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Frenking JH, Zhou X, Wagner V, Hielscher T, Kauer J, Mai EK, Friedrich MJ, Michel CS, Hajiyianni M, Breitkreutz I, Costello P, Nadeem O, Weinhold N, Goldschmidt H, Schmitt A, Luft T, Schmitt M, Müller-Tidow C, Topp M, Einsele H, Dreger P, Munshi NC, Sperling AS, Rasche L, Sauer S, Raab MS. EASIX-guided risk stratification for complications and outcome after CAR T-cell therapy with ide-cel in relapsed/refractory multiple myeloma. J Immunother Cancer 2024; 12:e009220. [PMID: 39379098 PMCID: PMC11459298 DOI: 10.1136/jitc-2024-009220] [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] [Accepted: 09/08/2024] [Indexed: 10/10/2024] Open
Abstract
BACKGROUND Chimeric antigen receptor (CAR) T-cell therapy has demonstrated significant benefits in the treatment of relapsed/refractory multiple myeloma (RRMM). However, these outcomes can be compromised by severe complications, including cytokine release syndrome, immune effector cell-associated neurotoxicity syndrome (ICANS) and immune effector cell-associated hematotoxicity (ICAHT), predisposing for life-threatening infections. METHODS This retrospective observational study examined a total of 129 patients with RRMM who had received idecabtagene vicleucel (ide-cel) at two major myeloma centers in Germany and one center in the USA to assess the Endothelial Activation and Stress Index (EASIX) as a risk marker for an unfavorable clinical course and outcome after CAR T-cell therapy. EASIX is calculated by lactate dehydrogenase (U/L) × creatinine (mg/dL) / platelets (109 cells/L) and was determined before lymphodepletion (baseline) and at the day of CAR T-cell infusion (day 0). The analysis was extended to EASIX derivatives and the CAR-HEMATOTOX score. RESULTS An elevated baseline EASIX (>median) was identified as a risk marker for severe late ICAHT, manifesting with an impaired hematopoietic reconstitution and pronounced cytopenias during the late post-CAR-T period. Patients with high EASIX levels (>upper quartile) were particularly at risk, as evidenced by an increased rate of an aplastic phenotype of neutrophil recovery, severe late-onset infections and ICANS. Finally, we found associations between baseline EASIX and an inferior progression-free and overall survival. Moreover, the EASIX at day 0 also demonstrated potential to serve as a risk marker for post-CAR-T complications and adverse outcomes. CONCLUSIONS In conclusion, EASIX aids in risk stratification at clinically relevant time points prior to CAR T-cell therapy with ide-cel. Increased EASIX levels might help clinicians to identify vulnerable patients to adapt peri-CAR-T management at an early stage.
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Affiliation(s)
- Jan H Frenking
- Department of Medicine V, University Hospital and Medical Faculty Heidelberg, Heidelberg, Baden-Württemberg, Germany
- Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center, Heidelberg, Baden-Württemberg, Germany
| | - Xiang Zhou
- Internal Medicine II, University Hospital of Würzburg, Würzburg, Bayern, Germany
| | - Vivien Wagner
- Internal Medicine II, University Hospital of Würzburg, Würzburg, Bayern, Germany
| | - Thomas Hielscher
- Division of Biostatistics, German Cancer Research Center, Heidelberg, Baden-Württemberg, Germany
| | - Joseph Kauer
- Department of Medicine V, University Hospital and Medical Faculty Heidelberg, Heidelberg, Baden-Württemberg, Germany
- Molecular Medicine Partnership Unit, Heidelberg, Baden-Württemberg, Germany
| | - Elias K Mai
- Department of Medicine V, University Hospital and Medical Faculty Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Mirco J Friedrich
- Department of Medicine V, University Hospital and Medical Faculty Heidelberg, Heidelberg, Baden-Württemberg, Germany
- Eli and Edythe L Broad Institute of Harvard and MIT, Cambridge, Massachusetts, USA
| | - Christian S Michel
- Department of Medicine V, University Hospital and Medical Faculty Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Marina Hajiyianni
- Department of Medicine V, University Hospital and Medical Faculty Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Iris Breitkreutz
- Department of Medicine V, University Hospital and Medical Faculty Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Patrick Costello
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Omar Nadeem
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Niels Weinhold
- Department of Medicine V, University Hospital and Medical Faculty Heidelberg, Heidelberg, Baden-Württemberg, Germany
- Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center, Heidelberg, Baden-Württemberg, Germany
| | - Hartmut Goldschmidt
- Department of Medicine V, University Hospital and Medical Faculty Heidelberg, Heidelberg, Baden-Württemberg, Germany
- National Center for Tumor Diseases, Heidelberg, Baden-Württemberg, Germany
| | - Anita Schmitt
- Department of Medicine V, University Hospital and Medical Faculty Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Thomas Luft
- Department of Medicine V, University Hospital and Medical Faculty Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Michael Schmitt
- Department of Medicine V, University Hospital and Medical Faculty Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Carsten Müller-Tidow
- Department of Medicine V, University Hospital and Medical Faculty Heidelberg, Heidelberg, Baden-Württemberg, Germany
- National Center for Tumor Diseases, Heidelberg, Baden-Württemberg, Germany
| | - Max Topp
- Internal Medicine II, University Hospital of Würzburg, Würzburg, Bayern, Germany
| | - Hermann Einsele
- Internal Medicine II, University Hospital of Würzburg, Würzburg, Bayern, Germany
| | - Peter Dreger
- Department of Medicine V, University Hospital and Medical Faculty Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Nikhil C Munshi
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Adam S Sperling
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Division of Hematology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Leo Rasche
- Internal Medicine II, University Hospital of Würzburg, Würzburg, Bayern, Germany
| | - Sandra Sauer
- Department of Medicine V, University Hospital and Medical Faculty Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Marc S Raab
- Department of Medicine V, University Hospital and Medical Faculty Heidelberg, Heidelberg, Baden-Württemberg, Germany
- Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center, Heidelberg, Baden-Württemberg, Germany
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2
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Bhagwat AS, Torres L, Shestova O, Shestov M, Mellors PW, Fisher HR, Farooki SN, Frost BF, Loken MR, Gaymon AL, Frazee D, Rogal W, Frey N, Hexner EO, Luger SM, Loren AW, Martin ME, McCurdy SR, Perl AE, Stadtmauer EA, Brogdon JL, Fraietta JA, Hwang WT, Siegel DL, Plesa G, Aplenc R, Porter DL, June CH, Gill SI. Cytokine-mediated CAR T therapy resistance in AML. Nat Med 2024:10.1038/s41591-024-03271-5. [PMID: 39333315 DOI: 10.1038/s41591-024-03271-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 08/27/2024] [Indexed: 09/29/2024]
Abstract
Acute myeloid leukemia (AML) is a rapidly progressive malignancy without effective therapies for refractory disease. So far, chimeric antigen receptor (CAR) T cell therapy in AML has not recapitulated the efficacy seen in B cell malignancies. Here we report a pilot study of autologous anti-CD123 CAR T cells in 12 adults with relapsed or refractory AML. CAR T cells targeting CD123+ cells were successfully manufactured in 90.4% of runs. Cytokine release syndrome was observed in 10 of 12 infused individuals (83.3%, 90% confidence interval 0.5-0.97). Three individuals achieved clinical response (25%, 90% confidence interval 0.07-0.53). We found that myeloid-supporting cytokines are secreted during cell therapy and support AML blast survival via kinase signaling, leading to CAR T cell exhaustion. The prosurvival effect of therapy-induced cytokines presents a unique resistance mechanism in AML that is distinct from any observed in B cell malignancies. Our findings suggest that autologous CART manufacturing is feasible in AML, but treatment is associated with high rates of cytokine release syndrome and relatively poor clinical efficacy. Combining CAR T cell therapies with cytokine signaling inhibitors could enhance immunotherapy efficacy in AML and achieve improved outcomes (ClinicalTrials.gov identifier: NCT03766126 ).
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Affiliation(s)
- Anand S Bhagwat
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Cellular Immunotherapies, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Leonel Torres
- Center for Cellular Immunotherapies, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Immunology Graduate Group, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Olga Shestova
- Center for Cellular Immunotherapies, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Maksim Shestov
- Center for Cellular Immunotherapies, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Patrick W Mellors
- Center for Cellular Immunotherapies, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Han R Fisher
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Saamia N Farooki
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Benjamin F Frost
- Center for Cellular Immunotherapies, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Avery L Gaymon
- Center for Cellular Immunotherapies, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Diane Frazee
- Center for Cellular Immunotherapies, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Walter Rogal
- Center for Cellular Immunotherapies, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Noelle Frey
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Cell Therapy and Transplant, University of Pennsylvania, Philadelphia, PA, USA
| | - Elizabeth O Hexner
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Cell Therapy and Transplant, University of Pennsylvania, Philadelphia, PA, USA
| | - Selina M Luger
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Alison W Loren
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Cell Therapy and Transplant, University of Pennsylvania, Philadelphia, PA, USA
| | - Mary Ellen Martin
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Cell Therapy and Transplant, University of Pennsylvania, Philadelphia, PA, USA
| | - Shannon R McCurdy
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Cell Therapy and Transplant, University of Pennsylvania, Philadelphia, PA, USA
| | - Alexander E Perl
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Cell Therapy and Transplant, University of Pennsylvania, Philadelphia, PA, USA
| | - Edward A Stadtmauer
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Cell Therapy and Transplant, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Joseph A Fraietta
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Wei-Ting Hwang
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Don L Siegel
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Gabriela Plesa
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Richard Aplenc
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - David L Porter
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Cell Therapy and Transplant, University of Pennsylvania, Philadelphia, PA, USA
| | - Carl H June
- Center for Cellular Immunotherapies, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Saar I Gill
- Center for Cellular Immunotherapies, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Center for Cell Therapy and Transplant, University of Pennsylvania, Philadelphia, PA, USA.
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3
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Su M, Chen L, Xie L, Fleurie A, Jonquieres R, Cao Q, Li B, Liang J, Tang Y. Identification of early predictive biomarkers for severe cytokine release syndrome in pediatric patients with chimeric antigen receptor T-cell therapy. Front Immunol 2024; 15:1450173. [PMID: 39328408 PMCID: PMC11424402 DOI: 10.3389/fimmu.2024.1450173] [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: 06/17/2024] [Accepted: 08/26/2024] [Indexed: 09/28/2024] Open
Abstract
CAR-T cell therapy is a revolutionary new treatment for hematological malignancies, but it can also result in significant adverse effects, with cytokine release syndrome (CRS) being the most common and potentially life-threatening. The identification of biomarkers to predict the severity of CRS is crucial to ensure the safety and efficacy of CAR-T therapy. To achieve this goal, we characterized the expression profiles of seven cytokines, four conventional biochemical markers, and five hematological markers prior to and following CAR-T cell infusion. Our results revealed that IL-2, IFN-γ, IL-6, and IL-10 are the key cytokines for predicting severe CRS (sCRS). Notably, IL-2 levels rise at an earlier stage of sCRS and have the potential to serve as the most effective cytokine for promptly detecting the condition's onset. Furthermore, combining these cytokine biomarkers with hematological factors such as lymphocyte counts can further enhance their predictive performance. Finally, a predictive tree model including lymphocyte counts, IL-2, and IL-6 achieved an accuracy of 85.11% (95% CI = 0.763-0.916) for early prediction of sCRS. The model was validated in an independent cohort and achieved an accuracy of 74.47% (95% CI = 0.597-0.861). This new prediction model has the potential to become an effective tool for assessing the risk of CRS in clinical practice.
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Affiliation(s)
- Meng Su
- Department of Hematology/Oncology, National Health Committee Key Laboratory of Pediatric Hematology & Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Luoquan Chen
- Shanghai Children's Medical Center-bioMérieux Laboratory, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- bioMérieux (Shanghai) Company Limited, Shanghai, China
| | - Li Xie
- Shanghai Children's Medical Center-bioMérieux Laboratory, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- bioMérieux (Shanghai) Company Limited, Shanghai, China
| | - Aurore Fleurie
- Open Innovation & Partnerships Department, bioMérieux SA, Marcy l'Etoile, France
| | - Renaud Jonquieres
- Open Innovation & Partnerships Department, bioMérieux SA, Marcy l'Etoile, France
| | - Qing Cao
- Infectious Disease Department, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Benshang Li
- Department of Hematology/Oncology, National Health Committee Key Laboratory of Pediatric Hematology & Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ji Liang
- Shanghai Children's Medical Center-bioMérieux Laboratory, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- bioMérieux (Shanghai) Company Limited, Shanghai, China
| | - Yanjing Tang
- Department of Hematology/Oncology, National Health Committee Key Laboratory of Pediatric Hematology & Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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4
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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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5
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Li J, Chen H, Xu C, Hu M, Li J, Chang W. Systemic toxicity of CAR-T therapy and potential monitoring indicators for toxicity prevention. Front Immunol 2024; 15:1422591. [PMID: 39253080 PMCID: PMC11381299 DOI: 10.3389/fimmu.2024.1422591] [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: 04/24/2024] [Accepted: 08/08/2024] [Indexed: 09/11/2024] Open
Abstract
Malignant tumors of the hematologic system have a high degree of malignancy and high mortality rates. Chimeric antigen receptor T cell (CAR-T) therapy has become an important option for patients with relapsed/refractory tumors, showing astonishing therapeutic effects and thus, it has brought new hope to the treatment of malignant tumors of the hematologic system. Despite the significant therapeutic effects of CAR-T, its toxic reactions, such as Cytokine Release Syndrome (CRS) and Immune Effector Cell-Associated Neurotoxicity Syndrome (ICANS), cannot be ignored since they can cause damage to multiple systems, including the cardiovascular system. We summarize biomarkers related to prediction, diagnosis, therapeutic efficacy, and prognosis, further exploring potential monitoring indicators for toxicity prevention. This review aims to summarize the effects of CAR-T therapy on the cardiovascular, hematologic, and nervous systems, as well as potential biomarkers, and to explore potential monitoring indicators for preventing toxicity, thereby providing references for clinical regulation and assessment of therapeutic effects.
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Affiliation(s)
- Jingxian Li
- Institute of Infection, Immunology and Tumor Microenvironment, School of Medicine, Wuhan University of Science and Technology, Wuhan, China
| | - Huiguang Chen
- Institute of Infection, Immunology and Tumor Microenvironment, School of Medicine, Wuhan University of Science and Technology, Wuhan, China
| | - Chaoping Xu
- Department of Hematology, Puren Hospital Affiliated to Wuhan University of Science and Technology, Wuhan, China
| | - Mengci Hu
- Department of Hematology, Puren Hospital Affiliated to Wuhan University of Science and Technology, Wuhan, China
| | - Jiangping Li
- Department of Blood Transfusion, Puren Hospital Affiliated to Wuhan University of Science and Technology, Wuhan, China
| | - Wei Chang
- Department of Hematology, Puren Hospital Affiliated to Wuhan University of Science and Technology, Wuhan, China
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Fischer-Riepe L, Kailayangiri S, Zimmermann K, Pfeifer R, Aigner M, Altvater B, Kretschmann S, Völkl S, Hartley J, Dreger C, Petry K, Bosio A, von Döllen A, Hartmann W, Lode H, Görlich D, Mackensen A, Jungblut M, Schambach A, Abken H, Rossig C. Preclinical Development of CAR T Cells with Antigen-Inducible IL18 Enforcement to Treat GD2-Positive Solid Cancers. Clin Cancer Res 2024; 30:3564-3577. [PMID: 38593230 DOI: 10.1158/1078-0432.ccr-23-3157] [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: 10/27/2023] [Revised: 12/19/2023] [Accepted: 01/30/2024] [Indexed: 04/11/2024]
Abstract
PURPOSE Cytokine-engineering of chimeric antigen receptor-redirected T cells (CAR T cells) is a promising principle to overcome the limited activity of canonical CAR T cells against solid cancers. EXPERIMENTAL DESIGN We developed an investigational medicinal product, GD2IL18CART, consisting of CAR T cells directed against ganglioside GD2 with CAR-inducible IL18 to enhance their activation response and cytolytic effector functions in the tumor microenvironment. To allow stratification of patients according to tumor GD2 expression, we established and validated immunofluorescence detection of GD2 on paraffin-embedded tumor tissues. RESULTS Lentiviral all-in-one vector engineering of human T cells with the GD2-specific CAR with and without inducible IL18 resulted in cell products with comparable proportions of CAR-expressing central memory T cells. Production of IL18 strictly depends on GD2 antigen engagement. GD2IL18CART respond to interaction with GD2-positive tumor cells with higher IFNγ and TNFα cytokine release and more effective target cytolysis compared with CAR T cells without inducible IL18. GD2IL18CART further have superior in vivo antitumor activity, with eradication of GD2-positive tumor xenografts. Finally, we established GMP-compliant manufacturing of GD2IL18CART and found it to be feasible and efficient at clinical scale. CONCLUSIONS These results pave the way for clinical investigation of GD2IL18CART in pediatric and adult patients with neuroblastoma and other GD2-positive cancers (EU CT 2022- 501725-21-00). See related commentary by Locatelli and Quintarelli, p. 3361.
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Affiliation(s)
- Lena Fischer-Riepe
- Department of Pediatric Hematology and Oncology, University Children's Hospital Muenster, Muenster, Germany
| | - Sareetha Kailayangiri
- Department of Pediatric Hematology and Oncology, University Children's Hospital Muenster, Muenster, Germany
| | - Katharina Zimmermann
- Institute of Experimental Hematology, Hannover Medical School, Hannover, Germany
| | - Rita Pfeifer
- Miltenyi Biotec B.V. & Co. KG, Bergisch Gladbach, Germany
| | - Michael Aigner
- Department of Internal Medicine 5 - Hematology and Oncology, Friedrich Alexander University Erlangen-Nuremberg (FAU) and Universitätsklinikum Erlangen, Erlangen, Germany
- Deutsches Zentrum für Immuntherapie (DZI), Friedrich Alexander University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Bianca Altvater
- Department of Pediatric Hematology and Oncology, University Children's Hospital Muenster, Muenster, Germany
| | - Sascha Kretschmann
- Department of Internal Medicine 5 - Hematology and Oncology, Friedrich Alexander University Erlangen-Nuremberg (FAU) and Universitätsklinikum Erlangen, Erlangen, Germany
- Deutsches Zentrum für Immuntherapie (DZI), Friedrich Alexander University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Simon Völkl
- Department of Internal Medicine 5 - Hematology and Oncology, Friedrich Alexander University Erlangen-Nuremberg (FAU) and Universitätsklinikum Erlangen, Erlangen, Germany
- Deutsches Zentrum für Immuntherapie (DZI), Friedrich Alexander University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Jordan Hartley
- Division of Genetic Immunotherapy, Leibniz Institute for Immunotherapy (LIT) and University of Regensburg, Regensburg, Germany
| | - Celine Dreger
- Division of Genetic Immunotherapy, Leibniz Institute for Immunotherapy (LIT) and University of Regensburg, Regensburg, Germany
| | - Katja Petry
- Miltenyi Biomedicine GmbH, Bergisch Gladbach, Germany
| | - Andreas Bosio
- Miltenyi Biotec B.V. & Co. KG, Bergisch Gladbach, Germany
| | - Angelika von Döllen
- Institute of Transfusion Medicine and Cell Therapy, University Hospital Muenster, Muenster, Germany
| | - Wolfgang Hartmann
- Gerhard-Domagk-Institute of Pathology, University of Muenster, Muenster, Germany
| | - Holger Lode
- Pediatric Hematology-Oncology Department, University Medicine Greifswald, Greifswald, Germany
| | - Dennis Görlich
- Institute of Biostatistics and Clinical Research, University of Muenster
| | - Andreas Mackensen
- Department of Internal Medicine 5 - Hematology and Oncology, Friedrich Alexander University Erlangen-Nuremberg (FAU) and Universitätsklinikum Erlangen, Erlangen, Germany
- Deutsches Zentrum für Immuntherapie (DZI), Friedrich Alexander University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | | | - Axel Schambach
- Institute of Experimental Hematology, Hannover Medical School, Hannover, Germany
- REBIRTH Research Center for Translational Regenerative Medicine, Hannover Medical School, Hannover, Germany
| | - Hinrich Abken
- Division of Genetic Immunotherapy, Leibniz Institute for Immunotherapy (LIT) and University of Regensburg, Regensburg, Germany
| | - Claudia Rossig
- Department of Pediatric Hematology and Oncology, University Children's Hospital Muenster, Muenster, Germany
- Institute of Transfusion Medicine and Cell Therapy, University Hospital Muenster, Muenster, Germany
- Cells-in-Motion Cluster of Excellence (EXC 1003 - CiM), University of Muenster, Muenster, Germany
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
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7
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Posey AD, Young RM, June CH. Future perspectives on engineered T cells for cancer. Trends Cancer 2024; 10:687-695. [PMID: 38853073 DOI: 10.1016/j.trecan.2024.05.007] [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: 04/23/2024] [Revised: 05/21/2024] [Accepted: 05/21/2024] [Indexed: 06/11/2024]
Abstract
Chimeric antigen receptor (CAR) T cell therapy has emerged as a revolutionary treatment for hematological malignancies, but its adaptation to solid tumors is impeded by multiple challenges, particularly T cell dysfunction and exhaustion. The heterogeneity and inhospitableness of the solid tumor microenvironment (TME) contribute to diminished CAR T cell efficacy exhibited by reduced cytotoxicity, proliferation, cytokine secretion, and the upregulation of inhibitory receptors, similar to the phenotype of tumor-infiltrating lymphocytes (TILs). In this review, we highlight recent advances in T cell therapy for solid tumors, particularly brain cancer. Innovative strategies, including locoregional delivery and 'armoring' CAR T cells with cytokines such as interleukin (IL)-18, are under investigation to improve efficacy and safety. We also highlight emerging issues with toxicity management of CAR T cell adverse events. This review discusses the obstacles associated with CAR T cell therapy in the context of solid tumors and outlines current and future strategies to overcome these challenges.
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MESH Headings
- Humans
- Immunotherapy, Adoptive/methods
- Immunotherapy, Adoptive/adverse effects
- Neoplasms/immunology
- Neoplasms/therapy
- Neoplasms/genetics
- T-Lymphocytes/immunology
- T-Lymphocytes/metabolism
- Tumor Microenvironment/immunology
- Receptors, Chimeric Antigen/immunology
- Receptors, Chimeric Antigen/genetics
- Lymphocytes, Tumor-Infiltrating/immunology
- Lymphocytes, Tumor-Infiltrating/metabolism
- Animals
- Receptors, Antigen, T-Cell/immunology
- Receptors, Antigen, T-Cell/metabolism
- Receptors, Antigen, T-Cell/genetics
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Affiliation(s)
- Avery D Posey
- Center for Cellular Immunotherapies, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Parker Institute for Cancer Immunotherapy at the University of Pennsylvania, Philadelphia, PA, USA; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Regina M Young
- Center for Cellular Immunotherapies, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Parker Institute for Cancer Immunotherapy at the University of Pennsylvania, Philadelphia, PA, USA; Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Carl H June
- Center for Cellular Immunotherapies, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Parker Institute for Cancer Immunotherapy at the University of Pennsylvania, Philadelphia, PA, USA; Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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8
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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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9
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Kaminski J, Fleming RA, Alvarez-Calderon F, Winschel MB, McGuckin C, Ho EE, Eng F, Rui X, Keskula P, Cagnin L, Charles J, Zavistaski J, Margossian SP, Kapadia MA, Rottman JB, Lane J, Baumeister SHC, Tkachev V, Shalek AK, Kean LS, Gerdemann U. B-cell-directed CAR T-cell therapy activates CD8+ cytotoxic CARneg bystander T cells in patients and nonhuman primates. Blood 2024; 144:46-60. [PMID: 38558106 DOI: 10.1182/blood.2023022717] [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: 10/19/2023] [Revised: 02/23/2024] [Accepted: 03/16/2024] [Indexed: 04/04/2024] Open
Abstract
ABSTRACT Chimeric antigen receptor (CAR) T cells hold promise as a therapy for B-cell-derived malignancies, and despite their impressive initial response rates, a significant proportion of patients ultimately experience relapse. Although recent studies have explored the mechanisms of in vivo CAR T-cell function, little is understood about the activation of surrounding CARneg bystander T cells and their potential to enhance tumor responses. We performed single-cell RNA sequencing on nonhuman primate (NHP) and patient-derived T cells to identify the phenotypic and transcriptomic hallmarks of bystander activation of CARneg T cells following B-cell-targeted CAR T-cell therapy. Using a highly translatable CD20 CAR NHP model, we observed a distinct population of activated CD8+ CARneg T cells emerging during CAR T-cell expansion. These bystander CD8+ CARneg T cells exhibited a unique transcriptional signature with upregulation of natural killer-cell markers (KIR3DL2, CD160, and KLRD1), chemokines, and chemokine receptors (CCL5, XCL1, and CCR9), and downregulation of naïve T-cell-associated genes (SELL and CD28). A transcriptionally similar population was identified in patients after a tisagenlecleucel infusion. Mechanistic studies revealed that interleukin-2 (IL-2) and IL-15 exposure induced bystander-like CD8+ T cells in a dose-dependent manner. In vitro activated and patient-derived T cells with a bystander phenotype efficiently killed leukemic cells through a T-cell receptor-independent mechanism. Collectively, to our knowledge, these data provide the first comprehensive identification and profiling of CARneg bystander CD8+ T cells following B-cell-targeting CAR T-cell therapy and suggest a novel mechanism through which CAR T-cell infusion might trigger enhanced antileukemic responses. Patient samples were obtained from the trial #NCT03369353, registered at www.ClinicalTrials.gov.
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Affiliation(s)
- James Kaminski
- Division of Pediatric Hematology-Oncology, Boston Children's Hospital, Boston, MA
- Broad Institute of MIT and Harvard, Cambridge, MA
| | - Ryan A Fleming
- Division of Pediatric Hematology-Oncology, Boston Children's Hospital, Boston, MA
| | - Francesca Alvarez-Calderon
- Division of Pediatric Hematology-Oncology, Boston Children's Hospital, Boston, MA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Marlana B Winschel
- Division of Pediatric Hematology-Oncology, Boston Children's Hospital, Boston, MA
| | - Connor McGuckin
- Division of Pediatric Hematology-Oncology, Boston Children's Hospital, Boston, MA
| | | | | | - Xianliang Rui
- Division of Pediatric Hematology-Oncology, Boston Children's Hospital, Boston, MA
| | - Paula Keskula
- Division of Pediatric Hematology-Oncology, Boston Children's Hospital, Boston, MA
| | - Lorenzo Cagnin
- Division of Pediatric Hematology-Oncology, Boston Children's Hospital, Boston, MA
| | - Joanne Charles
- Division of Pediatric Hematology-Oncology, Boston Children's Hospital, Boston, MA
| | - Jillian Zavistaski
- Division of Pediatric Hematology-Oncology, Boston Children's Hospital, Boston, MA
| | - Steven P Margossian
- Division of Pediatric Hematology-Oncology, Boston Children's Hospital, Boston, MA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Malika A Kapadia
- Division of Pediatric Hematology-Oncology, Boston Children's Hospital, Boston, MA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | | | - Jennifer Lane
- Division of Pediatric Hematology-Oncology, Boston Children's Hospital, Boston, MA
- Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA
| | - Susanne H C Baumeister
- Division of Pediatric Hematology-Oncology, Boston Children's Hospital, Boston, MA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Victor Tkachev
- Division of Pediatric Hematology-Oncology, Boston Children's Hospital, Boston, MA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
- Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA
| | - Alex K Shalek
- Broad Institute of MIT and Harvard, Cambridge, MA
- Department of Chemistry, Massachusetts Institute of Technology, Cambridge, MA
- Institute for Medical Engineering & Science, Massachusetts Institute of Technology, Cambridge, MA
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA
- Ragon Institute of Massachusetts General Hospital, MIT and Harvard, Cambridge, MA
| | - Leslie S Kean
- Division of Pediatric Hematology-Oncology, Boston Children's Hospital, Boston, MA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Ulrike Gerdemann
- Division of Pediatric Hematology-Oncology, Boston Children's Hospital, Boston, MA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
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10
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Géraud A, Hueso T, Laparra A, Bige N, Ouali K, Cauquil C, Stoclin A, Danlos FX, Hollebecque A, Ribrag V, Gazzah A, Goldschmidt V, Baldini C, Suzzoni S, Bahleda R, Besse B, Barlesi F, Lambotte O, Massard C, Marabelle A, Castilla-Llorente C, Champiat S, Michot JM. Reactions and adverse events induced by T-cell engagers as anti-cancer immunotherapies, a comprehensive review. Eur J Cancer 2024; 205:114075. [PMID: 38733717 DOI: 10.1016/j.ejca.2024.114075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 04/14/2024] [Accepted: 04/17/2024] [Indexed: 05/13/2024]
Abstract
T-cell engagers (TCE) are cancer immunotherapies that have recently demonstrated meaningful benefit for patients with hematological malignancies and solid tumors. The anticipated widespread use of T cell engagers poses implementation challenges and highlights the need for guidance to anticipate, mitigate, and manage adverse events. By mobilizing T-cells directly at the contact of tumor cells, TCE mount an obligatory and immediate anti-tumor immune response that could result in diverse reactions and adverse events. Cytokine release syndrome (CRS) is the most common reaction and is largely confined to the first drug administrations during step-up dosage. Cytokine release syndrome should be distinguished from infusion related reaction by clinical symptoms, timing to occurrence, pathophysiological aspects, and clinical management. Other common reactions and adverse events with TCE are immune effector Cell-Associated Neurotoxicity Syndrome (ICANS), infections, tumor flare reaction and cytopenias. The toxicity profiles of TCE and CAR-T cells have commonalities and distinctions that we sum-up in this review. As compared with CAR-T cells, TCE are responsible for less frequently severe CRS or ICANS. This review recapitulates terminology, pathophysiology, severity grading system and management of reactions and adverse events related to TCE.
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Affiliation(s)
- Arthur Géraud
- Gustave Roussy, Département d'Innovation Thérapeutique et d'Essais Précoces, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Thomas Hueso
- Gustave Roussy, Département d'Innovation Thérapeutique et d'Essais Précoces, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Ariane Laparra
- Gustave Roussy, Departement Interdisciplinaire d'Organisation des Parcours Patients, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Naike Bige
- Gustave Roussy, Service de réanimation et de soins intensifs, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Kaissa Ouali
- Gustave Roussy, Département d'Innovation Thérapeutique et d'Essais Précoces, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Cécile Cauquil
- Hôpital Universitaire du Kremlin Bicêtre, Service de Neurologie, 94270 Le Kremlin-Bicêtre, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Annabelle Stoclin
- Gustave Roussy, Service de réanimation et de soins intensifs, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - François-Xavier Danlos
- Gustave Roussy, Département d'Innovation Thérapeutique et d'Essais Précoces, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Antoine Hollebecque
- Gustave Roussy, Département d'Innovation Thérapeutique et d'Essais Précoces, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Vincent Ribrag
- Gustave Roussy, Department Hématologie, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Anas Gazzah
- Gustave Roussy, Département d'Innovation Thérapeutique et d'Essais Précoces, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Vincent Goldschmidt
- Gustave Roussy, Département d'Innovation Thérapeutique et d'Essais Précoces, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Capucine Baldini
- Gustave Roussy, Département d'Innovation Thérapeutique et d'Essais Précoces, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Steve Suzzoni
- Gustave Roussy, Department of Pharmacy, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Rastislav Bahleda
- Gustave Roussy, Département d'Innovation Thérapeutique et d'Essais Précoces, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Benjamin Besse
- Gustave Roussy, Department de Médecine Oncologique, 94805 Villejuif, France; Université Paris-Saclay, Gustave Roussy, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Fabrice Barlesi
- Gustave Roussy, Department de Médecine Oncologique, 94805 Villejuif, France; Université Paris-Saclay, Gustave Roussy, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Olivier Lambotte
- Université Paris-Saclay, Gustave Roussy, 94805 Villejuif, France; Hôpital Universitaire du Kremlin Bicêtre, Service de Médecine Interne, 94270 Le Kremlin-Bicêtre, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Christophe Massard
- Gustave Roussy, Département d'Innovation Thérapeutique et d'Essais Précoces, 94805 Villejuif, France; Université Paris-Saclay, Gustave Roussy, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Aurélien Marabelle
- Gustave Roussy, Département d'Innovation Thérapeutique et d'Essais Précoces, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Cristina Castilla-Llorente
- Gustave Roussy, Department Hématologie, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Stéphane Champiat
- Gustave Roussy, Département d'Innovation Thérapeutique et d'Essais Précoces, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France
| | - Jean-Marie Michot
- Gustave Roussy, Département d'Innovation Thérapeutique et d'Essais Précoces, 94805 Villejuif, France; Gustave Roussy, Department d'Hématologie Clinique, 94805 Villejuif, France.
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11
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Gagelmann N, Bishop M, Ayuk F, Bethge W, Glass B, Sureda A, Pasquini MC, Kröger N. Axicabtagene Ciloleucel versus Tisagenlecleucel for Relapsed or Refractory Large B Cell Lymphoma: A Systematic Review and Meta-Analysis. Transplant Cell Ther 2024; 30:584.e1-584.e13. [PMID: 38281590 DOI: 10.1016/j.jtct.2024.01.074] [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: 10/24/2023] [Revised: 12/28/2023] [Accepted: 01/23/2024] [Indexed: 01/30/2024]
Abstract
Axicabtagene ciloleucel (axi-cel) and tisagenlecleucel (tisa-cel) are CD19-directed chimeric antigen receptor T cell (CAR-T) therapies approved for relapsed/refractory aggressive large B cell lymphoma (LBCL). Significant costs and complex manufacturing underscore the importance of evidence-based counseling regarding the outcomes of these treatments. With the aim of examining the efficacy and safety of axi-cel versus tisa-cel in patients with relapsed/refractory aggressive LBCL, we performed a systematic literature search of comparative studies evaluating outcomes in relapsed/refractory aggressive LBCL after treatment with axi-cel or tisa-cel. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) for response, progression-free survival (PFS), overall survival (OS), cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), and hematotoxicity. Meta-analysis and meta-regression were used to generate summary statistics. A total of 2372 participants were included in the 8 studies in our analysis. The dropout rate between apheresis and infusion was 13% for axi-cel versus 18% for tisa-cel, and the median time from apheresis to infusion was 32 days versus 45 days. Axi-cel showed higher odds for a complete response (OR, 1.65; P < .001) and was associated with higher odds for PFS at 1 year after infusion (OR, .60; P < .001). OS appeared to be improved with axi-cel (OR, .84; 95% CI, .68 to 1.02; P = .08), whereas the cumulative incidence of nonrelapse mortality (NRM) was 11.5% for axi-cel versus 3.7% for tisa-cel (P = .002). The main predictors for survival were lactate dehydrogenase level, Eastern Cooperative Oncology Group Performance Status, and response to bridging, and axi-cel maintained superior efficacy even in elderly patients. In terms of safety, axi-cel was associated with significantly higher odds of any-grade CRS (OR, 3.23; P < .001), but not of grade ≥3 CRS (P = .92). Axi-cel was associated with significantly higher odds of severe ICANS grade ≥3 (OR, 4.03; P < .001). In terms of hematotoxicity, axi-cel was significantly associated with higher odds of severe neutropenia at 1 month after infusion (OR, 2.06; P = .003). As a result, axi-cel was associated with significantly greater resource utilization, including prolonged hospital stay, more frequent intensive care admission, and use of agents such as tocilizumab for toxicity management. We provide strong evidence of the greater efficacy of axi-cel versus tisa-cel in relapsed/refractory aggressive LBCL. The higher toxicity and NRM seen with axi-cel might not counterbalance the overall results, highlighting the need for timely intervention and careful selection of patients, balancing resource utilization and clinical benefit.
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Affiliation(s)
- Nico Gagelmann
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Michael Bishop
- The David and Etta Jonas Center for Cellular Therapy, University of Chicago, Chicago, Illinois
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Wolfgang Bethge
- Department of Hematology and Oncology, University Hospital Tuebingen, Tuebingen, Germany
| | - Bertram Glass
- Department of Hematology and Cell Therapy, Helios Klinikum Berlin-Buch, Berlin, Germany
| | - Anna Sureda
- Bellvitge Institute for Biomedical Research, Universitat de Barcelona, Hematology Department, Institut Català d'Oncologia-Hospitalet, Barcelona, Spain
| | - Marcelo C Pasquini
- Department of Medicine, Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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12
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Ghaffari S, Saleh M, Akbari B, Ramezani F, Mirzaei HR. Applications of single-cell omics for chimeric antigen receptor T cell therapy. Immunology 2024; 171:339-364. [PMID: 38009707 DOI: 10.1111/imm.13720] [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: 07/02/2023] [Accepted: 11/13/2023] [Indexed: 11/29/2023] Open
Abstract
Chimeric antigen receptor (CAR) T cell therapy is a promising cancer treatment modality. The breakthroughs in CAR T cell therapy were, in part, possible with the help of cell analysis methods, such as single-cell analysis. Bulk analyses have provided invaluable information regarding the complex molecular dynamics of CAR T cells, but their results are an average of thousands of signals in CAR T or tumour cells. Since cancer is a heterogeneous disease where each minute detail of a subclone could change the outcome of the treatment, single-cell analysis could prove to be a powerful instrument in deciphering the secrets of tumour microenvironment for cancer immunotherapy. With the recent studies in all aspects of adoptive cell therapy making use of single-cell analysis, a comprehensive review of the recent preclinical and clinical findings in CAR T cell therapy was needed. Here, we categorized and summarized the key points of the studies in which single-cell analysis provided insights into the genomics, epigenomics, transcriptomics and proteomics as well as their respective multi-omics of CAR T cell therapy.
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Affiliation(s)
- Sasan Ghaffari
- Department of Immunology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Mahshid Saleh
- Wisconsin National Primate Research Center, University of Wisconsin Graduate School, Madison, Wisconsin, USA
| | - Behnia Akbari
- Department of Medical Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Faezeh Ramezani
- Department of Medical Biotechnology, School of Paramedical Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Medical Laboratory Sciences, School of Paramedical Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamid Reza Mirzaei
- Department of Medical Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
- Molecular Imaging and Therapy Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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13
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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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14
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Landy E, Carol H, Ring A, Canna S. Biological and clinical roles of IL-18 in inflammatory diseases. Nat Rev Rheumatol 2024; 20:33-47. [PMID: 38081945 DOI: 10.1038/s41584-023-01053-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2023] [Indexed: 12/23/2023]
Abstract
Several new discoveries have revived interest in the pathogenic potential and possible clinical roles of IL-18. IL-18 is an IL-1 family cytokine with potent ability to induce IFNγ production. However, basic investigations and now clinical observations suggest a more complex picture. Unique aspects of IL-18 biology at the levels of transcription, activation, secretion, neutralization, receptor distribution and signalling help to explain its pleiotropic roles in mucosal and systemic inflammation. Blood biomarker studies reveal a cytokine for which profound elevation, associated with detectable 'free IL-18', defines a group of autoinflammatory diseases in which IL-18 dysregulation can be a primary driving feature, the so-called 'IL-18opathies'. This impressive specificity might accelerate diagnoses and identify patients amenable to therapeutic IL-18 blockade. Pathogenically, human and animal studies identify a preferential activation of CD8+ T cells over other IL-18-responsive lymphocytes. IL-18 agonist treatments that leverage the site of production or subversion of endogenous IL-18 inhibition show promise in augmenting immune responses to cancer. Thus, the unique aspects of IL-18 biology are finally beginning to have clinical impact in precision diagnostics, disease monitoring and targeted treatment of inflammatory and malignant diseases.
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Affiliation(s)
- Emily Landy
- Program in Microbiology and Immunology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hallie Carol
- Division of Rheumatology and Immune Dysregulation Program, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Aaron Ring
- Translational Science and Therapeutics, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Scott Canna
- Program in Microbiology and Immunology, University of Pittsburgh, Pittsburgh, PA, USA.
- Division of Rheumatology and Immune Dysregulation Program, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
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15
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Barrett D. IL-6 Blockade in Cytokine Storm Syndromes. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1448:565-572. [PMID: 39117839 DOI: 10.1007/978-3-031-59815-9_37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
Interleukin-6 (IL-6) is a pro-inflammatory cytokine elevated in cytokine storm syndromes, including hemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS). It is also elevated in cytokine release syndrome (CRS) after immune activating cancer therapies such as chimeric antigen receptor (CAR) T-cells or bispecific T-cell engagers (BITEs) and in some patients after infection with SARS-CoV-2. The interaction of IL-6 with its receptor complex can happen in several forms, making effectively blocking this cytokine's effects clinically challenging. Fortunately, effective clinical agents targeting the IL-6 receptor (tocilizumab) and IL-6 directly (siltuximab) have been developed and are approved for use in humans. IL-6 blockade has now been used to safely and effectively treat several cytokine storm syndromes (CSS). Other methods of investigation in effective IL-6 blockade are underway.
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Affiliation(s)
- David Barrett
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA.
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16
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Fugere T, Baltz A, Mukherjee A, Gaddam M, Varma A, Veeraputhiran M, Gentille Sanchez CG. Immune Effector Cell-Associated HLH-like Syndrome: A Review of the Literature of an Increasingly Recognized Entity. Cancers (Basel) 2023; 15:5149. [PMID: 37958323 PMCID: PMC10647774 DOI: 10.3390/cancers15215149] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 10/21/2023] [Accepted: 10/24/2023] [Indexed: 11/15/2023] Open
Abstract
Since CAR-T cell therapy was initially approved in 2017, its use has become more prevalent and so have its side effects. CAR-T-related HLH, also named immune effector cell-associated HLH-like syndrome (IEC-HS), is a rare but fatal toxicity if not recognized promptly. We conducted a review of the literature in order to understand the prevalence of IEC-HS as well as clarify the evolution of the diagnostic criteria and treatment recommendations. IEC-HS occurrence varies between CAR-T cell products and the type of malignancy treated. Diagnosis can be challenging as there are no standardized diagnostic criteria, and its clinical features can overlap with cytokine release syndrome and active hematological disease. Suggested treatment strategies have been extrapolated from prior experience in HLH and include anakinra, corticosteroids and ruxolitinib. IEC-HS is a potentially fatal toxicity associated with CAR-T cell therapy. Early recognition with reliable diagnostic criteria and prompt implementation of treatment specific to IEC-HS is imperative for improving patient outcomes.
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Affiliation(s)
- Tyler Fugere
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (A.B.); (A.M.); (M.G.); (A.V.); (M.V.); (C.G.G.S.)
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17
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Rocco JM, Inglefield J, Yates B, Lichtenstein DA, Wang Y, Goffin L, Filipovic D, Schiffrin EJ, Shah NN. Free interleukin-18 is elevated in CD22 CAR T-cell-associated hemophagocytic lymphohistiocytosis-like toxicities. Blood Adv 2023; 7:6134-6139. [PMID: 37389815 PMCID: PMC10582359 DOI: 10.1182/bloodadvances.2023010708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/06/2023] [Accepted: 06/06/2023] [Indexed: 07/01/2023] Open
Affiliation(s)
- Joseph M. Rocco
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Jon Inglefield
- Applied Developmental Research Directorate, Leidos Biomedical Research Inc, Frederick National Laboratory for Cancer Research, National Cancer Institute, Frederick, MD
| | - Bonnie Yates
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Daniel A. Lichtenstein
- Department of Internal Medicine, University of Cincinnati, Cincinnati, OH
- Department of Pediatrics, Cincinnati Children’s Hospital, University of Cincinnati, Cincinnati, OH
| | - Yanyu Wang
- Applied Developmental Research Directorate, Leidos Biomedical Research Inc, Frederick National Laboratory for Cancer Research, National Cancer Institute, Frederick, MD
| | | | | | | | - Nirali N. Shah
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
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18
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Shakoory B, Geerlinks A, Wilejto M, Kernan K, Hines M, Romano M, Piskin D, Ravelli A, Sinha R, Aletaha D, Allen C, Bassiri H, Behrens EM, Carcillo J, Carl L, Chatham W, Cohen JI, Cron RQ, Drewniak E, Grom AA, Henderson LA, Horne A, Jordan MB, Nichols KE, Schulert G, Vastert S, Demirkaya E, Goldbach-Mansky R, de Benedetti F, Marsh RA, Canna SW. The 2022 EULAR/ACR Points to Consider at the Early Stages of Diagnosis and Management of Suspected Haemophagocytic Lymphohistiocytosis/Macrophage Activation Syndrome (HLH/MAS). Arthritis Rheumatol 2023; 75:1714-1732. [PMID: 37486733 PMCID: PMC11040593 DOI: 10.1002/art.42636] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 06/21/2023] [Indexed: 07/25/2023]
Abstract
OBJECTIVE Haemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS) are life-threatening systemic hyperinflammatory syndromes that can develop in most inflammatory contexts. They can progress rapidly, and early identification and management are critical for preventing organ failure and mortality. This effort aimed to develop evidence-based and consensus-based points to consider to assist clinicians in optimising decision-making in the early stages of diagnosis, treatment and monitoring of HLH/MAS. METHODS A multinational, multidisciplinary task force of physician experts, including adult and paediatric rheumatologists, haematologist/oncologists, immunologists, infectious disease specialists, intensivists, allied healthcare professionals and patients/parents, formulated relevant research questions and conducted a systematic literature review (SLR). Delphi methodology, informed by SLR results and questionnaires of experts, was used to generate statements aimed at assisting early decision-making and optimising the initial care of patients with HLH/MAS. RESULTS The task force developed 6 overarching statements and 24 specific points to consider relevant to early recognition of HLH/MAS, diagnostic approaches, initial management and monitoring of HLH/MAS. Major themes included the simultaneous need for prompt syndrome recognition, systematic evaluation of underlying contributors, early intervention targeting both hyperinflammation and likely contributors, careful monitoring for progression/complications and expert multidisciplinary assistance. CONCLUSION These 2022 EULAR/American College of Rheumatology points to consider provide up-to-date guidance, based on the best available published data and expert opinion. They are meant to help guide the initial evaluation, management and monitoring of patients with HLH/MAS in order to halt disease progression and prevent life-threatening immunopathology.
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Affiliation(s)
- Bita Shakoory
- Translational Autoinflammatory Diseases Section, NIH, Bethesda, Maryland
| | - Ashley Geerlinks
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, and Hematology/Oncology, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
- Hematology/Oncology, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Marta Wilejto
- Hematology/Oncology, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Kate Kernan
- Pediatric Critical Care Medicine, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Melissa Hines
- Pediatric Critical Care Medicine, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Micol Romano
- Pediatrics, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - David Piskin
- Department of Epidemiology and Biostatistics, Western University and Department of Paediatrics, Lawson Health Research Institute, London, Ontario, Canada
| | - Angelo Ravelli
- Direzione Scientifica, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | | | - Daniel Aletaha
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Carl Allen
- Pediatric Oncology, Texas Children’s Hospital, Houston
| | - Hamid Bassiri
- Pediatric Infectious Diseases, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Edward M. Behrens
- Pediatric Rheumatology, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Joseph Carcillo
- Pediatric Critical Care Medicine, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Linda Carl
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Winn Chatham
- Rheumatology, University of Alabama at Birmingham
| | - Jeffrey I. Cohen
- Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, Maryland
| | - Randy Q. Cron
- Pediatric Rheumatology, University of Alabama at Birmingham
| | - Erik Drewniak
- Autoinflammatory Alliance, San Francisco, California
| | - Alexei A. Grom
- Pediatric Rheumatology, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Lauren A. Henderson
- Pediatric Immunology, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Annacarin Horne
- Department of Women’s and Children’s Health, Karolinska Institutet Cancerforskning KI, Stockholm, Sweden
| | - Michael B. Jordan
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Kim E. Nichols
- Division of Cancer Predisposition Department of Oncology, St. Jude Children’s Research Hospital Department of Oncology, Memphis, Tennessee
| | - Grant Schulert
- Pediatric Rheumatology, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Sebastiaan Vastert
- Center for Translational Immunology Research, UMC Utrecht, Utrecht, The Netherlands
| | - Erkan Demirkaya
- Pediatrics, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | | | | | - Rebecca A. Marsh
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Scott W. Canna
- Pediatric Rheumatology, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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19
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Shakoory B, Geerlinks A, Wilejto M, Kernan K, Hines M, Romano M, Piskin D, Ravelli A, Sinha R, Aletaha D, Allen C, Bassiri H, Behrens EM, Carcillo J, Carl L, Chatham W, Cohen JI, Cron RQ, Drewniak E, Grom AA, Henderson LA, Horne A, Jordan MB, Nichols KE, Schulert G, Vastert S, Demirkaya E, Goldbach-Mansky R, de Benedetti F, Marsh RA, Canna SW. The 2022 EULAR/ACR points to consider at the early stages of diagnosis and management of suspected haemophagocytic lymphohistiocytosis/macrophage activation syndrome (HLH/MAS). Ann Rheum Dis 2023; 82:1271-1285. [PMID: 37487610 PMCID: PMC11017727 DOI: 10.1136/ard-2023-224123] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 04/27/2023] [Indexed: 07/26/2023]
Abstract
OBJECTIVE Haemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS) are life-threatening systemic hyperinflammatory syndromes that can develop in most inflammatory contexts. They can progress rapidly, and early identification and management are critical for preventing organ failure and mortality. This effort aimed to develop evidence-based and consensus-based points to consider to assist clinicians in optimising decision-making in the early stages of diagnosis, treatment and monitoring of HLH/MAS. METHODS A multinational, multidisciplinary task force of physician experts, including adult and paediatric rheumatologists, haematologist/oncologists, immunologists, infectious disease specialists, intensivists, allied healthcare professionals and patients/parents, formulated relevant research questions and conducted a systematic literature review (SLR). Delphi methodology, informed by SLR results and questionnaires of experts, was used to generate statements aimed at assisting early decision-making and optimising the initial care of patients with HLH/MAS. RESULTS The task force developed 6 overarching statements and 24 specific points to consider relevant to early recognition of HLH/MAS, diagnostic approaches, initial management and monitoring of HLH/MAS. Major themes included the simultaneous need for prompt syndrome recognition, systematic evaluation of underlying contributors, early intervention targeting both hyperinflammation and likely contributors, careful monitoring for progression/complications and expert multidisciplinary assistance. CONCLUSION These 2022 EULAR/American College of Rheumatology points to consider provide up-to-date guidance, based on the best available published data and expert opinion. They are meant to help guide the initial evaluation, management and monitoring of patients with HLH/MAS in order to halt disease progression and prevent life-threatening immunopathology.
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Affiliation(s)
- Bita Shakoory
- Translational Autoinflammatory Diseases Section, National Institutes of Health, Bethesda, Maryland, USA
| | - Ashley Geerlinks
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
- Hematology/Oncology, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Marta Wilejto
- Hematology/Oncology, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Kate Kernan
- Pediatric Critical Care Medicine, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Melissa Hines
- Pediatric Critical Care Medicine, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Micol Romano
- Pediatrics, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - David Piskin
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- Department of Paediatrics, Lawson Health Research Institute, London, Ontario, Canada
| | - Angelo Ravelli
- Direzione Scientifica, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | | | - Daniel Aletaha
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Carl Allen
- Pediatric Oncology, Texas Children's Hospital, Houston, Texas, USA
| | - Hamid Bassiri
- Pediatric Infectious Diseases, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Edward M Behrens
- Pediatric Rheumatology, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Joseph Carcillo
- Pediatric Critical Care Medicine, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Linda Carl
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Winn Chatham
- Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jeffrey I Cohen
- Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA
| | - Randy Q Cron
- Pediatric Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Erik Drewniak
- Autoinflammatory Alliance, San Francisco, California, USA
| | - Alexei A Grom
- Pediatric Rheumatology, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Lauren A Henderson
- Pediatric Immunology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Annacarin Horne
- Department of Women's and Children's Health, Karolinska Institutet Cancerforskning KI, Stockholm, Sweden
| | - Michael B Jordan
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Kim E Nichols
- Division of Cancer Predisposition Department of Oncology, St Jude Children's Research Hospital Department of Oncology, Memphis, Tennessee, USA
| | - Grant Schulert
- Pediatric Rheumatology, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Sebastiaan Vastert
- Center for Translational Immunology Research, UMC Utrecht, The Netherlands
| | - Erkan Demirkaya
- Pediatrics, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Raphaela Goldbach-Mansky
- Translational Autoinflammatory Diseases Section, National Institutes of Health, Bethesda, Maryland, USA
| | | | - Rebecca A Marsh
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Scott W Canna
- Pediatric Rheumatology, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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20
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Montégut L, Abdellatif M, Motiño O, Madeo F, Martins I, Quesada V, López‐Otín C, Kroemer G. Acyl coenzyme A binding protein (ACBP): An aging- and disease-relevant "autophagy checkpoint". Aging Cell 2023; 22:e13910. [PMID: 37357988 PMCID: PMC10497816 DOI: 10.1111/acel.13910] [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: 04/17/2023] [Revised: 06/01/2023] [Accepted: 06/07/2023] [Indexed: 06/27/2023] Open
Abstract
Acyl coenzyme A binding protein (ACBP), also known as diazepam-binding inhibitor (DBI), is a phylogenetically ancient protein present in some eubacteria and the entire eukaryotic radiation. In several eukaryotic phyla, ACBP/DBI transcends its intracellular function in fatty acid metabolism because it can be released into the extracellular space. This ACBP/DBI secretion usually occurs in response to nutrient scarcity through an autophagy-dependent pathway. ACBP/DBI and its peptide fragments then act on a range of distinct receptors that diverge among phyla, namely metabotropic G protein-coupled receptor in yeast (and likely in the mammalian central nervous system), a histidine receptor kinase in slime molds, and ionotropic gamma-aminobutyric acid (GABA)A receptors in mammals. Genetic or antibody-mediated inhibition of ACBP/DBI orthologs interferes with nutrient stress-induced adaptations such as sporulation or increased food intake in multiple species, as it enhances lifespan or healthspan in yeast, plant leaves, nematodes, and multiple mouse models. These lifespan and healthspan-extending effects of ACBP/DBI suppression are coupled to the induction of autophagy. Altogether, it appears that neutralization of extracellular ACBP/DBI results in "autophagy checkpoint inhibition" to unleash the anti-aging potential of autophagy. Of note, in humans, ACBP/DBI levels increase in various tissues, as well as in the plasma, in the context of aging, obesity, uncontrolled infection or cardiovascular, inflammatory, neurodegenerative, and malignant diseases.
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Affiliation(s)
- Léa Montégut
- Centre de Recherche des Cordeliers, Equipe labellisée par la Ligue Contre le Cancer, Inserm U1138Université Paris Cité, Sorbonne UniversitéParisFrance
- Metabolomics and Cell Biology PlatformsGustave Roussy InstitutVillejuifFrance
- Faculté de MédecineUniversité de Paris SaclayParisFrance
| | - Mahmoud Abdellatif
- Centre de Recherche des Cordeliers, Equipe labellisée par la Ligue Contre le Cancer, Inserm U1138Université Paris Cité, Sorbonne UniversitéParisFrance
- Metabolomics and Cell Biology PlatformsGustave Roussy InstitutVillejuifFrance
- Department of CardiologyMedical University of GrazGrazAustria
- BioTechMed‐GrazGrazAustria
| | - Omar Motiño
- Centre de Recherche des Cordeliers, Equipe labellisée par la Ligue Contre le Cancer, Inserm U1138Université Paris Cité, Sorbonne UniversitéParisFrance
- Metabolomics and Cell Biology PlatformsGustave Roussy InstitutVillejuifFrance
| | - Frank Madeo
- BioTechMed‐GrazGrazAustria
- Institute of Molecular Biosciences, NAWI GrazUniversity of GrazGrazAustria
- Field of Excellence BioHealthUniversity of GrazGrazAustria
| | - Isabelle Martins
- Centre de Recherche des Cordeliers, Equipe labellisée par la Ligue Contre le Cancer, Inserm U1138Université Paris Cité, Sorbonne UniversitéParisFrance
- Metabolomics and Cell Biology PlatformsGustave Roussy InstitutVillejuifFrance
| | - Victor Quesada
- Departamento de Bioquímica y Biología Molecular, Instituto Universitario de Oncología del Principado de Asturias (IUOPA)Universidad de OviedoOviedoSpain
| | - Carlos López‐Otín
- Centre de Recherche des Cordeliers, Equipe labellisée par la Ligue Contre le Cancer, Inserm U1138Université Paris Cité, Sorbonne UniversitéParisFrance
- Departamento de Bioquímica y Biología Molecular, Instituto Universitario de Oncología del Principado de Asturias (IUOPA)Universidad de OviedoOviedoSpain
| | - Guido Kroemer
- Centre de Recherche des Cordeliers, Equipe labellisée par la Ligue Contre le Cancer, Inserm U1138Université Paris Cité, Sorbonne UniversitéParisFrance
- Metabolomics and Cell Biology PlatformsGustave Roussy InstitutVillejuifFrance
- Institut du Cancer Paris CARPEM, Department of BiologyHôpital Européen Georges Pompidou, AP‐HPParisFrance
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21
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Wang Y, Sun R, Ge W, Xue L, Xu Q, Xu H, Li S, Wu M, Guo T, Wang X. Longitudinal Serum Proteomics Characterization of CD19-CAR-T Cell Therapy for B-Cell Malignancies. J Proteome Res 2023; 22:2985-2994. [PMID: 37531193 DOI: 10.1021/acs.jproteome.3c00322] [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] [Indexed: 08/03/2023]
Abstract
Chimeric antigen receptor (CAR)-modified T cells have demonstrated remarkable efficacy in treating B-cell leukemia. However, treated patients may potentially develop side effects, such as cytokine release syndrome (CRS), the mechanisms of which remain unclear. Here, we collected 43 serum samples from eight patients with B-cell acute lymphoblastic leukemia (B-ALL) before and five time points after CD19-specific CAR-T cell treatment. Using TMTpro 16-plex-based quantitative proteomics, we quantified 1151 proteins and profiled the longitudinal proteomes analysis of each patient. Seven days after therapy, we found the most dysregulated inflammatory proteins. Lipid metabolism proteins, including APOA1, decreased after therapy, reached their minimum after 7 days, and then gradually recovered. Hence, APOA1 has been selected as a potential biomarker of the CRS disease progression. Furthermore, we identified CD163 as a potential biomarker of CRS severity. These two biomarkers were successfully validated using targeted proteomics in an independent cohort. Our study provides new insights into CAR-T cell therapy-induced CRS. The biomarkers we identified may help develop targeted drugs and monitoring strategies.
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Affiliation(s)
- Youming Wang
- First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui 230001, China
| | - Rui Sun
- Center for Intelligent Proteomics, Westlake Laboratory of Life Sciences and Biomedicine, Hangzhou, Zhejiang 310024, China
- Key Laboratory of Structural Biology of Zhejiang Province, School of Life Sciences, Westlake University, Hangzhou 310024, China
- Institute of Basic Medical Sciences, Westlake Institute for Advanced Study, Hangzhou 310024, China
| | - Weigang Ge
- Westlake Omics (Hangzhou) Biotechnology Co., Ltd., Hangzhou 310024, China
| | - Lei Xue
- First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui 230001, China
| | - Qianwen Xu
- First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui 230001, China
| | - Hui Xu
- First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui 230001, China
| | - Sujun Li
- First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui 230001, China
| | - Miaomiao Wu
- First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui 230001, China
| | - Tiannan Guo
- Center for Intelligent Proteomics, Westlake Laboratory of Life Sciences and Biomedicine, Hangzhou, Zhejiang 310024, China
- Key Laboratory of Structural Biology of Zhejiang Province, School of Life Sciences, Westlake University, Hangzhou 310024, China
- Institute of Basic Medical Sciences, Westlake Institute for Advanced Study, Hangzhou 310024, China
| | - Xingbing Wang
- First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui 230001, China
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22
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Gavriilaki E, Mallouri D, Bousiou Z, Demosthenous C, Vardi A, Dolgyras P, Batsis I, Stroggyli E, Karvouni P, Masmanidou M, Gavriilaki M, Bouinta A, Bitsianis S, Kapravelos N, Bitzani M, Vasileiadou G, Yannaki E, Sotiropoulos D, Papagiannopoulos S, Kazis D, Kimiskidis V, Anagnostopoulos A, Sakellari I. Molecular and Clinical Characteristics of Different Toxicity Rates in Anti-CD19 Chimeric Antigen Receptor T Cells: Real-World Experience. Cancers (Basel) 2023; 15:4253. [PMID: 37686529 PMCID: PMC10487155 DOI: 10.3390/cancers15174253] [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: 07/04/2023] [Revised: 08/21/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
Commercially available anti-CD19 chimeric antigen receptor T cells (CARΤ cells) have offered long-term survival to a constantly expanding patient population. Given that novel toxicities including cytokine release syndrome (CRS) and neurotoxicity (ICANS) have been observed, we aimed to document the safety and toxicity of this treatment in a real-world study. We enrolled 31 adult patients referred to our center for CAR T therapy. Tisagenlecleucel was infused in 12 patients, axicabtagene ciloleucel in 14, and brexucabtagene autoleucel in 5. Cytokine release syndrome was noted in 26 patients while neurotoxicity was observed in 7. Tocilizumab was administered for CRS in 18 patients, along with short-term, low-dose steroid administration in one patient who developed grade III CRS and, subsequently, grade I ICANS. High-dose steroids, along with anakinra and siltuximab, were administered in only two MCL patients. With a median follow-up time of 13.4 months, nine patients were then in CR. The progression-free (PFS) and overall survival (OS) rates were 41.2% and 88.1% at one year, respectively. MCL diagnosis, which coincides with the administration of brexucabtagene autoleucel, was the only factor to be independently associated with poor OS (p < 0.001); meanwhile, increased LDH independently predicted PFS (p = 0.027).In addition, CRP at day 14 was associated with a poor OS (p = 0.001). Therefore, our real-world experience confirmed that commercial CAR T therapy can be administered with minimal toxicity.
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Affiliation(s)
- E. Gavriilaki
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (D.M.); (Z.B.); (C.D.); (A.V.); (P.D.); (I.B.); (E.S.); (M.M.); (A.B.); (E.Y.); (D.S.); (A.A.); (I.S.)
- Medical School, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece;
| | - D. Mallouri
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (D.M.); (Z.B.); (C.D.); (A.V.); (P.D.); (I.B.); (E.S.); (M.M.); (A.B.); (E.Y.); (D.S.); (A.A.); (I.S.)
| | - Z. Bousiou
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (D.M.); (Z.B.); (C.D.); (A.V.); (P.D.); (I.B.); (E.S.); (M.M.); (A.B.); (E.Y.); (D.S.); (A.A.); (I.S.)
| | - C. Demosthenous
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (D.M.); (Z.B.); (C.D.); (A.V.); (P.D.); (I.B.); (E.S.); (M.M.); (A.B.); (E.Y.); (D.S.); (A.A.); (I.S.)
| | - A. Vardi
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (D.M.); (Z.B.); (C.D.); (A.V.); (P.D.); (I.B.); (E.S.); (M.M.); (A.B.); (E.Y.); (D.S.); (A.A.); (I.S.)
| | - P. Dolgyras
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (D.M.); (Z.B.); (C.D.); (A.V.); (P.D.); (I.B.); (E.S.); (M.M.); (A.B.); (E.Y.); (D.S.); (A.A.); (I.S.)
| | - I. Batsis
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (D.M.); (Z.B.); (C.D.); (A.V.); (P.D.); (I.B.); (E.S.); (M.M.); (A.B.); (E.Y.); (D.S.); (A.A.); (I.S.)
| | - E. Stroggyli
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (D.M.); (Z.B.); (C.D.); (A.V.); (P.D.); (I.B.); (E.S.); (M.M.); (A.B.); (E.Y.); (D.S.); (A.A.); (I.S.)
| | - P. Karvouni
- Medical School, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece;
| | - M. Masmanidou
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (D.M.); (Z.B.); (C.D.); (A.V.); (P.D.); (I.B.); (E.S.); (M.M.); (A.B.); (E.Y.); (D.S.); (A.A.); (I.S.)
| | - M. Gavriilaki
- 1st Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (M.G.); (V.K.)
| | - A. Bouinta
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (D.M.); (Z.B.); (C.D.); (A.V.); (P.D.); (I.B.); (E.S.); (M.M.); (A.B.); (E.Y.); (D.S.); (A.A.); (I.S.)
| | - S. Bitsianis
- Department of Surgery, G. Papanicolaou Hospital, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece;
| | - N. Kapravelos
- 1st Intensive Care Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (N.K.); (G.V.)
| | - M. Bitzani
- 2nd Intensive Care Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (M.B.); (S.P.)
| | - G. Vasileiadou
- 1st Intensive Care Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (N.K.); (G.V.)
| | - E. Yannaki
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (D.M.); (Z.B.); (C.D.); (A.V.); (P.D.); (I.B.); (E.S.); (M.M.); (A.B.); (E.Y.); (D.S.); (A.A.); (I.S.)
| | - D. Sotiropoulos
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (D.M.); (Z.B.); (C.D.); (A.V.); (P.D.); (I.B.); (E.S.); (M.M.); (A.B.); (E.Y.); (D.S.); (A.A.); (I.S.)
| | - S. Papagiannopoulos
- 2nd Intensive Care Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (M.B.); (S.P.)
| | - D. Kazis
- 3rd Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece;
| | - V. Kimiskidis
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (D.M.); (Z.B.); (C.D.); (A.V.); (P.D.); (I.B.); (E.S.); (M.M.); (A.B.); (E.Y.); (D.S.); (A.A.); (I.S.)
- 1st Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (M.G.); (V.K.)
| | - A. Anagnostopoulos
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (D.M.); (Z.B.); (C.D.); (A.V.); (P.D.); (I.B.); (E.S.); (M.M.); (A.B.); (E.Y.); (D.S.); (A.A.); (I.S.)
| | - I. Sakellari
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (D.M.); (Z.B.); (C.D.); (A.V.); (P.D.); (I.B.); (E.S.); (M.M.); (A.B.); (E.Y.); (D.S.); (A.A.); (I.S.)
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23
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Hines MR, Knight TE, McNerney KO, Leick MB, Jain T, Ahmed S, Frigault MJ, Hill JA, Jain MD, Johnson WT, Lin Y, Mahadeo KM, Maron GM, Marsh RA, Neelapu SS, Nikiforow S, Ombrello AK, Shah NN, Talleur AC, Turicek D, Vatsayan A, Wong SW, Maus MV, Komanduri KV, Berliner N, Henter JI, Perales MA, Frey NV, Teachey DT, Frank MJ, Shah NN. Immune Effector Cell-Associated Hemophagocytic Lymphohistiocytosis-Like Syndrome. Transplant Cell Ther 2023; 29:438.e1-438.e16. [PMID: 36906275 PMCID: PMC10330221 DOI: 10.1016/j.jtct.2023.03.006] [Citation(s) in RCA: 60] [Impact Index Per Article: 60.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 02/20/2023] [Accepted: 03/04/2023] [Indexed: 03/11/2023]
Abstract
T cell-mediated hyperinflammatory responses, such as cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS), are now well-established toxicities of chimeric antigen receptor (CAR) T cell therapy. As the field of CAR T cells advances, however, there is increasing recognition that hemophagocytic lymphohistiocytosis (HLH)-like toxicities following CAR T cell infusion are occurring broadly across patient populations and CAR T cell constructs. Importantly, these HLH-like toxicities are often not as directly associated with CRS and/or its severity as initially described. This emergent toxicity, however ill-defined, is associated with life-threatening complications, creating an urgent need for improved identification and optimal management. With the goal of improving patient outcomes and formulating a framework to characterize and study this HLH-like syndrome, we established an American Society for Transplantation and Cellular Therapy panel composed of experts in primary and secondary HLH, pediatric and adult HLH, infectious disease, rheumatology and hematology, oncology, and cellular therapy. Through this effort, we provide an overview of the underlying biology of classical primary and secondary HLH, explore its relationship with similar manifestations following CAR T cell infusions, and propose the term "immune effector cell-associated HLH-like syndrome (IEC-HS)" to describe this emergent toxicity. We also delineate a framework for identifying IEC-HS and put forward a grading schema that can be used to assess severity and facilitate cross-trial comparisons. Additionally, given the critical need to optimize outcomes for patients experiencing IEC-HS, we provide insight into potential treatment approaches and strategies to optimize supportive care and delineate alternate etiologies that should be considered in a patient presenting with IEC-HS. By collectively defining IEC-HS as a hyperinflammatory toxicity, we can now embark on further study of the pathophysiology underlying this toxicity profile and make strides toward a more comprehensive assessment and treatment approach.
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Affiliation(s)
- Melissa R Hines
- Department of Pediatric Medicine, Division of Critical Care, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Tristan E Knight
- Pediatric Hematology and Oncology, Seattle Children's Hospital and the University of Washington School of Medicine, Seattle, Washington
| | - Kevin O McNerney
- Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Mark B Leick
- Cellular Immunotherapy Program and Blood and Marrow Transplant Program, Cancer Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Tania Jain
- Division of Hematological Malignancies and Bone Marrow Transplantation, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Sairah Ahmed
- Departments of Lymphoma and Myeloma and Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Matthew J Frigault
- Cellular Immunotherapy Program and Blood and Marrow Transplant Program, Cancer Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Joshua A Hill
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | | | - William T Johnson
- Department of Medicine, Cellular Therapy Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Yi Lin
- Division Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Rochester, Minnesota
| | - Kris M Mahadeo
- Pediatric Transplantation and Cellular Therapy, Duke University, Durham, North Carolina
| | - Gabriela M Maron
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, and Department of Pediatrics, University of Tennessee Health Science Center College of Medicine, Memphis, Tennessee
| | - Rebecca A Marsh
- University of Cincinnati, and Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Sattva S Neelapu
- Departments of Lymphoma and Myeloma and Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sarah Nikiforow
- Division of Hematologic Oncology, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Amanda K Ombrello
- Inflammatory Disease Section, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
| | - Nirav N Shah
- Bone Marrow Transplant and Cellular Therapy Program, Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Aimee C Talleur
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee and Department of Pediatrics, University of Tennessee Health Science Center College of Medicine, Memphis, Tennessee
| | - David Turicek
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Anant Vatsayan
- Division of Blood and Marrow Transplantation, Children's National Health System, Washington, District of Columbia
| | - Sandy W Wong
- UCSF Health Division of Hematology and Oncology and Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, California
| | - Marcela V Maus
- Cellular Immunotherapy Program and Blood and Marrow Transplant Program, Cancer Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Krishna V Komanduri
- UCSF Health Division of Hematology and Oncology and Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, California
| | | | - Jan-Inge Henter
- Division of Pediatric Oncology and Surgery, Department of Women's and Children's Health, Karolinska Institute, and Department of Paediatric Oncology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Miguel-Angel Perales
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Noelle V Frey
- Division of Hematology-Oncology, Abramson Cancer Center and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David T Teachey
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Matthew J Frank
- Division of Blood and Marrow Transplantation and Cellular Therapy, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California
| | - Nirali N Shah
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
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24
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Diorio C, Teachey DT, Canna SW. Cytokine Storm Syndromes in Pediatric Patients. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1636-1644. [PMID: 36990432 DOI: 10.1016/j.jaip.2023.03.033] [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] [Received: 11/29/2022] [Revised: 03/15/2023] [Accepted: 03/16/2023] [Indexed: 03/29/2023]
Abstract
Cytokine storm syndromes (CSS) represent a diverse group of disorders characterized by severe overactivation of the immune system. In the majority of patients, CSS arise from a combination of host factors, including genetic risk and predisposing conditions, and acute triggers such as infections. CSS present differently in adults than in children, who are more likely to present with monogenic forms of these disorders. Individual CSS are rare, but in aggregate represent an important cause of severe illness in both children and adults. We present 3 rare, illustrative cases of CSS in pediatric patients that describe the spectrum of CSS.
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Affiliation(s)
- Caroline Diorio
- Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa; Immune Dysregulation Frontier Program, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa.
| | - David T Teachey
- Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa; Immune Dysregulation Frontier Program, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
| | - Scott W Canna
- Immune Dysregulation Frontier Program, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa; Division of Rheumatology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
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25
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Ludwig H, Terpos E, van de Donk N, Mateos MV, Moreau P, Dimopoulos MA, Delforge M, Rodriguez-Otero P, San-Miguel J, Yong K, Gay F, Einsele H, Mina R, Caers J, Driessen C, Musto P, Zweegman S, Engelhardt M, Cook G, Weisel K, Broijl A, Beksac M, Bila J, Schjesvold F, Cavo M, Hajek R, Touzeau C, Boccadoro M, Sonneveld P. Prevention and management of adverse events during treatment with bispecific antibodies and CAR T cells in multiple myeloma: a consensus report of the European Myeloma Network. Lancet Oncol 2023; 24:e255-e269. [PMID: 37269857 DOI: 10.1016/s1470-2045(23)00159-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/31/2023] [Accepted: 03/31/2023] [Indexed: 06/05/2023]
Abstract
T-cell redirecting bispecific antibodies (BsAbs) and chimeric antigen receptor T cells (CAR T cells) have revolutionised multiple myeloma therapy, but adverse events such as cytokine release syndrome, immune effector cell-associated neurotoxicity syndrome (ICANS), cytopenias, hypogammaglobulinaemia, and infections are common. This Policy Review presents a consensus from the European Myeloma Network on the prevention and management of these adverse events. Recommended measures include premedication, frequent assessing for symptoms and severity of cytokine release syndrome, step-up dosing for several BsAbs and some CAR T-cell therapies; corticosteroids; and tocilizumab in the case of cytokine release syndrome. Other anti-IL-6 drugs, high-dose corticosteroids, and anakinra might be considered in refractory cases. ICANS often arises concomitantly with cytokine release syndrome. Glucocorticosteroids in increasing doses are recommended if needed, as well as anakinra if the response is inadequate, and anticonvulsants if convulsions occur. Preventive measures against infections include antiviral and antibacterial drugs and administration of immunoglobulins. Treatment of infections and other complications is also addressed.
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Affiliation(s)
- Heinz Ludwig
- Department of Medicine, Clinic Ottakring, Wilhelminen Cancer Research Institute, Vienna, Austria.
| | - Evangelos Terpos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Niels van de Donk
- Department of Hematology, Amsterdam UMC, VU University, Amsterdam, Netherlands
| | - Maria-Victoria Mateos
- Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca, Centro de Investigación del Cancer, Salamanca, Spain
| | - Philippe Moreau
- Department of Hematology, University Hospital of Nantes, Nantes, France
| | | | - Michel Delforge
- Division of Hematology, University of Leuven, Leuven, Belgium
| | - Paula Rodriguez-Otero
- Cancer Center Clinica Universidad de Navarra, Pamplona, Spain; Centro de Investigación Medica Aplicada, Pamplona, Spain; Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain; Centro de investigación biomédica en red de Oncologia, Pamplona, Spain
| | - Jesús San-Miguel
- Cancer Center Clinica Universidad de Navarra, Pamplona, Spain; Centro de Investigación Medica Aplicada, Pamplona, Spain; Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain; Centro de investigación biomédica en red de Oncologia, Pamplona, Spain
| | - Kwee Yong
- University College London Cancer Institute, London, UK
| | - Francesca Gay
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza, Torino, Italy
| | - Hermann Einsele
- Department of Internal Medicine, University Hospital Würzburg, Germany
| | - Roberto Mina
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza, Torino, Italy
| | - Jo Caers
- Department of Hematology, CHU de Liège, Liège, Belgium
| | - Christoph Driessen
- Department of Oncology and Hematology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Pellegrino Musto
- Department of Precision and Regenerative Medicine and Ionian Area, Aldo Moro University School of Medicine, Bari, Italy; Unit of Hematology and Stem Cell Transplantation, AOUC Policlinico, Bari, Italy
| | - Sonja Zweegman
- Department of Hematology, Amsterdam UMC, VU University, Amsterdam, Netherlands
| | - Monika Engelhardt
- Department of Hematology, Oncology and Stem Cell Transplantation, Clinical Cancer Research Group, Universitätsklinikum Freiburg, Freiburg, Germany
| | - Gordon Cook
- Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trial Research, University of Leeds, Leeds, UK
| | - Katja Weisel
- Universitätsklinikum Hamburg-Eppendorf, Medizinische Klinik und Poliklinik, Hamburg, Germany
| | - Annemiek Broijl
- Erasmus MC Cancer Institute & Erasmus University of Rotterdam, Rotterdam, Netherlands
| | - Meral Beksac
- Department of Hematology, Ankara University, Ankara, Türkiye
| | - Jelena Bila
- Clinic of Hematology, University Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Fredrik Schjesvold
- Oslo Myeloma Center, Department of Hematology, Oslo University Hospital, Oslo, Norway; KG Jebsen Center for B Cell Malignancies, University of Oslo, Oslo, Norway
| | - Michele Cavo
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, SeràgnoliIstituto di Ematologia, Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Roman Hajek
- Department of Hemato-Oncology, University Hospital Ostrava & Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Cyrille Touzeau
- Department of Hematology, University Hospital of Nantes, Nantes, France
| | - Mario Boccadoro
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza, Torino, Italy
| | - Pieter Sonneveld
- Erasmus MC Cancer Institute & Erasmus University of Rotterdam, Rotterdam, Netherlands
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26
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Santomasso BD, Gust J, Perna F. How I treat unique and difficult-to-manage cases of CAR T-cell therapy-associated neurotoxicity. Blood 2023; 141:2443-2451. [PMID: 36877916 PMCID: PMC10329188 DOI: 10.1182/blood.2022017604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 02/01/2023] [Accepted: 02/17/2023] [Indexed: 03/08/2023] Open
Abstract
With growing indications for chimeric antigen receptor (CAR) T-cell therapy, toxicity profiles are evolving. There is an urgent and unmet need of approaches to optimally manage emerging adverse events that extend beyond the standard paradigm of cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome (ICANS). Although management guidelines exist for ICANS, there is little guidance on how to approach patients with neurologic comorbidities, and how to manage rare neurotoxicity presentations, such as CAR T-cell therapy-related cerebral edema, severe motor complications or late-onset neurotoxicity. In this study, we present 3 scenarios of patients treated with CAR T cells who develop unique types of neurotoxicity, and we describe an approach for the evaluation and management based on experience because objective data are limited. The goal of this study is to develop an awareness of emerging and unusual complications, discuss treatment approaches, and help institutions and health care providers establish frameworks to navigate how to best address unusual neurotoxicities to ultimately improve patient outcomes.
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Affiliation(s)
- Bianca D. Santomasso
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY
- Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Juliane Gust
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, WA
- Seattle Children's Research Institute Center for Integrative Brain Research, Seattle, WA
| | - Fabiana Perna
- Division of Hematology/Oncology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
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27
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Butt OH, Zhou AY, Ances BM, DiPersio JF, Ghobadi A. A systematic framework for predictive biomarkers in immune effector cell-associated neurotoxicity syndrome. Front Neurol 2023; 14:1110647. [PMID: 36860569 PMCID: PMC9969296 DOI: 10.3389/fneur.2023.1110647] [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: 11/29/2022] [Accepted: 01/23/2023] [Indexed: 02/15/2023] Open
Abstract
Chimeric antigen receptor (CAR)-T cell therapy has revolutionized the management of several life-threatening malignancies, often achieving durable sustained responses. The number of patients treated with this new class of cell-based therapy, along with the number of Food and Drug Association (FDA) approved indications, are growing significantly. Unfortunately Immune Effector Cell-Associated Neurotoxicity Syndrome (ICANS) can often occur after treatment with CAR-T cells, and severe ICANS can be associated with significant morbidity and mortality. Current standard treatments are mainly steroids and supportive care, highlighting the need for early identification. In the last several years, a range of predictive biomarkers have been proposed to distinguish patients at increased risk for developing ICANS. In this review, we discuss a systematic framework to organize potential predictive biomarkers that builds on our current understanding of ICANS.
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Affiliation(s)
- Omar H. Butt
- Division of Oncology, Department of Medicine, Siteman Cancer Center, Washington University in Saint Louis, St. Louis, MO, United States
| | - Alice Y. Zhou
- Division of Oncology, Department of Medicine, Siteman Cancer Center, Washington University in Saint Louis, St. Louis, MO, United States
| | - Beau M. Ances
- Department of Neurology, Washington University in Saint Louis, St. Louis, MO, United States
| | - John F. DiPersio
- Division of Oncology, Department of Medicine, Siteman Cancer Center, Washington University in Saint Louis, St. Louis, MO, United States
| | - Armin Ghobadi
- Division of Oncology, Department of Medicine, Siteman Cancer Center, Washington University in Saint Louis, St. Louis, MO, United States
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28
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Abstract
Clonal hematopoiesis of indeterminate potential (CHIP) is common in patients with hematologic malignancies. Recent publications provide evidence that CHIP may affect chimeric antigen receptor T-cell therapy efficacy and that the incidence of treatment-related toxicities such as cytokine release syndrome and immune effector-cell associated neurotoxicity syndrome may be affected. See related article by Saini et al., p. 385 (8).
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Affiliation(s)
- Ugur Uslu
- Center for Cellular Immunotherapies and Department of Pathology and Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Carl H. June
- Center for Cellular Immunotherapies and Department of Pathology and Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Parker Institute for Cancer Immunotherapy at the University of Pennsylvania, Philadelphia, Pennsylvania
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