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Zhao L, Li C, Zuo S, Han Y, Deng B, Ling Z, Zhang Y, Peng S, Xu J, Duan J, Wang Z, Yu X, Zheng Q, Xu X, Yuan Y, Tian Z, Tang K, Zhang Y, Niu Q, Zhang J, Chang AH, Luo Y, Feng X, Pan J. Autologous CD7 CAR-T cells generated without T cell pre-selection in pediatric patients with relapsed/refractory T-ALL: A phase I trial. Mol Ther 2024:S1525-0016(24)00594-X. [PMID: 39244642 DOI: 10.1016/j.ymthe.2024.09.006] [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: 04/16/2024] [Revised: 06/29/2024] [Accepted: 09/04/2024] [Indexed: 09/09/2024] Open
Abstract
Chimeric antigen receptor (CAR)-T cell therapy showed preliminary activity in patients with refractory or relapsed T cell acute lymphoblastic leukemia (r/r T-ALL). However, many obstacles remain, including manufacturing difficulties and risk of infections. This phase I study (NCT04840875) evaluated autologous CD7 CAR-T cells manufactured without pre-selection of healthy T cells in r/r T-ALL. Thirty patients (29 children and one adult) with a median of two lines of prior therapy but without detectable peripheral leukemia were enrolled. Excluding three cases of manufacturing failures, a total of 27 (90%) patients received infusions after products were confirmed free of leukemia contamination, including 16 (59%) meeting planned target doses. Common adverse events within 30 days included grade 3-4 cytopenias (100%), grade 1-2 (70%) and 3-4 (7%, including one dose-limiting toxicity) cytokine release syndrome, grade 1 neurotoxicity (7%), grade 2 infection (4%), and grade 2 graft-versus-host disease (4%). Two patients developed grade 2 infections after day 30. At day 30, 96% responded and 85% achieved complete remission (CR) or CR with incomplete hematologic recovery (CRi). Seventy-four percent underwent transplantation. Twelve-month progression-free survival with and without censoring transplantation was 22% (95% confidence interval 4%-100%) and 57% (41%-81%), respectively. These results support that autologous CD7 CAR-T therapy without T cell pre-selection is feasible in patients with r/r T-ALL.
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Affiliation(s)
- Liping Zhao
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China; Tianjin Institutes of Health Science, Tianjin 301600, China; Department of Hematology, Key Laboratory of Experimental Hematology, Boren Clinical Translational Center, Beijing Gobroad Boren Hospital, Beijing 100070, China
| | - Chuo Li
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China; Tianjin Institutes of Health Science, Tianjin 301600, China
| | - Shiyu Zuo
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China; Tianjin Institutes of Health Science, Tianjin 301600, China
| | - Yajing Han
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China; Tianjin Institutes of Health Science, Tianjin 301600, China
| | - Biping Deng
- Cytology Laboratory, Beijing GoBroad Boren Hospital, Beijing 100070, China
| | - Zhuojun Ling
- Department of Hematology, Key Laboratory of Experimental Hematology, Boren Clinical Translational Center, Beijing Gobroad Boren Hospital, Beijing 100070, China
| | - Yanlei Zhang
- Shanghai YaKe Biotechnology Ltd., Shanghai 200438, China
| | - Shuixiu Peng
- Shanghai YaKe Biotechnology Ltd., Shanghai 200438, China
| | - Jinlong Xu
- Department of Hematology, Key Laboratory of Experimental Hematology, Boren Clinical Translational Center, Beijing Gobroad Boren Hospital, Beijing 100070, China
| | - Jiajia Duan
- Department of Hematology, Key Laboratory of Experimental Hematology, Boren Clinical Translational Center, Beijing Gobroad Boren Hospital, Beijing 100070, China
| | - Zelin Wang
- Department of Hematology, Key Laboratory of Experimental Hematology, Boren Clinical Translational Center, Beijing Gobroad Boren Hospital, Beijing 100070, China
| | - Xinjian Yu
- Medical Laboratory, Beijing GoBroad Boren Hospital, Beijing 100070, China
| | - Qinlong Zheng
- Medical Laboratory, Beijing GoBroad Boren Hospital, Beijing 100070, China
| | - Xiuwen Xu
- Medical Laboratory, Beijing GoBroad Boren Hospital, Beijing 100070, China
| | - Ying Yuan
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Austin, TX 77030, USA
| | - Zhenglong Tian
- Gobroad Research Center, GoBroad Medical Group, Beijing 100070, China
| | - Kaiting Tang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China; Tianjin Institutes of Health Science, Tianjin 301600, China
| | - Yibing Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China; Tianjin Institutes of Health Science, Tianjin 301600, China
| | - Qing Niu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China; Tianjin Institutes of Health Science, Tianjin 301600, China
| | - Jiecheng Zhang
- Department of Hospital Management, GoBroad Medical Group, Beijing 100070, China
| | - Alex H Chang
- Shanghai YaKe Biotechnology Ltd., Shanghai 200438, China; Engineering Research Center of Gene Technology, Ministry of Education, Institute of Genetics, School of Life Science, Fudan University, Shanghai 200438, China
| | - Yuechen Luo
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China; Tianjin Institutes of Health Science, Tianjin 301600, China.
| | - Xiaoming Feng
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China; Tianjin Institutes of Health Science, Tianjin 301600, China; Central laboratory, Fujian Medical Union Hospital, Fuzhou 350001, China; CAMS Key Laboratory for Prevention and Control of Hematological Disease Treatment Related Infection, Tianjin 300020, China.
| | - Jing Pan
- Department of Hematology, Key Laboratory of Experimental Hematology, Boren Clinical Translational Center, Beijing Gobroad Boren Hospital, Beijing 100070, China.
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2
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Huang T, Fakurazi S, Cheah PS, Ling KH. Chromosomal and cellular therapeutic approaches for Down syndrome: A research update. Biochem Biophys Res Commun 2024; 735:150664. [PMID: 39260337 DOI: 10.1016/j.bbrc.2024.150664] [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: 06/01/2024] [Revised: 08/20/2024] [Accepted: 09/03/2024] [Indexed: 09/13/2024]
Abstract
In individuals with Down syndrome (DS), an additional HSA21 chromosome copy leads to the overexpression of a myriad of HSA21 genes, disrupting the transcription of the entire genome. This dysregulation in transcription and post-transcriptional modifications contributes to abnormal phenotypes across nearly all tissues and organs in DS individuals. The array of severe clinical symptoms associated with trisomy 21 poses a considerable challenge in the quest for a cure for DS. Fortunately, a wealth of research suggests that chromosome therapy, hinging on cutting-edge genome editing technologies, can potentially eliminate the extra copy of the human chromosome 21. Genome editing tools have demonstrated their efficacy in restoring trisomy to a normal diploid state in vitro DS cell models. Furthermore, we delve into the noteworthy findings in cellular therapy for DS, with recent studies showcasing the increasing feasibility of strategies involving stem cells and CAR T-cells to address corresponding clinical phenotypes.
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Affiliation(s)
- Tan Huang
- Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400, Serdang, Selangor, Malaysia
| | - Sharida Fakurazi
- Department of Human Anatomy, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400, Serdang, Selangor, Malaysia
| | - Pike-See Cheah
- Department of Human Anatomy, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400, Serdang, Selangor, Malaysia; Malaysian Research Institute on Ageing (MyAgeing(TM)), Universiti Putra Malaysia, 43400, Serdang, Selangor, Malaysia
| | - King-Hwa Ling
- Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400, Serdang, Selangor, Malaysia; Malaysian Research Institute on Ageing (MyAgeing(TM)), Universiti Putra Malaysia, 43400, Serdang, Selangor, Malaysia.
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3
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Perna F, Parekh S, Diorio C, Smith M, Subklewe M, Mehta R, Locke FL, Shah NN. CAR T-cell toxicities: from bedside to bench, how novel toxicities inform laboratory investigations. Blood Adv 2024; 8:4348-4358. [PMID: 38861351 PMCID: PMC11375260 DOI: 10.1182/bloodadvances.2024013044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 05/20/2024] [Accepted: 06/02/2024] [Indexed: 06/13/2024] Open
Abstract
ABSTRACT Multiple chimeric antigen receptor (CAR) T-cell therapies are US Food and Drug Administration-approved, and several are under development. Although effective for some cancers, toxicities remain a limitation. The most common toxicities, that is, cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome, are well described. With increasing utilization, providers worldwide are reporting other emergent and often complicated toxicities. Given the evolving toxicity profiles and urgent need to catalog these emerging and emergent CAR T-cell toxicities and describe management approaches, the American Society of Hematology Subcommittee on Emerging Gene and Cell Therapies organized the first scientific workshop on CAR T-cell toxicities during the annual society meeting. The workshop functioned to (1) aggregate reports of CAR T-cell emergent toxicities, including movement disorders after B-cell maturation antigen CAR T cell, coagulation abnormalities, and prolonged cytopenia; (2) disseminate bedside-to-bench efforts elucidating pathophysiological mechanisms of CAR T-cell toxicities, including the intestinal microbiota and systemic immune dysregulation; and (3) highlight gaps in the availability of clinical tests, such as cytokine measurements, which could be used to expand our knowledge around the monitoring of toxicities. Key themes emerged. First, although clinical manifestations may develop before the pathophysiologic mechanisms are understood, they must be studied to aid in the detection and prevention of such toxicities. Second, systemic immune dysregulation appears to be central to these emergent toxicities, and research is needed to elucidate the links between tumors, CAR T cells, and microbiota. Finally, there was a consensus around the urgency to create a repository to capture emergent CAR T-cell toxicities and the real-world management.
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Affiliation(s)
- Fabiana Perna
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL
| | - Samir Parekh
- Division of Hematology and Medical Oncology, The Tish Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Caroline Diorio
- Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Melody Smith
- Department of Medicine, Stanford University, Stanford, CA
| | - Marion Subklewe
- Department of Medicine III, University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Rakesh Mehta
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Frederick L Locke
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL
| | - Nirali N Shah
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD
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4
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Rotta G, Puca E, Cazzamalli S, Neri D, Dakhel Plaza S. Cytokine Biopharmaceuticals with "Activity-on-Demand" for Cancer Therapy. Bioconjug Chem 2024; 35:1075-1088. [PMID: 38885090 DOI: 10.1021/acs.bioconjchem.4c00187] [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: 06/20/2024]
Abstract
Cytokines are small proteins that modulate the activity of the immune system. Because of their potent immunomodulatory properties, some recombinant cytokines have undergone clinical development and have gained marketing authorization for the therapy of certain forms of cancer. Recombinant cytokines are typically administered at ultralow doses, as many of them can cause substantial toxicity even at submilligram quantities. In an attempt to increase the therapeutic index, fusion proteins based on tumor-homing antibodies (also called "immunocytokines") have been considered, and some products in this class have reached late-stage clinical trials. While antibody-cytokine fusions, which preferentially localize in the neoplastic mass, can activate tumor-resident leukocytes and may be more efficacious than their nontargeted counterparts, such products typically conserve an intact cytokine activity, which may prevent escalation to curative doses. To further improve tolerability, several strategies have been conceived for the development of antibody-cytokine fusions with "activity-on-demand", acting on tumors but helping spare normal tissues from undesired toxicity. In this article, we have reviewed some of the most promising strategies, outlining their potential as well as possible limitations.
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Affiliation(s)
- Giulia Rotta
- Philochem AG, CH-8112 Otelfingen, Switzerland
- Department of Cellular, Computational, and Integrative Biology (CIBIO), University of Trento, 38123 Trento, Italy
| | | | | | - Dario Neri
- Philogen S.p.A, 53100 Siena, Italy
- Institute of Pharmaceutical Sciences, ETH Zurich, CH-8093 Zurich, Switzerland
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5
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Hughes AD, Teachey DT, Diorio C. Riding the storm: managing cytokine-related toxicities in CAR-T cell therapy. Semin Immunopathol 2024; 46:5. [PMID: 39012374 PMCID: PMC11252192 DOI: 10.1007/s00281-024-01013-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 03/18/2024] [Indexed: 07/17/2024]
Abstract
The advent of chimeric antigen receptor T cells (CAR-T) has been a paradigm shift in cancer immunotherapeutics, with remarkable outcomes reported for a growing catalog of malignancies. While CAR-T are highly effective in multiple diseases, salvaging patients who were considered incurable, they have unique toxicities which can be life-threatening. Understanding the biology and risk factors for these toxicities has led to targeted treatment approaches which can mitigate them successfully. The three toxicities of particular interest are cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), and immune effector cell-associated hemophagocytic lymphohistiocytosis (HLH)-like syndrome (IEC-HS). Each of these is characterized by cytokine storm and hyperinflammation; however, they differ mechanistically with regard to the cytokines and immune cells that drive the pathophysiology. We summarize the current state of the field of CAR-T-associated toxicities, focusing on underlying biology and how this informs toxicity management and prevention. We also highlight several emerging agents showing promise in preclinical models and the clinic. Many of these established and emerging agents do not appear to impact the anti-tumor function of CAR-T, opening the door to additional and wider CAR-T applications.
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Affiliation(s)
- Andrew D Hughes
- Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - David T Teachey
- Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Immune Dysregulation Frontier Program, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Caroline Diorio
- Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
- Immune Dysregulation Frontier Program, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
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6
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Brudno JN, Kochenderfer JN. Current understanding and management of CAR T cell-associated toxicities. Nat Rev Clin Oncol 2024; 21:501-521. [PMID: 38769449 DOI: 10.1038/s41571-024-00903-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2024] [Indexed: 05/22/2024]
Abstract
Chimeric antigen receptor (CAR) T cell therapy has revolutionized the treatment of several haematological malignancies and is being investigated in patients with various solid tumours. Characteristic CAR T cell-associated toxicities such as cytokine-release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS) are now well-recognized, and improved supportive care and management with immunosuppressive agents has made CAR T cell therapy safer and more feasible than it was when the first regulatory approvals of such treatments were granted in 2017. The increasing clinical experience with these therapies has also improved recognition of previously less well-defined toxicities, including movement disorders, immune effector cell-associated haematotoxicity (ICAHT) and immune effector cell-associated haemophagocytic lymphohistiocytosis-like syndrome (IEC-HS), as well as the substantial risk of infection in patients with persistent CAR T cell-induced B cell aplasia and hypogammaglobulinaemia. A more diverse selection of immunosuppressive and supportive-care pharmacotherapies is now being utilized for toxicity management, yet no universal algorithm for their application exists. As CAR T cell products targeting new antigens are developed, additional toxicities involving damage to non-malignant tissues expressing the target antigen are a potential hurdle. Continued prospective evaluation of toxicity management strategies and the design of less-toxic CAR T cell products are both crucial for ongoing success in this field. In this Review, we discuss the evolving understanding and clinical management of CAR T cell-associated toxicities.
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Affiliation(s)
- Jennifer N Brudno
- Surgery Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA.
| | - James N Kochenderfer
- Surgery Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
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7
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Kamperschroer C, Guffroy M, Shen A, Dokmanovich M, Stubbs M, O'Donnell LM. Nonclinical Investigation of Cytokine Mitigation Strategies for T-cell-Engaging Bispecifics in the Cynomolgus Macaque. J Immunother 2024; 47:160-171. [PMID: 38562119 DOI: 10.1097/cji.0000000000000512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 01/29/2024] [Indexed: 04/04/2024]
Abstract
SUMMARY T-cell-directed cancer therapies such as T-cell-engaging bispecifics (TCBs) are commonly associated with cytokine release syndrome and associated clinical signs that can limit their tolerability and therapeutic benefit. Strategies for reducing cytokine release are therefore needed. Here, we report on studies performed in cynomolgus monkeys to test different approaches for mitigating cytokine release with TCBs. A "priming dose" as well as subcutaneous dosing reduced cytokine release compared with intravenous dosing but did not affect the intended T-cell response to the bispecific. As another strategy, cytokines or cytokine responses were blocked with an anti-IL-6 antibody, dexamethasone, or a JAK1/TYK2-selective inhibitor, and the effects on toxicity as well as T-cell responses to a TCB were evaluated. The JAK1/TYK2 inhibitor and dexamethasone prevented CRS-associated clinical signs on the day of TCB administration, but the anti-IL-6 had little effect. All interventions allowed for functional T-cell responses and expected damage to target-bearing tissues, but the JAK1/TYK2 inhibitor prevented the upregulation of activation markers on T cells, suggesting the potential for suppression of T-cell responses. Our results suggest that short-term prophylactic dexamethasone treatment may be an effective option for blocking cytokine responses without affecting desired T-cell responses to TCBs.
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Affiliation(s)
| | | | - Amy Shen
- Preclinical Safety, Research and Development, Sanofi
| | | | - Makeida Stubbs
- Pfizer Inc., Clinical Development and Operations, Groton, CT
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8
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Ferreri CJ, Bhutani M. Mechanisms and management of CAR T toxicity. Front Oncol 2024; 14:1396490. [PMID: 38835382 PMCID: PMC11148294 DOI: 10.3389/fonc.2024.1396490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 05/07/2024] [Indexed: 06/06/2024] Open
Abstract
Chimeric antigen receptor (CAR) T cell therapies have dramatically improved treatment outcomes for patients with relapsed or refractory B-cell acute lymphoblastic leukemia, large B-cell lymphoma, follicular lymphoma, mantle cell lymphoma, and multiple myeloma. Despite unprecedented efficacy, treatment with CAR T cell therapies can cause a multitude of adverse effects which require monitoring and management at specialized centers and contribute to morbidity and non-relapse mortality. Such toxicities include cytokine release syndrome, immune effector cell-associated neurotoxicity syndrome, neurotoxicity distinct from ICANS, immune effector cell-associated hemophagocytic lymphohistiocytosis-like syndrome, and immune effector cell-associated hematotoxicity that can lead to prolonged cytopenias and infectious complications. This review will discuss the current understanding of the underlying pathophysiologic mechanisms and provide guidelines for the grading and management of such toxicities.
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Affiliation(s)
- Christopher J Ferreri
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health Wake Forest University School of Medicine, Charlotte, NC, United States
| | - Manisha Bhutani
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health Wake Forest University School of Medicine, Charlotte, NC, United States
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9
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Berenson JR, Limon A, Rice S, Safaie T, Boccia R, Yang H, Moezi M, Lim S, Schwartz G, Eshaghian S, Brobeck M, Swift R, Eades BM, Bujarski S, Sebhat Y, Ray R, Kim S, Del Dosso A, Vescio R. A Phase I Trial Evaluating the Addition of Lenalidomide to Patients with Relapsed/Refractory Multiple Myeloma Progressing on Ruxolitinib and Methylprednisolone. Target Oncol 2024; 19:343-357. [PMID: 38643346 DOI: 10.1007/s11523-024-01049-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND Ruxolitinib (RUX), an orally administered selective Janus kinase 1/2 inhibitor, has received approval for the treatment of myelofibrosis, polycythemia vera, and graft-versus-host disease. We have previously demonstrated the anti-multiple myeloma effects of RUX alone and in combination with the immunomodulatory agent lenalidomide (LEN) and glucocorticosteroids both pre-clinically and clinically. OBJECTIVE This study aims to evaluate whether LEN can achieve clinical activity among patients with multiple myeloma progressing on the combination of RUX and methylprednisolone (MP). METHODS In this part of a phase I, multicenter, open-label study, we evaluated the safety and efficacy of RUX and MP for patients with multiple myeloma with progressive disease who had previously received a proteasome inhibitor, LEN, glucocorticosteroids, and at least three prior regimens; we also determined the safety and efficacy of adding LEN at the time of disease progression from the initial doublet treatment. Initially, all subjects received oral RUX 15 mg twice daily and oral MP 40 mg every other day. Those patients who developed progressive disease according to the International Myeloma Working Group criteria then received LEN 10 mg once daily on days 1-21 within a 28-day cycle in addition to RUX and MP, which were administered at the same doses these patients were receiving at the time progressive disease developed. RESULTS Twenty-nine subjects (median age 64 years; 18 [62%] male) were enrolled in this part of the study and initially received the two-drug combination of RUX and MP. The median number of prior therapies was six (range 3-12). The overall response rate from this two-drug combination was 31% and the clinical benefit rate was 34%. The best responses were 1 very good partial response, 8 partial responses, 1 minor response, 12 stable disease, and 7 progressive disease. The median progression-free survival was 3.5 months (range 0.5-36.2 months). The median time to response was 3.0 months. The median duration of response was 12.5 months (range 2.8-36.2 months). Twenty (69%) patients who showed progressive disease had LEN added to RUX and MP; all patients had prior exposure to LEN and all but one patient was refractory to their last LEN-containing regimen. After the addition of LEN, the overall response rate was 30% and the clinical benefit rate was 40%. The best responses of patients following the addition of LEN were 2 very good partial responses, 4 partial responses, 2 minor responses, 8 stable disease, and 4 progressive disease. The median time to response was 2.6 months (range 0.7-15.0 months). The median duration of response was not reached. The median progression-free survival following the addition of LEN was 3.5 months (range 0.3-25.9 months). CONCLUSIONS For patients with multiple myeloma, treatment with RUX and MP is effective and well tolerated, and LEN can be used to extend the benefit of this RUX-based treatment. CLINICAL TRIAL REGISTRATION This study is registered with ClinicalTrials.gov, NCT03110822, and is ongoing.
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Affiliation(s)
- James R Berenson
- Institute for Myeloma & Bone Cancer Research, West Hollywood, CA, USA.
- ONCOtherapeutics, 9201 Sunset Boulevard Suite 300, West Hollywood, CA, 90069, USA.
- Berenson Cancer Center, West Hollywood, CA, USA.
| | - Andrea Limon
- ONCOtherapeutics, 9201 Sunset Boulevard Suite 300, West Hollywood, CA, 90069, USA
| | - Stephanie Rice
- ONCOtherapeutics, 9201 Sunset Boulevard Suite 300, West Hollywood, CA, 90069, USA
| | - Tahmineh Safaie
- ONCOtherapeutics, 9201 Sunset Boulevard Suite 300, West Hollywood, CA, 90069, USA
| | - Ralph Boccia
- Center for Cancer and Blood Disorders, Bethesda, MD, USA
| | - Honghao Yang
- The Oncology Institute of Hope and Innovation, Alhambra, CA, USA
| | - Mehdi Moezi
- Cancer Specialists of North Florida, Fleming Island, FL, USA
| | - Stephen Lim
- Cedars Sinai Samuel Oschin Cancer Center, Los Angeles, CA, USA
| | | | | | - Matthew Brobeck
- ONCOtherapeutics, 9201 Sunset Boulevard Suite 300, West Hollywood, CA, 90069, USA
| | | | | | | | | | - Rudra Ray
- Berenson Cancer Center, West Hollywood, CA, USA
| | - Susanna Kim
- ONCOtherapeutics, 9201 Sunset Boulevard Suite 300, West Hollywood, CA, 90069, USA
| | - Ashley Del Dosso
- ONCOtherapeutics, 9201 Sunset Boulevard Suite 300, West Hollywood, CA, 90069, USA
| | - Robert Vescio
- Cedars Sinai Samuel Oschin Cancer Center, Los Angeles, CA, USA
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10
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Rotta G, Gilardoni E, Ravazza D, Mock J, Seehusen F, Elsayed A, Puca E, De Luca R, Pellegrino C, Look T, Weiss T, Manz MG, Halin C, Neri D, Dakhel Plaza S. A novel strategy to generate immunocytokines with activity-on-demand using small molecule inhibitors. EMBO Mol Med 2024; 16:904-926. [PMID: 38448543 PMCID: PMC11018789 DOI: 10.1038/s44321-024-00034-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 03/08/2024] Open
Abstract
Cytokine-based therapeutics have been shown to mediate objective responses in certain tumor entities but suffer from insufficient selectivity, causing limiting toxicity which prevents dose escalation to therapeutically active regimens. The antibody-based delivery of cytokines significantly increases the therapeutic index of the corresponding payload but still suffers from side effects associated with peak concentrations of the product in blood upon intravenous administration. Here we devise a general strategy (named "Intra-Cork") to mask systemic cytokine activity without impacting anti-cancer efficacy. Our technology features the use of antibody-cytokine fusions, capable of selective localization at the neoplastic site, in combination with pathway-selective inhibitors of the cytokine signaling, which rapidly clear from the body. This strategy, exemplified with a tumor-targeted IL12 in combination with a JAK2 inhibitor, allowed to abrogate cytokine-driven toxicity without affecting therapeutic activity in a preclinical model of cancer. This approach is readily applicable in clinical practice.
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Affiliation(s)
- Giulia Rotta
- Philochem AG, CH-8112, Otelfingen, Switzerland
- Department of Cellular, Computational, and Integrative Biology (CIBIO), University of Trento, 38123, Trento, Italy
| | | | | | | | - Frauke Seehusen
- Laboratory for Animal Model Pathology (LAMP), Institute of Veterinary Pathology, University of Zurich, CH-8057, Zurich, Switzerland
| | - Abdullah Elsayed
- Philochem AG, CH-8112, Otelfingen, Switzerland
- Institute of Pharmaceutical Sciences, ETH Zurich, CH-8093, Zurich, Switzerland
| | - Emanuele Puca
- Philochem AG, CH-8112, Otelfingen, Switzerland
- Philogen S.p.A, 53100, Siena, Italy
| | | | - Christian Pellegrino
- Department of Medical Oncology and Hematology, University Hospital Zurich and University of Zurich, CH-8091, Zurich, Switzerland
| | - Thomas Look
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, CH-8091, Zurich, Switzerland
| | - Tobias Weiss
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, CH-8091, Zurich, Switzerland
| | - Markus G Manz
- Department of Medical Oncology and Hematology, University Hospital Zurich and University of Zurich, CH-8091, Zurich, Switzerland
| | - Cornelia Halin
- Institute of Pharmaceutical Sciences, ETH Zurich, CH-8093, Zurich, Switzerland
| | - Dario Neri
- Philochem AG, CH-8112, Otelfingen, Switzerland.
- Institute of Pharmaceutical Sciences, ETH Zurich, CH-8093, Zurich, Switzerland.
- Philogen S.p.A, 53100, Siena, Italy.
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11
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Kegyes D, Ghiaur G, Bancos A, Tomuleasa C, Gale RP. Immune therapies of B-cell acute lymphoblastic leukaemia in children and adults. Crit Rev Oncol Hematol 2024; 196:104317. [PMID: 38437908 DOI: 10.1016/j.critrevonc.2024.104317] [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: 10/14/2023] [Revised: 01/26/2024] [Accepted: 02/27/2024] [Indexed: 03/06/2024] Open
Abstract
B-cell acute lymphoblastic leukaemia (B-cell ALL) is a common haematologic cancer in children and adults. About 10 percent of children and 50 percent of adults fail to achieve a histological complete remission or subsequently relapse despite current anti-leukaemia drug therapies and/or haematopoietic cell transplants. Several new immune therapies including monoclonal antibodies and chimeric antigen receptor (CAR)-T-cells are proved safe and effective in this setting. We review data on US Food and Drug Administration (FDA)-approved immune therapies for B-cell ALL in children and adults including blinatumomab, inotuzumab ozogamicin, tisagenlecleucel, and brexucabtagene autoleucel. We also summarize pharmaco-dynamics, pharmaco-kinetics, and pharmaco-economics of these interventions.
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Affiliation(s)
- David Kegyes
- Department of Hematology-Medfuture Research Center for Advanced Medicine, Iuliu Hațieganu University of Medicine and Pharmacy Cluj Napoca, Romania; Department of Hematology, Ion Chiricuta Oncology Institute, Cluj Napoca, Romania; Academy of Romanian Scientists, Bucharest, Romania
| | - Gabriel Ghiaur
- Department of Hematology-Medfuture Research Center for Advanced Medicine, Iuliu Hațieganu University of Medicine and Pharmacy Cluj Napoca, Romania; Department of Leukemia, Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University, Baltimore, MD, USA
| | - Anamaria Bancos
- Department of Hematology-Medfuture Research Center for Advanced Medicine, Iuliu Hațieganu University of Medicine and Pharmacy Cluj Napoca, Romania; Department of Hematology, Ion Chiricuta Oncology Institute, Cluj Napoca, Romania
| | - Ciprian Tomuleasa
- Department of Hematology-Medfuture Research Center for Advanced Medicine, Iuliu Hațieganu University of Medicine and Pharmacy Cluj Napoca, Romania; Department of Hematology, Ion Chiricuta Oncology Institute, Cluj Napoca, Romania; Academy of Romanian Scientists, Bucharest, Romania.
| | - Robert Peter Gale
- Centre for Haematology, Imperial College of Science, Technology and Medicine, London, UK; Department of Hematologic Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China; Department of Hematology, Peking University People's Hospital, Beijing, China
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12
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Walton ZE, Frigault MJ, Maus MV. Current and emerging pharmacotherapies for cytokine release syndrome, neurotoxicity, and hemophagocytic lymphohistiocytosis-like syndrome due to CAR T cell therapy. Expert Opin Pharmacother 2024; 25:263-279. [PMID: 38588525 DOI: 10.1080/14656566.2024.2340738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 03/01/2024] [Indexed: 04/10/2024]
Abstract
INTRODUCTION Chimeric antigen receptor (CAR) T cells have revolutionized the treatment of multiple hematologic malignancies. Engineered cellular therapies now offer similar hope to transform the management of solid tumors and autoimmune diseases. However, toxicities can be serious and often require hospitalization. AREAS COVERED We review the two chief toxicities of CAR T therapy, cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS), and the rarer immune effector cell-associated hemophagocytic lymphohistiocytosis-like syndrome. We discuss treatment paradigms and promising future pharmacologic strategies. Literature and therapies reviewed were identified by PubMed search, cited references therein, and review of registered trials. EXPERT OPINION Management of CRS and ICANS has improved, aided by consensus definitions and guidelines that facilitate recognition and timely intervention. Further data will define optimal timing of tocilizumab and corticosteroids, current foundations of management. Pathophysiologic understanding has inspired off-label use of IL-1 receptor antagonism, IFNγ and IL-6 neutralizing antibodies, and janus kinase inhibitors, with data emerging from ongoing clinical trials. Further strategies to reduce toxicities include novel pharmacologic targets and safety features engineered into CAR T cells themselves. As these potentially curative therapies are used earlier in oncologic therapy and even in non-oncologic indications, effective accessible strategies to manage toxicities are critical.
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Affiliation(s)
- Zandra E Walton
- Cellular Immunotherapy Program, Massachusetts General Hospital Cancer Center, Boston, MA, USA
- Division of Rheumatology, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Matthew J Frigault
- Cellular Immunotherapy Program, Massachusetts General Hospital Cancer Center, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Marcela V Maus
- Cellular Immunotherapy Program, Massachusetts General Hospital Cancer Center, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
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13
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Yang S, Xu J, Dai Y, Jin S, Sun Y, Li J, Liu C, Ma X, Chen Z, Chen L, Hou J, Mi JQ, Chen SJ. Neutrophil activation and clonal CAR-T re-expansion underpinning cytokine release syndrome during ciltacabtagene autoleucel therapy in multiple myeloma. Nat Commun 2024; 15:360. [PMID: 38191582 PMCID: PMC10774397 DOI: 10.1038/s41467-023-44648-3] [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: 02/21/2023] [Accepted: 12/21/2023] [Indexed: 01/10/2024] Open
Abstract
Cytokine release syndrome (CRS) is the most common complication of chimeric antigen receptor redirected T cells (CAR-T) therapy. CAR-T toxicity management has been greatly improved, but CRS remains a prime safety concern. Here we follow serum cytokine levels and circulating immune cell transcriptomes longitudinally in 26 relapsed/refractory multiple myeloma patients receiving the CAR-T product, ciltacabtagene autoleucel, to understand the immunological kinetics of CRS. We find that although T lymphocytes and monocytes/macrophages are the major overall cytokine source in manifest CRS, neutrophil activation peaks earlier, before the onset of severe symptoms. Intracellularly, signaling activation dominated by JAK/STAT pathway occurred prior to cytokine cascade and displayed regular kinetic changes. CRS severity is accurately described and potentially predicted by temporal cytokine secretion signatures. Notably, CAR-T re-expansion is found in three patients, including a fatal case characterized by somatic TET2-mutation, clonal expanded cytotoxic CAR-T, broadened cytokine profiles and irreversible hepatic toxicity. Together, our findings show that a latent phase with distinct immunological changes precedes manifest CRS, providing an optimal window and potential targets for CRS therapeutic intervention and that CAR-T re-expansion warrants close clinical attention and laboratory investigation to mitigate the lethal risk.
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Affiliation(s)
- Shuangshuang Yang
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Jie Xu
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Yuting Dai
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Shiwei Jin
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Yan Sun
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Jianfeng Li
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Chenglin Liu
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Xiaolin Ma
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Zhu Chen
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Lijuan Chen
- Department of Hematology, First affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, China
| | - Jian Hou
- Department of Hematology, Ren Ji Hospital affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China
| | - Jian-Qing Mi
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
| | - Sai-Juan Chen
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
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14
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Keenan C, Albeituni S, Nichols KE, Hines M. JAK Inhibitors in Cytokine Storm Syndromes. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1448:583-600. [PMID: 39117841 DOI: 10.1007/978-3-031-59815-9_39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
Cytokine storm syndromes (CSSs) comprise a group of severe and often fatal hyperinflammatory conditions driven by the overproduction of pro-inflammatory cytokines by activated cells of the immune system. Many of the CSS-associated cytokines mediate their downstream effects by signaling through the Janus kinases (JAKs) and signal transducers and activators of transcription (STATs). In addition, several of these cytokines are produced downstream of JAK/STAT pathway activation. Therefore, targeting JAK/STAT signaling using small molecule JAK inhibitors has become an increasingly appealing therapeutic option to dampen hyperinflammation in patients with CSSs. Application of JAK inhibitors in preclinical CSS models has shown improvements in multiple sequelae of hyperinflammation, and there is growing clinical evidence supporting the efficacy of JAK inhibition in patients with these conditions. Although generally well tolerated, JAK inhibitor use is not without potential for toxicity, especially in settings like CSSs where end-organ dysfunction is common. More prospective clinical trials incorporating JAK inhibitors, alone or in combination with other immunomodulatory therapies, are necessary to determine the optimal dosing, schedule, efficacy, and tolerability of these agents for patients experiencing CSSs.
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Affiliation(s)
- Camille Keenan
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Sabrin Albeituni
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Kim E Nichols
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Melissa Hines
- Department of Pediatric Medicine, Division of Critical Care Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA.
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15
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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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16
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Peters DT, Savoldo B, Grover NS. Building safety into CAR-T therapy. Hum Vaccin Immunother 2023; 19:2275457. [PMID: 37968136 PMCID: PMC10760383 DOI: 10.1080/21645515.2023.2275457] [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: 07/19/2023] [Accepted: 10/22/2023] [Indexed: 11/17/2023] Open
Abstract
Chimeric antigen receptor T cell (CAR-T) therapy is an innovative immunotherapeutic approach that utilizes genetically modified T-cells to eliminate cancer cells using the specificity of a monoclonal antibody (mAb) coupled to the potent cytotoxicity of the T-lymphocyte. CAR-T therapy has yielded significant improvements in relapsed/refractory B-cell malignancies. Given these successes, CAR-T has quickly spread to other hematologic malignancies and is being increasingly explored in solid tumors. From early clinical applications to present day, CAR-T cell therapy has been accompanied by significant toxicities, namely cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), and on-target off-tumor (OTOT) effects. While medical management has improved for CRS and ICANS, the ongoing threat of refractory symptoms and unanticipated idiosyncratic toxicities highlights the need for more powerful safety measures. This is particularly poignant as CAR T-cell therapy continues to expand into the solid tumor space, where the risk of unpredictable toxicities remains high. We will review CAR-T as an immunotherapeutic approach including emergence of unique toxicities throughout development. We will discuss known and novel strategies to mitigate these toxicities; additional safety challenges in the treatment of solid tumors, and how the inducible Caspase 9 "safety switch" provides an ideal platform for continued exploration.
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Affiliation(s)
- Daniel T. Peters
- Department of Hematology Oncology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Barbara Savoldo
- Lineberger Comprehensive Cancer Center, Department of Pediatrics, Hematology Oncology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Natalie S. Grover
- Lineberger Comprehensive Cancer Center, Department of Medicine, Hematology Oncology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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17
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Mu W, Zhang M, Hu G, Han Y, Mao X, Chen C, Shen K, Dai Z, Zhu X, Zhou X, Huang L, Ao Q, Xiao M. Case report: Differential diagnosis of highly amplified anti-CD5 CAR T cells and relapsed lymphoma cells in a patient with refractory ALK positive anaplastic large cell lymphoma. Front Immunol 2023; 14:1280007. [PMID: 38143760 PMCID: PMC10749197 DOI: 10.3389/fimmu.2023.1280007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 11/17/2023] [Indexed: 12/26/2023] Open
Abstract
Background Anaplastic Large Cell Lymphoma (ALCL) is one of the most common subtypes of T-cell lymphoma. Among these, refractory and relapsed (r/r) ALK positive ALCL lacks effective therapies. The chimeric antigen receptor-modified T (CAR-T) cell therapy holds great promise as a therapeutic strategy for this disease. However, it is not known yet whether anti-CD5 CAR-T cells are sufficient for the definitive treatment of relapsed ALK+ ALCL, nor the role of accurate laboratory-based diagnoses during CAR-T treatment. Case presentation The adolescent patient received autologous T cells containing sequences encoding VH domains specific to CD5. Following the infusion, there was an increase in both the copy number and proportion of CAR-T cells in peripheral blood. IL-6 and ferritin levels in the patient exhibited significant fluctuations, with increases of 13 and 70 folds respectively, compared to baseline after the treatment. Additionally, adverse effects were observed, including grade 4 rash, grade 1 headache, nausea, and neck-pain. Surprisingly, a relapsed disease phenotype was identified based on the results of PET/CT and histopathological analysis of the inguinal lymph node biopsy. After conducting a thorough diagnostic assessment, which included flow cytometry, next-generation sequencing (NGS), examination of immune-related gene rearrangements, and analysis of the immune repertoire of T-cell receptors (TCR), we conclusively determined that the hyperplastic T cells identified in the lymph node were the result of an expansion of CAR-T cells. Ultimately, the patient has attained complete remission (CR) and has sustained a disease-free survival state for 815 days as of the cutoff date on August 30, 2023. Conclusion Taken together, the results demonstrate that anti-CD5 CAR-T cells can induce a clinical response in r/r ALK+ ALCL patient. Furthermore, this case underscores the importance of utilizing advanced technologies with high sensitivity and accuracy for biological detection in clinical laboratory diagnosis and prognosis in CAR-T cell treatment. Trial registration number NCT04767308.
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Affiliation(s)
- Wei Mu
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Meilan Zhang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Guang Hu
- Nanjing IASO Biotherapeutics Ltd., Nanjing, China
| | - Yunfeng Han
- Department of Nuclear Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xia Mao
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Caixia Chen
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Kefeng Shen
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Zhenyu Dai
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xiaojian Zhu
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xiaoxi Zhou
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Liang Huang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Qilin Ao
- Institute of Pathology, School of Basic Medical Science, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Pathology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Min Xiao
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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18
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Pan J. Chimeric Antigen Receptor T Cell Therapy for Acute Leukemia. BLOOD CELL THERAPY 2023; 6:145-150. [PMID: 38149027 PMCID: PMC10749733 DOI: 10.31547/bct-2023-028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 09/22/2023] [Indexed: 12/28/2023]
Abstract
The worldwide use of CD19 chimeric antigen receptor (CAR)-T cells has increased the response rate in patients with refractory or relapsed B-cell acute lymphoblastic leukemia. Clinical practice has become much safer with the help of immunotherapy-related toxicity management guidelines, such as the ASTCT consensus grading system. Tocilizumab and steroids are the major interventions for controlling cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). New drugs and interventions for uncontrolled CRS and ICANS, including JAK1/2 inhibitors, have also been investigated. The combination of ruxolitinib and steroids effectively controlled severe CRS without impeding CAR-T cell expansion. Patients with refractory CNS3 status and CNS masses were excluded from the clinical trials because of the high risk of severe ICANS. Intracranial injections of steroids and Ommaya capsule implantation were effective. For some heavily treated patients, the difficulties in CAR-T cell manufacturing and expansion may be resolved by combination with blinatumumab. Relapse is a major concern after CAR-T therapy, and combination interventions, such as allogeneic stem cell transplantation, dual-target CAR-T cell therapies, and sequential CD19/22 CAR-T infusion, have been investigated in many centers. For T-lineage-targeted CAR-T therapies, the CAR T-cell fratricide can be overcome using many techniques. The efficacy and safety of CD7+ CAR-T cell therapy have been widely reported in recent years. A high response rate can be achieved when the immune reconstitution is prolonged. Infections, particularly viral reactivations, should be carefully monitored, as relapses are another potential issue. Switching targets and eliminating residual CD7+ CAR-T cells in the blood are key points for patients who relapse after CD7+ CAR-T cell therapy. CAR-T cell therapies for AML have not been investigated in a large-scale cohort, except for CD19-positive AML with the AML1-ETO fusion gene.
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Affiliation(s)
- Jing Pan
- State Key Laboratory of Experimental Hematology, Boren Clinical Translational Center, Department of Hematology, Beijing Gobroad Boren Hospital, Beijing, China
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19
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Chen L, Zhu MY, Wang GX, Lu LL, Lin L, Lei L, Wu T. Ruxolitinib ameliorated coxsackievirus B3-induced acute viral myocarditis by suppressing the JAK-STAT pathway. Int Immunopharmacol 2023; 124:110797. [PMID: 37634445 DOI: 10.1016/j.intimp.2023.110797] [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: 02/10/2023] [Revised: 08/02/2023] [Accepted: 08/11/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Accumulating evidences have demonstrated that overwhelming inflammation occurs in the process of Coxsackievirus B3 (CVB3)-induced acute viral myocarditis (AVM). No specific therapy is available. More than an effective Janus-associated kinase (JAK) inhibiter, ruxolitinib exerts a critical role in the inflammatory diseases. In this study, we investigated the potential effect of ruxolitinib on CVB3-induced acute viral myocarditis. METHOD In vivo, BALB/c mice were intraperitoneally injected of CVB3, treated of a successive gavage of ruxolitinib for seven days, and subjected to a series of analysis. In vitro, primary bone marrow-derived macrophages (BMDMs) and cardiac fibroblasts were isolated, cultured, treated, harvested and finally detected. RESULTS In vivo, acute viral myocarditis was successfully induced by the injection of CVB3 characterized by impaired cardiac function, predominant infiltration of inflammatory cells, necroptosis of myocardium, great increase of cardiac troponin I (cTnI) and cytokine levels, replication of CVB3, and excessive activation of JAK-STAT pathways. Oral administration of ruxolitinib suppressed the activation of JAK-STAT pathway in a dosage-dependent way, lessened the infiltration of inflammatory cells and necroptosis of myocardium, reduced the levels of cTnI and cytokines, and finally alleviated CVB3-induced cardiac dysfunction, with the reduced production of type I interferon and no promising effect on the replication of CVB3. In vitro, the treatment of ruxolitinib inhibited the activation of JAK-STAT pathway and increase of multiple cytokines mRNA levels in BMDMs and had no protective effect against CVB3 replication in cardiac fibroblasts. CONCLUSIONS Our study suggested that ruxolitinib ameliorated CVB3-induced AVM by inhibiting the activation of JAK-STAT pathway, infiltration of inflammatory cells and necroptosis of myocardium, which may provide a novel strategy for AVM therapy.
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Affiliation(s)
- Liang Chen
- Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Meng-Ying Zhu
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Gao-Xiang Wang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, Wuhan, Hubei 430030, China
| | - Li-Li Lu
- Institute of Pharmaceutical Innovation, College of Medicine, Wuhan University of Science and Technology, Wuhan 430065, Hubei, China
| | - Li Lin
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China.
| | - Lei Lei
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China.
| | - Ting Wu
- Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China.
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20
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Rosen RS, Yang JH, Peña JS, Schloss R, Yarmush ML. An in vitro model of the macrophage-endothelial interface to characterize CAR T-cell induced cytokine storm. Sci Rep 2023; 13:18835. [PMID: 37914765 PMCID: PMC10620221 DOI: 10.1038/s41598-023-46114-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: 02/17/2023] [Accepted: 10/27/2023] [Indexed: 11/03/2023] Open
Abstract
Chimeric Antigen Receptor (CAR) T-cell therapy is a highly effective treatment for B-cell malignancies but limited in use due to clinically significant hyperinflammatory toxicities. Understanding the pathophysiologic mechanisms which mediate these toxicities can help identify novel management strategies. Here we report a novel in vitro model of the macrophage-endothelial interface to study the effects of CAR T-cell-induced cytokine storm. Using this model, we demonstrate that macrophage-mediated inflammation is regulated by endothelial cell activity. Furthermore, endothelial inflammation occurs independently of macrophages following exposure to CAR T-cell products and the induced endothelial inflammation potentiates macrophage-mediated inflammatory signaling, leading to a hyperinflammatory environment. While corticosteroids, the current gold standard of care, attenuate the resulting macrophage inflammatory signaling, the endothelial activity remains refractory to this treatment strategy. Utilizing a network model, coupled to in vitro secretion profiling, we identified STAT3 programming as critical in regulating this endothelial behavior. Lastly, we demonstrate how targeting STAT3 activity can abrogate endothelial inflammation and attenuate this otherwise hyperinflammatory environment. Our results demonstrate that endothelial cells play a central role in the pathophysiology of CAR T-cell toxicities and targeting the mechanisms driving the endothelial response can guide future clinical management.
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Affiliation(s)
- Robert S Rosen
- Department of Biomedical Engineering, Rutgers University, Piscataway, NJ, USA
- Rutgers Robert Wood Johnson Medical School, Piscataway, NJ, USA
| | - Jason H Yang
- Department of Biomedical Engineering, Rutgers University, Piscataway, NJ, USA
- Center for Emerging and Re-Emerging Pathogens, Rutgers New Jersey Medical School, Newark, NJ, USA
- Department of Microbiology, Biochemistry and Molecular Genetics, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Juan S Peña
- Department of Biomedical Engineering, Rutgers University, Piscataway, NJ, USA
| | - Rene Schloss
- Department of Biomedical Engineering, Rutgers University, Piscataway, NJ, USA.
| | - Martin L Yarmush
- Department of Biomedical Engineering, Rutgers University, Piscataway, NJ, USA
- Center for Engineering in Medicine, Massachusetts General Hospital, Boston, MA, USA
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21
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Ong SY, Baird JH. A Primer on Chimeric Antigen Receptor T-cell Therapy-related Toxicities for the Intensivist. J Intensive Care Med 2023:8850666231205264. [PMID: 37899577 DOI: 10.1177/08850666231205264] [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: 10/31/2023]
Abstract
Chimeric antigen receptor (CAR) T-cell therapy is an innovative treatment approach that has shown remarkable efficacy against several hematologic malignancies. However, its use can be associated with unique and sometimes severe toxicities that require admission to intensive care unit in 30% of patients, and intensivists should be aware of immune-mediated toxicities of CAR T-cell therapy and management of adverse events. We will review available literature on current diagnostic criteria and therapeutic strategies for mitigating these most common toxicities associated with CAR T-cell therapy including cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS) in the post-infusion period. The authors will also review other toxicities associated with CAR T-cell therapy including cytopenias, acquired immunocompromised states, and infections, and discuss the available literature on best supportive care and prophylaxis recommendations. Critical care medicine specialists play a crucial role in the management of patients undergoing CAR T-cell therapies. With the expanding use of these products in increasing numbers of treating centers, intensivists' roles as part of the multidisciplinary team caring for these patients will have an outsized impact on the continued success of these promising therapies.
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Affiliation(s)
- Shin Yeu Ong
- Division of Lymphoma, Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
| | - John H Baird
- Division of Lymphoma, Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
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22
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Yang C, Nguyen J, Yen Y. Complete spectrum of adverse events associated with chimeric antigen receptor (CAR)-T cell therapies. J Biomed Sci 2023; 30:89. [PMID: 37864230 PMCID: PMC10590030 DOI: 10.1186/s12929-023-00982-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 10/12/2023] [Indexed: 10/22/2023] Open
Abstract
Chimeric antigen receptor (CAR)-T cell therapies have been approved by FDA to treat relapsed or refractory hematological malignancies. However, the adverse effects of CAR-T cell therapies are complex and can be challenging to diagnose and treat. In this review, we summarize the major adverse events, including cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), and CAR T-cell associated HLH (carHLH), and discuss their pathophysiology, symptoms, grading, and diagnosis systems, as well as management. In a future outlook, we also provide an overview of measures and modifications to CAR-T cells that are currently being explored to limit toxicity.
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Affiliation(s)
- Chieh Yang
- Department of Internal Medicine, School of Medicine, University of California Riverside, Riverside, CA USA
| | - John Nguyen
- Covina Discovery Center, Theragent Inc., Covina, CA USA
| | - Yun Yen
- College of Medical Technology, Taipei Medical University, Taipei City, Taiwan
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23
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Dada R. Redefining Precision Management of r/r Large B-Cell Lymphoma: Novel Antibodies Take on CART and BMT in the Quest for Future Treatment Strategies. Cells 2023; 12:1858. [PMID: 37508523 PMCID: PMC10378108 DOI: 10.3390/cells12141858] [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: 05/17/2023] [Revised: 06/25/2023] [Accepted: 07/03/2023] [Indexed: 07/30/2023] Open
Abstract
The treatment paradigms for patients with relapsed large B-cell lymphoma are expanding. Chimeric antigen receptor technology (CAR-T) has revolutionized the management of these patients. Novel bispecific antibodies and antibody-drug conjugates, used as chemotherapy-free single agents or in combination with other novel therapeutics, have been quickly introduced into the real-world setting. With such a paradigm shift, patients have an improved chance of better outcomes with unpredictable complete remission rates. Additionally, the excellent tolerance of new antibodies targeting B-cell lymphomas is another motivation to broaden its use in relapsed and refractory patients. With the increasing number of approved therapy approaches, future research needs to focus on optimizing the sequence and developing new combination strategies for these antibodies, both among themselves and with other agents. Clinical, pathological, and genetic risk profiling can assist in identifying which patients are most likely to benefit from these costly therapeutic options. However, new combinations may lead to new side effects, which we must learn to deal with. This review provides a comprehensive overview of the current state of research on several innovative antibodies for the precision management of large B-cell lymphoma. It explores various treatment strategies, such as CAR-T vs. ASCT, naked antibodies, antibody-drug conjugates, bispecific antibodies, and bispecific T-cell engagers, as well as discussing the challenges and future perspectives of novel treatment strategies. We also delve into resistance mechanisms and factors that may affect decision making. Moreover, each section provides a detailed analysis of the available literature and ongoing clinical trials.
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Affiliation(s)
- Reyad Dada
- King Faisal Specialist Hospital and Research Centre, Jeddah 21499, Saudi Arabia; ; Tel.: +966-2-6677777 (ext. 64065); Fax: +966-2-6677777 (ext. 64030)
- College of Medicine, Al-Faisal University, Riyadh 11533, Saudi Arabia
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24
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Zheng Z, Li S, Liu M, Chen C, Zhang L, Zhou D. Fine-Tuning through Generations: Advances in Structure and Production of CAR-T Therapy. Cancers (Basel) 2023; 15:3476. [PMID: 37444586 DOI: 10.3390/cancers15133476] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 06/23/2023] [Accepted: 06/27/2023] [Indexed: 07/15/2023] Open
Abstract
Chimeric antigen receptor (CAR)-T cell therapy is a promising form of immunotherapy that has seen significant advancements in the past few decades. It involves genetically modifying T cells to target cancer cells expressing specific antigens, providing a novel approach to treating various types of cancer. However, the initial success of first-generation CAR-T cells was limited due to inadequate proliferation and undesirable outcomes. Nonetheless, significant progress has been made in CAR-T cell engineering, leading to the development of the latest fifth-generation CAR-T cells that can target multiple antigens and overcome individual limitations. Despite these advancements, some shortcomings prevent the widespread use of CAR-T therapy, including life-threatening toxicities, T-cell exhaustion, and inadequate infiltration for solid tumors. Researchers have made considerable efforts to address these issues by developing new strategies for improving CAR-T cell function and reducing toxicities. This review provides an overview of the path of CAR-T cell development and highlights some of the prominent advances in its structure and manufacturing process, which include the strategies to improve antigen recognition, enhance T-cell activation and persistence, and overcome immune escape. Finally, the review briefly covers other immune cells for cancer therapy and ends with the discussion on the broad prospects of CAR-T in the treatment of various diseases, not just hematological tumors, and the challenges that need to be addressed for the widespread clinical application of CAR-T cell therapies.
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Affiliation(s)
- Zhibo Zheng
- Department of International Medical Services, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Siyuan Li
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Mohan Liu
- Department of Breast Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Chuyan Chen
- Department of Gastroenterology, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Friendship Hospital, Capital Medical University, Beijing 100730, China
| | - Lu Zhang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Daobin Zhou
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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25
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Shah D, Soper B, Shopland L. Cytokine release syndrome and cancer immunotherapies - historical challenges and promising futures. Front Immunol 2023; 14:1190379. [PMID: 37304291 PMCID: PMC10248525 DOI: 10.3389/fimmu.2023.1190379] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/09/2023] [Indexed: 06/13/2023] Open
Abstract
Cancer is the leading cause of death worldwide. Cancer immunotherapy involves reinvigorating the patient's own immune system to fight against cancer. While novel approaches like Chimeric Antigen Receptor (CAR) T cells, bispecific T cell engagers, and immune checkpoint inhibitors have shown promising efficacy, Cytokine Release Syndrome (CRS) is a serious adverse effect and remains a major concern. CRS is a phenomenon of immune hyperactivation that results in excessive cytokine secretion, and if left unchecked, it may lead to multi-organ failure and death. Here we review the pathophysiology of CRS, its occurrence and management in the context of cancer immunotherapy, and the screening approaches that can be used to assess CRS and de-risk drug discovery earlier in the clinical setting with more predictive pre-clinical data. Furthermore, the review also sheds light on the potential immunotherapeutic approaches that can be used to overcome CRS associated with T cell activation.
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Affiliation(s)
- Deep Shah
- In vivo Services, The Jackson Laboratory, Sacramento, CA, United States
| | - Brian Soper
- Technical Information Services, The Jackson Laboratory, Bar Harbor, ME, United States
| | - Lindsay Shopland
- In vivo Services, The Jackson Laboratory, Sacramento, CA, United States
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26
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Jain MD, Smith M, Shah NN. How I treat refractory CRS and ICANS after CAR T-cell therapy. Blood 2023; 141:2430-2442. [PMID: 36989488 PMCID: PMC10329191 DOI: 10.1182/blood.2022017414] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 03/01/2023] [Accepted: 03/01/2023] [Indexed: 03/31/2023] Open
Abstract
The clinical use of chimeric antigen receptor (CAR) T-cell therapy is growing rapidly because of the expanding indications for standard-of-care treatment and the development of new investigational products. The establishment of consensus diagnostic criteria for cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS), alongside the steady use of both tocilizumab and corticosteroids for treatment, have been essential in facilitating the widespread use. Preemptive interventions to prevent more severe toxicities have improved safety, facilitating CAR T-cell therapy in medically frail populations and in those at high risk of severe CRS/ICANS. Nonetheless, the development of persistent or progressive CRS and ICANS remains problematic because it impairs patient outcomes and is challenging to treat. In this case-based discussion, we highlight a series of cases of CRS and/or ICANS refractory to front-line interventions. We discuss our approach to managing refractory toxicities that persist or progress beyond initial tocilizumab or corticosteroid administration, delineate risk factors for severe toxicities, highlight the emerging use of anakinra, and review mitigation strategies and supportive care measures to improve outcomes in patients who develop these refractory toxicities.
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Affiliation(s)
- Michael D. Jain
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL
| | - Melody Smith
- Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Nirali N. Shah
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
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27
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Yu M, Zhang Q, Kong FC, Zhou YL, Li F. [Hemophagocytic lymphohistiocytosis following treatment with CAR-T therapy: two cases reports and literature review]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2023; 44:424-426. [PMID: 37550194 PMCID: PMC10440612 DOI: 10.3760/cma.j.issn.0253-2727.2023.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Indexed: 08/09/2023]
Affiliation(s)
- M Yu
- Department of Hematology, The First Affiliated Hospital of Nanchang University, Institute of Hematology, Academy of Clinical Medicine of Jiangxi Province, Institute of Lymphoma of Nanchang University, Nanchang 330006, China
| | - Q Zhang
- Department of Hematology, The First Affiliated Hospital of Nanchang University, Institute of Hematology, Academy of Clinical Medicine of Jiangxi Province, Institute of Lymphoma of Nanchang University, Nanchang 330006, China
| | - F C Kong
- Department of Hematology, The First Affiliated Hospital of Nanchang University, Institute of Hematology, Academy of Clinical Medicine of Jiangxi Province, Institute of Lymphoma of Nanchang University, Nanchang 330006, China
| | - Y L Zhou
- Department of Hematology, The First Affiliated Hospital of Nanchang University, Institute of Hematology, Academy of Clinical Medicine of Jiangxi Province, Institute of Lymphoma of Nanchang University, Nanchang 330006, China
| | - F Li
- Department of Hematology, The First Affiliated Hospital of Nanchang University, Institute of Hematology, Academy of Clinical Medicine of Jiangxi Province, Institute of Lymphoma of Nanchang University, Nanchang 330006, China
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28
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Cao X, Jin X, Zhang X, Utsav P, Zhang Y, Guo R, Lu W, Zhao M. Small-Molecule Compounds Boost CAR-T Cell Therapy in Hematological Malignancies. Curr Treat Options Oncol 2023; 24:184-211. [PMID: 36701037 PMCID: PMC9992085 DOI: 10.1007/s11864-023-01049-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2022] [Indexed: 01/27/2023]
Abstract
OPINION STATEMENT Although chimeric antigen receptor T cell immunotherapy has been successfully applied in patients with hematological malignancies, several obstacles still need to be overcome, such as high relapse rates and side effects. Overcoming the limitations of CAR-T cell therapy and boosting the efficacy of CAR-T cell therapy are urgent issues that must be addressed. The exploration of small-molecule compounds in combination with CAR-T cell therapies has achieved promising success in pre-clinical and clinical studies in recent years. Protein kinase inhibitors, demethylating drugs, HDAC inhibitors, PI3K inhibitors, immunomodulatory drugs, Akt inhibitors, mTOR inhibitors, and Bcl-2 inhibitors exhibited potential synergy in combination with CAR-T cell therapy. In this review, we will discuss the recent application of these combination therapies for improved outcomes of CAR-T cell therapy.
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Affiliation(s)
- Xinping Cao
- First Center Clinic College of Tianjin Medical University, Tianjin, 300192, China
| | - Xin Jin
- Department of Hematology, Tianjin First Central Hospital, Tianjin, 300192, China
| | - Xiaomei Zhang
- School of Medicine, Nankai University, Tianjin, 300071, China
| | - Paudel Utsav
- First Center Clinic College of Tianjin Medical University, Tianjin, 300192, China
| | - Yi Zhang
- First Center Clinic College of Tianjin Medical University, Tianjin, 300192, China
| | - Ruiting Guo
- First Center Clinic College of Tianjin Medical University, Tianjin, 300192, China
| | - Wenyi Lu
- Department of Hematology, Tianjin First Central Hospital, Tianjin, 300192, China.
| | - Mingfeng Zhao
- Department of Hematology, Tianjin First Central Hospital, Tianjin, 300192, China.
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29
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Berenson JR, Martinez D, Safaie T, Boccia R, Yang H, Moezi M, Lim S, Schwartz G, Eshaghian S, Swift R, Eades BM, Bujarski S, Regidor B, Kim C, Kim S, Vescio R. Ruxolitinib and methylprednisolone for treatment of patients with relapsed/refractory multiple myeloma. Br J Haematol 2023; 200:722-730. [PMID: 36482815 DOI: 10.1111/bjh.18593] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/22/2022] [Accepted: 11/25/2022] [Indexed: 12/13/2022]
Abstract
Although Janus kinase (JAK) inhibitors have demonstrated efficacy for treating autoimmune disorders and myeloproliferative neoplasms, their efficacy in treating other types of cancer has not been clearly demonstrated. We evaluated oral ruxolitinib (15 mg twice daily) with oral methylprednisolone (40 mg every other day) for multiple myeloma (MM) patients with progressive disease who had received a proteasome inhibitor, lenalidomide, glucocorticosteroids and three or more prior regimens. All of the planned 29 patients had been enrolled with follow-up until 28 April 2022. Median lines of prior therapy were 6 (range 3-12). Cytogenetics and fluorescent in situ hybridization were evaluable in 28 patients; 9 (32%) and 17 (70%) patients showed high-risk cytogenetics and/or 1q+, respectively. The overall response rate was 31%. The median duration of response was 13.1 (range 2.8-22.0) months. Median progression-free survival rate was 3.4 (range 0.5-24.6) months, Overall, the treatment was well tolerated. The combination of ruxolitinib and methylprednisolone demonstrated significant clinical activity among previously heavily-treated MM patients, and responses were achieved among patients who had high-risk cytogenetics. This is the first clinical study to show activity of JAK inhibitors in combination with steroids for MM patients and expands the potential use of these drugs to those with cancers other than myeloproliferative neoplasms.
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Affiliation(s)
- James R Berenson
- Institute for Myeloma and Bone Cancer Research, West Hollywood, California, USA.,Oncotherapeutics, West Hollywood, California, USA.,Berenson Cancer Center, West Hollywood, California, USA
| | | | | | - Ralph Boccia
- Center for Cancer and Blood Disorders, Bethesda, Maryland, USA
| | | | - Mehdi Moezi
- Cancer Specialists of North Florida, Fleming Island, Florida, USA
| | - Stephen Lim
- Cedars-Sinai Samuel Oschin Cancer Center, Los Angeles, California, USA
| | - Gary Schwartz
- Berenson Cancer Center, West Hollywood, California, USA
| | | | - Regina Swift
- Berenson Cancer Center, West Hollywood, California, USA
| | | | - Sean Bujarski
- Berenson Cancer Center, West Hollywood, California, USA
| | | | - Clara Kim
- Oncotherapeutics, West Hollywood, California, USA
| | - Susanna Kim
- Oncotherapeutics, West Hollywood, California, USA
| | - Robert Vescio
- Cedars-Sinai Samuel Oschin Cancer Center, Los Angeles, California, USA
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30
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Early Use of Corticosteroids following CAR T-Cell Therapy Correlates with Reduced Risk of High-Grade CRS without Negative Impact on Neurotoxicity or Treatment Outcome. Biomolecules 2023; 13:biom13020382. [PMID: 36830750 PMCID: PMC9953517 DOI: 10.3390/biom13020382] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/13/2023] [Accepted: 02/14/2023] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND Chimeric antigen receptor T-cell therapy (CAR T-cell therapy) is associated with potentially life-threatening toxicities, most commonly cytokine release syndrome (CRS) and immune-effector-cell-associated neurotoxicity syndrome (ICANS). These frequent adverse events are managed with the IL-6 receptor antagonist tocilizumab and/or corticosteroids. The prophylactic and early use of corticosteroids for CRS and ICANS have previously been reported, but eventual negative impacts on CAR T-cell efficacy are feared. METHODS Retrospective comparative analysis of two patient cohorts with hematological malignancies treated with CAR T-cell therapy: 43 patients received early administration of 10 mg dexamethasone preceding each dose of tocilizumab ("early corticosteroid/ tocilizumab", EcsTcz cohort) vs. 40 patients who received tocilizumab alone ("tocilizumab alone", Tcz cohort) for treatment of low-grade CRS. RESULTS Despite overall higher CRS incidence (91% vs. 70%; p = 0.0249), no high-grade CRS was observed (0% vs. 10%; p = 0.0497) among patients receiving early corticosteroids in combination with tocilizumab. In terms of neurotoxicity, no worsening regarding incidence of ICANS (30% vs. 33%; p = 0.8177) or high-grade ICANS (20% vs. 14%; p = 0.5624) was observed in the EcsTcz cohort. Moreover, overall response rates (80% vs. 77%; p = 0.7936), complete response rates (50% vs. 44%; p = 0.6628), progression-free survival (p = 0.6345) and overall survival (p = 0.1215) were comparable for both cohorts. CONCLUSIONS Our study suggests that the early use of corticosteroids in combination with the standard tocilizumab schedule for low-grade CRS following CAR T-cell therapy may significantly reduce the risk of high-grade CRS without negative impact on neurotoxicity or treatment outcome.
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31
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Kegyes D, Jitaru C, Ghiaur G, Ciurea S, Hoelzer D, Tomuleasa C, Gale RP. Switching from salvage chemotherapy to immunotherapy in adult B-cell acute lymphoblastic leukemia. Blood Rev 2023; 59:101042. [PMID: 36732205 DOI: 10.1016/j.blre.2023.101042] [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: 11/17/2022] [Revised: 12/27/2022] [Accepted: 01/18/2023] [Indexed: 01/21/2023]
Abstract
About one-half of adults with acute B-cell lymphoblastic leukemia (B-ALL) who do not achieve molecular complete remission or who subsequently relapse are not cured by current chemo- or targeted therapies. Previously, the sole therapeutic option for such persons was a hematopoietic stem cell transplant. Recently, several immune therapies including monoclonal antibodies, bispecific T-cell engagers (BiTEs), antibody-drug conjugates (ADCs), and chimeric antigen receptor T-cells (CARs) have been shown safe and effective in this setting. In this manuscript, we summarize data on US FDA-approved immune therapies of advanced adult B-ALL including rituximab, blinatumomab, inotuzumab ozogamicin, tisagenlecleucel and brexucabtagene autoleucel. We consider the results of clinical trials focusing on efficacy, safety, and quality of life (QoL). Real-world evidence is presented as well. We also briefly discuss pharmacodynamics, pharmacokinetics, and pharmacoeconomics followed by risk-benefit analyses. Lastly, we present future directions of immune therapies for advanced B-ALL in adults.
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Affiliation(s)
- David Kegyes
- Department of Hematology-Medfuture Research Center for Advanced Medicine, Iuliu Hațieganu University of Medicine and Pharmacy Cluj Napoca, Romania; Department of Hematology, Ion Chiricuta Oncology Institute, Cluj Napoca, Romania
| | - Ciprian Jitaru
- Department of Hematology-Medfuture Research Center for Advanced Medicine, Iuliu Hațieganu University of Medicine and Pharmacy Cluj Napoca, Romania; Department of Hematology, Ion Chiricuta Oncology Institute, Cluj Napoca, Romania
| | - Gabriel Ghiaur
- Department of Hematology-Medfuture Research Center for Advanced Medicine, Iuliu Hațieganu University of Medicine and Pharmacy Cluj Napoca, Romania; Department of Leukemia, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Stefan Ciurea
- Department of Stem Cell Transplant and Cellular Therapies, University of California, Irvine, CA, USA
| | - Dieter Hoelzer
- Department of Medicine, Goethe University, Frankfurt, Germany
| | - Ciprian Tomuleasa
- Department of Hematology-Medfuture Research Center for Advanced Medicine, Iuliu Hațieganu University of Medicine and Pharmacy Cluj Napoca, Romania; Department of Hematology, Ion Chiricuta Oncology Institute, Cluj Napoca, Romania.
| | - Robert Peter Gale
- Centre for Haematology, Imperial College of Science, Technology and Medicine, London, UK; Department of Hematologic Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
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32
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Genoud V, Migliorini D. Novel pathophysiological insights into CAR-T cell associated neurotoxicity. Front Neurol 2023; 14:1108297. [PMID: 36970518 PMCID: PMC10031128 DOI: 10.3389/fneur.2023.1108297] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 02/03/2023] [Indexed: 03/29/2023] Open
Abstract
Chimeric antigen receptor (CAR) T cell therapy represents a scientific breakthrough in the treatment of advanced hematological malignancies. It relies on cell engineering to direct the powerful cytotoxic T-cell activity toward tumor cells. Nevertheless, these highly powerful cell therapies can trigger substantial toxicities such as cytokine release syndrome (CRS) and immune cell-associated neurological syndrome (ICANS). These potentially fatal side effects are now better understood and managed in the clinic but still require intensive patient follow-up and management. Some specific mechanisms seem associated with the development of ICANS, such as cytokine surge caused by activated CAR-T cells, off-tumor targeting of CD19, and vascular leak. Therapeutic tools are being developed aiming at obtaining better control of toxicity. In this review, we focus on the current understanding of ICANS, novel findings, and current gaps.
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Affiliation(s)
- Vassilis Genoud
- Department of Oncology, University Hospital of Geneva, Geneva, Switzerland
- Center for Translational Research in Onco-Haematology, University of Geneva, Geneva, Switzerland
| | - Denis Migliorini
- Department of Oncology, University Hospital of Geneva, Geneva, Switzerland
- Center for Translational Research in Onco-Haematology, University of Geneva, Geneva, Switzerland
- Brain Tumor and Immune Cell Engineering Laboratory, AGORA Cancer Research Center, Lausanne, Switzerland
- Swiss Cancer Center Léman (SCCL), Lausanne and Geneva, Geneva, Switzerland
- *Correspondence: Denis Migliorini
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33
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Qi X, Li J, Luo P. Glycyrrhizin for treatment of CRS caused by CAR T-cell therapy: A pharmacological perspective. Front Pharmacol 2023; 14:1134174. [PMID: 36923358 PMCID: PMC10009180 DOI: 10.3389/fphar.2023.1134174] [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: 12/30/2022] [Accepted: 02/13/2023] [Indexed: 03/03/2023] Open
Abstract
Chimeric antigen receptor T (CAR T)-cell therapy promises to revolutionize the management of hematologic malignancies and possibly other tumors. However, the main side effect of cytokine release syndrome (CRS) is a great challenge for its clinical application. Currently, treatment of CRS caused by CAR T-cell therapy is limited to tocilizumab (TCZ) and corticosteroids in clinical guidelines. However, the theoretical risks of these two agents may curb clinicians' enthusiasm for their application, and the optimal treatment is still debated. CAR T-cell therapy induced-CRS treatment is a current research focus. Glycyrrhizin, which has diverse pharmacological effects, good tolerance, and affordability, is an ideal therapeutic alternative for CRS. It can also overcome the shortcoming of TCZ and corticosteroids. In this brief article, we discuss the therapeutic potential of glycyrrhizin for treating CRS caused by CAR T-cell therapy from the perspective of its pharmacological action.
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Affiliation(s)
- Xingxing Qi
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Juan Li
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Pan Luo
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Evaluating the Patient with Neurotoxicity after Chimeric Antigen Receptor T-cell Therapy. Curr Treat Options Oncol 2022; 23:1845-1860. [PMID: 36525238 DOI: 10.1007/s11864-022-01035-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2022] [Indexed: 12/23/2022]
Abstract
OPINION STATEMENT Chimeric antigen receptor (CAR) T-cells are now a well-established treatment for hematologic malignancies. Their use in clinical practice has expanded quite rapidly and hospitals have developed CAR T-cell protocols to evaluate patients for associated toxicities, and particularly for neurotoxicity. There are many variables that influence the risk for developing this complication, many of which are not fully understood. The severity can be related to a particular product. Clinical vigilance is critical to facilitate early recognition of neurotoxicity, hence the importance of pre-CAR T-cell neurological evaluation of each patient. While details of such an evaluation may slightly differ between institutions, generally a comprehensive neurological evaluation including assessment of cognitive abilities along with magnetic resonance imaging (MRI) of the brain is a gold standard. Management of neurotoxicity requires a well-orchestrated team approach with specialists from oncology, neurology, oftentimes neurosurgery and neuro-intensive care. Diagnostic work-up frequently includes detailed neurologic evaluation with comparison to the baseline assessment, imaging of the brain, electroencephalogram, and lumbar puncture. While steroids are uniformly used for treatment, many patients also receive tocilizumab for an underlying and frequently concomitant cytokine release syndrome (CRS) in addition to symptom-driven supportive care. Novel CAR T-cell constructs and other agents allowing for potentially lower risk of toxicity are being explored. While neurotoxicity is predominantly an early, and reversible, event, a growing body of literature suggests that late neurotoxicity with variable clinical presentation can also occur.
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Hernani R, Benzaquén A, Solano C. Toxicities following CAR-T therapy for hematological malignancies. Cancer Treat Rev 2022; 111:102479. [DOI: 10.1016/j.ctrv.2022.102479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 10/07/2022] [Accepted: 10/18/2022] [Indexed: 11/25/2022]
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Goldsmith SR, Ghobadi A, Dipersio JF, Hill B, Shadman M, Jain T. Chimeric Antigen Receptor T Cell Therapy versus Hematopoietic Stem Cell Transplantation: An Evolving Perspective. Transplant Cell Ther 2022; 28:727-736. [PMID: 35878743 PMCID: PMC10487280 DOI: 10.1016/j.jtct.2022.07.015] [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: 04/29/2022] [Revised: 06/30/2022] [Accepted: 07/16/2022] [Indexed: 11/27/2022]
Abstract
Cellular therapy modalities, including autologous (auto-) hematopoietic cell transplantation (HCT), allogeneic (allo-) HCT, and now chimeric antigen receptor (CAR) T cell therapy, have demonstrated long-term remission in advanced hematologic malignancies. Auto-HCT and allo-HCT, through hematopoietic rescue, have permitted the use of higher doses of chemotherapy. Allo-HCT also introduced a nonspecific immune-mediated targeting of malignancy resulting in protection from relapse, although at the expense of similar targeting of normal host cells. In contrast, CAR T therapy, through genetically engineered immunotherapeutic precision, allows for redirection of autologous immune effector cells against malignancy in an antigen-specific and MHC-independent fashion, with demonstrated efficacy in patients who are refractory to cytotoxic chemotherapy. It too has unique toxicities and challenges, however. Non-Hodgkin lymphoma (including large B cell lymphoma, mantle cell lymphoma, and follicular lymphoma), B cell acute lymphoblastic leukemia, and multiple myeloma are the 3 main diseases associated with the use of fully developed CAR T products with widespread deployment. Recent and ongoing clinical trials have been examining the interface among the 3 cellular therapy modalities (auto-HCT, allo-HCT, and CAR T) to determine whether they should be "complementary" or "competitive" therapies. In this review, we examine the current state of this interface with respect to the most recent data and delve into the controversies and conclusions that may inform clinical decision making.
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Affiliation(s)
- Scott R Goldsmith
- Judy and Bernard Briskin Center for Multiple Myeloma Research, City of Hope Comprehensive Cancer Center, Duarte, California; Division of Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri.
| | - Armin Ghobadi
- Division of Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - John F Dipersio
- Division of Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Brian Hill
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Mayzar Shadman
- Clinical Research Division, Fred Hutch Cancer Center and Medical Oncology division, University of Washington, Seattle, Washington
| | - Tania Jain
- Division of Hematological Malignancies and Bone Marrow Transplantation, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
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Therapeutic targets and biomarkers of tumor immunotherapy: response versus non-response. Signal Transduct Target Ther 2022; 7:331. [PMID: 36123348 PMCID: PMC9485144 DOI: 10.1038/s41392-022-01136-2] [Citation(s) in RCA: 132] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/25/2022] [Accepted: 07/25/2022] [Indexed: 02/05/2023] Open
Abstract
Cancers are highly complex diseases that are characterized by not only the overgrowth of malignant cells but also an altered immune response. The inhibition and reprogramming of the immune system play critical roles in tumor initiation and progression. Immunotherapy aims to reactivate antitumor immune cells and overcome the immune escape mechanisms of tumors. Represented by immune checkpoint blockade and adoptive cell transfer, tumor immunotherapy has seen tremendous success in the clinic, with the capability to induce long-term regression of some tumors that are refractory to all other treatments. Among them, immune checkpoint blocking therapy, represented by PD-1/PD-L1 inhibitors (nivolumab) and CTLA-4 inhibitors (ipilimumab), has shown encouraging therapeutic effects in the treatment of various malignant tumors, such as non-small cell lung cancer (NSCLC) and melanoma. In addition, with the advent of CAR-T, CAR-M and other novel immunotherapy methods, immunotherapy has entered a new era. At present, evidence indicates that the combination of multiple immunotherapy methods may be one way to improve the therapeutic effect. However, the overall clinical response rate of tumor immunotherapy still needs improvement, which warrants the development of novel therapeutic designs as well as the discovery of biomarkers that can guide the prescription of these agents. Learning from the past success and failure of both clinical and basic research is critical for the rational design of studies in the future. In this article, we describe the efforts to manipulate the immune system against cancer and discuss different targets and cell types that can be exploited to promote the antitumor immune response.
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Sudarsanam H, Buhmann R, Henschler R. Influence of Culture Conditions on Ex Vivo Expansion of T Lymphocytes and Their Function for Therapy: Current Insights and Open Questions. Front Bioeng Biotechnol 2022; 10:886637. [PMID: 35845425 PMCID: PMC9277485 DOI: 10.3389/fbioe.2022.886637] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 05/16/2022] [Indexed: 01/03/2023] Open
Abstract
Ex vivo expansion of T lymphocytes is a central process in the generation of cellular therapies targeted at tumors and other disease-relevant structures, which currently cannot be reached by established pharmaceuticals. The influence of culture conditions on T cell functions is, however, incompletely understood. In clinical applications of ex vivo expanded T cells, so far, a relatively classical standard cell culture methodology has been established. The expanded cells have been characterized in both preclinical models and clinical studies mainly using a therapeutic endpoint, for example antitumor response and cytotoxic function against cellular targets, whereas the influence of manipulations of T cells ex vivo including transduction and culture expansion has been studied to a much lesser detail, or in many contexts remains unknown. This includes the circulation behavior of expanded T cells after intravenous application, their intracellular metabolism and signal transduction, and their cytoskeletal (re)organization or their adhesion, migration, and subsequent intra-tissue differentiation. This review aims to provide an overview of established T cell expansion methodologies and address unanswered questions relating in vivo interaction of ex vivo expanded T cells for cellular therapy.
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Affiliation(s)
| | | | - Reinhard Henschler
- Institute of Transfusion Medicine, University Hospital Leipzig, Leipzig, Germany
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Thompson JA, Schneider BJ, Brahmer J, Achufusi A, Armand P, Berkenstock MK, Bhatia S, Budde LE, Chokshi S, Davies M, Elshoury A, Gesthalter Y, Hegde A, Jain M, Kaffenberger BH, Lechner MG, Li T, Marr A, McGettigan S, McPherson J, Medina T, Mohindra NA, Olszanski AJ, Oluwole O, Patel SP, Patil P, Reddy S, Ryder M, Santomasso B, Shofer S, Sosman JA, Wang Y, Zaha VG, Lyons M, Dwyer M, Hang L. Management of Immunotherapy-Related Toxicities, Version 1.2022, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2022; 20:387-405. [PMID: 35390769 DOI: 10.6004/jnccn.2022.0020] [Citation(s) in RCA: 161] [Impact Index Per Article: 80.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The aim of the NCCN Guidelines for Management of Immunotherapy-Related Toxicities is to provide guidance on the management of immune-related adverse events resulting from cancer immunotherapy. The NCCN Management of Immunotherapy-Related Toxicities Panel is an interdisciplinary group of representatives from NCCN Member Institutions, consisting of medical and hematologic oncologists with expertise across a wide range of disease sites, and experts from the areas of dermatology, gastroenterology, endocrinology, neurooncology, nephrology, cardio-oncology, ophthalmology, pulmonary medicine, and oncology nursing. The content featured in this issue is an excerpt of the recommendations for managing toxicities related to CAR T-cell therapies and a review of existing evidence. For the full version of the NCCN Guidelines, including recommendations for managing toxicities related to immune checkpoint inhibitors, visit NCCN.org.
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Affiliation(s)
- John A Thompson
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | | | - Julie Brahmer
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | | | | | | | | | | | - Saurin Chokshi
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | | | | | | | | | | | - Benjamin H Kaffenberger
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | | | | | | | | | | | - Nisha A Mohindra
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | | | | | - Pradnya Patil
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | | | | | | | - Jeffrey A Sosman
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | - Vlad G Zaha
- UT Southwestern Simmons Comprehensive Cancer Center; and
| | | | | | - Lisa Hang
- National Comprehensive Cancer Network
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40
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Anakinra utilization in refractory pediatric CAR T-cell associated toxicities. Blood Adv 2022; 6:3398-3403. [PMID: 35395068 PMCID: PMC9198909 DOI: 10.1182/bloodadvances.2022006983] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 03/22/2022] [Indexed: 11/25/2022] Open
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Xu N, Yang XF, Xue SL, Tan JW, Li MH, Ye J, Lou XY, Yu Z, Kang LQ, Yan ZQ, Yu L, Chen SN, Wang YT. Ruxolitinib reduces severe CRS response by suspending CAR-T cell function instead of damaging CAR-T cells. Biochem Biophys Res Commun 2022; 595:54-61. [PMID: 35101664 DOI: 10.1016/j.bbrc.2022.01.070] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 01/18/2022] [Indexed: 12/26/2022]
Abstract
The therapeutic effect of CAR-T is often accompanied by sCRS, which is the main obstacle to the promotion of CAR-T therapy. The JAK1/2 inhibitor ruxolitinib has recently been confirmed as clinically effective in maintaining control over sCRS, however, its mechanism remains unclear. In this study, we firstly revealed that ruxolitinib significantly inhibited the proliferation of CAR-T cells without damaging viability, and induced an efficacy-favored differentiation phenotype. Second, ruxolitinib reduced the level of cytokine release not only from CAR-T cells, but also from other cells in the immune system. Third, the cytolytic activity of CAR-T cells was restored once the ruxolitinib was removed; however, the cytokines released from the CAR-T cells maintained an inhibited state to some degree. Finally, ruxolitinib significantly reduced the proliferation rate of CAR-T cells in vivo without affecting the therapeutic efficacy after withdrawal at the appropriate dose. We demonstrated pre-clinically that ruxolitinib interferes with both CAR-T cells and the other immune cells that play an important role in triggering sCRS reactions. This work provides useful and important scientific data for clinicians on the question of whether ruxolitinib has an effect on CAR-T cell function loss causing CAR-T treatment failure when applied in the treatment of sCRS, the answer to which is of great clinical significance.
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Affiliation(s)
- Nan Xu
- 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
| | - Xiao-Fei Yang
- 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
| | - Sheng-Li Xue
- 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
| | - Jing-Wen Tan
- 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
| | - Ming-Hao Li
- 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
| | - Jing Ye
- Shanghai Unicar-Therapy Bio-medicine Technology Co., Ltd, Shanghai, China
| | - Xiao-Yan Lou
- Shanghai Unicar-Therapy Bio-medicine Technology Co., Ltd, Shanghai, China
| | - Zhou Yu
- Shanghai Unicar-Therapy Bio-medicine Technology Co., Ltd, Shanghai, China
| | - Li-Qing Kang
- Shanghai Unicar-Therapy Bio-medicine Technology Co., Ltd, Shanghai, China
| | - Zhi-Qiang Yan
- 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
| | - 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; Shanghai Unicar-Therapy Bio-medicine Technology Co., Ltd, Shanghai, China
| | - Su-Ning 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.
| | - Yi-Ting Wang
- 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.
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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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43
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Wallet F, Sesques P, Devic P, Levrard M, Ader F, Friggeri A, Bachy E. CAR-T cell: Toxicities issues: Mechanisms and clinical management. Bull Cancer 2021; 108:S117-S127. [PMID: 34920794 DOI: 10.1016/j.bulcan.2021.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/17/2021] [Accepted: 05/21/2021] [Indexed: 11/24/2022]
Abstract
CAR-T cells are modified T cells expressing a chimeric antigen receptor targeting a specific antigen. They have revolutionized the treatment of B cell malignancies (aggressive lymphomas, B-ALL), and this has raised hopes for application in many other pathologies (myeloma, AML, solid tumors, etc.). However, these therapies are associated with novel and specific toxicities (cytokine release syndrome and neurotoxicity). These complications, although mostly managed in a conventional hospitalization unit, can sometimes be life threatening, leading to admission of patients to the intensive care unit. Management relies mainly on anti-IL6R (tocilizumab) and corticosteroids. However, the optimal treatment regimen is still a matter of debate, and the management of the most severe forms is even less well codified. In addition to CRS and ICANS, infections, cytopenia and hypogammaglobulinemia are other frequent complications. This article reviews the mechanisms, risk factors, clinical presentation, and management of these toxicities.
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Affiliation(s)
- Florent Wallet
- Hospices Civils de Lyon, Service d'anesthésie, médecine intensive, réanimation, CHU Lyon sud, 415, chemin du grand revoyet, 69310 Pierre-Bénite, France; Université Claude bernard Lyon 1, 43, boulevard du 11 Novembre 1918, 69622 Villeurbanne cedex, France.
| | - Pierre Sesques
- Hospices Civils de Lyon, Service d'hématologie clinique, CHU Lyon sud, 415, chemin du grand revoyet, 69310 Pierre-Bénite, France; Université Claude bernard Lyon 1, 43, boulevard du 11 Novembre 1918, 69622 Villeurbanne cedex, France.
| | - Perrine Devic
- Hospices Civils de Lyon, Service de neurologie, CHU Lyon sud, 415, chemin du grand revoyet, 69310 Pierre-Bénite, France.
| | - Melanie Levrard
- Hospices Civils de Lyon, Service d'anesthésie, médecine intensive, réanimation, CHU Lyon sud, 415, chemin du grand revoyet, 69310 Pierre-Bénite, France.
| | - Florence Ader
- Hospices Civils de Lyon, Service de maladies infectieuses et tropicales, CHU de la croix rousse, grande rue de la croix rousse, 69004 Lyon, France; Université Claude bernard Lyon 1, 43, boulevard du 11 Novembre 1918, 69622 Villeurbanne cedex, France.
| | - Arnaud Friggeri
- Hospices Civils de Lyon, Service d'anesthésie, médecine intensive, réanimation, CHU Lyon sud, 415, chemin du grand revoyet, 69310 Pierre-Bénite, France; Université Claude bernard Lyon 1, 43, boulevard du 11 Novembre 1918, 69622 Villeurbanne cedex, France.
| | - Emmanuel Bachy
- Hospices Civils de Lyon, Service d'hématologie clinique, CHU Lyon sud, 415, chemin du grand revoyet, 69310 Pierre-Bénite, France; Université Claude bernard Lyon 1, 43, boulevard du 11 Novembre 1918, 69622 Villeurbanne cedex, France.
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Xiao X, Huang S, Chen S, Wang Y, Sun Q, Xu X, Li Y. Mechanisms of cytokine release syndrome and neurotoxicity of CAR T-cell therapy and associated prevention and management strategies. JOURNAL OF EXPERIMENTAL & CLINICAL CANCER RESEARCH : CR 2021; 40:367. [PMID: 34794490 PMCID: PMC8600921 DOI: 10.1186/s13046-021-02148-6] [Citation(s) in RCA: 83] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 10/20/2021] [Indexed: 02/08/2023]
Abstract
Chimeric antigen receptor (CAR) T-cell therapy has yielded impressive outcomes and transformed treatment algorithms for hematological malignancies. To date, five CAR T-cell products have been approved by the US Food and Drug Administration (FDA). Nevertheless, some significant toxicities pose great challenges to the development of CAR T-cell therapy, most notably cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). Understanding the mechanisms underlying these toxicities and establishing prevention and treatment strategies are important. In this review, we summarize the mechanisms underlying CRS and ICANS and provide potential treatment and prevention strategies.
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Affiliation(s)
- Xinyi Xiao
- The Second School of Clinical Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, 510282, People's Republic of China
| | - Shengkang Huang
- The Second School of Clinical Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, 510282, People's Republic of China
| | - Sifei Chen
- The Second School of Clinical Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, 510282, People's Republic of China
| | - Yazhuo Wang
- The Second School of Clinical Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, 510282, People's Republic of China.,Medical College of Rehabilitation, Southern Medical University, Guangzhou, Guangdong, 510515, People's Republic of China
| | - Qihang Sun
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, Guangdong, 510623, People's Republic of China
| | - Xinjie Xu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, People's Republic of China.
| | - Yuhua Li
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, 510282, People's Republic of China. .,Bioland Laboratory (Guangzhou Regenerative Medicine and Health Guangdong Laboratory), Guangzhou, Guangdong, 510005, People's Republic of China.
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Santomasso BD, Nastoupil LJ, Adkins S, Lacchetti C, Schneider BJ, Anadkat M, Atkins MB, Brassil KJ, Caterino JM, Chau I, Davies MJ, Ernstoff MS, Fecher L, Funchain P, Jaiyesimi I, Mammen JS, Naidoo J, Naing A, Phillips T, Porter LD, Reichner CA, Seigel C, Song JM, Spira A, Suarez-Almazor M, Swami U, Thompson JA, Vikas P, Wang Y, Weber JS, Bollin K, Ghosh M. Management of Immune-Related Adverse Events in Patients Treated With Chimeric Antigen Receptor T-Cell Therapy: ASCO Guideline. J Clin Oncol 2021; 39:3978-3992. [PMID: 34724386 DOI: 10.1200/jco.21.01992] [Citation(s) in RCA: 136] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To increase awareness, outline strategies, and offer guidance on the recommended management of immune-related adverse events (irAEs) in patients treated with chimeric antigen receptor (CAR) T-cell therapy. METHODS A multidisciplinary panel of medical oncology, neurology, hematology, emergency medicine, nursing, trialists, and advocacy experts was convened to develop the guideline. Guideline development involved a systematic literature review and an informal consensus process. The systematic review focused on evidence published from 2017 to 2021. RESULTS The systematic review identified 35 eligible publications. Because of the paucity of high-quality evidence, recommendations are based on expert consensus. RECOMMENDATIONS The multidisciplinary team issued recommendations to aid in the recognition, workup, evaluation, and management of the most common CAR T-cell-related toxicities, including cytokine release syndrome, immune effector cell-associated neurotoxicity syndrome, B-cell aplasia, cytopenias, and infections. Management of short-term toxicities associated with CAR T cells begins with supportive care for most patients, but may require pharmacologic interventions for those without adequate response. Management of patients with prolonged or severe CAR T-cell-associated cytokine release syndrome includes treatment with tocilizumab with or without a corticosteroid. On the basis of the potential for rapid decline, patients with moderate to severe immune effector cell-associated neurotoxicity syndrome should be managed with corticosteroids and supportive care.Additional information is available at www.asco.org/supportive-care-guidelines.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Ian Chau
- Royal Marsden Hospital and Institute of Cancer Research, London and Surrey, United Kingdom
| | | | | | | | | | | | | | - Jarushka Naidoo
- Beaumont Hospital, Dublin, Ireland and Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | | | | | | | | | | | | | | | | | - Umang Swami
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - John A Thompson
- Seattle Cancer Care Alliance, University of Washington/Fred Hutchinson, Seattle, WA
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46
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Shin YH, Tian X, Park JJ, Kim GYG, Aboujaoude E, Sturgill MG. Management of chimeric antigen receptor T-cell induced cytokine release syndrome: Current and emerging approaches. J Oncol Pharm Pract 2021; 28:159-174. [PMID: 34586003 DOI: 10.1177/10781552211039238] [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: 11/17/2022]
Abstract
The most common adverse event associated with chimeric antigen receptor T-cell therapy is cytokine release syndrome, which is characterized by fever, hypoxia, and hypotension in varying degrees of severity. In severe cases, cytokine release syndrome can result in life-threatening symptoms such as multi-organ failure. The widely accepted first-line therapy for cytokine release syndrome management is tocilizumab with or without corticosteroids, but there is very limited guidance on the proper management of patients unresponsive to this regimen. There are emerging strategies that target cytokine release syndrome through novel mechanisms, showing promise in treating or preventing severe cytokine release syndrome. Although further clinical investigation is necessary to assess the applicability of the emerging approaches, these exploratory therapies may shape the future landscape of chimeric antigen receptor T-cell induced cytokine release syndrome management. This review article provides a comprehensive overview of the current and emerging therapies for the management of chimeric antigen receptor T-cell induced cytokine release syndrome, especially cases that are refractory to tocilizumab and steroids.
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Affiliation(s)
- Yunjung H Shin
- 15484Rutgers University Ernest Mario School of Pharmacy, USA
| | - Xiaofan Tian
- 15484Rutgers University Ernest Mario School of Pharmacy, USA
| | - Jiyeon J Park
- 15484Rutgers University Ernest Mario School of Pharmacy, USA.,145249Rutgers Cancer Institute of New Jersey, USA
| | - Gee Y Geeny Kim
- 15484Rutgers University Ernest Mario School of Pharmacy, USA.,3673Hackensack University Medical Center, USA
| | - Emily Aboujaoude
- 15484Rutgers University Ernest Mario School of Pharmacy, USA.,25044Robert Wood Johnson University Hospital, USA
| | - Marc G Sturgill
- 15484Rutgers University Ernest Mario School of Pharmacy, USA
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Banerjee R, Fakhri B, Shah N. Toci or not toci: innovations in the diagnosis, prevention, and early management of cytokine release syndrome. Leuk Lymphoma 2021; 62:2600-2611. [PMID: 34151714 DOI: 10.1080/10428194.2021.1924370] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Cytokine release syndrome (CRS) remains a significant toxicity of chimeric antigen receptor T-cell (CAR-T) therapy for hematologic malignancies. While established guidelines exist for the management of Grade 2+ CRS with immunosuppressive agents such as tocilizumab or corticosteroids, the management of early-grade CRS (i.e. Grade 1 CRS with isolated fevers) has no such consensus beyond supportive care. In this review, we discuss early-grade CRS with an emphasis on its diagnosis, management, and prevention. Strategies to target early-grade CRS include immunosuppression preemptively (once CRS develops) or prophylactically (before CRS develops) as well as novel small-molecule inhibitors or fractionated CAR-T dosing. In the near future, next-generation CAR-T therapies may be able to target CRS precisely or obviate CRS entirely. If shown to prevent CRS-associated morbidity while maintaining therapeutic anti-neoplastic efficacy, these innovative strategies will enhance the safety of CAR-T therapy while also improving its operationalization and accessibility in the real-world setting.
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Affiliation(s)
- Rahul Banerjee
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Bita Fakhri
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Nina Shah
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
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