1
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Brudno JN, Kochenderfer JN. Current understanding and management of CAR T cell-associated toxicities. Nat Rev Clin Oncol 2024:10.1038/s41571-024-00903-0. [PMID: 38769449 DOI: 10.1038/s41571-024-00903-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2024] [Indexed: 05/22/2024]
Abstract
Chimeric antigen receptor (CAR) T cell therapy has revolutionized the treatment of several haematological malignancies and is being investigated in patients with various solid tumours. Characteristic CAR T cell-associated toxicities such as cytokine-release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS) are now well-recognized, and improved supportive care and management with immunosuppressive agents has made CAR T cell therapy safer and more feasible than it was when the first regulatory approvals of such treatments were granted in 2017. The increasing clinical experience with these therapies has also improved recognition of previously less well-defined toxicities, including movement disorders, immune effector cell-associated haematotoxicity (ICAHT) and immune effector cell-associated haemophagocytic lymphohistiocytosis-like syndrome (IEC-HS), as well as the substantial risk of infection in patients with persistent CAR T cell-induced B cell aplasia and hypogammaglobulinaemia. A more diverse selection of immunosuppressive and supportive-care pharmacotherapies is now being utilized for toxicity management, yet no universal algorithm for their application exists. As CAR T cell products targeting new antigens are developed, additional toxicities involving damage to non-malignant tissues expressing the target antigen are a potential hurdle. Continued prospective evaluation of toxicity management strategies and the design of less-toxic CAR T cell products are both crucial for ongoing success in this field. In this Review, we discuss the evolving understanding and clinical management of CAR T cell-associated toxicities.
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Affiliation(s)
- Jennifer N Brudno
- Surgery Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA.
| | - James N Kochenderfer
- Surgery Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
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2
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Kim SJ, Yoon SE, Kim WS. Current Challenges in Chimeric Antigen Receptor T-cell Therapy in Patients With B-cell Lymphoid Malignancies. Ann Lab Med 2024; 44:210-221. [PMID: 38205527 PMCID: PMC10813822 DOI: 10.3343/alm.2023.0388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 11/18/2023] [Accepted: 12/29/2023] [Indexed: 01/12/2024] Open
Abstract
Chimeric antigen receptor (CAR) T-cell therapy is a promising immunotherapy based on genetically engineered T cells derived from patients. The introduction of CAR T-cell therapy has changed the treatment paradigm of patients with B-cell lymphoid malignancies. However, challenging issues including managing life-threatening toxicities related to CAR T-cell infusion and resistance to CAR T-cell therapy, leading to progression or relapse, remain. This review summarizes the issues with currently approved CAR T-cell therapies for patients with relapsed or refractory B-cell lymphoid malignancies, including lymphoma and myeloma. We focus on unique toxicities after CAR T-cell therapy, such as cytokine-related events and hematological toxicities, and the mechanisms underlying post-CAR T-cell failure.
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Affiliation(s)
- Seok Jin Kim
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University School of Medicine, Seoul, Korea
- CAR T-cell Therapy Center, Samsung Comprehensive Cancer Center, Seoul, Korea
| | - Sang Eun Yoon
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- CAR T-cell Therapy Center, Samsung Comprehensive Cancer Center, Seoul, Korea
| | - Won Seog Kim
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University School of Medicine, Seoul, Korea
- CAR T-cell Therapy Center, Samsung Comprehensive Cancer Center, Seoul, Korea
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3
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Wu X, Cao Z, Chen Z, Wang Y, He H, Xiao P, Hu S, Lu J, Li B. Infectious complications in pediatric patients undergoing CD19+CD22+ chimeric antigen receptor T-cell therapy for relapsed/refractory B-lymphoblastic leukemia. Clin Exp Med 2024; 24:87. [PMID: 38662121 PMCID: PMC11045589 DOI: 10.1007/s10238-024-01339-7] [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: 12/25/2023] [Accepted: 03/26/2024] [Indexed: 04/26/2024]
Abstract
Chimeric antigen receptor T-cell (CAR-T) therapy is effective in the treatment of relapsed/refractory acute B-lymphoblastic leukemia (R/R B-ALL); however, patients who receive CAR-T therapy are predisposed to infections, with considerable detrimental effects on long-term survival rates and the quality of life of patients. This study retrospectively analyzed infectious complications in 79 pediatric patients with R/R B-ALL treated with CAR-T cells at our institution. Overall, 53 patients developed 88 infections. Nine patients experienced nine infections during lymphodepletion chemotherapy, 35 experienced 41 infections during the early phase (days 0-+ 30 after infusion), and 29 experienced 38 infections during the late phase (day + 31-+ 90 after infusion). Pathogens were identified in 31 infections, including 23 bacteria, seven viruses, and one fungus. Four patients were admitted to the intensive care unit for infection and one died. In a univariate analysis, there were ten factors associated with infection, including tumor load, lymphodepleting chemotherapy, neutrophil deficiency and lymphocyte reduction, cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS), etc. In a multivariate analysis, CRS ≥ grade 3 was identified as a risk factor for infection (hazard ratio = 2.41, 95% confidence interval: 1.08-5.36, P = 0.031). Therefore, actively reducing the CRS grade may decrease the risk of infection and improve the long-term quality of life of these patients.
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Affiliation(s)
- Xiaochen Wu
- Department of Hematology, Children's Hospital of Soochow University, Suzhou, 215002, Jiangsu, China
| | - Zhanmeng Cao
- Department of Hematology, Children's Hospital of Soochow University, Suzhou, 215002, Jiangsu, China
| | - Zihan Chen
- Department of Hematology, Children's Hospital of Soochow University, Suzhou, 215002, Jiangsu, China
| | - Yi Wang
- Department of Hematology, Children's Hospital of Soochow University, Suzhou, 215002, Jiangsu, China
| | - Hailong He
- Department of Hematology, Children's Hospital of Soochow University, Suzhou, 215002, Jiangsu, China
| | - Peifang Xiao
- Department of Hematology, Children's Hospital of Soochow University, Suzhou, 215002, Jiangsu, China
| | - Shaoyan Hu
- Department of Hematology, Children's Hospital of Soochow University, Suzhou, 215002, Jiangsu, China.
| | - Jun Lu
- Department of Hematology, Children's Hospital of Soochow University, Suzhou, 215002, Jiangsu, China.
| | - Benshang Li
- Key Laboratory of Pediatric Hematology and Oncology, Department of Hematology and Oncology, Shanghai Children's Medical Center, Ministry of Health, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China.
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4
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Qian H, Yang X, Zhang T, Zou P, Zhang Y, Tian W, Mao Z, Wei J. Improving the safety of CAR-T-cell therapy: The risk and prevention of viral infection for patients with relapsed or refractory B-cell lymphoma undergoing CAR-T-cell therapy. Am J Hematol 2024; 99:662-678. [PMID: 38197307 DOI: 10.1002/ajh.27198] [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: 09/14/2023] [Revised: 12/05/2023] [Accepted: 12/15/2023] [Indexed: 01/11/2024]
Abstract
Chimeric antigen receptor (CAR) T-cell therapy, an innovative immunotherapeutic against relapsed/refractory B-cell lymphoma, faces challenges due to frequent viral infections. Despite this, a comprehensive review addressing risk assessment, surveillance, and treatment management is notably absent. This review elucidates immune response compromises during viral infections in CAR-T recipients, collates susceptibility risk factors, and deliberates on preventive strategies. In the post-pandemic era, marked by the Omicron variant, new and severe threats to CAR-T therapy emerge, necessitating exploration of preventive and treatment measures for COVID-19. Overall, the review provides recommendations for viral infection prophylaxis and management, enhancing CAR-T product safety and recipient survival.
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Affiliation(s)
- Hu Qian
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xingcheng Yang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tingting Zhang
- Cancer Center, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
- Department of Hematology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
- Sino-German Joint Oncological Research Laboratory, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Taiyuan, China
| | - Ping Zou
- Department of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yicheng Zhang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Weiwei Tian
- Department of Hematology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
- Sino-German Joint Oncological Research Laboratory, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Taiyuan, China
| | - Zekai Mao
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jia Wei
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Hematology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
- Sino-German Joint Oncological Research Laboratory, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Taiyuan, China
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5
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Cheok KPL, Farrow A, Springell D, O'Reilly M, Morley S, Stone N, Roddie C. Mucormycosis after CD19 chimeric antigen receptor T-cell therapy: results of a US Food and Drug Administration adverse events reporting system analysis and a review of the literature. THE LANCET. INFECTIOUS DISEASES 2024; 24:e256-e265. [PMID: 38310904 DOI: 10.1016/s1473-3099(23)00563-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 08/08/2023] [Accepted: 09/01/2023] [Indexed: 02/06/2024]
Abstract
Chimeric antigen receptor (CAR) T-cell therapy leads to durable remissions in relapsed B-cell cancers, but treatment-associated immunocompromise leads to a substantial morbidity and mortality risk from atypical infection. Mucormycosis is an aggressive and invasive fungal infection with a mortality risk of 40-80% in patients with haematological malignancies. In this Grand Round, we report a case of mucormycosis in a 54-year-old patient undergoing CAR T-cell therapy who reached complete clinical control of Mucorales with combined aggressive surgical debridement, antifungal pharmacotherapy, and reversal of underlying risk factors, but with substantial morbidity from extensive oro-facial surgery affecting the patient's speech and swallowing. For broader context, we present our case alongside an US Food and Drugs Administration adverse events reporting database analysis and a review of the literature to fully evaluate the clinical burden of mucormycosis in patients treated with CAR T-cell therapy. We discuss epidemiology, clinical features, diagnostic tools, and current frameworks for treatment and prophylaxis. We did this analysis to promote increased vigilance for mucormycosis among physicians specialising in CAR T-cell therapy and microbiologists and to illustrate the importance of early initiation of therapy to effectively manage this condition. Mucormycosis prevention and early diagnosis, through targeted surveillance and mould prevention in patients at highest risk and Mucorales-specific screening assays, is likely to be key to improving outcomes in patients treated with CAR T-cell therapy.
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Affiliation(s)
- Kathleen P L Cheok
- University College London Hospital NHS Foundation Trust, London, UK; University College London Cancer Institute, London, UK.
| | - Adrian Farrow
- University College London Hospital NHS Foundation Trust, London, UK
| | | | - Maeve O'Reilly
- University College London Hospital NHS Foundation Trust, London, UK
| | - Simon Morley
- University College London Hospital NHS Foundation Trust, London, UK
| | - Neil Stone
- University College London Hospital NHS Foundation Trust, London, UK
| | - Claire Roddie
- University College London Hospital NHS Foundation Trust, London, UK; University College London Cancer Institute, London, UK
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6
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Vic S, Thibert JB, Bachy E, Cartron G, Gastinne T, Morschhauser F, Le Bras F, Bouabdallah K, Despas F, Bay JO, Rubio MT, Mohty M, Casasnovas O, Choquet S, Castilla-Llorente C, Guidez S, Loschi M, Guffroy B, Carras S, Drieu La Rochelle L, Guillet M, Houot R. Transfusion needs after CAR T-cell therapy for large B-cell lymphoma: predictive factors and outcome (a DESCAR-T study). Blood Adv 2024; 8:1573-1585. [PMID: 38181767 PMCID: PMC10982963 DOI: 10.1182/bloodadvances.2023011727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 12/19/2023] [Accepted: 12/20/2023] [Indexed: 01/07/2024] Open
Abstract
ABSTRACT Chimeric antigen receptor (CAR) T-cells targeting CD19 have been approved for the treatment of relapse/refractory large B-cell lymphoma. Hematotoxicity is the most frequent CAR T-cell-related adverse event. Transfusion support is a surrogate marker of severe cytopenias. Transfusion affects patients' quality of life, presents specific toxicities, and is known to affect immunity through the so-called transfusion-related immunomodulation that may affect CAR T-cell efficacy. We analyzed data from 671 patients from the French DESCAR-T registry for whom exhaustive transfusion data were available. Overall, 401 (59.8%) and 378 (56.3%) patients received transfusion in the 6-month period before and after CAR T-cell infusion, respectively. The number of patients receiving transfusion and the mean number of transfused products increased during the 6-month period before CAR T-cell infusion, peaked during the first month after infusion (early phase), and decreased over time. Predictive factors for transfusion at the early phase were age >60 years, ECOG PS ≥2, treatment with axicabtagene ciloleucel, pre-CAR T-cell transfusions, and CAR-HEMATOTOX score ≥2. Predictive factors for late transfusion (between 1 and 6 months after infusion) were pre-CAR T-cell transfusions, CAR-HEMATOTOX score ≥2, ICANS ≥3 (for red blood cells [RBC] transfusion), and tocilizumab use (for platelets transfusion). Early transfusions and late platelets (but not RBC) transfusions were associated with a shorter progression-free survival and overall survival. Lymphoma-related mortality and nonrelapse mortality were both increased in the transfused population. Our data shed light on the mechanisms of early and late cytopenia and on the potential impact of transfusions on CAR T-cell efficacy and toxicity.
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Affiliation(s)
- Samuel Vic
- Department of Hematology, CHU de Rennes, Rennes, France
| | | | - Emmanuel Bachy
- Hematology Department, CHU Lyon Sud, Pierre Bénite, Lyon, France
| | | | | | | | - Fabien Le Bras
- Department of Hematology, Lymphoid Malignancies Unit, CHU Henri Mondor, Créteil, France
| | - Kamal Bouabdallah
- Hematology and Cellular Therapy Department, CHU Bordeaux, Bordeaux, France
| | - Fabien Despas
- Hematology and Internal Medicine Department, Institut Universitaire du Cancer-Oncopole, CHU de Toulouse, Toulouse, France
| | - Jacques-Olivier Bay
- Hematology and Cellular Therapy Department, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - Marie-Thérèse Rubio
- Department of Hematology CHRU Nancy, biopole de l'Université de Lorraine, Nancy, France
| | - Mohamad Mohty
- Hematology Department Saint-Antoine Hospital, Sorbonne University, Paris, France
| | - Olivier Casasnovas
- Department of Hematology and INSERM 1231, CHU Dijon Bourgogne, Dijon, France
| | - Sylvain Choquet
- Hematology Department, hôpital de la Pitié-Salpêtrière, Sorbonne Université, Paris, France
| | | | - Stéphanie Guidez
- Hematology and Cellular Therapy Department, CHU de Poitiers, Poitiers, France
| | - Michaël Loschi
- Hematology Department CHU de Nice, Université Cote d’Azur, Nice, France
| | - Blandine Guffroy
- Department of Hematology, Institut de Cancérologie Strasbourg Europe, Strasbourg, France
| | - Sylvain Carras
- Institute for Advanced Biosciences, Hematology Department CHU Grenoble-Alpes, University Grenoble-Alpes, Grenoble, France
| | | | - Mathilde Guillet
- The Lymphoma Academic Research Organization, Statistics, Pierre-Bénite, France
| | - Roch Houot
- Department of Hematology, University Hospital of Rennes, UMR U1236 INSERM, University of Rennes, French Blood Establishment, Rennes, France
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7
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Bellal M, Malherbe J, Damaj G, Du Cheyron D. Toxicities, intensive care management, and outcome of chimeric antigen receptor T cells in adults: an update. Crit Care 2024; 28:69. [PMID: 38444031 PMCID: PMC10916319 DOI: 10.1186/s13054-024-04851-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 02/27/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND Chimeric antigen receptor T cells are a promising new immunotherapy for haematological malignancies. Six CAR-T cells products are currently available for adult patients with refractory or relapsed high-grade B cell malignancies, but they are associated with severe life-threatening toxicities and side effects that may require admission to ICU. OBJECTIVE The aim of this short pragmatic review is to synthesize for intensivists the knowledge on CAR-T cell therapy with emphasis on CAR-T cell-induced toxicities and ICU management of complications according to international recommendations, outcomes and future issues.
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Affiliation(s)
- Mathieu Bellal
- Department of Medical Intensive Care, Caen University Hospital, Avenue de la côte de nacre, 14000, Caen, France.
- UNICAEN, INSERM UMRS U1237 PhIND, Normandie Univ, 14000, Caen, France.
| | - Jolan Malherbe
- Department of Medical Intensive Care, Caen University Hospital, Avenue de la côte de nacre, 14000, Caen, France
| | - Gandhi Damaj
- Hematology Institute, Caen University Hospital, 14000, Caen, France
| | - Damien Du Cheyron
- Department of Medical Intensive Care, Caen University Hospital, Avenue de la côte de nacre, 14000, Caen, France
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8
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Galli E, Fresa A, Bellesi S, Metafuni E, Maiolo E, Pansini I, Frioni F, Autore F, Limongiello MA, Innocenti I, Giammarco S, Chiusolo P, Zini G, Sorà F. Hematopoiesis and immune reconstitution after CD19 directed chimeric antigen receptor T-cells (CAR-T): A comprehensive review on incidence, risk factors and current management. Eur J Haematol 2024; 112:184-196. [PMID: 37491951 DOI: 10.1111/ejh.14052] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 07/10/2023] [Accepted: 07/10/2023] [Indexed: 07/27/2023]
Abstract
Impaired function of hematopoiesis after treatment with chimeric antigen T-cells (CAR-T) is a frequent finding and can interest a wide range of patients, regardless of age and underlying disease. Trilinear cytopenias, as well as hypogammaglobulinemia, B-cell aplasia, and T-cell impairment, can severely affect the infectious risk of CAR-T recipients, as well as their quality of life. In this review, we provide an overview of defects in hematopoiesis after CAR-T, starting with a summary of different definitions and thresholds. We then move to summarize the main pathogenetic mechanisms of cytopenias, and we offer insight into cytomorphological aspects, the role of clonal hematopoiesis, and the risk of secondary myeloid malignancies. Subsequently, we expose the major findings and reports on T-cell and B-cell quantitative and functional impairment after CAR-T. Finally, we provide an overview of current recommendations and leading experiences regarding the management of cytopenias and defective B- and T-cell function.
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Affiliation(s)
- Eugenio Galli
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alberto Fresa
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Silvia Bellesi
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Elisabetta Metafuni
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Elena Maiolo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Ilaria Pansini
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Filippo Frioni
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Autore
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Maria Assunta Limongiello
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Idanna Innocenti
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Sabrina Giammarco
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Patrizia Chiusolo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gina Zini
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Federica Sorà
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
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9
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Rejeski K, Subklewe M, Locke FL. Recognizing, defining, and managing CAR-T hematologic toxicities. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:198-208. [PMID: 38066881 PMCID: PMC10727074 DOI: 10.1182/hematology.2023000472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Autologous CAR-T cell therapy (CAR-T) has improved outcomes for patients with B-cell malignancies. It is associated with the well-described canonical toxicities cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS), which may be abrogated by corticosteroids and the anti-IL6 receptor antagonist tocilizumab. Practitioners and researchers should be aware of additional toxicities. Here we review current understanding and management of hematologic toxicities after CAR-T, including cytopenias, coagulopathies, bleeding and clotting events, hemophagocytic-lymphohistiocytosis, and tumor lysis syndrome. We pay particular attention to cytopenias, recently termed immune effector cell-associated hematological toxicity (ICAHT). While the "H" is silent, hematotoxicity is not: ICAHT has the highest cumulative incidence of all immune adverse events following CAR-T. Early cytopenia (day 0-30) is closely linked to lymphodepleting chemotherapy and CRS-related inflammatory stressors. Late ICAHT (after day 30) can present either with or without antecedent count recovery (e.g., "intermittent" vs "aplastic" phenotype), and requires careful evaluation and management strategies. Growth factor support is the mainstay of treatment, with recent evidence demonstrating safety and feasibility of early granulocyte colony-stimulating factor (G-CSF) (e.g., within week 1). In G-CSF refractory cases, autologous stem cell boosts represent a promising treatment avenue, if available. The CAR-HEMATOTOX scoring system, validated for use across lymphoid malignancies (B-NHL, multiple myeloma), enables pretherapeutic risk assessment and presents the potential for risk-adapted management. Recent expert panels have led to diagnostic scoring criteria, severity grading systems, and management strategies for both ICAHT and the recently termed immune effector cell-associated hemophagocytic lymphohistiocytosis-like syndrome (IEC-HS), now clarified and defined as a distinct entity from CRS.
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Affiliation(s)
- Kai Rejeski
- Department of Medicine III, University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
- Gene Center and Department of Biochemistry, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Marion Subklewe
- Department of Medicine III, University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
- Gene Center and Department of Biochemistry, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Frederick L Locke
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL
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10
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Mohan M, Chakraborty R, Bal S, Nellore A, Baljevic M, D’Souza A, Pappas PG, Berdeja JG, Callander N, Costa LJ. Recommendations on prevention of infections during chimeric antigen receptor T-cell and bispecific antibody therapy in multiple myeloma. Br J Haematol 2023; 203:736-746. [PMID: 37287117 PMCID: PMC10700672 DOI: 10.1111/bjh.18909] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/26/2023] [Accepted: 05/29/2023] [Indexed: 06/09/2023]
Abstract
Chimeric antigen receptor T (CAR T) cell and bispecific antibody therapies have shown unprecedented efficacy in heavily pretreated patients with multiple myeloma (MM). However, their use is associated with a significant risk of severe infections, which can be attributed to various factors such as hypogammaglobulinemia, neutropenia, lymphopenia, T-cell exhaustion, cytokine-release syndrome and immune-effector cell-associated neurotoxicity syndrome. As these therapies have been recently approved by regulatory agencies, it is crucial to establish practical guidelines for infection monitoring and prevention until robust data from prospective clinical trials become available. To address this issue, a panel of experienced investigators from the Academic Consortium to Overcome Multiple Myeloma through Innovative Trials (COMMIT) developed consensus recommendations for mitigating infections associated with CAR T-cell and bispecific antibody therapies in MM patients.
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Affiliation(s)
- Meera Mohan
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI, U.S.A
| | - Rajshekhar Chakraborty
- Multiple Myeloma and Amyloidosis Program, Columbia University, Herbert Irving Comprehensive Cancer Center, NY, U.S.A
| | - Susan Bal
- Division of Hematology and Medical Oncology, University of Alabama at Birmingham, Birmingham, AL, U.S.A
| | - Anoma Nellore
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, U.S.A
| | - Muhamed Baljevic
- Division of Hematology/Oncology, Vanderbilt-Ingram Cancer Center, TN, U.S.A
| | - Anita D’Souza
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI, U.S.A
| | - Peter G Pappas
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, U.S.A
| | | | | | - Luciano J. Costa
- Division of Hematology and Medical Oncology, University of Alabama at Birmingham, Birmingham, AL, U.S.A
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11
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Ong SY, Baird JH. A Primer on Chimeric Antigen Receptor T-cell Therapy-related Toxicities for the Intensivist. J Intensive Care Med 2023:8850666231205264. [PMID: 37899577 DOI: 10.1177/08850666231205264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
Chimeric antigen receptor (CAR) T-cell therapy is an innovative treatment approach that has shown remarkable efficacy against several hematologic malignancies. However, its use can be associated with unique and sometimes severe toxicities that require admission to intensive care unit in 30% of patients, and intensivists should be aware of immune-mediated toxicities of CAR T-cell therapy and management of adverse events. We will review available literature on current diagnostic criteria and therapeutic strategies for mitigating these most common toxicities associated with CAR T-cell therapy including cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS) in the post-infusion period. The authors will also review other toxicities associated with CAR T-cell therapy including cytopenias, acquired immunocompromised states, and infections, and discuss the available literature on best supportive care and prophylaxis recommendations. Critical care medicine specialists play a crucial role in the management of patients undergoing CAR T-cell therapies. With the expanding use of these products in increasing numbers of treating centers, intensivists' roles as part of the multidisciplinary team caring for these patients will have an outsized impact on the continued success of these promising therapies.
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Affiliation(s)
- Shin Yeu Ong
- Division of Lymphoma, Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
| | - John H Baird
- Division of Lymphoma, Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
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12
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Li A, Feng R. [CAR-T cell therapy-related long-term cytopenias]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2023; 44:870-875. [PMID: 38049346 PMCID: PMC10694071 DOI: 10.3760/cma.j.issn.0253-2727.2023.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Indexed: 12/06/2023]
Affiliation(s)
- A Li
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - R Feng
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
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13
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Rejeski K, Subklewe M, Aljurf M, Bachy E, Balduzzi A, Barba P, Bruno B, Benjamin R, Carrabba MG, Chabannon C, Ciceri F, Corradini P, Delgado J, Di Blasi R, Greco R, Houot R, Iacoboni G, Jäger U, Kersten MJ, Mielke S, Nagler A, Onida F, Peric Z, Roddie C, Ruggeri A, Sánchez-Guijo F, Sánchez-Ortega I, Schneidawind D, Schubert ML, Snowden JA, Thieblemont C, Topp M, Zinzani PL, Gribben JG, Bonini C, Sureda A, Yakoub-Agha I. Immune effector cell-associated hematotoxicity: EHA/EBMT consensus grading and best practice recommendations. Blood 2023; 142:865-877. [PMID: 37300386 DOI: 10.1182/blood.2023020578] [Citation(s) in RCA: 36] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/15/2023] [Accepted: 05/23/2023] [Indexed: 06/12/2023] Open
Abstract
Hematological toxicity is the most common adverse event after chimeric antigen receptor (CAR) T-cell therapy. Cytopenias can be profound and long-lasting and can predispose for severe infectious complications. In a recent worldwide survey, we demonstrated that there remains considerable heterogeneity in regard to current practice patterns. Here, we sought to build consensus on the grading and management of immune effector cell-associated hematotoxicity (ICAHT) after CAR T-cell therapy. For this purpose, a joint effort between the European Society for Blood and Marrow Transplantation (EBMT) and the European Hematology Association (EHA) involved an international panel of 36 CAR T-cell experts who met in a series of virtual conferences, culminating in a 2-day meeting in Lille, France. On the basis of these deliberations, best practice recommendations were developed. For the grading of ICAHT, a classification system based on depth and duration of neutropenia was developed for early (day 0-30) and late (after day +30) cytopenia. Detailed recommendations on risk factors, available preinfusion scoring systems (eg, CAR-HEMATOTOX score), and diagnostic workup are provided. A further section focuses on identifying hemophagocytosis in the context of severe hematotoxicity. Finally, we review current evidence and provide consensus recommendations for the management of ICAHT, including growth factor support, anti-infectious prophylaxis, transfusions, autologous hematopoietic stem cell boost, and allogeneic hematopoietic cell transplantation. In conclusion, we propose ICAHT as a novel toxicity category after immune effector cell therapy, provide a framework for its grading, review literature on risk factors, and outline expert recommendations for the diagnostic workup and short- and long-term management.
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Affiliation(s)
- Kai Rejeski
- Department of Medicine III, LMU University Hospital, LMU Munich, Munich, Germany
| | - Marion Subklewe
- Department of Medicine III, LMU University Hospital, LMU Munich, Munich, Germany
| | - Mahmoud Aljurf
- Oncology Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Emmanuel Bachy
- Department of Hematology, Hospices Civils de Lyon and Université Claude Bernard Lyon 1, Lyon, France
| | - Adriana Balduzzi
- Pediatric Transplantation Unit, Department of Medicine and Surgery, University of Milan-Bicocca-Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Pere Barba
- Department of Hematology, Vall d'Hebron University Hospital, Experimental Hematology, Vall d'Hebron Institute of Oncology, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Benedetto Bruno
- Division of Hematology and Cell Therapy Unit, Department of Molecular Biotechnology and Health Sciences, University of Turin, Turin, Italy
| | - Reuben Benjamin
- School of Cancer & Pharmaceutical Sciences, King's College London, London, United Kingdom
| | - Matteo G Carrabba
- Unit of Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Hospital, Milan, Italy
| | - Christian Chabannon
- Institut Paoli-Calmettes Comprehensive Cancer Centre and Module Biothérapies du Centre d'Investigations Cliniques de Marseille, INSERM-Aix-Marseille Université-AP-HM-IPC, CBT-1409, Marseille, France
| | - Fabio Ciceri
- Unit of Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Hospital, Milan, Italy
| | - Paolo Corradini
- Division of Hematology and Stem Cell Transplantation, Fondazione IRCCS Instituto Nazionale dei Tumori, University of Milan, Milan, Italy
| | - Julio Delgado
- Oncoimmunotherapy Unit, Department of Hematology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Roberta Di Blasi
- Université de Paris, Assistance Publique-Hopitaux de Paris, Service d'hémato-oncologie, Paris, France
| | - Raffaella Greco
- Unit of Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Hospital, Milan, Italy
| | - Roch Houot
- Department of Hematology, CHU Rennes, University of Rennes, INSERM U1236, Rennes, France
| | - Gloria Iacoboni
- Department of Hematology, Vall d'Hebron University Hospital, Experimental Hematology, Vall d'Hebron Institute of Oncology, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Ulrich Jäger
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Marie José Kersten
- Department of Hematology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Stephan Mielke
- Department of Cellular Therapy and Allogeneic Stem Cell Transplantation, Department of Laboratory Medicine and Medicine Huddinge, Karolinska University Hospital and Institute, Stockholm, Sweden
| | - Arnon Nagler
- Division of Hematology, Chaim Sheba Medical Center, Tel Aviv University, Tel-Hashomer, Israel
| | - Francesco Onida
- Hematology and Bone Marrow Transplantation Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Zinaida Peric
- Department of Hematology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Claire Roddie
- Department of Hematology, University College London Hospital, London, United Kingdom
| | - Annalisa Ruggeri
- Unit of Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Hospital, Milan, Italy
| | - Fermín Sánchez-Guijo
- University of Salamanca, IBSAL-University Hospital of Salamanca, Salamanca, Spain
| | - Isabel Sánchez-Ortega
- Executive Office, European Society for Blood and Marrow Transplantation, Barcelona, Spain
| | - Dominik Schneidawind
- Department of Medical Oncology and Hematology, University Hospital Zurich, Zurich, Switzerland
| | | | - John A Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Catherine Thieblemont
- Université de Paris, Assistance Publique-Hopitaux de Paris, Service d'hémato-oncologie, Paris, France
| | - Max Topp
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Pier Luigi Zinzani
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli," Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - John G Gribben
- Barts Cancer Institute, Queen Mary, University of London, London, United Kingdom
| | - Chiara Bonini
- Division of Immunology, Transplantation and Infectious Disease, Experimental Hematology Unit, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Anna Sureda
- Clinical Hematology Department, Institut Català d'Oncologia-L'Hospitalet, Barcelona, Spain
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14
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Hines MR, Knight TE, McNerney KO, Leick MB, Jain T, Ahmed S, Frigault MJ, Hill JA, Jain MD, Johnson WT, Lin Y, Mahadeo KM, Maron GM, Marsh RA, Neelapu SS, Nikiforow S, Ombrello AK, Shah NN, Talleur AC, Turicek D, Vatsayan A, Wong SW, Maus MV, Komanduri KV, Berliner N, Henter JI, Perales MA, Frey NV, Teachey DT, Frank MJ, Shah NN. Immune Effector Cell-Associated Hemophagocytic Lymphohistiocytosis-Like Syndrome. Transplant Cell Ther 2023; 29:438.e1-438.e16. [PMID: 36906275 PMCID: PMC10330221 DOI: 10.1016/j.jtct.2023.03.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 02/20/2023] [Accepted: 03/04/2023] [Indexed: 03/11/2023]
Abstract
T cell-mediated hyperinflammatory responses, such as cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS), are now well-established toxicities of chimeric antigen receptor (CAR) T cell therapy. As the field of CAR T cells advances, however, there is increasing recognition that hemophagocytic lymphohistiocytosis (HLH)-like toxicities following CAR T cell infusion are occurring broadly across patient populations and CAR T cell constructs. Importantly, these HLH-like toxicities are often not as directly associated with CRS and/or its severity as initially described. This emergent toxicity, however ill-defined, is associated with life-threatening complications, creating an urgent need for improved identification and optimal management. With the goal of improving patient outcomes and formulating a framework to characterize and study this HLH-like syndrome, we established an American Society for Transplantation and Cellular Therapy panel composed of experts in primary and secondary HLH, pediatric and adult HLH, infectious disease, rheumatology and hematology, oncology, and cellular therapy. Through this effort, we provide an overview of the underlying biology of classical primary and secondary HLH, explore its relationship with similar manifestations following CAR T cell infusions, and propose the term "immune effector cell-associated HLH-like syndrome (IEC-HS)" to describe this emergent toxicity. We also delineate a framework for identifying IEC-HS and put forward a grading schema that can be used to assess severity and facilitate cross-trial comparisons. Additionally, given the critical need to optimize outcomes for patients experiencing IEC-HS, we provide insight into potential treatment approaches and strategies to optimize supportive care and delineate alternate etiologies that should be considered in a patient presenting with IEC-HS. By collectively defining IEC-HS as a hyperinflammatory toxicity, we can now embark on further study of the pathophysiology underlying this toxicity profile and make strides toward a more comprehensive assessment and treatment approach.
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Affiliation(s)
- Melissa R Hines
- Department of Pediatric Medicine, Division of Critical Care, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Tristan E Knight
- Pediatric Hematology and Oncology, Seattle Children's Hospital and the University of Washington School of Medicine, Seattle, Washington
| | - Kevin O McNerney
- Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Mark B Leick
- Cellular Immunotherapy Program and Blood and Marrow Transplant Program, Cancer Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Tania Jain
- Division of Hematological Malignancies and Bone Marrow Transplantation, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Sairah Ahmed
- Departments of Lymphoma and Myeloma and Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Matthew J Frigault
- Cellular Immunotherapy Program and Blood and Marrow Transplant Program, Cancer Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Joshua A Hill
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | | | - William T Johnson
- Department of Medicine, Cellular Therapy Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Yi Lin
- Division Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Rochester, Minnesota
| | - Kris M Mahadeo
- Pediatric Transplantation and Cellular Therapy, Duke University, Durham, North Carolina
| | - Gabriela M Maron
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, and Department of Pediatrics, University of Tennessee Health Science Center College of Medicine, Memphis, Tennessee
| | - Rebecca A Marsh
- University of Cincinnati, and Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Sattva S Neelapu
- Departments of Lymphoma and Myeloma and Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sarah Nikiforow
- Division of Hematologic Oncology, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Amanda K Ombrello
- Inflammatory Disease Section, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
| | - Nirav N Shah
- Bone Marrow Transplant and Cellular Therapy Program, Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Aimee C Talleur
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee and Department of Pediatrics, University of Tennessee Health Science Center College of Medicine, Memphis, Tennessee
| | - David Turicek
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Anant Vatsayan
- Division of Blood and Marrow Transplantation, Children's National Health System, Washington, District of Columbia
| | - Sandy W Wong
- UCSF Health Division of Hematology and Oncology and Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, California
| | - Marcela V Maus
- Cellular Immunotherapy Program and Blood and Marrow Transplant Program, Cancer Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Krishna V Komanduri
- UCSF Health Division of Hematology and Oncology and Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, California
| | | | - Jan-Inge Henter
- Division of Pediatric Oncology and Surgery, Department of Women's and Children's Health, Karolinska Institute, and Department of Paediatric Oncology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Miguel-Angel Perales
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Noelle V Frey
- Division of Hematology-Oncology, Abramson Cancer Center and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David T Teachey
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Matthew J Frank
- Division of Blood and Marrow Transplantation and Cellular Therapy, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California
| | - Nirali N Shah
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
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15
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Boulch M, Cazaux M, Cuffel A, Guerin MV, Garcia Z, Alonso R, Lemaître F, Beer A, Corre B, Menger L, Grandjean CL, Morin F, Thieblemont C, Caillat-Zucman S, Bousso P. Tumor-intrinsic sensitivity to the pro-apoptotic effects of IFN-γ is a major determinant of CD4 + CAR T-cell antitumor activity. NATURE CANCER 2023:10.1038/s43018-023-00570-7. [PMID: 37248395 PMCID: PMC10368531 DOI: 10.1038/s43018-023-00570-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 04/27/2023] [Indexed: 05/31/2023]
Abstract
CD4+ T cells and CD4+ chimeric antigen receptor (CAR) T cells display highly variable antitumor activity in preclinical models and in patients; however, the mechanisms dictating how and when CD4+ T cells promote tumor regression are incompletely understood. With the help of functional intravital imaging, we report that interferon (IFN)-γ production but not perforin-mediated cytotoxicity was the dominant mechanism for tumor elimination by anti-CD19 CD4+ CAR T cells. Mechanistically, mouse or human CD4+ CAR T-cell-derived IFN-γ diffused extensively to act on tumor cells at distance selectively killing tumors sensitive to cytokine-induced apoptosis, including antigen-negative variants. In anti-CD19 CAR T-cell-treated patients exhibiting elevated CAR CD4:CD8 ratios, strong induction of serum IFN-γ was associated with increased survival. We propose that the sensitivity of tumor cells to the pro-apoptotic activity of IFN-γ is a major determinant of CD4+ CAR T-cell efficacy and may be considered to guide the use of CD4+ T cells during immunotherapy.
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Affiliation(s)
- Morgane Boulch
- Institut Pasteur, Université de Paris Cité, INSERM U1223, Dynamics of Immune Responses Unit, Equipe Labellisée Ligue Contre le Cancer, Paris, France
| | - Marine Cazaux
- Institut Pasteur, Université de Paris Cité, INSERM U1223, Dynamics of Immune Responses Unit, Equipe Labellisée Ligue Contre le Cancer, Paris, France
| | - Alexis Cuffel
- Université de Paris Cité, Hôpital Saint-Louis, AP-HP Nord, Laboratoire d'Immunologie, Paris, France
- INSERM UMR976, Institut de Recherche St-Louis, Paris, France
| | - Marion V Guerin
- Institut Pasteur, Université de Paris Cité, INSERM U1223, Dynamics of Immune Responses Unit, Equipe Labellisée Ligue Contre le Cancer, Paris, France
| | - Zacarias Garcia
- Institut Pasteur, Université de Paris Cité, INSERM U1223, Dynamics of Immune Responses Unit, Equipe Labellisée Ligue Contre le Cancer, Paris, France
| | - Ruby Alonso
- Institut Pasteur, Université de Paris Cité, INSERM U1223, Dynamics of Immune Responses Unit, Equipe Labellisée Ligue Contre le Cancer, Paris, France
| | - Fabrice Lemaître
- Institut Pasteur, Université de Paris Cité, INSERM U1223, Dynamics of Immune Responses Unit, Equipe Labellisée Ligue Contre le Cancer, Paris, France
| | - Alexander Beer
- Institut Pasteur, Université de Paris Cité, INSERM U1223, Dynamics of Immune Responses Unit, Equipe Labellisée Ligue Contre le Cancer, Paris, France
| | - Béatrice Corre
- Institut Pasteur, Université de Paris Cité, INSERM U1223, Dynamics of Immune Responses Unit, Equipe Labellisée Ligue Contre le Cancer, Paris, France
| | - Laurie Menger
- Gustave Roussy, Villejuif, France; INSERM U1015, Villejuif, France
| | - Capucine L Grandjean
- Institut Pasteur, Université de Paris Cité, INSERM U1223, Dynamics of Immune Responses Unit, Equipe Labellisée Ligue Contre le Cancer, Paris, France
| | - Florence Morin
- Université de Paris Cité, Hôpital Saint-Louis, AP-HP Nord, Laboratoire d'Immunologie, Paris, France
| | - Catherine Thieblemont
- Service d'Hémato-Oncologie, Hôpital Saint-Louis, AP-HP, Université de Paris Cité, Paris, France
| | - Sophie Caillat-Zucman
- Université de Paris Cité, Hôpital Saint-Louis, AP-HP Nord, Laboratoire d'Immunologie, Paris, France
- INSERM UMR976, Institut de Recherche St-Louis, Paris, France
| | - Philippe Bousso
- Institut Pasteur, Université de Paris Cité, INSERM U1223, Dynamics of Immune Responses Unit, Equipe Labellisée Ligue Contre le Cancer, Paris, France.
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16
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Pilmis B, Kherabi Y, Huriez P, Zahar JR, Mokart D. Infectious Complications of Targeted Therapies for Solid Cancers or Leukemias/Lymphomas. Cancers (Basel) 2023; 15:cancers15071989. [PMID: 37046650 PMCID: PMC10093532 DOI: 10.3390/cancers15071989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/20/2023] [Accepted: 03/23/2023] [Indexed: 03/29/2023] Open
Abstract
Background: Infections are well known complications of some targeted drugs used to treat solid organ cancer and hematological malignancies. Furthermore, Individual patient risk factors are associated with underlying pathologies, concomitant immunosuppressive treatment, prior treatment and use of anti-infective prophylaxis. Immune-related adverse events (irAEs) are frequent among patients treated with new targeted drugs. Objectives: In this narrative review, we present the current state of knowledge concerning the infectious complications occurring in patients treated with immune checkpoint inhibitors (ICIs), Bruton’s tyrosine kinase (BTK) inhibitors, phosphatidylinositol 3-kinase (PI3K) inhibitors, antiapoptotic protein BCL-2 inhibitors, Janus kinase inhibitors or CAR-T cell infusion. Sources: We searched for studies treating infectious complications of ICIs, BTK inhibitors, PI3K inhibitors, antiapoptotic protein BCL-2 inhibitors and CAR-T cell therapy. We included randomized, observational studies and case reports. Content: Immune-related adverse events (irAEs) are frequent among patients treated with new targeted drugs. Treatment of irAEs with corticosteroids and other immunosuppressive agents can lead to opportunistic infections. Bruton’s tyrosine kinase (BTK) inhibitors are associated with higher rate of infections, including invasive fungal infections. Implications: Infections, particularly fungal ones, are common in patients treated with BTK inhibitors even though most of the complications occurring among patients treated by ICIs or CART-cells infusion are associated with the treatment of side effects related to the use of these new treatments. The diagnosis of these infectious complications can be difficult and may require extensive investigations.
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Affiliation(s)
- Benoît Pilmis
- Equipe Mobile de Microbiologie Clinique, Groupe Hospitalier Paris Saint-Joseph, 75014 Paris, France
- UMR 1319, Institut Micalis, Université Paris-Saclay, INRAeChâtenay Malabry, AgroParisTech, 92290 Chatenay Malabry, France
- Correspondence: ; Tel.: +33-1-44-12-78-20; Fax: +33-1-44-12-35-13
| | - Yousra Kherabi
- Equipe Mobile de Microbiologie Clinique, Groupe Hospitalier Paris Saint-Joseph, 75014 Paris, France
| | - Pauline Huriez
- Equipe Mobile de Microbiologie Clinique, Groupe Hospitalier Paris Saint-Joseph, 75014 Paris, France
| | - Jean-Ralph Zahar
- Infection Control Unit, AP-HP Hôpital Avicenne, Université Sorbonne Paris Nord, 93000 Bobigny, France
| | - Djamel Mokart
- Medical Surgical Intensive Care Unit, Institut Paoli Calmettes, 13009 Marseille, France
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17
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Nagler A, Perriello VM, Falini L, Falini B. How I treat refractory/relapsed diffuse large B-cell lymphomas with CD19-directed chimeric antigen receptor T cells. Br J Haematol 2023; 201:396-410. [PMID: 36916189 DOI: 10.1111/bjh.18724] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 02/10/2023] [Accepted: 02/17/2023] [Indexed: 03/15/2023]
Abstract
Chimeric antigen receptor (CAR) T cells targeting CD19 represent a promising salvage immunotherapy for relapsed/refractory diffuse large B-cell lymphoma (R/R DLBCL), offering ~40% of long-term responses. In everyday clinical practice, haematologists involved in CAR T cell treatment of patients with R/R DLBCL have to deal with diagnostically complex cases and difficult therapeutic choices. The availability of novel immunotherapeutic agents for R/R DLBCL and recent advances in understanding CAR T-cell failure mechanisms demand a rational approach to identify the best choice for bridging therapy and managing post-CAR T-cell therapy relapses. Moreover, positron emission tomography/computerised tomography may result in false-positive interpretation, highlighting the importance of post-treatment biopsy. In this review, we discuss all above issues, presenting four instructive cases, with the aim to provide criteria and new perspectives for CAR T-cell treatment of DLBCL.
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Affiliation(s)
- Arnon Nagler
- Division of Hematology, Sheba Medical Center, Tel Hashomer, Israel
| | - Vincenzo Maria Perriello
- Institute of Hematology and Center for Hemato-Oncology Research, University of Perugia and Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Lorenza Falini
- Institute of Hematology and Center for Hemato-Oncology Research, University of Perugia and Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Brunangelo Falini
- Institute of Hematology and Center for Hemato-Oncology Research, University of Perugia and Santa Maria della Misericordia Hospital, Perugia, Italy
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Ma S, Li H, Zhou D, Zhang X, Shi M, Cao J, Qi Y, Xia J, Liu Y, Wang X, Li D, Sang W, Yan Z, Zhu F, Sun H, Cheng H, Zheng J, Xu K, Li Z, Qi K, Wang Y. Associations of granulocyte colony-stimulating factor with toxicities and efficacy of chimeric antigen receptor T-cell therapy in relapsed or refractory multiple myeloma. Cytotherapy 2023; 25:653-658. [PMID: 36907717 DOI: 10.1016/j.jcyt.2023.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 01/13/2023] [Accepted: 01/23/2023] [Indexed: 03/13/2023]
Abstract
BACKGROUND AIMS Few studies have reported the associations of granulocyte colony-stimulating factor (G-CSF) with cytokine release syndrome (CRS), neurotoxic events (NEs) and efficacy after chimeric antigen receptor (CAR) T-cell therapy for relapsed or refractory (R/R) multiple myeloma (MM). We present a retrospective study performed on 113 patients with R/R MM who received single anti-BCMA CAR T-cell, combined with anti-CD19 CAR T-cell or anti-CD138 CAR T-cell therapy. METHODS Eight patients were given G-CSF after successful management of CRS, and no CRS re-occurred thereafter. Of the remaining 105 patients that were finally analyzed, 72 (68.6%) received G-CSF (G-CSF group), and 33 (31.4%) did not (non G-CSF group). We mainly analyzed the incidence and severity of CRS or NEs in two groups of patients, as well as the associations of G-CSF timing, cumulative dose and cumulative time with CRS, NEs and efficacy of CAR T-cell therapy. RESULTS Both groups of patients had similar duration of grade 3-4 neutropenia, and the incidence and severity of CRS or NEs.There were also no differences in the incidence and severity of CRS or NEs between patients with the timing of G-CSF administration ≤3 days and those >3 days after CAR T-cell infusion. The incidence of CRS was greater in patients receiving cumulative doses of G-CSF >1500 μg or cumulative time of G-CSF administration >5 days. Among patients with CRS, there was no difference in the severity of CRS between patients who used G-CSF and those who did not. The duration of CRS in anti-BCMA and anti-CD19 CAR T-cell-treated patients was prolonged after G-CSF administration. There were no significant differences in the overall response rate at 1 and 3 months between the G-CSF group and the non-G-CSF group. CONCLUSIONS Our results showed that low-dose or short-time use of G-CSF was not associated with the incidence or severity of CRS or NEs, and G-CSF administration did not influence the antitumor activity of CAR T-cell therapy.
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Affiliation(s)
- Sha Ma
- Blood Diseases Institute, Xuzhou Medical University, Xuzhou, China; Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Hujun Li
- Blood Diseases Institute, Xuzhou Medical University, Xuzhou, China; Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Dian Zhou
- Blood Diseases Institute, Xuzhou Medical University, Xuzhou, China; Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Xiaotian Zhang
- Blood Diseases Institute, Xuzhou Medical University, Xuzhou, China; Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Ming Shi
- Cancer Institute, Xuzhou Medical University, Xuzhou, China; Center of Clinical Oncology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Jiang Cao
- Blood Diseases Institute, Xuzhou Medical University, Xuzhou, China; Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Yuekun Qi
- Blood Diseases Institute, Xuzhou Medical University, Xuzhou, China; Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Jieyun Xia
- Blood Diseases Institute, Xuzhou Medical University, Xuzhou, China; Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Yang Liu
- Blood Diseases Institute, Xuzhou Medical University, Xuzhou, China; Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Xue Wang
- Blood Diseases Institute, Xuzhou Medical University, Xuzhou, China; Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Depeng Li
- Blood Diseases Institute, Xuzhou Medical University, Xuzhou, China; Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Wei Sang
- Blood Diseases Institute, Xuzhou Medical University, Xuzhou, China; Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Zhiling Yan
- Blood Diseases Institute, Xuzhou Medical University, Xuzhou, China; Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Feng Zhu
- Blood Diseases Institute, Xuzhou Medical University, Xuzhou, China; Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Haiying Sun
- Blood Diseases Institute, Xuzhou Medical University, Xuzhou, China; Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Hai Cheng
- Blood Diseases Institute, Xuzhou Medical University, Xuzhou, China; Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Junnian Zheng
- Cancer Institute, Xuzhou Medical University, Xuzhou, China; Center of Clinical Oncology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Kailin Xu
- Blood Diseases Institute, Xuzhou Medical University, Xuzhou, China; Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Zhenyu Li
- Blood Diseases Institute, Xuzhou Medical University, Xuzhou, China; Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China.
| | - Kunming Qi
- Blood Diseases Institute, Xuzhou Medical University, Xuzhou, China; Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Ying Wang
- Blood Diseases Institute, Xuzhou Medical University, Xuzhou, China; Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China.
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Reinhardt B, Lee P, Sasine JP. Chimeric Antigen Receptor T-Cell Therapy and Hematopoiesis. Cells 2023; 12:531. [PMID: 36831198 PMCID: PMC9954220 DOI: 10.3390/cells12040531] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 02/02/2023] [Accepted: 02/03/2023] [Indexed: 02/11/2023] Open
Abstract
Chimeric Antigen Receptor (CAR) T-cell therapy is a promising treatment option for patients suffering from B-cell- and plasma cell-derived hematologic malignancies and is being adapted for the treatment of solid cancers. However, CAR T is associated with frequently severe toxicities such as cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), macrophage activation syndrome (MAS), and prolonged cytopenias-a reduction in the number of mature blood cells of one or more lineage. Although we understand some drivers of these toxicities, their mechanisms remain under investigation. Since the CAR T regimen is a complex, multi-step process with frequent adverse events, ways to improve the benefit-to-risk ratio are needed. In this review, we discuss a variety of potential solutions being investigated to address the limitations of CAR T. First, we discuss the incidence and characteristics of CAR T-related cytopenias and their association with reduced CAR T-cell efficacy. We review approaches to managing or mitigating cytopenias during the CAR T regimen-including the use of growth factors, allogeneic rescue, autologous hematopoietic stem cell infusion, and alternative conditioning regimens. Finally, we introduce novel methods to improve CAR T-cell-infusion products and the implications of CAR T and clonal hematopoiesis.
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Affiliation(s)
- Bryanna Reinhardt
- School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA
| | - Patrick Lee
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Joshua P. Sasine
- Department of Medicine, Division of Hematology and Cellular Therapy, Samuel Oschin Cancer Center, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
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20
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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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21
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Hernani R, Benzaquén A, Solano C. Toxicities following CAR-T therapy for hematological malignancies. Cancer Treat Rev 2022; 111:102479. [DOI: 10.1016/j.ctrv.2022.102479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 10/07/2022] [Accepted: 10/18/2022] [Indexed: 11/25/2022]
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22
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Effect of granulocyte colony-stimulating factor on toxicities after CAR T cell therapy for lymphoma and myeloma. Blood Cancer J 2022; 12:146. [PMID: 36316312 PMCID: PMC9622902 DOI: 10.1038/s41408-022-00741-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 09/30/2022] [Accepted: 10/06/2022] [Indexed: 11/17/2022] Open
Abstract
Chimeric antigen receptor T cells (CAR T) are groundbreaking therapies but may cause significant toxicities including cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), and cytopenias. Granulocyte colony-stimulating factor (G-CSF) is often used to mitigate neutropenia after CAR T, but there is no consensus recommended strategy due to hypothesized, but largely unknown risks of exacerbating toxicities. To investigate the impact of G-CSF, we retrospectively analyzed 197 patients treated with anti-CD19 CAR T for lymphoma and 47 patients treated with anti-BCMA CAR T for multiple myeloma. In lymphoma, 140 patients (71%) received prophylactic G-CSF before CAR T (mostly pegylated G-CSF) and were compared with 57 patients (29%) treated with G-CSF after CAR T or not exposed. Prophylactic G-CSF was associated with faster neutrophil recovery (3 vs. 4 days, P < 0.01) but did not reduce recurrent neutropenia later. Prophylactic G-CSF was associated with increased grade ≥2 CRS (HR 2.15, 95% CI 1.11-4.18, P = 0.02), but not ICANS. In multiple myeloma, prophylactic G-CSF was not used; patients were stratified by early G-CSF exposure (≤2 days vs. ≥3 days after CAR T or no exposure), with no significant difference in toxicities. Future trials should clarify the optimal G-CSF strategy to improve outcomes after CAR T.
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23
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Si X, Gu T, Liu L, Huang Y, Han Y, Qian P, Huang H. Hematologic cytopenia post CAR T cell therapy: Etiology, potential mechanisms and perspective. Cancer Lett 2022; 550:215920. [PMID: 36122628 DOI: 10.1016/j.canlet.2022.215920] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 09/02/2022] [Accepted: 09/12/2022] [Indexed: 11/25/2022]
Abstract
Chimeric Antigen-Receptor (CAR) T-cell therapies have shown dramatic efficacy in treating relapsed and refractory cancers, especially B cell malignancies. However, these innovative therapies cause adverse toxicities that limit the broad application in clinical settings. Hematologic cytopenias, one frequently reported adverse event following CAR T cell treatment, are manifested as a disorder of hematopoiesis with decreased number of mature blood cells and subdivided into anemia, thrombocytopenia, leukopenia, and neutropenia, which increase the risk of infections, fatigue, bleeding, fever, and even fatality. Herein, we initially summarized the symptoms, etiology, risk factors and management of cytopenias. Further, we elaborated the cellular and molecular mechanisms underlying the initiation and progression of cytopenias following CAR T cell therapy based on previous studies about acquired cytopenias. Overall, this review will facilitate our understanding of the etiology of cytopenias and shed lights into developing new therapies against CAR T cell-induced cytopenias.
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Affiliation(s)
- Xiaohui Si
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou, China; Institute of Hematology, Zhejiang University, Hangzhou, China; Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Tianning Gu
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou, China; Institute of Hematology, Zhejiang University, Hangzhou, China; Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Lianxuan Liu
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou, China; Institute of Hematology, Zhejiang University, Hangzhou, China; Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Yue Huang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou, China; Institute of Hematology, Zhejiang University, Hangzhou, China; Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Yingli Han
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou, China; Institute of Hematology, Zhejiang University, Hangzhou, China; Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Pengxu Qian
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou, China; Institute of Hematology, Zhejiang University, Hangzhou, China; Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China.
| | - He Huang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou, China; Institute of Hematology, Zhejiang University, Hangzhou, China; Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China.
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24
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25
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Wudhikarn K, Perales MA. Infectious complications, immune reconstitution, and infection prophylaxis after CD19 chimeric antigen receptor T-cell therapy. Bone Marrow Transplant 2022; 57:1477-1488. [PMID: 35840746 PMCID: PMC9285870 DOI: 10.1038/s41409-022-01756-w] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 06/24/2022] [Accepted: 06/30/2022] [Indexed: 12/15/2022]
Abstract
CD19-targeted chimeric antigen receptor (CAR) T-cell becomes a breakthrough therapy providing excellent remission rates and durable disease control for patients with relapsed/refractory (R/R) hematologic malignancies. However, CAR T-cells have several potential side effects including cytokine release syndrome, neurotoxicities, cytopenia, and hypogammaglobulinemia. Infection has been increasingly recognized as a complication of CAR T-cell therapy. Several factors predispose CAR T-cell recipients to infection. Fortunately, although studies show a high incidence of infection post-CAR T-cells, most infections are manageable. In contrast to patients who undergo hematopoietic stem cell transplant, less is known about post-CAR T-cell immune reconstitution. Therefore, evidence regarding antimicrobial prophylaxis and vaccination strategies in these patients is more limited. As CAR T-cell therapy becomes the standard treatment for R/R B lymphoid malignancies, we should expect a larger impact of infections in these patients and the need for increased clinical attention. Studies exploring infection and immune reconstitution after CAR T-cell therapy are clinically relevant and will provide us with a better understanding of the dynamics of immune function after CAR T-cell therapy including insights into appropriate strategies for prophylaxis and treatment of infections in these patients. In this review, we describe infections in recipients of CAR T-cells, and discuss risk factors and potential mitigation strategies.
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Affiliation(s)
- Kitsada Wudhikarn
- Division of Hematology and Research Unit in Translational Hematology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
| | - Miguel-Angel Perales
- Department of Medicine, Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
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26
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Maneta E, Fultang L, Taylor J, Pugh M, Jenkinson W, Anderson G, Coomarasamy A, Kilby MD, Lissauer DM, Mussai F, De Santo C. G-CSF induces CD15 + CD14 + cells from granulocytes early in the physiological environment of pregnancy and the cancer immunosuppressive microenvironment. Clin Transl Immunology 2022; 11:e1395. [PMID: 35602884 PMCID: PMC9114661 DOI: 10.1002/cti2.1395] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 03/21/2022] [Accepted: 05/03/2022] [Indexed: 01/04/2023] Open
Abstract
Objectives Recombinant granulocyte colony-stimulating factor (G-CSF) is frequently administered to patients with cancer to enhance granulocyte recovery post-chemotherapy. Clinical trials have also used G-CSF to modulate myeloid cell function in pregnancy and inflammatory diseases. Although the contribution of G-CSF to expanding normal granulocytes is well known, the effect of this cytokine on the phenotype and function of immunosuppressive granulocytic cells remains unclear. Here, we investigate the impact of physiological and iatrogenic G-CSF on an as yet undescribed granulocyte phenotype and ensuing outcome on T cells in the settings of cancer and pregnancy. Methods Granulocytes from patients treated with recombinant G-CSF, patients with late-stage cancer and women enrolled on a trial of recombinant G-CSF were phenotyped by flow cytometry. The ability and mechanism of polarised granulocytes to suppress T-cell proliferation were assessed by cell proliferation assays, flow cytometry and ELISA. Results We observed that G-CSF leads to a significant upregulation of CD14 expression on CD15+ granulocytes. These CD15+CD14+ cells are identified in the blood of patients with patients undergoing neutrophil mobilisation with recombinant G-CSF, and physiologically in women early in pregnancy or in those treated as a part of a clinical trial. Immunohistochemistry of tumor tissue or placental tissue identified the expression of G-CSF. The G-CSF upregulates the release of reactive oxygen species (ROS) in CD15+CD14+ cells leading to the suppression of T-cell proliferation. Conclusions G-CSF induces a population of ROS+ immunosuppressive CD15+CD14+ granulocytes. Strategies for how recombinant G-CSF can be scheduled to reduce effects on T-cell therapies should be developed in future clinical studies.
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Affiliation(s)
- Ebtehag Maneta
- Institute of Immunology and Immunotherapy University of Birmingham Birmingham UK
| | - Livingstone Fultang
- Institute of Immunology and Immunotherapy University of Birmingham Birmingham UK
| | - Jemma Taylor
- Institute of Immunology and Immunotherapy University of Birmingham Birmingham UK
| | - Matthew Pugh
- Institute of Immunology and Immunotherapy University of Birmingham Birmingham UK
| | - William Jenkinson
- Institute of Immunology and Immunotherapy University of Birmingham Birmingham UK
| | - Graham Anderson
- Institute of Immunology and Immunotherapy University of Birmingham Birmingham UK
| | - Arri Coomarasamy
- Tommy's National Centre for Miscarriage Research Institute of Metabolism and Systems Research University of Birmingham Birmingham UK
| | - Mark D Kilby
- Institute of Metabolism and Systems Research University of Birmingham Birmingham UK.,Fetal Medicine Centre Birmingham Women's & Children's Foundation Trust Edgbaston, Birmingham UK
| | - David M Lissauer
- Institute of Life Course and Medical Sciences University of Liverpool Liverpool UK.,Malawi-Liverpool-Wellcome Trust Blantyre Malawi
| | - Francis Mussai
- Institute of Immunology and Immunotherapy University of Birmingham Birmingham UK
| | - Carmela De Santo
- Institute of Immunology and Immunotherapy University of Birmingham Birmingham UK
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Sharma N, Reagan PM, Liesveld JL. Cytopenia after CAR-T Cell Therapy-A Brief Review of a Complex Problem. Cancers (Basel) 2022; 14:1501. [PMID: 35326654 PMCID: PMC8946106 DOI: 10.3390/cancers14061501] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/02/2022] [Accepted: 03/07/2022] [Indexed: 02/06/2023] Open
Abstract
Chimeric Antigen Receptor T-cell (CAR-T) immunotherapy has emerged as an efficacious and life extending treatment modality with high response rates and durable remissions in patients with relapsed and refractory non-Hodgkin lymphoma (NHL), follicular lymphoma, and B-cell acute lymphoblastic leukemia (B-ALL) as well as in other diseases. Prolonged or recurrent cytopenias after CAR-T therapy have increasingly been reported at varying rates, and the pathogenesis of this complication is not yet well-understood but is likely contributed to by multiple factors. Current studies reported are primarily retrospective, heterogeneous in terms of CAR-Ts used and diseases treated, non-uniform in definitions of cytopenias and durations for end points, and vary in terms of recommended management. Prospective studies and correlative laboratory studies investigating the pathophysiology of prolonged cytopenias will enhance our understanding of this phenomenon. This review summarizes knowledge of these cytopenias to date.
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Affiliation(s)
- Naman Sharma
- Department of Hematology-Oncology, Baystate Medical Center, University of Massachusetts Medical School, Springfield, MA 100107, USA;
| | - Patrick M. Reagan
- Department of Medicine, Hematology-Oncology, James P. Wilmot Cancer Institute, University of Rochester, Rochester, NY 14642, USA;
| | - Jane L. Liesveld
- Department of Medicine, Hematology-Oncology, James P. Wilmot Cancer Institute, University of Rochester, Rochester, NY 14642, USA;
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Qian WB, Liu H. [How I manage B cell lymphoma patients treated with CD19 specific CAR-T cell throughout whole-process management]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2022; 43:197-202. [PMID: 35405776 PMCID: PMC9072073 DOI: 10.3760/cma.j.issn.0253-2727.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Indexed: 11/20/2022]
Affiliation(s)
- W B Qian
- Department of Hematology, the Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310009, China
| | - H Liu
- Department of Hematology, the Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310009, China
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29
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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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Liévin R, Di Blasi R, Morin F, Galli E, Allain V, De Jorna R, Vercellino L, Parquet N, Mebarki M, Larghero J, de Kerviler E, Madelaine I, Caillat-Zucman S, Chevret S, Thieblemont C. Effect of early granulocyte-colony-stimulating factor administration in the prevention of febrile neutropenia and impact on toxicity and efficacy of anti-CD19 CAR-T in patients with relapsed/refractory B-cell lymphoma. Bone Marrow Transplant 2022; 57:431-439. [PMID: 35094012 PMCID: PMC8907072 DOI: 10.1038/s41409-021-01526-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 10/05/2021] [Accepted: 10/29/2021] [Indexed: 12/31/2022]
Abstract
AbstractChimeric Antigen Receptor T cells (CAR-T) are an outbreaking treatment option for relapsed/refractory (R/R) diffuse large B-cell lymphoma (DLBCL). Cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS) are the most common specific toxicities, while severe neutropenia and infections are often observed as well. From March 2020, early G-CSF prophylaxis at day (D) two post-infusion was systematically proposed. We then compared patients treated before that date who did not receive G-CSF or who received late (after D5) G-CSF as control group. Patients administered with early G-CSF had similar duration of grade 4 neutropenia but significantly decreased incidence of febrile neutropenia (58% versus 81%, p = 0.018). Similar rate of toxicities was observed, including overall and grade 3-4 CRS (p = 0.93 and p = 0.28, respectively), and overall and grade 3-4 ICANS (p = 0.62 and p = 0.88, respectively). We observed no difference in the quality of CAR T-cells expansion (p = 0.79, %Cmax), nor in response rate (best ORR, 57.6% vs 61.8%, p = 0.93), nor survival even in a group of patients adjusted by a propensity score. In conclusion, early G-CSF administration was safe and effective in reducing febrile neutropenia without impact on toxicities nor on anti-lymphoma activity of CAR-T.
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Xing L, Wang Y, Liu H, Gao S, Shao Q, Yue L, Liu Z, Wang H, Shao Z, Fu R. Case Report: Sirolimus Alleviates Persistent Cytopenia After CD19 CAR-T-Cell Therapy. Front Oncol 2022; 11:798352. [PMID: 35004324 PMCID: PMC8733571 DOI: 10.3389/fonc.2021.798352] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 11/30/2021] [Indexed: 12/15/2022] Open
Abstract
Chimeric antigen receptor T (CAR-T) cells show good efficacy in the treatment of relapsed and refractory B-cell tumors, such as acute B-cell leukemia (ALL) and diffuse large B-cell lymphoma (DLBCL). The main toxicities of CAR-T include cytokine release syndrome, immune effector cell-associated neurotoxicity syndrome, cytopenia, and severe infection. It is still very difficult for CAR-T to kill tumor cells to the maximum extent and avoid damaging normal organs. Here, we report a case of DLBCL with persistent grade 4 thrombocytopenia and severe platelet transfusion dependence treated with CD19 CAR-T cells. We used sirolimus to inhibit the sustained activation of CAR-T cells and restore normal bone marrow hematopoiesis and peripheral blood cells. Moreover, sirolimus treatment did not affect the short-term efficacy of CAR-T cells, and DLBCL was in complete remission at the end of follow-up. In conclusion, sirolimus can represent a new strategy for the management of CAR-T cell therapy-related toxicity, including but not limited to hematotoxicity. However, further controlled clinical studies are required to confirm these findings.
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Affiliation(s)
- Limin Xing
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Yihao Wang
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Hui Liu
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Shan Gao
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Qing Shao
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Lanzhu Yue
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Zhaoyun Liu
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Huaquan Wang
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Zonghong Shao
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Rong Fu
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
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32
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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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33
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Wallet F, Sesques P, Devic P, Levrard M, Ader F, Friggeri A, Bachy E. CAR-T cell: Toxicities issues: Mechanisms and clinical management. Bull Cancer 2021; 108:S117-S127. [PMID: 34920794 DOI: 10.1016/j.bulcan.2021.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/17/2021] [Accepted: 05/21/2021] [Indexed: 11/24/2022]
Abstract
CAR-T cells are modified T cells expressing a chimeric antigen receptor targeting a specific antigen. They have revolutionized the treatment of B cell malignancies (aggressive lymphomas, B-ALL), and this has raised hopes for application in many other pathologies (myeloma, AML, solid tumors, etc.). However, these therapies are associated with novel and specific toxicities (cytokine release syndrome and neurotoxicity). These complications, although mostly managed in a conventional hospitalization unit, can sometimes be life threatening, leading to admission of patients to the intensive care unit. Management relies mainly on anti-IL6R (tocilizumab) and corticosteroids. However, the optimal treatment regimen is still a matter of debate, and the management of the most severe forms is even less well codified. In addition to CRS and ICANS, infections, cytopenia and hypogammaglobulinemia are other frequent complications. This article reviews the mechanisms, risk factors, clinical presentation, and management of these toxicities.
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Affiliation(s)
- Florent Wallet
- Hospices Civils de Lyon, Service d'anesthésie, médecine intensive, réanimation, CHU Lyon sud, 415, chemin du grand revoyet, 69310 Pierre-Bénite, France; Université Claude bernard Lyon 1, 43, boulevard du 11 Novembre 1918, 69622 Villeurbanne cedex, France.
| | - Pierre Sesques
- Hospices Civils de Lyon, Service d'hématologie clinique, CHU Lyon sud, 415, chemin du grand revoyet, 69310 Pierre-Bénite, France; Université Claude bernard Lyon 1, 43, boulevard du 11 Novembre 1918, 69622 Villeurbanne cedex, France.
| | - Perrine Devic
- Hospices Civils de Lyon, Service de neurologie, CHU Lyon sud, 415, chemin du grand revoyet, 69310 Pierre-Bénite, France.
| | - Melanie Levrard
- Hospices Civils de Lyon, Service d'anesthésie, médecine intensive, réanimation, CHU Lyon sud, 415, chemin du grand revoyet, 69310 Pierre-Bénite, France.
| | - Florence Ader
- Hospices Civils de Lyon, Service de maladies infectieuses et tropicales, CHU de la croix rousse, grande rue de la croix rousse, 69004 Lyon, France; Université Claude bernard Lyon 1, 43, boulevard du 11 Novembre 1918, 69622 Villeurbanne cedex, France.
| | - Arnaud Friggeri
- Hospices Civils de Lyon, Service d'anesthésie, médecine intensive, réanimation, CHU Lyon sud, 415, chemin du grand revoyet, 69310 Pierre-Bénite, France; Université Claude bernard Lyon 1, 43, boulevard du 11 Novembre 1918, 69622 Villeurbanne cedex, France.
| | - Emmanuel Bachy
- Hospices Civils de Lyon, Service d'hématologie clinique, CHU Lyon sud, 415, chemin du grand revoyet, 69310 Pierre-Bénite, France; Université Claude bernard Lyon 1, 43, boulevard du 11 Novembre 1918, 69622 Villeurbanne cedex, France.
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34
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Paul F, Vicente C, Courbon C, Moreau AS, Picard M, Pochon C, Sterin A, Tudesq JJ, Yakoub-Agha M, Bay JO, Yakoub-Agha I. [Prevention and management of infections in patients undergoing CAR T-cell therapy: Recommendations of the Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC)]. Bull Cancer 2021; 108:S90-S97. [PMID: 34876272 DOI: 10.1016/j.bulcan.2021.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/05/2021] [Accepted: 11/08/2021] [Indexed: 11/29/2022]
Abstract
Infections occurring after CAR T-cells are a common complication. At the acute phase of treatment following CAR T-cell infusion, the exact incidence of infections is unknown given the overlapping symptoms with cytokine release syndrome. The risk factors for infection include the malignant underlying disease and its multiple treatments, and an immunosuppressive state induced by CAR-T cells themselves and the treatment of their complications. 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 post-CAR infectious complications. In this review we discuss anti-infection prophylaxis and vaccination of patients undergoing CAR T-cell therapy as well as a special chapter for the specific case of COVID-19. These recommendations apply to commercial CAR-T cells, in order to guide strategies for the management and prevention of infectious complications associated with this new therapeutic approach.
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Affiliation(s)
- Franciane Paul
- CHU de Montpellier, hôpital Saint-Eloi, département d'hématologie clinique, 80, avenue Augusin-Fliche, 34090 Montpellier, France
| | - Céline Vicente
- CHU de Toulouse, service d'hématologie, IUCT-oncopole, 1, avenue Joliot-Curie, 31059 Toulouse, France
| | - Corinne Courbon
- Institut de cancérologie de la Loire Lucien Neuwirth, service d'hématologie, 108 bis, avenue Albert-Raimond, 42270 Saint-Priest-en-Jarez, France
| | - Anne-Sophie Moreau
- CHU de Lille, hôpital Salengro, service de médecine intensive réanimation, rue Emile-Laine, 59037 Lille, France
| | - Muriel Picard
- CHU de Toulouse, service de réanimation polyvalente, IUCT-oncopole, 1, avenue Joliot-Curie, 31059 Toulouse, France
| | - Cécile Pochon
- CHRU Nancy Brabois, service d'onco-hématologie pédiatrique, 5, rue du Morvan, 54500 Vandœuvre-lès-Nancy, France; Université de Lorraine, UMR7365 CNRS-UL IMoPA, campus biologie santé, 9, avenue de la Forêt-de-Haye, 54505 Vandœuvre-lès-Nancy, France
| | - Arthur Sterin
- Hôpital La Timone enfants, service hémato-immunologique pédiatrique, 246, rue Saint-Pierre, 13005 Marseille, France
| | - Jean-Jacques Tudesq
- CHU de Montpellier, hôpital Saint-Eloi, département d'hématologie clinique, 80, avenue Augustin-Fliche, 34090 Montpellier, France
| | - Mathilde Yakoub-Agha
- CHU Amiens-Picardie, service de médecine intensive réanimation, 1, rond-point du professeur Christian-Cabrol, 80054 Amiens, France
| | - Jacques-Olivier Bay
- CHU de Clermont-Ferrand, service de thérapie cellulaire et d'hématologie clinique adulte, site Estaing, 1, place Lucie-Aubrac, 63000 Clermond-Ferrand, France
| | - Ibrahim Yakoub-Agha
- CHU de Lille, université de Lille, maladies du sang-unité d'immunothérapie cellulaire, Inserm U1286, Infinite, 59000 Lille, France.
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State of the CAR-T: Risk of Infections with Chimeric Antigen Receptor T-Cell Therapy and Determinants of SARS-CoV-2 Vaccine Responses. Transplant Cell Ther 2021; 27:973-987. [PMID: 34587552 PMCID: PMC8473073 DOI: 10.1016/j.jtct.2021.09.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 09/06/2021] [Accepted: 09/19/2021] [Indexed: 02/08/2023]
Abstract
Chimeric antigen receptor T cell (CAR-T) therapy has shown unprecedented response rates in patients with relapsed/refractory (R/R) hematologic malignancies. Although CAR-T therapy gives hope to heavily pretreated patients, the rapid commercialization and cumulative immunosuppression of this therapy predispose patients to infections for a prolonged period. CAR-T therapy poses distinctive short- and long-term toxicities and infection risks among patients who receive CAR T-cells after multiple prior treatments, often including hematopoietic cell transplantation. The acute toxicities include cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome. The long-term B cell depletion, hypogammaglobulinemia, and cytopenia further predispose patients to severe infections and abrogate the remission success achieved by the living drug. These on-target-off-tumor toxicities deplete B-cells across the entire lineage and further diminish immune responses to vaccines. Early observational data suggest that patients with hematologic malignancies may not mount adequate humoral and cellular responses to SARS-CoV-2 vaccines. In this review, we summarize the immune compromising factors indigenous to CAR-T recipients. We discuss the immunogenic potential of different SARS-CoV-2 vaccines for CAR-T recipients based on the differences in vaccine manufacturing platforms. Given the lack of data related to the safety and efficacy of SARS-CoV-2 vaccines in this distinctively immunosuppressed cohort, we summarize the infection risks associated with Food and Drug Administration-approved CAR-T constructs and the potential determinants of vaccine responses. The review further highlights the potential need for booster vaccine dosing and the promise for heterologous prime-boosting and other novel vaccine strategies in CAR-T recipients. © 2021 American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc.
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36
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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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Barreto JN, Bansal R, Hathcock MA, Doleski CJ, Hayne JR, Truong TA, Nedved AN, Ansell SM, Bennani NN, Paludo J, Villasboas JC, Lin Y, Johnston PB. The impact of granulocyte colony stimulating factor on patients receiving chimeric antigen receptor T-cell therapy. Am J Hematol 2021; 96:E399-E402. [PMID: 34350612 DOI: 10.1002/ajh.26313] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/17/2021] [Accepted: 07/19/2021] [Indexed: 01/08/2023]
Affiliation(s)
| | - Radhika Bansal
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota USA
| | - Matthew A. Hathcock
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota USA
| | | | - Justin R. Hayne
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota USA
| | - Tuan A. Truong
- Department of Nursing Mayo Clinic Rochester Minnesota USA
| | | | - Stephen M. Ansell
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota USA
| | - N. Nora Bennani
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota USA
| | - Jonas Paludo
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota USA
| | - Jose C. Villasboas
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota USA
| | - Yi Lin
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota USA
| | - Patrick B. Johnston
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota USA
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38
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Martino M, Macheda S, Aguglia U, Arcudi L, Pucci G, Martino B, Altomonte M, Rossetti AM, Cusumano G, Russo L, Imbalzano L, Stelitano C, Alati C, Germano' J, Labate D, Amalfi V, Florenzano MT, Morabito A, Borzumati V, Dattola V, Gattuso C, Moschella A, Quattrone D, Curmaci F, Franzutti C, Scappatura G, Rao CM, Loddo V, Pontari A, Pellicano' M, Surace R, Sanguedolce C, Naso V, Ferreri A, Irrera G, Console G, Moscato T, Loteta B, Canale FA, Trimarchi A, Monteleone R, Al Sayyad S, Cirrone F, Bruno B. Identifying and managing CAR T-cell-mediated toxicities: on behalf of an Italian CAR-T multidisciplinary team. Expert Opin Biol Ther 2021; 22:407-421. [PMID: 34463175 DOI: 10.1080/14712598.2021.1974394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Chimeric antigen receptor (CAR)-T-cell therapy is a new treatment for patients with hematologic malignancies in which other therapies have failed. AREAS COVERED The review provides an overview for recognizing and managing the most acute toxicities related to CAR-T cells. EXPERT OPINION The development of immune-mediated toxicities is a common challenge of CAR-T therapy. The mechanism that determines this toxicity is still unclear, although an unfavorable tumor microenvironment and a pro-inflammatory state put patients at risk. The monitoring, diagnosis, and treatment of post-CAR-T toxicities must be determined and based on international guidelines and internal clinical practice. It is urgent to identify biomarkers that can identify patients at greater risk of developing complications. The adoption of consistent grading criteria is necessary to improve toxicity management strategies continually. The first-line therapy consists of supportive care and treatment with tocilizumab or corticosteroids. An early start of cytokine blockade therapies could mitigate toxicity. The plan will include cytokine release prophylaxis, a risk-adapted treatment, prevention of on-target/off-tumor effect, and a switch on/off CAR-T approach.
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Affiliation(s)
- Massimo Martino
- Stem Cell Transplant and Cellular Therapies Unit, Great Metropolitan Hospital "Bianchi-melacrino-morelli", Reggio, Calabria, Italy.,Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Sebastiano Macheda
- Intensive Care Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Umberto Aguglia
- Department of Medicine, Surgery and Health Sciences, Magna Græcia University, Catanzaro, Italy, Regional Epilepsy Centre, Great Metropolitan Hospital "Bianchi-melacrino-morelli," Reggio Calabria, Italy.,Neurology Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Luciano Arcudi
- Neurology Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Giulia Pucci
- Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy.,Stem Cell Processing Laboratory Unit, Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Bruno Martino
- Hematology Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Maria Altomonte
- Pharmacy Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Antonio Maria Rossetti
- Stem Cell Transplant and Cellular Therapies Unit, Great Metropolitan Hospital "Bianchi-melacrino-morelli", Reggio, Calabria, Italy.,Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Giuseppa Cusumano
- Stem Cell Transplant and Cellular Therapies Unit, Great Metropolitan Hospital "Bianchi-melacrino-morelli", Reggio, Calabria, Italy.,Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Letteria Russo
- Stem Cell Transplant and Cellular Therapies Unit, Great Metropolitan Hospital "Bianchi-melacrino-morelli", Reggio, Calabria, Italy.,Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Lucrezia Imbalzano
- Stem Cell Transplant and Cellular Therapies Unit, Great Metropolitan Hospital "Bianchi-melacrino-morelli", Reggio, Calabria, Italy.,Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Caterina Stelitano
- Hematology Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Caterina Alati
- Hematology Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Jessyca Germano'
- Hematology Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Demetrio Labate
- Intensive Care Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Vincenzo Amalfi
- Intensive Care Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Maria Teresa Florenzano
- Pharmacy Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Antonella Morabito
- Pharmacy Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Vittoria Borzumati
- Pharmacy Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Vincenzo Dattola
- Neurology Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Caterina Gattuso
- Neurology Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Antonio Moschella
- Pain Center Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Domenico Quattrone
- Pain Center Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Francesco Curmaci
- Pain Center Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Claudio Franzutti
- Radiology Department, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Giuseppe Scappatura
- Radiology Department, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Carmelo Massimiliano Rao
- Cardiology Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Viviana Loddo
- Catholic University of the Sacred Heart, Rome, Italy
| | - Antonella Pontari
- Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy.,Stem Cell Processing Laboratory Unit, Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Maria Pellicano'
- Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy.,Intensive Care Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Rosangela Surace
- Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy.,Intensive Care Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Cristina Sanguedolce
- Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy.,Intensive Care Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Virginia Naso
- Stem Cell Transplant and Cellular Therapies Unit, Great Metropolitan Hospital "Bianchi-melacrino-morelli", Reggio, Calabria, Italy.,Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Anna Ferreri
- Stem Cell Transplant and Cellular Therapies Unit, Great Metropolitan Hospital "Bianchi-melacrino-morelli", Reggio, Calabria, Italy.,Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Giuseppe Irrera
- Stem Cell Transplant and Cellular Therapies Unit, Great Metropolitan Hospital "Bianchi-melacrino-morelli", Reggio, Calabria, Italy.,Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Giuseppe Console
- Stem Cell Transplant and Cellular Therapies Unit, Great Metropolitan Hospital "Bianchi-melacrino-morelli", Reggio, Calabria, Italy.,Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Tiziana Moscato
- Stem Cell Transplant and Cellular Therapies Unit, Great Metropolitan Hospital "Bianchi-melacrino-morelli", Reggio, Calabria, Italy.,Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Barbara Loteta
- Stem Cell Transplant and Cellular Therapies Unit, Great Metropolitan Hospital "Bianchi-melacrino-morelli", Reggio, Calabria, Italy.,Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Filippo Antonio Canale
- Stem Cell Transplant and Cellular Therapies Unit, Great Metropolitan Hospital "Bianchi-melacrino-morelli", Reggio, Calabria, Italy.,Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Alfonso Trimarchi
- Immunotransfusion Service Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli,", Reggio, Calabria, Italy
| | - Renza Monteleone
- Stem Cell Transplant Program CIC 587, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio, Calabria, Italy
| | - Said Al Sayyad
- Onco-hematology and Radiotherapy Department, Great Metropolitan Hospital "Bianchi-melacrino-morelli", Reggio, Calabria, Italy
| | - Frank Cirrone
- Department of Pharmacy, Nyu Langone Health, New York, NY
| | - Benedetto Bruno
- Department of Molecular Biotechnology and Health Sciences, University of Torino and Department of Oncology, Division of Hematology, A.o.u. Città Della Salute E Della Scienza Di Torino, Presidio Molinette, Torino, Italy.,Division Of Hematology And Medical Oncology, Perlmutter Cancer Center, Grossman School Of Medicine, NYU Langone Health, New York, Ny
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39
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Tang K, Nastoupil LJ. Real-World Experiences of CAR T-Cell Therapy for Large B-Cell Lymphoma: How Similar Are They to the Prospective Studies? JOURNAL OF IMMUNOTHERAPY AND PRECISION ONCOLOGY 2021; 4:150-159. [PMID: 35663108 PMCID: PMC9138439 DOI: 10.36401/jipo-21-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 05/02/2021] [Accepted: 06/16/2021] [Indexed: 05/06/2023]
Abstract
Chimeric antigen receptor (CAR) T cell therapy has emerged as a revolutionary treatment option for highly aggressive B cell malignancies. Clinical trials of CD19 CAR T cells for the management of relapsed and/or refractory non-Hodgkin lymphoma (NHL) have shown markedly improved survival and response rates. The goal of this review is to evaluate whether the results from these clinical trials are reflective of real-world practices through the analysis of published literature of the commercially available CAR T cell products. We have found that despite the significantly different patient characteristics, the adverse events and response rates of real-world patients were similar to those of the clinical trials. Of interest, several groups excluded from the clinical trials, such as patients with HIV infection, chronic viral hepatitis, and secondary CNS (central nervous system) lymphoma, had case reports of promising outcomes.
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Affiliation(s)
- Kevin Tang
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Loretta J. Nastoupil
- Department of Lymphoma/Myeloma, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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40
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CAR-HEMATOTOX: A model for CAR T-cell related hematological toxicity in relapsed/refractory large B-cell lymphoma. Blood 2021; 138:2499-2513. [PMID: 34166502 DOI: 10.1182/blood.2020010543] [Citation(s) in RCA: 168] [Impact Index Per Article: 56.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 05/30/2021] [Indexed: 11/20/2022] Open
Abstract
Hematotoxicity represents a frequent chimeric antigen receptor (CAR) T-cell related adverse event and remains poorly understood. In this multicenter analysis, we studied patterns of hematopoietic reconstitution and evaluated potential predictive markers in 258 patients receiving Axicabtagene ciloleucel (Axi-cel) or Tisagenlecleucel (Tisa-cel) for relapsed/refractory large B-cell lymphoma. We observed profound (ANC<100/µl) and prolonged (≥day 21) neutropenia in 72 and 64% of patients respectively. The median duration of severe neutropenia (ANC<500/µl) was 9 days. We aimed to identify predictive biomarkers of hematotoxicity using the duration of severe neutropenia until day +60 as the primary endpoint. In the training cohort (n=58), we observed a significant correlation with baseline thrombocytopenia (r= -0.43, P=0.001) and hyperferritinemia (r=0.54, P<0.0001) on uni- and multivariate analysis. Incidence and severity of CRS, ICANS and peak cytokine levels were not associated with the primary endpoint. We calculated the CAR-HEMATOTOX model, which included markers associated with hematopoietic reserve (e.g. platelet count, hemoglobin and ANC) and baseline inflammation (e.g. C-reactive-protein, ferritin). This model was validated in two independent cohorts from Europe (n=91) and the USA (n=109), and discriminated patients with severe neutropenia ≥/<14 days (pooled validation: AUC=0.89, Sensitivity 89%, Specificity 68%). A high CAR-HEMATOTOX score resulted in a longer duration of neutropenia (12 vs. 5.5 days, P<0.001), and a higher incidence of severe thrombocytopenia (87% vs. 34%, P<0.001) and anemia (96% vs. 40%, P<0.001). The score implicates pre-CART bone marrow reserve and inflammatory state as key features associated with delayed cytopenia and will be useful for risk-adapted management of hematotoxicity.
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