Prognostic value of early positron emission tomography in patients with large B-cell lymphoma treated with anti-CD19 chimeric antigen receptor T-cell therapy

Not available.

Predictors of response to axicabtagene-ciloleucel CAR T cells in aggressive B cell lymphomas: A real-world study

Chimeric antigen receptor T-cell (CAR T) therapy has shown promising efficacy in relapsed and refractory diffuse large B cell lymphoma (DLBCL). While most patients undergo CAR T infusion with active disease, the impact of some clinical variables, such as responsiveness to the pre-CAR T chemotherapy on the response to CAR T, is unknown. In this single-institution study, we studied the impact of several pre-CAR T variables on the post-CAR outcomes. Sixty patients underwent apheresis for axicabtagene-ciloleucel (axi-cel) and 42 of them (70.0%) had primary refractory disease. Bridging therapy between apheresis and lymphodepletion was given in 34 patients (56.7%). After axi-cel, the overall response rate was 63.3%. Responsiveness to the immediate pre-CAR T therapy did not show a significant association with response to axi-cel, progression-free (PFS) or overall (OS) survival. Multivariable analysis determined that bulky disease before lymphodepletion was independently associated with inferior outcomes, and patients that presented with high-burden disease unresponsive to immediate pre-CAR T therapy had a dismal outcome. This data supports proceeding with treatment in CAR T candidates regardless of their response to immediate pre-CAR T therapy. Interim therapeutic interventions should be considered in patients who have known risk factors for poor outcomes (bulky disease, high LDH).

Predictors of cytopenias after treatment with axicabtagene ciloleucel in patients with large B-cell lymphoma

Cytopenias are important but less studied adverse events following chimeric antigen receptor-engineered T cell (CAR-T) therapy. In our analysis of patients with large cell lymphoma who received axicabtagene ciloleucel (axi-cel), we sought to determine the rate and risk factors of clinically significant short term cytopenias defined as grade ≥3 neutropenia, anemia, or thrombocytopenia, or treatment with growth factors or blood product transfusions between days 20-30 after axi-cel. Fifty-three pts received axi-cel during the study period and severe cytopenias were observed in 32 (60%) pts. Significant cytopenias were more common in non-responders (stable or progressive disease) vs. responders (partial or complete response) (100% vs. 70%; p = .01). In the multivariable model, platelet transfusion within a month before leukapheresis, number of red blood cell and platelet transfusions between leukapheresis to lymphodepletion, pre-lymphodepletion absolute neurophil count, pre-lymphodepletion lactate dehydrogenase, and number of dexamethasone treatments after CAR-T were significantly associated with severe cytopenias after axi-cel.

Assessing readmission after axicabtagene ciloleucel immunotherapy

3024

Background: Axicabtagene ciloleucel (axi-cel) is an FDA approved CD19 targeted CAR-T for patients (pts) with diffuse-large-B cell lymphoma (DLBCL) after 2 lines of treatment. Pts are monitored inpatient for minimum 7 days after CAR-T infusion but remain at risk of complications after discharge that can lead to readmission. We report our institutional experience on the rate and etiology of readmissions after initial discharge. Methods: In this retrospective study, readmission was defined as an inpatient stay greater than 48 hours while under the auspice of the Immunotherapy service. Cytokine release syndrome (CRS) and neurotoxicity (NT) were graded based on the Lee and CTC v.4 criteria, respectively. Logistic regression models were used to study the association between clinical factors and readmission. Results: 44 pts received axi-cel. Median age was 62 (25-79). 33 pts (75%) had primary refractory disease and 14 (30%) had prior transplant. Pts had median 3 lines (2 -9) of treatment before axi-cel. Median time from most recent treatment to leukapheresis was 10 weeks (0.5-109). 22 pts (48%) received bridging therapy between leukapheresis and lymphodepletion (LD). Median duration of initial planned admission was 7.5 days (6-16). Incidence of CRS was 88% (all grades) and 12% (grade 3/4). Median time to start of CRS was 3 days (0-13). Incidence of NT was 61% (all grades) and 16% (grade 3/4) and median time to NT was 6 days (3-14). 6 pts (14%) were readmitted after initial hospitalization (1 had 2 readmissions). Median day of readmission was 13 (9-25). Median duration of subsequent hospitalization was 5 days (2-31). Reasons for readmission were: infection (2), CRS (2), GI bleed (1), progressive disease (PD) (1) and NT (1). 4 of 6 pts had no CRS or NT before readmission. 2 of the 4 were readmitted on days 9 and 13 for NT. The other 2 pts were readmitted for infection and GI bleed. 1 pt had grade 2 CRS and grade 2 NT during first admission and was readmitted on day 25 for PD. Last pt had grade 2 CRS and grade 3 NT during first admission with discharge day 13, readmission day 14 through day 17 with recurrent NT and second readmission day 30 for infection. 3 of 6 pts had ICU admissions during second admissions. There was no association between pre- and post- CAR-T variables and risk of readmission in multivariable models. Conclusions: Readmissions after discharge from initial planned hospitalization for axi-cel are not uncommon. This data supports our current policy of close monitoring until at least a month after CAR-T therapy and supports the requirement of a full-time caregiver until discharge from the Immunotherapy service.

Patient-Reported Neuropsychiatric Outcomes of Long-Term Survivors after Chimeric Antigen Receptor T Cell Therapy

CD19-targeted chimeric antigen receptor (CAR) modified T cell immunotherapy is a novel treatment with promising results in patients with relapsed/refractory lymphoid malignancies. CAR T cell therapy has known early toxicities of cytokine release syndrome and neurotoxicity, but little is known about long-term neuropsychiatric adverse effects. We have used patient-reported outcomes, including Patient-Reported Outcomes Measurement Information System (PROMIS) measures, to assess neuropsychiatric and other patient-reported outcomes of 40 patients with relapse/refractory chronic lymphocytic leukemia, non-Hodgkin lymphoma, and acute lymphoblastic leukemia 1 to 5 years after treatment with CD19-targeted CAR T cells. Mean T scores of PROMIS domains of global mental health, global physical health, social function, anxiety, depression, fatigue, pain, and sleep disturbance were not clinically meaningfully different from the mean in the general US population. However, 19 patients (47.5%) reported at least 1 cognitive difficulty and/or clinically meaningful depression and/or anxiety, and 7 patients (17.5%) scored ≤40 in global mental health, indicating at least 1 standard deviation worse than the general population mean. Younger age was associated with worse long-term global mental health (P = .02), anxiety (P = .001), and depression (P= .01). Anxiety before CAR T cell therapy was associated with increased likelihood of anxiety after CAR T cell therapy (P = .001). Fifteen patients (37.5%) reported cognitive difficulties after CAR T cell therapy. Depression before CAR T cell therapy was statistically significantly associated with higher likelihood of self-reported post-CAR T cognitive difficulties (P = .02), and there was a trend for an association between acute neurotoxicity and self-reported post-CAR T cognitive difficulties (P = .08). Having more post-CAR T cognitive difficulties was associated with worse global mental health and global physical health. Our study demonstrates overall good neuropsychiatric outcomes in 40 long-term survivors after CAR T cell therapy. However, nearly 50% of patients in the cohort reported at least 1 clinically meaningful negative neuropsychiatric outcome (anxiety, depression, or cognitive difficulty), indicating that a significant number of patients would likely benefit from mental health services following CAR T cell therapy. Younger age, pre-CAR T anxiety or depression, and acute neurotoxicity may be risk factors for long-term neuropsychiatric problems in this patient population. Larger studies are needed to confirm these findings.

Phase I study of immunotherapy for advanced ROR1+ malignancies with autologous ROR1-specific chimeric antigen receptor-modified (CAR)-T cells

TPS79

Background: CAR-T cells have demonstrated marked tumor regression in patients (pts) with hematologic malignancies. ROR1, a tyrosine kinase orphan receptor, is expressed in triple negative breast cancers (TNBC) and non-small cell lung cancers (NSCLC) and is a novel candidate for CAR-T cell therapy. ROR1-specific CAR-T cells are engineered with lentiviral vector encoding ROR1 scFv/4-1BB/CD3ζ and a truncated EGFR molecule to permit elimination of ROR1 CAR-T cells in case of toxicity. Methods: NCT02706362 is a phase I study evaluating the safety and anti-tumor activity of adoptively transferred autologous ROR1 CAR-T cells in pts with advanced ROR1+ TNBC and NSCLC. Eligibility criteria include: metastatic TNBC or NSCLC; measurable disease; prior standard therapy with no maximum on number of prior regimens; tumor ROR1 expression > 20% by IHC; KPS > 70%; age ≥18; negative pregnancy test for women of childbearing potential; informed consent; adequate organ function. Exclusions are: active autoimmune disease or uncontrolled infection, HIV seropositive status, contraindication to cyclophosphamide, anticipated survival < 3 months, and/or untreated CNS metastases. After screening, leukapheresis is performed, CD8+ and CD4+ T cells are selected, then transduced with the ROR1+ CAR lentivirus and expanded. Lymphodepletion with cyclophosphamide and fludarabine is followed 36-96 hours later by infusion of ROR1 CAR-T cells in escalating doses (3.3 x 105/kg - 1 x 107/kg cells with defined CD8+ and CD4+ composition). Pts are treated in cohorts of 2 to determine cell dose associated with an estimated toxicity rate of < 25%. Primary aim is to determine the maximum tolerated dose (MTD) and safety of ex vivo expanded ROR1 CAR-T cells. Secondary aims include persistence and phenotype of transferred T cells, trafficking of T cells to tumor site, in vivo function, and preliminary antitumor activity of ROR1 CAR-T cells by RECIST 1.1. Dose escalation is determined by CRM algorithm with minimum of 21-day interval following infusion between pts. Preliminary estimates of efficacy will be obtained among all pts and those treated at estimated MTD. Six of 30 pts have been enrolled with no DLTs observed. Clinical trial information: NCT02706392.

Synthesis of silicon–germanium axial nanowire heterostructures in a solvent vapor growth system using indium and tin catalysts

The Si–Ge–Si_1−xGe_x nanowires (a,b) are grown directly on substrates placed in the vapour zone of a high boiling point solvent. DFSTEM image of In catalysed triple segmented Si–Ge–Si Ge nanowire is shown in (c) with arrow indicating the direction of the EDX line profile shown in (d).

Three phosphor plate systems and film compared for imaging root canals

AIM

The aim of this study was to compare three phosphor plate intraoral imaging systems (Digora (DA), Digident (DT), Denoptix (DX)) and E-speed conventional film (CF) for the imaging of root canals.

METHODOLOGY

Sixty extracted permanent teeth were exposed using CF, DA, DT and DX. The length of root canal visible from its most apical extent to a line drawn at the level of the cementoenamel junction was measured and this was expressed as a percentage of the distance between the radiographic apex and the cementoenamel line. All images were examined concurrently by two examiners. Films were viewed under standardized conditions and DA, DT and DX images were viewed directly from the monitor screen. The images on the monitor were enhanced to give the subjectively clearest image.

RESULTS

The mean percentage of canal visible on CF was 90%, DA 78%, DT 81% and DX 83%. The difference was significant for CF-DA (P < 0.001) and CF-DT (P = 0.001). There was no statistically significant difference for CF-DX or between any of the three phosphor plate imaging systems.

CONCLUSIONS

It is concluded that a greater length of root canal was visible on conventional film than on three phosphor plate imaging systems and that this may be of clinical significance.