DOI: 10.1007/s12028-023-01686-5] [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: 07/28/2022] [Accepted: 01/30/2023] [Indexed: 03/24/2023]
Abstract
Critically ill children with acute neurologic dysfunction are at risk for a variety of complications that can be detected by noninvasive bedside neuromonitoring. Continuous electroencephalography (cEEG) is the most widely available and utilized form of neuromonitoring in the pediatric intensive care unit. In this article, we review the role of cEEG and the emerging role of quantitative EEG (qEEG) in this patient population. cEEG has long been established as the gold standard for detecting seizures in critically ill children and assessing treatment response, and its role in background assessment and neuroprognostication after brain injury is also discussed. We explore the emerging utility of both cEEG and qEEG as biomarkers of degree of cerebral dysfunction after specific injuries and their ability to detect both neurologic deterioration and improvement.
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Affiliation(s)
- Giulia M Benedetti
- Division of Pediatric Neurology, Department of Neurology, Seattle Children's Hospital and the University of Washington School of Medicine, Seattle, WA, USA.
- Division of Pediatric Neurology, Department of Pediatrics, C.S. Mott Children's Hospital and the University of Michigan, 1540 E Hospital Drive, Ann Arbor, MI, 48109-4279, USA.
| | - Rejéan M Guerriero
- Division of Pediatric and Developmental Neurology, Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Craig A Press
- Departments of Neurology and Pediatric, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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4
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Rubinos C, Bruzzone MJ, Viswanathan V, Figueredo L, Maciel CB, LaRoche S. Electroencephalography as a Biomarker of Prognosis in Acute Brain Injury. Semin Neurol 2023; 43:675-688. [PMID: 37832589 DOI: 10.1055/s-0043-1775816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
Electroencephalography (EEG) is a noninvasive tool that allows the monitoring of cerebral brain function in critically ill patients, aiding with diagnosis, management, and prognostication. Specific EEG features have shown utility in the prediction of outcomes in critically ill patients with status epilepticus, acute brain injury (ischemic stroke, intracranial hemorrhage, subarachnoid hemorrhage, and traumatic brain injury), anoxic brain injury, and toxic-metabolic encephalopathy. Studies have also found an association between particular EEG patterns and long-term functional and cognitive outcomes as well as prediction of recovery of consciousness following acute brain injury. This review summarizes these findings and demonstrates the value of utilizing EEG findings in the determination of prognosis.
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Affiliation(s)
- Clio Rubinos
- Department of Neurology, University of North Carolina, Chapel Hill, North Carolina
| | | | - Vyas Viswanathan
- Department of Neurology, University of North Carolina, Chapel Hill, North Carolina
| | - Lorena Figueredo
- Department of Neurology, University of Florida, Gainesville, Florida
| | - Carolina B Maciel
- Department of Neurology, University of Florida, Gainesville, Florida
| | - Suzette LaRoche
- Department of Neurology, University of North Carolina, Chapel Hill, North Carolina
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5
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Pinto SN, Liu CSJ, Nelson MD, Bluml S, Livingston D, Tamrazi B. Neuroimaging of complications arising after CD19 chimeric antigen receptor T-cell therapy: A review. J Neuroimaging 2023; 33:703-715. [PMID: 37327044 DOI: 10.1111/jon.13138] [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: 05/12/2023] [Revised: 06/02/2023] [Accepted: 06/05/2023] [Indexed: 06/17/2023] Open
Abstract
Chimeric antigen receptor (CAR) T cells targeting the CD19 (cluster of differentiation 19) cell surface glycoprotein have emerged as a highly effective immunologic therapy in patients with relapsed or refractory B-cell malignancies. The engagement of CAR T cells with CD19 on the surface of neoplastic B cells causes a systemic cytokine release, which can compromise the blood-brain barrier and cause an immune effector cell-associated neurotoxicity syndrome (ICANS). In a small proportion of ICANS patients who demonstrate neuroimaging abnormalities, certain distinct patterns have been recognized, including signal changes in the thalami, external capsule, and brainstem, the subcortical and/or periventricular white matter, the splenium of the corpus callosum, and the cerebellum. On careful review of the underlying pathophysiology of ICANS, we noticed that these changes closely mirror the underlying blood-brain barrier disruption and neuroinflammatory and excitotoxic effects of the offending cytokines released during ICANS. Furthermore, other uncommon complications of CD19 CAR T-cell therapy such as posterior reversible encephalopathy syndrome, ocular complications, and opportunistic fungal infections can be catastrophic if not diagnosed in a timely manner, with neuroimaging playing a significant role in management. In this narrative review, we will summarize the current literature on the spectrum of neuroimaging findings in ICANS, list appropriate differential diagnoses, and explore the imaging features of other uncommon central nervous system complications of CD19 CAR T-cell therapy using illustrative cases from two tertiary care institutions.
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Affiliation(s)
- Soniya N Pinto
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Chia-Shang J Liu
- Division of Neuroradiology, Department of Radiology, Children's Hospital of Los Angeles, Los Angeles, California, USA
| | - Marvin D Nelson
- Division of Neuroradiology, Department of Radiology, Children's Hospital of Los Angeles, Los Angeles, California, USA
| | - Stefan Bluml
- Division of Neuroradiology, Department of Radiology, Children's Hospital of Los Angeles, Los Angeles, California, USA
| | - David Livingston
- Resident, Department of Radiology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Benita Tamrazi
- Division of Neuroradiology, Department of Radiology, Children's Hospital of Los Angeles, Los Angeles, California, USA
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6
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Santomasso BD, Gust J, Perna F. How I treat unique and difficult-to-manage cases of CAR T-cell therapy-associated neurotoxicity. Blood 2023; 141:2443-2451. [PMID: 36877916 PMCID: PMC10329188 DOI: 10.1182/blood.2022017604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 02/01/2023] [Accepted: 02/17/2023] [Indexed: 03/08/2023] Open
Abstract
With growing indications for chimeric antigen receptor (CAR) T-cell therapy, toxicity profiles are evolving. There is an urgent and unmet need of approaches to optimally manage emerging adverse events that extend beyond the standard paradigm of cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome (ICANS). Although management guidelines exist for ICANS, there is little guidance on how to approach patients with neurologic comorbidities, and how to manage rare neurotoxicity presentations, such as CAR T-cell therapy-related cerebral edema, severe motor complications or late-onset neurotoxicity. In this study, we present 3 scenarios of patients treated with CAR T cells who develop unique types of neurotoxicity, and we describe an approach for the evaluation and management based on experience because objective data are limited. The goal of this study is to develop an awareness of emerging and unusual complications, discuss treatment approaches, and help institutions and health care providers establish frameworks to navigate how to best address unusual neurotoxicities to ultimately improve patient outcomes.
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Affiliation(s)
- Bianca D. Santomasso
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY
- Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Juliane Gust
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, WA
- Seattle Children's Research Institute Center for Integrative Brain Research, Seattle, WA
| | - Fabiana Perna
- Division of Hematology/Oncology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
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7
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Shalabi H, Nellan A, Shah NN, Gust J. Immunotherapy Associated Neurotoxicity in Pediatric Oncology. Front Oncol 2022; 12:836452. [PMID: 35265526 PMCID: PMC8899040 DOI: 10.3389/fonc.2022.836452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/20/2022] [Indexed: 11/30/2022] Open
Abstract
Novel immunotherapies are increasingly being employed in pediatric oncology, both in the upfront and relapsed/refractory settings. Through various mechanisms of action, engagement and activation of the immune system can cause both generalized and disease site-specific inflammation, leading to immune-related adverse events (irAEs). One of the most worrisome irAEs is that of neurotoxicity. This can present as a large spectrum of neurological toxicities, including confusion, aphasia, neuropathies, seizures, and/or death, with variable onset and severity. Earlier identification and treatment, generally with corticosteroids, remains the mainstay of neurotoxicity management to optimize patient outcomes. The pathophysiology of neurotoxicity varies across the different therapeutic strategies and remains to be elucidated in most cases. Furthermore, little is known about long-term neurologic sequelae. This review will focus on neurotoxicity seen with the most common immunotherapies used in pediatric oncology, including CAR T cell therapy, alternative forms of adoptive cell therapy, antibody therapies, immune checkpoint inhibitors, and tumor vaccines. Herein we will discuss the incidence, pathophysiology, symptomatology, diagnosis, and management strategies currently being utilized for immunotherapy-associated neurotoxicity with a focus on pediatric specific considerations.
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Affiliation(s)
- Haneen Shalabi
- National Cancer Institute, Pediatric Oncology Branch, National Institutes of Health, Bethesda, MD, United States
| | - Anandani Nellan
- National Cancer Institute, Pediatric Oncology Branch, National Institutes of Health, Bethesda, MD, United States
| | - Nirali N. Shah
- National Cancer Institute, Pediatric Oncology Branch, National Institutes of Health, Bethesda, MD, United States
| | - Juliane Gust
- Seattle Children’s Research Institute, Seattle, WA, United States
- Department of Neurology, University of Washington, Seattle, WA, United States
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8
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[Consensus of Chinese experts on the clinical management of chimeric antigen receptor T-cell-associated neurotoxicity (2022)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2022; 43:96-101. [PMID: 35381668 PMCID: PMC8980636 DOI: 10.3760/cma.j.issn.0253-2727.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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9
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Gu T, Hu K, Si X, Hu Y, Huang H. Mechanisms of immune effector cell-associated neurotoxicity syndrome after CAR-T treatment. WIREs Mech Dis 2022; 14:e1576. [PMID: 35871757 PMCID: PMC9787013 DOI: 10.1002/wsbm.1576] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 06/05/2022] [Accepted: 06/22/2022] [Indexed: 12/30/2022]
Abstract
Chimeric antigen receptor T-cell (CAR-T) treatment has revolutionized the landscape of cancer therapy with significant efficacy on hematologic malignancy, especially in relapsed and refractory B cell malignancies. However, unexpected serious toxicities such as cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS) still hamper its broad application. Clinical trials using CAR-T cells targeting specific antigens on tumor cell surface have provided valuable information about the characteristics of ICANS. With unclear mechanism of ICANS after CAR-T treatment, unremitting efforts have been devoted to further exploration. Clinical findings from patients with ICANS strongly indicated existence of overactivated peripheral immune response followed by endothelial activation-induced blood-brain barrier (BBB) dysfunction, which triggers subsequent central nervous system (CNS) inflammation and neurotoxicity. Several animal models have been built but failed to fully replicate the whole spectrum of ICANS in human. Hopefully, novel and powerful technologies like single-cell analysis may help decipher the precise cellular response within CNS from a different perspective when ICANS happens. Moreover, multidisciplinary cooperation among the subjects of immunology, hematology, and neurology will facilitate better understanding about the complex immune interaction between the peripheral, protective barriers, and CNS in ICANS. This review elaborates recent findings about ICANS after CAR-T treatment from bed to bench, and discusses the potential cellular and molecular mechanisms that may promote effective management in the future. This article is categorized under: Cancer > Biomedical Engineering Immune System Diseases > Molecular and Cellular Physiology Neurological Diseases > Molecular and Cellular Physiology.
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Affiliation(s)
- Tianning Gu
- Bone Marrow Transplantation Centerthe First Affiliated Hospital, Zhejiang University School of MedicineHangzhouZhejiang310003China,Liangzhu LaboratoryZhejiang University Medical CenterHangzhouChina,Institute of HematologyZhejiang UniversityHangzhou310058China,Zhejiang Province Engineering Laboratory for Stem Cell and Immunity TherapyHangzhouChina
| | - Kejia Hu
- Bone Marrow Transplantation Centerthe First Affiliated Hospital, Zhejiang University School of MedicineHangzhouZhejiang310003China,Liangzhu LaboratoryZhejiang University Medical CenterHangzhouChina,Institute of HematologyZhejiang UniversityHangzhou310058China,Zhejiang Province Engineering Laboratory for Stem Cell and Immunity TherapyHangzhouChina
| | - Xiaohui Si
- Bone Marrow Transplantation Centerthe First Affiliated Hospital, Zhejiang University School of MedicineHangzhouZhejiang310003China,Liangzhu LaboratoryZhejiang University Medical CenterHangzhouChina,Institute of HematologyZhejiang UniversityHangzhou310058China,Zhejiang Province Engineering Laboratory for Stem Cell and Immunity TherapyHangzhouChina
| | - Yongxian Hu
- Bone Marrow Transplantation Centerthe First Affiliated Hospital, Zhejiang University School of MedicineHangzhouZhejiang310003China,Liangzhu LaboratoryZhejiang University Medical CenterHangzhouChina,Institute of HematologyZhejiang UniversityHangzhou310058China,Zhejiang Province Engineering Laboratory for Stem Cell and Immunity TherapyHangzhouChina
| | - He Huang
- Bone Marrow Transplantation Centerthe First Affiliated Hospital, Zhejiang University School of MedicineHangzhouZhejiang310003China,Liangzhu LaboratoryZhejiang University Medical CenterHangzhouChina,Institute of HematologyZhejiang UniversityHangzhou310058China,Zhejiang Province Engineering Laboratory for Stem Cell and Immunity TherapyHangzhouChina
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10
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Gust J, Ponce R, Liles WC, Garden GA, Turtle CJ. Cytokines in CAR T Cell-Associated Neurotoxicity. Front Immunol 2020; 11:577027. [PMID: 33391257 PMCID: PMC7772425 DOI: 10.3389/fimmu.2020.577027] [Citation(s) in RCA: 106] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 11/16/2020] [Indexed: 02/06/2023] Open
Abstract
Chimeric antigen receptor (CAR) T cells provide new therapeutic options for patients with relapsed/refractory hematologic malignancies. However, neurotoxicity is a frequent, and potentially fatal, complication. The spectrum of manifestations ranges from delirium and language dysfunction to seizures, coma, and fatal cerebral edema. This novel syndrome has been designated immune effector cell-associated neurotoxicity syndrome (ICANS). In this review, we draw an arc from our current understanding of how systemic and potentially local cytokine release act on the CNS, toward possible preventive and therapeutic approaches. We systematically review reported correlations of secreted inflammatory mediators in the serum/plasma and cerebrospinal fluid with the risk of ICANS in patients receiving CAR T cell therapy. Possible pathophysiologic impacts on the CNS are covered in detail for the most promising candidate cytokines, including IL-1, IL-6, IL-15, and GM-CSF. To provide insight into possible final common pathways of CNS inflammation, we place ICANS into the context of other systemic inflammatory conditions that are associated with neurologic dysfunction, including sepsis-associated encephalopathy, cerebral malaria, thrombotic microangiopathy, CNS infections, and hepatic encephalopathy. We then review in detail what is known about systemic cytokine interaction with components of the neurovascular unit, including endothelial cells, pericytes, and astrocytes, and how microglia and neurons respond to systemic inflammatory challenges. Current therapeutic approaches, including corticosteroids and blockade of IL-1 and IL-6 signaling, are reviewed in the context of what is known about the role of cytokines in ICANS. Throughout, we point out gaps in knowledge and possible new approaches for the investigation of the mechanism, prevention, and treatment of ICANS.
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Affiliation(s)
- Juliane Gust
- Department of Neurology, University of Washington, Seattle, WA, United States
- Seattle Children’s Research Institute, Center for Integrative Brain Research, Seattle, WA, United States
| | | | - W. Conrad Liles
- Department of Medicine, University of Washington, Seattle, WA, United States
| | - Gwenn A. Garden
- Department of Neurology, University of North Carolina, Chapel Hill, NC, United States
| | - Cameron J. Turtle
- Department of Medicine, University of Washington, Seattle, WA, United States
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States
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