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Palaskas NL, Ali HJ, Koutroumpakis E, Ganatra S, Deswal A. Cardiovascular toxicity of immune therapies for cancer. BMJ 2024; 385:e075859. [PMID: 38749554 DOI: 10.1136/bmj-2023-075859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
In addition to conventional chemoradiation and targeted cancer therapy, the use of immune based therapies, specifically immune checkpoint inhibitors (ICIs) and chimeric antigen receptor T cell therapy (CAR-T), has increased exponentially across a wide spectrum of cancers. This has been paralleled by recognition of off-target immune related adverse events that can affect almost any organ system including the cardiovascular system. The use of ICIs has been associated with myocarditis, a less common but highly fatal adverse effect, pericarditis and pericardial effusions, vasculitis, thromboembolism, and potentially accelerated atherosclerosis. CAR-T resulting in a systemic cytokine release syndrome has been associated with myriad cardiovascular consequences including arrhythmias, myocardial infarction, and heart failure. This review summarizes the current state of knowledge regarding adverse cardiovascular effects associated with ICIs and CAR-T.
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Affiliation(s)
| | - Hyeon-Ju Ali
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Sarju Ganatra
- Lahey Hospital and Medical Center, Burlington, MA 01805
| | - Anita Deswal
- University of Texas MD Anderson Cancer Center, Houston, TX, USA 01805
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2
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Yao J, Chen Y, Huang Y, Sun X, Shi X. The role of cardiac microenvironment in cardiovascular diseases: implications for therapy. Hum Cell 2024; 37:607-624. [PMID: 38498133 DOI: 10.1007/s13577-024-01052-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 02/25/2024] [Indexed: 03/20/2024]
Abstract
Due to aging populations and changes in lifestyle, cardiovascular diseases including cardiomyopathy, hypertension, and atherosclerosis, are the leading causes of death worldwide. The heart is a complicated organ composed of multicellular types, including cardiomyocytes, fibroblasts, endothelial cells, vascular smooth muscle cells, and immune cells. Cellular specialization and complex interplay between different cell types are crucial for the cardiac tissue homeostasis and coordinated function of the heart. Mounting studies have demonstrated that dysfunctional cells and disordered cardiac microenvironment are closely associated with the pathogenesis of various cardiovascular diseases. In this paper, we discuss the composition and the homeostasis of cardiac tissues, and focus on the role of cardiac environment and underlying molecular mechanisms in various cardiovascular diseases. Besides, we elucidate the novel treatment for cardiovascular diseases, including stem cell therapy and targeted therapy. Clarification of these issues may provide novel insights into the prevention and potential targets for cardiovascular diseases.
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Affiliation(s)
- Jiayu Yao
- School of Life Science and Technology, Key Laboratory of Developmental Genes and Human Disease, Southeast University, Nanjing, China
| | - Yuejun Chen
- School of Life Science and Technology, Key Laboratory of Developmental Genes and Human Disease, Southeast University, Nanjing, China
| | - Yuqing Huang
- School of Life Science and Technology, Key Laboratory of Developmental Genes and Human Disease, Southeast University, Nanjing, China
| | - Xiaoou Sun
- Institute of Biomedical and Pharmaceutical Sciences, Guangdong University of Technology, Guangzhou, China.
| | - Xingjuan Shi
- School of Life Science and Technology, Key Laboratory of Developmental Genes and Human Disease, Southeast University, Nanjing, China.
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3
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Patel NP, Dalal PJ, Meng Z, Baldridge AS, Cascino GJ, Sunderraj A, Sinha A, Karmali R, Feinstein MJ, Akhter N. Myocardial strain is associated with adverse cardiac events in patients treated with chimeric antigen receptor (CAR) T-cell therapy. Eur J Haematol 2024; 112:102-110. [PMID: 37649240 DOI: 10.1111/ejh.14088] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 08/10/2023] [Accepted: 08/16/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND Cardiovascular events, including heart failure and arrhythmias, following chimeric antigen receptor (CAR) T-cell therapy are increasingly recognized. Although global longitudinal strain (GLS) has demonstrated prognostic utility for other cancer therapy-related cardiac dysfunction, less is known regarding the association of GLS with adverse cardiac events following CAR T-cell therapy. OBJECTIVES To determine the association of baseline GLS with adverse cardiovascular events in adults receiving CAR-T cell therapy. METHODS Patients who had an echocardiogram within 6 months prior to receiving CAR T-cell therapy were retrospectively identified. Clinical data and cardiac events were collected via chart review. Echocardiograms were analyzed offline for GLS, left ventricular ejection fraction, and Doppler parameters. Multivariable logistic regression was used to determine the association between adverse cardiovascular events and echocardiographic parameters. RESULTS Among 75 CAR T-cell therapy patients (mean age 63.9, 34.7% female), nine patients (12%) experienced cardiac events (CEs) including cardiovascular death, new/worsening heart failure, and new/worsening arrhythmia within 1 year of treatment. In univariable models, higher baseline GLS (OR 0.78 [0.63, 0.96], p = .021) was associated with a lower risk of CE and higher baseline mitral E/e' (OR 1.40 [1.08, 1.81], p = .012) was associated with a higher risk of CE. After adjusting for age and LDH, higher baseline GLS (OR 0.65 [0.48-0.88], p = <.01) was associated with a lower risk of CE and higher baseline mitral E/e' (OR 1.56 [1.06, 2.29], p = .024) was associated with a higher risk of CE. CONCLUSION Lower GLS and higher mitral E/e' on a baseline echocardiogram were associated with higher risk for CEs in patients receiving CAR T-cell therapy.
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Affiliation(s)
- Nikita P Patel
- Robert H Lurie Comprehensive Cancer Center of Northwestern University, Chicago, Illinois, USA
| | - Prarthana J Dalal
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Zhiying Meng
- Division of Cardiovascular Medicine, Feinberg School of Medicine, Northwestern University, Illinois, USA
| | - Abigail S Baldridge
- Division of Cardiovascular Medicine, Feinberg School of Medicine, Northwestern University, Illinois, USA
| | - Gregory J Cascino
- Division of Cardiovascular Medicine, Feinberg School of Medicine, Northwestern University, Illinois, USA
| | - Ashwin Sunderraj
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Arjun Sinha
- Division of Cardiovascular Medicine, Feinberg School of Medicine, Northwestern University, Illinois, USA
| | - Reem Karmali
- Robert H Lurie Comprehensive Cancer Center of Northwestern University, Chicago, Illinois, USA
| | - Matthew J Feinstein
- Division of Cardiovascular Medicine, Feinberg School of Medicine, Northwestern University, Illinois, USA
| | - Nausheen Akhter
- Division of Cardiovascular Medicine, Feinberg School of Medicine, Northwestern University, Illinois, USA
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Lefebvre B, Kang Y, Vakilpour A, Onoue T, Frey NV, Brahmbhatt P, Huang B, Oladuja K, Koropeckyj-Cox D, Wiredu C, Smith AM, Chittams J, Carver J, Scherrer-Crosbie M. Incidence of MACE in Patients Treated With CAR-T Cell Therapy: A Prospective Study. JACC CardioOncol 2023; 5:747-754. [PMID: 38204993 PMCID: PMC10774789 DOI: 10.1016/j.jaccao.2023.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 07/19/2023] [Accepted: 07/31/2023] [Indexed: 01/12/2024] Open
Abstract
Background Previous retrospective studies have shown that chimeric antigen receptor T (CAR-T) cell therapy may be associated with major adverse cardiovascular events (MACE), especially in the context of cytokine-release syndrome (CRS) events. Objectives The aim of this prospective observational study was to define the occurrence of MACE in adults undergoing treatment with CAR-T cell therapy and identify associated risk factors. Methods Vital signs, blood samples, and an echocardiogram were collected prior to and 2 days, 1 week, 1 month, and 6 months after CAR-T cell infusion, and charts were consulted at 12 months. In the event of CRS, echocardiography was repeated within 72 hours. MACE were defined as cardiovascular death, symptomatic heart failure, acute coronary syndrome, ischemic stroke, and de novo cardiac arrhythmia. Results A total of 44 patients were enrolled (mean age 58 ± 11 years, 77% men). The median follow-up duration was 487 days (Q1-Q3: 258-622 days). There were 24 episodes of CRS in 23 patients (52%) (13 grade 1, 10 grade 2, and 1 grade 3), with a median time to CRS of 4 days. Two patients had MACE (heart failure with preserved ejection fraction and atrial fibrillation) within 1 year and 6 and 7 days after CAR-T cell infusion. There was no change in left ventricular ejection fraction, but a modest decrease in global longitudinal strain was noted. Conclusions There were few cardiac effects associated with contemporary CAR-T cell therapy. As MACE occurred after CRS episodes, aggressive treatment and close follow-up during CRS events are essential.
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Affiliation(s)
- Bénédicte Lefebvre
- Division of Cardiovascular Diseases, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yu Kang
- Division of Cardiovascular Diseases, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Azin Vakilpour
- Division of Cardiovascular Diseases, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Takeshi Onoue
- Division of Cardiovascular Diseases, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Noelle V. Frey
- Division of Hematology and Oncology Diseases, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Priya Brahmbhatt
- Division of Cardiovascular Diseases, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Brian Huang
- Division of Cardiovascular Diseases, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kemi Oladuja
- Division of Cardiovascular Diseases, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daniel Koropeckyj-Cox
- Division of Cardiovascular Diseases, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Courteney Wiredu
- Division of Cardiovascular Diseases, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Amanda M. Smith
- Division of Cardiovascular Diseases, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jesse Chittams
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joseph Carver
- Division of Cardiovascular Diseases, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marielle Scherrer-Crosbie
- Division of Cardiovascular Diseases, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Guo M, Wang X, Xiao S, Liu A, Xu T, Huan C, Wu H, Hu Y, Zhou S, Zhu H, Pan D. Preliminary assessment of cardiotoxicity in chimeric antigen receptor T cell therapy: a systematic review and meta-analysis. Clin Exp Med 2023; 23:2041-2050. [PMID: 36930381 DOI: 10.1007/s10238-023-01042-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 03/06/2023] [Indexed: 03/18/2023]
Abstract
As a novel anticancer therapy, chimeric antigen receptor T (CAR T) cell therapy may lead to cardiotoxic reactions. However, the exact incidence remains unclear. Our study aimed to preliminarily assess the prevalence of cardiotoxicity after CAR T cell treatment using a systematic review and meta-analysis. PubMed, Embase, Web of Science, and Cochrane databases were searched for potentially relevant studies. All types of relevant clinical studies were screened and assessed for risk bias. In most instances, random-effect models were used for data analysis, and heterogeneity between studies was evaluated. Standard quality assessment tools were used to assess quality. The study was registered with PROSPERO (CRD42022304611). Eight eligible studies comprising 3567 patients, including seven observational studies and one controlled study, were identified. The incidence of cardiovascular events was 16.7% [95% confidence interval (CI) 0.138-0.200, P < 0.01)]. Arrhythmia was the most common disorder, with an incidence of 6.5% (95% CI 0.029-0.115, P < 0.01). The occurrence of cardiotoxicity was associated with cytokine release syndrome (CRS), with a prevalence of 18.7% (95% CI 0.107-0.315, P < 0.01). Moreover, such adverse reactions were more common when CRS > 2 (OR = 0.07, 95% CI 0.02-0.29, P < 0.01). The risk of cardiotoxicity was not notably higher in patients receiving CAR T cell therapy than in those receiving traditional anticancer treatment. However, sufficient attention should be paid to this. And further evidence from large-scale clinical trials are needed.
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Affiliation(s)
- Minjia Guo
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, 99 Huaihai West Road, Xuzhou, 221004, Jiangsu, China
| | - Xiaotong Wang
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, 99 Huaihai West Road, Xuzhou, 221004, Jiangsu, China
| | - Shengjue Xiao
- Department of Cardiology, Zhongda Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao, Nanjing, 210009, China
| | - Aili Liu
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, 99 Huaihai West Road, Xuzhou, 221004, Jiangsu, China
| | - Tao Xu
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, 99 Huaihai West Road, Xuzhou, 221004, Jiangsu, China
| | - Chunyan Huan
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, 99 Huaihai West Road, Xuzhou, 221004, Jiangsu, China
| | - Huimin Wu
- Department of General Practice, The Affiliated Hospital of Xuzhou Medical University, 99 Huaihai West Road, Xuzhou, 221004, Jiangsu, China
| | - Yue Hu
- Department of General Practice, The Affiliated Hospital of Xuzhou Medical University, 99 Huaihai West Road, Xuzhou, 221004, Jiangsu, China
| | - Shuaishuai Zhou
- Department of General Practice, The Affiliated Hospital of Xuzhou Medical University, 99 Huaihai West Road, Xuzhou, 221004, Jiangsu, China
| | - Hong Zhu
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, 99 Huaihai West Road, Xuzhou, 221004, Jiangsu, China.
| | - Defeng Pan
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, 99 Huaihai West Road, Xuzhou, 221004, Jiangsu, China.
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Silbert SK, Madan S, Holland EM, Steinberg SM, Little L, Foley T, Epstein M, Sarkisian A, Lee DW, Nikitina E, Kakumanu S, Ruppin E, Shalabi H, Yates B, Shah NN. A comprehensive analysis of adverse events in the first 30 days of phase 1 pediatric CAR T-cell trials. Blood Adv 2023; 7:5566-5578. [PMID: 37486616 PMCID: PMC10514106 DOI: 10.1182/bloodadvances.2023009789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 06/28/2023] [Accepted: 07/13/2023] [Indexed: 07/25/2023] Open
Abstract
The tremendous success of chimeric antigen receptor (CAR) T cells in children and young adults (CAYAs) with relapsed/refractory B-cell acute lymphoblastic leukemia is tempered by toxicities such as cytokine release syndrome (CRS). Despite expansive information about CRS, profiling of specific end-organ toxicities secondary to CAR T-cell therapy in CAYAs is limited. This retrospective, single-center study sought to characterize end-organ specific adverse events (AEs) experienced by CAYAs during the first 30 days after CAR T-cell infusion. AEs graded using Common Terminology Criteria for Adverse Events were retrospectively analyzed for 134 patients enrolled in 1 of 3 phase 1 CAR T-cell trials (NCT01593696, NCT02315612, and NCT03448393), targeting CD19 and/or CD22. A total of 133 patients (99.3%) experienced at least 1 grade ≥3 (≥Gr3) AE across 17 organ systems, of which 75 (4.4%) were considered dose- or treatment-limiting toxicities. Excluding cytopenias, 109 patients (81.3%) experienced a median of 3 ≥Gr3 noncytopenia (NC) AEs. The incidence of ≥Gr3 NC AEs was associated with the development and severity of CRS as well as preinfusion disease burden (≥ 25% marrow blasts). Although those with complete remission trended toward experiencing more ≥Gr3 NC AEs than nonresponders (median, 4 vs 3), nonresponders experiencing CRS (n = 17; 37.8%) had the highest degree of NC AEs across all patients (median, 7 vs 4 in responders experiencing CRS). Greater understanding of these toxicities and the ability to predict which patients may experience more toxicities is critical as the array of CAR T-cell therapies expand. This retrospective study was registered at www.clinicaltrials.gov as NCT03827343.
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Affiliation(s)
- Sara K. Silbert
- Pediatric Oncology Branch, National Cancer Institute/Center for Cancer Research, National Institutes of Health, Bethesda, MD
| | - Sanna Madan
- Center for Cancer Research, Cancer Data Science Laboratory, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Elizabeth M. Holland
- Pediatric Oncology Branch, National Cancer Institute/Center for Cancer Research, National Institutes of Health, Bethesda, MD
| | - Seth M. Steinberg
- Biostatistics and Data Management Section, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Lauren Little
- Pediatric Oncology Branch, National Cancer Institute/Center for Cancer Research, National Institutes of Health, Bethesda, MD
| | - Toni Foley
- Pediatric Oncology Branch, National Cancer Institute/Center for Cancer Research, National Institutes of Health, Bethesda, MD
| | - Monica Epstein
- Pediatric Oncology Branch, National Cancer Institute/Center for Cancer Research, National Institutes of Health, Bethesda, MD
| | - Angela Sarkisian
- Pediatric Oncology Branch, National Cancer Institute/Center for Cancer Research, National Institutes of Health, Bethesda, MD
| | - Daniel W. Lee
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Virginia, Charlottesville, VA
| | - Ekaterina Nikitina
- Pediatric Oncology Branch, National Cancer Institute/Center for Cancer Research, National Institutes of Health, Bethesda, MD
| | - Showri Kakumanu
- Pediatric Oncology Branch, National Cancer Institute/Center for Cancer Research, National Institutes of Health, Bethesda, MD
| | - Eytan Ruppin
- Center for Cancer Research, Cancer Data Science Laboratory, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Haneen Shalabi
- Pediatric Oncology Branch, National Cancer Institute/Center for Cancer Research, National Institutes of Health, Bethesda, MD
| | - Bonnie Yates
- Pediatric Oncology Branch, National Cancer Institute/Center for Cancer Research, National Institutes of Health, Bethesda, MD
| | - Nirali N. Shah
- Pediatric Oncology Branch, National Cancer Institute/Center for Cancer Research, National Institutes of Health, Bethesda, MD
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Battisha A, Sawalha K, Obeidat Y, Patel B. Role of Cardiac Biomarkers in Monitoring Cardiotoxicity in Chemotherapy Patients. Crit Pathw Cardiol 2023; 22:83-87. [PMID: 37607037 DOI: 10.1097/hpc.0000000000000314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
PURPOSE This review aims to highlight the different types of chemotherapy-induced cardiotoxicity and will discuss the evidence base behind the use of different cardiac biomarkers to predict cardiovascular complications. Additionally, we will review the use of cardiac biomarkers to monitor cardiac outcomes and the role of cardioprotective medications in reducing cardiovascular side effects. RECENT FINDINGS Chemotherapy has been linked to an increased risk of cardiotoxicity and heart failure. Currently, patients receiving chemotherapy undergo echocardiogram before starting chemotherapy and every 6 months to monitor for any decline in cardiac function. We reviewed the current evidence and practice guidelines of monitoring chemotherapy cardiotoxicity. SUMMARY Cardio-oncology is a rapidly evolving subspecialty in cardiology, especially with the advent of new chemotherapeutic agents, which have cardiovascular side effects. Early detection of these effects is crucial to prevent life-threatening and irreversible cardiovascular outcomes. Monitoring troponin, pro-brain natriuretic peptide, and other cardiac biomarkers during chemotherapy will help to early detect cardiotoxicity.
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Affiliation(s)
- Ayman Battisha
- From the Department of Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield, MA
| | - Khalid Sawalha
- From the Department of Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield, MA
| | - Yasin Obeidat
- From the Department of Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield, MA
| | - Brijesh Patel
- Department of Cardiology, Heart and Vascular Institute, West Virginia University, Morgantown, WV
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Marar RI, Abbasi MA, Prathivadhi-Bhayankaram S, Acevedo AD, Villarraga H, Anavekar N, Bhatt VR, Paludo J. Cardiotoxicities of Novel Therapies in Hematologic Malignancies: Chimeric Antigen Receptor T-Cell Therapy and Bispecific T-Cell Engager Therapy. JCO Oncol Pract 2023:OP2200713. [PMID: 36930845 DOI: 10.1200/op.22.00713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023] Open
Abstract
The field of malignant hematology is transforming with novel immunotherapeutic approaches. Unfortunately, quality of life, treatment efficacy, and life expectancy are negatively affected by cardiotoxic side effects of treatment. To date, the exact mechanism and incidence of cardiotoxicity associated with these therapies is unclear. These events are believed to be triggered or occur concurrently with cytokine release syndrome. Furthermore, there are no formal guidelines to provide evaluation, treatment, and surveillance. We aim to synthesize available literature with updates on the cardiotoxic effects of novel therapies used in malignant hematologic disorders, with a focus on chimeric antigen receptor T-cell therapy and bispecific T-cell engager therapy, along with a proposed algorithm that may guide pretreatment evaluation, monitoring during treatment, and post-treatment surveillance.
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Affiliation(s)
- Rosalyn I Marar
- Division of Hematology-Oncology, University of Nebraska Medical Center, Omaha, NE
| | | | | | | | | | - Nandan Anavekar
- Division of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Vijaya Raj Bhatt
- Division of Hematology-Oncology, University of Nebraska Medical Center, Omaha, NE
| | - Jonas Paludo
- Division of Hematology-Oncology, Mayo Clinic, Rochester, MN
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Hegazy M, Ghaleb S, Das BB. Diagnosis and Management of Cancer Treatment-Related Cardiac Dysfunction and Heart Failure in Children. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10010149. [PMID: 36670699 PMCID: PMC9856743 DOI: 10.3390/children10010149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 01/05/2023] [Accepted: 01/09/2023] [Indexed: 01/13/2023]
Abstract
It is disheartening for parents to discover that their children have long-term cardiac dysfunction after being cured of life-threatening childhood cancers. As the number of childhood cancer survivors increases, early and late oncology-therapy-related cardiovascular complications continues to rise. It is essential to understand that cardiotoxicity in childhood cancer survivors is persistent and progressive. A child's cancer experience extends throughout his lifetime, and ongoing care for long-term survivors is recognized as an essential part of the cancer care continuum. Initially, there was a lack of recognition of late cardiotoxicities related to cancer therapy. About 38 years ago, in 1984, pioneers like Dr. Lipshultz and others published anecdotal case reports of late cardiotoxicities in children and adolescents exposed to chemotherapy, including some who ended up with heart transplantation. At that time, cardiac tests for cancer survivors were denied by insurance companies because they did not meet appropriate use criteria. Since then, cardio-oncology has been an emerging field of cardiology that focuses on the early detection of cancer therapy-related cardiac dysfunction occurring during and after oncological treatment. The passionate pursuit of many healthcare professionals to make life better for childhood cancer survivors led to more than 10,000 peer-reviewed publications in the last 40 years. We synthesized the existing evidence-based practice and described our experiences in this review to share our current method of surveillance and management of cardiac dysfunction related to cancer therapy. This review aims to discuss the pathological basis of cancer therapy-related cardiac dysfunction and heart failure, how to stratify patients prone to cardiotoxicity by identifying modifiable risk factors, early detection of cardiac dysfunction, and prevention and management of heart failure during and after cancer therapy in children. We emphasize serial longitudinal follow-ups of childhood cancer survivors and targeted intervention for high-risk patients. We describe our experience with the new paradigm of cardio-oncology care, and collaboration between cardiologist and oncologist is needed to maximize cancer survival while minimizing late cardiotoxicity.
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Affiliation(s)
- Mohamed Hegazy
- University of Mississippi Medical Center Program, Jackson, MS 39216, USA
| | - Stephanie Ghaleb
- Division of Pediatric Cardiology, Department of Pediatrics, Children’s of Mississippi Heart Center, University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - Bibhuti B Das
- Division of Pediatric Cardiology, Department of Pediatrics, McLane Children’s Baylor Scott and White Medical Center, Baylor College of Medicine-Temple, Temple, TX 76502, USA
- Correspondence: ; Tel.: +1-254-935-4980
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10
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Camilli M, Maggio L, Tinti L, Lamendola P, Lanza GA, Crea F, Lombardo A. Chimeric antigen receptor-T cell therapy-related cardiotoxicity in adults and children cancer patients: A clinical appraisal. Front Cardiovasc Med 2023; 10:1090103. [PMID: 36895831 PMCID: PMC9988907 DOI: 10.3389/fcvm.2023.1090103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 02/06/2023] [Indexed: 02/23/2023] Open
Abstract
Chimeric antigen receptor-T (CAR-T) cells therapies represent an innovative immunological treatment for patients suffering from advanced and refractory onco-hematological malignancies. The infusion of engineered T-cells, exposing chimeric receptors on the cell surface, leads to an immune response against the tumor cells. However, data from clinical trials and observational studies showed the occurrence of a constellation of adverse events related to CAR-T cells infusion, ranging from mild effects to life-threatening organ-specific complications. In particular, CAR-T cell-related cardiovascular toxicities represent an emerging group of adverse events observed in these patients, correlated with increased morbidity and mortality. Mechanisms involved are still under investigation, although the aberrant inflammatory activation observed in cytokine release syndrome (CRS) seems to play a pivotal role. The most frequently reported cardiac events, observed both in adults and in the pediatric population, are represented by hypotension, arrhythmias and left ventricular systolic dysfunction, sometimes associated with overt heart failure. Therefore, there is an increasing need to understand the pathophysiological basis of cardiotoxicity and risk factors related to its development, in order to identify most vulnerable patients requiring a close cardiological monitoring and long-term follow-up. This review aims at highlighting CAR-T cell-related cardiovascular complications and clarifying the pathogenetic mechanisms coming at play. Moreover, we will shed light on surveillance strategies and cardiotoxicity management protocols, as well as on future research perspectives in this expanding field.
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Affiliation(s)
- Massimiliano Camilli
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy.,Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luca Maggio
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Lorenzo Tinti
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Priscilla Lamendola
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Gaetano Antonio Lanza
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy.,Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Filippo Crea
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy.,Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Antonella Lombardo
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy.,Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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11
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Nath K, Wudhikarn K, Alarcon Tomas A, Perales MA. Safety evaluation of axicabtagene ciloleucel for relapsed or refractory large B-cell lymphoma. Expert Opin Drug Saf 2023; 22:5-15. [PMID: 36737060 PMCID: PMC9975047 DOI: 10.1080/14740338.2023.2177268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 02/02/2023] [Indexed: 02/05/2023]
Abstract
INTRODUCTION CD19-directed chimeric antigen receptor (CAR) T-cell therapy is a highly effective therapy for patients with relapsed/refractory large B-cell lymphoma (LBCL) and three CD19 CAR T-cell products (axicabtagene ciloleucel, tisagenlecleucel and lisocabtagene maraleucel) are currently approved for this indication. Despite the clinical benefit of CD19 directed CAR T-cell therapy, this treatment is associated with significant morbidity from treatment-emergent toxicities. AREAS COVERED This Review discusses the safety considerations of axicabtagene ciloleucel in patients with LBCL. This includes discussion of the frequently observed immune-mediated toxicities of cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome. Additionally, we review CAR T-cell therapy related cytopenias, infection, organ dysfunction and the more recently described hemophagocytic lymphohistiocytosis. EXPERT OPINION A thorough understanding of the toxicities associated with CD19-directed CAR T-cell therapy will facilitate the optimal selection of patients for this therapy. Furthermore, knowledge of preventative measures of CAR T-cell related complications, and early recognition and appropriate intervention will lead to the safe administration of these therapies, and ultimately improved outcomes for our patients.
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Affiliation(s)
- Karthik Nath
- Cellular Therapy Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kitsada Wudhikarn
- Division of Hematology and Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Ana Alarcon Tomas
- Division of Hematology and Hemotherapy, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
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12
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Gill J. Cardiovascular Toxicities with Chimeric Antigen Receptor T-cell Therapy. Curr Cardiol Rev 2023; 19:e230622206353. [PMID: 35747980 PMCID: PMC10201875 DOI: 10.2174/1573403x18666220623152350] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 04/25/2022] [Accepted: 04/25/2022] [Indexed: 02/08/2023] Open
Abstract
Chimeric antigen receptor (CAR) T-cell therapy has shown remarkable efficacy in treating highly refractory and relapsing hematological malignancies in pediatric and adult patients. However, this promising therapy is limited by severe and potentially life-threatening toxicities. Cytokine release syndrome (CRS) is the most commonly observed of these toxicities. The cardiovascular manifestations of CRS include tachycardia, hypotension, left ventricular dysfunction, arrhythmias, troponin elevation, cardiogenic shock, and pulmonary edema. Recent data suggest that cardiotoxicities may be transient and reversible in younger patients with few cardiac comorbidities; however, cardiotoxicities may be fatal in older patients with significant cardiac risk factors. The literature remains sparse regarding long-term cardiotoxicities associated with CAR-T cell therapy. Furthermore, consensus guidelines for monitoring and prevention of cardiotoxicities remain illdefined. Therefore, this review will detail the cardiovascular toxicities of CAR T-cell therapy seen in clinical trials and observational studies, summarize treatment approaches for CRS, outline the currently adopted surveillance protocols for CAR T-cell associated cardiotoxicity, and explore the future directions of research in this rapidly emerging field.
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Affiliation(s)
- Jashan Gill
- Department of Medicine, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
- Department of Medicine, Northwestern McHenry Hospital, McHenry, IL, USA
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13
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Ganatra S, Dani SS, Yang EH, Zaha VG, Nohria A. Cardiotoxicity of T-Cell Antineoplastic Therapies: JACC: CardioOncology Primer. JACC CardioOncol 2022; 4:616-623. [PMID: 36636447 PMCID: PMC9830211 DOI: 10.1016/j.jaccao.2022.07.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 07/27/2022] [Indexed: 01/11/2023] Open
Abstract
T-cell therapies, such as chimeric antigen receptor (CAR) T-cell, bispecific T-cell engager (BiTE) and tumor-infiltrating lymphocyte (TIL) therapies, fight cancer cells harboring specific tumor antigens. However, activation of the immune response by these therapies can lead to a systemic inflammatory response, termed cytokine release syndrome (CRS), that can result in adverse events, including cardiotoxicity. Retrospective studies have shown that cardiovascular complications occur in 10% to 20% of patients who develop high-grade CRS after CAR T-cell therapy and can include cardiomyopathy, heart failure, arrhythmias, and myocardial infarction. While cardiotoxicities have been less commonly reported with BiTE and TIL therapies, systematic surveillance for cardiotoxicity has not been performed. Patients undergoing T-cell therapies should be screened for cardiovascular conditions that may not be able to withstand the hemodynamic perturbations imposed by CRS. Generalized management of CRS, including the use of the interleukin-6 antagonist, tocilizumab, for high-grade CRS, is used to mitigate the risk of cardiotoxicity.
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Key Words
- BCMA, B-cell maturation antigen
- BiTE therapy
- BiTE, bispecific T-cell engager
- CAR T-cell therapy
- CAR, chimeric antigen receptor
- CRS, cytokine release syndrome
- HF, heart failure
- ICSR, individual case safety report
- IL, interleukin
- LVEF, left ventricular ejection fraction
- MACE, major adverse cardiovascular event(s)
- TIL, tumor-infiltrating lymphocyte
- arrhythmia
- cardiomyopathy
- cardiotoxicity
- heart failure
- tumor-infiltrating lymphocytes
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Affiliation(s)
- Sarju Ganatra
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital & Medical Center, Burlington, Massachusetts, USA
- Address for correspondence: Dr Sarju Ganatra, Department of Cardiovascular Medicine, Lahey Hospital & Medical Center, 41 Mall Road, Burlington, Massachusetts 01805, USA. @SarjuGanatraMD
| | - Sourbha S. Dani
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital & Medical Center, Burlington, Massachusetts, USA
| | - Eric H. Yang
- Division of Cardiology, Department of Medicine, UCLA-Cardio-Oncology Program, University of California-Los Angeles, Los Angeles, California, USA
| | - Vlad G. Zaha
- Cardio-Oncology Program, Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Parkland Health & Hospital System, Dallas, Texas, USA
| | - Anju Nohria
- Cardio-Oncology Program, Department of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
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14
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Bennati E, Girolami F, Spaziani G, Calabri GB, Favre C, Parrini I, Lucà F, Tamburini A, Favilli S. Cardio-Oncology in Childhood: State of the Art. Curr Oncol Rep 2022; 24:1765-1777. [PMID: 36181610 DOI: 10.1007/s11912-022-01329-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW Cardio-oncology is an increasingly important field of cardiology that focuses on the detection, monitoring, and treatment of cardiovascular disease (CVD) occurring during and after oncological treatments. The survival rate for childhood cancer patients has dramatically increased thanks to new treatment protocols and cardiovascular (CV) sequelae represent the third most frequent cause of mortality in surviving patients. This study aims to provide a complete and updated review of all the main aspects of cardio-oncology in childhood and to highlight the critical issues. RECENT FINDINGS The problem of CV complications in childhood cancer survivors raises the need to make an early diagnosis of cardiotoxicity by the new imaging and laboratory techniques in order to intervene promptly and to implement pharmacological strategies and lifestyle changes to reduce or even to prevent cardiac injury. Furthermore, a stratification of CV risk, also including new predisposing factors such as the presence of some genetic mutations, is of paramount importance before undertaking oncological treatments. Besides, a systematic and personalized planning of long-term follow-up is fundamental to ensure a transition from pediatric to adult hospital and to avoid missed or late diagnosis of cardiomyopathy. We reviewed the main risk factors for cardiotoxicity in children, both traditional and emerging ones: the mechanisms of toxicity of both old and new antineoplastic therapies, the techniques for detecting cardiac damage, and the current evidence regarding pharmacological cardioprotection. At the end, we focused our attention on the existing guidelines and strategies about the long-term follow-up of childhood cancer survivors.
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Affiliation(s)
- Elena Bennati
- Pediatric Cardiology Unit, Meyer Children's Hospital, Viale G. Pieraccini 24, Florence, Italy.
| | - Francesca Girolami
- Pediatric Cardiology Unit, Meyer Children's Hospital, Viale G. Pieraccini 24, Florence, Italy
| | - Gaia Spaziani
- Pediatric Cardiology Unit, Meyer Children's Hospital, Viale G. Pieraccini 24, Florence, Italy
| | | | - Claudio Favre
- Department of Pediatric Hematology-Oncology, Meyer Children's Hospital, Viale G. Pieraccini 24, Florence, Italy
| | - Iris Parrini
- Cardiology Unit, Mauriziano Umberto I Hospital, Corso Turati 62, Turin, Italy
| | - Fabiana Lucà
- Department of Cardiology, Grande Ospedale Metropolitano, Azienda Ospedaliera Bianchi Melacrino Morelli, Reggio Calabria, Italy
| | - Angela Tamburini
- Department of Pediatric Hematology-Oncology, Meyer Children's Hospital, Viale G. Pieraccini 24, Florence, Italy
| | - Silvia Favilli
- Pediatric Cardiology Unit, Meyer Children's Hospital, Viale G. Pieraccini 24, Florence, Italy
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15
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Chen LR, Li YJ, Zhang Z, Wang P, Zhou T, Qian K, Fan YX, Guo Y, He GH, Shen L. Cardiovascular effects associated with chimeric antigen receptor T cell therapy in cancer patients: A meta-analysis. Front Oncol 2022; 12:924208. [DOI: 10.3389/fonc.2022.924208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 10/19/2022] [Indexed: 11/10/2022] Open
Abstract
BackgroundAlthough numerous studies confirmed the marked efficacy of chimeric antigen receptor T cells (CAR-T cells) in many hematologic malignancies, severe cardiovascular toxicities remain to be a major obstacle when incorporating this technology. Furthermore, previous individual investigations regarding the cardiovascular toxicities of CAR-T cell therapy also reported controversial conclusions. Therefore, a meta-analysis was performed to further evaluate the impacts of CAR-T cell therapy on cardiovascular toxicities.MethodsThe PubMed, Embase, Web of Science, and ClinicalTrials.gov databases were searched for eligible studies up to April 2022. All analyses were carried out using the R 4.1.0 software.ResultsEventually, 25 related studies consisting of 2,059 patients were enrolled in the current meta-analysis. We discovered that the pooled incidence rate of the all-cause mortality rate was 14.1% and that the pooled incidence rates of overall cardiovascular (CV) events and CV events with cytokine release syndrome (CRS) grade ≥ 2 were 25.6% and 14.2%, respectively. The pooled incidence of hypotension was 28.6%. Further analysis showed that the incidence rates of arrhythmias, cardiovascular dysfunction, heart failure (HF), CV deaths, acute coronary syndrome (ACS), cardiomyopathy, cardiac arrest, and other CV events were 19.2%, 8.0%, 5.3%, 1.8%, 2.5%, 2.9%, 1.3%, and 1.9%, respectively.ConclusionCancer patients treated with CAR-T cell therapy were at risk for cardiovascular toxicities, of which the most common cardiovascular events were arrhythmias, cardiovascular dysfunction, and heart failure. These findings would contribute to achieving more rational and individualized use of CAR-T cells in clinical treatment.
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16
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Dalal PJ, Patel NP, Feinstein MJ, Akhter N. Adverse Cardiac Effects of CAR T-Cell Therapy: Characteristics, Surveillance, Management, and Future Research Directions. Technol Cancer Res Treat 2022; 21:15330338221132927. [PMID: 36254553 PMCID: PMC9580078 DOI: 10.1177/15330338221132927] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
This review summarizes the current literature on the adverse cardiac effects of CAR T-cell therapy. Case reports and series suggest that major adverse cardiovascular events are not uncommon after CAR T-cell therapy; however, limited data exist regarding incidence, pathophysiology, and prevention strategies related to CAR T-associated cardiovascular events. As cellular therapy advances and the indications for its use continue to expand, it is essential to better understand its associated cardiovascular toxicities. Biomarkers, cardiac imaging, longitudinal data from larger populations, and translational research are all essential areas for further research. Interestingly, CAR T-cell therapy can also be used to reverse cardiac fibrosis in murine models. Altogether this underscores the need to broadly understand how T-cells, endogenous and engineered, may impact cardiovascular diseases.
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Affiliation(s)
- Prarthana J. Dalal
- Department of Medicine, Northwestern Feinberg School of Medicine, Chicago, IL, USA
| | - Nikita P. Patel
- Department of Medicine, Northwestern Feinberg School of Medicine, Chicago, IL, USA
| | - Matthew J. Feinstein
- Department of Medicine, Division of Cardiology, Northwestern Feinberg School of Medicine, Chicago, IL, USA
| | - Nausheen Akhter
- Department of Medicine, Division of Cardiology, Northwestern Feinberg School of Medicine, Chicago, IL, USA,Nausheen Akhter, MD, Northwestern University Feinberg School of Medicine, Division of Cardiovascular Medicine, 676 N St. Clair, Suite 600, Chicago, IL, 60611.
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17
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Li Y, Ming Y, Fu R, Li C, Wu Y, Jiang T, Li Z, Ni R, Li L, Su H, Liu Y. The pathogenesis, diagnosis, prevention, and treatment of CAR-T cell therapy-related adverse reactions. Front Pharmacol 2022; 13:950923. [PMID: 36313336 PMCID: PMC9616161 DOI: 10.3389/fphar.2022.950923] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 09/29/2022] [Indexed: 11/13/2022] Open
Abstract
Chimeric antigen receptor (CAR)-T cell therapy is effective in the treatment of refractory/relapsed (r/r) hematological malignancies (r/r B-cell lymphoblastic leukemia, B-cell lymphoma, and multiple myeloma). In addition, it is being explored as a treatment option for solid tumors. As of 31 March 2022, seven CAR-T therapies for hematological malignancies have been approved worldwide. Although CAR-T therapy is an effective treatment for many malignancies, it also causes adverse effects. The incidence of cytokine release syndrome (CRS), the most common adverse reaction after infusion of CAR-T cells, is as high as 93%.CRS, is the leading risk factor of immune effector cell-associated neurotoxicity syndrome (ICANS), as well as cardiovascular, hematological, hepatorenal, skin, pulmonary, and gastrointestinal toxicity. Severe adverse reactions complicated by CRS severely impede the widespread application of CAR-T therapy. The CAR-T product was initially approved in 2017; however, only limited studies have investigated the adverse reactions owing to CAR-T therapy compared to that of clinically approved drugs. Thus, we aimed to elucidate the mechanisms, risk factors, diagnostic criteria, and treatment of toxicities concurrent with CRS, thereby providing a valuable reference for the safe, effective, and widespread application of CAR-T therapy.
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18
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Rao A, Stewart A, Eljalby M, Ramakrishnan P, Anderson LD, Awan FT, Chandra A, Vallabhaneni S, Zhang K, Zaha VG. Cardiovascular disease and chimeric antigen receptor cellular therapy. Front Cardiovasc Med 2022; 9:932347. [PMID: 36211558 PMCID: PMC9538377 DOI: 10.3389/fcvm.2022.932347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 08/16/2022] [Indexed: 11/13/2022] Open
Abstract
Chimeric antigen receptor T-cell (CAR T) therapy is a revolutionary personalized therapy that has significantly impacted the treatment of patients with hematologic malignancies refractory to other therapies. Cytokine release syndrome (CRS) is a major side effect of CAR T therapy that can occur in 70–90% of patients, with roughly 40% of patients at grade 2 or higher. CRS can cause an intense inflammatory state leading to cardiovascular complications, including troponin elevation, arrhythmias, hemodynamic instability, and depressed left ventricular systolic function. There are currently no standardized guidelines for the management of cardiovascular complications due to CAR T therapy, but systematic practice patterns are emerging. In this review, we contextualize the history and indications of CAR T cell therapy, side effects related to this treatment, strategies to optimize the cardiovascular health prior to CAR T and the management of cardiovascular complications related to CRS. We analyze the existing data and discuss potential future approaches.
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Affiliation(s)
- Anjali Rao
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, United States
- Cardio-Oncology Program, Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, United States
- Parkland Health and Hospital System, Dallas, TX, United States
| | - Andrew Stewart
- Parkland Health and Hospital System, Dallas, TX, United States
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, United States
| | - Mahmoud Eljalby
- Parkland Health and Hospital System, Dallas, TX, United States
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, United States
| | - Praveen Ramakrishnan
- Division of Hematology and Oncology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, United States
| | - Larry D. Anderson
- Division of Hematology and Oncology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, United States
- Myeloma, Waldenstrom's, and Amyloidosis Program, Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, United States
| | - Farrukh T. Awan
- Division of Hematology and Oncology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, United States
| | - Alvin Chandra
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, United States
- Cardio-Oncology Program, Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, United States
- Parkland Health and Hospital System, Dallas, TX, United States
| | - Srilakshmi Vallabhaneni
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, United States
- Cardio-Oncology Program, Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, United States
- Parkland Health and Hospital System, Dallas, TX, United States
| | - Kathleen Zhang
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, United States
- Cardio-Oncology Program, Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, United States
- Parkland Health and Hospital System, Dallas, TX, United States
| | - Vlad G. Zaha
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, United States
- Cardio-Oncology Program, Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, United States
- Parkland Health and Hospital System, Dallas, TX, United States
- *Correspondence: Vlad G. Zaha
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Adverse Renal Effects of Anticancer Immunotherapy: A Review. Cancers (Basel) 2022; 14:cancers14174086. [PMID: 36077623 PMCID: PMC9454552 DOI: 10.3390/cancers14174086] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/18/2022] [Accepted: 08/22/2022] [Indexed: 11/17/2022] Open
Abstract
Simple Summary The immune system has a natural ability to work against cancer cells; however, in many cases this ability is insufficient, and cancers develop methods enabling them to escape from the supervision of immune cells. Novel therapeutic methods used in neoplastic diseases are based on encouraging immune cells to fight against cancer. In some cases, boosted by this approach, the immune system may damage not only tumor cells, but also other cells, tissues and organs in the human body. Kidney involvement, for example, is directly dangerous for patients’ health and may have an impact on human body homeostasis and the excretion of xenobiotics. However, renal function impairment in patients treated with immunotherapy is thought to be relatively rare but may be severe. Knowledge of early diagnosis and proper management are essential for physicians utilizing immunotherapy in daily clinical practice. Abstract Modern oncological therapy utilizes various types of immunotherapy. Immune checkpoint inhibitors (ICIs), chimeric antigen receptor T cells (CAR-T) therapy, cancer vaccines, tumor-targeting monoclonal antibodies (TT-mAbs), bispecific antibodies and cytokine therapy improve patients’ outcomes. However, stimulation of the immune system, beneficial in terms of fighting against cancer, generates the risk of harm to other cells in a patient’s body. Kidney damage belongs to the relatively rare adverse events (AEs). Best described, but still, superficially, are renal AEs in patients treated with ICIs. International guidelines issued by the European Society for Medical Oncology (ESMO) and the American Society of Clinical Oncology (ASCO) cover the management of immune-related adverse events (irAEs) during ICI therapy. There are fewer data concerning real occurrence and possible presentations of renal adverse drug reactions of other immunotherapeutic methods. This implies the need for the collection of safety data during ongoing clinical trials and in the real-life world to characterize the hazard related to the use of new immunotherapies and management of irAEs.
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Hanna KS, Kaur H, Alazzeh MS, Thandavaram A, Channar A, Purohit A, Shrestha B, Patel D, Shah H, Mohammed L. Cardiotoxicity Associated With Chimeric Antigen Receptor (CAR)-T Cell Therapy for Hematologic Malignancies: A Systematic Review. Cureus 2022; 14:e28162. [PMID: 36148204 PMCID: PMC9482759 DOI: 10.7759/cureus.28162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 08/19/2022] [Indexed: 11/10/2022] Open
Abstract
Chimeric Antigen Receptor (CAR)-T cell therapy has been one of the most important breakthroughs for treating hematologic malignancies. On the other hand, the therapy had many toxicities. One of the toxicities of the CAR-T therapy is cardiotoxicity. The goal of the systematic review is to elaborate on the cardiotoxicities related to CAR-T therapy for hematologic malignancies. The systematic review is following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) 2020 guidelines. The systematic search was done using PubMed, PubMed Central (PMC), Google Scholar, Cochrane Library, ScienceDirect, and clinicaltrial.gov. The search and selection of studies were done on April 28, 2022, and May 6, 2022, respectively. The studies were selected based upon participants, intervention, and outcomes (PIO) elements and the articles that were included were, full-text articles published within the last ten years, clinical trials, meta-analyses, randomized controlled trial, review, and systematic review. The exclusion criteria were non-hematologic malignancy, non-English-language articles. The initial search had 2,159 publications. The publications were assessed with assessment tools of Scale of the Assessment of Narrative Review Articles (SANRA), Newcastle-Ottawa Scale (NCOS), and Cochrane Collaboration Risk of Bias Tool (CCRBT), which led to selection of eight publications. The systematic review concludes that cardiotoxicity happened in adults and pediatric patients receiving the CAR-T cell therapy and that those cardiac adverse events had many risk factors. Therefore, monitoring these cardiotoxicities is highly essential.
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21
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Talleur AC, Myers R, Annesley C, Shalabi H. Chimeric Antigen Receptor T-cell Therapy: Current Status and Clinical Outcomes in Pediatric Hematologic Malignancies. Hematol Oncol Clin North Am 2022; 36:701-727. [PMID: 35780062 DOI: 10.1016/j.hoc.2022.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Chimeric antigen receptor T-cell (CART) therapy has transformed the treatment paradigm for pediatric patients with relapsed/refractory B-cell acute lymphoblastic leukemia (B-ALL), with complete remission rates in key pivotal CD19-CART trials ranging from 65% to 90%. Alongside this new therapy, new toxicity profiles and treatment limitations have emerged, necessitating toxicity consensus grading systems, cooperative group trials, and novel management approaches. This review highlights the results of key clinical trials of CART for pediatric hematologic malignancies, discusses the most common toxicities seen to date, and elucidates challenges, opportunities, and areas of active research to optimize this therapy.
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Affiliation(s)
- Aimee C Talleur
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, 262 Danny Thomas Place, MS1130, Memphis, TN 38105, USA
| | - Regina Myers
- Division of Oncology, Children's Hospital of Philadelphia, Office 2568A, 3500 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Colleen Annesley
- Seattle Children's Research Institute, 4800 Sand Point Way NE, M/S MB8.501, Seattle, WA 98145-5005, USA
| | - Haneen Shalabi
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Building 10, Room 1W-5750, 9000 Rockville Pike, Bethesda, MD 20892-1104, USA.
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22
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Cardiotoxicity of Chimeric Antigen Receptor T-Cell (CAR-T) Therapy: Pathophysiology, Clinical Implications, and Echocardiographic Assessment. Int J Mol Sci 2022; 23:ijms23158242. [PMID: 35897819 PMCID: PMC9368621 DOI: 10.3390/ijms23158242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 07/18/2022] [Accepted: 07/23/2022] [Indexed: 02/04/2023] Open
Abstract
Contemporary anticancer immunotherapy with chimeric antigen receptor T-cell (CAR-T) therapy has dramatically changed the treatment of many hematologic malignancies previously associated with poor prognosis. The clinical improvement and the survival benefit unveiled the risk of cardiotoxicity, ranging from minimal effects to severe cardiac adverse events, including death. Immunotherapy should also be proposed even in patients with pre-existing cardiovascular risk factors, thereby increasing the potential harm of cardiotoxicity. CAR-T therapy frequently results in cytokine release syndrome (CRS), and inflammatory activation is sustained by circulating cytokines that foster a positive feedback mechanism. Prompt diagnosis and treatment of CAR-T cardiotoxicity might significantly improve outcomes and reduce the burden associated with cardiovascular complications. Clinical and echocardiographic examinations are crucial to perform a tailored evaluation and follow-up during CAR-T treatment. This review aims to summarize the pathophysiology, clinical implications, and echocardiographic assessment of CAR-T-related cardiotoxicity to enlighten new avenues for future research.
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23
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Stein-Merlob AF, Ganatra S, Yang EH. T-cell Immunotherapy and Cardiovascular Disease: Chimeric Antigen Receptor T-cell and Bispecific T-cell Engager Therapies. Heart Fail Clin 2022; 18:443-454. [PMID: 35718418 DOI: 10.1016/j.hfc.2022.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Chimeric antigen receptor (CAR) T-cell and bispecific T-cell engager (BiTE) therapies have revolutionized the treatment of refractory or relapsed leukemia and lymphoma. Increased use of these therapies has revealed signals of significant cardiotoxicity, including cardiomyopathy/heart failure, arrhythmia, myocardial injury, hemodynamic instability, and cardiovascular death mainly in the context of a profound inflammatory response to CAR T-cell antitumor effects known as cytokine release syndrome (CRS). Preexisting cardiovascular risk factors and disease may increase the risk of such cardiotoxicity. High index of suspicion and close monitoring is required for prompt recognition. Supportive hemodynamic care and targeted anti-IL-6 therapy, as well as possibly broader immunosuppression with corticosteroids, are the cornerstones of the management.
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Affiliation(s)
- Ashley F Stein-Merlob
- Division of Cardiology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA; Division of Cardiology, Department of Medicine, UCLA-Cardio-Oncology Program, University of California at Los Angeles, Los Angeles, CA, USA. https://twitter.com/A_SteinMerlob
| | - Sarju Ganatra
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital and Medical Center, Burlington, MA, USA.
| | - Eric H Yang
- Division of Cardiology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA; Division of Cardiology, Department of Medicine, UCLA-Cardio-Oncology Program, University of California at Los Angeles, Los Angeles, CA, USA.
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Staab A, Gakenheimer-Smith L, Boyer M, Harris A, Afify Z. Successful administration of CD19 chimeric antigen receptor T cells in association with severe cyanotic congenital heart disease. Pediatr Blood Cancer 2022; 69:e29671. [PMID: 35293676 DOI: 10.1002/pbc.29671] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 03/02/2022] [Indexed: 01/03/2023]
Affiliation(s)
- Ambur Staab
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | | | - Michael Boyer
- Division of Hematology Oncology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Andrew Harris
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Zeinab Afify
- Division of Hematology Oncology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
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Maraldo MV, Levis M, Andreis A, Armenian S, Bates J, Brady J, Ghigo A, Lyon AR, Manisty C, Ricardi U, Aznar MC, Filippi AR. An integrated approach to cardioprotection in lymphomas. Lancet Haematol 2022; 9:e445-e454. [PMID: 35512725 DOI: 10.1016/s2352-3026(22)00082-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/03/2022] [Accepted: 03/10/2022] [Indexed: 10/18/2022]
Abstract
In potentially curable cancers, long-term survival depends not only on the successful treatment of the malignancy but also on the risks associated with treatment-related toxicity, especially cardiotoxicity. Malignant lymphomas affect patients at any age, with acute and late toxicity risks that could have a severe effect on morbidity, mortality, and quality of life. Although our understanding of chemotherapy-associated and radiotherapy-associated cardiovascular disease has advanced considerably, new drugs with potential cardiotoxicity have been introduced for the treatment of lymphomas. In this Review, we summarise the mechanisms of treatment-related cardiac injury, available clinical data, and protocols for optimising cardioprotection in lymphomas. We discuss ongoing research strategies to advance our knowledge of the molecular basis of drug-induced and radiation-induced toxicity. Additionally, we emphasise the potential for personalised follow-up and early detection, including the role of biomarkers and novel diagnostic tests, highlighting the role of the cardio-oncology team.
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Affiliation(s)
- Maja V Maraldo
- Department of Clinical Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Mario Levis
- Department of Clinical Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Alessandro Andreis
- Division of Cardiology, Città della Salute e della Scienza di Torino Hospital, University of Turin, Turin, Italy
| | - Saro Armenian
- Department of Population Sciences, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - James Bates
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Jessica Brady
- Guy's Cancer Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Alessandra Ghigo
- Department of Molecular Biotechnology and Health Sciences, University of Turin, Turin, Italy
| | - Alexander R Lyon
- Imperial College London and Cardio-oncology Service, Royal Brompton Hospital, London, UK
| | - Charlotte Manisty
- Department of Cardio-oncology, Barts Heart Centre and University College London, London, UK
| | | | - Marianne C Aznar
- Division of Cancer Sciences, Faculty of Biology, Medicine, and Health, University of Manchester and Department of Radiotherapy-Related Research, The Christie NHS, Manchester, UK.
| | - Andrea Riccardo Filippi
- Radiation Oncology, Fondazione IRCCS Policlinico San Matteo and University of Pavia, Pavia, Italy
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Tisagenlecleucel in pediatric and young adult patients with Down syndrome-associated relapsed/refractory acute lymphoblastic leukemia. Leukemia 2022; 36:1508-1515. [DOI: 10.1038/s41375-022-01550-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 03/03/2022] [Accepted: 03/16/2022] [Indexed: 01/05/2023]
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Thompson JA, Schneider BJ, Brahmer J, Achufusi A, Armand P, Berkenstock MK, Bhatia S, Budde LE, Chokshi S, Davies M, Elshoury A, Gesthalter Y, Hegde A, Jain M, Kaffenberger BH, Lechner MG, Li T, Marr A, McGettigan S, McPherson J, Medina T, Mohindra NA, Olszanski AJ, Oluwole O, Patel SP, Patil P, Reddy S, Ryder M, Santomasso B, Shofer S, Sosman JA, Wang Y, Zaha VG, Lyons M, Dwyer M, Hang L. Management of Immunotherapy-Related Toxicities, Version 1.2022, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2022; 20:387-405. [PMID: 35390769 DOI: 10.6004/jnccn.2022.0020] [Citation(s) in RCA: 114] [Impact Index Per Article: 57.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The aim of the NCCN Guidelines for Management of Immunotherapy-Related Toxicities is to provide guidance on the management of immune-related adverse events resulting from cancer immunotherapy. The NCCN Management of Immunotherapy-Related Toxicities Panel is an interdisciplinary group of representatives from NCCN Member Institutions, consisting of medical and hematologic oncologists with expertise across a wide range of disease sites, and experts from the areas of dermatology, gastroenterology, endocrinology, neurooncology, nephrology, cardio-oncology, ophthalmology, pulmonary medicine, and oncology nursing. The content featured in this issue is an excerpt of the recommendations for managing toxicities related to CAR T-cell therapies and a review of existing evidence. For the full version of the NCCN Guidelines, including recommendations for managing toxicities related to immune checkpoint inhibitors, visit NCCN.org.
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Affiliation(s)
- John A Thompson
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | | | - Julie Brahmer
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | | | | | | | | | | | - Saurin Chokshi
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | | | | | | | | | | | - Benjamin H Kaffenberger
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | | | | | | | | | | | - Nisha A Mohindra
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | | | | | - Pradnya Patil
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | | | | | | | - Jeffrey A Sosman
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | - Vlad G Zaha
- UT Southwestern Simmons Comprehensive Cancer Center; and
| | | | | | - Lisa Hang
- National Comprehensive Cancer Network
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Baumeister SHC, Mohan GS, Elhaddad A, Lehmann L. Cytokine Release Syndrome and Associated Acute Toxicities in Pediatric Patients Undergoing Immune Effector Cell Therapy or Hematopoietic Cell Transplantation. Front Oncol 2022; 12:841117. [PMID: 35402259 PMCID: PMC8989409 DOI: 10.3389/fonc.2022.841117] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 02/08/2022] [Indexed: 02/05/2023] Open
Abstract
Immune effector cells (IEC) are a powerful and increasingly targeted tool, particularly for the control and eradication of malignant diseases. However, the infusion, expansion, and persistence of autologous or allogeneic IEC or engagement of endogenous immune cells can be associated with significant systemic multi-organ toxicities. Here we review the signs and symptoms, grading and pathophysiology of immune-related toxicities arising in the context of pediatric immunotherapies and haploidentical T cell replete Hematopoietic Cell Transplantation (HCT). Principles of management are discussed with particular focus on the intersection of these toxicities with the requirement for pediatric critical care level support.
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Affiliation(s)
- Susanne H. C. Baumeister
- Boston Children’s Hospital, Division of Pediatric Hematology-Oncology, Boston, MA, United States
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
- *Correspondence: Susanne H. C. Baumeister,
| | - Gopi S. Mohan
- Boston Children’s Hospital, Division of Pediatric Hematology-Oncology, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
- Division of Pediatric Critical Care, Massachusetts General Hospital, Boston, MA, United States
| | - Alaa Elhaddad
- Children’s Cancer Hospital of Egypt, National Cancer Institute Cairo, Cairo, Egypt
| | - Leslie Lehmann
- Boston Children’s Hospital, Division of Pediatric Hematology-Oncology, Boston, MA, United States
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
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Totzeck M, Michel L, Lin Y, Herrmann J, Rassaf T. Cardiotoxicity from chimeric antigen receptor-T cell therapy for advanced malignancies. Eur Heart J 2022; 43:1928-1940. [PMID: 35257157 PMCID: PMC9123242 DOI: 10.1093/eurheartj/ehac106] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 01/28/2022] [Accepted: 02/22/2022] [Indexed: 01/21/2023] Open
Abstract
Chimeric antigen receptor (CAR)-T cell therapy is the next revolutionary advance in cancer therapy. By using ex vivo engineered T cells to specifically target antigens, a targeted immune reaction is induced. Chimeric antigen receptor-T cell therapy is approved for patients suffering from advanced and refractory B cell and plasma cell malignancies and is undergoing testing for various other haematologic and solid malignancies. In the process of triggering an anticancer immune reaction, a systemic inflammatory response can emerge as cytokine release syndrome (CRS). The severity of CRS is highly variable across patients, ranging from mild flu-like symptoms to fulminant hyperinflammatory states with excessive immune activation, associated multiorgan failure and high mortality risk. Cytokine release syndrome is also an important factor for adverse cardiovascular (CV) events. Sinus tachycardia and hypotension are the most common reflections, similar to what is seen with other systemic inflammatory response syndromes. Corrected QT interval prolongation and tachyarrhythmias, including ventricular arrhythmias and atrial fibrillation, also show a close link with CRS. Events of myocardial ischaemia and venous thromboembolism can be provoked during CAR-T cell therapy. Although not as closely related to CRS, changes in cardiac function can be observed to the point of heart failure and cardiogenic shock. This may also be encountered in patients with severe valvular heart disease in the setting of CRS. This review will discuss the pertinent CV risks of the growing field of CAR-T cell therapy for today's cardiologists, including incidence, characteristics, and treatment options, and will conclude with an integrated management algorithm.
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Affiliation(s)
- Matthias Totzeck
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, Medical Faculty, University Hospital Essen, Hufelandstraße 55, 45147 Essen, Germany
| | - Lars Michel
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, Medical Faculty, University Hospital Essen, Hufelandstraße 55, 45147 Essen, Germany
| | - Yi Lin
- Division of Hematology and Division of Experimental Pathology, Mayo Clinic, Rochester, MN 55901, USA
| | - Joerg Herrmann
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, MN 55901, USA
| | - Tienush Rassaf
- Corresponding author. Tel: +49 201 723 4801, Fax: +49201 723 5401,
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30
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Hayden PJ, Roddie C, Bader P, Basak GW, Bonig H, Bonini C, Chabannon C, Ciceri F, Corbacioglu S, Ellard R, Sanchez-Guijo F, Jäger U, Hildebrandt M, Hudecek M, Kersten MJ, Köhl U, Kuball J, Mielke S, Mohty M, Murray J, Nagler A, Rees J, Rioufol C, Saccardi R, Snowden JA, Styczynski J, Subklewe M, Thieblemont C, Topp M, Ispizua ÁU, Chen D, Vrhovac R, Gribben JG, Kröger N, Einsele H, Yakoub-Agha I. Management of adults and children receiving CAR T-cell therapy: 2021 best practice recommendations of the European Society for Blood and Marrow Transplantation (EBMT) and the Joint Accreditation Committee of ISCT and EBMT (JACIE) and the European Haematology Association (EHA). Ann Oncol 2022; 33:259-275. [PMID: 34923107 DOI: 10.1016/j.annonc.2021.12.003] [Citation(s) in RCA: 130] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 12/06/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Several commercial and academic autologous chimeric antigen receptor T-cell (CAR-T) products targeting CD19 have been approved in Europe for relapsed/refractory B-cell acute lymphoblastic leukemia, high-grade B-cell lymphoma and mantle cell lymphoma. Products for other diseases such as multiple myeloma and follicular lymphoma are likely to be approved by the European Medicines Agency in the near future. DESIGN The European Society for Blood and Marrow Transplantation (EBMT)-Joint Accreditation Committee of ISCT and EBMT (JACIE) and the European Haematology Association collaborated to draft best practice recommendations based on the current literature to support health care professionals in delivering consistent, high-quality care in this rapidly moving field. RESULTS Thirty-six CAR-T experts (medical, nursing, pharmacy/laboratory) assembled to draft recommendations to cover all aspects of CAR-T patient care and supply chain management, from patient selection to long-term follow-up, post-authorisation safety surveillance and regulatory issues. CONCLUSIONS We provide practical, clinically relevant recommendations on the use of these high-cost, logistically complex therapies for haematologists/oncologists, nurses and other stakeholders including pharmacists and health sector administrators involved in the delivery of CAR-T in the clinic.
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Affiliation(s)
- P J Hayden
- Department of Haematology, Trinity College Dublin, St. James's Hospital, Dublin, Ireland
| | - C Roddie
- UCL Cancer Institute, London, UK; University College London Hospital NHS Foundation Trust, London, UK.
| | - P Bader
- Clinic for Children and Adolescents, University Children's Hospital, Frankfurt, Germany
| | - G W Basak
- Medical University of Warsaw, Department of Hematology, Transplantation and Internal Medicine, Warsaw, Poland
| | - H Bonig
- Institute for Transfusion Medicine and Immunohematology of Goethe University and German Red Cross Blood Service, Frankfurt, Germany
| | - C Bonini
- Ospedale San Raffaele and Università Vita-Salute San Raffaele, Milan, Italy
| | - C Chabannon
- Aix-Marseille université, Inserm CBT-1409, Institut Paoli-Calmettes, centre de thérapie cellulaire, unité de transplantation et de thérapie cellulaire, département de biologie du cancer, Marseille, France
| | - F Ciceri
- Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Milan, Italy
| | - S Corbacioglu
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, University Franz-Josef-Strauss-Allee 11, University Hospital of Regensburg, Regensburg, Germany
| | - R Ellard
- Royal Marsden Hospital, Fulham Rd, London, UK
| | - F Sanchez-Guijo
- IBSAL-Hospital Universitario de Salamanca, CIC, Universidad de Salamanca, Salamanca, Spain
| | - U Jäger
- Clinical Department for Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - M Hildebrandt
- Department of Transfusion Medicine, Cell Therapeutics and Haemostaseology, LMU University Hospital Grosshadern, Munich
| | - M Hudecek
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Würzburg, Germany
| | - M J Kersten
- Department of Hematology, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam and LYMMCARE, Amsterdam, the Netherlands
| | - U Köhl
- Fraunhofer Institute for Cell Therapy and Immunology (IZI) and Institute of Clinical Immunology, University of Leipzig, Leipzig, Germany; Institute of Cellular Therapeutics, Hannover Medical School, Hannover, Germany
| | - J Kuball
- Department of Hematology and Centre for Translational Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - S Mielke
- Karolinska Institutet and University Hospital, Department of Laboratory Medicine/Department of Cell Therapy and Allogeneic Stem Cell Transplantation (CAST), Stockholm, Sweden
| | - M Mohty
- Hôpital Saint-Antoine, APHP, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - J Murray
- Christie Hospital NHS Trust, Manchester, UK
| | - A Nagler
- The Chaim Sheba Medical Center, Tel-Hashomer, affiliated with the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - J Rees
- University College London Hospital NHS Foundation Trust, London, UK; UCL Institute of Neurology, University College of London Hospitals NHS Foundation Trust, London, UK
| | - C Rioufol
- Hospices Civils de Lyon, UCBL1, EMR 3738 CICLY, Lyon, France
| | - R Saccardi
- Cell Therapy and Transfusion Medicine Department, Careggi University Hospital, Florence, Italy
| | - J A Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - J Styczynski
- Department of Pediatric Hematology and Oncology, Collegium Medicum, Nicolaus Copernicus University Torun, Bydgoszcz, Poland
| | - M Subklewe
- German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - C Thieblemont
- AP-HP, Saint-Louis Hospital, Hemato-oncology, University of Paris, Paris, France
| | - M Topp
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Á U Ispizua
- Department of Hematology, ICMHO, Hospital Clínic de Barcelona, Barcelona, Spain
| | - D Chen
- University College London Hospital NHS Foundation Trust, London, UK; Centre for Haemato-Oncology, Barts Cancer Institute, Queen Mary University of London, London, UK
| | - R Vrhovac
- Department of Haematology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - J G Gribben
- Centre for Haemato-Oncology, Barts Cancer Institute, Queen Mary University of London, London, UK
| | - N Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg, Germany
| | - H Einsele
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Würzburg, Germany
| | - I Yakoub-Agha
- CHU de Lille, Univ Lille, INSERM U1286, Infinite, Lille, France
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31
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Lipe DN, Chaftari P, Reyes-Gibby C, Palaskas N. The evolving landscape of chimeric antigen receptor T-cell therapy associated cardiotoxicity. Am J Emerg Med 2022; 57:220-221. [DOI: 10.1016/j.ajem.2022.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 02/16/2022] [Indexed: 11/25/2022] Open
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32
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Profile of capillary-leak syndrome in patients received chimeric antigen receptor T cell therapy. Bone Marrow Transplant 2022; 57:661-663. [PMID: 35091688 PMCID: PMC8795291 DOI: 10.1038/s41409-022-01562-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 11/15/2021] [Accepted: 01/04/2022] [Indexed: 11/09/2022]
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Brickler M, Raskin A, Ryan TD. Current State of Pediatric Cardio-Oncology: A Review. CHILDREN 2022; 9:children9020127. [PMID: 35204848 PMCID: PMC8870613 DOI: 10.3390/children9020127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/23/2021] [Accepted: 11/30/2021] [Indexed: 01/03/2023]
Abstract
The landscape of pediatric oncology has dramatically changed over the course of the past several decades with five-year survival rates surpassing 80%. Anthracycline therapy has been the cornerstone of many chemotherapy regimens for pediatric patients since its introduction in the 1960s, and recent improved survival has been in large part due to advancements in chemotherapy, refinement of supportive care treatments, and development of novel therapeutics such as small molecule inhibitors, chimeric antigen receptor T-cell therapy, and immune checkpoint inhibitors. Unfortunately, many cancer-targeted therapies can lead to acute and chronic cardiovascular pathologies. The range of cardiotoxicity can vary but includes symptomatic or asymptotic heart failure, arrhythmias, coronary artery disease, valvar disease, pericardial disease, hypertension, and peripheral vascular disease. There is lack of data guiding primary prevention and treatment strategies in the pediatric population, which leads to substantial practice variability. Several important future research directions have been identified, including as they relate to cardiac disease, prevention strategies, management of cardiovascular risk factors, risk prediction, early detection, and the role of genetic susceptibility in development of cardiotoxicity. Continued collaborative research will be key in advancing the field. The ideal model for pediatric cardio-oncology is a proactive partnership between pediatric cardiologists and oncologists in order to better understand, treat, and ideally prevent cardiac disease in pediatric oncology patients.
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Affiliation(s)
| | | | - Thomas D. Ryan
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA;
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Taneja A, Jain T. CAR-T-OPENIA: Chimeric antigen receptor T-cell therapy-associated cytopenias. EJHAEM 2022; 3:32-38. [PMID: 35844301 PMCID: PMC9175816 DOI: 10.1002/jha2.350] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 10/21/2021] [Indexed: 05/01/2023]
Abstract
Chimeric antigen receptor (CAR) T-cell is the most recent version in the evolution of cellular therapy with promising responses, which has revolutionized the management of some hematological malignancies in the current times. As the clinical use has progressed rather rapidly since the first approval in 2017, toxicities beyond cytokine release syndrome and immune effector cell-associated neurological syndrome have surfaced. Cytopenias are common in <30 days ("early"), 30-90 days ("short-term") as well as >90 days ("prolonged"); and have clinical implications to patient care as well as resource utilization. We review the details of etiology, factors associated with cytopenias, and management considerations for patients with cytopenias for each of these time-frames. This would potentially serve as a clinical guide for hematological toxicity or CAR-T-OPENIA, which is commonly encountered with the use of CAR T-cell therapy.
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Affiliation(s)
- Alankrita Taneja
- Department of MedicineRoswell Park Comprehensive Cancer CenterBuffaloNew YorkUSA
| | - Tania Jain
- Department of Oncology, Sidney Kimmel Comprehensive Cancer CenterJohns Hopkins UniversityBaltimoreMarylandUSA
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35
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Pochon C, Courbon C, Bay JO, Moreau AS, Paul F, Picard M, Sterin A, Tudesq JJ, Vicente C, Yakoub-Agha M, Yakoub-Agha I. [Complications other than infections, CRS and ICANS following CAR T-cells therapy: Recommendations of the Francophone Society of bone marrow transplantation and cell therapy (SFGM-TC)]. Bull Cancer 2021; 108:S98-S103. [PMID: 34802718 DOI: 10.1016/j.bulcan.2021.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 10/15/2021] [Indexed: 10/19/2022]
Abstract
CAR-T cells are an innovative treatment for an increasing number of patients, particularly since the extension of their indication to mantle lymphoma and multiple myeloma. Several complications of CAR T-cell therapy, that were first described as exceptional, have now been reported in series of patients, since its first clinical use in 2011. Among them, cardiac complications, delayed cytopenias, acute and chronic Graft versus Host Disease, and tumoral lysis syndrome are recognized as specific potent complications following CAR T-cells infusion. 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 the management of these complications with focuses the epidemiology, the physiopathology and the risk factors of these 4 side effects. Our recommendations apply to commercial CAR-T cells, in order to guide strategies for the management of complications associated with this new therapeutic approach.
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Affiliation(s)
- Cécile Pochon
- CHRU de Nancy, service d'onco-hématologie pédiatrique, 54500 Vandœuvre-Lès-Nancy, France; Université de Lorraine, UMR 7365 CNRS-UL IMoPA, campus biologie santé, 9, avenue de la Forêt-de-Haye, 54505 Vandœuvre-Lès-Nancy, France.
| | - Corinne Courbon
- Institut de cancérologie de la Loire, service d'hématologie, 42270 Saint-Priest-en-Jarez, France
| | - Jacques-Olivier Bay
- CHU de Clermont-Ferrand, service de thérapie cellulaire et d'hématologie clinique adulte, site Estaing, 1, place Lucie-Aubrac, 63000 Clermont-Ferrand, France
| | - Anne-Sophie Moreau
- Hôpital Salengro, CHU de Lille, service de médecine intensive réanimation, rue Émile-Laine, 59037 Lille cedex, France
| | - Franciane Paul
- Université Montpellier, CHU de Montpellier, département d'hématologie clinique, Montpellier, France
| | - Muriel Picard
- CHU de Toulouse, réanimation polyvalente IUCT-oncopole, Toulouse, France
| | - Arthur Sterin
- Hôpital La Timone Enfants, service hémato-immunologie pédiatrique, 13005 Marseille, France
| | - Jean-Jacques Tudesq
- Université Montpellier, CHU de Montpellier, département d'hématologie clinique, Montpellier, France
| | - Céline Vicente
- CHU de Toulouse, service d'hématologie, IUCT-oncopole, 1, avenue Joliot-Curie, 31059 Toulouse, France
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Goldman A, Maor E, Bomze D, Liu JE, Herrmann J, Fein J, Steingart RM, Mahmood SS, Schaffer WL, Perales MA, Shouval R. Adverse Cardiovascular and Pulmonary Events Associated With Chimeric Antigen Receptor T-Cell Therapy. J Am Coll Cardiol 2021; 78:1800-1813. [PMID: 34711339 DOI: 10.1016/j.jacc.2021.08.044] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 08/16/2021] [Accepted: 08/17/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Pivotal trials of chimeric antigen receptor T-cell (CAR-T) have identified common toxicities but may have been underpowered to detect cardiovascular and pulmonary adverse events (CPAEs). OBJECTIVES This study sought to investigate CPAEs associated with commercial CD19-directed CAR-T therapy. METHODS In this retrospective, pharmacovigilance study, the authors used the Food and Drug Administration adverse event reporting system to identify CPAEs associated with axicabtagene-ciloleucel and tisagenlecleucel. The authors evaluated disproportionate reporting by the reporting odds ratio (ROR) and the lower bound of the information component 95% credibility interval (IC025 >0 is deemed significant). Significant associations were further adjusted to age and sex (adj.ROR). RESULTS The authors identified CAR-T reports of 2,657 patients, including 546 CPAEs (20.5%). CPAEs overlapped with cytokine release syndrome in 68.3% (373 of 546) of the reports. Compared with the full database, CAR-T was associated with overreporting of tachyarrhythmias (n = 74 [2.8%], adj.ROR = 2.78 [95% CI: 2.21-3.51]), cardiomyopathy (n = 69 [2.6%], adj.ROR = 3.51 [2.42-5.09]), pleural disorders (n = 46 [1.7%], adj.ROR = 3.91 [2.92-5.23]), and pericardial diseases (n = 11 [0.4%], adj.ROR = 2.26 [1.25-4.09], all IC025 >0). Venous thromboembolic events (VTEs) were associated only with axicabtagene-ciloleucel therapy (n = 28 [1.6%], adj.ROR = 1.80 [1.24-2.62], IC025 >0). Atrial fibrillation (n = 55) was the leading tachyarrhythmia, followed by ventricular arrhythmias (n = 14). Tachyarrhythmias and VTEs were reported more often following axicabtagene-ciloleucel than tisagenlecleucel in an age- and sex-adjusted model (adj.ROR = 1.82 [1.04-3.18] and adj.ROR = 2.86 [1.18-6.93], respectively). Finally, the fatality rate of CPAEs was 30.9%. CONCLUSIONS In this largest post-marketing study to date, the authors identified an association between CAR-T and various CPAEs, including tachyarrhythmias, cardiomyopathy, pericardial and pleural disorders, and VTEs. These findings should be considered in the multidisciplinary assessment for and monitoring of CAR-T therapy recipients.
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Affiliation(s)
- Adam Goldman
- Leviev Heart Center, Chaim Sheba Medical Center, Ramat Gan, Israel; School of Medicine, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Elad Maor
- Leviev Heart Center, Chaim Sheba Medical Center, Ramat Gan, Israel; School of Medicine, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - David Bomze
- School of Medicine, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Jennifer E Liu
- Cardiology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Joerg Herrmann
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota, USA
| | - Joshua Fein
- Department of Internal Medicine, UCONN Health, Farmington, Connecticut, USA
| | - Richard M Steingart
- Cardiology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Syed S Mahmood
- Cardiology Division, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York, USA
| | - Wendy L Schaffer
- Cardiology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Miguel-Angel Perales
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA; Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Roni Shouval
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA; Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA.
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Shin YH, Tian X, Park JJ, Kim GYG, Aboujaoude E, Sturgill MG. Management of chimeric antigen receptor T-cell induced cytokine release syndrome: Current and emerging approaches. J Oncol Pharm Pract 2021; 28:159-174. [PMID: 34586003 DOI: 10.1177/10781552211039238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The most common adverse event associated with chimeric antigen receptor T-cell therapy is cytokine release syndrome, which is characterized by fever, hypoxia, and hypotension in varying degrees of severity. In severe cases, cytokine release syndrome can result in life-threatening symptoms such as multi-organ failure. The widely accepted first-line therapy for cytokine release syndrome management is tocilizumab with or without corticosteroids, but there is very limited guidance on the proper management of patients unresponsive to this regimen. There are emerging strategies that target cytokine release syndrome through novel mechanisms, showing promise in treating or preventing severe cytokine release syndrome. Although further clinical investigation is necessary to assess the applicability of the emerging approaches, these exploratory therapies may shape the future landscape of chimeric antigen receptor T-cell induced cytokine release syndrome management. This review article provides a comprehensive overview of the current and emerging therapies for the management of chimeric antigen receptor T-cell induced cytokine release syndrome, especially cases that are refractory to tocilizumab and steroids.
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Affiliation(s)
- Yunjung H Shin
- 15484Rutgers University Ernest Mario School of Pharmacy, USA
| | - Xiaofan Tian
- 15484Rutgers University Ernest Mario School of Pharmacy, USA
| | - Jiyeon J Park
- 15484Rutgers University Ernest Mario School of Pharmacy, USA.,145249Rutgers Cancer Institute of New Jersey, USA
| | - Gee Y Geeny Kim
- 15484Rutgers University Ernest Mario School of Pharmacy, USA.,3673Hackensack University Medical Center, USA
| | - Emily Aboujaoude
- 15484Rutgers University Ernest Mario School of Pharmacy, USA.,25044Robert Wood Johnson University Hospital, USA
| | - Marc G Sturgill
- 15484Rutgers University Ernest Mario School of Pharmacy, USA
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Montisci A, Vietri MT, Palmieri V, Sala S, Donatelli F, Napoli C. Cardiac Toxicity Associated with Cancer Immunotherapy and Biological Drugs. Cancers (Basel) 2021; 13:4797. [PMID: 34638281 PMCID: PMC8508330 DOI: 10.3390/cancers13194797] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/15/2021] [Accepted: 09/22/2021] [Indexed: 12/19/2022] Open
Abstract
Cancer immunotherapy significantly contributed to an improvement in the prognosis of cancer patients. Immunotherapy, including human epidermal growth factor receptor 2 (HER2)-targeted therapies, immune checkpoint inhibitors (ICI), and chimeric antigen receptor-modified T (CAR-T), share the characteristic to exploit the capabilities of the immune system to kill cancerous cells. Trastuzumab is a monoclonal antibody against HER2 that prevents HER2-mediated signaling; it is administered mainly in HER2-positive cancers, such as breast, colorectal, biliary tract, and non-small-cell lung cancers. Immune checkpoint inhibitors (ICI) inhibit the binding of CTLA-4 or PD-1 to PDL-1, allowing T cells to kill cancerous cells. ICI can be used in melanomas, non-small-cell lung cancer, urothelial, and head and neck cancer. There are two main types of T-cell transfer therapy: tumor-infiltrating lymphocytes (or TIL) therapy and chimeric antigen receptor-modified T (CAR-T) cell therapy, mainly applied for B-cell lymphoma and leukemia and mantle-cell lymphoma. HER2-targeted therapies, mainly trastuzumab, are associated with left ventricular dysfunction, usually reversible and rarely life-threatening. PD/PDL-1 inhibitors can cause myocarditis, rare but potentially fulminant and associated with a high fatality rate. CAR-T therapy is associated with several cardiac toxic effects, mainly in the context of a systemic adverse effect, the cytokines release syndrome.
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Affiliation(s)
- Andrea Montisci
- Division of Cardiothoracic Intensive Care, ASST Spedali Civili, 25123 Brescia, Italy;
| | - Maria Teresa Vietri
- Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, 81100 Naples, Italy;
| | - Vittorio Palmieri
- Department of Cardiac Surgery and Transplantation, Ospedali dei Colli Monaldi-Cotugno-CTO, 80131 Naples, Italy;
| | - Silvia Sala
- Department of Anesthesia and Intensive Care, University of Brescia, 25121 Brescia, Italy;
| | - Francesco Donatelli
- Cardiac Surgery, University of Milan, 20122 Milan, Italy
- Department of Cardiac Surgery, Istituto Clinico Sant’Ambrogio, 20149 Milan, Italy
| | - Claudio Napoli
- Clinical Department of Internal Medicine and Specialistics, University Department of Advanced Clinical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, 81100 Naples, Italy;
- IRCCS SDN, 80143 Naples, Italy
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Mechanisms and Insights for the Development of Heart Failure Associated with Cancer Therapy. CHILDREN-BASEL 2021; 8:children8090829. [PMID: 34572260 PMCID: PMC8468170 DOI: 10.3390/children8090829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 09/11/2021] [Accepted: 09/18/2021] [Indexed: 01/01/2023]
Abstract
Cardiotoxicity is a well-recognized late effect among childhood cancer survivors. With various pediatric cancers becoming increasingly curable, it is imperative to understand the disease burdens that survivors may face in the future. In order to prevent or mitigate cardiovascular complications, we must first understand the mechanistic underpinnings. This review will examine the underlying mechanisms of cardiotoxicity that arise from traditional antineoplastic chemotherapies, radiation therapy, hematopoietic stem cell transplantation, as well as newer cellular therapies and targeted cancer therapies. We will then propose areas for prevention, primarily drawing from the anthracycline-induced cardiotoxicity literature. Finally, we will explore the role of human induced pluripotent stem cell cardiomyocytes and genetics in advancing the field of cardio-oncology.
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Cardiotoxicity associated with immune checkpoint inhibitors and CAR T-cell therapy. Am J Emerg Med 2021; 50:51-58. [PMID: 34274878 DOI: 10.1016/j.ajem.2021.07.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 07/01/2021] [Accepted: 07/02/2021] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION The expanding use of immunotherapy and the growing population of patients with cancer has led to an increase in the reporting of immune related adverse events (irAEs). The emergency clinician should be aware of these emerging toxicities, some of which can be fatal. In this review we discuss the cardiotoxic side effects of immune checkpoint inhibitors (ICIs) and chimeric antigen receptor T-cell (CAR T-cell) therapy. DISCUSSION Recognizing the possible presentations of cardiotoxic irAEs is of utmost important as the diagnosis of cardiotoxicity associated with ICI and CAR T-cell can be difficult to make in the emergency department. The emergency clinician will have to presume the diagnosis and treat it without final confirmation in most cases. For this reason, if the diagnosis is suspected, early involvement of the cardiologist and oncologist is important to help guide management. Most irAEs will be treated with glucocorticoids, but in the case of CAR T-cell cardiotoxicity, Tocilizumab should be used as first line. CONCLUSION Although cardiotoxicity is rare, it is often life-threatening. Treatment should be initiated as soon as the diagnosis is suspected, and early involvement of the cardiologist and oncologist is imperative for optimal treatment.
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Shalabi H, Gust J, Taraseviciute A, Wolters PL, Leahy AB, Sandi C, Laetsch TW, Wiener L, Gardner RA, Nussenblatt V, Hill JA, Curran KJ, Olson TS, Annesley C, Wang HW, Khan J, Pasquini MC, Duncan CN, Grupp SA, Pulsipher MA, Shah NN. Beyond the storm - subacute toxicities and late effects in children receiving CAR T cells. Nat Rev Clin Oncol 2021; 18:363-378. [PMID: 33495553 PMCID: PMC8335746 DOI: 10.1038/s41571-020-00456-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2020] [Indexed: 12/15/2022]
Abstract
As clinical advances with chimeric antigen receptor (CAR) T cells are increasingly described and the potential for extending their therapeutic benefit grows, optimizing the implementation of this therapeutic modality is imperative. The recognition and management of cytokine release syndrome (CRS) marked a milestone in this field; however, beyond the understanding gained in treating CRS, a host of additional toxicities and/or potential late effects of CAR T cell therapy warrant further investigation. A multicentre initiative involving experts in paediatric cell therapy, supportive care and/or study of late effects from cancer and haematopoietic stem cell transplantation was convened to facilitate the comprehensive study of extended CAR T cell-mediated toxicities and establish a framework for new systematic investigations of CAR T cell-related adverse events. Together, this group identified six key focus areas: extended monitoring of neurotoxicity and neurocognitive function, psychosocial considerations, infection and immune reconstitution, other end organ toxicities, evaluation of subsequent neoplasms, and strategies to optimize remission durability. Herein, we present the current understanding, gaps in knowledge and future directions of research addressing these CAR T cell-related outcomes. This systematic framework to study extended toxicities and optimization strategies will facilitate the translation of acquired experience and knowledge for optimal application of CAR T cell therapies.
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Affiliation(s)
- Haneen Shalabi
- Pediatric Oncology Branch, Center for Cancer Research, NCI, NIH, Bethesda, MD, USA
| | - Juliane Gust
- Seattle Children's Research Institute, Seattle, WA, USA
- Department of Pediatrics, University of Washington Seattle, Seattle, WA, USA
| | - Agne Taraseviciute
- Cancer and Blood Disease Institute, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Pamela L Wolters
- Pediatric Oncology Branch, Center for Cancer Research, NCI, NIH, Bethesda, MD, USA
| | - Allison B Leahy
- Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Carlos Sandi
- Pediatric Oncology Branch, Center for Cancer Research, NCI, NIH, Bethesda, MD, USA
- St. Baldrick's Foundation, Monrovia, CA, USA
| | - Theodore W Laetsch
- Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Pediatrics and Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA
| | - Lori Wiener
- Pediatric Oncology Branch, Center for Cancer Research, NCI, NIH, Bethesda, MD, USA
| | - Rebecca A Gardner
- Seattle Children's Research Institute, Seattle, WA, USA
- Department of Pediatrics, University of Washington Seattle, Seattle, WA, USA
| | - Veronique Nussenblatt
- National Institute of Allergy and Infectious Disease, Clinical Center, NIH, Bethesda, MD, USA
| | - Joshua A Hill
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Kevin J Curran
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Timothy S Olson
- Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Colleen Annesley
- Seattle Children's Research Institute, Seattle, WA, USA
- Department of Pediatrics, University of Washington Seattle, Seattle, WA, USA
| | - Hao-Wei Wang
- Laboratory of Pathology, NCI, NIH, Bethesda, MD, USA
| | - Javed Khan
- Oncogenomics Section, Genetics Branch, NCI, NIH, Bethesda, MD, USA
| | - Marcelo C Pasquini
- Blood and Marrow Transplant and Cellular Therapy Program, Medical College of Wisconsin, Milwaukee, WI, USA
- Center for International Blood and Marrow Transplant Research, Milwaukee, WI, USA
| | - Christine N Duncan
- Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA, USA
| | - Stephan A Grupp
- Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael A Pulsipher
- Cancer and Blood Disease Institute, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Nirali N Shah
- Pediatric Oncology Branch, Center for Cancer Research, NCI, NIH, Bethesda, MD, USA.
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DLBCL patients treated with CD19 CAR T cells experience a high burden of organ toxicities but low nonrelapse mortality. Blood Adv 2021; 4:3024-3033. [PMID: 32614964 DOI: 10.1182/bloodadvances.2020001972] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 05/29/2020] [Indexed: 01/26/2023] Open
Abstract
Cytokine release syndrome (CRS) immune effector cell-associated neurotoxicity syndrome are the most notable toxicities of CD19 chimeric antigen receptor (CAR) T-cell therapy. In addition, CAR T-cell-mediated toxicities can involve any organ system, with varied impacts on outcomes, depending on patient factors and involved organs. We performed detailed analysis of organ-specific toxicities and their association with outcomes in 60 patients with diffuse large B-cell lymphoma (DLBCL) treated with CD19 CAR T cells by assessing all toxicities in organ-based groups during the first year posttreatment. We observed 539 grade ≥2 and 289 grade ≥3 toxicities. Common grade ≥3 toxicities included hematological, metabolic, infectious, and neurological complications, with corresponding 1-year cumulative incidence of 57.7%, 54.8%, 35.4%, and 18.3%, respectively. Patients with impaired performance status had a higher risk of grade ≥3 metabolic complications, whereas elevated lactate dehydrogenase was associated with higher risks of grade ≥3 neurological and pulmonary toxicities. CRS was associated with higher incidence of grade ≥3 metabolic, pulmonary, and neurologic complications. The 1-year nonrelapse mortality and overall survival were 1.7% and 69%, respectively. Only grade ≥3 pulmonary toxicities were associated with an increased mortality risk. In summary, toxicity burdens after CD19 CAR T-cell therapy were high and varied by organ systems. Most toxicities were manageable and were rarely associated with mortality. Our study emphasizes the importance of toxicity assessment, which could serve as a benchmark for further research to reduce symptom burdens and improve tolerability in patients treated with CAR T cells.
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Patel NP, Doukas PG, Gordon LI, Akhter N. Cardiovascular Toxicities of CAR T-cell Therapy. Curr Oncol Rep 2021; 23:78. [PMID: 33937946 DOI: 10.1007/s11912-021-01068-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This review provides a contemporary overview of current studies outlining the incidence and characteristics of CAR T-cell cardiotoxicity in an effort to identify future directions for research and potential opportunities for prevention and intervention. RECENT FINDINGS Cardiovascular events occurred in anywhere between 10 and 36% of patients in CAR T-cell clinical trials, ranging from tachycardia, hypotension, arrhythmia, decreased left ventricular systolic function to cardiogenic shock and death. Cardiac events are more often associated higher grades (> 2) of cytokine release syndrome and frequently proceeded by an elevated troponin. There is a growing recognition of cardiotoxicities of CAR T-cell therapy but has a limited study in this area. The mechanism of left ventricular dysfunction due to CAR T-cell therapy is also unknown. As CAR T-cell use expands, it becomes imperative to truly understand the mechanism behind cardiac injury and to assess long-term follow-up data as this will allow for surveillance, early intervention, and potentially prevention of cardiotoxicity.
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Affiliation(s)
- Nikita P Patel
- Department of Medicine, Northwestern Feinberg School of Medicine, 676 N. St. Clair St., Arkes Suite 2330, Chicago, IL, 60611, USA
| | - Peter G Doukas
- Department of Medicine, Northwestern Feinberg School of Medicine, 676 N. St. Clair St., Arkes Suite 2330, Chicago, IL, 60611, USA
| | - Leo I Gordon
- Division of Hematology and Oncology, Northwestern Feinberg School of Medicine, 675 N. St. Clair St. Ste 21-100, Chicago, IL, 60611, USA
| | - Nausheen Akhter
- Division of Cardiology, Northwestern Feinberg School of Medicine, 675 N. St. Clair St. Ste 19-100, Chicago, IL, 60611, USA.
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Abstract
ABSTRACT The successful application of chimeric antigen receptor (CAR) T cells for the treatment of relapsed and refractory B-cell malignancies has ushered in a new frontier for the immunotherapy of cancer. Despite its successes, CAR T-cell therapy presents several challenges. Cytokine release syndrome (CRS) triggered by robust and exponential CAR T-cell expansion is the most common adverse effect and may be severe or life-threatening. Although modulation of the interleukin 6 axis was appreciated early on as a means to manage CRS, the exact underlying mechanisms leading to severe CRS remain to be elucidated. What is clear is that severe CRS involves recruitment of the broader immune system into a hyperinflammatory and unregulated state. Myeloid-derived cells appear to play a critical role in this regard and are at the center of active investigation. In this article, we will focus on important elements of CRS, the clinical manifestations, underlying biology, and management strategies including grading, supportive care, and treatment via immunosuppression.
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Burns EA, Gentille C, Trachtenberg B, Pingali SR, Anand K. Cardiotoxicity Associated with Anti-CD19 Chimeric Antigen Receptor T-Cell (CAR-T) Therapy: Recognition, Risk Factors, and Management. Diseases 2021; 9:20. [PMID: 33802788 PMCID: PMC8006027 DOI: 10.3390/diseases9010020] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/04/2021] [Accepted: 03/15/2021] [Indexed: 12/12/2022] Open
Abstract
Chimeric antigen receptor T-cells (CAR-T) are improving outcomes in pediatric and adult patients with relapsed or refractory B-cell acute lymphoblastic leukemias and subtypes of non-Hodgkin Lymphoma. As this treatment is being increasingly utilized, a better understanding of the unique toxicities associated with this therapy is warranted. While there is growing knowledge on the diagnosis and treatment of cytokine release syndrome (CRS), relatively little is known about the associated cardiac events that occur with CRS that may result in prolonged length of hospital stay, admission to the intensive care unit for pressor support, or cardiac death. This review focuses on the various manifestations of cardiotoxicity, potential risk factors, real world and clinical trial data on prevalence of reported cardiotoxicity events, and treatment recommendations.
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Affiliation(s)
- Ethan A. Burns
- Houston Methodist Cancer Center, Houston Methodist Hospital, 6445 Main Street, Outpatient Center, 24th Floor, Houston, TX 77030, USA; (C.G.); (S.R.P.)
| | - Cesar Gentille
- Houston Methodist Cancer Center, Houston Methodist Hospital, 6445 Main Street, Outpatient Center, 24th Floor, Houston, TX 77030, USA; (C.G.); (S.R.P.)
| | - Barry Trachtenberg
- Houston Methodist DeBakey Heart and Vascular Center, 6565 Fannin St, Houston, TX 77030, USA;
| | - Sai Ravi Pingali
- Houston Methodist Cancer Center, Houston Methodist Hospital, 6445 Main Street, Outpatient Center, 24th Floor, Houston, TX 77030, USA; (C.G.); (S.R.P.)
| | - Kartik Anand
- Callahan Cancer Center, Great Plains Health, 601 W Leota St, North Platte, NE 69101, USA
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Stein-Merlob AF, Rothberg MV, Ribas A, Yang EH. Cardiotoxicities of novel cancer immunotherapies. Heart 2021; 107:1694-1703. [PMID: 33722826 DOI: 10.1136/heartjnl-2020-318083] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/28/2021] [Accepted: 02/13/2021] [Indexed: 12/28/2022] Open
Abstract
Immunotherapy revolutionised oncology by harnessing the native immune system to effectively treat a wide variety of malignancies even at advanced stages. Off-target immune activation leads to immune-related adverse events affecting multiple organ systems, including the cardiovascular system. In this review, we discuss the current literature describing the epidemiology, mechanisms and proposed management of cardiotoxicities related to immune checkpoint inhibitors (ICIs), chimeric antigen receptor (CAR) T-cell therapies and bispecific T-cell engagers. ICIs are monoclonal antibody antagonists that block a co-inhibitory pathway used by tumour cells to evade a T cell-mediated immune response. ICI-associated cardiotoxicities include myocarditis, pericarditis, atherosclerosis, arrhythmias and vasculitis. ICI-associated myocarditis is the most recognised and potentially fatal cardiotoxicity with mortality approaching 50%. Recently, ICI-associated dysregulation of the atherosclerotic plaque immune response with prolonged use has been linked to early progression of atherosclerosis and myocardial infarction. Treatment strategies include immunosuppression with corticosteroids and supportive care. In CAR T-cell therapy, autologous T cells are genetically engineered to express receptors targeted to cancer cells. While stimulating an effective tumour response, they also elicit a profound immune reaction called cytokine release syndrome (CRS). High-grade CRS causes significant systemic abnormalities, including cardiovascular effects such as arrhythmias, haemodynamic compromise and cardiomyopathy. Treatment with interleukin-6 inhibitors and corticosteroids is associated with improved outcomes. The evidence shows that, although uncommon, immunotherapy-related cardiovascular toxicities confer significant risk of morbidity and mortality and benefit from rapid immunosuppressive treatment. As new immunotherapies are developed and adopted, it will be imperative to closely monitor for cardiotoxicity.
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Affiliation(s)
- Ashley F Stein-Merlob
- Division of Cardiology, Department of Medicine, University of California at Los Angeles, Los Angeles, California, USA
| | - Michael V Rothberg
- University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Antoni Ribas
- Division of Hematology-Oncology, Jonsson Comprehensive Cancer Center, Department of Medicine, University of California at Los Angeles, Los Angeles, California, USA
| | - Eric H Yang
- UCLA-Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California at Los Angeles, Los Angeles, California, USA
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Stein-Merlob AF, Rothberg MV, Holman P, Yang EH. Immunotherapy-Associated Cardiotoxicity of Immune Checkpoint Inhibitors and Chimeric Antigen Receptor T Cell Therapy: Diagnostic and Management Challenges and Strategies. Curr Cardiol Rep 2021; 23:11. [PMID: 33483873 PMCID: PMC7821837 DOI: 10.1007/s11886-021-01440-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Immunotherapies have demonstrated robust clinical efficacy in treating malignancies with increasing use and FDA approvals. We review the epidemiology, risk factors, diagnosis, and treatment of immunotherapy-associated cardiovascular toxicities. RECENT FINDINGS Cardiotoxicity is reported in patients receiving immune checkpoint inhibitors (ICI) and chimeric antigen receptor (CAR) T cell therapies. The incidence of ICI-related cardiotoxicity is above 1% and includes myocarditis, pericardial disease, arrhythmia, acute coronary syndrome, and vasculitis. The incidence of CAR T cell-associated cardiotoxicities was shown to be as high as 26% and thought to be primarily mediated by cytokine release syndrome. The presentations of cardiotoxicities are variable but are associated with significant morbidity and mortality and benefit from prompt initiation of immunosuppressive therapy. There is increasing evidence for cardiotoxicities following cancer immunotherapy. Available evidence suggests that pretreatment evaluation, close monitoring, and early intervention may reduce cardiovascular morbidity and improve outcomes in the cancer immunotherapy population.
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Affiliation(s)
- Ashley F. Stein-Merlob
- Division of Cardiology, Department of Medicine, University of California, Los Angeles, Los Angeles, CA USA
| | - Michael V. Rothberg
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA USA
| | - Patrick Holman
- Department of Medicine, University of California, Los Angeles, Los Angeles, CA USA
| | - Eric H. Yang
- Division of Cardiology, Department of Medicine, University of California, Los Angeles, Los Angeles, CA USA
- UCLA-Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California, Los Angeles, 100 Medical Plaza, Suite 630, Los Angeles, CA 90095 USA
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Hall EM, Yin DE, Goyal RK, Ahmed AA, Mitchell GS, St Peter SD, Flatt TG, Ahmed IA, Li W, Hendrickson RJ, August KJ, Myers GD. Tisagenlecleucel infusion in patients with relapsed/refractory ALL and concurrent serious infection. J Immunother Cancer 2021; 9:jitc-2020-001225. [PMID: 33472856 PMCID: PMC7818837 DOI: 10.1136/jitc-2020-001225] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Tisagenlecleucel, an anti-CD19 chimeric antigen receptor T (CAR-T) cell therapy, has demonstrated durable efficacy and a manageable safety profile in pediatric and young adult patients with relapsed/refractory B-cell acute lymphoblastic leukemia (B-ALL) in the ELIANA pivotal trial and real-world experience. Experience from investigator-led studies prior to ELIANA suggests that infections and inflammatory conditions may exacerbate the severity of cytokine release syndrome (CRS) associated with CAR-T cell therapy, leading to extreme caution and strong restrictions for on-study and commercial infusion of tisagenlecleucel in patients with active infection. CRS intervention with interleukin (IL)-6 blockade and/or steroid therapy was introduced late in the course during clinical trials due to concern for potential negative effect on efficacy and persistence. However, earlier CRS intervention is now viewed more favorably. Earlier intervention and consistency in management between providers may promote broader use of tisagenlecleucel, including potential curative therapy in patients who require remission and recovery of hematopoiesis for management of severe infection. MAIN BODY Patient 1 was diagnosed with B-ALL at 23 years old. Fourteen days before tisagenlecleucel infusion, the patient developed fever and neutropenia and was diagnosed with invasive Mucorales infection and BK virus hemorrhagic cystitis. Aggressive measures were instituted to control infection and to manage prolonged cytopenias during CAR-T cell manufacturing. Adverse events, including CRS, were manageable despite elevated inflammatory markers and active infection. The patient attained remission and recovered hematopoiesis, and infections resolved. The patient remains in remission ≥1 year postinfusion.Patient 2 was diagnosed with pre-B-ALL at preschool age. She developed severe septic shock 3 days postinitiation of lymphodepleting chemotherapy. After receiving tisagenlecleucel, she experienced CRS with cardiac dysfunction and extensive lymphadenopathy leading to renovascular compromise. The patient attained remission and was discharged in good condition to her country of origin. She remained in remission but expired on day 208 postinfusion due to cardiac arrest of unclear etiology. CONCLUSIONS Infusion was feasible, and toxicity related to tisagenlecleucel was manageable despite active infections and concurrent inflammation, allowing attainment of remission in otherwise refractory pediatric/young adult ALL. This may lead to consideration of tisagenlecleucel as a potential curative therapy in patients with managed active infections.
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Affiliation(s)
- Erin M Hall
- School of Medicine, University of Missouri Kansas City, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Dwight E Yin
- School of Medicine, University of Missouri Kansas City, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Rakesh K Goyal
- School of Medicine, University of Missouri Kansas City, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Atif A Ahmed
- School of Medicine, University of Missouri Kansas City, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Grace S Mitchell
- School of Medicine, University of Missouri Kansas City, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Shawn D St Peter
- School of Medicine, University of Missouri Kansas City, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Terrie G Flatt
- School of Medicine, University of Missouri Kansas City, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Ibrahim A Ahmed
- School of Medicine, University of Missouri Kansas City, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Weijie Li
- School of Medicine, University of Missouri Kansas City, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Richard J Hendrickson
- School of Medicine, University of Missouri Kansas City, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Keith J August
- School of Medicine, University of Missouri Kansas City, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - G Doug Myers
- School of Medicine, University of Missouri Kansas City, Children's Mercy Kansas City, Kansas City, Missouri, USA
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Jamal FA, Khaled SK. The Cardiovascular Complications of Chimeric Antigen Receptor T Cell Therapy. Curr Hematol Malig Rep 2020; 15:130-132. [PMID: 32016789 DOI: 10.1007/s11899-020-00567-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE OF REVIEW Chimeric antigen receptor T cell therapy is gaining clinical use in the management of B cell lymphomas. As the use of this unique treatment option increases, its associated toxicities will require recognition and treatment. In this review, we aim to discuss the cardiovascular toxicities of chimeric antigen receptor T cell therapy and our approach to their clinical management. RECENT FINDINGS Cardiotoxicity may be due to direct or indirect effects of infused chimeric antigen receptor T cells. The cytokine release syndrome has been described extensively in the literature. Studies have also reported cardiovascular dysfunction including hypotension, left ventricular dysfunction, heart failure, and cardiogenic shock in the setting of cytokine release syndrome. While there are no standardized guidelines for the treatment of cytokine release syndrome or associated cardiotoxicity, we present our current clinical practices. Further research is indicated into the pathophysiology of therapy-associated cardiac dysfunction and effective management strategies to optimize patient outcomes.
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Affiliation(s)
- Faizi A Jamal
- Division of Cardiology, Department of Medicine, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA, 91010, USA.
| | - Samer K Khaled
- Department of Hematology, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA, 91010, USA
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50
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Maus MV, Alexander S, Bishop MR, Brudno JN, Callahan C, Davila ML, Diamonte C, Dietrich J, Fitzgerald JC, Frigault MJ, Fry TJ, Holter-Chakrabarty JL, Komanduri KV, Lee DW, Locke FL, Maude SL, McCarthy PL, Mead E, Neelapu SS, Neilan TG, Santomasso BD, Shpall EJ, Teachey DT, Turtle CJ, Whitehead T, Grupp SA. Society for Immunotherapy of Cancer (SITC) clinical practice guideline on immune effector cell-related adverse events. J Immunother Cancer 2020; 8:jitc-2020-001511. [PMID: 33335028 PMCID: PMC7745688 DOI: 10.1136/jitc-2020-001511] [Citation(s) in RCA: 121] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2020] [Indexed: 12/20/2022] Open
Abstract
Immune effector cell (IEC) therapies offer durable and sustained remissions in significant numbers of patients with hematological cancers. While these unique immunotherapies have improved outcomes for pediatric and adult patients in a number of disease states, as 'living drugs,' their toxicity profiles, including cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS), differ markedly from conventional cancer therapeutics. At the time of article preparation, the US Food and Drug Administration (FDA) has approved tisagenlecleucel, axicabtagene ciloleucel, and brexucabtagene autoleucel, all of which are IEC therapies based on genetically modified T cells engineered to express chimeric antigen receptors (CARs), and additional products are expected to reach marketing authorization soon and to enter clinical development in due course. As IEC therapies, especially CAR T cell therapies, enter more widespread clinical use, there is a need for clear, cohesive recommendations on toxicity management, motivating the Society for Immunotherapy of Cancer (SITC) to convene an expert panel to develop a clinical practice guideline. The panel discussed the recognition and management of common toxicities in the context of IEC treatment, including baseline laboratory parameters for monitoring, timing to onset, and pharmacological interventions, ultimately forming evidence- and consensus-based recommendations to assist medical professionals in decision-making and to improve outcomes for patients.
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Affiliation(s)
- Marcela V Maus
- Department of Medicine, Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - Sara Alexander
- Cancer Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michael R Bishop
- Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | | | - Colleen Callahan
- Cancer Immunotherapy Program, Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Marco L Davila
- Blood and Marrow Transplantation and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida, USA
| | - Claudia Diamonte
- Cellular Therapeutics Center, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jorg Dietrich
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Julie C Fitzgerald
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew J Frigault
- Bone Marrow Transplant and Cellular Immunotherapy Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Terry J Fry
- Pediatric Hematology/Oncology/BMT, Children's Hospital Colorado and University of Colorado Anschutz School of Medicine, Aurora, Colorado, USA
| | - Jennifer L Holter-Chakrabarty
- Department of Hematology/Oncology/Bone Marrow Transplant and Cellular Therapy, The University of Oklahoma Stephenson Cancer Center, Oklahoma City, Oklahoma, USA
| | - Krishna V Komanduri
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida, USA
| | - Daniel W Lee
- Department of Pediatrics, University of Virginia Cancer Center, Charlottesville, Virginia, USA
| | - Frederick L Locke
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida, USA
| | - Shannon L Maude
- Cancer Immunotherapy Program, Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Philip L McCarthy
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Elena Mead
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Sattva S Neelapu
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Tomas G Neilan
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Bianca D Santomasso
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Elizabeth J Shpall
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David T Teachey
- Cancer Center, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Cameron J Turtle
- Clinical Research Division, Fred Hutchinson Cancer Research Center Division of Medical Oncology, University of Washington, Seattle, Washington, USA
| | - Tom Whitehead
- Emily Whitehead Foundation, Phillipsburg, Pennsylvania, USA
| | - Stephan A Grupp
- Cancer Immunotherapy Program, Division of Oncology, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania, USA
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