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DiGiacomo D, Barmettler S. Secondary hypogammaglobulinemia: diagnosis and management of a pediatric condition of clinical importance. Curr Opin Pediatr 2024:00008480-990000000-00212. [PMID: 39254658 DOI: 10.1097/mop.0000000000001396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Abstract
PURPOSE OF REVIEW Secondary hypogammaglobulinemia, or low serum immunoglobulins, is associated with a variety of medications or medical conditions and may be symptomatic and lead to increased infectious risk. There is limited data regarding the study of acquired, or secondary, hypogammaglobulinemia (SHG) in pediatrics. The data to date has suffered from methodologic issues including retrospective study design, lack of baseline immunoglobulin measurements, and limited longitudinal follow-up. RECENT FINDINGS There is emerging research on the impact of B-cell depleting therapies, specifically rituximab and chimeric antigen T-cells, along with other autoimmune and malignant disease states, in the development of SHG in pediatric patients. This review will also summarize other relevant pediatric conditions related to SHG. SUMMARY The clinical relevance of SHG in pediatrics is increasingly appreciated. Improved understanding of the specific etiologies, risk factors, and natural history of SHG have informed screening and management recommendations.
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Affiliation(s)
- Daniel DiGiacomo
- Department of Pediatrics, K. Hovnanian Children's Hospital, Jersey Shore University Medical Center, Neptune
- Hackensack Meridian School of Medicine, Nutley, New Jersey
| | - Sara Barmettler
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital
- Harvard Medical School, Boston, Massachusetts, USA
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Alsaati N, Grier A, Ochfeld E, McClory S, Heimall J. Hematopoietic stem cell transplantation for primary immunodeficiency. Allergy Asthma Proc 2024; 45:371-383. [PMID: 39294909 DOI: 10.2500/aap.2024.45.240069] [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: 09/21/2024]
Abstract
Primary immunodeficiencies, also commonly called inborn errors of immunity (IEI), are commonly due to developmental or functional defects in peripheral blood cells derived from hematopoietic stem cells. In light of this, for the past 50 years, hematopoietic stem cell transplantation (HSCT) has been used as a definitive therapy for IEI. The fields of both clinical immunology and transplantation medicine have had significant advances. This, in turn, has allowed for both an increasing ability to determine a monogenic etiology for many IEIs and an increasing ability to successfully treat these patients with HSCT. Therefore, it has become more common for the practicing allergist/immunologist to diagnose and manage a broad range of patients with IEI before and after HSCT. This review aims to provide practical guidance for the clinical allergist/immunologist on the basics of HSCT and known outcomes in selected forms of IEI, the importance of pre-HSCT supportive care, and the critical importance of and guidance for life-long immunologic and medical monitoring of these patients.
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Affiliation(s)
- Nouf Alsaati
- From the Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia Pennsylvania; and
| | - Alexandra Grier
- From the Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia Pennsylvania; and
| | - Elisa Ochfeld
- From the Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia Pennsylvania; and
| | - Susan McClory
- Cell Therapy and Transplant Section, Division of Oncology, Children's Hospital of Philadelphia, Philadelphia Pennsylvania
| | - Jennifer Heimall
- From the Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia Pennsylvania; and
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3
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Hill JA, Martens MJ, Young JAH, Bhavsar K, Kou J, Chen M, Lee LW, Baluch A, Dhodapkar MV, Nakamura R, Peyton K, Howard DS, Ibrahim U, Shahid Z, Armistead P, Westervelt P, McCarty J, McGuirk J, Hamadani M, DeWolf S, Hosszu K, Sharon E, Spahn A, Toor AA, Waldvogel S, Greenberger LM, Auletta JJ, Horowitz MM, Riches ML, Perales MA. SARS-CoV-2 Vaccination in the First Year After Hematopoietic Cell Transplant or Chimeric Antigen Receptor T-Cell Therapy: A Prospective, Multicenter, Observational Study. Clin Infect Dis 2024; 79:542-554. [PMID: 38801746 PMCID: PMC11327798 DOI: 10.1093/cid/ciae291] [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: 05/03/2024] [Accepted: 05/23/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND The optimal timing of vaccination with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines after cellular therapy is incompletely understood. The objectives of this study are to determine whether humoral and cellular responses after SARS-CoV-2 vaccination differ if initiated <4 months versus 4-12 months after cellular therapy. METHODS We conducted a multicenter, prospective, observational study at 30 cancer centers in the United States. SARS-CoV-2 vaccination was administered as part of routine care. We obtained blood prior to and after vaccinations at up to 5 time points and tested for SARS-CoV-2 spike (anti-S) IgG in all participants and neutralizing antibodies for Wuhan D614G, Delta B.1.617.2, and Omicron B.1.1.529 strains, as well as SARS-CoV-2-specific T-cell receptors, in a subgroup. RESULTS We enrolled 466 allogeneic hematopoietic cell transplantation (HCT) (n = 231), autologous HCT (n = 170), and chimeric antigen receptor T-cell (CAR-T-cell) therapy (n = 65) recipients between April 2021 and June 2022. Humoral and cellular responses did not significantly differ among participants initiating vaccinations <4 months versus 4-12 months after cellular therapy. Anti-S IgG ≥2500 U/mL was correlated with high neutralizing antibody titers and attained by the last time point in 70%, 69%, and 34% of allogeneic HCT, autologous HCT, and CAR-T-cell recipients, respectively. SARS-CoV-2-specific T-cell responses were attained in 57%, 83%, and 58%, respectively. Pre-cellular therapy SARS-CoV-2 infection or vaccination and baseline B-cell count were key predictors of post-cellular therapy immunity. CONCLUSIONS These data support mRNA SARS-CoV-2 vaccination prior to, and reinitiation 3 to 4 months after, cellular therapies with allogeneic HCT, autologous HCT, and CAR-T-cell therapy.
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Grants
- Kyowa Kirin
- OptumHealth
- Takeda Oncology Co
- Xenikos BV
- Talaris Therapeutics
- Karyopharm Therapeutics
- Sanofi Genzyme
- MorphoSys
- U10HL069294 National Cancer Institute [NCI]
- Karius
- Vertex
- OncoImmune, Inc
- Orca Biosystems, Inc
- Medexus, Merck & Co.
- Kyowa Kirin International plc
- Seagen, Inc
- P30 CA015704 NCI NIH HHS
- Bristol Myers Squibb Co
- HistoGenetics
- Millennium
- U24 CA076518 NCI NIH HHS
- Oncopeptides, Inc
- Janssen Research & Development, LLC
- Miltenyi Biotec, Inc
- AlloVir, Inc
- Janssen/Johnson & Johnson
- HRSA HHS
- Terumo Blood and Cell Technologies
- N00014-20-1-2705 Department of Health and Human Services [DHHS]
- Adienne SA
- Novartis
- Kiadis Pharma
- Actinium Pharmaceuticals, Inc
- Bluebird Bio, Inc
- Novartis Pharmaceuticals Corporation
- Medical College of Wisconsin
- HHSH234200637015C National Institute of Allergy and Infectious Diseases
- TG Therapeutics
- Pfizer, Inc
- Kite Pharma, Inc
- P30 CA008748 NCI NIH HHS
- Incyte Corporation
- Pharmacyclics, LLC
- Tscan
- National Heart, Lung, and Blood Institute [NHLBI]
- CytoSen Therapeutics, Inc
- Gilead
- Astellas Pharma US
- Takeda Pharmaceuticals
- Accenture
- AbbVie
- Gilead Company
- Be the Match Foundation
- Leukemia and Lymphoma Society
- Adaptive Biotechnologies
- National Marrow Donor Program/Be the Match
- Multiple Myeloma Research Foundation
- Stemcyte
- DBA Eurofins Transplant Diagnostics
- CareDx
- Eurofins Viracor
- NIH HHS
- CSL Behring
- Medac GmbH
- GlaxoSmithKline
- Fate Therapeutics
- American Society for Transplantation and Cellular Therapy
- Gamida-Cell, Ltd
- NCI
- Legend Biotech
- Kadmon
- Ossium Health, Inc
- Vor Biopharma
- Jasper Therapeutics
- Jazz Pharmaceuticals, Inc
- Iovance
- U24CA076518
- LabCorp
- Omeros Corporation
- Amgen, Inc
- Magenta Therapeutics
- Daiichi Sankyo Co, Ltd
- Priothera
- Office of Naval Research
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Affiliation(s)
- Joshua A Hill
- Vaccine and Infectious Disease, Fred Hutchinson Cancer Center, and Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Michael J Martens
- Center for International Blood and Marrow Transplantation Research, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jo-Anne H Young
- Division of Infectious Diseases, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kavita Bhavsar
- Center for International Blood and Marrow Transplantation Research, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jianqun Kou
- Center for International Blood and Marrow Transplantation Research, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Min Chen
- Center for International Blood and Marrow Transplantation Research, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Lik Wee Lee
- Adaptive Biotechnologies Corporation, Seattle, Washington, USA
| | - Aliyah Baluch
- Division of Infectious Diseases, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Madhav V Dhodapkar
- Department of Hematology and Medical Oncology, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Ryotaro Nakamura
- Department of Hematology & Hematopoietic Cell Transplantation, City of Hope, Duarte, California, USA
| | | | - Dianna S Howard
- Division of Hematology and Oncology, Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Uroosa Ibrahim
- Division of Hematology and Medical Oncology, Mount Sinai Hospital, New York, New York, USA
| | - Zainab Shahid
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Paul Armistead
- Division of Hematology, University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
| | - Peter Westervelt
- Division of Oncology, Barnes-Jewish Hospital, Washington University, St. Louis, Missouri, USA
| | - John McCarty
- Division of Hematology, Oncology & Palliative Care, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Joseph McGuirk
- Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas, Lawrence, Kansas, USA
| | - Mehdi Hamadani
- Division of Hematology & Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Susan DeWolf
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Kinga Hosszu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Elad Sharon
- National Cancer Institute, Bethesda, Maryland, USA
| | - Ashley Spahn
- National Marrow Donor Program/Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota, USA
| | - Amir A Toor
- Lehigh Valley Health Network, Allentown, Pennsylvania, USA
| | - Stephanie Waldvogel
- National Marrow Donor Program/Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota, USA
| | - Lee M Greenberger
- The Leukemia and Lymphoma Society, Rye Brook, New York, New York, USA
| | - Jeffery J Auletta
- National Marrow Donor Program/Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota, USA
- Division of Hematology/Oncology/BMT and Infectious Diseases, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Mary M Horowitz
- Center for International Blood and Marrow Transplantation Research, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Marcie L Riches
- Center for International Blood and Marrow Transplantation Research, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Miguel-Angel Perales
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
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Arıcı G, Ince E, Ince E, Ileri T, Ciftci E, Dogu F, Ozdemir H, Cakmakli HF, Ertem M. Varicella-Zoster Virus Reactivation After Pediatric Allogeneic Hematopoietic Stem Cell Transplantation, Single-Center Experience of Acyclovir Prophylaxis. Pediatr Transplant 2024; 28:e14819. [PMID: 38924278 DOI: 10.1111/petr.14819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 06/13/2024] [Accepted: 06/15/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Varicella-zoster virus (VZV) reactivation is the most common infectious complication in the late posthematopoietic stem cell transplantation (HSCT) period and is reported as 16%-41%. Acyclovir prophylaxis is recommended for at least 1 year after HSCT to prevent VZV infections. However, studies on the most appropriate prophylaxis are ongoing in pediatric patients. METHODS Patients who underwent allogeneic HSCT between January 1, 1996 and January 1, 2020 were retrospectively analyzed to outline the characteristics of VZV reactivation after allogeneic HSCT in pediatric patients using 6 months acyclovir prophylaxis. RESULTS There were 260 patients and 273 HSCTs. Median age was 10.43 (0.47-18.38), and 56% was male. Median follow-up was 2325 days (18-7579 days). VZV reactivation occurred in 21.2% (n = 58) at a median of 354 (55-3433) days post-HSCT. The peak incidence was 6-12 months post-HSCT (43.1%). Older age at HSCT, female gender, history of varicella infection, lack of varicella vaccination, low lymphocyte, CD4 count, and CD4/CD8 ratio at 9 and 12 months post-HSCT was found as a significant risk for herpes zoster (HZ) in univariate analysis, whereas history of varicella infection and low CD4/CD8 ratio at 12 months post-HSCT was an independent risk factor in multivariate analysis. CONCLUSIONS Tailoring acyclovir prophylaxis according to pre-HCT varicella history, posttransplant CD4 T lymphocyte counts and functions, and ongoing immunosuppression may help to reduce HZ-related morbidity and mortality.
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Affiliation(s)
- Galip Arıcı
- Department of Pediatric Cardiology, Etlik City Hospital, Ankara, Turkey
| | - Elif Ince
- Department of Pediatric Hematology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Erdal Ince
- Department of Pediatrics, Memorial Hospital, Ankara, Turkey
| | - Talia Ileri
- Department of Pediatric Hematology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Ergin Ciftci
- Department of Pediatric Infection, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Figen Dogu
- Department of Pediatric Allergy and Immunology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Halil Ozdemir
- Department of Pediatric Infection, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Hasan Fatih Cakmakli
- Department of Pediatric Hematology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Mehmet Ertem
- Department of Pediatric Hematology, Ankara University Faculty of Medicine, Ankara, Turkey
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5
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Arya S, Shahid Z. Overview of infectious complications among CAR T- cell therapy recipients. Front Oncol 2024; 14:1398078. [PMID: 39026972 PMCID: PMC11255439 DOI: 10.3389/fonc.2024.1398078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 06/04/2024] [Indexed: 07/20/2024] Open
Abstract
Chimeric antigen receptor-modified T cell (CAR T-cell) therapy has revolutionized the management of hematological malignancies. In addition to impressive malignancy-related outcomes, CAR T-cell therapy has significant toxicity-related adverse events, including cytokine release syndrome (CRS), immune effector cell associated neurotoxicity syndrome (ICANS), immune effector cell-associated hematotoxicity (ICAHT), and opportunistic infections. Different CAR T-cell targets have different epidemiology and risk factors for infection, and these targets result in different long-term immunodeficiency states due to their distinct on-target and off- tumor effects. These effects are exacerbated by the use of multimodal immunosuppression in the management of CRS and ICANS. The most effective course of action for managing infectious complications involves determining screening, prophylactic, and monitoring strategies and understanding the role of immunoglobulin replacement and re-vaccination strategies. This involves considering the nature of prior immunomodulating therapies, underlying malignancy, the CAR T-cell target, and the development and management of related adverse events. In conclusion, we now have an increasing understanding of infection management for CAR T-cell recipients. As additional effector cells and CAR T-cell targets become available, infection management strategies will continue to evolve.
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Affiliation(s)
- Swarn Arya
- Infectious Disease Service, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Zainab Shahid
- Infectious Disease Service, Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Department of Medicine, Weill Cornell School of Medicine, New York, NY, United States
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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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Ahmed N, Oluwole O, Mahmoudjafari Z, Suleman N, McGuirk JP. Managing Infection Complications in the Setting of Chimeric Antigen Receptor T cell (CAR-T) Therapy. Clin Hematol Int 2024; 6:31-45. [PMID: 38817309 PMCID: PMC11086990 DOI: 10.46989/001c.115932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 01/23/2024] [Indexed: 06/01/2024] Open
Abstract
Chimeric antigen receptor T-cell (CAR T-cell) therapy has changed the paradigm of management of non-Hodgkin's lymphoma (NHL) and Multiple Myeloma. Infection complications have emerged as a concern that can arise in the setting of therapy and lead to morbidity and mortality. In this review, we classified infection complications into three categories, pre-infusion phase from the time pre- lymphodepletion (LD) up to day zero, early phase from day of infusion to day 30 post-infusion, and late phase after day 30 onwards. Infections arising in the pre-infusion phase are closely related to previous chemotherapy and bridging therapy. Infections arising in the early phase are more likely related to LD chemo and the expected brief period of grade 3-4 neutropenia. Infections arising in the late phase are particularly worrisome because they are associated with adverse risk features including prolonged neutropenia, dysregulation of humoral and adaptive immunity with lymphopenia, hypogammaglobinemia, and B cell aplasia. Bacterial, respiratory and other viral infections, protozoal and fungal infections can occur during this time . We recommend enhanced supportive care including prompt recognition and treatment of neutropenia with growth factor support, surveillance testing for specific viruses in the appropriate instance, management of hypogammaglobulinemia with repletion as appropriate and extended antimicrobial prophylaxis in those at higher risk (e.g. high dose steroid use and prolonged cytopenia). Finally, we recommend re-immunizing patients post CAR-T based on CDC and transplant guidelines.
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Affiliation(s)
- Nausheen Ahmed
- Hematologic Malignancies and Cellular TherapeuticsUniversity of Kansas Cancer Center
| | - Olalekan Oluwole
- Medicine, Hematology and OncologyVanderbilt University Medical Center
| | - Zahra Mahmoudjafari
- Hematologic Malignancies and Cellular TherapeuticsUniversity of Kansas Cancer Center
| | - Nahid Suleman
- Hematologic Malignancies and Cellular TherapeuticsUniversity of Kansas Cancer Center
| | - Joseph P McGuirk
- Hematologic Malignancies and Cellular TherapeuticsUniversity of Kansas Cancer Center
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8
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Hill JA, Martens MJ, Young JAH, Bhavsar K, Kou J, Chen M, Lee LW, Baluch A, Dhodapkar MV, Nakamura R, Peyton K, Howard DS, Ibrahim U, Shahid Z, Armistead P, Westervelt P, McCarty J, McGuirk J, Hamadani M, DeWolf S, Hosszu K, Sharon E, Spahn A, Toor AA, Waldvogel S, Greenberger LM, Auletta JJ, Horowitz MM, Riches ML, Perales MA. SARS-CoV-2 vaccination in the first year after hematopoietic cell transplant or chimeric antigen receptor T cell therapy: A prospective, multicenter, observational study (BMT CTN 2101). MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.01.24.24301058. [PMID: 38343800 PMCID: PMC10854344 DOI: 10.1101/2024.01.24.24301058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
Background The optimal timing of vaccination with SARS-CoV-2 vaccines after cellular therapy is incompletely understood. Objective To describe humoral and cellular responses after SARS-CoV-2 vaccination initiated <4 months versus 4-12 months after cellular therapy. Design Multicenter prospective observational study. Setting 34 centers in the United States. Participants 466 allogeneic hematopoietic cell transplant (HCT; n=231), autologous HCT (n=170), or chimeric antigen receptor T cell (CAR-T cell) therapy (n=65) recipients enrolled between April 2021 and June 2022. Interventions SARS-CoV-2 vaccination as part of routine care. Measurements We obtained blood prior to and after vaccinations at up to five time points and tested for SARS-CoV-2 spike (anti-S) IgG in all participants and neutralizing antibodies for Wuhan D614G, Delta B.1.617.2, and Omicron B.1.1.529 strains, as well as SARS-CoV-2-specific T cell receptors (TCRs), in a subgroup. Results Anti-S IgG and neutralizing antibody responses increased with vaccination in HCT recipients irrespective of vaccine initiation timing but were unchanged in CAR-T cell recipients initiating vaccines within 4 months. Anti-S IgG ≥2,500 U/mL was correlated with high neutralizing antibody titers and attained by the last time point in 70%, 69%, and 34% of allogeneic HCT, autologous HCT, and CAR-T cell recipients, respectively. SARS-CoV-2-specific T cell responses were attained in 57%, 83%, and 58%, respectively. Humoral and cellular responses did not significantly differ among participants initiating vaccinations <4 months vs 4-12 months after cellular therapy. Pre-cellular therapy SARS-CoV-2 infection or vaccination were key predictors of post-cellular therapy anti-S IgG levels. Limitations The majority of participants were adults and received mRNA vaccines. Conclusions These data support starting mRNA SARS-CoV-2 vaccination three to four months after allogeneic HCT, autologous HCT, and CAR-T cell therapy. Funding National Marrow Donor Program, Leukemia and Lymphoma Society, Multiple Myeloma Research Foundation, Novartis, LabCorp, American Society for Transplantation and Cellular Therapy, Adaptive Biotechnologies, and the National Institutes of Health.
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Affiliation(s)
- Joshua A Hill
- Vaccine and Infectious Disease, Fred Hutchinson Cancer Center, and Department of Medicine, University of Washington, Seattle, WA, USA
| | - Michael J Martens
- Center for International Blood and Marrow Transplantation Research, Medical College of Wisconsin, Milwaukee, WI, USA
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Kavita Bhavsar
- Center for International Blood and Marrow Transplantation Research, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jianqun Kou
- Center for International Blood and Marrow Transplantation Research, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Min Chen
- Center for International Blood and Marrow Transplantation Research, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Lik Wee Lee
- Adaptive Biotechnologies Corp, Seattle, WA, USA
| | - Aliyah Baluch
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | | | | | | | | | | | - Zainab Shahid
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Paul Armistead
- University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Peter Westervelt
- Barnes-Jewish Hospital, Washington University, St. Louis, MO, USA
| | - John McCarty
- Virginia Commonwealth University, Richmond, VA, USA
| | | | | | - Susan DeWolf
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kinga Hosszu
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Elad Sharon
- National Cancer Institute, Bethesda, MD, USA
| | - Ashley Spahn
- National Marrow Donor Program/Center for International Blood and Marrow Transplant Research, Minneapolis, MN, USA
| | - Amir A Toor
- Lehigh Valley Health Network, Allentown, PA, USA
| | - Stephanie Waldvogel
- National Marrow Donor Program/Center for International Blood and Marrow Transplant Research, Minneapolis, MN, USA
| | | | - Jeffery J Auletta
- National Marrow Donor Program/Center for International Blood and Marrow Transplant Research, Minneapolis, MN, USA
- Nationwide Children's Hospital, Columbus, OH, USA
| | - Mary M Horowitz
- Center for International Blood and Marrow Transplantation Research, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Marcie L Riches
- Center for International Blood and Marrow Transplantation Research, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Miguel-Angel Perales
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
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9
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Kampouri E, Little JS, Rejeski K, Manuel O, Hammond SP, Hill JA. Infections after chimeric antigen receptor (CAR)-T-cell therapy for hematologic malignancies. Transpl Infect Dis 2023; 25 Suppl 1:e14157. [PMID: 37787373 DOI: 10.1111/tid.14157] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 08/30/2023] [Accepted: 09/10/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND Chimeric antigen receptor (CAR)-T-cell therapies have revolutionized the management of acute lymphoblastic leukemia, non-Hodgkin lymphoma, and multiple myeloma but come at the price of unique toxicities, including cytokine release syndrome, immune effector cell-associated neurotoxicity syndrome, and long-term "on-target off-tumor" effects. METHODS All of these factors increase infection risk in an already highly immunocompromised patient population. Indeed, infectious complications represent the key determinant of non-relapse mortality after CAR-T cells. The temporal distribution of these risk factors shapes different infection patterns early versus late post-CAR-T-cell infusion. Furthermore, due to the expression of their targets on B lineage cells at different stages of differentiation, CD19, and B-cell maturation antigen (BCMA) CAR-T cells induce distinct immune deficits that could require different prevention strategies. Infection incidence is the highest during the first month post-infusion and subsequently decreases thereafter. However, infections remain relatively common even a year after infusion. RESULTS Bacterial infections predominate early after CD19, while a more equal distribution between bacterial and viral causes is seen after BCMA CAR-T-cell therapy, and fungal infections are universally rare. Cytomegalovirus (CMV) and other herpesviruses are increasingly breported, but whether routine monitoring is warranted for all, or a subgroup of patients, remains to be determined. Clinical practices vary substantially between centers, and many areas of uncertainty remain, including CMV monitoring, antibacterial and antifungal prophylaxis and duration, use of immunoglobulin replacement therapy, and timing of vaccination. CONCLUSION Risk stratification tools are available and may help distinguish between infectious and non-infectious causes of fever post-infusion and predict severe infections. These tools need prospective validation, and their integration in clinical practice needs to be systematically studied.
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Affiliation(s)
- Eleftheria Kampouri
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jessica S Little
- Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Kai Rejeski
- Department of Medicine III-Hematology/Oncology, LMU University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), Munich site, and German Cancer Research Center, Heidelberg, Germany
| | - Oriol Manuel
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Sarah P Hammond
- Division of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
- Divisions of Hematology/Oncology and Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Joshua A Hill
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
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