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Pu LF, Zheng HM, Feng XJ, Charwudzi A, Liang X, Hu LH, Ding YY, Liu ZL, Liao Y, Xiong SD. Rapid identification of early infections in febrile patients after CD19 target CAR-T cell therapy for B-cell malignancies. J Transl Med 2024; 22:613. [PMID: 38956649 PMCID: PMC11221099 DOI: 10.1186/s12967-024-05308-2] [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: 02/28/2024] [Accepted: 05/15/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND CD19-targeted chimeric antigen receptor T (CAR-T) cell therapy stands out as a revolutionary intervention, exhibiting remarkable remission rates in patients with refractory/relapsed (R/R) B-cell malignancies. However, the potential side effects of therapy, particularly cytokine release syndrome (CRS) and infections, pose significant challenges due to their overlapping clinical features. Promptly distinguishing between CRS and infection post CD19 target CAR-T cell infusion (CTI) remains a clinical dilemma. Our study aimed to analyze the incidence of infections and identify key indicators for early infection detection in febrile patients within 30 days post-CTI for B-cell malignancies. METHODS In this retrospective cohort study, a cohort of 104 consecutive patients with R/R B-cell malignancies who underwent CAR-T therapy was reviewed. Clinical data including age, gender, CRS, ICANS, treatment history, infection incidence, and treatment responses were collected. Serum biomarkers procalcitonin (PCT), interleukin-6 (IL-6), and C-reactive protein (CRP) levels were analyzed using chemiluminescent assays. Statistical analyses employed Pearson's Chi-square test, t-test, Mann-Whitney U-test, Kaplan-Meier survival analysis, Cox proportional hazards regression model, Spearman rank correlation, and receiver operating characteristic (ROC) curve analysis to evaluate diagnostic accuracy and develop predictive models through multivariate logistic regression. RESULTS In this study, 38 patients (36.5%) experienced infections (30 bacterial, 5 fungal, and 3 viral) within the first 30 days of CAR T-cell infusion. In general, bacterial, fungal, and viral infections were detected at a median of 7, 8, and 9 days, respectively, after CAR T-cell infusion. Prior allogeneic hematopoietic cell transplantation (HCT) was an independent risk factor for infection (Hazard Ratio [HR]: 4.432 [1.262-15.565], P = 0.020). Furthermore, CRS was an independent risk factor for both infection ((HR: 2.903 [1.577-5.345], P < 0.001) and severe infection (9.040 [2.256-36.232], P < 0.001). Serum PCT, IL-6, and CRP were valuable in early infection prediction post-CAR-T therapy, particularly PCT with the highest area under the ROC curve (AUC) of 0.897. A diagnostic model incorporating PCT and CRP demonstrated an AUC of 0.903 with sensitivity and specificity above 83%. For severe infections, a model including CRS severity and PCT showed an exceptional AUC of 0.991 with perfect sensitivity and high specificity. Based on the aforementioned analysis, we proposed a workflow for the rapid identification of early infection during CAR-T cell therapy. CONCLUSIONS CRS and prior allogeneic HCT are independent infection risk factors post-CTI in febrile B-cell malignancy patients. Our identification of novel models using PCT and CRP for predicting infection, and PCT and CRS for predicting severe infection, offers potential to guide therapeutic decisions and enhance the efficacy of CAR-T cell therapy in the future.
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Affiliation(s)
- Lian-Fang Pu
- Hematological Lab, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People's Republic of China
- Department of Hematology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People's Republic of China
| | - Hui-Min Zheng
- Hematological Lab, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People's Republic of China
- Department of Hematology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People's Republic of China
| | - Xiang-Jiang Feng
- Hematological Lab, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People's Republic of China
- Department of Hematology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People's Republic of China
| | - Alice Charwudzi
- University of Cape Coast School of Medical Sciences, Cape Coast, Ghana
| | - Xue Liang
- Hematological Lab, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People's Republic of China
- Department of Hematology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People's Republic of China
| | - Lin-Hui Hu
- Hematological Lab, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People's Republic of China
- Department of Hematology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People's Republic of China
| | - Yang-Yang Ding
- Hematological Lab, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People's Republic of China
- Department of Hematology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People's Republic of China
| | - Ze-Lin Liu
- Hematological Lab, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People's Republic of China
- Department of Hematology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People's Republic of China
| | - Ya Liao
- Hematological Lab, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People's Republic of China
- Department of Hematology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People's Republic of China
| | - Shu-Dao Xiong
- Hematological Lab, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People's Republic of China.
- Department of Hematology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People's Republic of China.
- Research Center for Translational Medicine, The Second Hospital of Anhui Medical University, Hefei, Anhui, People's Republic of China.
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Rejeski K, Jain MD, Shah NN, Perales MA, Subklewe M. Immune effector cell-associated haematotoxicity after CAR T-cell therapy: from mechanism to management. Lancet Haematol 2024; 11:e459-e470. [PMID: 38734026 DOI: 10.1016/s2352-3026(24)00077-2] [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: 01/20/2024] [Revised: 02/28/2024] [Accepted: 03/06/2024] [Indexed: 05/13/2024]
Abstract
Genetically engineered chimeric antigen receptor (CAR) T cells have become an effective treatment option for several advanced B-cell malignancies. Haematological side-effects, classified in 2023 as immune effector cell-associated haematotoxicity (ICAHT), are very common and can predispose for clinically relevant infections. As haematopoietic reconstitution after CAR T-cell therapy differs from chemotherapy-associated myelosuppression, a novel classification system for early and late ICAHT has been introduced. Furthermore, a risk stratification score named CAR-HEMATOTOX has been developed to identify candidates at high risk of ICAHT, thereby enabling risk-based interventional strategies. Therapeutically, growth factor support with granulocyte colony-stimulating factor (G-CSF) is the mainstay of treatment, with haematopoietic stem cell (HSC) boosts available for patients who are refractory to G-CSF (if available). Although the underlying pathophysiology remains poorly understood, translational studies from the past 3 years suggest that CAR T-cell-induced inflammation and baseline haematopoietic function are key contributors to prolonged cytopenia. In this Review, we provide an overview of the spectrum of haematological toxicities after CAR T-cell therapy and offer perspectives on future translational and clinical developments.
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Affiliation(s)
- Kai Rejeski
- Adult BMT and Cellular Therapy Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Medicine III, LMU University Hospital, LMU Munich, Munich, Germany; Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany.
| | - Michael D Jain
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL, USA
| | - Nirali N Shah
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Miguel-Angel Perales
- Adult BMT and Cellular Therapy Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Marion Subklewe
- Department of Medicine III, LMU University Hospital, LMU Munich, Munich, Germany; Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany.
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3
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Rejeski K, Wang Y, Hansen DK, Iacoboni G, Bachy E, Bansal R, Penack O, Müller F, Bethge W, Munoz J, Mohty R, Bücklein VL, Barba P, Locke FL, Lin Y, Jain MD, Subklewe M. Applying the EHA/EBMT grading for ICAHT after CAR-T: comparative incidence and association with infections and mortality. Blood Adv 2024; 8:1857-1868. [PMID: 38181508 PMCID: PMC11007437 DOI: 10.1182/bloodadvances.2023011767] [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: 09/24/2023] [Revised: 12/19/2023] [Accepted: 12/20/2023] [Indexed: 01/07/2024] Open
Abstract
ABSTRACT Cytopenias represent the most common side effect of CAR T-cell therapy (CAR-T) and can predispose for severe infectious complications. Current grading systems, such as the Common Terminology Criteria for Adverse Events (CTCAE), neither reflect the unique quality of post-CAR-T neutrophil recovery, nor do they reflect the inherent risk of infections due to protracted neutropenia. For this reason, a novel EHA/EBMT consensus grading was recently developed for Immune Effector Cell-Associated HematoToxicity (ICAHT). In this multicenter, observational study, we applied the grading system to a large real-world cohort of 549 patients treated with BCMA- or CD19-directed CAR-T for refractory B-cell malignancies (112 multiple myeloma [MM], 334 large B-cell lymphoma [LBCL], 103 mantle cell lymphoma [MCL]) and examined the clinical sequelae of severe (≥3°) ICAHT. The ICAHT grading was strongly associated with the cumulative duration of severe neutropenia (r = 0.92, P < .0001), the presence of multilineage cytopenias, and the use of platelet and red blood cell transfusions. We noted an increased rate of severe ICAHT in patients with MCL vs those with LBCL and MM (28% vs 23% vs 15%). Severe ICAHT was associated with a higher rate of severe infections (49% vs 13%, P < .0001), increased nonrelapse mortality (14% vs 4%, P < .0001), and inferior survival outcomes (1-year progression-free survival: 35% vs 51%, 1-year overall survival: 52% vs 73%, both P < .0001). Importantly, the ICAHT grading demonstrated superior capacity to predict severe infections compared with the CTCAE grading (c-index 0.73 vs 0.55, P < .0001 vs nonsignificant). Taken together, these data highlight the clinical relevance of the novel grading system and support the reporting of ICAHT severity in clinical trials evaluating CAR-T therapies.
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Affiliation(s)
- Kai Rejeski
- Department of Medicine III – Hematology/Oncology, University Hospital, LMU Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
- German Cancer Consortium (DKTK), Munich and Berlin Sites, and German Cancer Research Center, Heidelberg, Germany
- Adult BMT and Cellular Therapy Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Yucai Wang
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - Doris K. Hansen
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL
| | - Gloria Iacoboni
- Department of Hematology, Vall d’Hebron Institute of Oncology, University Hospital Vall d’Hebron and Autonomous University of Barcelona, Barcelona, Spain
| | - Emmanuel Bachy
- Department of Hematology, Lyon Sud Hospital, Claude Bernard University Lyon 1, INSERM 1052, Pierre-Bénite, France
| | | | - Olaf Penack
- German Cancer Consortium (DKTK), Munich and Berlin Sites, and German Cancer Research Center, Heidelberg, Germany
- Department of Hematology, Oncology and Tumorimmunology, Charité – Berlin University Medicine, Corporate Member of Free University of Berlin and Humboldt University, Berlin, Germany
| | - Fabian Müller
- Department of Internal Medicine 5, Hematology and Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg and University Hospital Erlangen, Erlangen, Germany
| | - Wolfgang Bethge
- Department of Hematology, Oncology, Immunology and Rheumatology, University Hospital Tübingen, Tübingen, Germany
| | - Javier Munoz
- Division of Hematology and Oncology, Mayo Clinic, Phoenix, AZ
| | - Razan Mohty
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL
| | - Veit L. Bücklein
- Department of Medicine III – Hematology/Oncology, University Hospital, LMU Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
| | - Pere Barba
- Department of Hematology, Vall d’Hebron Institute of Oncology, University Hospital Vall d’Hebron and Autonomous University of Barcelona, Barcelona, Spain
| | - Frederick L. Locke
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL
| | - Yi Lin
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - Michael D. Jain
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL
| | - Marion Subklewe
- Department of Medicine III – Hematology/Oncology, University Hospital, LMU Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
- German Cancer Consortium (DKTK), Munich and Berlin Sites, and German Cancer Research Center, Heidelberg, Germany
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Ligon JA, Ramakrishna S, Ceppi F, Calkoen FGJ, Diorio C, Davis KL, Jacoby E, Gottschalk S, Schultz LM, Capitini CM. INSPIRED Symposium Part 4B: Chimeric Antigen Receptor T Cell Correlative Studies-Established Findings and Future Priorities. Transplant Cell Ther 2024; 30:155-170. [PMID: 37863355 DOI: 10.1016/j.jtct.2023.10.012] [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: 10/03/2023] [Revised: 10/11/2023] [Accepted: 10/13/2023] [Indexed: 10/22/2023]
Abstract
Chimeric antigen receptor (CAR) T cell therapy has revolutionized the treatment of B cell malignancies, with multiple CAR T cell products approved for numerous indications by regulatory agencies worldwide. However, significant work remains to be done to enhance these treatments. In March 2023, a group of experts in CAR T cell therapy assembled at the National Institutes of Health in Bethesda, Maryland at the Insights in Pediatric CAR T Cell Immunotherapy: Recent Advances and Future Directions (INSPIRED) Symposium to identify key areas for research for the coming years. In session 4B, correlative studies to be incorporated into future clinical trials and real-world settings were discussed. Active areas of research identified included (1) optimizing CAR T cell product manufacturing; (2) ensuring adequate lymphodepletion prior to CAR T cell administration; (3) overcoming immunoregulatory cells and tumor stroma present in the tumor microenvironment, particularly in solid tumors; (4) understanding tumor intrinsic properties that lead to CAR T cell immunotherapy resistance; and (5) uncovering biomarkers predictive of treatment resistance, treatment durability, or immune-related adverse events. Here we review the results of previously published clinical trials and real-world studies to summarize what is currently known about each of these topics. We then outline priorities for future research that we believe will be important for improving our understanding of CAR T cell therapy and ultimately leading to better outcomes for patients.
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Affiliation(s)
- John A Ligon
- Department of Pediatrics, Division of Hematology/Oncology, University of Florida, Gainesville, Florida; University of Florida Health Cancer Center, Gainesville, Florida.
| | - Sneha Ramakrishna
- Stanford Center for Cancer Cell Therapy, Stanford University School of Medicine, Stanford, California; Department of Pediatrics, Stanford University, Stanford, California
| | - Francesco Ceppi
- Division of Pediatrics, Department of Woman-Mother-Child, Pediatric Hematology-Oncology Unit, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| | - Friso G J Calkoen
- Division of Pediatric Oncology, Princess Maxima Center, Utrecht, The Netherlands
| | - Caroline Diorio
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Kara L Davis
- Stanford Center for Cancer Cell Therapy, Stanford University School of Medicine, Stanford, California; Department of Pediatrics, Stanford University, Stanford, California
| | - Elad Jacoby
- Pediatric Hemato-Oncology, Sheba Medical Center and Tel Aviv University, Tel Aviv, Israel
| | - Stephen Gottschalk
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Liora M Schultz
- Stanford Center for Cancer Cell Therapy, Stanford University School of Medicine, Stanford, California; Department of Pediatrics, Stanford University, Stanford, California
| | - Christian M Capitini
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; University of Wisconsin Carbone Cancer Center, Madison, Wisconsin
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O'Reilly MA, Neill L, Collin SM, Stone N, Springell D, Mensah J, Cheok KPL, Jalowiec K, Benjamin R, Kuhnl A, Roddie C, Sanderson R. High pretreatment disease burden as a risk factor for infectious complications following CD19 chimeric antigen receptor T-cell therapy for large B-cell lymphoma. Hemasphere 2024; 8:e29. [PMID: 38434533 PMCID: PMC10878197 DOI: 10.1002/hem3.29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 11/22/2023] [Indexed: 03/05/2024] Open
Abstract
Infection has emerged as the chief cause of non-relapse mortality (NRM) post CD19-targeting chimeric antigen receptor T-cell therapy (CAR-T) therapy. Even though up to 50% of patients may remain infection-free, many suffer multiple severe, life-threatening, or fatal infectious events. The primary aim of this study was to explore severe and life-threatening infections post licensed CAR-T therapy in large B-cell lymphoma, with a focus on the role of disease burden and disease sites in assessing individual risk. We sought to understand the cohort of patients who experience ≥2 infections and those at the highest risk of infectious NRM. Our analysis identifies a higher disease burden after bridging therapy as associated with infection events. Those developing ≥2 infections emerged as a uniquely high-risk cohort, particularly if the second (or beyond) infection occurred during an episode of immune effector cell-associated neurotoxicity syndrome (ICANS) or while on steroids and/or anakinra for ICANS. Herein, we also describe the first reported cases of "CAR-T cold sepsis," a phenomenon characterized by the lack of an appreciable systemic inflammatory response at the time of detection of infection. We propose a risk-based strategy to encourage heightened clinician awareness of cold sepsis, with a view to reducing NRM.
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Affiliation(s)
- Maeve A. O'Reilly
- Department of HaematologyUniversity College London HospitalLondonUK
- University College London Cancer InstituteLondonUK
| | - Lorna Neill
- Department of HaematologyUniversity College London HospitalLondonUK
| | | | - Neil Stone
- Department of Infectious DiseasesUniversity College London HospitalLondonUK
| | | | - Jeremy Mensah
- Department of HaematologyKing's College London HospitalLondonUK
| | | | | | - Reuben Benjamin
- Department of HaematologyKing's College London HospitalLondonUK
| | - Andrea Kuhnl
- Department of HaematologyKing's College London HospitalLondonUK
| | - Claire Roddie
- Department of HaematologyUniversity College London HospitalLondonUK
- University College London Cancer InstituteLondonUK
| | - Robin Sanderson
- Department of HaematologyKing's College London HospitalLondonUK
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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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Kampouri E, Little JS, Rejeski K, Manuel O, Hammond SP, Hill JA. Infections after chimeric antigen receptor (CAR)-T-cell therapy for hematologic malignancies. Transpl Infect Dis 2023; 25 Suppl 1:e14157. [PMID: 37787373 DOI: 10.1111/tid.14157] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 08/30/2023] [Accepted: 09/10/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND Chimeric antigen receptor (CAR)-T-cell therapies have revolutionized the management of acute lymphoblastic leukemia, non-Hodgkin lymphoma, and multiple myeloma but come at the price of unique toxicities, including cytokine release syndrome, immune effector cell-associated neurotoxicity syndrome, and long-term "on-target off-tumor" effects. METHODS All of these factors increase infection risk in an already highly immunocompromised patient population. Indeed, infectious complications represent the key determinant of non-relapse mortality after CAR-T cells. The temporal distribution of these risk factors shapes different infection patterns early versus late post-CAR-T-cell infusion. Furthermore, due to the expression of their targets on B lineage cells at different stages of differentiation, CD19, and B-cell maturation antigen (BCMA) CAR-T cells induce distinct immune deficits that could require different prevention strategies. Infection incidence is the highest during the first month post-infusion and subsequently decreases thereafter. However, infections remain relatively common even a year after infusion. RESULTS Bacterial infections predominate early after CD19, while a more equal distribution between bacterial and viral causes is seen after BCMA CAR-T-cell therapy, and fungal infections are universally rare. Cytomegalovirus (CMV) and other herpesviruses are increasingly breported, but whether routine monitoring is warranted for all, or a subgroup of patients, remains to be determined. Clinical practices vary substantially between centers, and many areas of uncertainty remain, including CMV monitoring, antibacterial and antifungal prophylaxis and duration, use of immunoglobulin replacement therapy, and timing of vaccination. CONCLUSION Risk stratification tools are available and may help distinguish between infectious and non-infectious causes of fever post-infusion and predict severe infections. These tools need prospective validation, and their integration in clinical practice needs to be systematically studied.
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Affiliation(s)
- Eleftheria Kampouri
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jessica S Little
- Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Kai Rejeski
- Department of Medicine III-Hematology/Oncology, LMU University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), Munich site, and German Cancer Research Center, Heidelberg, Germany
| | - Oriol Manuel
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Sarah P Hammond
- Division of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
- Divisions of Hematology/Oncology and Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Joshua A Hill
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
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Rejeski K, Wang Y, Albanyan O, Munoz J, Sesques P, Iacoboni G, Lopez-Corral L, Ries I, Bücklein VL, Mohty R, Dreyling M, Baluch A, Shah B, Locke FL, Hess G, Barba P, Bachy E, Lin Y, Subklewe M, Jain MD. The CAR-HEMATOTOX score identifies patients at high risk for hematological toxicity, infectious complications, and poor treatment outcomes following brexucabtagene autoleucel for relapsed or refractory MCL. Am J Hematol 2023; 98:1699-1710. [PMID: 37584447 PMCID: PMC10659121 DOI: 10.1002/ajh.27056] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 06/21/2023] [Accepted: 07/25/2023] [Indexed: 08/17/2023]
Abstract
CD19-directed CAR T-cell therapy with brexucabtagene autoleucel (brexu-cel) has substantially improved treatment outcomes for patients with relapsed/refractory mantle cell lymphoma (r/r MCL). Prolonged cytopenias and infections represent common and clinically relevant side effects. In this multicenter observational study, we describe cytopenias and infections in 103 r/r MCL patients receiving brexu-cel. Furthermore, we report associations between the baseline CAR-HEMATOTOX (HT) score and toxicity events, non-relapse mortality (NRM), and progression-free/overall survival (PFS/OS). At lymphodepletion, 56 patients were HTlow (score 0-1) while 47 patients were HThigh (score ≥2). The HThigh cohort exhibited prolonged neutropenia (median 14 vs. 6 days, p < .001) and an increased rate of severe infections (30% vs. 5%, p = .001). Overall, 1-year NRM was 10.4%, primarily attributed to infections, and differed by baseline HT score (high vs. low: 17% vs. 4.6%, p = .04). HThigh patients experienced inferior 90-day complete response rate (68% vs. 93%, p = .002), PFS (median 9 months vs. not-reached, p < .0001), and OS (median 26 months vs. not-reached, p < .0001). Multivariable analyses showed that high HT scores were independently associated with severe hematotoxicity, infections, and poor PFS/OS. In conclusion, infections and hematotoxicity are common after brexu-cel and contribute to NRM. The baseline HT score identified patients at increased risk of poor treatment outcomes.
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Affiliation(s)
- Kai Rejeski
- Department of Medicine III – Hematology/Oncology, University Hospital, LMU Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
- German Cancer Consortium (DKTK), Munich Site, and German Cancer Research Center, Heidelberg, Germany
| | - Yucai Wang
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Omar Albanyan
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, USA
| | - Javier Munoz
- Division of Hematology and Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Pierre Sesques
- Hospices Civils de Lyon, Université Claude Bernard Lyon 1, INSERM 1052, Pierre-Bénite, France
| | - Gloria Iacoboni
- Department of Hematology, Vall d’Hebron Institute of Oncology (VHIO), University Hospital Vall d’Hebron, Universitat Autònoma of Barcelona (UAB), Department of Medicine, Barcelona, Spain
| | - Lucia Lopez-Corral
- Department of Hematology, Hospital Clínico Universitario de Salamanca, IBSAL, CIBERONC, Salamanca, Spain
- Centro de Investigación del Cáncer-IBMCC, Salamanca, Spain
| | - Isabelle Ries
- Department of Hematology, Oncology and Pneumology, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Veit L. Bücklein
- Department of Medicine III – Hematology/Oncology, University Hospital, LMU Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
| | - Razan Mohty
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, USA
| | - Martin Dreyling
- Department of Medicine III – Hematology/Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Aliyah Baluch
- Infectious Diseases, Moffitt Cancer Center, Tampa, USA
| | - Bijal Shah
- Dept. of Malignant Hematology, Moffitt Cancer Center, Tampa, USA
| | - Frederick L Locke
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, USA
| | - Georg Hess
- Department of Hematology, Oncology and Pneumology, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Pere Barba
- Department of Hematology, Vall d’Hebron Institute of Oncology (VHIO), University Hospital Vall d’Hebron, Universitat Autònoma of Barcelona (UAB), Department of Medicine, Barcelona, Spain
| | - Emmanuel Bachy
- Hospices Civils de Lyon, Université Claude Bernard Lyon 1, INSERM 1052, Pierre-Bénite, France
| | - Yi Lin
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Marion Subklewe
- Department of Medicine III – Hematology/Oncology, University Hospital, LMU Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
- German Cancer Consortium (DKTK), Munich Site, and German Cancer Research Center, Heidelberg, Germany
| | - Michael D. Jain
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, USA
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9
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Rejeski K, Perez A, Iacoboni G, Blumenberg V, Bücklein VL, Völkl S, Penack O, Albanyan O, Stock S, Müller F, Karschnia P, Petrera A, Reid K, Faramand R, Davila ML, Modi K, Dean EA, Bachmeier C, von Bergwelt-Baildon M, Locke FL, Bethge W, Bullinger L, Mackensen A, Barba P, Jain MD, Subklewe M. Severe hematotoxicity after CD19 CAR-T therapy is associated with suppressive immune dysregulation and limited CAR-T expansion. SCIENCE ADVANCES 2023; 9:eadg3919. [PMID: 37738350 PMCID: PMC10516499 DOI: 10.1126/sciadv.adg3919] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 08/23/2023] [Indexed: 09/24/2023]
Abstract
Prolonged cytopenias after chimeric antigen receptor (CAR) T cell therapy are a significant clinical problem and the underlying pathophysiology remains poorly understood. Here, we investigated how (CAR) T cell expansion dynamics and serum proteomics affect neutrophil recovery phenotypes after CD19-directed CAR T cell therapy. Survival favored patients with "intermittent" neutrophil recovery (e.g., recurrent neutrophil dips) compared to either "quick" or "aplastic" recovery. While intermittent patients displayed increased CAR T cell expansion, aplastic patients exhibited an unfavorable relationship between expansion and tumor burden. Proteomics of patient serum collected at baseline and in the first month after CAR-T therapy revealed higher markers of endothelial dysfunction, inflammatory cytokines, macrophage activation, and T cell suppression in the aplastic phenotype group. Prolonged neutrophil aplasia thus occurs in patients with systemic immune dysregulation at baseline with subsequently impaired CAR-T expansion and myeloid-related inflammatory changes. The association between neutrophil recovery and survival outcomes highlights critical interactions between host hematopoiesis and the immune state stimulated by CAR-T infusion.
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Affiliation(s)
- Kai Rejeski
- Department of Medicine III – Hematology/Oncology, University Hospital, LMU Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
- German Cancer Consortium (DKTK), Munich and Berlin sites, and German Cancer Research Center, Heidelberg, Germany
- Bavarian Cancer Research Center (BZKF), partner sites, Munich and Erlangen, Germany
| | - Ariel Perez
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL, USA
- Blood and Marrow Transplant Program, Miami Cancer Institute, Miami, FL, USA
| | - Gloria Iacoboni
- Department of Hematology, University Hospital Vall d’Hebron, Vall d’Hebron Institute of Oncology (VHIO), Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Viktoria Blumenberg
- Department of Medicine III – Hematology/Oncology, University Hospital, LMU Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
- German Cancer Consortium (DKTK), Munich and Berlin sites, and German Cancer Research Center, Heidelberg, Germany
- Bavarian Cancer Research Center (BZKF), partner sites, Munich and Erlangen, Germany
| | - Veit L. Bücklein
- Department of Medicine III – Hematology/Oncology, University Hospital, LMU Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
- German Cancer Consortium (DKTK), Munich and Berlin sites, and German Cancer Research Center, Heidelberg, Germany
- Bavarian Cancer Research Center (BZKF), partner sites, Munich and Erlangen, Germany
| | - Simon Völkl
- Bavarian Cancer Research Center (BZKF), partner sites, Munich and Erlangen, Germany
- Department of Internal Medicine 5, Hematology and Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg and University Hospital Erlangen, Erlangen, Germany
| | - Olaf Penack
- German Cancer Consortium (DKTK), Munich and Berlin sites, and German Cancer Research Center, Heidelberg, Germany
- Department of Hematology, Oncology and Tumorimmunology, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt-Universität zu Berlin, Berlin, Germany
| | - Omar Albanyan
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL, USA
- Adult Hematology-Oncology and Stem Cell Transplantation, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Sophia Stock
- Department of Medicine III – Hematology/Oncology, University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), Munich and Berlin sites, and German Cancer Research Center, Heidelberg, Germany
| | - Fabian Müller
- Bavarian Cancer Research Center (BZKF), partner sites, Munich and Erlangen, Germany
- Department of Internal Medicine 5, Hematology and Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg and University Hospital Erlangen, Erlangen, Germany
| | - Philipp Karschnia
- Department of Neurosurgery, University Hospital, LMU Munich, Munich, Germany
| | - Agnese Petrera
- Metabolomics and Proteomics Core Facility, Helmholtz Zentrum Munich – German Research Center for Environmental Health, Munich, Germany
| | - Kayla Reid
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL, USA
| | - Rawan Faramand
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL, USA
| | - Marco L. Davila
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL, USA
| | - Karnav Modi
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL, USA
| | - Erin A. Dean
- Division of Hematology and Oncology, Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Christina Bachmeier
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL, USA
| | - Michael von Bergwelt-Baildon
- Department of Medicine III – Hematology/Oncology, University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), Munich and Berlin sites, and German Cancer Research Center, Heidelberg, Germany
- Bavarian Cancer Research Center (BZKF), partner sites, Munich and Erlangen, Germany
| | - Frederick L Locke
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL, USA
| | - Wolfgang Bethge
- Department of Hematology, Oncology, Immunology and Rheumatology, University Hospital Tübingen, Tübingen, Germany
| | - Lars Bullinger
- German Cancer Consortium (DKTK), Munich and Berlin sites, and German Cancer Research Center, Heidelberg, Germany
- Department of Hematology, Oncology and Tumorimmunology, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt-Universität zu Berlin, Berlin, Germany
| | - Andreas Mackensen
- Bavarian Cancer Research Center (BZKF), partner sites, Munich and Erlangen, Germany
- Department of Internal Medicine 5, Hematology and Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg and University Hospital Erlangen, Erlangen, Germany
| | - Pere Barba
- Department of Hematology, University Hospital Vall d’Hebron, Vall d’Hebron Institute of Oncology (VHIO), Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Michael D. Jain
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL, USA
| | - Marion Subklewe
- Department of Medicine III – Hematology/Oncology, University Hospital, LMU Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
- German Cancer Consortium (DKTK), Munich and Berlin sites, and German Cancer Research Center, Heidelberg, Germany
- Bavarian Cancer Research Center (BZKF), partner sites, Munich and Erlangen, Germany
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10
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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: 56] [Impact Index Per Article: 56.0] [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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11
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Rejeski K, Hansen DK, Bansal R, Sesques P, Ailawadhi S, Logue JM, Bräunlein E, Cordas Dos Santos DM, Freeman CL, Alsina M, Theurich S, Wang Y, Krackhardt AM, Locke FL, Bachy E, Jain MD, Lin Y, Subklewe M. The CAR-HEMATOTOX score as a prognostic model of toxicity and response in patients receiving BCMA-directed CAR-T for relapsed/refractory multiple myeloma. J Hematol Oncol 2023; 16:88. [PMID: 37525244 PMCID: PMC10391746 DOI: 10.1186/s13045-023-01465-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 06/09/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND BCMA-directed CAR T-cell therapy (CAR-T) has altered the treatment landscape of relapsed/refractory (r/r) multiple myeloma, but is hampered by unique side effects that can lengthen hospital stays and increase morbidity. Hematological toxicity (e.g. profound and prolonged cytopenias) represents the most common grade ≥ 3 toxicity and can predispose for severe infectious complications. Here, we examined the utility of the CAR-HEMATOTOX (HT) score to predict toxicity and survival outcomes in patients receiving standard-of-care idecabtagene vicleucel and ciltacabtagene autoleucel. METHODS Data were retrospectively collected from 113 r/r multiple myeloma patients treated between April 2021 and July 2022 across six international CAR-T centers. The HT score-composed of factors related to hematopoietic reserve and baseline inflammatory state-was determined prior to lymphodepleting chemotherapy. RESULTS At lymphodepletion, 63 patients were HTlow (score 0-1) and 50 patients were HThigh (score ≥ 2). Compared to their HTlow counterparts, HThigh patients displayed prolonged severe neutropenia (median 9 vs. 3 days, p < 0.001), an increased severe infection rate (40% vs. 5%, p < 0.001), and more severe ICANS (grade ≥ 3: 16% vs. 0%, p < 0.001). One-year non-relapse mortality was higher in the HThigh group (13% vs. 2%, p = 0.019) and was predominantly attributable to fatal infections. Response rates according to IMWG criteria were higher in HTlow patients (≥ VGPR: 70% vs. 44%, p = 0.01). Conversely, HThigh patients exhibited inferior progression-free (median 5 vs. 15 months, p < 0.001) and overall survival (median 10.5 months vs. not reached, p < 0.001). CONCLUSIONS These data highlight the prognostic utility of the CAR-HEMATOTOX score for both toxicity and treatment response in multiple myeloma patients receiving BCMA-directed CAR-T. The score may guide toxicity management (e.g. anti-infective prophylaxis, early G-CSF, stem cell boost) and help to identify suitable CAR-T candidates.
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Affiliation(s)
- Kai Rejeski
- Department of Medicine III - Hematology/Oncology, LMU University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany.
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany.
- German Cancer Consortium (DKTK), Munich Site, and German Cancer Research Center, Heidelberg, Germany.
- Bavarian Cancer Research Center (BZKF), Munich partner site, Munich, Germany.
| | - Doris K Hansen
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, USA
| | | | - Pierre Sesques
- Hospices Civils de Lyon, Université Claude Bernard Lyon 1, INSERM 1052, Pierre-Bénite, France
| | | | - Jennifer M Logue
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, USA
| | - Eva Bräunlein
- IIIrd Medical Department, Klinikum rechts der Isar and Center for Translational Cancer Research (TranslaTUM), School of Medicine, Technical University of Munich, Munich, Germany
| | - David M Cordas Dos Santos
- Department of Medicine III - Hematology/Oncology, LMU University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
- German Cancer Consortium (DKTK), Munich Site, and German Cancer Research Center, Heidelberg, Germany
| | - Ciara L Freeman
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, USA
| | - Melissa Alsina
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, USA
| | - Sebastian Theurich
- Department of Medicine III - Hematology/Oncology, LMU University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
- German Cancer Consortium (DKTK), Munich Site, and German Cancer Research Center, Heidelberg, Germany
| | - Yucai Wang
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Angela M Krackhardt
- German Cancer Consortium (DKTK), Munich Site, and German Cancer Research Center, Heidelberg, Germany
- Bavarian Cancer Research Center (BZKF), Munich partner site, Munich, Germany
- IIIrd Medical Department, Klinikum rechts der Isar and Center for Translational Cancer Research (TranslaTUM), School of Medicine, Technical University of Munich, Munich, Germany
- Department of Medicine I, Malteser Hospital St. Franziskus Hospital, Flensburg, Germany
| | - Frederick L Locke
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, USA
| | - Emmanuel Bachy
- Hospices Civils de Lyon, Université Claude Bernard Lyon 1, INSERM 1052, Pierre-Bénite, France
| | - Michael D Jain
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, USA
| | - Yi Lin
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Marion Subklewe
- Department of Medicine III - Hematology/Oncology, LMU University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
- German Cancer Consortium (DKTK), Munich Site, and German Cancer Research Center, Heidelberg, Germany
- Bavarian Cancer Research Center (BZKF), Munich partner site, Munich, Germany
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12
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Rejeski K, Greco R, Onida F, Sánchez-Ortega I, Bonini C, Sureda A, Gribben JG, Yakoub-Agha I, Subklewe M. An International Survey on Grading, Diagnosis, and Management of Immune Effector Cell-Associated Hematotoxicity (ICAHT) Following CAR T-cell Therapy on Behalf of the EBMT and EHA. Hemasphere 2023; 7:e889. [PMID: 37125259 PMCID: PMC10145722 DOI: 10.1097/hs9.0000000000000889] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 04/06/2023] [Indexed: 05/02/2023] Open
Abstract
Hematological toxicity represents the most common grade ≥3 toxicity after chimeric antigen receptor (CAR) T-cell therapy. However, its underlying pathophysiology is incompletely understood and its grading and management remains ill-defined. To inform the forthcoming European Hematology Association/European Society for Blood and Marrow Transplantation (EHA/EBMT) guidelines on the management of "immune effector cell-associated hematotoxicity" (ICAHT), we undertook a survey of experienced clinicians using an online survey focusing on (1) grading, (2) risk-stratification and diagnostic work-up, (3) short-term, and (4) long-term management of ICAHT. There were 81 survey respondents across 18 countries. A high degree of variability was noted for cytopenia grading in regards to depth, duration, and time from CAR-T infusion. The majority of experts favored pre-CAR-T bone marrow studies, especially in case of a high-risk profile. Most respondents felt that the work-up for patients with severe hematotoxicity should rule-out viral infections (96%), substrate deficiency (80%), or coincident sHLH/MAS (serum ferritin, 92%), and should include bone marrow aspiration (86%) and/or biopsy (61%). Clinicians were divided as to whether the occurrence of coincident immunotoxicity should influence the decision to apply G-CSF, and when to initiate G-CSF support. In case of prolonged thrombocytopenia, most survey participants favored thrombopoietin agonists (86%). Conversely, autologous hematopoietic cell boosts represented the preferred choice for neutropenia (63%), although they were frequently not available and no consensus was reached regarding the optimal trigger point. These findings underline the current heterogeneity of practice patterns regarding ICAHT and invite the development of consensus guidelines, which may harmonize grading, establish standard operating procedures for diagnosis, and set management guidelines.
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Affiliation(s)
- Kai Rejeski
- Department of Medicine III – Hematology/Oncology, University Hospital, LMU Munich, Germany
| | - Raffaella Greco
- Unit of Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Francesco Onida
- Hematology and BMT Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, University of Milan, Italy
| | - Isabel Sánchez-Ortega
- European Society for Blood and Marrow Transplantation (EBMT) Executive Office, Barcelona, Spain
| | - Chiara Bonini
- Experimental Hematology Unit, Division of Immunology, Transplantation and Infectious Diseases, Vita-Salute San Raffaele University, IRCCS Ospedale San Raffaele Scientific Institute, Milan, Italy
| | - Anna Sureda
- Institut Català d’Oncologia-Hospital Duran i Reynals, Barcelona, Spain
| | - John G. Gribben
- Centre for Haemato-Oncology, Barts Cancer Institute, Queen Mary University London, United Kingdom
| | | | - Marion Subklewe
- Department of Medicine III – Hematology/Oncology, University Hospital, LMU Munich, Germany
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