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Sales C, Anderson MA, Kuznetsova V, Rosenfeld H, Malpas CB, Roos I, Dickinson M, Harrison S, Kalincik T. Patterns of neurotoxicity among patients receiving chimeric antigen receptor T-cell therapy: A single-centre cohort study. Eur J Neurol 2024; 31:e16174. [PMID: 38085272 DOI: 10.1111/ene.16174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 09/28/2023] [Accepted: 11/23/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND AND PURPOSE Immune effector cell-associated neurotoxicity syndrome (ICANS) is an important complication of chimeric antigen receptor T-cell (CAR-T) therapy. This study aims to identify the patterns of neurotoxicity among patients with ICANS at a tertiary referral centre in Australia. METHODOLOGY This single-centre, prospective cohort study included all consecutively recruited patients who underwent CAR-T therapy for eligible haematological malignancies. All patients underwent a comprehensive neurological assessment and cognitive screening before CAR-T infusion, during the development of ICANS, and 1 month after treatment. Baseline demographic characteristics, incidence, and neurological patterns of neurotoxicity management were evaluated. RESULTS Over a 19-month period, 23% (12) of the 53 eligible patients developed neurotoxicity (10/12 [83%] being grade 1). All patients showed changes in handwriting and tremor as their initial presentation. Changes in cognition were manifested in most of the patients, with a more substantial drop noted in their Montreal Cognitive Assessment compared to immune effector cell-associated encephalopathy scores. All manifestations of neurotoxicity were short-lived and resolved within a 1-month period, with a mean duration of 8.2 days (range = 1-33). CONCLUSIONS The patterns of CAR-T-related neurotoxicity often include change in handwriting, tremor, and mild confusional state, especially early in their evolution. These may remain undetected by routine neurological surveillance. These features represent accessible clinical markers of incipient ICANS.
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Affiliation(s)
- Carmela Sales
- Neuroimmunology Centre, Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Clinical Haematology, Peter MacCallum Cancer Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Mary Ann Anderson
- Department of Clinical Haematology, Peter MacCallum Cancer Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Division of Blood Cells and Blood Cancer, Walter and Eliza Hall Institute, Parkville, Victoria, Australia
| | - Valeriya Kuznetsova
- Neuroimmunology Centre, Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Clinical Haematology, Peter MacCallum Cancer Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Clinical Outcomes Research (CORe), Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Hannah Rosenfeld
- Neuroimmunology Centre, Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Clinical Haematology, Peter MacCallum Cancer Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Charles B Malpas
- Neuroimmunology Centre, Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Clinical Outcomes Research (CORe), Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Melbourne School of Psychological Sciences, University of Melbourne, Parkville, Victoria, Australia
| | - Izanne Roos
- Neuroimmunology Centre, Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Clinical Outcomes Research (CORe), Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Michael Dickinson
- Department of Clinical Haematology, Peter MacCallum Cancer Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - Simon Harrison
- Department of Clinical Haematology, Peter MacCallum Cancer Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - Tomas Kalincik
- Neuroimmunology Centre, Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Clinical Outcomes Research (CORe), Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
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Koch C, Fleischer J, Popov T, Frontzek K, Schreiner B, Roth P, Manz MG, Unseld S, Müller AMS, Russkamp NF. Diabetes insipidus and Guillain-Barré-like syndrome following CAR-T cell therapy: a case report. J Immunother Cancer 2023; 11:e006059. [PMID: 36690387 PMCID: PMC9872508 DOI: 10.1136/jitc-2022-006059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Immune effector cell-associated neurotoxicity syndrome (ICANS) is a common adverse event of CD19-directed chimeric antigen receptor (CAR) T cell therapy. Other neurological adverse events, however, have not methodically been described and studied. Furthermore, safety data on CAR-T cell therapy in patients with central nervous system (CNS) lymphoma remain limited. MAIN BODY We here report occurrence of a Guillain-Barré-like syndrome (GBS) and central diabetes insipidus (cDI) following tisagenlecleucel therapy for relapsed high-grade lymphoma with CNS involvement. Both complications were refractory to standard treatment of ICANS. Weakness of respiratory muscles required mechanical ventilation and tracheostomy while cDI was treated with desmopressin substitution for several weeks. Muscle-nerve biopsy and nerve conduction studies confirmed an axonal pattern of nerve damage. T cell-rich infiltrates and detection of the CAR transgene in muscle-nerve sections imply a direct or indirect role of CAR-T cell-mediated inflammation. In line with current treatment guidelines for GBS, intravenous immunoglobulin was administered and gradual but incomplete recovery was observed over the course of several months. CONCLUSIONS This case report highlights the risk of rare but severe neurological adverse events, such as acute GBS or cDI, in patients treated with CAR-T cells. It further underlines the importance of appropriate patient surveillance and systematic reporting of rare complications to eventually improve treatment.
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Affiliation(s)
- Christian Koch
- Department of Medical Oncology and Hematology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Juliane Fleischer
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Todor Popov
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Karl Frontzek
- Institute of Neuropathology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Bettina Schreiner
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Patrick Roth
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Markus G Manz
- Department of Medical Oncology and Hematology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Simone Unseld
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Antonia M S Müller
- Department of Transfusion Medicine and Cell Therapy, Medical University Vienna, Vienna, Austria
| | - Norman F Russkamp
- Department of Medical Oncology and Hematology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Department of Internal Medicine, University Hospital Zurich, Zurich, Switzerland
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