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Katsin M, Shman T, Migas A, Lutskovich D, Serada Y, Khalankova Y, Kostina Y, Dubovik S. Case report: Rapid resolution of grade IV ICANS after first line intrathecal chemotherapy with methotrexate, cytarabine and dexamethasone. Front Immunol 2024; 15:1380451. [PMID: 38765003 PMCID: PMC11099209 DOI: 10.3389/fimmu.2024.1380451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 04/22/2024] [Indexed: 05/21/2024] Open
Abstract
Corticosteroid therapy is the mainstay of immune effector cell-associated neurotoxicity syndrome (ICANS) management, although its use has been associated with worse overall survival (OS) and progression-free survival (PFS) after chimeric antigen receptor T-cell (CAR-T cell) therapy. Many options are being investigated for prophylaxis and management. Accumulating evidence supports the use of intrathecal (IT) chemotherapy for the management of high-grade ICANS. Here, we describe a case of a patient with stage IV Primary mediastinal B-cell lymphoma (PMBCL) successfully treated with IT methotrexate, cytarabine, and dexamethasone as first-line therapy for CD19 CAR-T cell-associated grade IV ICANS. The stable and rapid resolution of ICANS to grade 0 allowed us to discontinue systemic corticosteroid use, avoiding CAR-T cells ablation and ensuring preservation of CAR-T cell function. The described patient achieved a complete radiologic and clinical response to CD19 CAR-T cell therapy and remains disease-free after 9 months. This case demonstrates a promising example of how IT chemotherapy could be used as first-line treatment for the management of high-grade ICANS.
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Affiliation(s)
- Mikalai Katsin
- Department of Hematology, Vitebsk Regional Clinical Cancer Centre, Vitebsk, Belarus
| | - Tatsiana Shman
- Laboratory of Genetic Biotechnologies, Belarusian Research Center for Pediatric Oncology, Hematology and Immunology, Minsk, Belarus
| | - Alexandr Migas
- Laboratory of Genetic Biotechnologies, Belarusian Research Center for Pediatric Oncology, Hematology and Immunology, Minsk, Belarus
| | - Dzmitry Lutskovich
- Laboratory of Genetic Biotechnologies, Belarusian Research Center for Pediatric Oncology, Hematology and Immunology, Minsk, Belarus
| | - Yuliya Serada
- Department of Hematology, Vitebsk Regional Clinical Cancer Centre, Vitebsk, Belarus
| | - Yauheniya Khalankova
- Department of Hematology, Vitebsk Regional Clinical Cancer Centre, Vitebsk, Belarus
| | - Yuliya Kostina
- Department of Hematology, Vitebsk Regional Clinical Cancer Centre, Vitebsk, Belarus
| | - Simon Dubovik
- Laboratory of Molecular Diagnostics and Biotechnology, Institute of Bioorganic Chemistry of the National Academy of Sciences of Belarus, Minsk, Belarus
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Sales C, Anderson MA, Kuznetsova V, Rosenfeld H, Malpas CB, Roos I, Dickinson M, Harrison S, Kalincik T. Patterns of neurotoxicity among patients receiving chimeric antigen receptor T-cell therapy: A single-centre cohort study. Eur J Neurol 2024; 31:e16174. [PMID: 38085272 PMCID: PMC11235605 DOI: 10.1111/ene.16174] [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: 05/02/2023] [Revised: 09/28/2023] [Accepted: 11/23/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND AND PURPOSE Immune effector cell-associated neurotoxicity syndrome (ICANS) is an important complication of chimeric antigen receptor T-cell (CAR-T) therapy. This study aims to identify the patterns of neurotoxicity among patients with ICANS at a tertiary referral centre in Australia. METHODOLOGY This single-centre, prospective cohort study included all consecutively recruited patients who underwent CAR-T therapy for eligible haematological malignancies. All patients underwent a comprehensive neurological assessment and cognitive screening before CAR-T infusion, during the development of ICANS, and 1 month after treatment. Baseline demographic characteristics, incidence, and neurological patterns of neurotoxicity management were evaluated. RESULTS Over a 19-month period, 23% (12) of the 53 eligible patients developed neurotoxicity (10/12 [83%] being grade 1). All patients showed changes in handwriting and tremor as their initial presentation. Changes in cognition were manifested in most of the patients, with a more substantial drop noted in their Montreal Cognitive Assessment compared to immune effector cell-associated encephalopathy scores. All manifestations of neurotoxicity were short-lived and resolved within a 1-month period, with a mean duration of 8.2 days (range = 1-33). CONCLUSIONS The patterns of CAR-T-related neurotoxicity often include change in handwriting, tremor, and mild confusional state, especially early in their evolution. These may remain undetected by routine neurological surveillance. These features represent accessible clinical markers of incipient ICANS.
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Affiliation(s)
- Carmela Sales
- Neuroimmunology Centre, Department of NeurologyRoyal Melbourne HospitalMelbourneVictoriaAustralia
- Department of Clinical HaematologyPeter MacCallum Cancer Centre, Royal Melbourne HospitalMelbourneVictoriaAustralia
| | - Mary Ann Anderson
- Department of Clinical HaematologyPeter MacCallum Cancer Centre, Royal Melbourne HospitalMelbourneVictoriaAustralia
- Division of Blood Cells and Blood CancerWalter and Eliza Hall InstituteParkvilleVictoriaAustralia
| | - Valeriya Kuznetsova
- Neuroimmunology Centre, Department of NeurologyRoyal Melbourne HospitalMelbourneVictoriaAustralia
- Department of Clinical HaematologyPeter MacCallum Cancer Centre, Royal Melbourne HospitalMelbourneVictoriaAustralia
- Clinical Outcomes Research (CORe), Department of MedicineUniversity of MelbourneParkvilleVictoriaAustralia
| | - Hannah Rosenfeld
- Neuroimmunology Centre, Department of NeurologyRoyal Melbourne HospitalMelbourneVictoriaAustralia
- Department of Clinical HaematologyPeter MacCallum Cancer Centre, Royal Melbourne HospitalMelbourneVictoriaAustralia
| | - Charles B. Malpas
- Neuroimmunology Centre, Department of NeurologyRoyal Melbourne HospitalMelbourneVictoriaAustralia
- Clinical Outcomes Research (CORe), Department of MedicineUniversity of MelbourneParkvilleVictoriaAustralia
- Melbourne School of Psychological SciencesUniversity of MelbourneParkvilleVictoriaAustralia
| | - Izanne Roos
- Neuroimmunology Centre, Department of NeurologyRoyal Melbourne HospitalMelbourneVictoriaAustralia
- Clinical Outcomes Research (CORe), Department of MedicineUniversity of MelbourneParkvilleVictoriaAustralia
| | - Michael Dickinson
- Department of Clinical HaematologyPeter MacCallum Cancer Centre, Royal Melbourne HospitalMelbourneVictoriaAustralia
- Sir Peter MacCallum Department of OncologyUniversity of MelbourneParkvilleVictoriaAustralia
| | - Simon Harrison
- Department of Clinical HaematologyPeter MacCallum Cancer Centre, Royal Melbourne HospitalMelbourneVictoriaAustralia
- Sir Peter MacCallum Department of OncologyUniversity of MelbourneParkvilleVictoriaAustralia
| | - Tomas Kalincik
- Neuroimmunology Centre, Department of NeurologyRoyal Melbourne HospitalMelbourneVictoriaAustralia
- Clinical Outcomes Research (CORe), Department of MedicineUniversity of MelbourneParkvilleVictoriaAustralia
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Oluwole OO, Dholaria B, Knight TE, Jain T, Locke FL, Ramsdell L, Nikiforow S, Hashmi H, Mooney K, Bhaskar ST, Morris K, Gatwood K, Baer B, Anderson LD, Hamadani M. Chimeric Antigen Receptor T-Cell Therapy in the Outpatient Setting: An Expert Panel Opinion from the American Society for Transplantation and Cellular Therapy. Transplant Cell Ther 2024; 30:131-142. [PMID: 37951502 DOI: 10.1016/j.jtct.2023.11.008] [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: 11/03/2023] [Accepted: 11/06/2023] [Indexed: 11/14/2023]
Abstract
The first series of chimeric antigen receptor T (CAR-T) cell therapy products were approved in 2017 to 2019 and have shown remarkable efficacy in both clinical trials and the real-world setting, but at the cost of prolonged patient hospitalization. As the toxicity management protocols were refined, the concept of cellular therapy administered in the outpatient setting gained steam, and single institutions began to perform certain aspects of CAR-T monitoring in the outpatient setting for select patients. However, there are many considerations for a successful outpatient program. In anticipation of increasing use of CAR-T-cell therapy in the outpatient setting as a mechanism to overcome frequent hospital bed shortages and high cost of inpatient care, the American Society for Transplantation and Cellular Therapy convened a group of experts in hematology, oncology, and cellular therapy to provide a comprehensive review of the existing publications on outpatient CAR-T cell therapy, discuss selected ongoing clinical trials of outpatient CAR-T, and describe strategies to optimize safety without compromising efficacy for patients treated and monitored in the outpatient setting.
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Affiliation(s)
- Olalekan O Oluwole
- Division of Hematology Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Bhagirathbhai Dholaria
- Division of Hematology Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tristan E Knight
- Cancer and Blood Disorders Center, Seattle Children's Hospital - Seattle, Washington; Division of Pediatric Hematology and Oncology, Department of Pediatrics, University of Washington School of Medicine - Seattle, Washington
| | - Tania Jain
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Linda Ramsdell
- Division of Hematologic Oncology, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Sarah Nikiforow
- Division of Hematologic Oncology, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Hamza Hashmi
- Medical University of South Carolina, Charleston, South Carolina
| | - Kathy Mooney
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shakthi T Bhaskar
- Division of Hematology Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Katrina Morris
- Division of Hematology Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Katie Gatwood
- Division of Hematology Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Pharmacy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brittney Baer
- Division of Hematology Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Larry D Anderson
- Myeloma, Waldenstrom's, and Amyloidosis Program, Hematologic Malignancies and Cellular Therapies Program, Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, Texas
| | - Mehdi Hamadani
- BMT & Cellular Therapy Program, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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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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Ramapriyan R, Sun J, Curry A, Richardson LG, Ramesh T, Gaffey MA, Gedeon PC, Gerstner ER, Curry WT, Choi BD. The Role of Antibody-Based Therapies in Neuro-Oncology. Antibodies (Basel) 2023; 12:74. [PMID: 37987252 PMCID: PMC10660525 DOI: 10.3390/antib12040074] [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: 08/30/2023] [Revised: 10/16/2023] [Accepted: 11/07/2023] [Indexed: 11/22/2023] Open
Abstract
This review explores the evolving landscape of antibody-based therapies in neuro-oncology, in particular, immune checkpoint inhibitors and immunomodulatory antibodies. We discuss their mechanisms of action, blood-brain barrier (BBB) penetration, and experience in neuro-oncological conditions. Evidence from recent trials indicates that while these therapies can modulate the tumor immune microenvironment, their clinical benefits remain uncertain, largely due to challenges with BBB penetration and tumor-derived immunosuppression. This review also examines emerging targets such as TIGIT and LAG3, the potential of antibodies in modulating the myeloid compartment, and tumor-specific targets for monoclonal antibody therapy. We further delve into advanced strategies such as antibody-drug conjugates and bispecific T cell engagers. Lastly, we explore innovative techniques being investigated to enhance antibody delivery, including CAR T cell therapy. Despite current limitations, these therapies hold significant therapeutic potential for neuro-oncology. Future research should focus on optimizing antibody delivery to the CNS, identifying novel biological targets, and discovering combination therapies to address the hostile tumor microenvironment.
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Affiliation(s)
- Rishab Ramapriyan
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA 02114, USA (A.C.); (L.G.R.); (W.T.C.)
- Harvard Medical School, Boston, MA 02115, USA (E.R.G.)
| | - Jing Sun
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA 02114, USA (A.C.); (L.G.R.); (W.T.C.)
| | - Annabel Curry
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA 02114, USA (A.C.); (L.G.R.); (W.T.C.)
| | - Leland G. Richardson
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA 02114, USA (A.C.); (L.G.R.); (W.T.C.)
| | - Tarun Ramesh
- Harvard Medical School, Boston, MA 02115, USA (E.R.G.)
| | - Matthew A. Gaffey
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA 02114, USA (A.C.); (L.G.R.); (W.T.C.)
| | - Patrick C. Gedeon
- Harvard Medical School, Boston, MA 02115, USA (E.R.G.)
- Department of Surgery, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Elizabeth R. Gerstner
- Harvard Medical School, Boston, MA 02115, USA (E.R.G.)
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - William T. Curry
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA 02114, USA (A.C.); (L.G.R.); (W.T.C.)
- Harvard Medical School, Boston, MA 02115, USA (E.R.G.)
| | - Bryan D. Choi
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA 02114, USA (A.C.); (L.G.R.); (W.T.C.)
- Harvard Medical School, Boston, MA 02115, USA (E.R.G.)
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6
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Andrew EC, Hughes D, Gilsenan M, Mignone C, Khaw SL, Wang SS. Severe persistent neurotoxicity associated with CAR T therapy in children. Br J Haematol 2023; 203:651-655. [PMID: 37528536 DOI: 10.1111/bjh.19015] [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: 05/08/2023] [Accepted: 07/20/2023] [Indexed: 08/03/2023]
Abstract
CD19-directed chimeric antigen receptor (CAR) T-cell therapy is an important therapy for relapsed or refractory acute lymphoblastic leukaemia, but its use carries the risk of immune effector cell-associated neurotoxicity syndrome (ICANS). In children, severe ICANS is almost universally reported in association with cytokine release syndrome and is reversible. We describe two cases of severe, intractable neurotoxicity following CAR T-cell therapy in children with pre-existing central nervous system (CNS) vulnerabilities. The cases were atypical in their delayed onset and independence from cytokine release syndrome and did not respond to standard therapies.
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Affiliation(s)
- Eden C Andrew
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Victoria, Australia
| | - David Hughes
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Maddie Gilsenan
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Cristina Mignone
- Medical Imaging Department, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Seong Lin Khaw
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Stacie Shiqi Wang
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
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7
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Heo BY, Lee MW, Choi S, Jung Y, Pham TTD, Jang Y, Park JH, Kang S, Koh JS, Jo DY, Kwon J, Song IC. Autoimmune Limbic Encephalitis in Patients with Hematologic Malignancies after Haploidentical Hematopoietic Stem Cell Transplantation with Post-Transplant Cyclophosphamide. Cells 2023; 12:2049. [PMID: 37626859 PMCID: PMC10453524 DOI: 10.3390/cells12162049] [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: 07/13/2023] [Revised: 08/05/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
Autoimmune limbic encephalitis (LE) is a rare, but devastating complication of allogeneic hematopoietic stem cell transplantation (HSCT). There is currently limited evidence describing the risk factors, laboratory features, and underlying mechanisms of this neurologic adverse event. We retrospectively reviewed available clinical, imaging, and laboratory data from adult patients with hematological malignancies who underwent haploidentical HSCT with post-transplant cyclophosphamide (PTCy) at Chungnam National University Hospital from June 2016 to May 2020. Patients who developed LE were compared to those who did not based on clinical assessment, serum inflammatory biomarkers, and reconstitution of various T cell populations. Of 35 patients, 4 developed LE. There were no differences in patient demographics, donor demographics, or treatment conditions between patients that did and did not develop LE. Overall, patients with LE had worse clinical outcomes and overall survival than those without. In addition, they tended to have higher markers of systemic inflammation in the early post-transplant period, including fever, C-reactive protein (CRP), and cytokines. Remarkably, baseline interleukin-6 levels before HSCT were found to be higher in patients who developed LE than those who did not. In addition, analysis of T cell subsets showed impaired expansion of CD25+FOXP3+ regulatory T (Treg) cells in LE compared to non-LE patients despite appropriate reconstitution of the total CD4+ T cell population. Patients that developed LE within the first 30 days of HSCT were likely to have high serum IL-6 among other inflammatory cytokines coupled with suppression of regulatory T cell differentiation. Further work is needed on the mechanisms underlying impaired Treg expansion following HSCT and potential therapies.
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Affiliation(s)
- Bu Yeon Heo
- Department of Medical Science, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
- Brain Korea 21 FOUR Project for Medical Science, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - Myung-Won Lee
- Department of Internal Medicine, College of Medicine, Chungnam National University, 282 Munwha-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - Suyoung Choi
- Department of Medical Science, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
- Brain Korea 21 FOUR Project for Medical Science, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - Yunju Jung
- Department of Medical Science, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - Thi Thuy Duong Pham
- Department of Medical Science, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
- Brain Korea 21 FOUR Project for Medical Science, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - Yunseon Jang
- Translational Immunology Institute, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - Jung-Hyun Park
- Translational Immunology Institute, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - Sora Kang
- Department of Internal Medicine, College of Medicine, Chungnam National University, 282 Munwha-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - Jeong Suk Koh
- Department of Internal Medicine, College of Medicine, Chungnam National University, 282 Munwha-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - Deog-Yeon Jo
- Department of Internal Medicine, College of Medicine, Chungnam National University, 282 Munwha-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - Jaeyul Kwon
- Department of Medical Science, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
- Brain Korea 21 FOUR Project for Medical Science, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
- Translational Immunology Institute, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - Ik-Chan Song
- Department of Medical Science, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
- Brain Korea 21 FOUR Project for Medical Science, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
- Department of Internal Medicine, College of Medicine, Chungnam National University, 282 Munwha-ro, Jung-gu, Daejeon 35015, Republic of Korea
- Translational Immunology Institute, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
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8
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Yan L, Li J, Zhang C. The role of MSCs and CAR-MSCs in cellular immunotherapy. Cell Commun Signal 2023; 21:187. [PMID: 37528472 PMCID: PMC10391838 DOI: 10.1186/s12964-023-01191-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 06/07/2023] [Indexed: 08/03/2023] Open
Abstract
Chimeric antigen receptors (CARs) are widely used by T cells (CAR-T cells), natural killer cells dendritic cells and macrophages, and they are of great importance in cellular immunotherapy. However, the use of CAR-related products faces several challenges, including the poor persistence of cells carrying CARs, cell dysfunction or exhaustion, relapse of disease, immune effector cell-associated neurotoxicity syndrome, cytokine release syndrome, low efficacy against solid tumors and immunosuppression by the tumor microenvironment. Another important cell therapy regimen involves mesenchymal stem cells (MSCs). Recent studies have shown that MSCs can improve the anticancer functions of CAR-related products. CAR-MSCs can overcome the flaws of cellular immunotherapy. Thus, MSCs can be used as a biological vehicle for CARs. In this review, we first discuss the characteristics and immunomodulatory functions of MSCs. Then, the role of MSCs as a source of exosomes, including the characteristics of MSC-derived exosomes and their immunomodulatory functions, is discussed. The role of MSCs in CAR-related products, CAR-related product-derived exosomes and the effect of MSCs on CAR-related products are reviewed. Finally, the use of MSCs as CAR vehicles is discussed. Video Abstract.
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Affiliation(s)
- Lun Yan
- Medical Center of Hematology, State Key Laboratory of Trauma, Burn and Combined Injury, Xinqiao Hospital, Army Medical University, Chongqing, 400037, China
| | - Jing Li
- Medical Center of Hematology, State Key Laboratory of Trauma, Burn and Combined Injury, Xinqiao Hospital, Army Medical University, Chongqing, 400037, China
| | - Cheng Zhang
- Medical Center of Hematology, State Key Laboratory of Trauma, Burn and Combined Injury, Xinqiao Hospital, Army Medical University, Chongqing, 400037, China.
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Saleki K, Mohamadi MH, Alijanizadeh P, Rezaei N. Neurological adverse effects of chimeric antigen receptor T-cell therapy. Expert Rev Clin Immunol 2023; 19:1361-1383. [PMID: 37578341 DOI: 10.1080/1744666x.2023.2248390] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/07/2023] [Accepted: 08/10/2023] [Indexed: 08/15/2023]
Abstract
INTRODUCTION Chimeric antigen receptor (CAR) T-cell is among the most prevalent approaches that act by directing T-cells toward cancer; however, they need to be optimized to minimize side effects and maximize efficacy before being used as standard treatment for malignancies. Neurotoxicity associated with CAR T-cell therapy has been well-documented in recent works. AREAS COVERED In this regard, two established syndromes exist. Immune effector cell-associated neurotoxicity syndrome (ICANS), previously called cytokine release encephalopathy syndrome (CRES), is a neuropsychiatric condition which can occur after therapy by immune effector cells (IEC) and T-lymphocytes utilizing treatments. Another syndrome is cytokine release syndrome (CRS), which may overlap with ICANS. EXPERT OPINION ICANS clinical manifestations include cerebral edema, mild lethargy, aphasia, and seizures. Notably, ICANS is associated with changes to EEG and neuroradiological findings. Therefore, it is necessary to make a timely and accurate diagnosis of neurological complications of CAR T-cells by clinical presentations, neuroimaging, and EEG. Since neurological events by different CAR T-cell products are heterogeneous, guides should be developed according to each product. Here, we provide an updated review of general information on CAR T-cell therapies and applications, neurological syndromes associated with their use, and risk factors contributing to ICANS.
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Affiliation(s)
- Kiarash Saleki
- Student Research Committee, Babol University of Medical Sciences, Babol, Iran
- USERN Office, Babol University of Medical Sciences, Babol, Iran
- Department of e-Learning, Virtual School of Medical Education and Management, Shahid Beheshti University of Medical Sciences(SBMU), Tehran, Iran
| | | | - Parsa Alijanizadeh
- Student Research Committee, Babol University of Medical Sciences, Babol, Iran
- USERN Office, Babol University of Medical Sciences, Babol, Iran
| | - Nima Rezaei
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
- Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
- Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran
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10
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Velasco R, Mussetti A, Villagrán-García M, Sureda A. CAR T-cell-associated neurotoxicity in central nervous system hematologic disease: Is it still a concern? Front Neurol 2023; 14:1144414. [PMID: 37090983 PMCID: PMC10117964 DOI: 10.3389/fneur.2023.1144414] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 03/06/2023] [Indexed: 04/25/2023] Open
Abstract
Chimeric antigen receptor (CAR) T-cell systemic immunotherapy has revolutionized how clinicians treat several refractory and relapsed hematologic malignancies. Due to its peculiar mechanism of action, CAR T-cell-based therapy has enlarged the spectrum of neurological toxicities. CAR T-cell-associated neurotoxicity-initially defined as CAR T-cell-related encephalopathy syndrome (CRES) and currently coined within the acronym ICANS (immune effector cell-associated neurotoxicity syndrome)-is perhaps the most concerning toxicity of CAR T-cell therapy. Importantly, hematologic malignancies (especially lymphoid malignancies) may originate in or spread to the central nervous system (CNS) in the form of parenchymal and/or meningeal disease. Due to the emergence of deadly and neurological adverse events, such as fatal brain edema in some patients included in early CAR T-cell trials, safety concerns for those with CNS primary or secondary infiltration arose and contributed to the routine exclusion of individuals with pre-existing or active CNS involvement from pivotal trials. However, based primarily on the lack of evidence, it remains unknown whether CNS involvement increases the risk and/or severity of CAR T-cell-related neurotoxicity. Given the limited treatment options available for patients once they relapse with CNS involvement, it is of high interest to explore the role of novel clinical strategies including CAR T cells to treat leukemias/lymphomas and myeloma with CNS involvement. The purpose of this review was to summarize currently available neurological safety data of CAR T-cell-based immunotherapy from the clinical trials and real-world experiences in adult patients with CNS disease due to lymphoma, leukemia, or myeloma. Increasing evidence supports that CNS involvement in hematologic disease should no longer be considered per se as an absolute contraindication to CAR T-cell-based therapy. While the incidence may be high, severity does not appear to be impacted significantly by pre-existing CNS status. Close monitoring by trained neurologists is recommended.
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Affiliation(s)
- Roser Velasco
- Neuro-Oncology Unit, Department of Neurology, Hospital Universitari de Bellvitge-Institut Català d'Oncologia, Barcelona, Spain
- Department of Cell Biology, Physiology and Immunology, Institute of Neurosciences, Cerdanyola del Vallés, Spain
| | - Alberto Mussetti
- Department of Hematology, Catalan Institute of Oncology, Hospital Duran i Reynals, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Macarena Villagrán-García
- French Reference Center on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron. UMR MeLiS team SynatAc, INSERM1314/CNRS5284, Lyon, France
| | - Anna Sureda
- Department of Hematology, Catalan Institute of Oncology, Hospital Duran i Reynals, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
- Medicine Department, Universitat de Barcelona, Barcelona, Spain
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11
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Mahdi J, Dietrich J, Straathof K, Roddie C, Scott BJ, Davidson TB, Prolo LM, Batchelor TT, Campen CJ, Davis KL, Gust J, Lim M, Majzner RG, Park JR, Partap S, Ramakrishna S, Richards R, Schultz L, Vitanza NA, Wang LD, Mackall CL, Monje M. Tumor inflammation-associated neurotoxicity. Nat Med 2023; 29:803-810. [PMID: 37024595 PMCID: PMC10166099 DOI: 10.1038/s41591-023-02276-w] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 02/24/2023] [Indexed: 04/08/2023]
Abstract
Cancer immunotherapies have unique toxicities. Establishment of grading scales and standardized grade-based treatment algorithms for toxicity syndromes can improve the safety of these treatments, as observed for cytokine release syndrome (CRS) and immune effector cell associated neurotoxicity syndrome (ICANS) in patients with B cell malignancies treated with chimeric antigen receptor (CAR) T cell therapy. We have observed a toxicity syndrome, distinct from CRS and ICANS, in patients treated with cell therapies for tumors in the central nervous system (CNS), which we term tumor inflammation-associated neurotoxicity (TIAN). Encompassing the concept of 'pseudoprogression,' but broader than inflammation-induced edema alone, TIAN is relevant not only to cellular therapies, but also to other immunotherapies for CNS tumors. To facilitate the safe administration of cell therapies for patients with CNS tumors, we define TIAN, propose a toxicity grading scale for TIAN syndrome and discuss the potential management of this entity, with the goal of standardizing both reporting and management.
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Affiliation(s)
- Jasia Mahdi
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA
- Stanford Center for Cancer Cell Therapy, Stanford University School of Medicine, Stanford, CA, USA
| | - Jorg Dietrich
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Karin Straathof
- Research Department of Hematology and Oncology, Cancer Institute, University College London, London, UK
| | - Claire Roddie
- Research Department of Hematology and Oncology, Cancer Institute, University College London, London, UK
| | - Brian J Scott
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA
| | - Tom Belle Davidson
- Cancer and Blood Disease Institute, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Laura M Prolo
- Department of Neurosurgery, Stanford University, Stanford, CA, USA
| | - Tracy T Batchelor
- Department of Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Dana-Farber/Harvard Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Cynthia J Campen
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA
| | - Kara L Davis
- Stanford Center for Cancer Cell Therapy, Stanford University School of Medicine, Stanford, CA, USA
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Juliane Gust
- Department of Neurology, University of Washington, Seattle, WA, USA
- Seattle Children's Research Institute, Center for Integrative Brain Research, Seattle, WA, USA
| | - Michael Lim
- Department of Neurosurgery, Stanford University, Stanford, CA, USA
| | - Robbie G Majzner
- Stanford Center for Cancer Cell Therapy, Stanford University School of Medicine, Stanford, CA, USA
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Julie R Park
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, WA, USA
| | - Sonia Partap
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA
- Department of Neurosurgery, Stanford University, Stanford, CA, USA
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Sneha Ramakrishna
- Stanford Center for Cancer Cell Therapy, Stanford University School of Medicine, Stanford, CA, USA
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Rebecca Richards
- Stanford Center for Cancer Cell Therapy, Stanford University School of Medicine, Stanford, CA, USA
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Liora Schultz
- Stanford Center for Cancer Cell Therapy, Stanford University School of Medicine, Stanford, CA, USA
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Nicholas A Vitanza
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, WA, USA
| | - Leo D Wang
- City of Hope, Departments of Pediatrics and Immuno-oncology, Beckman Research Institute, City of Hope National Medical Center, Duarte, CA, USA
| | - Crystal L Mackall
- Stanford Center for Cancer Cell Therapy, Stanford University School of Medicine, Stanford, CA, USA.
- Department of Pediatrics, Stanford University, Stanford, CA, USA.
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.
| | - Michelle Monje
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA.
- Stanford Center for Cancer Cell Therapy, Stanford University School of Medicine, Stanford, CA, USA.
- Department of Neurosurgery, Stanford University, Stanford, CA, USA.
- Department of Pediatrics, Stanford University, Stanford, CA, USA.
- Department of Pathology, Stanford University, Stanford, CA, USA.
- Howard Hughes Medical Institute, Stanford University, Stanford, CA, USA.
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12
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Parikh RH, Lonial S. Chimeric antigen receptor T-cell therapy in multiple myeloma: A comprehensive review of current data and implications for clinical practice. CA Cancer J Clin 2023; 73:275-285. [PMID: 36627265 DOI: 10.3322/caac.21771] [Citation(s) in RCA: 43] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 11/10/2022] [Accepted: 12/02/2022] [Indexed: 01/12/2023] Open
Abstract
Multiple myeloma (MM) is a hematologic malignancy defined by the clonal proliferation of transformed plasma cells. Despite tremendous advances in the treatment paradigm of MM, a cure remains elusive for most patients. Although long-term disease control can be achieved in a very large number of patients, the acquisition of tumor resistance leads to disease relapse, especially in patients with triple-class refractory MM (defined as resistance to immunomodulatory agents, proteosome inhibitors, and monoclonal antibodies). There is an unmet need for effective treatment options in these patients. Chimeric antigen receptor (CAR) T-cell therapy is a novel approach that has demonstrated promising efficacy in the treatment of relapsed, refractory MM (RRMM). These genetically modified cellular therapies have demonstrated deep and durable remissions in other B-cell malignancies, and current efforts aim to achieve similar results in patients with RRMM. Early studies have demonstrated remarkable response rates with CAR T-cell therapy in RRMM; however, durable responses with CAR T-cell therapies in myeloma have yet to be realized. In this comprehensive review, the authors describe the development of CAR T-cell therapies in myeloma, the outcomes of notable clinical trials, the toxicities and limitations of CAR T-cell therapies, and the strategies to overcome therapeutic challenges of CAR T cells in the hope of achieving a cure for multiple myeloma.
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Affiliation(s)
- Rujul H Parikh
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sagar Lonial
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia, USA
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13
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Genoud V, Migliorini D. Novel pathophysiological insights into CAR-T cell associated neurotoxicity. Front Neurol 2023; 14:1108297. [PMID: 36970518 PMCID: PMC10031128 DOI: 10.3389/fneur.2023.1108297] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 02/03/2023] [Indexed: 03/29/2023] Open
Abstract
Chimeric antigen receptor (CAR) T cell therapy represents a scientific breakthrough in the treatment of advanced hematological malignancies. It relies on cell engineering to direct the powerful cytotoxic T-cell activity toward tumor cells. Nevertheless, these highly powerful cell therapies can trigger substantial toxicities such as cytokine release syndrome (CRS) and immune cell-associated neurological syndrome (ICANS). These potentially fatal side effects are now better understood and managed in the clinic but still require intensive patient follow-up and management. Some specific mechanisms seem associated with the development of ICANS, such as cytokine surge caused by activated CAR-T cells, off-tumor targeting of CD19, and vascular leak. Therapeutic tools are being developed aiming at obtaining better control of toxicity. In this review, we focus on the current understanding of ICANS, novel findings, and current gaps.
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Affiliation(s)
- Vassilis Genoud
- Department of Oncology, University Hospital of Geneva, Geneva, Switzerland
- Center for Translational Research in Onco-Haematology, University of Geneva, Geneva, Switzerland
| | - Denis Migliorini
- Department of Oncology, University Hospital of Geneva, Geneva, Switzerland
- Center for Translational Research in Onco-Haematology, University of Geneva, Geneva, Switzerland
- Brain Tumor and Immune Cell Engineering Laboratory, AGORA Cancer Research Center, Lausanne, Switzerland
- Swiss Cancer Center Léman (SCCL), Lausanne and Geneva, Geneva, Switzerland
- *Correspondence: Denis Migliorini
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14
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Ragoonanan D, Sheikh IN, Gupta S, Khazal SJ, Tewari P, Petropoulos D, Li S, Mahadeo KM. The Evolution of Chimeric Antigen Receptor T-Cell Therapy in Children, Adolescents and Young Adults with Acute Lymphoblastic Leukemia. Biomedicines 2022; 10:biomedicines10092286. [PMID: 36140387 PMCID: PMC9496125 DOI: 10.3390/biomedicines10092286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 08/05/2022] [Accepted: 09/09/2022] [Indexed: 11/16/2022] Open
Abstract
Chimeric antigen receptor T-cell (CAR T) therapy is a revolutionary treatment for pediatric, adolescent and young adult patients (AYA) with relapsed/refractory B-cell acute lymphoblastic leukemia. While the landscape of immunotherapy continues to rapidly evolve, widespread use of CAR T therapy is limited and many questions remain regarding the durability of CAR T therapy, methods to avoid CAR T therapy resistance and the role of consolidative stem cell transplant. Modified strategies to develop effective and persistent CAR T cells at lower costs and decreased toxicities are warranted. In this review we present current indications, limitations and future directions of CAR T therapy for ALL in the pediatric and AYA population.
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Affiliation(s)
- Dristhi Ragoonanan
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Correspondence: (D.R.); (I.N.S.)
| | - Irtiza N. Sheikh
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Correspondence: (D.R.); (I.N.S.)
| | - Sumit Gupta
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Sajad J. Khazal
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Priti Tewari
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Demetrios Petropoulos
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Shulin Li
- Department of Pediatrics Research, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Kris M. Mahadeo
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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15
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Immunogenic Cell Death Enhances Immunotherapy of Diffuse Intrinsic Pontine Glioma: From Preclinical to Clinical Studies. Pharmaceutics 2022; 14:pharmaceutics14091762. [PMID: 36145510 PMCID: PMC9502387 DOI: 10.3390/pharmaceutics14091762] [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: 06/29/2022] [Revised: 08/02/2022] [Accepted: 08/20/2022] [Indexed: 11/16/2022] Open
Abstract
Diffuse intrinsic pontine glioma (DIPG) is the most lethal tumor involving the pediatric central nervous system. The median survival of children that are diagnosed with DIPG is only 9 to 11 months. More than 200 clinical trials have failed to increase the survival outcomes using conventional cytotoxic or myeloablative chemotherapy. Immunotherapy presents exciting therapeutic opportunities against DIPG that is characterized by unique and heterogeneous features. However, the non-inflammatory DIPG microenvironment greatly limits the role of immunotherapy in DIPG. Encouragingly, the induction of immunogenic cell death, accompanied by the release of damage-associated molecular patterns (DAMPs) shows satisfactory efficacy of immune stimulation and antitumor strategies. This review dwells on the dilemma and advances in immunotherapy for DIPG, and the potential efficacy of immunogenic cell death (ICD) in the immunotherapy of DIPG.
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16
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Wagner DL, Koehl U, Chmielewski M, Scheid C, Stripecke R. Review: Sustainable Clinical Development of CAR-T Cells – Switching From Viral Transduction Towards CRISPR-Cas Gene Editing. Front Immunol 2022; 13:865424. [PMID: 35784280 PMCID: PMC9248912 DOI: 10.3389/fimmu.2022.865424] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 05/06/2022] [Indexed: 12/21/2022] Open
Abstract
T cells modified for expression of Chimeric Antigen Receptors (CARs) were the first gene-modified cell products approved for use in cancer immunotherapy. CAR-T cells engineered with gammaretroviral or lentiviral vectors (RVs/LVs) targeting B-cell lymphomas and leukemias have shown excellent clinical efficacy and no malignant transformation due to insertional mutagenesis to date. Large-scale production of RVs/LVs under good-manufacturing practices for CAR-T cell manufacturing has soared in recent years. However, manufacturing of RVs/LVs remains complex and costly, representing a logistical bottleneck for CAR-T cell production. Emerging gene-editing technologies are fostering a new paradigm in synthetic biology for the engineering and production of CAR-T cells. Firstly, the generation of the modular reagents utilized for gene editing with the CRISPR-Cas systems can be scaled-up with high precision under good manufacturing practices, are interchangeable and can be more sustainable in the long-run through the lower material costs. Secondly, gene editing exploits the precise insertion of CARs into defined genomic loci and allows combinatorial gene knock-ins and knock-outs with exciting and dynamic perspectives for T cell engineering to improve their therapeutic efficacy. Thirdly, allogeneic edited CAR-effector cells could eventually become available as “off-the-shelf” products. This review addresses important points to consider regarding the status quo, pending needs and perspectives for the forthright evolution from the viral towards gene editing developments for CAR-T cells.
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Affiliation(s)
- Dimitrios L. Wagner
- Berlin Center for Advanced Therapies (BeCAT), Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- BIH-Center for Regenerative Therapies (BCRT), Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Berlin, Germany
- Institute of Transfusion Medicine, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Ulrike Koehl
- Institute of Cellular Therapeutics, Hannover Medical School, Hannover, Germany
- Fraunhofer Institute for Cell Therapy and Immunology (IZI) as well as Institute of Clinical Immunology, University of Leipzig, Leipzig, Germany
| | - Markus Chmielewski
- Clinic I for Internal Medicine, University Hospital Cologne, Cologne, Germany
| | - Christoph Scheid
- Clinic I for Internal Medicine, University Hospital Cologne, Cologne, Germany
| | - Renata Stripecke
- Clinic I for Internal Medicine, University Hospital Cologne, Cologne, Germany
- Laboratory of Regenerative Immune Therapies Applied, Research Center for Translational Regenerative Medicine (Rebirth), Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
- German Centre for Infection Research (DZIF), Partner site Hannover, Hannover, Germany
- Cancer Research Center Cologne Essen (CCCE), Cologne, Germany
- *Correspondence: Renata Stripecke, ;
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17
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Persson ML, Douglas AM, Alvaro F, Faridi P, Larsen MR, Alonso MM, Vitanza NA, Dun MD. The intrinsic and microenvironmental features of diffuse midline glioma; implications for the development of effective immunotherapeutic treatment strategies. Neuro Oncol 2022; 24:1408-1422. [PMID: 35481923 PMCID: PMC9435509 DOI: 10.1093/neuonc/noac117] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Diffuse midline glioma (DMG), including those of the brainstem (diffuse intrinsic pontine glioma), are pediatric tumors of the central nervous system (CNS). Recognized as the most lethal of all childhood cancers, palliative radiotherapy remains the only proven treatment option, however, even for those that respond, survival is only temporarily extended. DMG harbor an immunologically “cold” tumor microenvironment (TME) with few infiltrating immune cells. The mechanisms underpinning the cold TME are not well understood. Low expression levels of immune checkpoint proteins, including PD-1, PD-L1, and CTLA-4, are recurring features of DMG and likely contribute to the lack of response to immune checkpoint inhibitors (ICIs). The unique epigenetic signatures (including stem cell-like methylation patterns), a low tumor mutational burden, and recurring somatic mutations (H3K27M, TP53, ACVR1, MYC, and PIK3CA), possibly play a role in the reduced efficacy of traditional immunotherapies. Therefore, to circumvent the lack of efficacy thus far seen for the use of ICIs, adoptive cell transfer (including chimeric antigen receptor T cells) and the use of oncolytic viruses, are currently being evaluated for the treatment of DMG. It remains an absolute imperative that we improve our understanding of DMG’s intrinsic and TME features if patients are to realize the potential benefits offered by these sophisticated treatments. Herein, we summarize the limitations of immunotherapeutic approaches, highlight the emerging safety and clinical efficacy shown for sophisticated cell-based therapies, as well as the evolving knowledge underpinning the DMG-immune axis, to guide the development of immunotherapies that we hope will improve outcomes.
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Affiliation(s)
- Mika L Persson
- Cancer Signalling Research Group, School of Biomedical Sciences and Pharmacy, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia.,Precision Medicine Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Alicia M Douglas
- Cancer Signalling Research Group, School of Biomedical Sciences and Pharmacy, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia.,Precision Medicine Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Frank Alvaro
- Cancer Signalling Research Group, School of Biomedical Sciences and Pharmacy, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia.,Precision Medicine Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia.,John Hunter Children's Hospital, New Lambton Heights, NSW, Australia
| | - Pouya Faridi
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Martin R Larsen
- Department of Molecular Biology and Biochemistry, Protein Research Group, University of Southern Denmark, Odense, Denmark
| | - Marta M Alonso
- Department of Pediatrics, University Hospital of Navarra, Pamplona, Spain.,Program in Solid Tumors and Biomarkers, Foundation for Applied Medical Research (CIMA), Pamplona, Spain
| | - Nicholas A Vitanza
- The Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, WA, USA.,Division of Pediatric Hematology, Oncology, Bone Marrow Transplant, and Cellular Therapy, Department of Pediatrics, Seattle Children's Hospital, Seattle, WA, USA
| | - Matthew D Dun
- Cancer Signalling Research Group, School of Biomedical Sciences and Pharmacy, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia.,Precision Medicine Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
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18
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Chan LY, Dass SA, Tye GJ, Imran SAM, Wan Kamarul Zaman WS, Nordin F. CAR-T Cells/-NK Cells in Cancer Immunotherapy and the Potential of MSC to Enhance Its Efficacy: A Review. Biomedicines 2022; 10:biomedicines10040804. [PMID: 35453554 PMCID: PMC9024487 DOI: 10.3390/biomedicines10040804] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/25/2022] [Accepted: 03/23/2022] [Indexed: 02/04/2023] Open
Abstract
The chimeric antigen receptor (CAR) plays a dynamic role in targeting tumour-associated antigens in cancer cells. This novel therapeutic discovery combines fragments of monoclonal antibodies with the signalling and co-stimulatory domains that have been modified to its current fourth generation. CAR has been widely implemented in T-cells and natural killer (NK) cells immunotherapy. The significant advancement in CAR technology is evident based on numerous ongoing clinical trials on CAR-T/-NK cells and successful CAR-related products such as Kymriah (Novartis) and Yescarta (Kite Pharma, Gilead). Another important cell-based therapy is the engineering of mesenchymal stem cells (MSC). Researchers have been exploring MSCs and their innate homing abilities to tumour sites and secretion cytokines that bridge both CAR and MSC technologies as a therapeutic agent. This combination allows for both therapies to overcome each one’s flaw as an immunotherapy intervention. Herein, we have provided a concise review on the background of CAR and its applications in different cancers, as well as MSCs’ unique ability as delivery vectors for cancer therapy and the possibility of enhancing the CAR-immune cells’ activity. Hence, we have highlighted throughout this review the synergistic effects of both interventions.
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Affiliation(s)
- Ler Yie Chan
- Centre for Tissue Engineering and Regenerative Medicine (CTERM), Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latiff, Bandar Tun Razak, Kuala Lumpur 56000, Malaysia; (L.Y.C.); (S.A.M.I.)
- INTEC Education College, Jalan Senangin Satu 17/2A, Seksyen 17, Shah Alam 40200, Malaysia
| | - Sylvia Annabel Dass
- Institute for Research in Molecular Medicine (INFORMM), Universiti Sains Malaysia, Minden 11800, Malaysia; (S.A.D.); (G.J.T.)
| | - Gee Jun Tye
- Institute for Research in Molecular Medicine (INFORMM), Universiti Sains Malaysia, Minden 11800, Malaysia; (S.A.D.); (G.J.T.)
| | - Siti A. M. Imran
- Centre for Tissue Engineering and Regenerative Medicine (CTERM), Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latiff, Bandar Tun Razak, Kuala Lumpur 56000, Malaysia; (L.Y.C.); (S.A.M.I.)
| | - Wan Safwani Wan Kamarul Zaman
- Department of Biomedical Engineering, Faculty of Engineering, Universiti Malaya, Kuala Lumpur 50603, Malaysia;
- Centre for Innovation in Medical Engineering (CIME), Department of Biomedical Engineering, Faculty of Engineering, Universiti Malaya, Kuala Lumpur 50603, Malaysia
| | - Fazlina Nordin
- Centre for Tissue Engineering and Regenerative Medicine (CTERM), Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latiff, Bandar Tun Razak, Kuala Lumpur 56000, Malaysia; (L.Y.C.); (S.A.M.I.)
- Correspondence: ; Tel.: +60-3-91457670
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19
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Baumeister SHC, Mohan GS, Elhaddad A, Lehmann L. Cytokine Release Syndrome and Associated Acute Toxicities in Pediatric Patients Undergoing Immune Effector Cell Therapy or Hematopoietic Cell Transplantation. Front Oncol 2022; 12:841117. [PMID: 35402259 PMCID: PMC8989409 DOI: 10.3389/fonc.2022.841117] [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: 12/21/2021] [Accepted: 02/08/2022] [Indexed: 02/05/2023] Open
Abstract
Immune effector cells (IEC) are a powerful and increasingly targeted tool, particularly for the control and eradication of malignant diseases. However, the infusion, expansion, and persistence of autologous or allogeneic IEC or engagement of endogenous immune cells can be associated with significant systemic multi-organ toxicities. Here we review the signs and symptoms, grading and pathophysiology of immune-related toxicities arising in the context of pediatric immunotherapies and haploidentical T cell replete Hematopoietic Cell Transplantation (HCT). Principles of management are discussed with particular focus on the intersection of these toxicities with the requirement for pediatric critical care level support.
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Affiliation(s)
- Susanne H. C. Baumeister
- Boston Children’s Hospital, Division of Pediatric Hematology-Oncology, Boston, MA, United States
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
- *Correspondence: Susanne H. C. Baumeister,
| | - Gopi S. Mohan
- Boston Children’s Hospital, Division of Pediatric Hematology-Oncology, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
- Division of Pediatric Critical Care, Massachusetts General Hospital, Boston, MA, United States
| | - Alaa Elhaddad
- Children’s Cancer Hospital of Egypt, National Cancer Institute Cairo, Cairo, Egypt
| | - Leslie Lehmann
- Boston Children’s Hospital, Division of Pediatric Hematology-Oncology, Boston, MA, United States
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
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Orzetti S, Tommasi F, Bertola A, Bortolin G, Caccin E, Cecco S, Ferrarin E, Giacomin E, Baldo P. Genetic Therapy and Molecular Targeted Therapy in Oncology: Safety, Pharmacovigilance, and Perspectives for Research and Clinical Practice. Int J Mol Sci 2022; 23:ijms23063012. [PMID: 35328435 PMCID: PMC8951339 DOI: 10.3390/ijms23063012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/07/2022] [Accepted: 03/09/2022] [Indexed: 01/27/2023] Open
Abstract
The impressive advances in the knowledge of biomarkers and molecular targets has enabled significant progress in drug therapy for crucial diseases such as cancer. Specific areas of pharmacology have contributed to these therapeutic outcomes—mainly targeted therapy, immunomodulatory therapy, and gene therapy. This review focuses on the pharmacological profiles of these therapeutic classes and intends, on the one hand, to provide a systematic definition and, on the other, to highlight some aspects related to pharmacovigilance, namely the monitoring of safety and the identification of potential toxicities and adverse drug reactions. Although clinicians often consider pharmacovigilance a non-priority area, it highlights the risk/benefit ratio, an essential factor, especially for these advanced therapies, which represent the most innovative and promising horizon in oncology.
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Affiliation(s)
- Sabrina Orzetti
- Hospital Pharmacy Unit of the “Centro di Riferimento Oncologico (CRO) di Aviano IRCCS”, Via F. Gallini, 33081 Aviano, Italy; (S.O.); (F.T.); (A.B.); (G.B.); (E.C.); (S.C.); (E.G.)
- Department of Hospital Pharmacy, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), 33100 Udine, Italy
| | - Federica Tommasi
- Hospital Pharmacy Unit of the “Centro di Riferimento Oncologico (CRO) di Aviano IRCCS”, Via F. Gallini, 33081 Aviano, Italy; (S.O.); (F.T.); (A.B.); (G.B.); (E.C.); (S.C.); (E.G.)
| | - Antonella Bertola
- Hospital Pharmacy Unit of the “Centro di Riferimento Oncologico (CRO) di Aviano IRCCS”, Via F. Gallini, 33081 Aviano, Italy; (S.O.); (F.T.); (A.B.); (G.B.); (E.C.); (S.C.); (E.G.)
| | - Giorgia Bortolin
- Hospital Pharmacy Unit of the “Centro di Riferimento Oncologico (CRO) di Aviano IRCCS”, Via F. Gallini, 33081 Aviano, Italy; (S.O.); (F.T.); (A.B.); (G.B.); (E.C.); (S.C.); (E.G.)
| | - Elisabetta Caccin
- Hospital Pharmacy Unit of the “Centro di Riferimento Oncologico (CRO) di Aviano IRCCS”, Via F. Gallini, 33081 Aviano, Italy; (S.O.); (F.T.); (A.B.); (G.B.); (E.C.); (S.C.); (E.G.)
| | - Sara Cecco
- Hospital Pharmacy Unit of the “Centro di Riferimento Oncologico (CRO) di Aviano IRCCS”, Via F. Gallini, 33081 Aviano, Italy; (S.O.); (F.T.); (A.B.); (G.B.); (E.C.); (S.C.); (E.G.)
| | - Emanuela Ferrarin
- Scientific and Patients Library of the “Centro di Riferimento Oncologico (CRO) di Aviano IRCCS”, Via F. Gallini, 33081 Aviano, Italy;
| | - Elisa Giacomin
- Hospital Pharmacy Unit of the “Centro di Riferimento Oncologico (CRO) di Aviano IRCCS”, Via F. Gallini, 33081 Aviano, Italy; (S.O.); (F.T.); (A.B.); (G.B.); (E.C.); (S.C.); (E.G.)
| | - Paolo Baldo
- Hospital Pharmacy Unit of the “Centro di Riferimento Oncologico (CRO) di Aviano IRCCS”, Via F. Gallini, 33081 Aviano, Italy; (S.O.); (F.T.); (A.B.); (G.B.); (E.C.); (S.C.); (E.G.)
- Correspondence: ; Tel.: +39-0434-659221
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21
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Grant SJ, Grimshaw AA, Silberstein J, Murdaugh D, Wildes TM, E Rosko A, Giri S. Clinical presentation, risk factors, and outcomes of immune effector cell-associated neurotoxicity syndrome following CAR-T cell therapy: A Systematic Review. Transplant Cell Ther 2022; 28:294-302. [DOI: 10.1016/j.jtct.2022.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 02/26/2022] [Accepted: 03/07/2022] [Indexed: 12/11/2022]
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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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Guha P, Katz SC. Strategies for manufacturing cell therapy products aligned with patient needs. Methods Cell Biol 2022; 167:203-226. [DOI: 10.1016/bs.mcb.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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