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Fischbach F, Richter J, Pfeffer LK, Fehse B, Berger SC, Reinhardt S, Kuhle J, Badbaran A, Rathje K, Gagelmann N, Borie D, Seibel J, Ayuk F, Friese MA, Heesen C, Kröger N. CD19-targeted chimeric antigen receptor T cell therapy in two patients with multiple sclerosis. Med 2024:S2666-6340(24)00114-4. [PMID: 38554710 DOI: 10.1016/j.medj.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 02/12/2024] [Accepted: 03/06/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND Progressive multiple sclerosis (MS) is characterized by compartmentalized smoldering neuroinflammation caused by the proliferation of immune cells residing in the central nervous system (CNS), including B cells. Although inflammatory activity can be prevented by immunomodulatory therapies during early disease, such therapies typically fail to halt disease progression. CD19 chimeric antigen receptor (CAR)-T cell therapies have revolutionized the field of hematologic malignancies. Although generally considered efficacious, serious adverse events associated with CAR-T cell therapies such as immune effector cell-associated neurotoxicity syndrome (ICANS) have been observed. Successful use of CD19 CAR-T cells in rheumatic diseases like systemic lupus erythematosus and neuroimmunological diseases like myasthenia gravis have recently been observed, suggesting possible application in other autoimmune diseases. METHODS Here, we report the first individual treatment with a fully human CD19 CAR-T cell therapy (KYV-101) in two patients with progressive MS. FINDINGS CD19 CAR-T cell administration resulted in acceptable safety profiles for both patients. No ICANS was observed despite detection of CD19 CAR-T cells in the cerebrospinal fluid. In case 1, intrathecal antibody production in the cerebrospinal fluid decreased notably after CAR-T cell infusion and was sustained through day 64. CONCLUSIONS CD19 CAR-T cell administration in progressive MS resulted in an acceptable safety profile. CAR-T cell presence and expansion were observed in the cerebrospinal fluid without clinical signs of neurotoxicity, which, along with intrathecal antibody reduction, indicates expansion-dependent effects of CAR-T cells on CD19+ target cells in the CNS. Larger clinical studies assessing CD19 CAR-T cells in MS are warranted. FUNDING Both individual treatments as well the generated data were not based on external funding.
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Affiliation(s)
- Felix Fischbach
- Institute of Neuroimmunology and Multiple Sclerosis and Department of Neurology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Johanna Richter
- Department for Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Lena Kristina Pfeffer
- Institute of Neuroimmunology and Multiple Sclerosis and Department of Neurology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Boris Fehse
- Department for Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Susanna Carolina Berger
- Department for Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Stefanie Reinhardt
- Institute of Neuroimmunology and Multiple Sclerosis and Department of Neurology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Jens Kuhle
- Multiple Sclerosis Center and Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), Departments of Head, Spine and Neuromedicine, Biomedicine and Clinical Research, University Hospital Basel and University of Basel, 4031 Basel, Switzerland
| | - Anita Badbaran
- Department for Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Kristin Rathje
- Department for Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Nico Gagelmann
- Department for Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | | | - Johan Seibel
- Institute for Transfusion Medicine, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Francis Ayuk
- Department for Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Manuel A Friese
- Institute of Neuroimmunology and Multiple Sclerosis and Department of Neurology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Christoph Heesen
- Institute of Neuroimmunology and Multiple Sclerosis and Department of Neurology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany.
| | - Nicolaus Kröger
- Department for Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany.
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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 DOI: 10.1111/ene.16174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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 Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Clinical Haematology, Peter MacCallum Cancer Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Mary Ann Anderson
- Department of Clinical Haematology, Peter MacCallum Cancer Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Division of Blood Cells and Blood Cancer, Walter and Eliza Hall Institute, Parkville, Victoria, Australia
| | - Valeriya Kuznetsova
- Neuroimmunology Centre, Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Clinical Haematology, Peter MacCallum Cancer Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Clinical Outcomes Research (CORe), Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Hannah Rosenfeld
- Neuroimmunology Centre, Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Clinical Haematology, Peter MacCallum Cancer Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Charles B Malpas
- Neuroimmunology Centre, Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Clinical Outcomes Research (CORe), Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Melbourne School of Psychological Sciences, University of Melbourne, Parkville, Victoria, Australia
| | - Izanne Roos
- Neuroimmunology Centre, Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Clinical Outcomes Research (CORe), Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Michael Dickinson
- Department of Clinical Haematology, Peter MacCallum Cancer Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - Simon Harrison
- Department of Clinical Haematology, Peter MacCallum Cancer Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - Tomas Kalincik
- Neuroimmunology Centre, Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Clinical Outcomes Research (CORe), Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
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Yamshon S, Gribbin C, Alhomoud M, Chokr N, Chen Z, Demetres M, Pasciolla M, Leonard J, Shore T, Martin P. Safety and Toxicity Profiles of CAR T Cell Therapy in Non-Hodgkin Lymphoma: A Systematic Review and Meta-Analysis. Clin Lymphoma Myeloma Leuk 2024:S2152-2650(24)00066-1. [PMID: 38582666 DOI: 10.1016/j.clml.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 02/08/2024] [Accepted: 02/11/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND The application of CD19-directed chimeric antigen receptor T (CAR T) cell therapy has improved outcomes for thousands of patients with non-Hodgkin B cell lymphoma (NHL). The toxicities associated with various CAR T cell products, however, can be severe and difficult to anticipate. METHODS In this systematic review and meta-analysis, we set out to determine whether there are measurable differences in common toxicities, including cytokine release syndrome (CRS), immune effector cell associated neurotoxicity syndrome (ICANS), cytopenias, and infections, between CAR T products that are commercially available for the treatment of NHL. RESULTS After a stringent study selection process, we used a cohort of 1364 patients enrolled in 15 prospective clinical trials investigating the use of axicabtagene ciloleucel (axi-cel), lisocabtagene maraleucel (liso-cel), and tisagenlecleucel (tisa-cel). We found that the rates of CRS and ICANS were significantly higher with axi-cel as compared to both liso-cel and tisa-cel. Conversely, we demonstrated that rates of all-grade and severe neutropenia were significantly greater with liso-cel. Febrile neutropenia and all-grade infection rates did not differ significantly between products though rates of severe infection were increased with axi-cel. CONCLUSIONS Overall, this study serves as the first to delineate toxicity profiles associated with various available CAR T products. By better understanding associated toxicities, it may become possible to tailor therapies towards individual patients and anticipate the development of toxicities at earlier stages.
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Affiliation(s)
- Samuel Yamshon
- Division of Hematology and Medical Oncology, Weill Cornell Medicine, New York, NY.
| | - Caitlin Gribbin
- Division of Hematology and Medical Oncology, Weill Cornell Medicine, New York, NY
| | - Mohammad Alhomoud
- Division of Hematology and Medical Oncology, Weill Cornell Medicine, New York, NY
| | - Nora Chokr
- Division of Hematology and Medical Oncology, Weill Cornell Medicine, New York, NY
| | - Zhengming Chen
- Division of Biostatistics and Epidemiology, Weill Cornell Medicine and New York Presbyterian Hospital, New York, NY
| | - Michelle Demetres
- Samuel J. Wood Library & C.V. Starr Biomedical Information Center, Weill Cornell Medicine, New York, NY
| | - Michelle Pasciolla
- Department of Pharmacy, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY
| | - John Leonard
- Division of Hematology and Medical Oncology, Weill Cornell Medicine, New York, NY
| | - Tsiporah Shore
- Division of Hematology and Medical Oncology, Weill Cornell Medicine, New York, NY
| | - Peter Martin
- Division of Hematology and Medical Oncology, Weill Cornell Medicine, New York, NY
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Walton ZE, Frigault MJ, Maus MV. Current and emerging pharmacotherapies for cytokine release syndrome, neurotoxicity, and hemophagocytic lymphohistiocytosis-like syndrome due to CAR T cell therapy. Expert Opin Pharmacother 2024; 25:263-279. [PMID: 38588525 DOI: 10.1080/14656566.2024.2340738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 03/01/2024] [Indexed: 04/10/2024]
Abstract
INTRODUCTION Chimeric antigen receptor (CAR) T cells have revolutionized the treatment of multiple hematologic malignancies. Engineered cellular therapies now offer similar hope to transform the management of solid tumors and autoimmune diseases. However, toxicities can be serious and often require hospitalization. AREAS COVERED We review the two chief toxicities of CAR T therapy, cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS), and the rarer immune effector cell-associated hemophagocytic lymphohistiocytosis-like syndrome. We discuss treatment paradigms and promising future pharmacologic strategies. Literature and therapies reviewed were identified by PubMed search, cited references therein, and review of registered trials. EXPERT OPINION Management of CRS and ICANS has improved, aided by consensus definitions and guidelines that facilitate recognition and timely intervention. Further data will define optimal timing of tocilizumab and corticosteroids, current foundations of management. Pathophysiologic understanding has inspired off-label use of IL-1 receptor antagonism, IFNγ and IL-6 neutralizing antibodies, and janus kinase inhibitors, with data emerging from ongoing clinical trials. Further strategies to reduce toxicities include novel pharmacologic targets and safety features engineered into CAR T cells themselves. As these potentially curative therapies are used earlier in oncologic therapy and even in non-oncologic indications, effective accessible strategies to manage toxicities are critical.
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Affiliation(s)
- Zandra E Walton
- Cellular Immunotherapy Program, Massachusetts General Hospital Cancer Center, Boston, MA, USA
- Division of Rheumatology, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Matthew J Frigault
- Cellular Immunotherapy Program, Massachusetts General Hospital Cancer Center, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Marcela V Maus
- Cellular Immunotherapy Program, Massachusetts General Hospital Cancer Center, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
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Gagelmann N, Bishop M, Ayuk F, Bethge W, Glass B, Sureda A, Pasquini MC, Kröger N. Axicabtagene Ciloleucel versus Tisagenlecleucel for Relapsed or Refractory Large B Cell Lymphoma: A Systematic Review and Meta-Analysis. Transplant Cell Ther 2024:S2666-6367(24)00171-4. [PMID: 38281590 DOI: 10.1016/j.jtct.2024.01.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 12/28/2023] [Accepted: 01/23/2024] [Indexed: 01/30/2024]
Abstract
Axicabtagene ciloleucel (axi-cel) and tisagenlecleucel (tisa-cel) are CD19-directed chimeric antigen receptor T cell (CAR-T) therapies approved for relapsed/refractory aggressive large B cell lymphoma (LBCL). Significant costs and complex manufacturing underscore the importance of evidence-based counseling regarding the outcomes of these treatments. With the aim of examining the efficacy and safety of axi-cel versus tisa-cel in patients with relapsed/refractory aggressive LBCL, we performed a systematic literature search of comparative studies evaluating outcomes in relapsed/refractory aggressive LBCL after treatment with axi-cel or tisa-cel. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) for response, progression-free survival (PFS), overall survival (OS), cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), and hematotoxicity. Meta-analysis and meta-regression were used to generate summary statistics. A total of 2372 participants were included in the 8 studies in our analysis. The dropout rate between apheresis and infusion was 13% for axi-cel versus 18% for tisa-cel, and the median time from apheresis to infusion was 32 days versus 45 days. Axi-cel showed higher odds for a complete response (OR, 1.65; P < .001) and was associated with higher odds for PFS at 1 year after infusion (OR, .60; P < .001). OS appeared to be improved with axi-cel (OR, .84; 95% CI, .68 to 1.02; P = .08), whereas the cumulative incidence of nonrelapse mortality (NRM) was 11.5% for axi-cel versus 3.7% for tisa-cel (P = .002). The main predictors for survival were lactate dehydrogenase level, Eastern Cooperative Oncology Group Performance Status, and response to bridging, and axi-cel maintained superior efficacy even in elderly patients. In terms of safety, axi-cel was associated with significantly higher odds of any-grade CRS (OR, 3.23; P < .001), but not of grade ≥3 CRS (P = .92). Axi-cel was associated with significantly higher odds of severe ICANS grade ≥3 (OR, 4.03; P < .001). In terms of hematotoxicity, axi-cel was significantly associated with higher odds of severe neutropenia at 1 month after infusion (OR, 2.06; P = .003). As a result, axi-cel was associated with significantly greater resource utilization, including prolonged hospital stay, more frequent intensive care admission, and use of agents such as tocilizumab for toxicity management. We provide strong evidence of the greater efficacy of axi-cel versus tisa-cel in relapsed/refractory aggressive LBCL. The higher toxicity and NRM seen with axi-cel might not counterbalance the overall results, highlighting the need for timely intervention and careful selection of patients, balancing resource utilization and clinical benefit.
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Affiliation(s)
- Nico Gagelmann
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Michael Bishop
- The David and Etta Jonas Center for Cellular Therapy, University of Chicago, Chicago, Illinois
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Wolfgang Bethge
- Department of Hematology and Oncology, University Hospital Tuebingen, Tuebingen, Germany
| | - Bertram Glass
- Department of Hematology and Cell Therapy, Helios Klinikum Berlin-Buch, Berlin, Germany
| | - Anna Sureda
- Bellvitge Institute for Biomedical Research, Universitat de Barcelona, Hematology Department, Institut Català d'Oncologia-Hospitalet, Barcelona, Spain
| | - Marcelo C Pasquini
- Department of Medicine, Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Chen Z, Hu Y, Mei H. Harnessing Biomaterials for Safeguarding Chimeric Antigen Receptor T Cell Therapy: An Artful Expedition in Mitigating Adverse Effects. Pharmaceuticals (Basel) 2024; 17:139. [PMID: 38276012 PMCID: PMC10819334 DOI: 10.3390/ph17010139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/11/2024] [Accepted: 01/16/2024] [Indexed: 01/27/2024] Open
Abstract
Chimeric antigen receptor T cell (CAR-T) therapy has emerged as a groundbreaking approach in cancer treatment, showcasing remarkable efficacy. However, the formidable challenge lies in taming the formidable side effects associated with this innovative therapy, among which cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS) and on-target off-tumor toxicities (OTOT) are typical representatives. Championing the next frontier in cellular immunotherapy, this comprehensive review embarks on an artistic exploration of leveraging biomaterials to meticulously navigate the intricate landscape of CAR-T cell therapy. Unraveling the tapestry of potential toxicities, our discourse unveils a symphony of innovative strategies designed to elevate the safety profile of this revolutionary therapeutic approach. Through the lens of advanced medical science, we illuminate the promise of biomaterial interventions in sculpting a safer and more efficacious path for CAR-T cell therapy, transcending the boundaries of conventional treatment paradigms.
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Affiliation(s)
- Zhaozhao Chen
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan 430022, China;
- Hubei Clinical Medical Center of Cell Therapy for Neoplastic Disease, Wuhan 430022, China
| | - Yu Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan 430022, China;
- Hubei Clinical Medical Center of Cell Therapy for Neoplastic Disease, Wuhan 430022, China
| | - Heng Mei
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan 430022, China;
- Hubei Clinical Medical Center of Cell Therapy for Neoplastic Disease, Wuhan 430022, China
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7
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Fischer L, Grieb N, Platzbecker U, Vucinic V, Merz M. CAR T cell therapy in multiple myeloma, where are we now and where are we heading for? Eur J Haematol 2024; 112:19-27. [PMID: 37547971 DOI: 10.1111/ejh.14051] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 07/07/2023] [Accepted: 07/10/2023] [Indexed: 08/08/2023]
Abstract
The introduction of chimeric antigen receptor (CAR) T cells revolutionized treatment of relapsed and refractory multiple myeloma (RRMM) in recent years. Currently, two CAR T cell products-idecabtagene vicleucel and ciltacabtagene autoleucel-are approved in the United States and the European Union to treat patients with three prior lines of therapy, including a proteasome inhibitor, an immunomodulatory drug, and an anti-CD38 antibody. Moreover, seminal phase III trials of both agents in earlier lines of therapy have been published recently. Despite unprecedented rates of deep and lasting remissions in RRMM, there are still areas of uncertainty regarding the optimal use and distribution of CAR T cells in multiple myeloma. In the current review, we discuss the available data on approved CAR T cell products as well as unmet clinical needs and ongoing developments to optimize usage of this promising treatment modality in multiple myeloma.
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Affiliation(s)
- Luise Fischer
- Department of Hematology, Cellular Therapy, Hemostaseology and Infectiology, University Hospital of Leipzig, Leipzig, Germany
| | - Nora Grieb
- Department of Hematology, Cellular Therapy, Hemostaseology and Infectiology, University Hospital of Leipzig, Leipzig, Germany
- Innovation Center Computer Assisted Surgery (ICCAS), University of Leipzig, Leipzig, Germany
| | - Uwe Platzbecker
- Department of Hematology, Cellular Therapy, Hemostaseology and Infectiology, University Hospital of Leipzig, Leipzig, Germany
| | - Vladan Vucinic
- Department of Hematology, Cellular Therapy, Hemostaseology and Infectiology, University Hospital of Leipzig, Leipzig, Germany
| | - Maximilian Merz
- Department of Hematology, Cellular Therapy, Hemostaseology and Infectiology, University Hospital of Leipzig, Leipzig, Germany
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8
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Gaffney KJ, Davis JA, McGann M, Edwards K, Ahmed Z, Butcher C, Greenwell B, Hess BT, Hashmi H. Early versus standard management of chimeric antigen receptor therapy toxicities and management's impact on safety and efficacy. J Oncol Pharm Pract 2024; 30:151-158. [PMID: 37097891 DOI: 10.1177/10781552231170757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Abstract
BACKGROUND Cytokine release syndrome (CRS) and immune effector cell-associated neurologic syndrome (ICANS) are well-documented toxicities of CAR T-cell therapy. To mitigate excessive toxicity, our center has formulated treatment protocols (early vs. standard) for timely management of CRS and ICANS with tocilizumab and/or corticosteroids. METHODS This retrospective, single-center analysis included patients treated with CAR T-cell therapy. The goal was to describe the association of two management protocols with toxicity and efficacy outcomes. RESULTS Fifty-five percent of the 40 patients assigned to early management, out of which 5% and 9% developed grade 3+ CRS and ICANS, respectively. Seventy-seven percent and 41% of these patients received tocilizumab and corticosteroids, respectively. Forty-five percent of patients were stratified as standard management, out of which 0% and 11% developed grade 3+ CRS and ICANS, respectively. Seventeen percent and 28% of these patients received tocilizumab and corticosteroids, respectively. The day +90 overall response rate (ORR) for all patients was 63%, with an ORR of 89% for those managed per early management versus 50% for those managed per standard protocol. CONCLUSION Early use of tocilizumab and corticosteroids is effective in preventing excessive CAR-T-related toxicities with no negative impact on efficacy.
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Affiliation(s)
| | - James A Davis
- Medical University of South Carolina, Charleston, SC, USA
| | - Mary McGann
- Medical University of South Carolina, Charleston, SC, USA
| | - Kathy Edwards
- Medical University of South Carolina, Charleston, SC, USA
| | - Zaheer Ahmed
- Medical University of South Carolina, Charleston, SC, USA
| | | | | | - Brian T Hess
- Medical University of South Carolina, Charleston, SC, USA
| | - Hamza Hashmi
- Medical University of South Carolina, Charleston, SC, USA
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Peters DT, Savoldo B, Grover NS. Building safety into CAR-T therapy. Hum Vaccin Immunother 2023; 19:2275457. [PMID: 37968136 PMCID: PMC10760383 DOI: 10.1080/21645515.2023.2275457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 10/22/2023] [Indexed: 11/17/2023] Open
Abstract
Chimeric antigen receptor T cell (CAR-T) therapy is an innovative immunotherapeutic approach that utilizes genetically modified T-cells to eliminate cancer cells using the specificity of a monoclonal antibody (mAb) coupled to the potent cytotoxicity of the T-lymphocyte. CAR-T therapy has yielded significant improvements in relapsed/refractory B-cell malignancies. Given these successes, CAR-T has quickly spread to other hematologic malignancies and is being increasingly explored in solid tumors. From early clinical applications to present day, CAR-T cell therapy has been accompanied by significant toxicities, namely cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), and on-target off-tumor (OTOT) effects. While medical management has improved for CRS and ICANS, the ongoing threat of refractory symptoms and unanticipated idiosyncratic toxicities highlights the need for more powerful safety measures. This is particularly poignant as CAR T-cell therapy continues to expand into the solid tumor space, where the risk of unpredictable toxicities remains high. We will review CAR-T as an immunotherapeutic approach including emergence of unique toxicities throughout development. We will discuss known and novel strategies to mitigate these toxicities; additional safety challenges in the treatment of solid tumors, and how the inducible Caspase 9 "safety switch" provides an ideal platform for continued exploration.
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Affiliation(s)
- Daniel T. Peters
- Department of Hematology Oncology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Barbara Savoldo
- Lineberger Comprehensive Cancer Center, Department of Pediatrics, Hematology Oncology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Natalie S. Grover
- Lineberger Comprehensive Cancer Center, Department of Medicine, Hematology Oncology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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Bouziana S. Editorial: Novel insights into CAR T-cell associated neurotoxicity. Front Neurol 2023; 14:1322843. [PMID: 38020630 PMCID: PMC10660261 DOI: 10.3389/fneur.2023.1322843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 10/25/2023] [Indexed: 12/01/2023] Open
Affiliation(s)
- Stella Bouziana
- Department of Haematology, King's College Hospital NHS Foundation Trust, London, United Kingdom
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11
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Ong SY, Baird JH. A Primer on Chimeric Antigen Receptor T-cell Therapy-related Toxicities for the Intensivist. J Intensive Care Med 2023:8850666231205264. [PMID: 37899577 DOI: 10.1177/08850666231205264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
Chimeric antigen receptor (CAR) T-cell therapy is an innovative treatment approach that has shown remarkable efficacy against several hematologic malignancies. However, its use can be associated with unique and sometimes severe toxicities that require admission to intensive care unit in 30% of patients, and intensivists should be aware of immune-mediated toxicities of CAR T-cell therapy and management of adverse events. We will review available literature on current diagnostic criteria and therapeutic strategies for mitigating these most common toxicities associated with CAR T-cell therapy including cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS) in the post-infusion period. The authors will also review other toxicities associated with CAR T-cell therapy including cytopenias, acquired immunocompromised states, and infections, and discuss the available literature on best supportive care and prophylaxis recommendations. Critical care medicine specialists play a crucial role in the management of patients undergoing CAR T-cell therapies. With the expanding use of these products in increasing numbers of treating centers, intensivists' roles as part of the multidisciplinary team caring for these patients will have an outsized impact on the continued success of these promising therapies.
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Affiliation(s)
- Shin Yeu Ong
- Division of Lymphoma, Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
| | - John H Baird
- Division of Lymphoma, Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Valery M, Saleh K, Ecea R, Michot JM, Ribrag V, Fizazi K, Hollebecque A, Lecesne A, Ponce S, Loriot Y, Champiat S, Baldini C, Sarkozy C, Castilla-Llorente C. Infections occurring following IL6 blockade for the management of cytokine release syndrome in onco-hematology patients. Cancer Chemother Pharmacol 2023:10.1007/s00280-023-04551-6. [PMID: 37354233 DOI: 10.1007/s00280-023-04551-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 06/07/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND Cytokine release syndrome (CRS) is a common adverse event of CAR T cell or bispecific antibody (bsAb) therapy. Anti-IL6/IL6R drugs are used in the management of auto-immune diseases. Some reports showed increased risk of bacterial infection in this context. In onco-hematology, there are few data about the occurrence of infection after administration of an anti-IL6/IL6R for CRS. METHODS We retrospectively reviewed all consecutive patients treated in Gustave Roussy Cancer Campus between 2018 and 2021, who received anti-IL6/IL6R for CRS due to bsAb in phase I clinical trials or adoptive cellular therapy (ACT). We constituted a control group including all the patients treated in the same clinical trials or standard of care ACT, naïve of anti-IL6/IL6R. RESULTS Fifty-two patients have been included. In the anti-IL6/IL6R group (n = 26), five patients developed a grade 2 to 5 infection within a month after anti-IL6/IL6R treatment, including two grade 5 infections. In the control group (n = 26), only one patient had a grade 3 infection. The two patients who had grade 5 infections were treated for diffuse large B cell lymphoma (DLBCL), one with bsAb and the other with CAR T cell. Fifty percent (3/6) of DLBCL patients who received an anti-IL6/IL6R presented an infection, one of which was a grade 5. In solid tumor patients treated with bsAb and anti-IL6/IL6R, only one patient (/9, 11%) developed a grade 2 viral infection. CONCLUSION It seems that the use of anti-IL6/IL6R in CRS secondary to bsAb administration in solid tumors patients does not significantly increase the risk of infection, as opposed to DLBCL patients where secondary infection might be a concern.
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Affiliation(s)
- M Valery
- Department of Medical Oncology, Gustave Roussy Cancer Campus, 94805, Villejuif, France.
| | - K Saleh
- Department of Hematology, Gustave Roussy Cancer Campus, 94805, Villejuif, France
| | - R Ecea
- Department of Medical Oncology, Gustave Roussy Cancer Campus, 94805, Villejuif, France
| | - J M Michot
- Département d'Innovation Thérapeutique et d'essais précoces (DITEP), Gustave Roussy Cancer Campus, 94805, Villejuif, France
| | - V Ribrag
- Department of Hematology, Gustave Roussy Cancer Campus, 94805, Villejuif, France
- Département d'Innovation Thérapeutique et d'essais précoces (DITEP), Gustave Roussy Cancer Campus, 94805, Villejuif, France
| | - K Fizazi
- Department of Medical Oncology, Gustave Roussy Cancer Campus, 94805, Villejuif, France
| | - A Hollebecque
- Department of Medical Oncology, Gustave Roussy Cancer Campus, 94805, Villejuif, France
- Département d'Innovation Thérapeutique et d'essais précoces (DITEP), Gustave Roussy Cancer Campus, 94805, Villejuif, France
| | - A Lecesne
- International Department, Gustave Roussy Cancer Campus, 94805, Villejuif, France
| | - S Ponce
- Département d'Innovation Thérapeutique et d'essais précoces (DITEP), Gustave Roussy Cancer Campus, 94805, Villejuif, France
| | - Y Loriot
- Department of Medical Oncology, Gustave Roussy Cancer Campus, 94805, Villejuif, France
| | - S Champiat
- Département d'Innovation Thérapeutique et d'essais précoces (DITEP), Gustave Roussy Cancer Campus, 94805, Villejuif, France
| | - C Baldini
- Département d'Innovation Thérapeutique et d'essais précoces (DITEP), Gustave Roussy Cancer Campus, 94805, Villejuif, France
| | - C Sarkozy
- Department of Hematology, Institut Curie, 92210, Saint-Cloud, France
| | - C Castilla-Llorente
- Department of Hematology, Gustave Roussy Cancer Campus, 94805, Villejuif, France
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Gazeau N, Liang EC, Wu QV, Voutsinas JM, Barba P, Iacoboni G, Kwon M, Ortega JLR, Lopez-Corral L, Hernani R, Ortiz-Maldonado V, Martínez-Cibrian N, Martinez AP, Maziarz RT, Williamson S, Nemecek ER, Shadman M, Cowan AJ, Green DJ, Kimble E, Hirayama AV, Maloney DG, Turtle CJ, Gauthier J. Anakinra for refractory CRS or ICANS after CAR T-cell therapy. Transplant Cell Ther 2023:S2666-6367(23)01233-2. [PMID: 37031746 DOI: 10.1016/j.jtct.2023.04.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/02/2023] [Accepted: 04/02/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND Chimeric antigen receptor-engineered (CAR) T-cell therapy remains limited by significant toxicities such as cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). The optimal management of severe and/or refractory CRS/ICANS remains ill-defined. Anakinra has emerged as a promising agent based on preclinical data, but its safety and efficacy in CAR T-cell patients remains unknown. OBJECTIVES Our primary objective was to evaluate the safety of anakinra to treat refractory CRS and ICANS after CAR T-cell therapy. Our secondary objective was to evaluate the impact of key treatment, patient, and disease-related variables on time to CRS/ICANS resolution and treatment-related mortality (TRM). STUDY DESIGN We retrospectively analyzed the outcomes of 43 patients with B-cell or plasma cell malignancies treated with anakinra for refractory CRS or ICANS at 9 institutions in the United States and Spain between 2019 and 2022. Cause-specific Cox regression was used to account for competing risks. Multivariable cause-specific Cox regression was used to estimate the effect of the anakinra dose on outcomes while minimizing treatment allocation bias by including age, CAR-T product, prelymphodepletion (pre-LD) ferritin and performance status. RESULTS Indications for anakinra treatment were as follows: grade ≥2 ICANS with worsening or lack of symptom improvement despite treatment with high-dose corticosteroids (n=40), grade ≥2 CRS with worsening symptoms despite treatment with tocilizumab (n=3). Anakinra treatment was feasible and was safe; anakinra discontinuation due to anakinra-related side effects was only reported in 3 patients (7%). The overall response rate (ORR) to CAR T-cell therapy was 77%. The cumulative incidence of TRM in the whole cohort at day-28 and day-60 after CAR T-cell infusion was 7% (95%CI, 2-17) and 23% (95%CI, 11-38), respectively. The cumulative incidence of TRM at day-28 after anakinra initiation was 0% and 47% (95%CI, 20-70) in the high-dose (>200mg/day administered intravenously [IV]) and low-dose (100-200mg/day administered subcutaneously or IV) anakinra patients, respectively. The median cumulative incidence of CRS/ICANS resolution from the time of anakinra initiation was 7 days in patients who received high-dose anakinra and was not reached in patients who received low-dose anakinra due to the high TRM in this group. Univariate Cox modeling suggested shorter time to CRS/ICANS resolution in high-dose anakinra patients (HR, 2.19; 95%CI, 0.94-5.12; p=0.069). In a multivariable Cox model for TRM including age, CAR-T product, pre-LD ferritin and pre-LD KPS, higher anakinra dose remained associated with lower TRM (HR = 0.41 per 1mg/kg/day increase; 95% CI, 0.17-0.96; p=0.039. The only factor independently associated with time to CRS/ICANS resolution in a multivariable Cox model including age, CAR-T product, pre-LD ferritin, and anakinra dose, was higher pre-LD KPS HR = 1.05 per 10% increase; 95%CI, 1.01-1.09; p=0.02). CONCLUSION Anakinra treatment for refractory CRS or ICANS was safe at doses up to 12mg/kg/day IV. We observed an ORR of 77% after CAR T-cell therapy despite anakinra treatment, suggesting limited impact of anakinra on CAR T-cell efficacy. Higher anakinra dose may be associated with faster CRS/ICANS resolution and was independently associated with lower TRM. Prospective comparative studies are needed to confirm our findings.
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Affiliation(s)
- Nicolas Gazeau
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA; Centre Hospitalier Universitaire de Lille, service d'hématologie, Lille, France
| | - Emily C Liang
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA; Department of Medicine, University of Washington, Seattle, WA
| | - Qian Vicky Wu
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Jenna M Voutsinas
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Pere Barba
- Hematology Department, Hospital Universitari Vall d'Hebron. Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Gloria Iacoboni
- Hematology Department, Hospital Universitari Vall d'Hebron. Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Mi Kwon
- Department of Hematology, Hospital General Universitario Gregrorio Marañon, Institute of Health Research Gregorio Marañon. Universidad Complutense de Madrid, Madrid, Spain
| | - Juan Luis Reguera Ortega
- Servicio de Hematología, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla, Sevilla, Spain
| | - Lucia Lopez-Corral
- Hematology Department, Complejo Asistencial Universitario de Salamanca-IBSAL; Centro de Investigación del Cáncer-IBMCC, Spain
| | - Rafael Hernani
- Hematology Department, Hospital Clinico Universitario, INCLIVA Research Institut, Valencia,Spain
| | | | | | | | - Richard T Maziarz
- Center for Hematologic Malignancies, Knight Cancer Institute, Oregon Health and Science University, Portland, OR
| | - Staci Williamson
- Center for Hematologic Malignancies, Knight Cancer Institute, Oregon Health and Science University, Portland, OR
| | - Eneida R Nemecek
- Center for Hematologic Malignancies, Knight Cancer Institute, Oregon Health and Science University, Portland, OR
| | - Mazyar Shadman
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA; Department of Medicine, University of Washington, Seattle, WA
| | - Andrew J Cowan
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA; Department of Medicine, University of Washington, Seattle, WA
| | - Damian J Green
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA; Department of Medicine, University of Washington, Seattle, WA
| | - Erik Kimble
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA; Department of Medicine, University of Washington, Seattle, WA
| | - Alexandre V Hirayama
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA; Department of Medicine, University of Washington, Seattle, WA
| | - David G Maloney
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA; Department of Medicine, University of Washington, Seattle, WA
| | - Cameron J Turtle
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA; Department of Medicine, University of Washington, Seattle, WA; University of Sydney, NSW, Australia
| | - Jordan Gauthier
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA; Department of Medicine, University of Washington, Seattle, WA.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Abstract
PURPOSE OF REVIEW Chimeric antigen receptor (CAR) T cell therapy is an immunotherapy that has resulted in tremendous progress in the treatment of patients with B cell malignancies. However, the remarkable efficacy of therapy is not without significant safety concerns. Herein, we will review the unique and potentially life-threatening toxicities associated with CAR-T cell therapy and their association with treatment efficacy. RECENT FINDINGS Currently, CAR-T cell therapy is approved for the treatment of B cell relapsed or refractory leukemia and lymphoma, and most recently, multiple myeloma (MM). In these different diseases, it has led to excellent complete and overall response rates depending on the patient population and therapy. Despite promising efficacy, CAR-T cell therapy is associated with significant side effects; the two most notable toxicities are cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). The treatment of CAR-T-induced toxicity is supportive; however, as higher-grade adverse events occur, toxicity-directed therapy with tocilizumab, an IL-6 receptor antibody, and steroids is standard practice. Overall, a careful risk-benefit balance exists between the efficacy and toxicities of therapies. The challenge lies in the underlying pathophysiology of CAR-T-related toxicity which relies upon the activation of CAR-T cells. Some degree of toxicity is expected to achieve an effective response to therapy, and certain aspects of treatment are also associated with toxicity. As progress is made in the investigation and approval of new CARs, novel toxicity-directed therapies and toxicity-limited constructs will be the focus of attention.
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Affiliation(s)
| | - Elizabeth L Siegler
- T Cell Engineering, Mayo Clinic, Rochester, MN, USA
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Saad S Kenderian
- T Cell Engineering, Mayo Clinic, Rochester, MN, USA.
- Division of Hematology, Mayo Clinic, Rochester, MN, USA.
- Department of Molecular Medicine, Mayo Clinic, Rochester, MN, USA.
- Department of Immunology, Mayo Clinic, Rochester, MN, USA.
- Department of Molecular Pharmacology & Experimental Therapeutics, Mayo Clinic, 200 1st ST SW, Rochester, MN, 55902, USA.
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Abstract
Chimeric antigen receptor (CAR) T-cell therapy targeting CD19 is the current standard of care for the treatment of relapsed refractory large B cell lymphoma, demonstrating impressive response rates in the second- and third-line setting. Despite these advances, this treatment strategy can result in significant toxicities, such as cytokine release syndrome or immune effector cell associated neurotoxicity syndrome. While the exact mechanisms of these immune-mediated toxicities are not clearly understood, emerging pre-clinical and clinical studies have revealed the pivotal role of myeloid cells, particularly macrophages, as key contributors to the efficacy of treatments and as crucial mediators of toxicity. In this review, we discuss the current understanding of how macrophages mediate these effects, highlighting specific mechanisms of macrophage biology relevant to CAR T-cell therapy activity and side effects. These findings are resulting in novel treatment strategies that target macrophages, and able to mitigate toxicity while preserving CAR T-cell therapy efficacy.
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Affiliation(s)
- Ajlan Al Zaki
- Department of Lymphoma and Myeloma, The University of Texas, Houston, TX, USA
| | - Dustin McCurry
- Department of Lymphoma and Myeloma, The University of Texas, Houston, TX, USA
| | - Paolo Strati
- Department of Lymphoma and Myeloma, The University of Texas, Houston, TX, USA.,Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Lakomy T, Akhoundova D, Nilius H, Kronig MN, Novak U, Daskalakis M, Bacher U, Pabst T. Early Use of Corticosteroids following CAR T-Cell Therapy Correlates with Reduced Risk of High-Grade CRS without Negative Impact on Neurotoxicity or Treatment Outcome. Biomolecules 2023; 13. [PMID: 36830750 DOI: 10.3390/biom13020382] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/13/2023] [Accepted: 02/14/2023] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND Chimeric antigen receptor T-cell therapy (CAR T-cell therapy) is associated with potentially life-threatening toxicities, most commonly cytokine release syndrome (CRS) and immune-effector-cell-associated neurotoxicity syndrome (ICANS). These frequent adverse events are managed with the IL-6 receptor antagonist tocilizumab and/or corticosteroids. The prophylactic and early use of corticosteroids for CRS and ICANS have previously been reported, but eventual negative impacts on CAR T-cell efficacy are feared. METHODS Retrospective comparative analysis of two patient cohorts with hematological malignancies treated with CAR T-cell therapy: 43 patients received early administration of 10 mg dexamethasone preceding each dose of tocilizumab ("early corticosteroid/ tocilizumab", EcsTcz cohort) vs. 40 patients who received tocilizumab alone ("tocilizumab alone", Tcz cohort) for treatment of low-grade CRS. RESULTS Despite overall higher CRS incidence (91% vs. 70%; p = 0.0249), no high-grade CRS was observed (0% vs. 10%; p = 0.0497) among patients receiving early corticosteroids in combination with tocilizumab. In terms of neurotoxicity, no worsening regarding incidence of ICANS (30% vs. 33%; p = 0.8177) or high-grade ICANS (20% vs. 14%; p = 0.5624) was observed in the EcsTcz cohort. Moreover, overall response rates (80% vs. 77%; p = 0.7936), complete response rates (50% vs. 44%; p = 0.6628), progression-free survival (p = 0.6345) and overall survival (p = 0.1215) were comparable for both cohorts. CONCLUSIONS Our study suggests that the early use of corticosteroids in combination with the standard tocilizumab schedule for low-grade CRS following CAR T-cell therapy may significantly reduce the risk of high-grade CRS without negative impact on neurotoxicity or treatment outcome.
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Butt OH, Zhou AY, Ances BM, DiPersio JF, Ghobadi A. A systematic framework for predictive biomarkers in immune effector cell-associated neurotoxicity syndrome. Front Neurol 2023; 14:1110647. [PMID: 36860569 PMCID: PMC9969296 DOI: 10.3389/fneur.2023.1110647] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 01/23/2023] [Indexed: 02/15/2023] Open
Abstract
Chimeric antigen receptor (CAR)-T cell therapy has revolutionized the management of several life-threatening malignancies, often achieving durable sustained responses. The number of patients treated with this new class of cell-based therapy, along with the number of Food and Drug Association (FDA) approved indications, are growing significantly. Unfortunately Immune Effector Cell-Associated Neurotoxicity Syndrome (ICANS) can often occur after treatment with CAR-T cells, and severe ICANS can be associated with significant morbidity and mortality. Current standard treatments are mainly steroids and supportive care, highlighting the need for early identification. In the last several years, a range of predictive biomarkers have been proposed to distinguish patients at increased risk for developing ICANS. In this review, we discuss a systematic framework to organize potential predictive biomarkers that builds on our current understanding of ICANS.
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Affiliation(s)
- Omar H. Butt
- Division of Oncology, Department of Medicine, Siteman Cancer Center, Washington University in Saint Louis, St. Louis, MO, United States,*Correspondence: Omar H. Butt ✉
| | - Alice Y. Zhou
- Division of Oncology, Department of Medicine, Siteman Cancer Center, Washington University in Saint Louis, St. Louis, MO, United States
| | - Beau M. Ances
- Department of Neurology, Washington University in Saint Louis, St. Louis, MO, United States
| | - John F. DiPersio
- Division of Oncology, Department of Medicine, Siteman Cancer Center, Washington University in Saint Louis, St. Louis, MO, United States
| | - Armin Ghobadi
- Division of Oncology, Department of Medicine, Siteman Cancer Center, Washington University in Saint Louis, St. Louis, MO, United States
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Picard M, Sterin A, Bay JO, Courbon C, Moreau AS, Paul F, Pochon C, Tudesq JJ, Vicente C, Yakoub-Agha M, Yakoub-Agha I. [Management of neurotoxicity following CAR-T cell therapy: Recommendations of the SFGM-TC]. Bull Cancer 2023; 110:S123-31. [PMID: 35094839 DOI: 10.1016/j.bulcan.2021.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 12/08/2021] [Accepted: 12/12/2021] [Indexed: 11/20/2022]
Abstract
The immune effector cell-associated syndrome (ICANS) has been described as the second most frequent specific complication following CAR-T cell therapy. The median time to the onset of neurological symptoms is five days after CAR-T infusion. ICANS can be concomitant to cytokine release syndrome but often follows the resolution of the latter. However, 10 % of patients experience delayed onset after 3 weeks of CAR-T cell infusion. The duration of symptoms is usually short, around five days if an early appropriate treatment is given. Symptoms are heterogeneous, ranging from mild symptoms quickly reversible (alterations of consciousness, deterioration in handwriting) to more serious forms with seizures or even a coma. The ICANS severity is currently based on the ASTCT score. The diagnosis of ICANS is clinical but EEG, MRI and lumbar punction can help ruling out alternative diagnoses. The first line treatment consists of high-dose corticosteroids. During the twelfth edition of practice harmonization workshops of the Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC), a working group focused its work on updating the SFGM-TC recommendations on the management of ICANS. In this review we discuss the management of ICANS and other neurological toxicities in patients undergoing of CAR-T cell therapy. These recommendations apply to commercial CAR-T cells, in order to guide strategies for the management neurological complications associated with this new therapeutic approach.
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21
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Davis JA, Gaffney KJ, McGann M, Smith D, Edwards K, Baldino E, Bakos K, Butcher C, Greenwell B, Hess BT, Hashmi H. Fever Characteristics and Impact on Safety and Efficacy of Chimeric Antigen Receptor T-Cell Therapy. Clin Lymphoma Myeloma Leuk 2023; 23:e14-e18. [PMID: 36319568 DOI: 10.1016/j.clml.2022.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 09/29/2022] [Accepted: 09/30/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Fever is a hallmark symptom of cytokine release syndrome (CRS) after chimeric antigen receptor (CAR) T-cell therapy. Fever characteristics and the impact of fever on safety and efficacy post CAR T are not well understood. We sought to explore the impact of fever and its characteristics on safety and efficacy post CAR T-cell therapy. PATIENTS AND METHODS We reviewed 40 patients with various hematologic malignancies (non-Hodgkin lymphoma, acute lymphoblastic leukemia, multiple myeloma) treated with CAR T-cell therapy between March 2019 and March 2022. We evaluated all patients who developed fever after CAR T infusion and analyzed the association of fever with toxicity (CRS and neurotoxicity) and efficacy (overall response (ORR) and complete response (CR) at day +90 post CAR T infusion). Fever was defined as per Lee criteria (equal to or greater than 38°C). CRS and immune-effector cell associated neurotoxicity syndrome (ICANS) were graded using American Society for Transplantation and Cellular Therapy grading system. RESULTS Fever occurred in 75% (30/40) of patients. Rates of all grade and grade 3+ CRS and ICANS were 75%, 2%, 33% and 10%, respectively. Fever occurred within 24 and 72 hours after CAR T infusion in 40% and 53% of patients, respectively. Fifty percent of patients received tocilizumab (toci) for CRS. After the first dose of toci, fever recurred in 38% of the patients, of which 67% had recurrence within 24 hours. Day +90 CR rates were 43% and 10% in patients with and without fever, respectively (Table 3). CONCLUSION While fever is common after CAR T-cell therapy, early-onset and higher magnitude do not appear to affect safety or efficacy of CAR T. Absence of fever may affect response to CAR T.
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Affiliation(s)
- James A Davis
- Department of Malignant Hematology and Bone Marrow Transplant, Medical University of South Carolina, Charleston, SC.
| | - Kelly J Gaffney
- Department of Malignant Hematology and Bone Marrow Transplant, Medical University of South Carolina, Charleston, SC
| | - Mary McGann
- Department of Malignant Hematology and Bone Marrow Transplant, Medical University of South Carolina, Charleston, SC
| | - Deidra Smith
- Department of Malignant Hematology and Bone Marrow Transplant, Medical University of South Carolina, Charleston, SC
| | - Kathy Edwards
- Department of Malignant Hematology and Bone Marrow Transplant, Medical University of South Carolina, Charleston, SC
| | - Ellen Baldino
- Department of Malignant Hematology and Bone Marrow Transplant, Medical University of South Carolina, Charleston, SC
| | - Keegan Bakos
- Department of Malignant Hematology and Bone Marrow Transplant, Medical University of South Carolina, Charleston, SC
| | - Coleen Butcher
- Department of Malignant Hematology and Bone Marrow Transplant, Medical University of South Carolina, Charleston, SC
| | - Brian Greenwell
- Department of Malignant Hematology and Bone Marrow Transplant, Medical University of South Carolina, Charleston, SC
| | - Brian T Hess
- Department of Malignant Hematology and Bone Marrow Transplant, Medical University of South Carolina, Charleston, SC
| | - Hamza Hashmi
- Department of Malignant Hematology and Bone Marrow Transplant, Medical University of South Carolina, Charleston, SC
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22
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Goto H. [Management of adverse effects in CAR T-cell therapy]. Rinsho Ketsueki 2023; 64:1203-1212. [PMID: 37899201 DOI: 10.11406/rinketsu.64.1203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
Immunotherapies such as immune checkpoint inhibitors, bispecific antibodies, and chimeric antigen receptor (CAR) T-cell therapy are emerging as new treatments for relapsed and/or refractory hematological malignancies. CAR T-cell therapy has attracted attention as a potentially curative treatment for patients incurable by chemotherapy. However, appropriate management is required to avoid serious complications specific to CAR T-cell therapy, such as cytokine release syndrome (CRS), neurotoxicity (ICANS), hypogammaglobulinemia and prolonged cytopenia, as well as post-treatment infections caused by suppressed immune function.
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Affiliation(s)
- Hideki Goto
- Department of Hematology, Hokkaido University Hospital
- Division of Laboratory and Transfusion Medicine
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23
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Chen X, Li P, Tian B, Kang X. Serious adverse events and coping strategies of CAR-T cells in the treatment of malignant tumors. Front Immunol 2022; 13:1079181. [PMID: 36569917 PMCID: PMC9772271 DOI: 10.3389/fimmu.2022.1079181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 11/24/2022] [Indexed: 12/12/2022] Open
Abstract
Chimeric antigen receptor T (CAR-T) cells technology has been successfully used in the treatment of B cell-derived hematological tumors and multiple myeloma. CAR-T cells are also being studied in a variety of solid tumors. Current clinical reports on CAR-T cells in the treatment of malignant tumors are abundant. The tumor-killing activity of CAR-T cells and the unique adverse effects of CAR-T cells have been confirmed by many studies. There is evidence that serious adverse events can be life-threatening. CAR-T cells therapy is increasingly used in clinical settings, so it is important to pay attention to its serious adverse events. In this review, we summarized the serious adverse events of CAR-T cells in the treatment of malignant tumors by reading literature and searching relevant clinical studies, and discussed the management and treatment of serious adverse events in an effort to provide theoretical support for clinicians who deal with such patients.
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24
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Gideon J. CAR T-Cell Therapy for Relapsed/Refractory Aggressive Large B-Cell Lymphoma. Clin J Oncol Nurs 2022; 26:597-601. [PMID: 36413724 DOI: 10.1188/22.cjon.597-601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Cellular immunotherapy with CD19-directed chimeric antigen receptor (CAR) T-cell therapy has changed the treatment landscape for aggressive B-cell non-Hodgkin lymphoma (B-NHL). Three CAR T-cell therapies are commercially avai.
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25
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Perales MA, Anderson LD, Jain T, Kenderian SS, Oluwole OO, Shah GL, Svoboda J, Hamadani M. Role of CD19 Chimeric Antigen Receptor T Cells in Second-Line Large B Cell Lymphoma: Lessons from Phase 3 Trials. An Expert Panel Opinion from the American Society for Transplantation and Cellular Therapy. Transplant Cell Ther 2022; 28:546-559. [PMID: 35768052 PMCID: PMC9427727 DOI: 10.1016/j.jtct.2022.06.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 06/20/2022] [Accepted: 06/22/2022] [Indexed: 12/25/2022]
Abstract
Since 2017, 3 CD19-directed chimeric antigen receptor (CAR) T cell therapies-axicabtagene ciloleucel, tisagenlecleucel, and lisocabtagene maraleucel-have been approved for relapsed/refractory aggressive diffuse large B cell lymphoma after 2 lines of therapy. Recently, 3 prospective phase 3 randomized clinical trials were conducted to define the optimal second-line treatment by comparing each of the CAR T cell products to the current standard of care: ZUMA-7 for axicabtagene ciloleucel, BELINDA for tisagenlecleucel, and TRANSFORM for lisocabtagene maraleucel. These 3 studies, although largely addressing the same question, had different outcomes, with ZUMA-7 and TRANSFORM demonstrating significant improvement with CD19 CAR T cells in second-line therapy compared with standard of care but BELINDA not showing any benefit. The US Food and Drug Administration has now approved axicabtagene ciloleucel and lisocabtagene maraleucel for LBCL that is refractory to first-line chemoimmunotherapy or relapse occurring within 12 months of first-line chemoimmunotherapy. Following the reporting of these practice changing studies, here a group of experts convened by the American Society for Transplantation and Cellular Therapy provides a comprehensive review of the 3 studies, emphasizing potential differences, and shares perspectives on what these results mean to clinical practice in this new era of treatment of B cell lymphomas.
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Affiliation(s)
- Miguel-Angel Perales
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York.
| | - Larry D Anderson
- Hematologic Malignancies, Transplantation, and Cellular Therapy Program, Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, Texas
| | - Tania Jain
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Saad S Kenderian
- T Cell Engineering, Mayo Clinic, Mayo Clinic Graduate School of Biomedical Sciences, Division of Hematology, Department of Immunology and Department of Molecular Medicine, Rochester, Minnesota
| | - Olalekan O Oluwole
- Division of Hematology/Oncology, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | - Gunjan L Shah
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Jakub Svoboda
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mehdi Hamadani
- BMT & Cellular Therapy Program, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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26
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Asawa P, Vusqa U, Khan C, Samhouri Y, Fazal S. Intrathecal Chemotherapy as a Potential Treatment for Steroid-refractory Immune Effector Cell-associated Neurotoxicity Syndrome. Anticancer Res 2022; 42:3853-3856. [PMID: 35896259 DOI: 10.21873/anticanres.15876] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/15/2022] [Accepted: 06/29/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM Chimeric antigen receptor (CAR) T-cell therapy has revolutionized the treatment of various B-cell malignancies. However, it can cause serious adverse effects like immune effector cell-associated neurotoxicity syndrome (ICANS). ICANS is attributed to disruption of the blood-brain barrier due to inflammatory cytokines and increased levels of immune effector cells (IECs) in the cerebrospinal fluid (CSF). Corticosteroids and supportive management are the mainstays of ICANS treatment. However, no guidelines exist for the treatment of steroid-refractory ICANS. Some reports have shown favorable outcomes with no long-term complications in patients with steroid-refractory ICANS treated with intrathecal (IT) chemotherapy. CASE REPORT We describe the outcomes of two patients with steroid-refractory ICANS treated with IT chemotherapy. Both patients had refractory large B-cell lymphoma and were not candidates for autologous transplant. They developed steroid-refractory ICANS after CAR T-cell infusion. IT chemotherapy with 12 mg methotrexate and 50 mg hydrocortisone resulted in prompt neurological improvement in both patients. One of them passed away due to multiple other comorbidities, and the other patient continues to do well without any complications. CONCLUSION IT chemotherapy could be considered as a potential approach for the management of steroid-refractory ICANS based on our experience. Prospective studies are needed to validate this approach.
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Affiliation(s)
- Palash Asawa
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, PA, U.S.A.;
| | - Urwat Vusqa
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, PA, U.S.A
| | - Cyrus Khan
- Division of Hematology and Cellular Therapy, Allegheny Health Network Cancer Institute, Pittsburgh, PA, U.S.A
| | - Yazan Samhouri
- Division of Hematology and Cellular Therapy, Allegheny Health Network Cancer Institute, Pittsburgh, PA, U.S.A
| | - Salman Fazal
- Division of Hematology and Cellular Therapy, Allegheny Health Network Cancer Institute, Pittsburgh, PA, U.S.A
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27
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Parol W, Anderson GSF, Chapman MA. CAR-T cell therapies for cancer: what novel technologies are being developed for toxicity data? Expert Opin Drug Metab Toxicol 2022; 18:241-244. [PMID: 35686653 DOI: 10.1080/17425255.2022.2085551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 05/31/2022] [Indexed: 11/04/2022]
Affiliation(s)
- Wiktoria Parol
- University of Cambridge, MRC Toxicology Unit, Cambridge, UK
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28
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Wudhikarn K, Soh SY, Huang H, Perales MA. Toxicity of Chimeric Antigen Receptor T Cells and its Management. Blood Cell Ther 2021; 4:S1-S7. [PMID: 36713468 PMCID: PMC9847268 DOI: 10.31547/bct-2021-011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 08/15/2021] [Indexed: 02/01/2023]
Abstract
Recently, chimeric antigen receptor (CAR) T cell therapy has transformed the treatment armamentarium of relapsed/refractory B lymphoid malignancies. CAR T cells provide an excellent response rate and potential cure for these patients. However, CAR T cells also possess unique and potentially life-threatening immune-mediated side effects. Among these, cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS) are the two most common complications associated with CAR T cell therapy. While the pathogenesis of CRS involves the activation of complex immune axes, including both cellular networks and inflammatory cytokine milieu, the mechanism of ICANS has not been fully elucidated. Other notable toxicities of CAR T cells include macrophage activation syndrome, cytopenia, and potential organ toxicities. Treatments for these complications typically encompass close observation, multidisciplinary supportive measures, and cytokine-modifying agents such as anti-interleukin-6 antibody and systemic corticosteroids. CAR T therapies can cause immunologic adverse events and management of these toxicities could also instigate a profound immune suppression state that predisposes patients to a variety of infectious complications. Prompt diagnosis and proper management of these complications are crucial to minimize CAR T cell-associated complications and to maximize the outcome of CAR T cell therapy.
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Affiliation(s)
- Kitsada Wudhikarn
- Division of Hematology and Research Unit in Translational Hematology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Shui Yen Soh
- Paediatric Haematology/Oncology Service, KK Women's and Children's Hospital, Singapore
| | - He Huang
- The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA,Department of Medicine, Weill Cornell Medical College, New York, NY, USA
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29
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Martino M, Macheda S, Aguglia U, Arcudi L, Pucci G, Martino B, Altomonte M, Rossetti AM, Cusumano G, Russo L, Imbalzano L, Stelitano C, Alati C, Germano' J, Labate D, Amalfi V, Florenzano MT, Morabito A, Borzumati V, Dattola V, Gattuso C, Moschella A, Quattrone D, Curmaci F, Franzutti C, Scappatura G, Rao CM, Loddo V, Pontari A, Pellicano' M, Surace R, Sanguedolce C, Naso V, Ferreri A, Irrera G, Console G, Moscato T, Loteta B, Canale FA, Trimarchi A, Monteleone R, Al Sayyad S, Cirrone F, Bruno B. Identifying and managing CAR T-cell-mediated toxicities: on behalf of an Italian CAR-T multidisciplinary team. Expert Opin Biol Ther 2021; 22:407-421. [PMID: 34463175 DOI: 10.1080/14712598.2021.1974394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Chimeric antigen receptor (CAR)-T-cell therapy is a new treatment for patients with hematologic malignancies in which other therapies have failed. AREAS COVERED The review provides an overview for recognizing and managing the most acute toxicities related to CAR-T cells. EXPERT OPINION The development of immune-mediated toxicities is a common challenge of CAR-T therapy. The mechanism that determines this toxicity is still unclear, although an unfavorable tumor microenvironment and a pro-inflammatory state put patients at risk. The monitoring, diagnosis, and treatment of post-CAR-T toxicities must be determined and based on international guidelines and internal clinical practice. It is urgent to identify biomarkers that can identify patients at greater risk of developing complications. The adoption of consistent grading criteria is necessary to improve toxicity management strategies continually. The first-line therapy consists of supportive care and treatment with tocilizumab or corticosteroids. An early start of cytokine blockade therapies could mitigate toxicity. The plan will include cytokine release prophylaxis, a risk-adapted treatment, prevention of on-target/off-tumor effect, and a switch on/off CAR-T approach.
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Affiliation(s)
- Massimo Martino
- Stem Cell Transplant and Cellular Therapies Unit, Great Metropolitan Hospital "Bianchi-melacrino-morelli", Reggio, Calabria, Italy.,Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Sebastiano Macheda
- Intensive Care Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Umberto Aguglia
- Department of Medicine, Surgery and Health Sciences, Magna Græcia University, Catanzaro, Italy, Regional Epilepsy Centre, Great Metropolitan Hospital "Bianchi-melacrino-morelli," Reggio Calabria, Italy.,Neurology Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Luciano Arcudi
- Neurology Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Giulia Pucci
- Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy.,Stem Cell Processing Laboratory Unit, Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Bruno Martino
- Hematology Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Maria Altomonte
- Pharmacy Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Antonio Maria Rossetti
- Stem Cell Transplant and Cellular Therapies Unit, Great Metropolitan Hospital "Bianchi-melacrino-morelli", Reggio, Calabria, Italy.,Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Giuseppa Cusumano
- Stem Cell Transplant and Cellular Therapies Unit, Great Metropolitan Hospital "Bianchi-melacrino-morelli", Reggio, Calabria, Italy.,Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Letteria Russo
- Stem Cell Transplant and Cellular Therapies Unit, Great Metropolitan Hospital "Bianchi-melacrino-morelli", Reggio, Calabria, Italy.,Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Lucrezia Imbalzano
- Stem Cell Transplant and Cellular Therapies Unit, Great Metropolitan Hospital "Bianchi-melacrino-morelli", Reggio, Calabria, Italy.,Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Caterina Stelitano
- Hematology Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Caterina Alati
- Hematology Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Jessyca Germano'
- Hematology Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Demetrio Labate
- Intensive Care Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Vincenzo Amalfi
- Intensive Care Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Maria Teresa Florenzano
- Pharmacy Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Antonella Morabito
- Pharmacy Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Vittoria Borzumati
- Pharmacy Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Vincenzo Dattola
- Neurology Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Caterina Gattuso
- Neurology Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Antonio Moschella
- Pain Center Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Domenico Quattrone
- Pain Center Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Francesco Curmaci
- Pain Center Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Claudio Franzutti
- Radiology Department, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Giuseppe Scappatura
- Radiology Department, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Carmelo Massimiliano Rao
- Cardiology Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Viviana Loddo
- Catholic University of the Sacred Heart, Rome, Italy
| | - Antonella Pontari
- Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy.,Stem Cell Processing Laboratory Unit, Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Maria Pellicano'
- Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy.,Intensive Care Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Rosangela Surace
- Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy.,Intensive Care Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Cristina Sanguedolce
- Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy.,Intensive Care Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Virginia Naso
- Stem Cell Transplant and Cellular Therapies Unit, Great Metropolitan Hospital "Bianchi-melacrino-morelli", Reggio, Calabria, Italy.,Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Anna Ferreri
- Stem Cell Transplant and Cellular Therapies Unit, Great Metropolitan Hospital "Bianchi-melacrino-morelli", Reggio, Calabria, Italy.,Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Giuseppe Irrera
- Stem Cell Transplant and Cellular Therapies Unit, Great Metropolitan Hospital "Bianchi-melacrino-morelli", Reggio, Calabria, Italy.,Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Giuseppe Console
- Stem Cell Transplant and Cellular Therapies Unit, Great Metropolitan Hospital "Bianchi-melacrino-morelli", Reggio, Calabria, Italy.,Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Tiziana Moscato
- Stem Cell Transplant and Cellular Therapies Unit, Great Metropolitan Hospital "Bianchi-melacrino-morelli", Reggio, Calabria, Italy.,Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Barbara Loteta
- Stem Cell Transplant and Cellular Therapies Unit, Great Metropolitan Hospital "Bianchi-melacrino-morelli", Reggio, Calabria, Italy.,Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Filippo Antonio Canale
- Stem Cell Transplant and Cellular Therapies Unit, Great Metropolitan Hospital "Bianchi-melacrino-morelli", Reggio, Calabria, Italy.,Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Alfonso Trimarchi
- Immunotransfusion Service Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli,", Reggio, Calabria, Italy
| | - Renza Monteleone
- Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Said Al Sayyad
- Onco-hematology and Radiotherapy Department, Great Metropolitan Hospital "Bianchi-melacrino-morelli", Reggio, Calabria, Italy
| | - Frank Cirrone
- Department of Pharmacy, Nyu Langone Health, New York, NY
| | - Benedetto Bruno
- Department of Molecular Biotechnology and Health Sciences, University of Torino and Department of Oncology, Division of Hematology, A.o.u. Città Della Salute E Della Scienza Di Torino, Presidio Molinette, Torino, Italy.,Division Of Hematology And Medical Oncology, Perlmutter Cancer Center, Grossman School Of Medicine, NYU Langone Health, New York, Ny
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30
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Castaneda-Puglianini O, Chavez JC. Assessing and Management of Neurotoxicity After CAR-T Therapy in Diffuse Large B-Cell Lymphoma. J Blood Med 2021; 12:775-783. [PMID: 34466048 PMCID: PMC8403007 DOI: 10.2147/jbm.s281247] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 07/31/2021] [Indexed: 11/23/2022] Open
Abstract
Chimeric antigen receptor T-cell (CAR-T) therapy represents the most important advances in cancer immunotherapy, especially in hematological malignancies such as B-cell lymphomas. CAR-T cell therapy has significant activity in poor risk B-cell lymphomas. CAR-T cell therapy is associated with potentially life-threatening toxicities such as cytokine release syndrome (CRS) and neurotoxicity (NT). While CRS pathophysiology and management are well established, the understanding and treatment of NT continues to develop. All current CAR-T products approved for DLBCL have been associated with NT with some differences in their severity. As cell therapies continue to advance and its access broadening, it will be imperative for clinicians to be aware of the signs and symptoms of NT, its stratification and basic management.
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Affiliation(s)
- Omar Castaneda-Puglianini
- Virginia Commonwealth University, Massey Cancer Center, Cellular Immunotherapies and Transplant Program, Richmond, VA, USA
| | - Julio C Chavez
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL, USA
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31
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Beuchat I, Danish H, Rubin DB, Jacobson C, Robertson M, Vaitkevicius H, Lee JW. EEG findings in CART T associated neurotoxicity: clinical and radiological correlations. Neuro Oncol 2021; 24:313-325. [PMID: 34265061 DOI: 10.1093/neuonc/noab174] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND While EEG is frequently reported as abnormal after CAR T cell therapy, its clinical significance remains unclear. We aim to systematically describe EEG features in a large single-center cohort and correlate them with clinical and radiological findings. METHODS We retrospectively identified patients undergoing CAR T cell therapy who had continuous EEG. Neurotoxicity grades, detailed neurological symptoms, and brain MRI or FDG-PET were obtained. Correlation between clinical and radiological findings and EEG features was assessed. RESULTS In 81 patients with median neurotoxicity grade 3 (IQR 2-3), diffuse EEG background slowing was the most common finding and correlated with neurotoxicity severity (p <0.001). A total of 42 patients had rhythmic or periodic patterns, 16 of them within the ictal-interictal-continuum (IIC), 5 with clinical seizures, and 3 with only electrographic seizures. Focal EEG abnormalities, consisting of lateralized periodic discharges (LPD, n=1), lateralized rhythmic delta activity (LRDA, n=6), or focal slowing (n=19), were found in 22 patients. All patients with LRDA, LPD, and 10/19 patients with focal slowing had focal clinical symptoms concordant with these EEG abnormalities. In addition, these focal EEG changes often correlated with PET hypometabolism or MRI hypoperfusion, in absence of a structural lesion. CONCLUSION In adult patients experiencing neurotoxicity after CAR T cell infusion, EEG degree of background disorganization correlated with neurotoxicity severity. IIC patterns and focal EEG abnormalities are frequent and often correlate with focal clinical symptoms and with PET-hypometabolism/MRI-hypoperfusion, without structural lesion. The etiology of these findings remains to be elucidated.
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Affiliation(s)
- Isabelle Beuchat
- Department of Neurology, Brigham and Women's Hospital, Harvard School of Medicine, Boston, MA, USA
| | - Husain Danish
- Department of Neurology, Brigham and Women's Hospital, Harvard School of Medicine, Boston, MA, USA.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel B Rubin
- Department of Neurology, Brigham and Women's Hospital, Harvard School of Medicine, Boston, MA, USA.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Caron Jacobson
- Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Matthew Robertson
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Henrikas Vaitkevicius
- Department of Neurology, Brigham and Women's Hospital, Harvard School of Medicine, Boston, MA, USA
| | - Jong Woo Lee
- Department of Neurology, Brigham and Women's Hospital, Harvard School of Medicine, Boston, MA, USA
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32
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Pensato U, Muccioli L, Janigro D, Guarino M, Bisulli F, Cortelli P. Akinetic mutism in COVID-19-related encephalopathy: A cytokine-mediated maladaptive sickness behavioral response? Brain Behav Immun Health 2021; 15:100272. [PMID: 34002170 PMCID: PMC8117477 DOI: 10.1016/j.bbih.2021.100272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/09/2021] [Accepted: 05/10/2021] [Indexed: 11/21/2022] Open
Affiliation(s)
- Umberto Pensato
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy
| | - Lorenzo Muccioli
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy
| | - Damir Janigro
- Department of Physiology, Case Western Reserve University, Cleveland, OH, United States
| | - Maria Guarino
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Full Member of the ERN-EpiCARE network, Bologna, Italy
| | - Francesca Bisulli
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Full Member of the ERN-EpiCARE network, Bologna, Italy
| | - Pietro Cortelli
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Full Member of the ERN-EpiCARE network, Bologna, Italy
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33
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Alsuliman T, Drieu La Rochelle L, Campidelli A, Duléry R, Fayard A, Mamez AC, Mear JB, Schneider PO, Trevet A, Vicente C, Yakoub-Agha I. [Medium-term follow-up of patients treated with chimeric antigen receptor T cells (CAR T cells): Recommendations of the Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC)]. Bull Cancer 2021:S0007-4551(21)00041-2. [PMID: 33678408 DOI: 10.1016/j.bulcan.2020.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 11/10/2020] [Accepted: 11/14/2020] [Indexed: 11/21/2022]
Abstract
Chimeric antigen receptor (CAR) T cells are a new class of anti-cancer therapy that involves manipulating autologous or allogeneic T cells to express a CAR directed against a membrane antigen. In Europe, tisagenlecleucel (Kymriah™) has marketing authorization for the treatment of relapsed / refractory acute lymphoblastic leukemia (ALL) in children and young adults, in addition to the treatment of relapsed/refractory diffuse large B-cell lymphoma (DLBCL); the marketing authorization for axicabtagene ciloleucel (Yescarta™) is for the treatment of relapsed / refractory high-grade B-cell lymphoma and for the treatment of primary mediastinal B-cell lymphoma. Both cell products are genetically modified autologous T cells directed against CD19. These recommendations, drawn up by a working group of the Francophone Society of Bone Marrow transplantation and cellular Therapy (SFGM-TC) relate to the management of patients and the supply chain: medium-term complications, in particular cytopenias and B-cell aplasia, nursing and psychological supportive care. In another work, we will address long-term monitoring, post-marketing authorization pharmacovigilance and issues relating to JACIE and regulatory authorities. These recommendations are not prescriptive; their aim is to provide guidelines for the use of this new therapeutic approach. The purpose of this workshop is to outline the organizational aspects of this new therapeutic approach.
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34
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Foster MC, Savoldo B, Lau W, Rubinos C, Grover N, Armistead P, Coghill J, Hagan RS, Morrison K, Buchanan FB, Cheng C, Laing S, Ivanova A, West J, Foster A, Serody J, Dotti G. Utility of a safety switch to abrogate CD19.CAR T-cell-associated neurotoxicity. Blood 2021; 137:3306-9. [PMID: 33624095 DOI: 10.1182/blood.2021010784] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 02/10/2021] [Indexed: 12/17/2022] Open
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35
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Pilotto A, Masciocchi S, Volonghi I, De Giuli V, Caprioli F, Mariotto S, Ferrari S, Bozzetti S, Imarisio A, Risi B, Premi E, Benussi A, Focà E, Castelli F, Zanusso G, Monaco S, Stefanelli P, Gasparotti R, Zekeridou A, McKeon A, Ashton NJ, Blennov K, Zetterberg H, Padovani A. SARS-CoV-2 encephalitis is a cytokine release syndrome: evidences from cerebrospinal fluid analyses. Clin Infect Dis 2021; 73:e3019-e3026. [PMID: 33395482 PMCID: PMC7799260 DOI: 10.1093/cid/ciaa1933] [Citation(s) in RCA: 112] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Indexed: 01/01/2023] Open
Abstract
Background Recent findings indicated that SARS-CoV-2 related neurological manifestations involve cytokine release syndrome along with endothelial activation, blood brain barrier dysfunction, and immune‐mediated mechanisms. Very few studies have fully investigated the CSF correlates of SARS-CoV-2 encephalitis. Methods Patients with PCR-confirmed SARS-CoV-2 infection and encephalitis (COV-Enc), encephalitis without SARS-CoV-2 infection (ENC) and healthy controls (HC) underwent an extended panel of CSF neuronal (NfL, T-tau), glial (GFAP, TREM2, YKL-40) and inflammatory biomarkers (IL-1β, IL-6, Il-8, TNF- α, CXCL-13 and β2-microglobulin). Results Thirteen COV-Enc, 21 ENC and 18 HC entered the study. In COV-Enc cases, CSF was negative for SARS-CoV-2 real-time PCR but exhibited increased IL-8 levels independently from presence of pleocytosis/hyperproteinorracchia. COV-Enc patients showed increased IL-6, TNF- α, and β2-microglobulin and glial markers (GFAP, sTREM-2, YKL-40) levels similar to ENC but normal CXCL13 levels. Neuronal markers NfL and T-Tau were abnormal only in severe cases. Conclusions SARS-CoV-2-related encephalitis were associated with prominent glial activation and neuroinflammatory markers, whereas neuronal markers were increased in severe cases only. The pattern of CSF alterations suggested a cytokine-release syndrome as the main inflammatory mechanism of SARS-CoV-2 related encephalitis.
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Affiliation(s)
- Andrea Pilotto
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Italy.,Parkinson's Disease Rehabilitation Centre, FERB ONLUS - S. Isidoro Hospital, Trescore Balneario (BG), Italy
| | - Stefano Masciocchi
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Italy
| | - Irene Volonghi
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Italy
| | - Valeria De Giuli
- Neurology Unit, Istituti Ospedalieri, ASST Cremona, Cremona, Italy
| | | | - Sara Mariotto
- Neurology Unit, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Sergio Ferrari
- Neurology Unit, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Silvia Bozzetti
- Neurology Unit, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Alberto Imarisio
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Italy
| | - Barbara Risi
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Italy
| | - Enrico Premi
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Italy
| | - Alberto Benussi
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Italy
| | - Emanuele Focà
- University Division of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili Hospital, Brescia, Italy
| | - Francesco Castelli
- University Division of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili Hospital, Brescia, Italy
| | - Gianluigi Zanusso
- Neurology Unit, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Salvatore Monaco
- Neurology Unit, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Paola Stefanelli
- Department of Infectious Diseases, Italian National Public Health Institute, Rome, Italy
| | - Roberto Gasparotti
- Neuroradiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia and ASST Spedali Civili Hospital, Brescia, Italy
| | - Anastasia Zekeridou
- Departments of Laboratory Medicine and Pathology, and Neurology, Mayo Clinic, Rochester, MN 55906, USA
| | - Andrew McKeon
- Departments of Laboratory Medicine and Pathology, and Neurology, Mayo Clinic, Rochester, MN 55906, USA
| | - Nicholas J Ashton
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience & Physiology, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden.,King's College London, Institute of Psychiatry, Psychology and Neuroscience, Maurice Wohl Institute Clinical Neuroscience Institute, London, UK.,NIHR Biomedical Research Centre for Mental Health and Biomedical Research Unit for Dementia at South London and Maudsley NHS Foundation, London, UK
| | - Kaj Blennov
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience & Physiology, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience & Physiology, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK.,UK Dementia Research Institute at UCL, London, UK
| | - Alessandro Padovani
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Italy
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Abstract
Chimeric antigen receptor (CAR) T cells provide new therapeutic options for patients with relapsed/refractory hematologic malignancies. However, neurotoxicity is a frequent, and potentially fatal, complication. The spectrum of manifestations ranges from delirium and language dysfunction to seizures, coma, and fatal cerebral edema. This novel syndrome has been designated immune effector cell-associated neurotoxicity syndrome (ICANS). In this review, we draw an arc from our current understanding of how systemic and potentially local cytokine release act on the CNS, toward possible preventive and therapeutic approaches. We systematically review reported correlations of secreted inflammatory mediators in the serum/plasma and cerebrospinal fluid with the risk of ICANS in patients receiving CAR T cell therapy. Possible pathophysiologic impacts on the CNS are covered in detail for the most promising candidate cytokines, including IL-1, IL-6, IL-15, and GM-CSF. To provide insight into possible final common pathways of CNS inflammation, we place ICANS into the context of other systemic inflammatory conditions that are associated with neurologic dysfunction, including sepsis-associated encephalopathy, cerebral malaria, thrombotic microangiopathy, CNS infections, and hepatic encephalopathy. We then review in detail what is known about systemic cytokine interaction with components of the neurovascular unit, including endothelial cells, pericytes, and astrocytes, and how microglia and neurons respond to systemic inflammatory challenges. Current therapeutic approaches, including corticosteroids and blockade of IL-1 and IL-6 signaling, are reviewed in the context of what is known about the role of cytokines in ICANS. Throughout, we point out gaps in knowledge and possible new approaches for the investigation of the mechanism, prevention, and treatment of ICANS.
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Affiliation(s)
- Juliane Gust
- Department of Neurology, University of Washington, Seattle, WA, United States
- Seattle Children’s Research Institute, Center for Integrative Brain Research, Seattle, WA, United States
| | | | - W. Conrad Liles
- Department of Medicine, University of Washington, Seattle, WA, United States
| | - Gwenn A. Garden
- Department of Neurology, University of North Carolina, Chapel Hill, NC, United States
| | - Cameron J. Turtle
- Department of Medicine, University of Washington, Seattle, WA, United States
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States
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37
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Pensato U, Muccioli L, Pasini E, Tappatà M, Ferri L, Volpi L, Licchetta L, Battaglia S, Rossini G, Bon I, Re MC, Cirillo L, Simonetti L, Gramegna LL, Michelucci R, Cortelli P, Zini A, Bisulli F. Encephalopathy in COVID-19 Presenting With Acute Aphasia Mimicking Stroke. Front Neurol 2020; 11:587226. [PMID: 33193051 PMCID: PMC7604480 DOI: 10.3389/fneur.2020.587226] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 08/24/2020] [Indexed: 12/25/2022] Open
Abstract
Introduction: Neurological manifestations are emerging as relatively frequent complications of corona virus disease 2019 (COVID-19), including stroke and encephalopathy. Clinical characteristics of the latter are heterogeneous and not yet fully elucidated, while the pathogenesis appears related to neuroinflammation in a subset of patients. Case: A middle-aged man presented with acute language disturbance at the emergency department. Examination revealed expressive aphasia, mild ideomotor slowing, and severe hypocapnic hypoxemia. Multimodal CT assessment and electroencephalogram (EEG) did not reveal any abnormalities. COVID-19 was diagnosed based on chest CT findings and positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reverse transcription PCR (RT-PCR) on nasopharyngeal swab. The following day, neurological symptoms progressed to agitated delirium and respiratory status worsened, requiring admission to the ICU and mechanical ventilation. Brain MRI and cerebrospinal fluid (CSF) studies were unremarkable. RT-PCR for SARS-CoV-2 on CSF was negative. He received supportive treatment and intravenous low-dose steroids. His neurological and respiratory status resolved completely within 2 weeks. Conclusions: We report a patient with reversible COVID-19-related encephalopathy presenting as acute aphasia, mimicking stroke or status epilepticus, eventually evolving into delirium. Although large-vessel stroke is frequently encountered in COVID-19, our case suggests that focal neurological deficits may occur as the earliest feature of encephalopathy. Neurological status reversibility and the absence of abnormalities on brain MRI are consistent with a functional rather than a structural neuronal network impairment.
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Affiliation(s)
- Umberto Pensato
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Lorenzo Muccioli
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Elena Pasini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy‡
| | - Maria Tappatà
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy‡
| | - Lorenzo Ferri
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Lilia Volpi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy‡
| | - Laura Licchetta
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy‡
| | - Stella Battaglia
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy‡
| | - Giada Rossini
- Microbiology Unit, DIMES, University of Bologna, Bologna, Italy
| | - Isabella Bon
- Microbiology Unit, DIMES, University of Bologna, Bologna, Italy
| | - Maria Carla Re
- Microbiology Unit, DIMES, University of Bologna, Bologna, Italy
| | - Luigi Cirillo
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy‡
| | - Luigi Simonetti
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy‡
| | | | | | - Pietro Cortelli
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy‡
| | - Andrea Zini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy‡
| | - Francesca Bisulli
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy‡
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Tan AP. CAR-T Cell Therapy-Related Neurotoxicity in Pediatric Acute Lymphoblastic Leukemia: Spectrum of Imaging Findings. Pediatr Neurol 2020; 111:51-58. [PMID: 32951662 DOI: 10.1016/j.pediatrneurol.2020.06.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/18/2020] [Accepted: 06/22/2020] [Indexed: 10/23/2022]
Abstract
The emergence of CD19-targeted chimeric antigen receptor-T (CAR-T) cell therapy has created a new era in the management of pediatric patients with refractory B-cell malignancies such as B-cell acute lymphoblastic leukemia. Immune effector cell-associated neurotoxicity syndrome (ICANS) is frequently encountered in the postinfusion period of CD19-targeted chimeric antigen receptor-T cell therapy and in some cases may be fatal. Knowledge related to the spectrum of imaging findings of CD19-targeted CAR-T cell therapy-related ICANS is, however, still very much lacking, underscoring the need for continued research in this area. In this review, we hope to provide an overview of current knowledge and provide an in-depth literature review related to this topic. A brief discussion of possible imaging differential diagnoses, specifically in children with acute lymphoblastic leukemia, will also be included. Illustrative cases for each imaging phenotype will be provided to facilitate a better understanding. A greater level of insight of the spectrum of imaging findings related to ICANS will improve patients' management and enhance efforts to safely deliver CAR-T cell immunotherapy. It will also facilitate further studies to derive mechanistic insights of ICANS and potentially assist in the testing and monitoring of therapeutic interventions.
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Affiliation(s)
- Ai Peng Tan
- Department of Diagnostic Radiology, National University Health System, Singapore.
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39
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Abstract
Adoptive transfer of T cells modified with chimeric antigen receptors (CAR-T cells) has changed the therapeutic landscape of hematological malignancies, particularly for acute lymphoblastic leukemia and large B cell lymphoma, where two different CAR-T products are now considered standard of care. Furthermore, intense research efforts are under way to expand the clinical application of CAR-T cell therapy for the benefit of patients suffering from other types of cancers. Nevertheless, CAR-T cell treatment is associated with toxicities such as cytokine release syndrome, which can range in severity from mild flu-like symptoms to life-threatening vasodilatory shock, and a neurological syndrome termed ICANS (immune effector cell-associated neurotoxicity syndrome), which can also range in severity from a temporary cognitive deficit lasting only a few hours to lethal cerebral edema. In this review, we provide an in-depth discussion of different types of CAR-T cell-associated toxicities, including an overview of clinical presentation and grading, pathophysiology, and treatment options. We also address future perspectives and opportunities, with a special focus on hematological malignancies.
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Affiliation(s)
- Andrea Schmidts
- Cellular Immunotherapy Program, Massachusetts General Hospital Cancer Center, Boston, Massachusetts 02129, USA; .,Department of Medicine, Harvard Medical School, Boston, Massachusetts 02115, USA
| | - Marc Wehrli
- Cellular Immunotherapy Program, Massachusetts General Hospital Cancer Center, Boston, Massachusetts 02129, USA; .,Department of Medicine, Harvard Medical School, Boston, Massachusetts 02115, USA
| | - Marcela V Maus
- Cellular Immunotherapy Program, Massachusetts General Hospital Cancer Center, Boston, Massachusetts 02129, USA; .,Department of Medicine, Harvard Medical School, Boston, Massachusetts 02115, USA
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40
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He B, Lu Z, He W, Wu L, Cui B, Hu X, Yu L, Huang C, Jiang H. Effects of ganglionated plexi ablation on ventricular electrophysiological properties in normal hearts and after acute myocardial ischemia. Int J Cardiol 2012; 168:86-93. [PMID: 23041007 DOI: 10.1016/j.ijcard.2012.09.067] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2011] [Revised: 06/14/2012] [Accepted: 09/14/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND Ganglionated plexi (GP) ablation has been shown to play an important role in atrial fibrillation (AF) initiation and maintenance. Also, GP ablation increases chances for prevention of AF recurrence. This study investigated the effects of GP ablation on ventricular electrophysiological properties in normal dog hearts and after acute myocardial ischemia (AMI). METHODS Fifty anesthetized dogs were assigned into normal heart group (n=16) and AMI heart group (n=34). Ventricular dynamic restitution, effective refractory period (ERP), electrical alternans and ventricular fibrillation threshold (VFT) were measured before and after GP ablation in the normal heart group. In the AMI heart group, the incidence of ventricular arrhythmias and VFT were determined. RESULTS In the normal heart group, GP ablation significantly prolonged ERP, facilitated electrical alternans but did not increase ERP dispersion, the slope of restitution curves and its spatial dispersion. Also, GP ablation did not cause significant change of VFT. In the AMI heart group, the incidence of ventricular arrhythmias after GP ablation was significantly higher than that in the control group or the GP plus stellate ganglion (SG) ablation group (P<0.05). Spontaneous VF occurred in 8/12, 1/10 and 2/12 dogs in the GP ablation group, the GP plus SG ablation group and the control group, respectively (P<0.05). VFT in the GP ablation group showed a decreased trend though a significant difference was not achieved compared with the control or the GP plus SG ablation group. CONCLUSIONS GP ablation increases the risk of ventricular arrhythmias in the AMI heart compared to the normal heart.
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Affiliation(s)
- Bo He
- Department of Cardiology, Renmin Hospital of Wuhan University and Cardiovascular Research Institute of Wuhan University, PR China
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