1
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Brudno JN, Kochenderfer JN. Current understanding and management of CAR T cell-associated toxicities. Nat Rev Clin Oncol 2024; 21:501-521. [PMID: 38769449 DOI: 10.1038/s41571-024-00903-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2024] [Indexed: 05/22/2024]
Abstract
Chimeric antigen receptor (CAR) T cell therapy has revolutionized the treatment of several haematological malignancies and is being investigated in patients with various solid tumours. Characteristic CAR T cell-associated toxicities such as cytokine-release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS) are now well-recognized, and improved supportive care and management with immunosuppressive agents has made CAR T cell therapy safer and more feasible than it was when the first regulatory approvals of such treatments were granted in 2017. The increasing clinical experience with these therapies has also improved recognition of previously less well-defined toxicities, including movement disorders, immune effector cell-associated haematotoxicity (ICAHT) and immune effector cell-associated haemophagocytic lymphohistiocytosis-like syndrome (IEC-HS), as well as the substantial risk of infection in patients with persistent CAR T cell-induced B cell aplasia and hypogammaglobulinaemia. A more diverse selection of immunosuppressive and supportive-care pharmacotherapies is now being utilized for toxicity management, yet no universal algorithm for their application exists. As CAR T cell products targeting new antigens are developed, additional toxicities involving damage to non-malignant tissues expressing the target antigen are a potential hurdle. Continued prospective evaluation of toxicity management strategies and the design of less-toxic CAR T cell products are both crucial for ongoing success in this field. In this Review, we discuss the evolving understanding and clinical management of CAR T cell-associated toxicities.
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Affiliation(s)
- Jennifer N Brudno
- Surgery Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA.
| | - James N Kochenderfer
- Surgery Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
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2
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Zajc CU, Sylvander E, Lehner M, Traxlmayr MW. Small molecule-regulated switches to provide functional control of CAR T cells within the patient. Expert Opin Biol Ther 2024; 24:425-432. [PMID: 38943466 DOI: 10.1080/14712598.2024.2371034] [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: 03/21/2024] [Accepted: 06/18/2024] [Indexed: 07/01/2024]
Abstract
INTRODUCTION CAR T cells have generated great excitement due to their remarkable clinical response rates in selected hematologic malignancies. However, these engineered immune cells are living drugs which are hard to control after administration. AREAS COVERED We discuss small molecule-regulated switch systems which can potentially be used to control CAR T cell function within the patient, as well as the most important obstacles in the CAR T cell field, which might be overcome with those switch systems. EXPERT OPINION There is an urgent need to develop advanced switch systems. Once available, we expect that they will open up new avenues for future CAR T cell generations.
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Affiliation(s)
- Charlotte U Zajc
- Department of Chemistry, Institute of Biochemistry, BOKU University, Vienna, Austria
- CD Laboratory for Next Generation CAR T Cells, Vienna, Austria
| | - Elise Sylvander
- CD Laboratory for Next Generation CAR T Cells, Vienna, Austria
- St. Anna Children´s Cancer Research Institute, CCRI, Vienna, Austria
| | - Manfred Lehner
- CD Laboratory for Next Generation CAR T Cells, Vienna, Austria
- St. Anna Children´s Cancer Research Institute, CCRI, Vienna, Austria
- Department of Pediatrics, St. Anna Kinderspital, Medical University of Vienna, Vienna, Austria
| | - Michael W Traxlmayr
- Department of Chemistry, Institute of Biochemistry, BOKU University, Vienna, Austria
- CD Laboratory for Next Generation CAR T Cells, Vienna, Austria
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3
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Asensi Cantó P, Arnao Herraiz M, de la Rubia Comos J. [Immunotherapy in multiple myeloma]. Med Clin (Barc) 2024; 162:485-493. [PMID: 38218655 DOI: 10.1016/j.medcli.2023.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 11/14/2023] [Accepted: 11/15/2023] [Indexed: 01/15/2024]
Abstract
Patients with multiple myeloma who present with refractory disease or relapse after receiving the main classes of available drugs -immunomodulators, proteasome inhibitors and antibodies against CD38- do not have satisfactory therapeutic alternatives. New treatments based on the redirection of T lymphocytes to act directly against tumor cells, such as bispecific antibodies and T cells with chimeric antigen receptors, are changing this scenario. The published information confirms unprecedented antitumor activity of these agents in patients with refractory myeloma and they will certainly represent the backbone of the treatment of these patients in the immediate future. However, these therapies also present specific characteristics and medium or long-term toxicities that pose new healthcare challenges. In this review, we address the current results and future challenges of the administration of these treatments in patients with relapsed or refractory multiple myeloma.
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Affiliation(s)
- Pedro Asensi Cantó
- Servicio de Hematología y Hemoterapia, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Mario Arnao Herraiz
- Servicio de Hematología y Hemoterapia, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Javier de la Rubia Comos
- Servicio de Hematología y Hemoterapia, Hospital Universitario y Politécnico La Fe, Valencia, España; Facultad de Medicina y Odontología, Universidad Católica de Valencia, Valencia, España; Instituto de Investigación Sanitaria La Fe, Valencia, España; Ciberonc CB16/12/00284, Valencia, España.
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4
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Al Hadidi S, Heslop HE, Brenner MK, Suzuki M. Bispecific antibodies and autologous chimeric antigen receptor T cell therapies for treatment of hematological malignancies. Mol Ther 2024:S1525-0016(24)00341-1. [PMID: 38822527 DOI: 10.1016/j.ymthe.2024.05.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 05/14/2024] [Accepted: 05/29/2024] [Indexed: 06/03/2024] Open
Abstract
In recent years, the therapeutic landscape for hematological malignancies has markedly advanced, particularly since the inaugural approval of autologous chimeric antigen receptor T cell (CAR-T) therapy in 2017 for relapsed/refractory acute lymphoblastic leukemia (ALL). Autologous CAR-T therapy involves the genetic modification of a patient's T cells to specifically identify and attack cancer cells, while bispecific antibodies (BsAbs) function by binding to both cancer cells and immune cells simultaneously, thereby triggering an immune response against the tumor. The subsequent approval of various CAR-T therapies and BsAbs have revolutionized the treatment of multiple hematological malignancies, highlighting high response rates and a subset of patients achieving prolonged disease control. This review explores the mechanisms underlying autologous CAR-T therapies and BsAbs, focusing on their clinical application in multiple myeloma, ALL, and non-Hodgkin lymphoma. We provide comprehensive insights into their individual efficacy, limitations concerning broad application, and the potential of combination therapies. These upcoming strategies aim to propel the field forward, paving the way for safer and more effective therapeutic interventions in hematological malignancies.
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Affiliation(s)
- Samer Al Hadidi
- Myeloma Center, Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Helen E Heslop
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston Methodist Hospital, Texas Children's Hospital, Houston, TX, USA
| | - Malcolm K Brenner
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston Methodist Hospital, Texas Children's Hospital, Houston, TX, USA
| | - Masataka Suzuki
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston Methodist Hospital, Texas Children's Hospital, Houston, TX, USA.
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5
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Nakashima T, Kagoya Y. Current progress of CAR-T-cell therapy for patients with multiple myeloma. Int J Hematol 2024:10.1007/s12185-024-03794-0. [PMID: 38777913 DOI: 10.1007/s12185-024-03794-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Revised: 05/11/2024] [Accepted: 05/16/2024] [Indexed: 05/25/2024]
Abstract
Currently available chimeric antigen receptor (CAR)-engineered T-cell therapies targeting B-cell maturation antigen (BCMA), namely, idecabtagene vicleucel and ciltacabtagene autoleucel, have shown marked efficacy against relapsed and refractory multiple myeloma. However, further improvement in CAR-T-cell function is warranted as most patients treated with these products eventually relapse due to various mechanisms such as antigen loss and T-cell dysfunction or disappearance. Strategies for improving CAR-T-cell function include targeting of dual antigens, enhancing cell longevity through genetic modification, and eliminating the immunosuppressive tumor microenvironment. Serious side effects can also occur after CAR-T-cell infusions. Although understanding of the molecular pathogenesis of cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome is growing, the unique movement disorder caused by BCMA-targeted therapy is less understood, and its molecular mechanisms must be further elucidated to establish better management strategies. In this article, we will review the current status of BCMA-targeting CAR-T-cell therapy. We will also highlight progress in the development of CAR-T cells targeting other antigens, as well as universal allogeneic CAR-T cells and bispecific antibodies.
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Affiliation(s)
- Takahiro Nakashima
- Division of Tumor Immunology, Institute for Advanced Medical Research, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
- Department of Hematology and Oncology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Yuki Kagoya
- Division of Tumor Immunology, Institute for Advanced Medical Research, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
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6
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Ferreri CJ, Bhutani M. Mechanisms and management of CAR T toxicity. Front Oncol 2024; 14:1396490. [PMID: 38835382 PMCID: PMC11148294 DOI: 10.3389/fonc.2024.1396490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 05/07/2024] [Indexed: 06/06/2024] Open
Abstract
Chimeric antigen receptor (CAR) T cell therapies have dramatically improved treatment outcomes for patients with relapsed or refractory B-cell acute lymphoblastic leukemia, large B-cell lymphoma, follicular lymphoma, mantle cell lymphoma, and multiple myeloma. Despite unprecedented efficacy, treatment with CAR T cell therapies can cause a multitude of adverse effects which require monitoring and management at specialized centers and contribute to morbidity and non-relapse mortality. Such toxicities include cytokine release syndrome, immune effector cell-associated neurotoxicity syndrome, neurotoxicity distinct from ICANS, immune effector cell-associated hemophagocytic lymphohistiocytosis-like syndrome, and immune effector cell-associated hematotoxicity that can lead to prolonged cytopenias and infectious complications. This review will discuss the current understanding of the underlying pathophysiologic mechanisms and provide guidelines for the grading and management of such toxicities.
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Affiliation(s)
- Christopher J Ferreri
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health Wake Forest University School of Medicine, Charlotte, NC, United States
| | - Manisha Bhutani
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health Wake Forest University School of Medicine, Charlotte, NC, United States
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7
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Lee WH, Graham CE, Wiggin HR, Nolan HK, Graham KJ, Korell F, Leick MB, Barselau AL, Emmanuel-Alejandro E, Trailor MA, Gildea JM, Preffer F, Frigault MJ, Maus MV, Gallagher KME. Optimization of a flow cytometry test for routine monitoring of B cell maturation antigen targeted CAR in peripheral blood. CYTOMETRY. PART B, CLINICAL CYTOMETRY 2024; 106:162-170. [PMID: 38418432 DOI: 10.1002/cyto.b.22165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 01/11/2024] [Accepted: 02/06/2024] [Indexed: 03/01/2024]
Abstract
Chimeric antigen receptor (CAR) modified T cell therapies targeting BCMA have displayed impressive activity in the treatment of multiple myeloma. There are currently two FDA licensed products, ciltacabtagene autoleucel and idecabtagene vicleucel, for treating relapsed and refractory disease. Although correlative analyses performed by product manufacturers have been reported in clinical trials, there are limited options for reliable BCMA CAR T detection assays for physicians and researchers looking to explore it as a biomarker for clinical outcome. Given the known association of CAR T cell expansion kinetics with toxicity and response, being able to quantify BCMA CAR T cells routinely and accurately in the blood of patients can serve as a valuable asset. Here, we optimized an accurate and sensitive flow cytometry test using a PE-conjugated soluble BCMA protein, with a lower limit of quantitation of 0.19% of CD3+ T cells, suitable for use as a routine assay for monitoring the frequency of BCMA CAR T cells in the blood of patients receiving either ciltacabtagene autoleucel or idecabtagene vicleucel.
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Affiliation(s)
- Won-Ho Lee
- Cellular Immunotherapy Program, Cancer Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Charlotte E Graham
- Cellular Immunotherapy Program, Cancer Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Pathology and Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Hadley R Wiggin
- Cellular Immunotherapy Program, Cancer Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Hannah K Nolan
- Cellular Immunotherapy Program, Cancer Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kiana J Graham
- Cellular Immunotherapy Program, Cancer Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Felix Korell
- Cellular Immunotherapy Program, Cancer Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Pathology and Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark B Leick
- Cellular Immunotherapy Program, Cancer Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Pathology and Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Alexis L Barselau
- Cellular Immunotherapy Program, Cancer Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Estelle Emmanuel-Alejandro
- Cellular Immunotherapy Program, Cancer Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michael A Trailor
- Cellular Immunotherapy Program, Cancer Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Juliane M Gildea
- Cellular Immunotherapy Program, Cancer Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Frederic Preffer
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Matthew J Frigault
- Cellular Immunotherapy Program, Cancer Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Pathology and Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Marcela V Maus
- Cellular Immunotherapy Program, Cancer Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Pathology and Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Kathleen M E Gallagher
- Cellular Immunotherapy Program, Cancer Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Pathology and Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
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8
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Strassl I, Podar K. The preclinical discovery and clinical development of ciltacabtagene autoleucel (Cilta-cel) for the treatment of multiple myeloma. Expert Opin Drug Discov 2024; 19:377-391. [PMID: 38369760 DOI: 10.1080/17460441.2024.2319672] [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: 10/29/2023] [Accepted: 02/12/2024] [Indexed: 02/20/2024]
Abstract
INTRODUCTION Despite remarkable therapeutic advances over the last two decades, which have resulted in dramatic improvements in patient survival, multiple myeloma (MM) is still considered an incurable disease. Therefore, there is a high need for new treatment strategies. Genetically engineered/redirected chimeric antigen receptor (CAR) T cells may represent the most compelling modality of immunotherapy for cancer treatment in general, and MM in particular. Indeed, unprecedented response rates have led to the recent approvals of the first two BCMA-targeted CAR T cell products idecabtagene-vicleucel ('Ide-cel') and ciltacabtagene-autoleucel ('Cilta-Cel') for the treatment of heavily pretreated MM patients. In addition, both are emerging as a new standard-of-care also in earlier lines of therapy. AREAS COVERED This article briefly reviews the history of the preclinical development of CAR T cells, with a particular focus on Cilta-cel. Moreover, it summarizes the newest clinical data on Cilta-cel and discusses strategies to further improve its activity and reduce its toxicity. EXPERT OPINION Modern next-generation immunotherapy is continuously transforming the MM treatment landscape. Despite several caveats of CAR T cell therapy, including its toxicity, costs, and limited access, prolonged disease-free survival and potential cure of MM are finally within reach.
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Affiliation(s)
- Irene Strassl
- Division of Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Department of Internal Medicine I, Ordensklinikum Linz Hospital, Linz, Austria
- Medical Faculty, Johannes Kepler University Linz, Linz, Austria
| | - Klaus Podar
- Department of Internal Medicine II, University Hospital Krems, Austria
- Division of Molecular Oncology and Hematology, Department of General and Translational Oncology and Hematology, Karl Landsteiner University of Health Sciences, Krems an der Donau, Austria
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9
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Mikkilineni L, Natrakul DA, Lam N, Manasanch EE, Mann J, Weissler KA, Wong N, Brudno JN, Goff SL, Yang JC, Ganaden M, Patel R, Zheng Z, Gartner JJ, Martin KR, Wang HW, Yuan CM, Lowe T, Maric I, Shao L, Jin P, Stroncek DF, Highfill SL, Rosenberg SA, Kochenderfer JN. Rapid anti-myeloma activity by T cells expressing an anti-BCMA CAR with a human heavy-chain-only antigen-binding domain. Mol Ther 2024; 32:503-526. [PMID: 38155568 PMCID: PMC10861980 DOI: 10.1016/j.ymthe.2023.12.018] [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: 10/09/2023] [Revised: 12/08/2023] [Accepted: 12/21/2023] [Indexed: 12/30/2023] Open
Abstract
Multiple myeloma (MM) is a rarely curable malignancy of plasma cells. MM expresses B cell maturation antigen (BCMA). We developed a fully human anti-BCMA chimeric antigen receptor (CAR) with a heavy-chain-only antigen-recognition domain, a 4-1BB domain, and a CD3ζ domain. The CAR was designated FHVH33-CD8BBZ. We conducted the first-in-humans clinical trial of T cells expressing FHVH33-CD8BBZ (FHVH-T). Twenty-five patients with relapsed MM were treated. The stringent complete response rate (sCR) was 52%. Median progression-free survival (PFS) was 78 weeks. Of 24 evaluable patients, 6 (25%) had a maximum cytokine-release syndrome (CRS) grade of 3; no patients had CRS of greater than grade 3. Most anti-MM activity occurred within 2-4 weeks of FHVH-T infusion as shown by decreases in the rapidly changing MM markers serum free light chains, urine light chains, and bone marrow plasma cells. Blood CAR+ cell levels peaked during the time that MM elimination was occurring, between 7 and 15 days after FHVH-T infusion. C-C chemokine receptor type 7 (CCR7) expression on infusion CD4+ FHVH-T correlated with peak blood FHVH-T levels. Single-cell RNA sequencing revealed a shift toward more differentiated FHVH-T after infusion. Anti-CAR antibody responses were detected in 4 of 12 patients assessed. FHVH-T has powerful, rapid, and durable anti-MM activity.
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Affiliation(s)
- Lekha Mikkilineni
- Surgery Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Danielle A Natrakul
- Surgery Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Norris Lam
- Surgery Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | | | - Jennifer Mann
- Surgery Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Katherine A Weissler
- Surgery Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Nathan Wong
- Advanced Biomedical Computational Science, Frederick National Laboratory for Cancer Research in the CCR Collaborative Bioinformatics Resource, National Cancer Institute, Bethesda, MD, USA
| | - Jennifer N Brudno
- Surgery Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Stephanie L Goff
- Surgery Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - James C Yang
- Surgery Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Micaela Ganaden
- Surgery Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Rashmika Patel
- Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Zhili Zheng
- Surgery Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Jared J Gartner
- Surgery Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Kathryn R Martin
- Center for Cellular Engineering, Department of Transfusion Medicine, National Institutes of Health, Bethesda, MD, USA
| | - Hao-Wei Wang
- Flow Cytometry Unit, Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Constance M Yuan
- Flow Cytometry Unit, Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Tyler Lowe
- Flow Cytometry Unit, Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Irina Maric
- Hematology Service, Department of Laboratory Medicine, Clinical Center, NIH, Bethesda, MD, USA
| | - Lipei Shao
- Center for Cellular Engineering, Department of Transfusion Medicine, National Institutes of Health, Bethesda, MD, USA
| | - Ping Jin
- Center for Cellular Engineering, Department of Transfusion Medicine, National Institutes of Health, Bethesda, MD, USA
| | - David F Stroncek
- Center for Cellular Engineering, Department of Transfusion Medicine, National Institutes of Health, Bethesda, MD, USA
| | - Steven L Highfill
- Center for Cellular Engineering, Department of Transfusion Medicine, National Institutes of Health, Bethesda, MD, USA
| | - Steven A Rosenberg
- Surgery Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - James N Kochenderfer
- Surgery Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA.
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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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11
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Rasche L, Hudecek M, Einsele H. CAR T-cell therapy in multiple myeloma: mission accomplished? Blood 2024; 143:305-310. [PMID: 38033289 DOI: 10.1182/blood.2023021221] [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: 10/10/2023] [Revised: 11/22/2023] [Accepted: 11/28/2023] [Indexed: 12/02/2023] Open
Abstract
ABSTRACT B-cell maturation antigen (BCMA) chimeric antigen receptor (CAR) T cells are the most potent treatment against multiple myeloma (MM). Here, we review the increasing body of clinical and correlative preclinical data that support their inclusion into firstline therapy and sequencing before T-cell-engaging antibodies. The ambition to cure MM with (BCMA-)CAR T cells is informed by genomic and phenotypic analysis that assess BCMA expression for patient stratification and monitoring, steadily improving early diagnosis and management of side effects, and advances in rapid, scalable CAR T-cell manufacturing to improve access.
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Affiliation(s)
- Leo Rasche
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Würzburg, Germany
- Mildred Scheel Early Career Center, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Michael Hudecek
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Würzburg, Germany
- Medizinische Klinik und Poliklinik II, Lehrstuhl für Zelluläre Immuntherapie, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Hermann Einsele
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Würzburg, Germany
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12
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Affiliation(s)
- Juliane Gust
- Seattle Children's Research Institute and University of Washington
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