CAR T-Cell Therapy: Pediatric Patients With Relapsed and Refractory Acute Lymphoblastic Leukemia

Chimeric Antigen Receptor T-Cell Emergencies: Inpatient Administration, Assessment, and Management

OBJECTIVE

Chimeric antigen receptor (CAR) T-cell therapy is a genetically modified cellular therapy approved for the treatment of acute lymphocytic leukemia and B-cell lymphoma. This therapy requires patients to remain hospitalized for at least 7 days to monitor for two black-box warnings: cytokine release syndrome and neurotoxicity. Both toxicities require astute monitoring and early treatment to prevent complication.

DATA SOURCE

We use a case study to illustrate the assessment and toxicity management of a patient receiving CAR T-cell therapy for diffuse large B-cell lymphoma at an academic medical center.

CONCLUSION

Cytokine release syndrome and neurotoxicity are two common, potentially life-threatening toxicities that can be reversed with early nursing identification and treatment using evidence-based interventions.

IMPLICATIONS FOR NURSING PRACTICE

Objective assessment and consensus grading is essential for identification and management of CAR T-cell toxicities.

Adult Acute Lymphoblastic Leukemia: Treatment and Management Updates

OBJECTIVE

To present an overview of novel therapies for the treatment of adult acute lymphoblastic leukemia and to discuss nursing implications for these new therapies.

DATA SOURCES

Published manuscripts, Web sites, and pharmaceutical package inserts.

CONCLUSION

Several promising therapies have emerged in the treatment of relapsed/refractory and minimal residual disease acute lymphoblastic leukemia.

IMPLICATIONS FOR NURSING PRACTICE

With the changing paradigm for hematologic malignancies, nurses must remain current in their knowledge regarding novel therapies, including their administration, toxicity profile, and management of adverse events. This article addresses the clinical benefits of novel agents and nursing implications for those agents.

Role of CAR-T cell therapy in B-cell acute lymphoblastic leukemia

Chimeric antigen receptor (CAR) T cells are genetically engineered cells containing fusion proteins combining an extracellular epitope-specific binding domain, a transmembrane and signaling domains of the T cell receptor. The CD19-CAR T cell product tisagenlecleucel has been approved by the US Food and Drug Administration and the European Medicines Agency for therapy of children and young adults under 25 years with relapsed/refractory B‑cell acute lymphoblastic leukemia (ALL) due to a high overall response rate of 81% at 3 months after therapy. The rates of event-free and overall survival were 50 and 76% at 12 months. Despite the high initial response rate with CD19-CAR‑T cells in B‑ALL, relapses occur in a significant fraction of patients. Current strategies to improve CAR‑T cell efficacy focus on improved persistence of CAR‑T cells in vivo, use of multispecific CARs to overcome immune escape and new CAR designs. The approved CAR‑T cell products are from autologous T cells generated on a custom-made basis with an inherent risk of production failure. For large scale clinical applications, universal CAR‑T cells serving as “off-the-shelf” agents would be of advantage. During recent years CAR‑T cells have been frequently used for bridging to allogeneic hematopoietic stem cell transplantation (HSCT) in patients with relapsed/refractory B‑ALL since we currently are not able to distinguish those CAR‑T cell induced CRs that will persist without further therapy from those that are likely to be short-lived. CAR‑T cells are clearly of benefit for treatment following relapse after allogeneic HSCT. Future improvements in CAR‑T cell constructs may allow longer term remissions without additional HSCT.

Adverse Events of Oncologic Immunotherapy and Their Management

Over the past two decades, immunotherapy has emerged as a promising treatment option for patients with cancer. However, newer versions of immunotherapy, such as checkpoint inhibitors, may be associated with unusual adverse effects (AEs) that can range in severity from mild to life-threatening. Unlike common AEs of conventional chemotherapy, which have a predictable nadir or cyclic pattern after administration, AEs of these newer immunotherapies are variable, depending on the type of immunotherapy, route of administration, and mechanism of action. The onset and resolution of these AEs may be present at any time, during administration of treatment, a few weeks after administration of treatment, or several months after completion of treatment. Therefore, improving outcomes in patients undergoing oncologic immunotherapy requires oncology nurses' knowledge and understanding of various immunotherapy agents, as well as early recognition and management of potential AEs, especially AEs associated with checkpoint inhibitors and other therapies that manipulate T-cell activation causing autoimmune toxicity. This article draws upon current evidence from systematic reviews, meta-analyses, and expert consensus guidelines to provide a brief overview of common immunotherapies used in cancer and management of their associated AEs.

Chimeric Antigen Receptor T-cell (CAR T) Therapy for Hematologic and Solid Malignancies: Efficacy and Safety-A Systematic Review with Meta-Analysis

Chimeric antigen receptors T cells (CAR T) had been used for treating various tumor patients in clinic, and owned an incredible efficacy in part of malignancies. However, CAR T therapy remains controversial due to doubts about its efficacy and safety in the clinical treatment of various malignancies. A total of 997 tumor patients from 52 studies were included in this review. Eligible studies were searched and reviewed from the databases of PubMed, Web of Science, Wanfang and Clinicaltrials.gov. Then meta-analysis and subgroup analysis were used to investigate the overall response rate (ORR), complete response rate (CRR), common side effect rate (CSER) and relapse rate (RR) of CAR T therapy for patients in clinical researches, respectively. The results further confirmed that CAR T therapy had a higher response rate for hematologic malignancies. More importantly, CAR T therapy had a higher CSER in patients with hematologic malignancies, and it had a similar RR in patients with different malignancies. Cell cultured without the addition of IL-2 and total administration less than 10⁸ cells were recommended. This study offers a reference for future research regarding the application in solid and hematologic malignancies, side effects and relapse, and even the production processes of CAR T cells.

Salvaged allogeneic hematopoietic stem cell transplantation for pediatric chemotherapy refractory acute leukemia

There is an ongoing debate concerning the performance of salvaged allogeneic hematopoietic stem cell transplantation (allo-HSCT) in pediatric patients with acute refractory leukemia, in whom the prognosis is quite dismal. Few studies have ever been conducted on this subject. This may be partly due to missed opportunities by majority of the patients in such situations. To investigate the feasibility, evaluate the efficiency, and identify the prognostic factors of allo-HSCT in this sub-setting, the authors performed a single institution-based retrospective analysis. A total of 44 patients, of whom 28 had acute myeloid leukemia (AML), 13 had acute lymphocytic leukemia (ALL), and 3 had mixed phenotype leukemia (MPL), were enrolled in this study. With a median follow-up of 19 months, the estimated 2-year overall survival (OS) and progression free survival (PFS) were 34.3% (95% CI, 17.9–51.4%) and 33.6% (95% CI, 18.0–50.1%), respectively. The estimated 2-year incidence rates of relapse and non-relapse mortality (NRM) were 43.8% (95% CI 26.4–60.0%) and 19.6% (95% CI 9.1–32.9%), respectively. The estimated 100-day cumulative incidence of acute graft versus host disease (aGvHD) was 43.6% (95% CI 28.7–57.5%), and the 1-year cumulative incidence of chronic GvHD (cGvHD) was 45.5% (95% CI 30.5–59.3%). Compared with the previous studies, the multivariate analysis in this study additionally identified that female donors and cGvHD were associated with lower relapse and better PFS and OS. Male recipients, age younger than 10 years, a diagnosis of ALL, and the intermediate-adverse cytogenetic risk group were associated with increased relapse. On the contrary, extramedullary disease (EMD) and aGvHD were only linked to worse PFS. These data suggested that although only one-third of the patients would obtain PFS over 2 years, salvaged allo-HSCT is still the most reliable and best therapeutic strategy for refractory pediatric acute leukemia. If probable, choosing a female donor, better management of aGvHD, and induction of cGvHD promotes patient survival.

Cytokine Release Syndrome: Inpatient Care for Side Effects of CAR T-Cell Therapy

BACKGROUND

Pediatric patients with relapsed and refractory acute lymphoblastic leukemia are more often being treated with chimeric antigen receptor (CAR) T-cell therapy. As with any new therapy, the management of this patient population has a unique set of challenges. The side effects of this therapy can range from mild to severe, with cytokine release syndrome being the most common reason for hospitalization.
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OBJECTIVES

This article presents common side effects, treatments, and challenges of caring for hospitalized patients who have received CAR T-cell therapy.
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METHODS

A case study is used to illustrate a patient's inpatient hospitalization course after receiving CAR T-cell therapy, including the management of treatment-related toxicities.
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FINDINGS

As treatments emerge, nurses will be challenged with learning the associated side effects and toxicities. CAR T-cell therapy can result in a unique trajectory of potential symptoms and the potential for complete resolution of disease.

Building blocks for institutional preparation of CTL019 delivery

Chimeric antigen receptor (CAR) T-cell therapy is an investigational immunocellular therapy that reprograms a patient's cytotoxic T cells to engage and eliminate malignant cells. CAR T-cell therapies targeting the CD19 antigen have demonstrated high efficacy in clinical trials for patients with B-cell malignancies and may potentially be available on a broader scale in the future. CAR T-cell therapy begins with the collection of a sufficient number of T cells from a patient's peripheral blood through leukapheresis. Several factors must be considered when patients undergo leukapheresis for CAR T-cell therapy, including age and prior therapies. The leukapheresis material is shipped to a manufacturing facility, followed by return of the CAR T cells to the treatment center. Careful coordination of a multidisciplinary team composed of physicians, nurses, pharmacists and other hospital personnel is critical for the proper care of the patient before, during and after CAR T-cell therapy. CAR T-cell therapy has been associated with adverse events (AEs) such as cytokine release syndrome, which requires rapid attention by the emergency department, intensive care unit and hospital pharmacy. In this review, we discuss several aspects of institutional preparation for leukapheresis, CAR T-cell infusion and AE management based on our experience with clinical trials of the CD19 CAR T-cell therapy CTL019.