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Gampa G, Spinosa P, Getz J, Zhong Y, Halpern W, Esen E, Davies J, Chou C, Kwong M, Wang Y, Arenzana TL, Shivva V, Huseni M, Hsieh R, Schartner J, Koerber JT, Rutz S, Hosseini I. Preclinical and translational pharmacology of afucosylated anti-CCR8 antibody for depletion of tumour-infiltrating regulatory T cells. Br J Pharmacol 2024; 181:2033-2052. [PMID: 38486310 DOI: 10.1111/bph.16326] [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: 03/10/2023] [Revised: 10/13/2023] [Accepted: 12/14/2023] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND AND PURPOSE RO7502175 is an afucosylated antibody designed to eliminate C-C motif chemokine receptor 8 (CCR8)+ Treg cells in the tumour microenvironment through enhanced antibody-dependent cellular cytotoxicity (ADCC). EXPERIMENTAL APPROACH We report findings from preclinical studies characterizing pharmacology, pharmacokinetics (PK)/pharmacodynamics (PD) and safety profile of RO7502175 and discuss the translational PK/PD approach used to inform first-in-human (FiH) dosing strategy and clinical development in solid tumour indications. KEY RESULTS RO7502175 demonstrated selective ADCC against human CCR8+ Treg cells from dissociated tumours in vitro. In cynomolgus monkeys, RO7502175 exhibited a biphasic concentration-time profile consistent with immunoglobulin G1 (IgG1) antibodies, reduced CCR8+ Treg cells in the blood, induced minimal and transient cytokine secretion, and was well tolerated with a no-observed-adverse-effect level (NOAEL) of 100 mg·kg-1. Moreover, RO7502175 caused minimal cytokine release from peripheral blood mononuclear cells (PBMCs) in vitro. A quantitative model was developed to capture surrogate anti-murine CCR8 antibody PK/PD and tumour dynamics in mice and RO7502175 PK/PD in cynomolgus monkeys. Subsequently, the model was used to project RO7502175 human PK and receptor occupancy (RO) in patients. Because traditional approaches resulted in a low FiH dose for this molecule, even with its superior preclinical safety profile, an integrated approach based on the totality of preclinical data and modelling insights was used for starting dose selection. CONCLUSION AND IMPLICATIONS This work demonstrates a translational research strategy for collecting and utilizing relevant nonclinical data, developing a mechanistic PK/PD model and using a comprehensive approach to inform clinical study design for RO7502175.
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Affiliation(s)
- Gautham Gampa
- Department of Preclinical and Translational Pharmacokinetics and Pharmacodynamics, Genentech, Inc., South San Francisco, California, USA
| | - Phillip Spinosa
- Department of Preclinical and Translational Pharmacokinetics and Pharmacodynamics, Genentech, Inc., South San Francisco, California, USA
| | - Jennifer Getz
- Department of Bioanalytical Sciences, Genentech, Inc., South San Francisco, California, USA
| | - Yu Zhong
- Department of Safety Assessment, Genentech, Inc., South San Francisco, California, USA
| | - Wendy Halpern
- Department of Safety Assessment, Genentech, Inc., South San Francisco, California, USA
| | - Emel Esen
- Department of Oncology Biomarker Development, Genentech, Inc., South San Francisco, California, USA
| | - John Davies
- Department of Safety Assessment, Genentech, Inc., South San Francisco, California, USA
| | - Cassie Chou
- Department of Early Clinical Development, Genentech, Inc., South San Francisco, California, USA
| | - Mandy Kwong
- Department of Biochemical Cellular Pharmacology, Genentech, Inc., South San Francisco, California, USA
| | - Yingyun Wang
- Department of Translational Oncology, Genentech, Inc., South San Francisco, California, USA
| | - Teresita L Arenzana
- Department of Cancer Immunology, Genentech, Inc., South San Francisco, California, USA
| | - Vittal Shivva
- Department of Preclinical and Translational Pharmacokinetics and Pharmacodynamics, Genentech, Inc., South San Francisco, California, USA
| | - Mahrukh Huseni
- Department of Oncology Biomarker Development, Genentech, Inc., South San Francisco, California, USA
| | - Robert Hsieh
- Department of Early Clinical Development, Genentech, Inc., South San Francisco, California, USA
| | - Jill Schartner
- Department of Translational Oncology, Genentech, Inc., South San Francisco, California, USA
| | - James T Koerber
- Department of Antibody Engineering, Genentech, Inc., South San Francisco, California, USA
| | - Sascha Rutz
- Department of Cancer Immunology, Genentech, Inc., South San Francisco, California, USA
| | - Iraj Hosseini
- Department of Preclinical and Translational Pharmacokinetics and Pharmacodynamics, Genentech, Inc., South San Francisco, California, USA
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Kamperschroer C, Guffroy M, Shen A, Dokmanovich M, Stubbs M, O'Donnell LM. Nonclinical Investigation of Cytokine Mitigation Strategies for T-cell-Engaging Bispecifics in the Cynomolgus Macaque. J Immunother 2024; 47:160-171. [PMID: 38562119 DOI: 10.1097/cji.0000000000000512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 01/29/2024] [Indexed: 04/04/2024]
Abstract
SUMMARY T-cell-directed cancer therapies such as T-cell-engaging bispecifics (TCBs) are commonly associated with cytokine release syndrome and associated clinical signs that can limit their tolerability and therapeutic benefit. Strategies for reducing cytokine release are therefore needed. Here, we report on studies performed in cynomolgus monkeys to test different approaches for mitigating cytokine release with TCBs. A "priming dose" as well as subcutaneous dosing reduced cytokine release compared with intravenous dosing but did not affect the intended T-cell response to the bispecific. As another strategy, cytokines or cytokine responses were blocked with an anti-IL-6 antibody, dexamethasone, or a JAK1/TYK2-selective inhibitor, and the effects on toxicity as well as T-cell responses to a TCB were evaluated. The JAK1/TYK2 inhibitor and dexamethasone prevented CRS-associated clinical signs on the day of TCB administration, but the anti-IL-6 had little effect. All interventions allowed for functional T-cell responses and expected damage to target-bearing tissues, but the JAK1/TYK2 inhibitor prevented the upregulation of activation markers on T cells, suggesting the potential for suppression of T-cell responses. Our results suggest that short-term prophylactic dexamethasone treatment may be an effective option for blocking cytokine responses without affecting desired T-cell responses to TCBs.
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Affiliation(s)
| | | | - Amy Shen
- Preclinical Safety, Research and Development, Sanofi
| | | | - Makeida Stubbs
- Pfizer Inc., Clinical Development and Operations, Groton, CT
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Wang Y, Dong H, Dong T, Zhao L, Fan W, Zhang Y, Yao W. Treatment of cytokine release syndrome-induced vascular endothelial injury using mesenchymal stem cells. Mol Cell Biochem 2024; 479:1149-1164. [PMID: 37392343 DOI: 10.1007/s11010-023-04785-1] [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: 04/13/2023] [Accepted: 06/04/2023] [Indexed: 07/03/2023]
Abstract
Cytokine release syndrome (CRS) is an acute systemic inflammatory reaction in which hyperactivated immune cells suddenly release a large amount of cytokines, leading to exaggerated inflammatory responses, multiple organ dysfunction, and even death. Although palliative treatment strategies have significantly reduced the overall mortality, novel targeted treatment regimens with superior therapy efficacy are urgently needed. Vascular endothelial cells (ECs) are important target cells of systemic inflammation, and their destruction is considered to be the initiating event underlying many serious complications of CRS. Mesenchymal stem/stromal cells (MSCs) are multipotent cells with self-renewing differentiation capacity and immunomodulatory properties. MSC transplantation can effectively suppress the activation of immune cells, reduce the bulk release of cytokines, and repair damaged tissues and organs. Here, we review the molecular mechanisms underlying CRS-induced vascular endothelial injury and discuss potential treatments using MSCs. Preclinical studies demonstrate that MSC therapy can effectively repair endothelium damage and thus reduce the incidence and severity of ensuing CRS-induced complications. This review highlights the therapeutic role of MSCs in fighting against CRS-induced EC damage, and summarizes the possible therapeutic formulations of MSCs for improved efficacy in future clinical trials.
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Affiliation(s)
- Yuyan Wang
- Department of Laboratory Medicine, The First Affiliated Hospital of Yangtze University, Jingzhou, China
- Health Science Center, Yangtze University, Jingzhou, China
| | - Haibo Dong
- Wuhan Optics Valley Vcanbiopharma Co., Ltd, Wuhan, China
- Key Industrial Base for Stem Cell Engineering Products, Tianjin, China
| | - Tengyun Dong
- Wuhan Optics Valley Vcanbiopharma Co., Ltd, Wuhan, China
- Key Industrial Base for Stem Cell Engineering Products, Tianjin, China
| | - Lulu Zhao
- Wuhan Optics Valley Vcanbiopharma Co., Ltd, Wuhan, China
- Key Industrial Base for Stem Cell Engineering Products, Tianjin, China
| | - Wen Fan
- Department of Laboratory Medicine, The First Affiliated Hospital of Yangtze University, Jingzhou, China.
| | - Yu Zhang
- Wuhan Optics Valley Vcanbiopharma Co., Ltd, Wuhan, China.
- Key Industrial Base for Stem Cell Engineering Products, Tianjin, China.
- Haihe Laboratory of Cell Ecosystem, Tianjin, China.
| | - Weiqi Yao
- Wuhan Optics Valley Vcanbiopharma Co., Ltd, Wuhan, China.
- Key Industrial Base for Stem Cell Engineering Products, Tianjin, China.
- Department of Biology and Medicine, Hubei University of Technology, Wuhan, China.
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4
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Kim SJ, Yoon SE, Kim WS. Current Challenges in Chimeric Antigen Receptor T-cell Therapy in Patients With B-cell Lymphoid Malignancies. Ann Lab Med 2024; 44:210-221. [PMID: 38205527 PMCID: PMC10813822 DOI: 10.3343/alm.2023.0388] [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: 09/30/2023] [Revised: 11/18/2023] [Accepted: 12/29/2023] [Indexed: 01/12/2024] Open
Abstract
Chimeric antigen receptor (CAR) T-cell therapy is a promising immunotherapy based on genetically engineered T cells derived from patients. The introduction of CAR T-cell therapy has changed the treatment paradigm of patients with B-cell lymphoid malignancies. However, challenging issues including managing life-threatening toxicities related to CAR T-cell infusion and resistance to CAR T-cell therapy, leading to progression or relapse, remain. This review summarizes the issues with currently approved CAR T-cell therapies for patients with relapsed or refractory B-cell lymphoid malignancies, including lymphoma and myeloma. We focus on unique toxicities after CAR T-cell therapy, such as cytokine-related events and hematological toxicities, and the mechanisms underlying post-CAR T-cell failure.
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Affiliation(s)
- Seok Jin Kim
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University School of Medicine, Seoul, Korea
- CAR T-cell Therapy Center, Samsung Comprehensive Cancer Center, Seoul, Korea
| | - Sang Eun Yoon
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- CAR T-cell Therapy Center, Samsung Comprehensive Cancer Center, Seoul, Korea
| | - Won Seog Kim
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University School of Medicine, Seoul, Korea
- CAR T-cell Therapy Center, Samsung Comprehensive Cancer Center, Seoul, Korea
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Matasar M, Bartlett NL, Shadman M, Budde LE, Flinn I, Gregory GP, Kim WS, Hess G, El-Sharkawi D, Diefenbach CS, Huang H, To I, Parreira J, Wu M, Kwan A, Assouline S. Mosunetuzumab Safety Profile in Patients With Relapsed/Refractory B-cell Non-Hodgkin Lymphoma: Clinical Management Experience From a Pivotal Phase I/II Trial. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024; 24:240-253. [PMID: 38195322 DOI: 10.1016/j.clml.2023.12.005] [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: 09/13/2023] [Revised: 12/04/2023] [Accepted: 12/07/2023] [Indexed: 01/11/2024]
Abstract
BACKGROUND Mosunetuzumab is a CD20xCD3 T-cell engaging bispecific antibody approved in Europe and the United States for relapsed/refractory (R/R) follicular lymphoma (FL) after ≥ 2 prior therapies. MATERIALS AND METHODS We present interim safety data from the mosunetuzumab GO29781 (NCT02500407) phase I/II dose-escalation study in R/R non-Hodgkin lymphoma (NHL), focusing on FL. RESULTS Overall, 218 patients with R/R NHL, including 90 with R/R FL, received a median of eight 21-day cycles of intravenous mosunetuzumab with step-up dosing in Cycle (C) 1 (C1 Day [D] 1, 1 mg; C1D8, 2 mg; C1D15/C2D1, 60 mg; C3D1 and onwards, 30 mg). Cytokine release syndrome (CRS) was the most common adverse event (AE), occurring in 39.4% (NHL) and 44.4% (FL) of patients. Events occurred predominantly during C1 at the first loading dose; the majority were grade 1/2. CRS events were managed at the investigator's discretion with supportive care, steroids, and tocilizumab, based on protocol management guidelines. Immune effector cell-associated neurotoxicity syndrome was uncommon, reported in 0.9% (NHL) and 1.1% (FL) of patients. Neutropenia occurred in 27.5% (NHL) and 28.9% (FL) of patients (mostly grade 3/4) and could be effectively managed using granulocyte colony-stimulating factor. Tumor lysis syndrome occurred in 0.9% (NHL) and 1.1% (FL) of patients (all grade 3/4 with CRS; all resolved). CONCLUSION Mosunetuzumab monotherapy as treatment for R/R B-cell NHL, including FL, was associated with low rates of severe AEs (including CRS) and is suitable for outpatient administration in the community setting. Adapted protocol guidance for the management of select AEs during mosunetuzumab treatment is included.
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Affiliation(s)
- Matthew Matasar
- Rutgers Cancer Institute of New Jersey and RWJBarnabas Health, New Brunswick, NJ
| | - Nancy L Bartlett
- Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO
| | | | | | - Ian Flinn
- Sarah Cannon Research Institute/Tennessee Oncology, Nashville, TN
| | - Gareth P Gregory
- Monash Health and School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
| | - Won Seog Kim
- Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, South Korea
| | - Georg Hess
- University Cancer Center Mainz, University Medical School of the Johannes Gutenberg-University, Mainz, Germany
| | | | | | - Huang Huang
- Hoffmann-La Roche Ltd, Mississauga, ON, Canada
| | - Iris To
- Genentech, Inc., South San Francisco, CA
| | | | - Mei Wu
- Genentech, Inc., South San Francisco, CA
| | | | - Sarit Assouline
- Jewish General Hospital, McGill University, Montreal, QC, Canada.
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Zhao N, Hu F, Zhai Y, Ye X, Ruan Y, Liu Z, Wang Z, Shen W, Yuan L. Ocular toxicities in chimeric antigen receptor T-cell therapy: a real-world study leveraging FAERS database. Immunotherapy 2024; 16:161-172. [PMID: 38126138 DOI: 10.2217/imt-2023-0220] [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] [Indexed: 12/23/2023] Open
Abstract
Aim: The purpose of this study was to comprehensively explore the ocular toxicity associated with chimeric antigen receptor (CAR) T-cell therapy. Materials & methods: Data were assembled from the US FDA's Adverse Event Reporting System (FAERS) database from 2017 to 2023. Information component and reporting odds ratio methods were used for signal detection in total/categorized CAR T-cell therapy. Results: A total of 17 positive signals (preferred term) were detected, yet none of them were documented in the product information. Some adverse events were with death outcomes and overlapped a lot with cytokine-release syndrome. Conclusion: The ocular adverse events associated with CAR-T cell therapy are noteworthy, and it is imperative to maintain increased alertness and institute early intervention strategies.
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Affiliation(s)
- Na Zhao
- Ophthalmology Department, Naval Hospital of Eastern Theater of PLA, Zhejiang Province, Zhoushan, China
| | - Fangyuan Hu
- Health Service Department, Naval Hospital of Eastern Theater of PLA, Zhejiang Province, Zhoushan, China
| | - Yinghong Zhai
- Clinical Research Unit, School of Medicine, Shanghai Ninth People's Hospital Affiliated to Shanghai JiaoTong University, Shanghai, China
| | - Xia Ye
- Ophthalmology Department, Naval Hospital of Eastern Theater of PLA, Zhejiang Province, Zhoushan, China
| | - Yiming Ruan
- Health Service Department, The First Naval Hospital of Southern Theater of PLA, Guangdong Province, Zhanjiang, China
| | - Zhen Liu
- Ophthalmology Department, Naval Hospital of Eastern Theater of PLA, Zhejiang Province, Zhoushan, China
| | - Zhiyan Wang
- Ophthalmology Department, Naval Hospital of Eastern Theater of PLA, Zhejiang Province, Zhoushan, China
| | - Wei Shen
- Ophthalmology Department, The First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Lei Yuan
- Department of Health Management, Faculty of Military Health Service, Naval Medical University, Shanghai, China
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7
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Liang EC, Sidana S. Managing side effects: guidance for use of immunotherapies in multiple myeloma. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:348-356. [PMID: 38066898 PMCID: PMC10727020 DOI: 10.1182/hematology.2023000435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Chimeric antigen receptor T-cell therapy and bispecific T-cell recruiting antibodies have transformed the treatment landscape for relapsed/refractory multiple myeloma, with B-cell maturation antigen being the most common target and other targets in clinical development. However, these therapies are associated with unique and severe toxicities, including cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), delayed neurotoxicity, cytopenias, and infection. In addition, immune effector cell-associated hemophagocytic lymphohistiocytosis (HLH)-like syndrome (IEC-HS), which exhibits overlap between CRS and HLH, can be challenging to diagnose and treat. In this review, we provide an overview of toxicities associated with novel immunotherapies for treatment of multiple myeloma and describe management recommendations. The pathophysiology and risk factors behind these toxicities are not yet comprehensively understood. Based on consensus recommendations, treatment for CRS consists of tocilizumab and steroids, while treatment for ICANS includes steroids and anakinra in severe cases. Management of cytopenias and infection is similar to post-hematopoietic cell transplantation principles with antimicrobial prophylaxis, growth factor support, immunoglobulin replacement, and vaccinations. In contrast, effective treatments for delayed neurotoxicity and IEC-HS are lacking, although steroids and anakinra are commonly used. Management of all these toxicities should include a broad differential and multidisciplinary collaboration with infectious diseases, neurology, and/or critical care providers.
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Affiliation(s)
- Emily C Liang
- University of Washington and Fred Hutchinson Cancer Center, Seattle, WA
| | - Surbhi Sidana
- Department of Medicine, Division of Blood and Marrow Transplantation and Cellular Therapy, Stanford University School of Medicine, Stanford, CA
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Epperly R, Giordani VM, Mikkilineni L, Shah NN. Early and Late Toxicities of Chimeric Antigen Receptor T-Cells. Hematol Oncol Clin North Am 2023; 37:1169-1188. [PMID: 37349152 PMCID: PMC10592597 DOI: 10.1016/j.hoc.2023.05.010] [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] [Indexed: 06/24/2023]
Abstract
As chimeric antigen receptor (CAR) T-cell therapy is increasingly integrated into clinical practice across a range of malignancies, identifying and treating inflammatory toxicities will be vital to success. Early experiences with CD19-targeted CAR T-cell therapy identified cytokine release syndrome and neurotoxicity as key acute toxicities and led to unified initiatives to mitigate the influence of these complications. In this section, we provide an update on the current state of CAR T-cell-related toxicities, with an emphasis on emerging acute toxicities affecting additional organ systems and considerations for delayed toxicities and late effects.
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Affiliation(s)
- Rebecca Epperly
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, 262 Danny Thomas Place, MS 1130, Memphis, TN 38105, USA
| | - Victoria M Giordani
- Pediatric Oncology Branch, Center for Cancer Research (CCR), National Cancer Institute (NCI), NIH, Building 10, Room 1W-3750, 9000 Rockville Pike MSC 1104, Bethesda, MD 20892, USA; Pediatric Hematology/Oncology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Lekha Mikkilineni
- Blood and Marrow Transplantation & Cellular Therapy, Stanford University, Palo Alto, CA, USA; Stanford School of Medicine, 300 Pasteur Drive, Room H0101, Stanford, CA 94305, USA
| | - Nirali N Shah
- Pediatric Oncology Branch, Center for Cancer Research (CCR), National Cancer Institute (NCI), NIH, Building 10, Room 1W-3750, 9000 Rockville Pike MSC 1104, Bethesda, MD 20892, USA.
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Bak GG, Micklethwaite K, Maddock K, Coggins A. Chimeric antigen receptor T-cell therapy: Prospective observational study of unplanned emergency department presentations. Emerg Med Australas 2023; 35:1034-1037. [PMID: 37669879 DOI: 10.1111/1742-6723.14300] [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: 01/16/2023] [Revised: 07/22/2023] [Accepted: 08/09/2023] [Indexed: 09/07/2023]
Abstract
OBJECTIVE Chimeric antigen receptor T-cell (CAR-T) therapy is an emerging treatment for refractory hematologic malignancy. Unplanned ED presentations following CAR-T present the increasing need for an integrated model of care that allows for the early recognition of its specific complications. METHODS This is a prospective observational study at a tertiary centre. CAR-T patients (n = 17) were universally enrolled into a study registry by treating providers. These patients were flagged by investigators to trigger a pop-up notification CAR-T information warning at ED triage. Medical records were reviewed 90 days for unplanned presentations, complications and patient-oriented outcomes. RESULTS Patients receiving CAR-T frequently encountered toxicity within 7 days of therapy. This was typically mild and occurred in an inpatient setting. Medical record review revealed five unplanned ED presentations (that were recognised as post CAR-T) and not directly attributable to specific toxicities. CONCLUSION If CAR-T therapy is to be used more widely especially in an outpatient model of care, a standardised ED model of care for recognition of specific complications is needed.
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Affiliation(s)
- Grace G Bak
- Department of General Medicine, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Kenneth Micklethwaite
- Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
- Department of Haematology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Karen Maddock
- Department of Haematology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Andrew Coggins
- Simulated Learning Environment for Clinical Training, Westmead Hospital, Sydney, New South Wales, Australia
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Talbot LJ, Lautz TB, Aldrink JH, Ehrlich PF, Dasgupta R, Mattei P, Tracy ET, Glick RD, Grant CM, Brown EG, Christison-Lagay ER, Rodeberg DA. Implications of Immunotherapy for Pediatric Malignancies: A Summary from the APSA Cancer Committee. J Pediatr Surg 2023; 58:2119-2127. [PMID: 37550134 DOI: 10.1016/j.jpedsurg.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 06/01/2023] [Accepted: 07/01/2023] [Indexed: 08/09/2023]
Abstract
Although survival for many pediatric cancers has improved with advances in conventional chemotherapeutic regimens and surgical techniques in the last several decades, it remains a leading cause of disease-related death in children. Outcomes in patients with recurrent, refractory, or metastatic disease are especially poor. Recently, the advent of alternative classes of therapies, including immunotherapies, have revolutionized systemic treatment for pediatric malignancies. Several classes of immunotherapies, including chimeric antigen receptor (CAR) T cell therapy, transgenic T-cell receptor (TCR)-T cell therapy, bispecific T-cell engagers, and monoclonal antibody checkpoint inhibitors have been FDA-approved or entered early-phase clinical trials in children and young adults. The pediatric surgeon is likely to encounter these therapies during the care of children with malignancies and should be familiar with the classes of therapy, indications, adverse events, and potential need for surgical intervention in these cases. This review from the APSA Cancer Committee offers a brief discussion of the three most encountered classes of immunotherapy in children and young adults and discusses surgical relevance. LEVEL OF EVIDENCE: IV.
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Affiliation(s)
| | - Timothy B Lautz
- Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University, Chicago, IL, USA
| | - Jennifer H Aldrink
- Division of Pediatric Surgery, Department of Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Peter F Ehrlich
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Roshni Dasgupta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Peter Mattei
- General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa, USA
| | - Elisabeth T Tracy
- Division of Pediatric Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Richard D Glick
- Division of Pediatric Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Christa M Grant
- Division of Pediatric Surgery, Maria Fareri Children's Hospital, Westchester Medical Center, Valhalla, NY, USA
| | - Erin G Brown
- Division of Pediatric General and Thoracic Surgery, Department of Surgery, University of California, Davis, Sacramento, CA, USA
| | - Emily R Christison-Lagay
- Division of Pediatric Surgery, Department of Surgery, Yale School of Medicine, Yale-New Haven Children's Hospital, New Haven, CT, USA
| | - David A Rodeberg
- Division of Pediatric Surgery, Department of Surgery, East Carolina University, Greenville, NC, USA
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11
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Pfister F, Dörrie J, Schaft N, Buchele V, Unterweger H, Carnell LR, Schreier P, Stein R, Kubánková M, Guck J, Hackstein H, Alexiou C, Janko C. Human T cells loaded with superparamagnetic iron oxide nanoparticles retain antigen-specific TCR functionality. Front Immunol 2023; 14:1223695. [PMID: 37662937 PMCID: PMC10470061 DOI: 10.3389/fimmu.2023.1223695] [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: 05/16/2023] [Accepted: 07/28/2023] [Indexed: 09/05/2023] Open
Abstract
Background Immunotherapy of cancer is an emerging field with the potential to improve long-term survival. Thus far, adoptive transfer of tumor-specific T cells represents an effective treatment option for tumors of the hematological system such as lymphoma, leukemia or myeloma. However, in solid tumors, treatment efficacy is low owing to the immunosuppressive microenvironment, on-target/off-tumor toxicity, limited extravasation out of the blood vessel, or ineffective trafficking of T cells into the tumor region. Superparamagnetic iron oxide nanoparticles (SPIONs) can make cells magnetically controllable for the site-specific enrichment. Methods In this study, we investigated the influence of SPION-loading on primary human T cells for the magnetically targeted adoptive T cell therapy. For this, we analyzed cellular mechanics and the T cell response after stimulation via an exogenous T cell receptor (TCR) specific for the melanoma antigen MelanA or the endogenous TCR specific for the cytomegalovirus antigen pp65 and compared them to T cells that had not received SPIONs. Results SPION-loading of human T cells showed no influence on cellular mechanics, therefore retaining their ability to deform to external pressure. Additionally, SPION-loading did not impair the T cell proliferation, expression of activation markers, cytokine secretion, and tumor cell killing after antigen-specific activation mediated by the TCR. Conclusion In summary, we demonstrated that SPION-loading of T cells did not affect cellular mechanics or the functionality of the endogenous or an exogenous TCR, which allows future approaches using SPIONs for the magnetically enrichment of T cells in solid tumors.
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Affiliation(s)
- Felix Pfister
- Department of Otorhinolaryngology, Head and Neck Surgery, Section of Experimental Oncology and Nanomedicine (SEON), Else Kröner-Fresenius-Stiftung Professorship, University Hospital Erlangen, Erlangen, Germany
| | - Jan Dörrie
- Department of Dermatology, University Hospital Erlangen, Erlangen, Germany
| | - Niels Schaft
- Department of Dermatology, University Hospital Erlangen, Erlangen, Germany
| | - Vera Buchele
- Department of Transfusion Medicine and Hemostaseology, University Hospital Erlangen, Erlangen, Germany
| | - Harald Unterweger
- Department of Otorhinolaryngology, Head and Neck Surgery, Section of Experimental Oncology and Nanomedicine (SEON), Else Kröner-Fresenius-Stiftung Professorship, University Hospital Erlangen, Erlangen, Germany
| | - Lucas R. Carnell
- Department of Otorhinolaryngology, Head and Neck Surgery, Section of Experimental Oncology and Nanomedicine (SEON), Else Kröner-Fresenius-Stiftung Professorship, University Hospital Erlangen, Erlangen, Germany
- Organic Chemisty Laboratory, Department of Biochemistry, University of Bayreuth, Bayreuth, Germany
| | - Patrick Schreier
- Department of Otorhinolaryngology, Head and Neck Surgery, Section of Experimental Oncology and Nanomedicine (SEON), Else Kröner-Fresenius-Stiftung Professorship, University Hospital Erlangen, Erlangen, Germany
- Faculty of Applied Natural Sciences and Health, Hochschule Coburg, Coburg, Germany
| | - Rene Stein
- Department of Otorhinolaryngology, Head and Neck Surgery, Section of Experimental Oncology and Nanomedicine (SEON), Else Kröner-Fresenius-Stiftung Professorship, University Hospital Erlangen, Erlangen, Germany
| | - Markéta Kubánková
- Max-Planck-Institute for the Science of Light & Max-Planck-Zentrum für Physik und Medizin, Erlangen, Germany
| | - Jochen Guck
- Max-Planck-Institute for the Science of Light & Max-Planck-Zentrum für Physik und Medizin, Erlangen, Germany
- Department of Physics, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Holger Hackstein
- Department of Transfusion Medicine and Hemostaseology, University Hospital Erlangen, Erlangen, Germany
| | - Christoph Alexiou
- Department of Otorhinolaryngology, Head and Neck Surgery, Section of Experimental Oncology and Nanomedicine (SEON), Else Kröner-Fresenius-Stiftung Professorship, University Hospital Erlangen, Erlangen, Germany
| | - Christina Janko
- Department of Otorhinolaryngology, Head and Neck Surgery, Section of Experimental Oncology and Nanomedicine (SEON), Else Kröner-Fresenius-Stiftung Professorship, University Hospital Erlangen, Erlangen, Germany
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Pan D, Richter J. Teclistamab for Multiple Myeloma: Clinical Insights and Practical Considerations for a First-in-Class Bispecific Antibody. Cancer Manag Res 2023; 15:741-751. [PMID: 37497430 PMCID: PMC10368105 DOI: 10.2147/cmar.s372237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 07/05/2023] [Indexed: 07/28/2023] Open
Abstract
Teclistamab is a BCMAxCD3 bispecific antibody, the first approved for the treatment of relapsed or refractory multiple myeloma. Given its impressive efficacy in heavily pretreated patients and better accessibility compared to BCMA-directed CAR T cells, teclistamab is sure to become a staple of relapsed/refractory multiple myeloma therapy. Teclistamab carries a set of notable adverse effects including cytokine release syndrome (CRS), infections, and neurotoxicity for which providers must take unique precautions and prophylactic measures. Here, we review the preclinical and clinical data, which led to teclistamab's approval, important patient selection considerations, strategies for managing CRS and other side effects, and finally the future of bispecific antibody therapy in multiple myeloma.
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Affiliation(s)
- Darren Pan
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Joshua Richter
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
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Dagar G, Gupta A, Masoodi T, Nisar S, Merhi M, Hashem S, Chauhan R, Dagar M, Mirza S, Bagga P, Kumar R, Akil ASAS, Macha MA, Haris M, Uddin S, Singh M, Bhat AA. Harnessing the potential of CAR-T cell therapy: progress, challenges, and future directions in hematological and solid tumor treatments. J Transl Med 2023; 21:449. [PMID: 37420216 PMCID: PMC10327392 DOI: 10.1186/s12967-023-04292-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 06/21/2023] [Indexed: 07/09/2023] Open
Abstract
Traditional cancer treatments use nonspecific drugs and monoclonal antibodies to target tumor cells. Chimeric antigen receptor (CAR)-T cell therapy, however, leverages the immune system's T-cells to recognize and attack tumor cells. T-cells are isolated from patients and modified to target tumor-associated antigens. CAR-T therapy has achieved FDA approval for treating blood cancers like B-cell acute lymphoblastic leukemia, large B-cell lymphoma, and multiple myeloma by targeting CD-19 and B-cell maturation antigens. Bi-specific chimeric antigen receptors may contribute to mitigating tumor antigen escape, but their efficacy could be limited in cases where certain tumor cells do not express the targeted antigens. Despite success in blood cancers, CAR-T technology faces challenges in solid tumors, including lack of reliable tumor-associated antigens, hypoxic cores, immunosuppressive tumor environments, enhanced reactive oxygen species, and decreased T-cell infiltration. To overcome these challenges, current research aims to identify reliable tumor-associated antigens and develop cost-effective, tumor microenvironment-specific CAR-T cells. This review covers the evolution of CAR-T therapy against various tumors, including hematological and solid tumors, highlights challenges faced by CAR-T cell therapy, and suggests strategies to overcome these obstacles, such as utilizing single-cell RNA sequencing and artificial intelligence to optimize clinical-grade CAR-T cells.
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Affiliation(s)
- Gunjan Dagar
- Department of Medical Oncology (Lab.), Dr. BRAIRCH, All India Institute of Medical Sciences (AIIMS), New Delhi, Delhi, 110029, India
| | - Ashna Gupta
- Department of Medical Oncology (Lab.), Dr. BRAIRCH, All India Institute of Medical Sciences (AIIMS), New Delhi, Delhi, 110029, India
| | - Tariq Masoodi
- Laboratory of Cancer Immunology and Genetics, Sidra Medicine, Doha, Qatar
| | - Sabah Nisar
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Maysaloun Merhi
- National Center for Cancer Care and Research, Hamad Medical Corporation, 3050, Doha, Qatar
| | - Sheema Hashem
- Department of Human Genetics, Sidra Medicine, Doha, Qatar
| | - Ravi Chauhan
- Department of Medical Oncology (Lab.), Dr. BRAIRCH, All India Institute of Medical Sciences (AIIMS), New Delhi, Delhi, 110029, India
| | - Manisha Dagar
- Shiley Eye Institute, University of California San Diego, San Diego, CA, USA
| | - Sameer Mirza
- Department of Chemistry, College of Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Puneet Bagga
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Rakesh Kumar
- School of Biotechnology, Shri Mata Vaishno Devi University, Katra, Jammu and Kashmir, 182320, India
| | - Ammira S Al-Shabeeb Akil
- Department of Human Genetics-Precision Medicine in Diabetes, Obesity and Cancer Program, Sidra Medicine, P.O. Box 26999, Doha, Qatar
| | - Muzafar A Macha
- Watson-Crick Centre for Molecular Medicine, Islamic University of Science and Technology, Pulwama, Jammu and Kashmir, India
| | - Mohammad Haris
- Center for Advanced Metabolic Imaging in Precision Medicine, Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Laboratory Animal Research Center, Qatar University, Doha, Qatar
| | - Shahab Uddin
- Laboratory Animal Research Center, Qatar University, Doha, Qatar.
- Translational Research Institute, Academic Health System, Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar.
| | - Mayank Singh
- Department of Medical Oncology (Lab.), Dr. BRAIRCH, All India Institute of Medical Sciences (AIIMS), New Delhi, Delhi, 110029, India.
| | - Ajaz A Bhat
- Department of Human Genetics-Precision Medicine in Diabetes, Obesity and Cancer Program, Sidra Medicine, P.O. Box 26999, Doha, Qatar.
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14
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Martino M, Canale FA, Porto G, Verduci C, Utano G, Policastro G, Germanò J, Alati C, Santoro L, Imbalzano L, Pitea M. Integrating CAR-T cell therapy into the management of DLBCL: what we are learning. Expert Opin Biol Ther 2023; 23:1277-1285. [PMID: 38078446 DOI: 10.1080/14712598.2023.2292634] [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: 08/23/2023] [Accepted: 12/05/2023] [Indexed: 12/29/2023]
Abstract
INTRODUCTION Chimeric Antigen Receptor ;(CAR) T cells therapies have become part of the standard of care for patients with relapsed/refractory (R/R) diffuse large B-cell lymphoma (DLBCL). The weakness of CAR-T therapies is that there are no comparative clinical trials, although many publications based on real-life data have confirmed the results obtained in pivotal studies. After several years of the commercialization of CAR-T, some points still need to be fully clarified. Healthcare professionals have questions about identifying patients who may benefit from therapy. There are aspects inherent in the accessibility of care related to improved relationships between CAR-T-delivering and referral centers. AREAS COVERED Open questions are inherent in the salvage and bridge therapy, predictive criteria for response and persistence of CAR-T after infusion. Managing toxicities remain a top priority and one of the points on which further knowledge is needed. EXPERT OPINION This review aims to describe the current landscape of CAR-T cells in DLBCL, outline their outcomes and toxicities, and explain the outstanding questions that remain to be addressed.
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Affiliation(s)
- Massimo Martino
- Stem Cell Transplantation and Cellular Therapies Unit (CTMO), Department of Hemato-Oncology and Radiotherapy Grande OspedaleMetropolitano "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Filippo Antonio Canale
- Stem Cell Transplantation and Cellular Therapies Unit (CTMO), Department of Hemato-Oncology and Radiotherapy Grande OspedaleMetropolitano "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Gaetana Porto
- Stem Cell Transplantation and Cellular Therapies Unit (CTMO), Department of Hemato-Oncology and Radiotherapy Grande OspedaleMetropolitano "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Chiara Verduci
- Stem Cell Transplantation and Cellular Therapies Unit (CTMO), Department of Hemato-Oncology and Radiotherapy Grande OspedaleMetropolitano "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Giovanna Utano
- Stem Cell Transplantation and Cellular Therapies Unit (CTMO), Department of Hemato-Oncology and Radiotherapy Grande OspedaleMetropolitano "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Giorgia Policastro
- Stem Cell Transplantation and Cellular Therapies Unit (CTMO), Department of Hemato-Oncology and Radiotherapy Grande OspedaleMetropolitano "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Jessyca Germanò
- Hematology Unit, Department of Hemato-Oncology and Radiotherapy Grande Ospedale Metropolitano "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Caterina Alati
- Hematology Unit, Department of Hemato-Oncology and Radiotherapy Grande Ospedale Metropolitano "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Ludovica Santoro
- Stem Cell Transplantation and Cellular Therapies Unit (CTMO), Department of Hemato-Oncology and Radiotherapy Grande OspedaleMetropolitano "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Lucrezia Imbalzano
- Stem Cell Transplantation and Cellular Therapies Unit (CTMO), Department of Hemato-Oncology and Radiotherapy Grande OspedaleMetropolitano "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Martina Pitea
- Stem Cell Transplantation and Cellular Therapies Unit (CTMO), Department of Hemato-Oncology and Radiotherapy Grande OspedaleMetropolitano "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
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15
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Martin TG, Mateos MV, Nooka A, Banerjee A, Kobos R, Pei L, Qi M, Verona R, Doyle M, Smit J, Sun W, Trancucci D, Uhlar C, van de Donk NWCJ, Rodriguez C. Detailed overview of incidence and management of cytokine release syndrome observed with teclistamab in the MajesTEC-1 study of patients with relapsed/refractory multiple myeloma. Cancer 2023; 129:2035-2046. [PMID: 36991547 DOI: 10.1002/cncr.34756] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 02/02/2023] [Accepted: 02/07/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND Teclistamab, a B-cell maturation antigen × CD3 bispecific antibody, demonstrated an overall response rate of 63.0% in 165 heavily pretreated patients with relapsed or refractory multiple myeloma in the phase 1/2 MajesTEC-1 study. Cytokine release syndrome (CRS), a known manifestation of T-cell redirection, was observed in 119 of 165 patients (72.1%). METHODS Patients received once-weekly teclistamab 1.5 mg/kg subcutaneously after two step-up doses (0.06 and 0.3 mg/kg). CRS was graded according to American Society for Transplantation and Cellular Therapy criteria and managed according to the study protocol, including use of tocilizumab and/or steroids. RESULTS Most cases of CRS occurred during the step-up dosing schedule of teclistamab and were grade 1 (50.3% of patients) or grade 2 (21.2% of patients); a single case of grade 3 CRS was reported in a patient with concurrent grade 3 pneumonia. All CRS cases resolved and none led to treatment discontinuation. Overall, 33.3% of patients had >1 CRS event; CRS recurrence was reduced when tocilizumab was administered for the first CRS event compared with when it was not (20.0% vs. 62.2%, respectively). Baseline characteristics such as tumor burden and cytokine levels did not appear to predict CRS incidence or severity. CONCLUSIONS Findings of this study support the need for preemptive planning and prompt management of CRS in patients treated with T-cell-engaging bispecific antibodies. Intervention with tocilizumab for CRS appears to decrease the likelihood of patients experiencing subsequent CRS events without compromising response to teclistamab. PLAIN LANGUAGE SUMMARY Cytokine release syndrome (CRS), observed in 72.1% of patients treated with teclistamab in the MajesTEC-1 study, was mostly grade 1 or 2 and manageable, without requiring treatment discontinuation. Most CRS occurred during the step-up schedule, requiring vigilance during treatment initiation. Ensure fever is resolved and patients have no signs of infection before initiating the teclistamab step-up schedule or administering the next teclistamab dose, to avoid exacerbating CRS. Tocilizumab reduced the risk of subsequent CRS in patients receiving it for their first CRS event (20.0% vs. 62.2% in those not receiving it), without affecting response to teclistamab. No baseline characteristics, including tumor burden or cytokine levels, appeared to clearly predict for CRS occurrence or severity.
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Affiliation(s)
- Thomas G Martin
- University of California, San Francisco, San Francisco, California, USA
| | | | - Ajay Nooka
- Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Arnob Banerjee
- Janssen Research and Development, Spring House, Pennsylvania, USA
| | - Rachel Kobos
- Janssen Research and Development, Raritan, New Jersey, USA
| | - Lixia Pei
- Janssen Research and Development, Raritan, New Jersey, USA
| | - Ming Qi
- Janssen Research and Development, Spring House, Pennsylvania, USA
| | - Raluca Verona
- Janssen Research and Development, Spring House, Pennsylvania, USA
| | | | - Jennifer Smit
- Janssen Research and Development, Spring House, Pennsylvania, USA
| | - Weili Sun
- Janssen Research and Development, Los Angeles, California, USA
| | | | - Clarissa Uhlar
- Janssen Research and Development, Spring House, Pennsylvania, USA
| | | | - Cesar Rodriguez
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Hoffmann MS, Hunter BD, Cobb PW, Varela JC, Munoz J. Overcoming Barriers to Referral for Chimeric Antigen Receptor T-Cell Therapy in Patients With Relapsed/Refractory Diffuse Large B-Cell Lymphoma. Transplant Cell Ther 2023:S2666-6367(23)01234-4. [PMID: 37031747 DOI: 10.1016/j.jtct.2023.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 03/18/2023] [Accepted: 04/03/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND Diffuse large B-cell lymphoma (DLBCL) is the most prevalent subtype of non-Hodgkin lymphoma. Although outcomes to frontline therapy are encouraging, patients who are refractory to or relapse after first-line therapy experience inferior outcomes. A significant proportion of patients treated with additional lines of cytotoxic chemotherapy ultimately succumb to their disease as established in the SCHOLAR-1 study. CHIMERIC ANTIGEN RECEPTOR (CAR)-T CELL THERAPY CAR-T cell therapy is a novel approach to cancer management that reprograms a patient's own T cells to better target and eliminate cancer cells. It was initially approved by the US Food and Drug Administration (FDA) for patients with relapsed/refractory (r/r) DLBCL in the third line of treatment. Based on recently published randomized data, CAR-T cell therapy (axicabtagene ciloleucel and lisocabtagene maraleucel) has also been approved in the second line of treatment for patients who are primary refractory or relapse within 12 months of initiation of first-line therapy. Despite the proven efficacy in treating r/r DLBCL with cluster of differentiation (CD)19-directed CAR-T cell therapy, several barriers exist that may prevent eligible patients from receiving treatment. KEY BARRIERS TO CAR-T CELL TREATMENT Barriers to treatment include cost of therapy, patient hesitancy, required travel to academic treatment centers, nonreferrals, lack of understanding of CAR-T cell therapy, lack of caregiver support, knowledge of resources available, and timely patient selection by referring oncologists. CONCLUSION In this review, an overview of the FDA-approved CD19-directed CAR-T cell therapies (tisagenlecleucel, axicabtagene ciloleucel, and lisocabtagene maraleucel) is provided from pivotal clinical trials and supporting real-world evidence from retrospective studies. In both clinical trials and real-world settings CAR-T cell therapy has been shown to be safe and efficacious for treating patients with r/r DLBCL. However, several barriers prevent eligible patients from accessing these therapies. Barriers to referrals for CAR-T cell therapy are presented with recommendations to improve collaboration between community oncologists and physicians from CAR-T cell therapy treatment centers and subsequent long-term care of patients in community treatment centers.
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Affiliation(s)
- Marc S Hoffmann
- University of Kansas Cancer Center, Division of Hematologic Malignancies and Cellular Therapeutics, Westwood, KS
| | - Bradley D Hunter
- Blood and Marrow Transplantation, LDS Hospital, Intermountain Healthcare, Salt Lake City, UT
| | | | - Juan C Varela
- Blood and Marrow Transplant Program, AdventHealth Hospital, Orlando, FL; Beth Israel Deaconess Medical Center, Dana Farber/Harvard Cancer Center, Boston, MA
| | - Javier Munoz
- Department of Hematology, Mayo Clinic, Phoenix, AZ.
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17
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Marar RI, Abbasi MA, Prathivadhi-Bhayankaram S, Acevedo AD, Villarraga H, Anavekar N, Bhatt VR, Paludo J. Cardiotoxicities of Novel Therapies in Hematologic Malignancies: Chimeric Antigen Receptor T-Cell Therapy and Bispecific T-Cell Engager Therapy. JCO Oncol Pract 2023:OP2200713. [PMID: 36930845 DOI: 10.1200/op.22.00713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023] Open
Abstract
The field of malignant hematology is transforming with novel immunotherapeutic approaches. Unfortunately, quality of life, treatment efficacy, and life expectancy are negatively affected by cardiotoxic side effects of treatment. To date, the exact mechanism and incidence of cardiotoxicity associated with these therapies is unclear. These events are believed to be triggered or occur concurrently with cytokine release syndrome. Furthermore, there are no formal guidelines to provide evaluation, treatment, and surveillance. We aim to synthesize available literature with updates on the cardiotoxic effects of novel therapies used in malignant hematologic disorders, with a focus on chimeric antigen receptor T-cell therapy and bispecific T-cell engager therapy, along with a proposed algorithm that may guide pretreatment evaluation, monitoring during treatment, and post-treatment surveillance.
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Affiliation(s)
- Rosalyn I Marar
- Division of Hematology-Oncology, University of Nebraska Medical Center, Omaha, NE
| | | | | | | | | | - Nandan Anavekar
- Division of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Vijaya Raj Bhatt
- Division of Hematology-Oncology, University of Nebraska Medical Center, Omaha, NE
| | - Jonas Paludo
- Division of Hematology-Oncology, Mayo Clinic, Rochester, MN
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18
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Steinhardt MJ, Reinhardt L, Luu M, Danhof S, Hudecek M. CAR-T-Zell-basierte Immuntherapien in der Hämatoonkologie. DIE ONKOLOGIE 2023. [PMCID: PMC9842198 DOI: 10.1007/s00761-022-01299-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- M. J. Steinhardt
- Lehrstuhl für Zelluläre Immuntherapie, Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Würzburg, Deutschland
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080 Würzburg, Deutschland
| | - L. Reinhardt
- Lehrstuhl für Zelluläre Immuntherapie, Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Würzburg, Deutschland
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080 Würzburg, Deutschland
| | - M. Luu
- Lehrstuhl für Zelluläre Immuntherapie, Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Würzburg, Deutschland
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080 Würzburg, Deutschland
| | - S. Danhof
- Lehrstuhl für Zelluläre Immuntherapie, Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Würzburg, Deutschland
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080 Würzburg, Deutschland
| | - M. Hudecek
- Lehrstuhl für Zelluläre Immuntherapie, Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Würzburg, Deutschland
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080 Würzburg, Deutschland
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19
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Gill J. Cardiovascular Toxicities with Chimeric Antigen Receptor T-cell Therapy. Curr Cardiol Rev 2023; 19:e230622206353. [PMID: 35747980 PMCID: PMC10201875 DOI: 10.2174/1573403x18666220623152350] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 04/25/2022] [Accepted: 04/25/2022] [Indexed: 02/08/2023] Open
Abstract
Chimeric antigen receptor (CAR) T-cell therapy has shown remarkable efficacy in treating highly refractory and relapsing hematological malignancies in pediatric and adult patients. However, this promising therapy is limited by severe and potentially life-threatening toxicities. Cytokine release syndrome (CRS) is the most commonly observed of these toxicities. The cardiovascular manifestations of CRS include tachycardia, hypotension, left ventricular dysfunction, arrhythmias, troponin elevation, cardiogenic shock, and pulmonary edema. Recent data suggest that cardiotoxicities may be transient and reversible in younger patients with few cardiac comorbidities; however, cardiotoxicities may be fatal in older patients with significant cardiac risk factors. The literature remains sparse regarding long-term cardiotoxicities associated with CAR-T cell therapy. Furthermore, consensus guidelines for monitoring and prevention of cardiotoxicities remain illdefined. Therefore, this review will detail the cardiovascular toxicities of CAR T-cell therapy seen in clinical trials and observational studies, summarize treatment approaches for CRS, outline the currently adopted surveillance protocols for CAR T-cell associated cardiotoxicity, and explore the future directions of research in this rapidly emerging field.
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Affiliation(s)
- Jashan Gill
- Department of Medicine, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
- Department of Medicine, Northwestern McHenry Hospital, McHenry, IL, USA
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20
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MSC-Exosomes Carrying miRNA - Could they Enhance Tocilizumab Activity in Neuropathology of COVID-19? Stem Cell Rev Rep 2023; 19:279-283. [PMID: 35794511 PMCID: PMC9261118 DOI: 10.1007/s12015-022-10409-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2022] [Indexed: 01/29/2023]
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21
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Lipe BC, Renaud T. Siltuximab as a primary treatment for cytokine release syndrome in a patient receiving a bispecific antibody in a clinical trial setting. J Oncol Pharm Pract 2022:10781552221140320. [DOI: 10.1177/10781552221140320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction Cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS) are common toxicities associated with immunotherapies, including T cell redirecting bispecific antibodies. Although cooperative group guidelines recommend the use of tocilizumab or other IL-6/IL-6R inhibitors for the management of CRS and ICANS, reports on the use of siltuximab, an IL-6 inhibitor, for the treatment of CRS are limited. Case report We present the case of a 77-year-old male who received T cell redirecting bispecific antibody therapy with talquetamab for relapsed/refractory multiple myeloma (RRMM) and developed CRS with concurrent ICANS after receiving a second dose of talquetamab. Management and Outcome The patient received an infusion of siltuximab. The patient recovered from CRS within 1 h of siltuximab administration and ICANS within 7 h of siltuximab administration. Patient tolerated the subsequent dose of talquetamab with no evidence of CRS and continued on study. Discussion This case describes the successful use of siltuximab for the management of CRS in a patient treated with a T cell redirecting bispecific antibody for RRMM.
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Affiliation(s)
- Brea C Lipe
- University of Rochester Medical Center, Rochester, NY, USA
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22
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Chen F, Zhong X, Dai Q, Li K, Zhang W, Wang J, Zhao Y, Shen J, Xiao Z, Xing H, Li J. Human Umbilical Cord MSC Delivered-Soluble TRAIL Inhibits the Proliferation and Promotes Apoptosis of B-ALL Cell In Vitro and In Vivo. Pharmaceuticals (Basel) 2022; 15:1391. [PMID: 36422522 PMCID: PMC9693801 DOI: 10.3390/ph15111391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 11/09/2022] [Accepted: 11/09/2022] [Indexed: 09/19/2023] Open
Abstract
The TNF-related apoptosis-inducing ligand (TRAIL) could induce apoptosis of leukemic cells, while showed no cytotoxic effect on normal cells. One of the limitations for application of recombinant TRAIL (rhTRAIL) in leukemia treatment is that the serum half-life of this protein is short. Gene delivery is a good strategy to prolong the half-life of TRAIL. In this study, we genetically engineered umbilical cord-MSCs to continuously express and secrete soluble TRAIL (MSC-sTRAIL), to investigate the effects of MSC-sTRAIL on B-cell acute lymphocytic leukemia (B-ALL) cells. In vitro, MSC-sTRAIL significantly inhibited the proliferation of B-ALL cells by suppressing PI3K/AKT and MEK/ERK signaling pathways, and induced apoptosis of B-ALL cells via the caspase cascade-mediated pathway and mitochondrial-mediated pathway. In vivo, MSC-sTRAIL dramatically inhibited B-ALL cell growth. Meanwhile, B-ALL-induced splenic and renal injuries were significantly alleviated after MSC-sTRAIL treatment. Moreover, the serum levels of MSC-secreted sTRAIL were still high in MSC-sTRAIL treated mice, indicating an extended half-life of sTRAIL. Our study suggests that MSC delivered-TRAIL secretion is a potential therapeutic strategy for B-ALL treatment.
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Affiliation(s)
- Fangshan Chen
- Department of Oncology and Hematology, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou 646000, China
| | - Xianmei Zhong
- Laboratory of Molecular Pharmacology, Department of Pharmacology, School of Pharmacy, Southwest Medical University, Luzhou 646000, China
- Cell Therapy & Cell Drugs of Luzhou Key Laboratory, Luzhou 646000, China
- South Sichuan Institute of Translational Medicine, Luzhou 646000, China
- Department of Pharmacy, People’s Hospital of Nanbu County, Nanchong 637300, China
| | - Qian Dai
- Laboratory of Molecular Pharmacology, Department of Pharmacology, School of Pharmacy, Southwest Medical University, Luzhou 646000, China
- Cell Therapy & Cell Drugs of Luzhou Key Laboratory, Luzhou 646000, China
- South Sichuan Institute of Translational Medicine, Luzhou 646000, China
| | - Kuo Li
- Department of Oncology and Hematology, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou 646000, China
| | - Wei Zhang
- Department of Oncology and Hematology, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou 646000, China
| | - Jie Wang
- Department of Oncology and Hematology, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou 646000, China
| | - Yueshui Zhao
- Laboratory of Molecular Pharmacology, Department of Pharmacology, School of Pharmacy, Southwest Medical University, Luzhou 646000, China
- Cell Therapy & Cell Drugs of Luzhou Key Laboratory, Luzhou 646000, China
- South Sichuan Institute of Translational Medicine, Luzhou 646000, China
| | - Jing Shen
- Laboratory of Molecular Pharmacology, Department of Pharmacology, School of Pharmacy, Southwest Medical University, Luzhou 646000, China
- Cell Therapy & Cell Drugs of Luzhou Key Laboratory, Luzhou 646000, China
- South Sichuan Institute of Translational Medicine, Luzhou 646000, China
| | - Zhangang Xiao
- Laboratory of Molecular Pharmacology, Department of Pharmacology, School of Pharmacy, Southwest Medical University, Luzhou 646000, China
- Cell Therapy & Cell Drugs of Luzhou Key Laboratory, Luzhou 646000, China
- South Sichuan Institute of Translational Medicine, Luzhou 646000, China
| | - Hongyun Xing
- Department of Hematology, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, China
| | - Jing Li
- Department of Oncology and Hematology, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou 646000, China
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Gould Rothberg BE, Quest TE, Yeung SCJ, Pelosof LC, Gerber DE, Seltzer JA, Bischof JJ, Thomas CR, Akhter N, Mamtani M, Stutman RE, Baugh CW, Anantharaman V, Pettit NR, Klotz AD, Gibbs MA, Kyriacou DN. Oncologic emergencies and urgencies: A comprehensive review. CA Cancer J Clin 2022; 72:570-593. [PMID: 35653456 DOI: 10.3322/caac.21727] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/15/2022] [Accepted: 02/23/2022] [Indexed: 12/12/2022] Open
Abstract
Patients with advanced cancer generate 4 million visits annually to emergency departments (EDs) and other dedicated, high-acuity oncology urgent care centers. Because of both the increasing complexity of systemic treatments overall and the higher rates of active therapy in the geriatric population, many patients experiencing acute decompensations are frail and acutely ill. This article comprehensively reviews the spectrum of oncologic emergencies and urgencies typically encountered in acute care settings. Presentation, underlying etiology, and up-to-date clinical pathways are discussed. Criteria for either a safe discharge to home or a transition of care to the inpatient oncology hospitalist team are emphasized. This review extends beyond familiar conditions such as febrile neutropenia, hypercalcemia, tumor lysis syndrome, malignant spinal cord compression, mechanical bowel obstruction, and breakthrough pain crises to include a broader spectrum of topics encompassing the syndrome of inappropriate antidiuretic hormone secretion, venous thromboembolism and malignant effusions, as well as chemotherapy-induced mucositis, cardiomyopathy, nausea, vomiting, and diarrhea. Emergent and urgent complications associated with targeted therapeutics, including small molecules, naked and drug-conjugated monoclonal antibodies, as well as immune checkpoint inhibitors and chimeric antigen receptor T-cells, are summarized. Finally, strategies for facilitating same-day direct admission to hospice from the ED are discussed. This article not only can serve as a point-of-care reference for the ED physician but also can assist outpatient oncologists as well as inpatient hospitalists in coordinating care around the ED visit.
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Affiliation(s)
- Bonnie E Gould Rothberg
- Yale Cancer Center Innovations Laboratory, Yale Comprehensive Cancer Center, New Haven, Connecticut
| | - Tammie E Quest
- Department of Emergency Medicine, Emory University, Atlanta, Georgia
| | - Sai-Ching J Yeung
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lorraine C Pelosof
- Office of Oncologic Diseases, US Food and Drug Administration, Silver Spring, Maryland
| | - David E Gerber
- Division of Hematology-Oncology, Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical School, Dallas, Texas
| | - Justin A Seltzer
- Department of Emergency Medicine, University of California San Diego, San Diego, California
| | - Jason J Bischof
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Charles R Thomas
- Department of Radiation Oncology, Geisel School of Medicine at Dartmouth, Norris Cotton Cancer Center, Lebanon, New Hampshire
| | - Nausheen Akhter
- Department of Medicine, Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mira Mamtani
- Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Robin E Stutman
- Department of Medicine, Division of Urgent Care Services, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Christopher W Baugh
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Venkataraman Anantharaman
- Department of Emergency Medicine, Singapore General Hospital, SingHealth Duke-National University of Singapore Academic Medical Center, Singapore, Singapore
| | - Nicholas R Pettit
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Adam D Klotz
- Department of Medicine, Division of Urgent Care Services, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael A Gibbs
- Department of Emergency Medicine, Atrium Health-Carolinas Medical Center, Charlotte, North Carolina
| | - Demetrios N Kyriacou
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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24
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Li Y, Ming Y, Fu R, Li C, Wu Y, Jiang T, Li Z, Ni R, Li L, Su H, Liu Y. The pathogenesis, diagnosis, prevention, and treatment of CAR-T cell therapy-related adverse reactions. Front Pharmacol 2022; 13:950923. [PMID: 36313336 PMCID: PMC9616161 DOI: 10.3389/fphar.2022.950923] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 09/29/2022] [Indexed: 11/13/2022] Open
Abstract
Chimeric antigen receptor (CAR)-T cell therapy is effective in the treatment of refractory/relapsed (r/r) hematological malignancies (r/r B-cell lymphoblastic leukemia, B-cell lymphoma, and multiple myeloma). In addition, it is being explored as a treatment option for solid tumors. As of 31 March 2022, seven CAR-T therapies for hematological malignancies have been approved worldwide. Although CAR-T therapy is an effective treatment for many malignancies, it also causes adverse effects. The incidence of cytokine release syndrome (CRS), the most common adverse reaction after infusion of CAR-T cells, is as high as 93%.CRS, is the leading risk factor of immune effector cell-associated neurotoxicity syndrome (ICANS), as well as cardiovascular, hematological, hepatorenal, skin, pulmonary, and gastrointestinal toxicity. Severe adverse reactions complicated by CRS severely impede the widespread application of CAR-T therapy. The CAR-T product was initially approved in 2017; however, only limited studies have investigated the adverse reactions owing to CAR-T therapy compared to that of clinically approved drugs. Thus, we aimed to elucidate the mechanisms, risk factors, diagnostic criteria, and treatment of toxicities concurrent with CRS, thereby providing a valuable reference for the safe, effective, and widespread application of CAR-T therapy.
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25
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Aliyu M, Zohora FT, Anka AU, Ali K, Maleknia S, Saffarioun M, Azizi G. Interleukin-6 cytokine: An overview of the immune regulation, immune dysregulation, and therapeutic approach. Int Immunopharmacol 2022; 111:109130. [PMID: 35969896 DOI: 10.1016/j.intimp.2022.109130] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 07/26/2022] [Accepted: 08/03/2022] [Indexed: 12/19/2022]
Abstract
Several studies have shown that interleukin 6 (IL-6) is a multifunctional cytokine with both pro-inflammatory and anti-inflammatory activity, depending on the immune response context. Macrophages are among several cells that secrete IL-6, which they express upon activation by antigens, subsequently inducing fever and production of acute-phase proteins from the liver. Moreover, IL-6 induces the final maturation of B cells into memory B cells and plasma cells as well as an adaptive role for short-term energy allocation. Activation of IL-6 receptors results in the intracellular activation of the JAK/STAT pathway with resultant production of inflammatory cytokines. Several mechanisms-controlled IL-6 expression, but aberrant production was shown to be crucial in the pathogenesis of many diseases, which include autoimmune and chronic inflammatory diseases. IL-6 in combination with transforming growth factor β (TGF-β) induced differentiation of naïve T cells to Th17 cells, which is the cornerstone in autoimmune diseases. Recently, IL-6 secretion was shown to form the backbone of hypercytokinemia seen in the Coronavirus disease 2019 (COVID-19)-associated hyperinflammation and multiorgan failure. There are two classes of approved IL-6 inhibitors: anti-IL-6 receptor monoclonal antibodies (e.g., tocilizumab) and anti-IL-6 monoclonal antibodies (i.e., siltuximab). These drugs have been evaluated in patients with rheumatoid arthritis, juvenile idiopathic arthritis, cytokine release syndrome, and COVID-19 who have systemic inflammation. JAK/STAT pathway blockers were also successfully used in dampening IL-6 signal transduction. A better understanding of different mechanisms that modulate IL-6 expression will provide the much-needed solution with excellent safety and efficacy profiles for the treatment of autoimmune and inflammatory diseases in which IL-6 derives their pathogenesis.
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Affiliation(s)
- Mansur Aliyu
- Department of Immunology, School of Public Health, Tehran University of Medical Sciences, International Campus, TUMS-IC, Tehran, Iran; Department of Medical Microbiology, Faculty of Clinical Science, College of Health Sciences, Bayero University, Kano, Nigeria
| | - Fatema Tuz Zohora
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Malaysia
| | - Abubakar Umar Anka
- Department of Medical Laboratory Science, College of Medical Sciences, Ahmadu Bello University, Zaria, Nigeria
| | - Kashif Ali
- Department of Pharmacy Abdul Wali, Khan University Mardan, Pakistan
| | - Shayan Maleknia
- Biopharmaceutical Research Center, AryoGen Pharmed Inc., Alborz University of Medical Sciences, Karaj, Iran
| | - Mohammad Saffarioun
- Biopharmaceutical Research Center, AryoGen Pharmed Inc., Alborz University of Medical Sciences, Karaj, Iran
| | - Gholamreza Azizi
- Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran.
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26
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Cardiotoxicity of Chimeric Antigen Receptor T-Cell (CAR-T) Therapy: Pathophysiology, Clinical Implications, and Echocardiographic Assessment. Int J Mol Sci 2022; 23:ijms23158242. [PMID: 35897819 PMCID: PMC9368621 DOI: 10.3390/ijms23158242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 07/18/2022] [Accepted: 07/23/2022] [Indexed: 02/04/2023] Open
Abstract
Contemporary anticancer immunotherapy with chimeric antigen receptor T-cell (CAR-T) therapy has dramatically changed the treatment of many hematologic malignancies previously associated with poor prognosis. The clinical improvement and the survival benefit unveiled the risk of cardiotoxicity, ranging from minimal effects to severe cardiac adverse events, including death. Immunotherapy should also be proposed even in patients with pre-existing cardiovascular risk factors, thereby increasing the potential harm of cardiotoxicity. CAR-T therapy frequently results in cytokine release syndrome (CRS), and inflammatory activation is sustained by circulating cytokines that foster a positive feedback mechanism. Prompt diagnosis and treatment of CAR-T cardiotoxicity might significantly improve outcomes and reduce the burden associated with cardiovascular complications. Clinical and echocardiographic examinations are crucial to perform a tailored evaluation and follow-up during CAR-T treatment. This review aims to summarize the pathophysiology, clinical implications, and echocardiographic assessment of CAR-T-related cardiotoxicity to enlighten new avenues for future research.
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27
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Interleukin Inhibitors in Cytokine Release Syndrome and Neurotoxicity Secondary to CAR-T Therapy. Diseases 2022; 10:diseases10030041. [PMID: 35892735 PMCID: PMC9326641 DOI: 10.3390/diseases10030041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 06/29/2022] [Accepted: 07/01/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction: Chimeric antigen receptor T-cell (CAR-T) therapy is an innovative therapeutic option for addressing certain recurrent or refractory hematological malignancies. However, CAR-T cells also cause the release of pro-inflammatory cytokines that lead to life-threatening cytokine release syndrome and neurotoxicity. Objective: To study the efficacy of interleukin inhibitors in addressing cytokine release syndrome (CRS) and neurotoxicity secondary to CAR-T therapy. Methodology: The authors conducted a bibliographic review in which 10 articles were analyzed. These included cut-off studies, case reports, and clinical trials involving 11 cancer centers and up to 475 patients over 18 years of age. Results: Tocilizumab is the only interleukin inhibitor approved to address CRS secondary to CAR-T therapy due to its efficacy and safety. Other inhibitors, such as siltuximab and anakinra, could be useful in combination with tocilizumab for preventing severe cytokine release and neurotoxicity. In addition, the new specific inhibitors could be effective in mitigating CRS without affecting the cytotoxic efficacy of CAR-T therapy. Conclusion: More lines of research should be opened to elucidate the true implications of these drugs in treating the side effects of CAR-T therapy.
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Stein-Merlob AF, Ganatra S, Yang EH. T-cell Immunotherapy and Cardiovascular Disease: Chimeric Antigen Receptor T-cell and Bispecific T-cell Engager Therapies. Heart Fail Clin 2022; 18:443-454. [PMID: 35718418 DOI: 10.1016/j.hfc.2022.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Chimeric antigen receptor (CAR) T-cell and bispecific T-cell engager (BiTE) therapies have revolutionized the treatment of refractory or relapsed leukemia and lymphoma. Increased use of these therapies has revealed signals of significant cardiotoxicity, including cardiomyopathy/heart failure, arrhythmia, myocardial injury, hemodynamic instability, and cardiovascular death mainly in the context of a profound inflammatory response to CAR T-cell antitumor effects known as cytokine release syndrome (CRS). Preexisting cardiovascular risk factors and disease may increase the risk of such cardiotoxicity. High index of suspicion and close monitoring is required for prompt recognition. Supportive hemodynamic care and targeted anti-IL-6 therapy, as well as possibly broader immunosuppression with corticosteroids, are the cornerstones of the management.
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Affiliation(s)
- Ashley F Stein-Merlob
- Division of Cardiology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA; Division of Cardiology, Department of Medicine, UCLA-Cardio-Oncology Program, University of California at Los Angeles, Los Angeles, CA, USA. https://twitter.com/A_SteinMerlob
| | - Sarju Ganatra
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital and Medical Center, Burlington, MA, USA.
| | - Eric H Yang
- Division of Cardiology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA; Division of Cardiology, Department of Medicine, UCLA-Cardio-Oncology Program, University of California at Los Angeles, Los Angeles, CA, USA.
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29
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Holzinger A, Abken H. Treatment with Living Drugs: Pharmaceutical Aspects of CAR T Cells. Pharmacology 2022; 107:446-463. [PMID: 35696994 DOI: 10.1159/000525052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 05/05/2022] [Indexed: 12/26/2022]
Abstract
BACKGROUND Adoptive therapy with genetically modified T cells achieves spectacular remissions in advanced hematologic malignancies. In contrast to conventional drugs, this kind of therapy applies viable autologous T cells that are ex vivo genetically engineered with a chimeric antigen receptor (CAR) and are classified as advanced therapy medicinal products. SUMMARY As "living drugs," CAR T cells differ from classical pharmaceutical drugs as they provide a panel of cellular capacities upon CAR signaling, including the release of effector molecules and cytokines, redirected cytotoxicity, CAR T cell amplification, active migration, and long-term persistence and immunological memory. Here, we discuss pharmaceutical aspects, the regulatory requirements for CAR T cell manufacturing, and how CAR T cell pharmacokinetics are connected with the clinical outcome. KEY MESSAGES From the pharmacological perspective, the development of CAR T cells with high translational potential needs to address pharmacodynamic markers to balance safety and efficacy of CAR T cells and to address pharmacokinetics with respect to trafficking, homing, infiltration, and persistence of CAR T cells.
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Affiliation(s)
- Astrid Holzinger
- Division of Genetic Immunotherapy, Leibniz Institute for Immunotherapy (LIT) and University of Regensburg, Regensburg, Germany,
| | - Hinrich Abken
- Division of Genetic Immunotherapy, Leibniz Institute for Immunotherapy (LIT) and University of Regensburg, Regensburg, Germany
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30
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Leclercq G, Steinhoff N, Haegel H, De Marco D, Bacac M, Klein C. Novel strategies for the mitigation of cytokine release syndrome induced by T cell engaging therapies with a focus on the use of kinase inhibitors. Oncoimmunology 2022; 11:2083479. [PMID: 35694193 PMCID: PMC9176235 DOI: 10.1080/2162402x.2022.2083479] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 05/16/2022] [Accepted: 05/25/2022] [Indexed: 11/03/2022] Open
Abstract
T cell engaging therapies, like CAR-T cells and T cell engagers, redirect T cells toward tumor cells, facilitating the formation of a cytotoxic synapse and resulting in subsequent tumor cell killing. T cell receptor or CAR-T downstream signaling triggers a release of pro-inflammatory cytokines, which can induce a Cytokine Release Syndrome (CRS). The incidence of CRS is still hardly predictable among individuals and remains one of the major dose-limiting safety liabilities associated with on-target activity of T cell engaging therapies. This emphasizes the need to elaborate mitigation strategies, which reduce cytokine release while retaining efficacy. Here, we review pre-clinical and clinical approaches applied for the management of CRS symptoms in the context of T cell engaging therapies, highlighting the use of tyrosine kinase inhibitors as an emerging mitigation strategy. In particular, we focus on the effects of Bruton's tyrosine kinase (BTK), Src family including Lck, mammalian target of rapamycin (mTOR) and Janus tyrosine kinase (JAK) inhibitors on T cell functionality and cytokine release, to provide a rationale for their use as mitigation strategies against CRS in the context of T cell engaging therapies.
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Affiliation(s)
- Gabrielle Leclercq
- Oncology Disease Therapeutic Area, Roche Innovation Center Zurich, Roche Pharmaceutical Research and Early Development, pRED, Schlieren, Switzerland
| | - Nathalie Steinhoff
- Oncology Disease Therapeutic Area, Roche Innovation Center Zurich, Roche Pharmaceutical Research and Early Development, pRED, Schlieren, Switzerland
| | - Hélène Haegel
- Phamaceutical Sciences, Roche Innovation Center Basel, Roche Pharmaceutical Research and Early Development, pRED, Basel, Switzerland
| | - Donata De Marco
- Phamaceutical Sciences, Roche Innovation Center Basel, Roche Pharmaceutical Research and Early Development, pRED, Basel, Switzerland
| | - Marina Bacac
- Oncology Disease Therapeutic Area, Roche Innovation Center Zurich, Roche Pharmaceutical Research and Early Development, pRED, Schlieren, Switzerland
| | - Christian Klein
- Oncology Disease Therapeutic Area, Roche Innovation Center Zurich, Roche Pharmaceutical Research and Early Development, pRED, Schlieren, Switzerland
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31
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Giardino Torchia ML, Letizia M, Gilbreth R, Merlino A, Sult E, Monks N, Chesebrough J, Tammali R, Chu N, Tong J, Meekin J, Schifferli K, Vashisht K, DaCosta K, Clarke L, Gesse C, Yao XT, Bridges C, Moody G. Rational design of chimeric antigen receptor T cells against glypican 3 decouples toxicity from therapeutic efficacy. Cytotherapy 2022; 24:720-732. [DOI: 10.1016/j.jcyt.2022.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 02/28/2022] [Accepted: 03/18/2022] [Indexed: 12/11/2022]
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32
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Boettcher M, Joechner A, Li Z, Yang SF, Schlegel P. Development of CAR T Cell Therapy in Children-A Comprehensive Overview. J Clin Med 2022; 11:jcm11082158. [PMID: 35456250 PMCID: PMC9024694 DOI: 10.3390/jcm11082158] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 04/08/2022] [Accepted: 04/11/2022] [Indexed: 01/27/2023] Open
Abstract
CAR T cell therapy has revolutionized immunotherapy in the last decade with the successful establishment of chimeric antigen receptor (CAR)-expressing cellular therapies as an alternative treatment in relapsed and refractory CD19-positive leukemias and lymphomas. There are fundamental reasons why CAR T cell therapy has been approved by the Food and Drug administration and the European Medicines Agency for pediatric and young adult patients first. Commonly, novel therapies are developed for adult patients and then adapted for pediatric use, due to regulatory and commercial reasons. Both strategic and biological factors have supported the success of CAR T cell therapy in children. Since there is an urgent need for more potent and specific therapies in childhood malignancies, efforts should also include the development of CAR therapeutics and expand applicability by introducing new technologies. Basic aspects, the evolution and the drawbacks of childhood CAR T cell therapy are discussed as along with the latest clinically relevant information.
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Affiliation(s)
- Michael Boettcher
- Department of Pediatric Surgery, University Medical Centre Mannheim, University of Heidelberg, 69117 Heidelberg, Germany;
| | - Alexander Joechner
- School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Sydney 2006, Australia;
- Cellular Cancer Therapeutics Unit, Children’s Medical Research Institute, Sydney 2145, Australia; (Z.L.); (S.F.Y.)
| | - Ziduo Li
- Cellular Cancer Therapeutics Unit, Children’s Medical Research Institute, Sydney 2145, Australia; (Z.L.); (S.F.Y.)
| | - Sile Fiona Yang
- Cellular Cancer Therapeutics Unit, Children’s Medical Research Institute, Sydney 2145, Australia; (Z.L.); (S.F.Y.)
| | - Patrick Schlegel
- School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Sydney 2006, Australia;
- Cellular Cancer Therapeutics Unit, Children’s Medical Research Institute, Sydney 2145, Australia; (Z.L.); (S.F.Y.)
- Department of Pediatric Hematology and Oncology, Westmead Children’s Hospital, Sydney 2145, Australia
- Correspondence:
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33
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Paul B, Rodriguez C, Usmani SZ. BCMA-Targeted Biologic Therapies: The Next Standard of Care in Multiple Myeloma Therapy. Drugs 2022; 82:613-631. [PMID: 35412114 PMCID: PMC9554894 DOI: 10.1007/s40265-022-01697-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2022] [Indexed: 11/03/2022]
Abstract
With recent advances in myeloma therapy, patients can achieve long-term remissions, but eventually relapses will occur. Triple-class refractory myeloma (disease that is refractory to an immunomodulatory agent, a proteasome inhibitor, and an anti-CD38 monoclonal antibody) and penta-refractory myeloma (disease that is refractory to two proteasome inhibitors, two immunomodulatory agents, and an anti-CD38 antibody) are associated with a particularly poor prognosis, and novel treatments are desperately needed for these patients. Targeting B cell maturation antigen (BCMA), which is ubiquitously expressed on plasma cells, has emerged as a well-tolerated and highly efficacious strategy in patients with relapsed and refractory myeloma. Several mechanisms of targeting BCMA are currently under investigation, including antibody-drug conjugates, bispecific antibodies, and chimeric antigen receptor T cells and natural killer (NK) cells, all with unique side effect profiles. Early phase clinical trials showed unprecedented response rates in highly refractory myeloma patients, leading to the recent approvals of some of these agents. Still, many questions remain with regard to this target, including how best to target it, how to treat patients who have progressed on a BCMA-targeting therapy, and whether response rates will deepen if these agents are used in earlier lines of therapy. In this review, we examine the rationale for targeting BCMA and summarize the data for several agents across multiple classes of BCMA-targeting therapeutics, paying special attention to the diverse mechanisms and unique challenges of each therapeutic class.
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Affiliation(s)
- Barry Paul
- Division of Plasma Cell Disorders, Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute/Atrium Health, Charlotte, NC, USA
| | | | - Saad Z Usmani
- Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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34
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Villaescusa L, Zaragozá F, Gayo-Abeleira I, Zaragozá C. A New Approach to the Management of COVID-19. Antagonists of IL-6: Siltuximab. Adv Ther 2022; 39:1126-1148. [PMID: 35072887 PMCID: PMC8784859 DOI: 10.1007/s12325-022-02042-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 01/06/2022] [Indexed: 02/06/2023]
Abstract
Since the beginning of the pandemic, numerous national and international clinical trials have been conducted with a large number of drugs. Many of them are intended for the treatment of other pathologies; however, despite the great effort made, no specific drug is available for the treatment of the symptoms of respiratory disease caused by SARS-CoV-2 infection. The aim of this article is to provide data to justify the use of drugs to tackle the effects produced by IL-6 as the main inflammatory mediator in patients with COVID-19 with severe respiratory complications, considering all clinical evidence linking the poor prognosis of these patients with increased IL-6 levels in the context of cytokine release syndrome. Furthermore, data are provided to justify the proposal of a rational dosing of siltuximab, a monoclonal antibody specifically targeting IL-6, based on RCP levels, considering the limited results published so far on the use of this drug in COVID-19. A literature search was conducted on the clinical trials of siltuximab published to date as well as on the different IL-6 signalling pathways and the effects of its overexpression. Knowledge of the mechanisms of action on these pathways may provide important information for the design of drugs useful in the treatment of these patients. This article describes the characteristics, properties, mechanism of action, therapeutic uses and clinical studies conducted with siltuximab so far. The results confirm that administration of siltuximab downregulates IL-6 levels, thereby reducing the inflammatory process in COVID-19 patients with severe respiratory disease, suggesting that it can be successfully used to prevent cytokine release syndrome and death from this cause.
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Affiliation(s)
- Lucinda Villaescusa
- Pharmacology Unit, Biomedical Sciences Department, University of Alcalá, Madrid, 28805, Alcalá de Henares, Spain.
| | - Francisco Zaragozá
- Pharmacology Unit, Biomedical Sciences Department, University of Alcalá, Madrid, 28805, Alcalá de Henares, Spain
| | - Irene Gayo-Abeleira
- Pharmacology Unit, Biomedical Sciences Department, University of Alcalá, Madrid, 28805, Alcalá de Henares, Spain
| | - Cristina Zaragozá
- Pharmacology Unit, Biomedical Sciences Department, University of Alcalá, Madrid, 28805, Alcalá de Henares, Spain
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Significance of Immune Status of SARS-CoV-2 Infected Patients in Determining the Efficacy of Therapeutic Interventions. J Pers Med 2022; 12:jpm12030349. [PMID: 35330349 PMCID: PMC8955701 DOI: 10.3390/jpm12030349] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 02/12/2022] [Accepted: 02/14/2022] [Indexed: 12/15/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) is now being investigated for its distinctive patterns in the course of disease development which can be indicated with miscellaneous immune responses in infected individuals. Besides this series of investigations on the pathophysiology of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), significant fundamental immunological and physiological processes are indispensable to address clinical markers of COVID-19 disease and essential to identify or design effective therapeutics. Recent developments in the literature suggest that deficiency of type I interferon (IFN) in serum samples can be used to represent a severe progression of COVID-19 disease and can be used as the basis to develop combined immunotherapeutic strategies. Precise control over inflammatory response is a significant aspect of targeting viral infections. This account presents a brief review of the pathophysiological characteristics of the SARS-CoV-2 virus and the understanding of the immune status of infected patients. We further discuss the immune system’s interaction with the SARS-CoV-2 virus and their subsequent involvement of dysfunctional immune responses during the progression of the disease. Finally, we highlight some of the implications of the different approaches applicable in developing promising therapeutic interventions that redirect immunoregulation and viral infection.
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Leclercq G, Servera LA, Danilin S, Challier J, Steinhoff N, Bossen C, Odermatt A, Nicolini V, Umaña P, Klein C, Bacac M, Giusti AM, Schneider A, Haegel H. Dissecting the mechanism of cytokine release induced by T-cell engagers highlights the contribution of neutrophils. Oncoimmunology 2022; 11:2039432. [PMID: 35186442 PMCID: PMC8855852 DOI: 10.1080/2162402x.2022.2039432] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
T cell engagers represent a novel promising class of cancer-immunotherapies redirecting T cells to tumor cells and have some promising outcomes in the clinic. These molecules can be associated with a mode-of-action related risk of cytokine release syndrome (CRS) in patients. CRS is characterized by the rapid release of pro-inflammatory cytokines such as TNF-α, IFN-γ, IL-6 and IL-1β and immune cell activation eliciting clinical symptoms of fever, hypoxia and hypotension. In this work, we investigated the biological mechanisms triggering and amplifying cytokine release after treatment with T cell bispecific antibodies (TCBs) employing an in vitro co-culture assay of human PBMCs or total leukocytes (PBMCs + neutrophils) and corresponding target antigen-expressing cells with four different TCBs. We identified T cells as the triggers of the TCB-mediated cytokine cascade and monocytes and neutrophils as downstream amplifier cells. Furthermore, we assessed the chronology of events by neutralization of T-cell derived cytokines. For the first time, we demonstrate the contribution of neutrophils to TCB-mediated cytokine release and confirm these findings by single-cell RNA sequencing of human whole blood incubated with a B-cell depleting TCB. This work could contribute to the construction of mechanistic models of cytokine release and definition of more specific molecular and cellular biomarkers of CRS in the context of treatment with T-cell engagers. In addition, it provides insight for the elaboration of prophylactic mitigation strategies that can reduce the occurrence of CRS and increase the therapeutic index of TCBs.
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Affiliation(s)
- Gabrielle Leclercq
- Roche Pharma Research and Early Development, pRED, Roche Innovation Center Zurich, Zurich, Switzerland
- Department of Pharmaceutical Sciences, Division of Molecular and Systems Toxicology, University of Basel, Basel, Switzerland
| | - Llucia Alberti Servera
- Roche Pharma Research and Early Development, pRED, Roche Innovation Center Basel, Basel, Switzerland
| | - Sabrina Danilin
- Roche Pharma Research and Early Development, pRED, Roche Innovation Center Basel, Basel, Switzerland
| | - John Challier
- Roche Pharma Research and Early Development, pRED, Roche Innovation Center Zurich, Zurich, Switzerland
| | - Nathalie Steinhoff
- Roche Pharma Research and Early Development, pRED, Roche Innovation Center Zurich, Zurich, Switzerland
| | - Claudia Bossen
- Roche Pharma Research and Early Development, pRED, Roche Innovation Center Basel, Basel, Switzerland
| | - Alex Odermatt
- Department of Pharmaceutical Sciences, Division of Molecular and Systems Toxicology, University of Basel, Basel, Switzerland
| | - Valeria Nicolini
- Roche Pharma Research and Early Development, pRED, Roche Innovation Center Zurich, Zurich, Switzerland
| | - Pablo Umaña
- Roche Pharma Research and Early Development, pRED, Roche Innovation Center Zurich, Zurich, Switzerland
| | - Christian Klein
- Roche Pharma Research and Early Development, pRED, Roche Innovation Center Zurich, Zurich, Switzerland
| | - Marina Bacac
- Roche Pharma Research and Early Development, pRED, Roche Innovation Center Zurich, Zurich, Switzerland
| | - Anna-Maria Giusti
- Roche Pharma Research and Early Development, pRED, Roche Innovation Center Zurich, Zurich, Switzerland
| | - Anneliese Schneider
- Roche Pharma Research and Early Development, pRED, Roche Innovation Center Zurich, Zurich, Switzerland
| | - Hélène Haegel
- Roche Pharma Research and Early Development, pRED, Roche Innovation Center Zurich, Zurich, Switzerland
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Leclercq G, Haegel H, Toso A, Zimmermann T, Green L, Steinhoff N, Sam J, Pulko V, Schneider A, Giusti AM, Challier J, Freimoser-Grundschober A, Larivière L, Odermatt A, Stern M, Umana P, Bacac M, Klein C. JAK and mTOR inhibitors prevent cytokine release while retaining T cell bispecific antibody in vivo efficacy. J Immunother Cancer 2022; 10:jitc-2021-003766. [PMID: 35064010 PMCID: PMC8785208 DOI: 10.1136/jitc-2021-003766] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2021] [Indexed: 12/30/2022] Open
Abstract
Background T cell engaging therapies, like chimeric antigen receptor T cells and T cell bispecific antibodies (TCBs), efficiently redirect T cells towards tumor cells, facilitating the formation of a cytotoxic synapse and resulting in subsequent tumor cell killing, a process that is accompanied by the release of cytokines. Despite their promising efficacy in the clinic, treatment with TCBs is associated with a risk of cytokine release syndrome (CRS). The aim of this study was to identify small molecules able to mitigate cytokine release while retaining T cell-mediated tumor killing. Methods By screening a library of 52 Food and Drug Administration approved kinase inhibitors for their impact on T cell proliferation and cytokine release after CD3 stimulation, we identified mTOR, JAK and Src kinases inhibitors as potential candidates to modulate TCB-mediated cytokine release at pharmacologically active doses. Using an in vitro model of target cell killing by human peripheral blood mononuclear cells, we assessed the effects of mTOR, JAK and Src kinase inhibitors combined with 2+1 T cell bispecific antibodies (TCBs) including CEA-TCB and CD19-TCB on T cell activation, proliferation and target cell killing measured by flow cytometry and cytokine release measured by Luminex. The combination of mTOR, JAK and Src kinase inhibitors together with CD19-TCB was evaluated in vivo in non-tumor bearing stem cell humanized NSG mice in terms of B cell depletion and in a lymphoma patient-derived xenograft (PDX) model in humanized NSG mice in terms of antitumor efficacy. Results The effect of Src inhibitors differed from those of mTOR and JAK inhibitors with the suppression of CD19-TCB-induced tumor cell lysis in vitro, whereas mTOR and JAK inhibitors primarily affected TCB-mediated cytokine release. Importantly, we confirmed in vivo that Src, JAK and mTOR inhibitors strongly reduced CD19-TCB-induced cytokine release. In humanized NSG mice, continuous treatment with a Src inhibitor prevented CD19-TCB-mediated B cell depletion in contrast to mTOR and JAK inhibitors, which retained CD19-TCB efficacy. Ultimately, transient treatment with Src, mTOR and JAK inhibitors minimally interfered with antitumor efficacy in a lymphoma PDX model. Conclusions Taken together, these data support further evaluation of the use of Src, JAK and mTOR inhibitors as prophylactic treatment to prevent occurrence of CRS.
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Affiliation(s)
- Gabrielle Leclercq
- Roche Pharmaceutical Research and Early Development, Roche Innovation Center Zurich, Schlieren, Switzerland
- Department of Pharmaceutical Sciences, Division Molecular and Systems Toxicology, University of Basel, Basel, Switzerland
| | - Hélène Haegel
- Roche Pharmaceutical Research and Early Development, Roche Innovation Center Zurich, Schlieren, Switzerland
| | - Alberto Toso
- Roche Pharmaceutical Research and Early Development, Roche Innovation Center Basel, Basel, Switzerland
| | - Tina Zimmermann
- Roche Pharmaceutical Research and Early Development, Roche Innovation Center Basel, Basel, Switzerland
| | - Luke Green
- Roche Pharmaceutical Research and Early Development, Roche Innovation Center Basel, Basel, Switzerland
| | - Nathalie Steinhoff
- Roche Pharmaceutical Research and Early Development, Roche Innovation Center Zurich, Schlieren, Switzerland
| | - Johannes Sam
- Roche Pharmaceutical Research and Early Development, Roche Innovation Center Zurich, Schlieren, Switzerland
| | - Vesna Pulko
- Roche Pharmaceutical Research and Early Development, Roche Innovation Center Zurich, Schlieren, Switzerland
| | - Anneliese Schneider
- Roche Pharmaceutical Research and Early Development, Roche Innovation Center Zurich, Schlieren, Switzerland
| | - Anna Maria Giusti
- Roche Pharmaceutical Research and Early Development, Roche Innovation Center Zurich, Schlieren, Switzerland
| | - John Challier
- Roche Pharmaceutical Research and Early Development, Roche Innovation Center Zurich, Schlieren, Switzerland
| | | | - Laurent Larivière
- Roche Pharmaceutical Research and Early Development, Roche Innovation Center Munich, Penzberg, Germany
| | - Alex Odermatt
- Department of Pharmaceutical Sciences, Division Molecular and Systems Toxicology, University of Basel, Basel, Switzerland
| | - Martin Stern
- Roche Pharmaceutical Research and Early Development, Roche Innovation Center Zurich, Schlieren, Switzerland
| | - Pablo Umana
- Roche Pharmaceutical Research and Early Development, Roche Innovation Center Zurich, Schlieren, Switzerland
| | - Marina Bacac
- Roche Pharmaceutical Research and Early Development, Roche Innovation Center Zurich, Schlieren, Switzerland
| | - Christian Klein
- Roche Pharmaceutical Research and Early Development, Roche Innovation Center Zurich, Schlieren, Switzerland
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Gu T, Hu K, Si X, Hu Y, Huang H. Mechanisms of immune effector cell-associated neurotoxicity syndrome after CAR-T treatment. WIREs Mech Dis 2022; 14:e1576. [PMID: 35871757 PMCID: PMC9787013 DOI: 10.1002/wsbm.1576] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 06/05/2022] [Accepted: 06/22/2022] [Indexed: 12/30/2022]
Abstract
Chimeric antigen receptor T-cell (CAR-T) treatment has revolutionized the landscape of cancer therapy with significant efficacy on hematologic malignancy, especially in relapsed and refractory B cell malignancies. However, unexpected serious toxicities such as cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS) still hamper its broad application. Clinical trials using CAR-T cells targeting specific antigens on tumor cell surface have provided valuable information about the characteristics of ICANS. With unclear mechanism of ICANS after CAR-T treatment, unremitting efforts have been devoted to further exploration. Clinical findings from patients with ICANS strongly indicated existence of overactivated peripheral immune response followed by endothelial activation-induced blood-brain barrier (BBB) dysfunction, which triggers subsequent central nervous system (CNS) inflammation and neurotoxicity. Several animal models have been built but failed to fully replicate the whole spectrum of ICANS in human. Hopefully, novel and powerful technologies like single-cell analysis may help decipher the precise cellular response within CNS from a different perspective when ICANS happens. Moreover, multidisciplinary cooperation among the subjects of immunology, hematology, and neurology will facilitate better understanding about the complex immune interaction between the peripheral, protective barriers, and CNS in ICANS. This review elaborates recent findings about ICANS after CAR-T treatment from bed to bench, and discusses the potential cellular and molecular mechanisms that may promote effective management in the future. This article is categorized under: Cancer > Biomedical Engineering Immune System Diseases > Molecular and Cellular Physiology Neurological Diseases > Molecular and Cellular Physiology.
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Affiliation(s)
- Tianning Gu
- Bone Marrow Transplantation Centerthe First Affiliated Hospital, Zhejiang University School of MedicineHangzhouZhejiang310003China,Liangzhu LaboratoryZhejiang University Medical CenterHangzhouChina,Institute of HematologyZhejiang UniversityHangzhou310058China,Zhejiang Province Engineering Laboratory for Stem Cell and Immunity TherapyHangzhouChina
| | - Kejia Hu
- Bone Marrow Transplantation Centerthe First Affiliated Hospital, Zhejiang University School of MedicineHangzhouZhejiang310003China,Liangzhu LaboratoryZhejiang University Medical CenterHangzhouChina,Institute of HematologyZhejiang UniversityHangzhou310058China,Zhejiang Province Engineering Laboratory for Stem Cell and Immunity TherapyHangzhouChina
| | - Xiaohui Si
- Bone Marrow Transplantation Centerthe First Affiliated Hospital, Zhejiang University School of MedicineHangzhouZhejiang310003China,Liangzhu LaboratoryZhejiang University Medical CenterHangzhouChina,Institute of HematologyZhejiang UniversityHangzhou310058China,Zhejiang Province Engineering Laboratory for Stem Cell and Immunity TherapyHangzhouChina
| | - Yongxian Hu
- Bone Marrow Transplantation Centerthe First Affiliated Hospital, Zhejiang University School of MedicineHangzhouZhejiang310003China,Liangzhu LaboratoryZhejiang University Medical CenterHangzhouChina,Institute of HematologyZhejiang UniversityHangzhou310058China,Zhejiang Province Engineering Laboratory for Stem Cell and Immunity TherapyHangzhouChina
| | - He Huang
- Bone Marrow Transplantation Centerthe First Affiliated Hospital, Zhejiang University School of MedicineHangzhouZhejiang310003China,Liangzhu LaboratoryZhejiang University Medical CenterHangzhouChina,Institute of HematologyZhejiang UniversityHangzhou310058China,Zhejiang Province Engineering Laboratory for Stem Cell and Immunity TherapyHangzhouChina
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Mehrabadi AZ, Ranjbar R, Farzanehpour M, Shahriary A, Dorostkar R, Hamidinejad MA, Ghaleh HEG. Therapeutic potential of CAR T cell in malignancies: A scoping review. Biomed Pharmacother 2021; 146:112512. [PMID: 34894519 DOI: 10.1016/j.biopha.2021.112512] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 11/20/2021] [Accepted: 12/06/2021] [Indexed: 02/08/2023] Open
Abstract
Although tremendous advancements in cancer therapy over the last several years, cancer still is a complex illness to cure. Traditional cancer treatments, including chemotherapy, radiotherapy, and surgery, have a poor therapeutic effect, emphasizing the significance of employing innovative treatments like activated cell therapy. Chimeric antigen receptor T cell is one of the most prevalent types of activated cell therapy have been developed to direct T lymphocytes toward cancers (CAR-T cells). CAR-T cells therapy has illustrated poor impact versus solid tumors despite the remarkable success in patients suffering from hematological malignancies. CAR-T cells must overcome various hurdles to obtain full responses to solid tumors, including growth, stability, trafficking, and destiny inside tumors. As a result, novel treatment methods will entail overcoming the challenges that CAR-T cells face in solid tumors. The use of CAR-T cells in combination with other therapeutic approaches such as chemotherapy, radiotherapy, immuno-checkpoint inhibitors, and oncolytic viruses can promote the effectiveness of CAR-T cell therapy for the treatment of solid tumors. However, more research is needed to determine the safety and effectiveness of these therapies. CAR-T cell treatment success rates vary by type of disease, but are predicted to reach up to 90% in patients with leukemia. However, since this kind of immunotherapy is still in its infancy, there is much to learn about its efficacy. This review provided an in-depth examination of CAR-T cell therapy and its success and failure as a cancer treatment approach. We also discuss combination therapies with CAR-T Cell.
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Affiliation(s)
| | - Reza Ranjbar
- Molecular Biology Research Center, Systems Biology and Poisonings Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Mahdieh Farzanehpour
- Applied Virology Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Alireza Shahriary
- Chemical Injuries Research Center, Systems Biology and Poisonings Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Ruhollah Dorostkar
- Applied Virology Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Mohammad Ali Hamidinejad
- Department of Medical Biotechnology, Faculty of Allied Medicine, Iran University of Medical Sciences, Tehran, Iran
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Gopcsa L, Bobek I, Bekő G, Lakatos B, Molnár E, Réti M, Reményi P, Sinkó J, Szlávik J, Tatai G, Vályi-Nagy I. Common points of therapeutic intervention in COVID-19 and in allogeneic hematopoietic stem cell transplantation associated severe cytokine release syndrome. Acta Microbiol Immunol Hung 2021; 68:240-255. [PMID: 34797216 DOI: 10.1556/030.2021.01620] [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: 10/03/2021] [Accepted: 10/22/2021] [Indexed: 11/19/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) and coronavirus disease 2019 (COVID-19) infection can both lead to severe cytokine release syndrome (sCRS) resulting in critical illness and death. In this single institution, preliminary comparative case-series study we compared clinical and laboratory co-variates as well as response to tocilizumab (TCZ)-based therapy of 15 allogeneic-HSCT- and 17 COVID-19-associated sCRS patients. Reaction to a TCZ plus posttransplant cyclophosphamide (PTCY) consolidation therapy in the allogeneic-HSCT-associated sCRS group yielded significantly inferior long-term outcome as compared to TCZ-based therapy in the COVID-19-associated group (P = 0.003). We report that a TCZ followed by consolidation therapy with a Janus kinase/signal transducer and activator of transcription (JAK/STAT) inhibitor given to 4 out of 8 critically ill COVID-19 patients resulted in their complete recovery. Non-selective JAK/STAT inhibitors influencing the action of several cytokines exhibit a broader effect than TCZ alone in calming down sCRS. Serum levels of cytokines and chemokines show similar changes in allogeneic-HSCT- and COVID-19-associated sCRS with marked elevation of interleukin-6 (IL-6), regulated upon activation normal T-cell expressed and secreted (RANTES), monocyte chemoattractant protein-1 (MCP-1) and interferon γ-induced protein 10 kDa (IP-10) levels. In addition, levels of IL-5, IL-10, IL-15 were also elevated in allogeneic-HSCT-associated sCRS. Our multi-cytokine expression data indicate that the pathophysiology of allogeneic-HSCT and COVID-19-associated sCRS are similar therefore the same clinical grading system and TCZ-based treatment approaches can be applied. TCZ with JAK/STAT inhibitor consolidation therapy might be highly effective in COVID-19 sCRS patients.
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Affiliation(s)
- László Gopcsa
- 1Central Hospital of Southern-Pest, National Institute of Hematology and Infectious Diseases, Department of Hematology and Stem Cell Transplantation, Albert Florian ut 5-7, H-1097, Budapest, Hungary
| | - Ilona Bobek
- 2Central Hospital of Southern-Pest, National Institute of Hematology and Infectious Diseases, Department of Intensive Care Unit, Albert Florian ut 5-7, H-1097, Budapest, Hungary
| | - Gabriella Bekő
- 3Central Hospital of Southern-Pest, National Institute of Hematology and Infectious Diseases, Department of Central Laboratory, Albert Florian ut 5-7, H-1097, Budapest, Hungary
| | - Botond Lakatos
- 4Central Hospital of Southern-Pest, National Institute of Hematology and Infectious Diseases, Department of Infectious Diseases, Albert Florian ut 5-7, H-1097, Budapest, Hungary
| | - Eszter Molnár
- 2Central Hospital of Southern-Pest, National Institute of Hematology and Infectious Diseases, Department of Intensive Care Unit, Albert Florian ut 5-7, H-1097, Budapest, Hungary
| | - Marienn Réti
- 1Central Hospital of Southern-Pest, National Institute of Hematology and Infectious Diseases, Department of Hematology and Stem Cell Transplantation, Albert Florian ut 5-7, H-1097, Budapest, Hungary
| | - Péter Reményi
- 1Central Hospital of Southern-Pest, National Institute of Hematology and Infectious Diseases, Department of Hematology and Stem Cell Transplantation, Albert Florian ut 5-7, H-1097, Budapest, Hungary
| | - János Sinkó
- 1Central Hospital of Southern-Pest, National Institute of Hematology and Infectious Diseases, Department of Hematology and Stem Cell Transplantation, Albert Florian ut 5-7, H-1097, Budapest, Hungary
| | - János Szlávik
- 4Central Hospital of Southern-Pest, National Institute of Hematology and Infectious Diseases, Department of Infectious Diseases, Albert Florian ut 5-7, H-1097, Budapest, Hungary
| | - Gábor Tatai
- 1Central Hospital of Southern-Pest, National Institute of Hematology and Infectious Diseases, Department of Hematology and Stem Cell Transplantation, Albert Florian ut 5-7, H-1097, Budapest, Hungary
| | - István Vályi-Nagy
- 1Central Hospital of Southern-Pest, National Institute of Hematology and Infectious Diseases, Department of Hematology and Stem Cell Transplantation, Albert Florian ut 5-7, H-1097, Budapest, Hungary
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Dave P, Pallares Vela E, Cancarevic I. Is Prophylaxis the Only Way Out for Cytokine Release Syndrome Associated With Chimeric Antigen T-cell Therapy? Cureus 2021; 13:e17709. [PMID: 34650883 PMCID: PMC8489777 DOI: 10.7759/cureus.17709] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 09/04/2021] [Indexed: 12/25/2022] Open
Abstract
Chimeric antigen receptor T-cell (CAR-T) therapy is a new advancement in hematology and oncology with its use in treating many refractory malignancies. Cytokine release syndrome (CRS) is CAR-T's clinically hazardous side effect, ranging from mild to life-threatening events. It was one of the first side effects detected with CAR-T. We conducted a literature review using PubMed (MeSH) to study CRS incidence after the administration of CAR-T to reflect its clinical importance. Nine studies are mentioned, with a total of 1357 patients enrolled for different types of refractory/relapsed cancers, and an average incidence of CRS of 64% is being noted. We have also stated numerous studies which mentioned the use and effectiveness of the commonly used drugs like tocilizumab, corticosteroids, and some new drugs. Although statistical data on CRS's conservative and supportive management is not available, the role of different supportive measures is evident. An overview of how it sets the framework of a peri-management approach has been considered. Through heightened incidence and relatively complex management of CRS, we would like to raise the question of the need for early prophylaxis against CRS when considering CAR-T. The need for more clinical trials in the future to prove the effectiveness of the latter is stated.
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Affiliation(s)
- Prashil Dave
- General Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Elisa Pallares Vela
- General Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ivan Cancarevic
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Winter SF, Jo J, Schiff D, Dietrich J. Central Nervous System Complications Among Oncology Patients. Hematol Oncol Clin North Am 2021; 36:217-236. [PMID: 34607715 DOI: 10.1016/j.hoc.2021.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Cancer treatment related injury to the central nervous system (CNS) is well-recognized in the setting of brain-directed radiation therapies and conventional and novel systemic anticancer therapies. Late-delayed treatment-induced CNS complications frequently result in permanent neurologic disability. Therapeutic options are supportive with limited clinical benefit, whereby alteration or discontinuation of the overall antineoplastic treatment plan is frequently necessary to prevent further neurologic injury. Better identification of patients at high risk for developing late CNS toxicities, neuroprotective strategies with modification of existing antineoplastic treatment regimens, and research efforts directed at earlier recognition and improved treatment of central neurologic complications are paramount.
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Affiliation(s)
- Sebastian F Winter
- Department of Neurology and MGH Cancer Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of Neurology and Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117 Berlin, Germany
| | - Jasmin Jo
- Division of Hematology and Oncology, Department of Internal Medicine, East Carolina University, 600 Moye Boulevard, Greenville, NC 27858-4353, USA
| | - David Schiff
- Division of Neuro-Oncology, Department of Neurology, University of Virginia, 1240 Lee Street, Charlottesville, VA 22903, USA.
| | - Jorg Dietrich
- Department of Neurology and MGH Cancer Center, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Yawkey 9E, Boston, MA 02114, USA.
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Shin YH, Tian X, Park JJ, Kim GYG, Aboujaoude E, Sturgill MG. Management of chimeric antigen receptor T-cell induced cytokine release syndrome: Current and emerging approaches. J Oncol Pharm Pract 2021; 28:159-174. [PMID: 34586003 DOI: 10.1177/10781552211039238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The most common adverse event associated with chimeric antigen receptor T-cell therapy is cytokine release syndrome, which is characterized by fever, hypoxia, and hypotension in varying degrees of severity. In severe cases, cytokine release syndrome can result in life-threatening symptoms such as multi-organ failure. The widely accepted first-line therapy for cytokine release syndrome management is tocilizumab with or without corticosteroids, but there is very limited guidance on the proper management of patients unresponsive to this regimen. There are emerging strategies that target cytokine release syndrome through novel mechanisms, showing promise in treating or preventing severe cytokine release syndrome. Although further clinical investigation is necessary to assess the applicability of the emerging approaches, these exploratory therapies may shape the future landscape of chimeric antigen receptor T-cell induced cytokine release syndrome management. This review article provides a comprehensive overview of the current and emerging therapies for the management of chimeric antigen receptor T-cell induced cytokine release syndrome, especially cases that are refractory to tocilizumab and steroids.
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Affiliation(s)
- Yunjung H Shin
- 15484Rutgers University Ernest Mario School of Pharmacy, USA
| | - Xiaofan Tian
- 15484Rutgers University Ernest Mario School of Pharmacy, USA
| | - Jiyeon J Park
- 15484Rutgers University Ernest Mario School of Pharmacy, USA.,145249Rutgers Cancer Institute of New Jersey, USA
| | - Gee Y Geeny Kim
- 15484Rutgers University Ernest Mario School of Pharmacy, USA.,3673Hackensack University Medical Center, USA
| | - Emily Aboujaoude
- 15484Rutgers University Ernest Mario School of Pharmacy, USA.,25044Robert Wood Johnson University Hospital, USA
| | - Marc G Sturgill
- 15484Rutgers University Ernest Mario School of Pharmacy, USA
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Wang S, Chen K, Lei Q, Ma P, Yuan AQ, Zhao Y, Jiang Y, Fang H, Xing S, Fang Y, Jiang N, Miao H, Zhang M, Sun S, Yu Z, Tao W, Zhu Q, Nie Y, Li N. The state of the art of bispecific antibodies for treating human malignancies. EMBO Mol Med 2021; 13:e14291. [PMID: 34431224 PMCID: PMC8422067 DOI: 10.15252/emmm.202114291] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 07/08/2021] [Accepted: 07/09/2021] [Indexed: 12/26/2022] Open
Abstract
Bispecific antibodies (bsAb) that target two independent epitopes or antigens have been extensively explored in translational and clinical studies since they were first developed in the 1960s. Many bsAbs are being tested in clinical trials for treating a variety of diseases, mostly cancer. Here, we provide an overview of various types of bsAbs in clinical studies and discuss their targets, safety profiles, and efficacy. We also highlight the current challenges, potential solutions, and future directions of bsAb development for cancer treatment.
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Affiliation(s)
- Shuhang Wang
- Clinical Cancer Center/National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Kun Chen
- NHC Key Laboratory of Pulmonary Immunological Diseases is supported by the non‐profit Central Research Institute fund of Chinese Academy of Medical Sciences (2019PT320003)Guizhou Provincial People’s HospitalGuiyangChina
| | - Qi Lei
- Clinical Cancer Center/National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Peiwen Ma
- Clinical Cancer Center/National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | | | - Yong Zhao
- Nanjing Umab‐biopharma Co., LtdNanjingChina
| | | | - Hong Fang
- Clinical Cancer Center/National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Shujun Xing
- Clinical Cancer Center/National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Yuan Fang
- Clinical Cancer Center/National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Ning Jiang
- Clinical Cancer Center/National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Huilei Miao
- Clinical Cancer Center/National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Minghui Zhang
- Department of Medical OncologyHarbin Medical University Cancer HospitalHarbinChina
| | - Shujun Sun
- Queen Mary SchoolNanchang UniversityNanchangChina
| | | | - Wei Tao
- China Pharmaceutical UniversityNanjingChina
| | - Qi Zhu
- China Pharmaceutical UniversityNanjingChina
| | - Yingjie Nie
- NHC Key Laboratory of Pulmonary Immunological Diseases is supported by the non‐profit Central Research Institute fund of Chinese Academy of Medical Sciences (2019PT320003)Guizhou Provincial People’s HospitalGuiyangChina
| | - Ning Li
- Clinical Cancer Center/National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
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Hernández-López A, Téllez-González MA, Mondragón-Terán P, Meneses-Acosta A. Chimeric Antigen Receptor-T Cells: A Pharmaceutical Scope. Front Pharmacol 2021; 12:720692. [PMID: 34489708 PMCID: PMC8417740 DOI: 10.3389/fphar.2021.720692] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/02/2021] [Indexed: 12/18/2022] Open
Abstract
Cancer is among the leading causes of death worldwide. Therefore, improving cancer therapeutic strategies using novel alternatives is a top priority on the contemporary scientific agenda. An example of such strategies is immunotherapy, which is based on teaching the immune system to recognize, attack, and kill malignant cancer cells. Several types of immunotherapies are currently used to treat cancer, including adoptive cell therapy (ACT). Chimeric Antigen Receptors therapy (CAR therapy) is a kind of ATC where autologous T cells are genetically engineered to express CARs (CAR-T cells) to specifically kill the tumor cells. CAR-T cell therapy is an opportunity to treat patients that have not responded to other first-line cancer treatments. Nowadays, this type of therapy still has many challenges to overcome to be considered as a first-line clinical treatment. This emerging technology is still classified as an advanced therapy from the pharmaceutical point of view, hence, for it to be applied it must firstly meet certain requirements demanded by the authority. For this reason, the aim of this review is to present a global vision of different immunotherapies and focus on CAR-T cell technology analyzing its elements, its history, and its challenges. Furthermore, analyzing the opportunity areas for CAR-T technology to become an affordable treatment modality taking the basic, clinical, and practical aspects into consideration.
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Affiliation(s)
- Alejandrina Hernández-López
- Laboratorio 7 Biotecnología Farmacéutica, Facultad de Farmacia, Universidad Autónoma Del Estado de Morelos, UAEM, Cuernavaca, Mexico
| | - Mario A. Téllez-González
- Laboratorio 7 Biotecnología Farmacéutica, Facultad de Farmacia, Universidad Autónoma Del Estado de Morelos, UAEM, Cuernavaca, Mexico
- Coordinación de Investigación, Centro Médico Nacional “20 de Noviembre” ISSSTE, Mexico city, Mexico
| | - Paul Mondragón-Terán
- Coordinación de Investigación, Centro Médico Nacional “20 de Noviembre” ISSSTE, Mexico city, Mexico
| | - Angélica Meneses-Acosta
- Laboratorio 7 Biotecnología Farmacéutica, Facultad de Farmacia, Universidad Autónoma Del Estado de Morelos, UAEM, Cuernavaca, Mexico
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Jayakumar I, Uppuluri R, Lakshmanan C, Kumar Gowdhaman A, Vellaichamy Swaminathan V, Raj R. Risk-adapted therapy for the management of cytokine release syndrome in children undergoing unmanipulated haploidentical stem cell transplantation. Pediatr Transplant 2021; 25:e13964. [PMID: 33370509 DOI: 10.1111/petr.13964] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 12/06/2020] [Accepted: 12/13/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND We aimed to describe an algorithm for the management of cytokine release syndrome (CRS) associated with haploidentical hematopoietic stem cell transplantation (haploSCT). PATIENTS AND METHODS We performed a prospective study where children up to 18 years of age undergoing haploSCT with post-transplant cyclophosphamide from September 2014 to March 2020 were included. Supportive care included low-dose adrenaline, high-flow nasal cannula, and N-acetylcysteine (NAC). Methylprednisolone and tocilizumab were administered in the peri-engraftment phase for grade 2 CRS or one-log increase and grade 3 CRS or a two-log increase in ferritin, respectively. RESULTS Data were analyzed in 135/148 children as 13 children died before engraftment due to sepsis. CRS was noted in 97% transplants (grade 1-74.1%, grade 2-15.6%, grade 3-6.7%, grade 4-1.4%). Grade 2 and above CRS was higher in non-malignant conditions (33% vs 13%, P-value .009). The percentage median rise in ferritin was 129%-grade 1, 171%-grade 2, and 344%-grade 3. Seven children received tocilizumab, and two of whom had ferritin values greater than 100 000 ng/mL with no mortality in this group. Low-dose adrenaline, high-flow nasal cannula, and ventilator support were needed in 13%, 10%, and 4%, respectively. Mortality in our cohort was 3/135 (2.2%), with two deaths due to sepsis and one due to grade 4 CRS. CONCLUSIONS A risk-stratified approach using steroids in grade 2 and tocilizumab in grade 3/4 in the setting of haploSCT with NAC infusion and early use of low-dose adrenaline and HFNC can help provide adequate control of CRS, thereby ensuring optimal outcomes and survival.
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Affiliation(s)
- Indira Jayakumar
- Department of Pediatric Critical Care, Apollo Hospital, Chennai, India
| | - Ramya Uppuluri
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplantation, Apollo Hospital, Chennai, India
| | | | | | | | - Revathi Raj
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplantation, Apollo Hospital, Chennai, India
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Leclercq G, Haegel H, Schneider A, Giusti AM, Marrer-Berger E, Boetsch C, Walz AC, Pulko V, Sam J, Challier J, Ferlini C, Odermatt A, Umaña P, Bacac M, Klein C. Src/lck inhibitor dasatinib reversibly switches off cytokine release and T cell cytotoxicity following stimulation with T cell bispecific antibodies. J Immunother Cancer 2021; 9:jitc-2021-002582. [PMID: 34326166 PMCID: PMC8323395 DOI: 10.1136/jitc-2021-002582] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2021] [Indexed: 12/29/2022] Open
Abstract
Background T cell engagers are bispecific antibodies recognizing, with one moiety, the CD3ε chain of the T cell receptor and, with the other moiety, specific tumor surface antigens. Crosslinking of CD3 upon simultaneous binding to tumor antigens triggers T cell activation, proliferation and cytokine release, leading to tumor cell killing. Treatment with T cell engagers can be associated with safety liabilities due to on-target on-tumor, on-target off-tumor cytotoxic activity and cytokine release syndrome (CRS). Tyrosine kinases such as SRC, LCK or ZAP70 are involved in downstream signaling pathways after engagement of the T cell receptor and blocking these kinases might serve to abrogate T cell activation when required (online supplemental material 1). Dasatinib was previously identified as a potent kinase inhibitor that switches off CAR T cell functionality. Methods Using an in vitro model of target cell killing by human peripheral blood mononuclear cells, we assessed the effects of dasatinib combined with 2+1 T cell bispecific antibodies (TCBs) including CEA-TCB, CD19-TCB or HLA-A2 WT1-TCB on T cell activation, proliferation and target cell killing measured by flow cytometry and cytokine release measured by Luminex. To determine the effective dose of dasatinib, the Incucyte system was used to monitor the kinetics of TCB-mediated target cell killing in the presence of escalating concentrations of dasatinib. Last, the effects of dasatinib were evaluated in vivo in humanized NSG mice co-treated with CD19-TCB. The count of CD20+ blood B cells was used as a readout of efficacy of TCB-mediated killing and cytokine levels were measured in the serum. Results Dasatinib concentrations above 50 nM prevented cytokine release and switched off-target cell killing, which were subsequently restored on removal of dasatinib. In addition, dasatinib prevented CD19-TCB-mediated B cell depletion in humanized NSG mice. These data confirm that dasatinib can act as a rapid and reversible on/off switch for activated T cells at pharmacologically relevant doses as they are applied in patients according to the label. Conclusion Taken together, we provide evidence for the use of dasatinib as a pharmacological on/off switch to mitigate off-tumor toxicities or CRS by T cell bispecific antibodies.
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Affiliation(s)
- Gabrielle Leclercq
- Roche Pharma Research and Early Development, Roche Innovation Centre Zurich, Schlieren, Switzerland .,Department of Pharmaceutical Sciences, Division of Molecular and Systems Toxicology, University of Basel, Basel, Switzerland
| | - Hélène Haegel
- Roche Pharma Research and Early Development, Roche Innovation Centre Zurich, Schlieren, Switzerland
| | - Anneliese Schneider
- Roche Pharma Research and Early Development, Roche Innovation Centre Zurich, Schlieren, Switzerland
| | - Anna Maria Giusti
- Roche Pharma Research and Early Development, Roche Innovation Centre Zurich, Schlieren, Switzerland
| | - Estelle Marrer-Berger
- Roche Pharma Research and Early Development, Roche Innovation Center Basel, Basel, Switzerland
| | - Christophe Boetsch
- Roche Pharma Research and Early Development, Roche Innovation Center Basel, Basel, Switzerland
| | - Antje-Christine Walz
- Roche Pharma Research and Early Development, Roche Innovation Center Basel, Basel, Switzerland
| | - Vesna Pulko
- Roche Pharma Research and Early Development, Roche Innovation Centre Zurich, Schlieren, Switzerland
| | - Johannes Sam
- Roche Pharma Research and Early Development, Roche Innovation Centre Zurich, Schlieren, Switzerland
| | - John Challier
- Roche Pharma Research and Early Development, Roche Innovation Centre Zurich, Schlieren, Switzerland
| | - Cristiano Ferlini
- Roche Pharma Research and Early Development, Roche Innovation Centre Zurich, Schlieren, Switzerland
| | - Alex Odermatt
- Department of Pharmaceutical Sciences, Division of Molecular and Systems Toxicology, University of Basel, Basel, Switzerland
| | - Pablo Umaña
- Roche Pharma Research and Early Development, Roche Innovation Centre Zurich, Schlieren, Switzerland
| | - Marina Bacac
- Roche Pharma Research and Early Development, Roche Innovation Centre Zurich, Schlieren, Switzerland
| | - Christian Klein
- Roche Pharma Research and Early Development, Roche Innovation Centre Zurich, Schlieren, Switzerland
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48
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Constantinescu C, Pasca S, Tat T, Teodorescu P, Vlad C, Iluta S, Dima D, Tomescu D, Scarlatescu E, Tanase A, Sigurjonsson OE, Colita A, Einsele H, Tomuleasa C. Continuous renal replacement therapy in cytokine release syndrome following immunotherapy or cellular therapies? J Immunother Cancer 2021; 8:jitc-2020-000742. [PMID: 32474415 PMCID: PMC7264828 DOI: 10.1136/jitc-2020-000742] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2020] [Indexed: 02/07/2023] Open
Abstract
Recently, an increasing number of novel drugs were approved in oncology and hematology. Nevertheless, pharmacology progress comes with a variety of side effects, of which cytokine release syndrome (CRS) is a potential complication of some immunotherapies that can lead to multiorgan failure if not diagnosed and treated accordingly. CRS generally occurs with therapies that lead to highly activated T cells, like chimeric antigen receptor T cells or in the case of bispecific T-cell engaging antibodies. This, in turn, leads to a proinflammatory state with subsequent organ damage. To better manage CRS there is a need for specific therapies or to repurpose strategies that are already known to be useful in similar situations. Current management strategies for CRS are represented by anticytokine directed therapies and corticosteroids. Based on its pathophysiology and the resemblance of CRS to sepsis and septic shock, as well as based on the principles of initiation of continuous renal replacement therapy (CRRT) in sepsis, we propose the rationale of using CRRT therapy as an adjunct treatment in CRS where all the other approaches have failed in controlling the clinically significant manifestations.
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Affiliation(s)
- Catalin Constantinescu
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania.,Department of Anesthesia - Intensive Care, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Sergiu Pasca
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania.,Medfuture Research Center for Advanced Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Tiberiu Tat
- Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj-Napoca, Romania
| | - Patric Teodorescu
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania.,Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj-Napoca, Romania
| | - Catalin Vlad
- Department of Surgery, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Sabina Iluta
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania.,Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj-Napoca, Romania
| | - Delia Dima
- Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj-Napoca, Romania
| | - Dana Tomescu
- Department of Anesthesia - Intensive Care, Carol Davila University of Medicine and Pharmacy, Bucuresti, Romania.,Department of Anesthesia - Intensive Care, Fundeni Clinical Institute, Bucuresti, Romania
| | - Ecaterina Scarlatescu
- Department of Stem Cell Transplantation, Clinical Institute Fundeni, Bucuresti, Romania
| | - Alina Tanase
- Department of Stem Cell Transplantation, Clinical Institute Fundeni, Bucuresti, Romania
| | - Olafur Eysteinn Sigurjonsson
- University of Reykjavik, Reykjavik, Iceland.,Bloodbank, Landspitali National University Hospital of Iceland, Reykjavik, Iceland
| | - Anca Colita
- Department of Stem Cell Transplantation, Clinical Institute Fundeni, Bucuresti, Romania
| | - Hermann Einsele
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Wurzburg, Bayern, Germany
| | - Ciprian Tomuleasa
- Research Center for Functional Genomics and Translational Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
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Oluwole OO, Bouabdallah K, Muñoz J, De Guibert S, Vose JM, Bartlett NL, Lin Y, Deol A, McSweeney PA, Goy AH, Kersten MJ, Jacobson CA, Farooq U, Minnema MC, Thieblemont C, Timmerman JM, Stiff P, Avivi I, Tzachanis D, Kim JJ, Bashir Z, McLeroy J, Zheng Y, Rossi JM, Johnson L, Goyal L, van Meerten T. Prophylactic corticosteroid use in patients receiving axicabtagene ciloleucel for large B-cell lymphoma. Br J Haematol 2021; 194:690-700. [PMID: 34296427 PMCID: PMC8457222 DOI: 10.1111/bjh.17527] [Citation(s) in RCA: 97] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 03/21/2021] [Indexed: 01/22/2023]
Abstract
ZUMA‐1 (NCT02348216) examined the safety and efficacy of axicabtagene ciloleucel (axi‐cel), an autologous CD19‐directed chimaeric antigen receptor (CAR)‐T cell therapy, in refractory large B‐cell lymphoma. To reduce treatment‐related toxicity, several exploratory safety management cohorts were added to ZUMA‐1. Specifically, cohort 6 investigated management of cytokine release syndrome (CRS) and neurologic events (NEs) with prophylactic corticosteroids and earlier corticosteroid and tocilizumab intervention. CRS and NE incidence and severity were primary end‐points. Following leukapheresis, patients could receive optional bridging therapy per investigator discretion. All patients received conditioning chemotherapy (days −5 through −3), 2 × 106 CAR‐T cells/kg (day 0) and once‐daily oral dexamethasone [10 mg, day 0 (before axi‐cel) through day 2]. Forty patients received axi‐cel. CRS occurred in 80% of patients (all grade ≤2). Any grade and grade 3 or higher NEs occurred in 58% and 13% of patients respectively. Sixty‐eight per cent of patients did not experience CRS or NEs within 72 h of axi‐cel. With a median follow‐up of 8·9 months, objective and complete response rates were 95% and 80% respectively. Overall, prophylactic corticosteroids and earlier corticosteroid and/or tocilizumab intervention resulted in no grade 3 or higher CRS, a low rate of grade 3 or higher NEs and high response rates in this study population.
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Affiliation(s)
| | - Krimo Bouabdallah
- Service d'Hématologie et Thérapie Cellulaire, CHU Bordeaux, Bordeaux, France
| | - Javier Muñoz
- Banner MD Anderson Cancer Center, Gilbert, AZ, USA
| | | | - Julie M Vose
- University of Nebraska Medical Center, Omaha, NE, USA
| | - Nancy L Bartlett
- Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Yi Lin
- Mayo Clinic, Rochester, MN, USA
| | - Abhinav Deol
- Karmanos Cancer Center, Wayne State University, Detroit, MI, USA
| | | | - Andre H Goy
- John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Marie José Kersten
- Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands, on behalf of HOVON/LLPC
| | | | | | - Monique C Minnema
- University Medical Center Utrecht, Utrecht, Netherlands, on behalf of HOVON/LLPC
| | - Catherine Thieblemont
- Université de Paris, AP-HP, Hôpital Saint-Louis, Hemato-oncology, DMU HI; Research Unit NF-kappaB, Différenciation et Cancer, Paris, France
| | | | - Patrick Stiff
- Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Irit Avivi
- Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Jenny J Kim
- Kite, a Gilead Company, Santa Monica, CA, USA
| | | | | | - Yan Zheng
- Kite, a Gilead Company, Santa Monica, CA, USA
| | | | | | | | - Tom van Meerten
- University Medical Center Groningen, Groningen, Netherlands, on behalf of HOVON/PPLC
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50
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Raja K, Daniel N, Morrison S, Patel R, Gerges J, Nadeem K, Chen B, Kang S, Patel M, Beggs D, Attalla M, Ballem N, Philips M. Impact of Tocilizumab on Clinical Outcomes in COVID-19-Associated Cytokine Release Syndrome: A Single-Center Experience. J Pharm Pract 2021; 36:213-220. [PMID: 34231415 DOI: 10.1177/08971900211028208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Tocilizumab is an interleukin-6 receptor antagonist hypothesized to blunt the uncontrolled immune response, cytokine release syndrome, in severe COVID-19 and prevent attributable morbidity and mortality. Objective: The objective of this study was to assess the impact of tocilizumab on clinical outcomes in COVID-19-associated cytokine release syndrome. METHODS Single-center, retrospective cohort study assessing sixty-nine adult patients receiving tocilizumab for suspected COVID-19 cytokine release syndrome. The primary outcome was change in WHO clinical status scale on day seven post-dose analyzed using the Wilcoxon signed rank test. Secondary outcomes assessed impact of timing of administration on clinical outcome. Safety analyses included development of neutropenia, thrombocytopenia, transaminitis, and sepsis within 7 days post-dose. Statistical analyses were conducted using Microsoft Excel. RESULTS No aggregate clinical change was found between day 0 and day 7. Eleven patients improved, twenty-seven worsened, and thirty-one showed no change. Clinical outcomes were weakly correlated with time from symptom onset (rs = 0.21; p = 0.08) or hospital admission (rs = -0.08; p = 0.49) to dose. In-hospital mortality was 63%. Sepsis was diagnosed in 21 patients, five of which were post-dose. Transaminitis, neutropenia, and thrombocytopenia occurred in seven, one, and six patients, respectively. CONCLUSION Tocilizumab did not appear to influence clinical outcomes in our study population, irrespective of timing of administration. Adverse events were not considered drug-related.
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Affiliation(s)
- Karan Raja
- Department of Pharmacy, Clara Maass Medical Center, Belleville, NJ, USA
| | - Nicole Daniel
- Department of Pharmacy, Clara Maass Medical Center, Belleville, NJ, USA
| | - Susan Morrison
- Department of Medicine, Clara Maass Medical Center, Belleville, NJ, USA
| | - Ruben Patel
- Department of Pharmacy, Clara Maass Medical Center, Belleville, NJ, USA
| | - Jessica Gerges
- Department of Pharmacy, Clara Maass Medical Center, Belleville, NJ, USA
| | - Komal Nadeem
- Department of Pharmacy, Clara Maass Medical Center, Belleville, NJ, USA
| | - Brandon Chen
- Department of Pharmacy, Clara Maass Medical Center, Belleville, NJ, USA
| | - Soo Kang
- Department of Pharmacy, Clara Maass Medical Center, Belleville, NJ, USA
| | - Mitesh Patel
- Department of Pharmacy, Clara Maass Medical Center, Belleville, NJ, USA
| | - Donald Beggs
- Department of Medicine, Clara Maass Medical Center, Belleville, NJ, USA
| | - Mark Attalla
- Department of Pharmacy, Clara Maass Medical Center, Belleville, NJ, USA
| | - Naveen Ballem
- Department of Medicine, Clara Maass Medical Center, Belleville, NJ, USA
| | - Mona Philips
- Department of Pharmacy, Clara Maass Medical Center, Belleville, NJ, USA
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