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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] [What about the content of this article? (0)] [Affiliation(s)] [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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2
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Storgard R, Rejeski K, Perales MA, Goldman A, Shouval R. T-Cell Malignant Neoplasms After Chimeric Antigen Receptor T-Cell Therapy. JAMA Oncol 2024:2817658. [PMID: 38635228 DOI: 10.1001/jamaoncol.2024.0662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
This cohort study assesses the increase in second primary malignant neoplasms and T-cell malignant neoplasm cases associated with chimeric antigen receptor–T cells.
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Affiliation(s)
- Ryan Storgard
- Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Kai Rejeski
- Adult Bone Marrow Transplant and Cellular Therapy Service, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Medicine III, LMU University Hospital, LMU Munich, Munich, Germany
| | - Miguel-Angel Perales
- Department of Medicine, Weill Cornell Medical College, New York, New York
- Adult Bone Marrow Transplant and Cellular Therapy Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Adam Goldman
- Department of Internal Medicine, Sheba Medical Center, Ramat-Gan, Israel
| | - Roni Shouval
- Department of Medicine, Weill Cornell Medical College, New York, New York
- Adult Bone Marrow Transplant and Cellular Therapy Service, Memorial Sloan Kettering Cancer Center, New York, New York
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Stock S, Fertig L, Gottschlich A, Dörr J, Märkl F, Majed L, Menkhoff VD, Grünmeier R, Rejeski K, Cordas Dos Santos DM, Theurich S, von Bergwelt-Baildon M, Endres S, Subklewe M, Kobold S. Comparative performance of scFv-based anti-BCMA CAR formats for improved T cell therapy in multiple myeloma. Cancer Immunol Immunother 2024; 73:100. [PMID: 38630291 DOI: 10.1007/s00262-024-03688-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 03/22/2024] [Indexed: 04/19/2024]
Abstract
In multiple myeloma (MM), B cell maturation antigen (BCMA)-directed CAR T cells have emerged as a novel therapy with potential for long-term disease control. Anti-BCMA CAR T cells with a CD8-based transmembrane (TM) and CD137 (41BB) as intracellular costimulatory domain are in routine clinical use. As the CAR construct architecture can differentially impact performance and efficacy, the optimal construction of a BCMA-targeting CAR remains to be elucidated. Here, we hypothesized that varying the constituents of the CAR structure known to impact performance could shed light on how to improve established anti-BCMA CAR constructs. CD8TM.41BBIC-based anti-BCMA CAR vectors with either a long linker or a short linker between the light and heavy scFv chain, CD28TM.41BBIC-based and CD28TM.CD28IC-based anti-BCMA CAR vector systems were used in primary human T cells. MM cell lines were used as target cells. The short linker anti-BCMA CAR demonstrated higher cytokine production, whereas in vitro cytotoxicity, T cell differentiation upon activation and proliferation were superior for the CD28TM.CD28IC-based CAR. While CD28TM.CD28IC-based CAR T cells killed MM cells faster, the persistence of 41BBIC-based constructs was superior in vivo. While CD28 and 41BB costimulation come with different in vitro and in vivo advantages, this did not translate into a superior outcome for either tested model. In conclusion, this study showcases the need to study the influence of different CAR architectures based on an identical scFv individually. It indicates that current scFv-based anti-BCMA CAR with clinical utility may already be at their functional optimum regarding the known structural variations of the scFv linker.
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Affiliation(s)
- Sophia Stock
- Division of Clinical Pharmacology, Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany.
- Department of Medicine III, LMU University Hospital, LMU Munich, Munich, Germany.
- German Cancer Consortium (DKTK), Partner Site Munich, a partnership between the DKFZ Heidelberg and the LMU University Hospital, Munich, Germany.
| | - Luisa Fertig
- Division of Clinical Pharmacology, Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Adrian Gottschlich
- Division of Clinical Pharmacology, Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
- Department of Medicine III, LMU University Hospital, LMU Munich, Munich, Germany
| | - Janina Dörr
- Division of Clinical Pharmacology, Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Florian Märkl
- Division of Clinical Pharmacology, Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Lina Majed
- Division of Clinical Pharmacology, Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Vivien D Menkhoff
- Division of Clinical Pharmacology, Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Ruth Grünmeier
- Division of Clinical Pharmacology, Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Kai Rejeski
- Department of Medicine III, LMU University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, a partnership between the DKFZ Heidelberg and the LMU University Hospital, Munich, Germany
- Laboratory of Translational Cancer Immunology, LMU Gene Center, Munich, Germany
| | - David M Cordas Dos Santos
- Department of Medicine III, LMU University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, a partnership between the DKFZ Heidelberg and the LMU University Hospital, Munich, Germany
- Cancer- and Immunometabolism Research Group, LMU Gene Center, Munich, Germany
| | - Sebastian Theurich
- Department of Medicine III, LMU University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, a partnership between the DKFZ Heidelberg and the LMU University Hospital, Munich, Germany
- Cancer- and Immunometabolism Research Group, LMU Gene Center, Munich, Germany
| | - Michael von Bergwelt-Baildon
- Department of Medicine III, LMU University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, a partnership between the DKFZ Heidelberg and the LMU University Hospital, Munich, Germany
| | - Stefan Endres
- Division of Clinical Pharmacology, Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, a partnership between the DKFZ Heidelberg and the LMU University Hospital, Munich, Germany
- Einheit für Klinische Pharmakologie (EKLiP), Helmholtz Zentrum München, German Research Center for Environmental Health (HMGU), Neuherberg, Germany
| | - Marion Subklewe
- Department of Medicine III, LMU University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, a partnership between the DKFZ Heidelberg and the LMU University Hospital, Munich, Germany
- Laboratory of Translational Cancer Immunology, LMU Gene Center, Munich, Germany
| | - Sebastian Kobold
- Division of Clinical Pharmacology, Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany.
- German Cancer Consortium (DKTK), Partner Site Munich, a partnership between the DKFZ Heidelberg and the LMU University Hospital, Munich, Germany.
- Einheit für Klinische Pharmakologie (EKLiP), Helmholtz Zentrum München, German Research Center for Environmental Health (HMGU), Neuherberg, Germany.
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Alhomoud M, Rejeski K. Navigating the prognostic role of transfusions after CAR-T. Blood Adv 2024; 8:1570-1572. [PMID: 38530306 PMCID: PMC10982968 DOI: 10.1182/bloodadvances.2024012583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2024] Open
Affiliation(s)
- Mohammad Alhomoud
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kai Rejeski
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine III - Hematology/Oncology, LMU University Hospital, LMU Munich, Munich, Germany
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Faramand RG, Lee SB, Jain MD, Cao B, Wang X, Rejeski K, Subklewe M, Fahrmann JF, Saini NY, Hanash SM, Kang YP, Chang D, Rodriguez PC, Dean EA, Nishihori T, Shah BD, Lazaryan A, Chavez J, Khimani F, Pinilla-Ibarz JA, Dam M, Reid KM, Corallo SA, Menges M, Hidalgo Vargas M, Mandula JK, Holliday BA, Bachmeier CA, Speth K, Song Q, Mattie M, Locke FL, Davila ML. Baseline Serum Inflammatory Proteins Predict Poor CAR T Outcomes in Diffuse Large B-cell Lymphoma. Blood Cancer Discov 2024; 5:106-113. [PMID: 38194367 PMCID: PMC10905320 DOI: 10.1158/2643-3230.bcd-23-0056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 09/28/2023] [Accepted: 01/05/2024] [Indexed: 01/10/2024] Open
Abstract
A subset of patients with diffuse large B-cell lymphoma (DLBCL) treated with CD19 chimeric antigen receptor (CAR) T-cell therapy have poor clinical outcomes. We report serum proteins associated with severe immune-mediated toxicities and inferior clinical responses in 146 patients with DLBCL treated with axicabtagene ciloleucel. We develop a simple stratification based on pre-lymphodepletion C reactive protein (CRP) and ferritin to classify patients into low-, intermediate-, and high-risk groups. We observe that patients in the high-risk category were more likely to develop grade ≥3 toxicities and had inferior overall and progression-free survival. We sought to validate our findings with two independent international cohorts demonstrating that patients classified as low-risk have excellent efficacy and safety outcomes. Based on routine and readily available laboratory tests that can be obtained prior to lymphodepleting chemotherapy, this simple risk stratification can inform patient selection for CAR T-cell therapy. SIGNIFICANCE CAR T-cell therapy has changed the treatment paradigm for patients with relapsed/refractory hematologic malignancies. Despite encouraging efficacy, a subset of patients have poor clinical outcomes. We show that a simple clinically applicable model using pre-lymphodepletion CRP and ferritin can identify patients at high risk of poor outcomes. This article is featured in Selected Articles from This Issue, p. 80.
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Affiliation(s)
- Rawan G. Faramand
- Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Sae Bom Lee
- Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Michael D. Jain
- Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Biwei Cao
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Xuefeng Wang
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Kai Rejeski
- Department of Medicine III, University Hospital, Ludwig Maximilian University (LMU) Munich, Germany
| | - Marion Subklewe
- Department of Medicine III, University Hospital, Ludwig Maximilian University (LMU) Munich, Germany
| | - Johannes F. Fahrmann
- Department of Clinical Cancer Prevention, Division of Cancer Prevention and Population Sciences, MD Anderson Cancer Center, Houston, Texas
| | - Neeraj Y. Saini
- Department of Clinical Cancer Prevention, Division of Cancer Prevention and Population Sciences, MD Anderson Cancer Center, Houston, Texas
| | - Samir M. Hanash
- Department of Clinical Cancer Prevention, Division of Cancer Prevention and Population Sciences, MD Anderson Cancer Center, Houston, Texas
| | - Yun Pyo Kang
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea
| | - Darwin Chang
- Department of Immunology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Paolo C. Rodriguez
- Department of Immunology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Erin A. Dean
- Division of Hematology and Oncology, University of Florida, Gainesville, Florida
| | - Taiga Nishihori
- Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Bijal D. Shah
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Aleksandr Lazaryan
- Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Julio Chavez
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Farhad Khimani
- Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Javier A. Pinilla-Ibarz
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Marian Dam
- Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Kayla M. Reid
- Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Salvatore A. Corallo
- Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Meghan Menges
- Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Melanie Hidalgo Vargas
- Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Jay K. Mandula
- Pelotonia Institute for Immuno-Oncology, The Ohio State University Comprehensive Cancer Center - Arthur G James Cancer Hospital and Richard J Solove Research Institute, The Ohio State University, Columbus, Ohio
| | | | - Christina A. Bachmeier
- Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Kelly Speth
- Kite, a Gilead Company, Santa Monica, California
| | - Qinghua Song
- Kite, a Gilead Company, Santa Monica, California
| | - Mike Mattie
- Kite, a Gilead Company, Santa Monica, California
| | - Frederick L. Locke
- Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Marco L. Davila
- Department of Medical Oncology, Roswell Park Cancer Center, Buffalo, New York
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Iacoboni G, Navarro V, Martín-López AÁ, Rejeski K, Kwon M, Jalowiec KA, Amat P, Reguera-Ortega JL, Gallur L, Blumenberg V, Gutiérrez-Herrero S, Roddie C, Benzaquén A, Delgado-Serrano J, Sánchez-Salinas MA, Bailén R, Carpio C, López-Corral L, Hernani R, Bastos M, O'Reilly M, Martín-Martín L, Subklewe M, Barba P. Recent Bendamustine Treatment Before Apheresis Has a Negative Impact on Outcomes in Patients With Large B-Cell Lymphoma Receiving Chimeric Antigen Receptor T-Cell Therapy. J Clin Oncol 2024; 42:205-217. [PMID: 37874957 DOI: 10.1200/jco.23.01097] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 08/10/2023] [Accepted: 08/21/2023] [Indexed: 10/26/2023] Open
Abstract
PURPOSE Approximately 30%-40% of patients with relapsed/refractory (R/R) large B-cell lymphoma (LBCL) infused with CD19-targeted chimeric antigen receptor (CAR) T cells achieve durable responses. Consensus guidelines suggest avoiding bendamustine before apheresis, but specific data in this setting are lacking. We report distinct outcomes after CAR T-cell therapy according to previous bendamustine exposure. METHODS The study included CAR T-cell recipients from seven European sites. Safety, efficacy, and CAR T-cell expansion kinetics were analyzed according to preapheresis bendamustine exposure. Additional studies on the impact of the washout period and bendamustine dose were performed. Inverse probability treatment weighting (IPTW) and propensity score matching (PSM) analyses were carried out for all efficacy comparisons between bendamustine-exposed and bendamustine-naïve patients. RESULTS The study included 439 patients with R/R LBCL infused with CD19-targeted commercial CAR T cells, of whom 80 had received bendamustine before apheresis. Exposed patients had significantly lower CD3+ cells and platelets at apheresis. These patients had a lower overall response rate (ORR, 53% v 72%; P < .01), a shorter progression-free survival (PFS, 3.1 v 6.2 months; P = .04), and overall survival (OS, 10.3 v 23.5 months; P = .01) in comparison with the bendamustine-naïve group. Following adjustment methods for baseline variables, these differences were mitigated. Focusing on the impact of bendamustine washout before apheresis, those with recent (<9 months) exposure (N = 42) displayed a lower ORR (40% v 72%; P < .01), shorter PFS (1.3 v 6.2 months; P < .01), and OS (4.6 v 23.5 months; P < .01) in comparison with bendamustine-naïve patients. These differences remained significant after IPTW and PSM analysis. Conversely, the cumulative dose of bendamustine before apheresis did not affect CAR-T efficacy outcomes. CONCLUSION Recent bendamustine exposure before apheresis was associated with negative treatment outcomes after CD19-targeted CAR T-cell therapy and should be therefore avoided in CAR T-cell candidates.
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Affiliation(s)
- Gloria Iacoboni
- Department of Hematology, University Hospital Vall d'Hebron, Barcelona, Spain
- Experimental Hematology, Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Víctor Navarro
- Oncology Data Science (ODySey) Group, Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Ana África Martín-López
- Hematology Department, Hospital Clínico Universitario de Salamanca, IBSAL, CIBERONC, Salamanca, Spain
- Centro de Investigación del Cáncer-IBMCC, Salamanca, Spain
| | - Kai Rejeski
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, Gene Center of the LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK) and Bavarian Center for Cancer Research (BZKF), partner site Munich, Munich, Germany
| | - Mi Kwon
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Gregorio Marañón Health Research Institute (IiSGM), Madrid, Spain
| | - Katarzyna Aleksandra Jalowiec
- Hematology Department, University College London Cancer Institute, London, United Kingdom
- Department of Hematology and Central Hematology Laboratory, University Hospital of Bern, Bern, Switzerland
| | - Paula Amat
- Haematology Department, Hospital Clínico Universitario, Valencia, Spain
- INCLIVA Research Institute, Valencia, Spain
| | - Juan Luis Reguera-Ortega
- Hematology Department, Hospital Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBIS)/CSIC, Universidad de Sevilla, Sevilla, Spain
| | - Laura Gallur
- Department of Hematology, University Hospital Vall d'Hebron, Barcelona, Spain
- Experimental Hematology, Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Viktoria Blumenberg
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, Gene Center of the LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK) and Bavarian Center for Cancer Research (BZKF), partner site Munich, Munich, Germany
| | - Sara Gutiérrez-Herrero
- Cancer Research Centre (IBMCC, USAL-CSIC), Institute for Biomedical Research of Salamanca (IBSAL) and Department of Medicine and Cytometry Service (NUCLEUS Research Support Platform), University of Salamanca (USAL), Salamanca, Spain
| | - Claire Roddie
- Hematology Department, University College London Cancer Institute, London, United Kingdom
| | - Ana Benzaquén
- Haematology Department, Hospital Clínico Universitario, Valencia, Spain
- INCLIVA Research Institute, Valencia, Spain
| | - Javier Delgado-Serrano
- Hematology Department, Hospital Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBIS)/CSIC, Universidad de Sevilla, Sevilla, Spain
| | - Mario Andrés Sánchez-Salinas
- Department of Hematology, University Hospital Vall d'Hebron, Barcelona, Spain
- Experimental Hematology, Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Rebeca Bailén
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Gregorio Marañón Health Research Institute (IiSGM), Madrid, Spain
| | - Cecilia Carpio
- Department of Hematology, University Hospital Vall d'Hebron, Barcelona, Spain
- Experimental Hematology, Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Lucia López-Corral
- Hematology Department, Hospital Clínico Universitario de Salamanca, IBSAL, CIBERONC, Salamanca, Spain
- Centro de Investigación del Cáncer-IBMCC, Salamanca, Spain
| | - Rafael Hernani
- Haematology Department, Hospital Clínico Universitario, Valencia, Spain
- INCLIVA Research Institute, Valencia, Spain
| | - Mariana Bastos
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Gregorio Marañón Health Research Institute (IiSGM), Madrid, Spain
| | - Maeve O'Reilly
- Hematology Department, University College London Cancer Institute, London, United Kingdom
| | - Lourdes Martín-Martín
- Cancer Research Centre (IBMCC, USAL-CSIC), Institute for Biomedical Research of Salamanca (IBSAL) and Department of Medicine and Cytometry Service (NUCLEUS Research Support Platform), University of Salamanca (USAL), Salamanca, Spain
| | - Marion Subklewe
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, Gene Center of the LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK) and Bavarian Center for Cancer Research (BZKF), partner site Munich, Munich, Germany
| | - Pere Barba
- Department of Hematology, University Hospital Vall d'Hebron, Barcelona, Spain
- Experimental Hematology, Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain
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Winkelmann M, Blumenberg V, Rejeski K, Quell C, Bücklein VL, Ingenerf M, Unterrainer M, Schmidt C, Dekorsy FJ, Bartenstein P, Ricke J, von Bergwelt-Baildon M, Subklewe M, Kunz WG. Predictive value of pre-infusion tumor growth rate for the occurrence and severity of CRS and ICANS in lymphoma under CAR T-cell therapy. Ann Hematol 2024; 103:259-268. [PMID: 37861736 DOI: 10.1007/s00277-023-05507-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 10/10/2023] [Indexed: 10/21/2023]
Abstract
Chimeric antigen receptor T-cell therapy (CART) can be administered outpatient yet requires management of potential side effects such as cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). The pre-infusion tumor burden is associated with CRS, yet there is no data on the relevance of pre-infusion tumor growth rate (TGR). Our objective was to investigate TGR for the occurrence and severity of CRS and ICANS. Consecutive patients with available pre-baseline and baseline (BL) imaging before CART were included. TGR was determined as both absolute (abs) and percentage change (%) of Lugano criteria-based tumor burden in relation to days between exams. CRS and ICANS were graded according to ASTCT consensus criteria. Clinical metadata was collected including the international prognostic index (IPI), patient age, ECOG performance status, and LDH. Sixty-two patients were included (median age: 62 years, 40% female). The median pre-BL TGR [abs] and pre-BL TGR [%] was 7.5 mm2/d and 30.9%/d. Pre-BL TGR [abs] and pre-BL TGR [%] displayed a very weak positive correlation with the grade of CRS (r[abs] = 0.14 and r[%] = 0.13) and no correlation with ICANS (r[abs] = - 0.06 and r[%] = - 0.07). There was a weak positive correlation between grade of CRS and grade of ICANS (r = 0.35; p = 0.005) whereas there was no significant correlation of CRS or ICANS to any other of the examined parameters. The pre-infusion TGR before CART was weakly associated with the occurrence of CRS, but not the severity, whereas there were no significant differences in the prediction of ICANS. There was no added information when compared to pre-infusion tumor burden alone. Outpatient planning and toxicity management should not be influenced by the pre-infusion TGR.
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Affiliation(s)
- Michael Winkelmann
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Viktoria Blumenberg
- Laboratory for Translational Cancer Immunology, Gene Center of the LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK) and Bavarian Center for Cancer Research (BZKF), Partner Site Munich, Munich, Germany
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Kai Rejeski
- Laboratory for Translational Cancer Immunology, Gene Center of the LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK) and Bavarian Center for Cancer Research (BZKF), Partner Site Munich, Munich, Germany
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Christina Quell
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Veit L Bücklein
- Laboratory for Translational Cancer Immunology, Gene Center of the LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK) and Bavarian Center for Cancer Research (BZKF), Partner Site Munich, Munich, Germany
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Maria Ingenerf
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Marcus Unterrainer
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Christian Schmidt
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Franziska J Dekorsy
- Department of Nuclear Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Peter Bartenstein
- Department of Nuclear Medicine, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Cancer Center München-LMU (CCCM LMU), LMU Munich, Munich, Germany
| | - Jens Ricke
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Cancer Center München-LMU (CCCM LMU), LMU Munich, Munich, Germany
| | - Michael von Bergwelt-Baildon
- German Cancer Consortium (DKTK) and Bavarian Center for Cancer Research (BZKF), Partner Site Munich, Munich, Germany
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Cancer Center München-LMU (CCCM LMU), LMU Munich, Munich, Germany
| | - Marion Subklewe
- Laboratory for Translational Cancer Immunology, Gene Center of the LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK) and Bavarian Center for Cancer Research (BZKF), Partner Site Munich, Munich, Germany
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Cancer Center München-LMU (CCCM LMU), LMU Munich, Munich, Germany
| | - Wolfgang G Kunz
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany.
- German Cancer Consortium (DKTK) and Bavarian Center for Cancer Research (BZKF), Partner Site Munich, Munich, Germany.
- Comprehensive Cancer Center München-LMU (CCCM LMU), LMU Munich, Munich, Germany.
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8
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Karschnia P, Arrillaga-Romany IC, Eichler A, Forst DA, Gerstner E, Jordan JT, Ly I, Plotkin SR, Wang N, Martinez-Lage M, Winter SF, Tonn JC, Rejeski K, von Baumgarten L, Cahill DP, Nahed BV, Shankar GM, Abramson JS, Barnes JA, El-Jawahri A, Hochberg EP, Johnson PC, Soumerai JD, Takvorian RW, Chen YB, Frigault MJ, Dietrich J. Neurotoxicity and management of primary and secondary central nervous system lymphoma after adoptive immunotherapy with CD19-directed chimeric antigen receptor T-cells. Neuro Oncol 2023; 25:2239-2249. [PMID: 37402650 PMCID: PMC10708936 DOI: 10.1093/neuonc/noad118] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND Chimeric antigen receptor (CAR) T-cells targeting CD19 have been established as a leading engineered T-cell therapy for B-cell lymphomas; however, data for patients with central nervous system (CNS) involvement are limited. METHODS We retrospectively report on CNS-specific toxicities, management, and CNS response of 45 consecutive CAR T-cell transfusions for patients with active CNS lymphoma at the Massachusetts General Hospital over a 5-year period. RESULTS Our cohort includes 17 patients with primary CNS lymphoma (PCNSL; 1 patient with 2 CAR T-cell transfusions) and 27 patients with secondary CNS lymphoma (SCNSL). Mild ICANS (grade 1-2) was observed after 19/45 transfusions (42.2%) and severe immune effector cell-associated neurotoxicity syndrome (ICANS) (grade 3-4) after 7/45 transfusions (15.6%). A larger increase in C-reactive protein (CRP) levels and higher rates of ICANS were detected in SCNSL. Early fever and baseline C-reactive protein levels were associated with ICANS occurrence. CNS response was seen in 31 cases (68.9%), including a complete response of CNS disease in 18 cases (40.0%) which lasted for a median of 11.4 ± 4.5 months. Dexamethasone dose at time of lymphodepletion (but not at or after CAR T-cell transfusion) was associated with an increased risk for CNS progression (hazard ratios [HR] per mg/d: 1.16, P = .031). If bridging therapy was warranted, the use of ibrutinib translated into favorable CNS-progression-free survival (5 vs. 1 month, HR 0.28, CI 0.1-0.7; P = .010). CONCLUSIONS CAR T-cells exhibit promising antitumor effects and a favorable safety profile in CNS lymphoma. Further evaluation of the role of bridging regimens and corticosteroids is warranted.
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Affiliation(s)
- Philipp Karschnia
- Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurosurgery, Section for Neuro-Oncology, Ludwig-Maximilians-University, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Germany
| | - Isabel C Arrillaga-Romany
- Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - April Eichler
- Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Deborah A Forst
- Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Elizabeth Gerstner
- Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Justin T Jordan
- Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ina Ly
- Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Scott R Plotkin
- Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Nancy Wang
- Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Maria Martinez-Lage
- Department of Pathology, Division of Neuropathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sebastian F Winter
- Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Joerg-Christian Tonn
- Department of Neurosurgery, Section for Neuro-Oncology, Ludwig-Maximilians-University, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Germany
| | - Kai Rejeski
- German Cancer Consortium (DKTK), Partner Site Munich, Germany
- Department of Medicine III, Section for Cellular Immunotherapy, Ludwig-Maximilians-University, Munich, Germany
| | - Louisa von Baumgarten
- Department of Neurosurgery, Section for Neuro-Oncology, Ludwig-Maximilians-University, Munich, Germany
| | - Daniel P Cahill
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Brian V Nahed
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ganesh M Shankar
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeremy S Abramson
- Department of Medicine, Hematology, and Oncology Division, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeffrey A Barnes
- Department of Medicine, Hematology, and Oncology Division, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Areej El-Jawahri
- Department of Medicine, Hematology, and Oncology Division, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ephraim P Hochberg
- Department of Medicine, Hematology, and Oncology Division, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - P Connor Johnson
- Department of Medicine, Hematology, and Oncology Division, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jacob D Soumerai
- Department of Medicine, Hematology, and Oncology Division, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ronald W Takvorian
- Department of Medicine, Hematology, and Oncology Division, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Yi-Bin Chen
- Department of Medicine, Cellular Immunotherapy Program, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew J Frigault
- Department of Medicine, Cellular Immunotherapy Program, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jorg Dietrich
- Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
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9
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Rejeski K, Subklewe M, Locke FL. Recognizing, defining, and managing CAR-T hematologic toxicities. Hematology Am Soc Hematol Educ 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] [What about the content of this article? (0)] [Affiliation(s)] [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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Blumenberg V, Busch G, Baumann S, Jitschin R, Iacoboni G, Gallur L, Iraola-Truchuelo J, Hoster E, Winkelmann M, Hellwig K, Schmidt C, Frölich L, Tast B, Hildebrand F, Rejeski K, Dekorsy F, Schmidkonz C, Bäuerle T, Kunz WG, Mougiakakos D, Müller F, von Bergwelt-Baildon M, Barba P, Bücklein VL, Mackensen A, Völkl S, Subklewe M. Early quantification of anti-CD19 CAR T cells by flow cytometry predicts response in R/R DLBCL. Blood Adv 2023; 7:6844-6849. [PMID: 37748131 PMCID: PMC10679803 DOI: 10.1182/bloodadvances.2023010364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 08/02/2023] [Accepted: 09/07/2023] [Indexed: 09/27/2023] Open
Affiliation(s)
- Viktoria Blumenberg
- Department of Medicine III, LMU University Hospital, LMU Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), partner site Munich, Munich, Germany
- Bavarian Center for Cancer Research (BZKF), partner site Munich, Munich, Germany
| | - Galina Busch
- Laboratory for Translational Cancer Immunology, LMU Gene Center, LMU Munich, Munich, Germany
| | - Stephan Baumann
- Laboratory for Translational Cancer Immunology, LMU Gene Center, LMU Munich, Munich, Germany
| | - Regina Jitschin
- Department of Internal Medicine 5, Hematology and Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg and University Hospital Erlangen, Erlangen, Germany
- Department for Hematology and Oncology, Otto-von-Guericke University, Magdeburg, Germany
| | - Gloria Iacoboni
- Department of Hematology, Vall d'Hebron University Hospital, Experimental Hematology, Vall d'Hebron Institute of Oncology, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Department of Medicine, Universitat Autònoma of Barcelona, Barcelona, Spain
| | - Laura Gallur
- Department of Hematology, Vall d'Hebron University Hospital, Experimental Hematology, Vall d'Hebron Institute of Oncology, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Department of Medicine, Universitat Autònoma of Barcelona, Barcelona, Spain
| | - Josu Iraola-Truchuelo
- Department of Hematology, Vall d'Hebron University Hospital, Experimental Hematology, Vall d'Hebron Institute of Oncology, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Eva Hoster
- Department of Medicine III, LMU University Hospital, LMU Munich, Munich, Germany
- Institute for Medical Informatics, Biometry and Epidemiology, LMU Munich, Munich, Germany
| | - Michael Winkelmann
- Department of Radiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Konstantin Hellwig
- Department of Radiology, Friedrich-Alexander-Universität Erlangen-Nürnberg and University Hospital Erlangen, Erlangen, Germany
| | - Christian Schmidt
- Department of Medicine III, LMU University Hospital, LMU Munich, Munich, Germany
| | - Lisa Frölich
- Department of Medicine III, LMU University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), partner site Munich, Munich, Germany
| | - Benjamin Tast
- Laboratory for Translational Cancer Immunology, LMU Gene Center, LMU Munich, Munich, Germany
| | | | - Kai Rejeski
- Department of Medicine III, LMU University Hospital, LMU Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), partner site Munich, Munich, Germany
- Bavarian Center for Cancer Research (BZKF), partner site Munich, Munich, Germany
| | - Franziska Dekorsy
- Department of Nuclear Medicine, LMU University Hospital, LMU Munich, Munich, Germany
| | - Christian Schmidkonz
- Bavarian Center for Cancer Research (BZKF), partner site Munich, Munich, Germany
- Department of Nuclear Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg and University Hospital Erlangen, Erlangen, Germany
- Institute for Medical Engineering, University of Applied Sciences Amberg-Weiden, Weiden, Germany
| | - Tobias Bäuerle
- Department of Radiology, Friedrich-Alexander-Universität Erlangen-Nürnberg and University Hospital Erlangen, Erlangen, Germany
| | - Wolfgang G. Kunz
- Department of Radiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Dimitrios Mougiakakos
- Department of Internal Medicine 5, Hematology and Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg and University Hospital Erlangen, Erlangen, Germany
- Department for Hematology and Oncology, Otto-von-Guericke University, Magdeburg, Germany
- Bavarian Cancer Research Center (BZKF), partner site Erlangen, Erlangen, Germany
| | - Fabian Müller
- Department of Internal Medicine 5, Hematology and Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg and University Hospital Erlangen, Erlangen, Germany
- Bavarian Cancer Research Center (BZKF), partner site Erlangen, Erlangen, Germany
| | - Michael von Bergwelt-Baildon
- Department of Medicine III, LMU University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), partner site Munich, Munich, Germany
- Bavarian Center for Cancer Research (BZKF), partner site Munich, Munich, Germany
| | - Pere Barba
- Department of Hematology, Vall d'Hebron University Hospital, Experimental Hematology, Vall d'Hebron Institute of Oncology, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Department of Medicine, Universitat Autònoma of Barcelona, Barcelona, Spain
| | - Veit L. Bücklein
- Department of Medicine III, LMU University Hospital, LMU Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, LMU Munich, Munich, Germany
- Bavarian Center for Cancer Research (BZKF), partner site Munich, Munich, Germany
| | - Andreas Mackensen
- Department of Internal Medicine 5, Hematology and Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg and University Hospital Erlangen, Erlangen, Germany
- Bavarian Cancer Research Center (BZKF), partner site Erlangen, Erlangen, Germany
| | - Simon Völkl
- Department of Internal Medicine 5, Hematology and Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg and University Hospital Erlangen, Erlangen, Germany
- Bavarian Cancer Research Center (BZKF), partner site Erlangen, Erlangen, Germany
| | - Marion Subklewe
- Department of Medicine III, LMU University Hospital, LMU Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), partner site Munich, Munich, Germany
- Bavarian Center for Cancer Research (BZKF), partner site Munich, Munich, Germany
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11
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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: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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12
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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13
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Karschnia P, Miller KC, Yee AJ, Rejeski K, Johnson PC, Raje N, Frigault MJ, Dietrich J. Neurologic toxicities following adoptive immunotherapy with BCMA-directed CAR T cells. Blood 2023; 142:1243-1248. [PMID: 37471607 DOI: 10.1182/blood.2023020571] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 06/06/2023] [Accepted: 07/02/2023] [Indexed: 07/22/2023] Open
Abstract
In 2 complementary Letters to Blood, Karschnia et al and Graham et al provide new insights into the neurological toxicities that are observed with B-cell maturation antigen–directed chimeric antigen receptor T-cell treatment for multiple myeloma, identifying a frequency of immune effector cell–associated neurotoxicity syndrome (ICANS) that exceeds 40%. Severe ICANS is identified in 8% of patients in this real-world series. Outcomes were generally favorable, although the authors describe rare, late Parkinsonism-like hypokinetic movement disorders (also known as movement and neurocognitive toxicities) post-ICANS in 2 patients.
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Affiliation(s)
- Philipp Karschnia
- Division of Neuro-Oncology, Department of Neurology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
- Section for Neuro-Oncology, Department of Neurosurgery, Ludwig Maximilian University, Munich, Germany
- German Cancer Consortium, Partner Site Munich, Germany
| | - Kevin C Miller
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Andrew J Yee
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Kai Rejeski
- Department of Medicine III, Section for Cellular Immunotherapy, Ludwig Maximilian University, Munich, Germany
| | - P Connor Johnson
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Noopur Raje
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Matthew J Frigault
- Cellular Immunotherapy Program, Department of Medicine, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Jorg Dietrich
- Division of Neuro-Oncology, Department of Neurology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
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14
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Winkelmann M, Blumenberg V, Rejeski K, Quell C, Bücklein V, Ingenerf M, Unterrainer M, Schmidt C, Dekorsy FJ, Bartenstein P, Ricke J, von Bergwelt-Baildon M, Subklewe M, Kunz WG. Modification of Lugano criteria by pre-infusion tumor kinetics improves early survival prediction for patients with lymphoma under chimeric antigen receptor T-cell therapy. J Immunother Cancer 2023; 11:e006659. [PMID: 37880181 PMCID: PMC10603350 DOI: 10.1136/jitc-2022-006659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND Chimeric antigen receptor T-cell therapy (CART) is effective for patients with refractory or relapsed lymphoma with prolongation of survival. We aimed to improve the prediction of Lugano criteria for overall survival (OS) at 30-day follow-up (FU1) by including the pre-infusion tumor growth rate (TGRpre-BL) and its early change to 30-day FU1 imaging (TGRpost-BL). METHODS Consecutive patients with pre-baseline (pre-BL), baseline (BL) and FU1 imaging with CT or positron emission tomography/CT before CART were included. TGR was defined as change of Lugano criteria-based tumor burden between pre-BL, BL and FU1 examinations in relation to days between imaging examinations. Overall response and progression-free survival were determined based on Lugano criteria. Proportional Cox regression analysis studied association of TGR with OS. For survival analysis, OS was analyzed using Kaplan-Meier survival curves. RESULTS Fifty-nine out of 81 patients met the inclusion criteria. At 30-day FU1 8 patients (13.6%) had a complete response (CR), 25 patients (42.4%) a partial response (PR), 15 patients (25.4%) a stable disease (SD), and 11 patients (18.6%) a progressive disease (PD) according to CT-based Lugano criteria. The median TGRpre-BL was -0.6 mm2/day, 24.4 mm2/day, -5.1 mm2/day, and 18.6 mm2/day and the median TGRpost-BL was -16.7 mm2/day, -102.0 mm2/day, -19.8 mm2/day and 8.5 mm2/day in CR, PR, SD, and PD patients, respectively. PD patients could be subclassified into a cohort with an increase in TGR (7 of 11 patients (64%), PD TGRpre-to-post-BL INCR) and a cohort with a decrease in TGR (4 of 11 patients (36%), PD TGRpre-to-post-BL DECR) from pre-BL to post-BL. PD TGRpre-to-post-BL DECR patients exhibited similar OS to patients classified as SD, while PD TGRpre-to-post-BL INCR patients had significantly shorter OS (65 days vs 471 days, p<0.001). CONCLUSION In the context of CART, the additional use of TGRpre-BL and its change to TGRpost-BL determined at 30-day FU1 showed better OS prognostication for patients with overall PD according to Lugano criteria. Therefore, this modification of the Lugano classification should be explored as a potential novel imaging biomarker of early response and should be validated prospectively in future studies.
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Affiliation(s)
- Michael Winkelmann
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Viktoria Blumenberg
- Department of Hematology and Oncology, University Hospital Munich Campus Grosshadern, Munich, Germany
- German Cancer Consortium, Heidelberg, Germany
| | - Kai Rejeski
- Department of Hematology and Oncology, University Hospital Munich Campus Grosshadern, Munich, Germany
- German Cancer Consortium, Heidelberg, Germany
| | - Christina Quell
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Veit Bücklein
- Department of Hematology and Oncology, University Hospital Munich Campus Grosshadern, Munich, Germany
- German Cancer Consortium, Heidelberg, Germany
| | - Maria Ingenerf
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Marcus Unterrainer
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Christian Schmidt
- Department of Hematology and Oncology, University Hospital Munich Campus Grosshadern, Munich, Germany
- German Cancer Consortium, Heidelberg, Germany
| | | | - Peter Bartenstein
- German Cancer Consortium, Heidelberg, Germany
- Department of Nuclear Medicine, University Hospital, Munich, Germany
| | - Jens Ricke
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium, Heidelberg, Germany
| | - Michael von Bergwelt-Baildon
- Department of Hematology and Oncology, University Hospital Munich Campus Grosshadern, Munich, Germany
- German Cancer Consortium, Heidelberg, Germany
| | - Marion Subklewe
- Department of Hematology and Oncology, University Hospital Munich Campus Grosshadern, Munich, Germany
- German Cancer Consortium, Heidelberg, Germany
| | - Wolfgang G Kunz
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium, Heidelberg, Germany
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15
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Ayuk F, Gagelmann N, von Tresckow B, Wulf G, Rejeski K, Stelljes M, Penack O, Baldus CD, Kröger N, Bethge W, Dreger P. Real-world results of CAR T-cell therapy for large B-cell lymphoma with CNS involvement: a GLA/DRST study. Blood Adv 2023; 7:5316-5319. [PMID: 37450376 PMCID: PMC10506090 DOI: 10.1182/bloodadvances.2023010336] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 07/03/2023] [Accepted: 07/06/2023] [Indexed: 07/18/2023] Open
Affiliation(s)
- Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Lymphoma Alliance, Munich, Germany
| | - Nico Gagelmann
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bastian von Tresckow
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Gerald Wulf
- Department of Hematology and Medical Oncology, University Medical Center Göttingen, Göttingen, Germany
| | - Kai Rejeski
- Department of Medicine III – Hematology/Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Matthias Stelljes
- Department of Medicine A, University Medical Center Münster, Münster, Germany
| | - Olaf Penack
- Department of Hematology and Oncology, Charité University Medicine, Berlin, Germany
| | - Claudia D. Baldus
- Department of Internal Medicine II, University Medical Center Kiel, Kiel, Germany
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Stem Cell Transplant Registry (DRST), Ulm, Germany
| | - Wolfgang Bethge
- Department of Hematology and Oncology, University Medical Center Tübingen, Tübingen, Germany
| | - Peter Dreger
- German Lymphoma Alliance, Munich, Germany
- Department Medicine V, University of Heidelberg, Heidelberg, Germany
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16
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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. Sci Adv 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] [What about the content of this article? (0)] [Affiliation(s)] [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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17
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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: 31] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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18
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Bücklein V, Perez A, Rejeski K, Iacoboni G, Jurinovic V, Holtick U, Penack O, Kharboutli S, Blumenberg V, Ackermann J, Frölich L, Johnson G, Patel K, Arciola B, Mhaskar R, Wood A, Schmidt C, Albanyan O, Gödel P, Hoster E, Bullinger L, Mackensen A, Locke F, von Bergwelt M, Barba P, Subklewe M, Jain MD. Inferior Outcomes of EU Versus US Patients Treated With CD19 CAR-T for Relapsed/Refractory Large B-cell Lymphoma: Association With Differences in Tumor Burden, Systemic Inflammation, Bridging Therapy Utilization, and CAR-T Product Use. Hemasphere 2023; 7:e907. [PMID: 37449196 PMCID: PMC10337711 DOI: 10.1097/hs9.0000000000000907] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 05/03/2023] [Indexed: 07/18/2023] Open
Abstract
Real-world evidence suggests a trend toward inferior survival of patients receiving CD19 chimeric antigen receptor (CAR) T-cell therapy in Europe (EU) and with tisagenlecleucel. The underlying logistic, patient- and disease-related reasons for these discrepancies remain poorly understood. In this multicenter retrospective observational study, we studied the patient-individual journey from CAR-T indication to infusion, baseline features, and survival outcomes in 374 patients treated with tisagenlecleucel (tisa-cel) or axicabtagene-ciloleucel (axi-cel) in EU and the United States (US). Compared with US patients, EU patients had prolonged indication-to-infusion intervals (66 versus 50 d; P < 0.001) and more commonly received intermediary therapies (holding and/or bridging therapy, 94% in EU versus 74% in US; P < 0.001). Baseline lactate dehydrogenase (LDH) (median 321 versus 271 U/L; P = 0.02) and ferritin levels (675 versus 425 ng/mL; P = 0.004) were significantly elevated in the EU cohort. Overall, we observed inferior survival in EU patients (median progression-free survival [PFS] 3.1 versus 9.2 months in US; P < 0.001) and with tisa-cel (3.2 versus 9.2 months with axi-cel; P < 0.001). On multivariate Lasso modeling, nonresponse to bridging, elevated ferritin, and increased C-reactive protein represented independent risks for treatment failure. Weighing these variables into a patient-individual risk balancer (high risk [HR] balancer), we found higher levels in EU versus US and tisa-cel versus axi-cel cohorts. Notably, superior PFS with axi-cel was exclusively evident in patients at low risk for progression (according to the HR balancer), but not in high-risk patients. These data demonstrate that inferior survival outcomes in EU patients are associated with longer time-to-infusion intervals, higher tumor burden/LDH levels, increased systemic inflammatory markers, and CAR-T product use.
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Affiliation(s)
- Veit Bücklein
- Department of Medicine III, University Hospital, LMU Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, 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
| | - Kai Rejeski
- Department of Medicine III, University Hospital, LMU Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
- German Cancer Consortium (DKTK) Munich Site, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Gloria Iacoboni
- Department of Hematology, Vall d’Hebron Institute of Oncology (VHIO), University Hospital Vall d’Hebron, Department of Medicine, Universitat Autònoma of Barcelona (UAB), Spain
| | - Vindi Jurinovic
- Institute for Medical Information Processing, Biometry, and Epidemiology, LMU Munich, Germany
| | - Udo Holtick
- Department I of Internal Medicine, Medical Faculty and University Hospital, Cologne, University of Cologne, Germany
| | - Olaf Penack
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Hematology, Oncology and Tumorimmunology, Berlin, Germany
| | - Soraya Kharboutli
- Department of Internal Medicine 5, Hematology and Oncology, University of Erlangen-Nuremberg, Germany
| | - Viktoria Blumenberg
- Department of Medicine III, University Hospital, LMU Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
- German Cancer Consortium (DKTK) Munich Site, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | | | - Lisa Frölich
- Department of Medicine III, University Hospital, LMU Munich, Germany
| | - Grace Johnson
- USF Health Morsani College of Medicine, Tampa, FL, USA
| | - Kedar Patel
- USF Health Morsani College of Medicine, Tampa, FL, USA
| | - Brian Arciola
- USF Health Morsani College of Medicine, Tampa, FL, USA
| | - Rahul Mhaskar
- USF Health Morsani College of Medicine, Tampa, FL, USA
| | - Anthony Wood
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL, USA
| | - Christian Schmidt
- Department of Medicine III, University Hospital, LMU Munich, Germany
| | - Omar Albanyan
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL, USA
| | - Philipp Gödel
- Department I of Internal Medicine, Medical Faculty and University Hospital, Cologne, University of Cologne, Germany
| | - Eva Hoster
- Institute for Medical Information Processing, Biometry, and Epidemiology, LMU Munich, Germany
| | - Lars Bullinger
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Hematology, Oncology and Tumorimmunology, Berlin, Germany
| | - Andreas Mackensen
- Department of Internal Medicine 5, Hematology and Oncology, University of Erlangen-Nuremberg, Germany
| | - Frederick Locke
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL, USA
| | - Michael von Bergwelt
- Department of Medicine III, University Hospital, LMU Munich, Germany
- German Cancer Consortium (DKTK) Munich Site, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Pere Barba
- Department of Hematology, Vall d’Hebron Institute of Oncology (VHIO), University Hospital Vall d’Hebron, Department of Medicine, Universitat Autònoma of Barcelona (UAB), Spain
| | - Marion Subklewe
- Department of Medicine III, University Hospital, LMU Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
- German Cancer Consortium (DKTK) Munich Site, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Michael D. Jain
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL, USA
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19
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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: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [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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20
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Rejeski K, Jain MD, Smith EL. Mechanisms of Resistance and Treatment of Relapse after CAR T-cell Therapy for Large B-cell Lymphoma and Multiple Myeloma. Transplant Cell Ther 2023; 29:418-428. [PMID: 37076102 PMCID: PMC10330792 DOI: 10.1016/j.jtct.2023.04.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/04/2023] [Accepted: 04/11/2023] [Indexed: 04/21/2023]
Abstract
Although chimeric antigen receptor (CAR) T cell therapy (CAR-T) has altered the treatment landscape for relapsed/refractory B cell malignancies and multiple myeloma, only a minority of patients attain long-term disease remission. The underlying reasons for CAR-T resistance are multifaceted and can be broadly divided into host-related, tumor-intrinsic, microenvironmental and macroenvironmental, and CAR-T-related factors. Emerging host-related determinants of response to CAR-T relate to gut microbiome composition, intact hematopoietic function, body composition, and physical reserve. Emerging tumor-intrinsic resistance mechanisms include complex genomic alterations and mutations to immunomodulatory genes. Furthermore, the extent of systemic inflammation prior to CAR-T is a potent biomarker of response and reflects a proinflammatory tumor micromilieu characterized by infiltration of myeloid-derived suppressor cells and regulatory T cell populations. The tumor and its surrounding micromilieu also can shape the response of the host to CAR-T infusion and the subsequent expansion and persistence of CAR T cells, a prerequisite for efficient eradication of tumor cells. Here, focusing on both large B cell lymphoma and multiple myeloma, we review resistance mechanisms, explore therapeutic avenues to overcome resistance to CAR-T, and discuss the management of patients who relapse after CAR-T.
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Affiliation(s)
- Kai Rejeski
- Department of Medicine III – Hematology/Oncology, University Hospital, LMU Munich, 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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21
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Winkelmann M, Blumenberg V, Rejeski K, Bücklein VL, Ingenerf M, Unterrainer M, Schmidt C, Dekorsy FJ, Bartenstein P, Ricke J, von Bergwelt-Baildon M, Subklewe M, Kunz WG. Staging of lymphoma under chimeric antigen receptor T-cell therapy: reasons for discordance among imaging response criteria. Cancer Imaging 2023; 23:44. [PMID: 37189191 PMCID: PMC10184388 DOI: 10.1186/s40644-023-00566-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 05/06/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND Chimeric antigen receptor T-cell therapy (CART) prolongs survival for patients with refractory or relapsed lymphoma. Discrepancies among different response criteria for lymphoma under CART were recently shown. Our objective was to evaluate reasons for discordance among different response criteria and their relation to overall survival. METHODS Consecutive patients with baseline and follow-up imaging at 30 (FU1) and 90 days (FU2) after CART were included. Overall response was determined based on Lugano, Cheson, response evaluation criteria in lymphoma (RECIL) and lymphoma response to immunomodulatory therapy criteria (LYRIC). Overall response rate (ORR) and rates of progressive disease (PD) were determined. For each criterion reasons for PD were analyzed in detail. RESULTS 41 patients were included. ORR was 68%, 68%, 63%, and 68% at FU2 by Lugano, Cheson, RECIL, and LYRIC, respectively. PD rates differed among criteria with 32% by Lugano, 27% by Cheson, 17% by RECIL, and 17% by LYRIC. Dominant reasons for PD according to Lugano were target lesion (TL) progression (84.6%), new appearing lesions (NL; 53.8%), non-TL progression (27.3%), and progressive metabolic disease (PMD; 15.4%). Deviations among the criteria for defining PD were largely explained by PMD of preexisting lesions that are defined as PD only by Lugano and non-TL progression, which is not defined as PD by RECIL and in some cases classified as indeterminate response by LYRIC. CONCLUSIONS Following CART, lymphoma response criteria show differences in imaging endpoints, especially in defining PD. The response criteria must be considered when interpreting imaging endpoints and outcomes from clinical trials.
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Affiliation(s)
- Michael Winkelmann
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Viktoria Blumenberg
- Laboratory for Translational Cancer Immunology, Gene Center of the LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK) and Bavarian Center for Cancer Research (BZKF), partner site Munich, Munich, Germany
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Kai Rejeski
- Laboratory for Translational Cancer Immunology, Gene Center of the LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK) and Bavarian Center for Cancer Research (BZKF), partner site Munich, Munich, Germany
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Veit L Bücklein
- Laboratory for Translational Cancer Immunology, Gene Center of the LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK) and Bavarian Center for Cancer Research (BZKF), partner site Munich, Munich, Germany
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Maria Ingenerf
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Marcus Unterrainer
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Christian Schmidt
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Franziska J Dekorsy
- Department of Nuclear Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Peter Bartenstein
- Department of Nuclear Medicine, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Cancer Center München-LMU (CCCM LMU ), LMU Munich, Munich, Germany
| | - Jens Ricke
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
- Comprehensive Cancer Center München-LMU (CCCM LMU ), LMU Munich, Munich, Germany
| | - Michael von Bergwelt-Baildon
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Cancer Center München-LMU (CCCM LMU ), LMU Munich, Munich, Germany
| | - Marion Subklewe
- Laboratory for Translational Cancer Immunology, Gene Center of the LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK) and Bavarian Center for Cancer Research (BZKF), partner site Munich, Munich, Germany
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Cancer Center München-LMU (CCCM LMU ), LMU Munich, Munich, Germany
| | - Wolfgang G Kunz
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.
- Comprehensive Cancer Center München-LMU (CCCM LMU ), LMU Munich, Munich, Germany.
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22
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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: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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23
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Rejeski K, Cordas Dos Santos DM, Parker NH, Bücklein VL, Winkelmann M, Jhaveri KS, Liu L, Trinkner P, Günther S, Karschnia P, Blumenberg V, Schmidt C, Kunz WG, von Bergwelt-Baildon M, Jain MD, Theurich S, Subklewe M. Influence of adipose tissue distribution, sarcopenia, and nutritional status on clinical outcomes after CD19 CAR T-cell therapy. Cancer Immunol Res 2023:725728. [PMID: 37040425 DOI: 10.1158/2326-6066.cir-22-0487] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 12/06/2022] [Accepted: 04/05/2023] [Indexed: 04/12/2023]
Abstract
Although CD19-directed chimeric antigen receptor T-cell therapy (CD19.CAR-T) has proven clinical efficacy for multiple refractory B-cell malignancies, over 50% of patients ultimately relapse. Recent evidence has underlined the critical role of the host in determining treatment responses. In this retrospective observational study of 106 relapsed/refractory large B-cell lymphoma (LBCL) patients receiving standard-of-care CD19.CAR-T, we analyzed the impact of immunometabolic host features and detailed body composition measurements on post-CAR-T clinical outcomes. We extracted muscle and adipose tissue distributions from pre-lymphodepletion CT images and assessed laboratory-based immuno-nutritional scores. Early responders displayed increased total abdominal adipose tissue deposits (TAT: 336 vs. 266 mm3, P=0.008) and favorable immuno-nutritional scores compared to non-responding patients. On univariate Cox regression analysis, visceral fat distribution, sarcopenia, and nutritional indices significantly impacted both progression-free (PFS) and overall survival (OS). Patients with a low skeletal muscle index (e.g. SMI<34.5), a sarcopenia indicator, exhibited poor clinical outcomes (mOS 3.0 vs. 17.6 months, log-rank p=0.0026). Prognostically adverse immuno-nutritional scores were linked to inferior survival (low PNI, HROS: 6.31, 95% CI: 3.35-11.90, P<0.001). In a multivariable analysis adjusting for baseline ECOG, CRP, and LDH, increased TAT independently associated with improved clinical outcomes (adjusted HROS: 0.27, 95% CI: 0.08-0.90, P=0.03). We noted particularly favorable treatment outcomes in patients with both increased abdominal fat and muscle mass (TAThigh/SMIhigh: 1-yr PFS 50%, 1-yr OS 83%). These real-world data provide evidence for a role of body composition and immuno-nutritional status in the context of CD19.CAR-T and suggest that the obesity paradox extends to modern T-cell based immunotherapies.
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Affiliation(s)
- Kai Rejeski
- University Hospital, LMU Munich, Munich, Germany
| | | | | | | | | | | | - Lian Liu
- University Hospital, LMU Munich, Munich, Germany
| | | | - Sophie Günther
- Cancer- and Immunmetabolism Research Group, Gene Center, LMU Munich, Munich, Germany, Munich, Germany
| | | | | | | | | | | | | | - Sebastian Theurich
- University Hospital Munich, Ludwig-Maximilians-University, Munich, Germany
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24
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Winkelmann M, Blumenberg V, Rejeski K, Quell C, Bücklein VL, Ingenerf M, Unterrainer M, Schmidt C, Dekorsy FJ, Bartenstein P, Ricke J, von Bergwelt-Baildon M, Subklewe M, Kunz WG. Prognostic value of pre-infusion tumor growth rate for patients with lymphoma receiving chimeric antigen receptor T-cell therapy. Cytotherapy 2023:S1465-3249(23)00069-5. [PMID: 37055322 DOI: 10.1016/j.jcyt.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 03/01/2023] [Accepted: 03/15/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND AIMS Chimeric antigen receptor T-cell therapy (CART) prolongs survival for patients with refractory or relapsed lymphoma, yet its efficacy is affected by the tumor burden. The relevance of tumor kinetics before infusion is unknown. We aimed to study the prognostic value of the pre-infusion tumor growth rate (TGRpre-BL) for progression-free (PFS) and overall survival (OS). METHODS Consecutive patients with available pre-baseline (pre-BL) and baseline (BL) computed tomography or positron emission tomography/computed tomography scan before CART were included. TGR was determined as change of Lugano criteria-based tumor burden between pre-BL, BL and follow-up examinations (FU) in relation to days between imaging exams. Overall response rate (ORR), depth or response (DoR) and PFS were determined based on Lugano criteria. Multivariate regression analysis studied association of TGR with ORR and DoR. Proportional Cox regression analysis studied association of TGR with PFS and OS. RESULTS In total, 62 patients met the inclusion criteria. The median TGRpre-BL was 7.5 mm2/d (interquartile range -14.6 mm2/d to 48.7 mm2/d); TGRpre-BL was positive (TGRpre-BL POS) in 58% of patients and negative (TGRpre-BL NEG, indicating tumor shrinkage) in 42% of patients. Patients who were TGRpre-BL POS had a 90-day (FU2) ORR of 62%, a DoR of -86% and a median PFS of 124 days. Patients who were TGRpre-BL NEG had a 90-day ORR of 44%, DoR of -47% and a median PFS of 105 days. ORR and DoR were not associated with slower TGR (P = 0.751, P = 0.198). Patients with an increase of TGR from pre-BL over BL to 30-day FU (FU1) ≥100% (TGRpre-BL-to-FU1≥100%) showed a significant association with shorter median PFS (31 days versus 343 days, P = 0.002) and shorter median OS after CART (93 days versus not reached, P < 0.001), compared with patients with TGRpre-BL-to-FU1<100%. CONCLUSIONS In the context of CART, differences in pre-infusion tumor kinetics showed minor differences in ORR, DoR, PFS and OS, whereas the change of the TGR from pre-BL to 30-day FU significantly stratified PFS and OS. In this patient population of refractory or relapsed lymphomas, TGR is readily available based on pre-BL imaging, and its change throughout CART should be explored as a potential novel imaging biomarker of early response.
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Affiliation(s)
- Michael Winkelmann
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Viktoria Blumenberg
- Laboratory for Translational Cancer Immunology, Gene Center of the LMU Munich, Munich, Germany; German Cancer Consortium (DKTK) and Bavarian Center for Cancer Research (BZKF), partner site Munich, Munich, Germany; Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Kai Rejeski
- Laboratory for Translational Cancer Immunology, Gene Center of the LMU Munich, Munich, Germany; German Cancer Consortium (DKTK) and Bavarian Center for Cancer Research (BZKF), partner site Munich, Munich, Germany; Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Christina Quell
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Veit L Bücklein
- Laboratory for Translational Cancer Immunology, Gene Center of the LMU Munich, Munich, Germany; German Cancer Consortium (DKTK) and Bavarian Center for Cancer Research (BZKF), partner site Munich, Munich, Germany; Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Maria Ingenerf
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Marcus Unterrainer
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Christian Schmidt
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Franziska J Dekorsy
- Department of Nuclear Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Peter Bartenstein
- Department of Nuclear Medicine, University Hospital, LMU Munich, Munich, Germany; Comprehensive Cancer Center München-LMU (CCCMLMU), LMU Munich, Munich, Germany
| | - Jens Ricke
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany; Comprehensive Cancer Center München-LMU (CCCMLMU), LMU Munich, Munich, Germany
| | - Michael von Bergwelt-Baildon
- German Cancer Consortium (DKTK) and Bavarian Center for Cancer Research (BZKF), partner site Munich, Munich, Germany; Department of Medicine III, University Hospital, LMU Munich, Munich, Germany; Comprehensive Cancer Center München-LMU (CCCMLMU), LMU Munich, Munich, Germany
| | - Marion Subklewe
- Laboratory for Translational Cancer Immunology, Gene Center of the LMU Munich, Munich, Germany; German Cancer Consortium (DKTK) and Bavarian Center for Cancer Research (BZKF), partner site Munich, Munich, Germany; Department of Medicine III, University Hospital, LMU Munich, Munich, Germany; Comprehensive Cancer Center München-LMU (CCCMLMU), LMU Munich, Munich, Germany
| | - Wolfgang G Kunz
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany; German Cancer Consortium (DKTK) and Bavarian Center for Cancer Research (BZKF), partner site Munich, Munich, Germany; Comprehensive Cancer Center München-LMU (CCCMLMU), LMU Munich, Munich, Germany.
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25
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Rejeski K, Blumenberg V, Iacoboni G, Lopez-Corral L, Kharboutli S, Hernani R, Petrera A, Müller N, Hildebrand F, Frölich L, Karschnia P, Schmidt C, Cordas dos Santos DM, Piñana JL, Müller F, Martin AA, Dreyling M, von Bergwelt-Baildon M, Barba P, Subklewe M, Bücklein VL. Identifying Early Infections in the Setting of CRS With Routine and Exploratory Serum Proteomics and the HT10 Score Following CD19 CAR-T for Relapsed/Refractory B-NHL. Hemasphere 2023; 7:e858. [PMID: 37038465 PMCID: PMC10082278 DOI: 10.1097/hs9.0000000000000858] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 02/06/2023] [Indexed: 04/08/2023] Open
Abstract
Early fever after chimeric antigen receptor T-cell (CAR-T) therapy can reflect both an infection or cytokine release syndrome (CRS). Identifying early infections in the setting of CRS and neutropenia represents an unresolved clinical challenge. In this retrospective observational analysis, early fever events (day 0-30) were characterized as infection versus CRS in 62 patients treated with standard-of-care CD19.CAR-T for relapsed/refractory B-cell non-Hodgkin lymphoma. Routine serum inflammatory markers (C-reactive protein [CRP], interleukin-6 [IL-6], procalcitonin [PCT]) were recorded daily. Exploratory plasma proteomics were performed longitudinally in 52 patients using a multiplex proximity extension assay (Olink proteomics). Compared with the CRSonly cohort, we noted increased event-day IL-6 (median 2243 versus 64 pg/mL, P = 0.03) and particularly high PCT levels (median 1.6 versus 0.3 µg/L, P < 0.0001) in the patients that developed severe infections. For PCT, an optimal discriminatory threshold of 1.5 µg/L was established (area under the receiver operating characteristic curve [AUCROC] = 0.78). Next, we incorporated day-of-fever PCT levels with the patient-individual CAR-HEMATOTOX score. In a multicenter validation cohort (n = 125), we confirmed the discriminatory capacity of this so-called HT10 score for early infections at first fever (AUCROC = 0.87, P < 0.0001, sens. 86%, spec. 86%). Additionally, Olink proteomics revealed pronounced immune dysregulation and endothelial dysfunction in patients with severe infections as evidenced by an increased ANGPT2/1 ratio and an altered CD40/CD40L-axis. In conclusion, the high discriminatory capacity of the HT10 score for infections highlights the advantage of dynamic risk assessment and supports the incorporation of PCT into routine inflammatory panels. Candidate markers from Olink proteomics may further refine risk-stratification. If validated prospectively, the score will enable risk-adapted decisions on antibiotic use.
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26
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Winkelmann M, Blumenberg V, Rejeski K, Bücklein VL, Ruzicka M, Unterrainer M, Schmidt C, Dekorsy FJ, Bartenstein P, Ricke J, von Bergwelt-Baildon M, Subklewe M, Kunz WG. Prognostic value of the International Metabolic Prognostic Index for lymphoma patients receiving chimeric antigen receptor T-cell therapy. Eur J Nucl Med Mol Imaging 2023; 50:1406-1413. [PMID: 36513818 DOI: 10.1007/s00259-022-06075-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 12/04/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE Chimeric antigen receptor T-cell therapy (CART) prolongs survival for patients with relapsed/refractory B-cell non-Hodgkin's lymphoma. The recently introduced International Metabolic Prognostic Index (IMPI) was shown to improve prognostication in the first-line treatment of large B-cell lymphoma. Here, we investigate the prognostic value of the IMPI for progression-free (PFS) and overall survival (OS) in the setting of CD19 CART. METHODS Consecutively treated patients with baseline 18F-FDG PET/CT imaging and follow-up imaging at 30 days after CART were included. IMPI is composed of age, stage, and metabolic tumor volume (MTV) at baseline and was compared with the International Prognostic Index (IPI). Both indices were grouped into quartiles, as previously described for IPI. In addition, the continuous IMPI was subdivided into tertiaries for better separation of risk groups. Overall response rate (ORR), depth of response (DoR), and PFS were determined based on Lugano criteria. Proportional Cox regression analysis studied association of IMPI and IPI with PFS and OS. RESULTS Thirty-nine patients were included. The IPI was 1 in 23%, 2 in 21%, 3 in 26%, 4 in 21%, and 5 in 10% of the patients. IMPIlow risk, IMPIintermediate risk, and IMPIhigh risk patients had 30-day ORR of 69%, 62%, and 62% and 30-day DoR of - 67%, - 66%, and - 54% with a PFS of 187 days, 97 days, and 87 days, respectively. ORR and DoR showed no correlation with lower IMPI (r = 0.065, p = 0.697). Dividing patients into three risk groups showed a significant trend for PFS stratification (p = 0.030), while IPI did not (p = 0.133). Neither IPI nor IMPI yielded a significant association with OS after CART (both p > 0.05). CONCLUSION In the context of CART, the IMPI yielded prognostic value regarding PFS estimation. In contrast with IMPI in the first-line DLBCL setting, we did not observe a significant association of IMPI at baseline with OS after CART.
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Affiliation(s)
- Michael Winkelmann
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Viktoria Blumenberg
- Laboratory for Translational Cancer Immunology, Gene Center of the LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK) and Bavarian Center for Cancer Research (BZKF), Partner Site Munich, Munich, Germany
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Kai Rejeski
- Laboratory for Translational Cancer Immunology, Gene Center of the LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK) and Bavarian Center for Cancer Research (BZKF), Partner Site Munich, Munich, Germany
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Veit L Bücklein
- Laboratory for Translational Cancer Immunology, Gene Center of the LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK) and Bavarian Center for Cancer Research (BZKF), Partner Site Munich, Munich, Germany
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Michael Ruzicka
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Marcus Unterrainer
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Christian Schmidt
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Franziska J Dekorsy
- Department of Nuclear Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Peter Bartenstein
- Department of Nuclear Medicine, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Cancer Center München-LMU (CCCMLMU), LMU Munich, Munich, Germany
| | - Jens Ricke
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
- Comprehensive Cancer Center München-LMU (CCCMLMU), LMU Munich, Munich, Germany
| | - Michael von Bergwelt-Baildon
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Cancer Center München-LMU (CCCMLMU), LMU Munich, Munich, Germany
| | - Marion Subklewe
- Laboratory for Translational Cancer Immunology, Gene Center of the LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK) and Bavarian Center for Cancer Research (BZKF), Partner Site Munich, Munich, Germany
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Wolfgang G Kunz
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.
- Comprehensive Cancer Center München-LMU (CCCMLMU), LMU Munich, Munich, Germany.
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27
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Teske N, Chiquillo-Domínguez M, Skrap B, Harter PN, Rejeski K, Blobner J, von Baumgarten L, Tonn JC, Kunz M, Thon N, Karschnia P. Shunt dependency in supratentorial intraventricular tumors depends on the extent of tumor resection. Acta Neurochir (Wien) 2023; 165:1053-1064. [PMID: 36862214 PMCID: PMC10068640 DOI: 10.1007/s00701-023-05532-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 02/13/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND Supratentorial intraventricular tumors (SIVTs) are rare lesions of various entities characteristically presenting with hydrocephalus and often posing a surgical challenge due to their deep-seated localization. We aimed to elaborate on shunt dependency after tumor resection, clinical characteristics, and perioperative morbidity. METHODS We retrospectively searched the institutional database for patients with supratentorial intraventricular tumors treated at the Department of Neurosurgery of the Ludwig-Maximilians-University in Munich, Germany, between 2014 and 2022. RESULTS We identified 59 patients with over 20 different SIVT entities, most often subependymoma (8/59 patients, 14%). Mean age at diagnosis was 41 ± 3 years. Hydrocephalus and visual symptoms were observed in 37/59 (63%) and 10/59 (17%) patients, respectively. Microsurgical tumor resection was provided in 46/59 patients (78%) with complete resection in 33/46 patients (72%). Persistent postoperative neurological deficits were encountered in 3/46 patients (7%) and generally mild in nature. Complete tumor resection was associated with less permanent shunting in comparison to incomplete tumor resection, irrespective of tumor histology (6% versus 31%, p = 0.025). Stereotactic biopsy was utilized in 13/59 patients (22%), including 5 patients who received synchronous internal shunt implantation for symptomatic hydrocephalus. Median overall survival was not reached and did not differ between patients with or without open resection. CONCLUSIONS SIVT patients display a high risk of developing hydrocephalus and visual symptoms. Complete resection of SIVTs can often be achieved, preventing the need for long-term shunting. Stereotactic biopsy along with internal shunting represents an effective approach to establish diagnosis and ameliorate symptoms if resection cannot be safely performed. Due to the rather benign histology, the outcome appears excellent when adjuvant therapy is provided.
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Affiliation(s)
- Nico Teske
- Department of Neurosurgery, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany. .,German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany.
| | | | - Benjamin Skrap
- Department of Neurosurgery, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Patrick N Harter
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany.,Center for Neuropathology and Prion Research, University Hospital, LMU Munich, Munich, Germany
| | - Kai Rejeski
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany.,Department of Medicine III, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Jens Blobner
- Department of Neurosurgery, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany.,German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Louisa von Baumgarten
- Department of Neurosurgery, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany.,German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Joerg-Christian Tonn
- Department of Neurosurgery, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany.,German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Mathias Kunz
- Department of Neurosurgery, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany.,German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Niklas Thon
- Department of Neurosurgery, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany.,German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Philipp Karschnia
- Department of Neurosurgery, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany. .,German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany.
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28
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Xu T, Karschnia P, Cadilha BL, Dede S, Lorenz M, Seewaldt N, Nikolaishvili E, Müller K, Blobner J, Teske N, Herold JJ, Rejeski K, Langer S, Obeck H, Lorenzini T, Mulazzani M, Zhang W, Ishikawa-Ankerhold H, Buchholz VR, Subklewe M, Thon N, Straube A, Tonn JC, Kobold S, von Baumgarten L. In vivo dynamics and anti-tumor effects of EpCAM-directed CAR T-cells against brain metastases from lung cancer. Oncoimmunology 2023; 12:2163781. [PMID: 36687005 PMCID: PMC9851202 DOI: 10.1080/2162402x.2022.2163781] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Lung cancer patients are at risk for brain metastases and often succumb to their intracranial disease. Chimeric Antigen Receptor (CAR) T-cells emerged as a powerful cell-based immunotherapy for hematological malignancies; however, it remains unclear whether CAR T-cells represent a viable therapy for brain metastases. Here, we established a syngeneic orthotopic cerebral metastasis model in mice by combining a chronic cranial window with repetitive intracerebral two-photon laser scanning-microscopy. This approach enabled in vivo-characterization of fluorescent CAR T-cells and tumor cells on a single-cell level over weeks. Intraparenchymal injection of Lewis lung carcinoma cells (expressing the tumor cell-antigen EpCAM) was performed, and EpCAM-directed CAR T-cells were injected either intravenously or into the adjacent brain parenchyma. In mice receiving EpCAM-directed CAR T-cells intravenously, we neither observed substantial CAR T-cell accumulation within the tumor nor relevant anti-tumor effects. Local CAR T-cell injection, however, resulted in intratumoral CAR T-cell accumulation compared to controls treated with T-cells lacking a CAR. This finding was accompanied by reduced tumorous growth as determined per in vivo-microscopy and immunofluorescence of excised brains and also translated into prolonged survival. However, the intratumoral number of EpCAM-directed CAR T-cells decreased during the observation period, pointing toward insufficient persistence. No CNS-specific or systemic toxicities of EpCAM-directed CAR T-cells were observed in our fully immunocompetent model. Collectively, our findings indicate that locally (but not intravenously) injected CAR T-cells may safely induce relevant anti-tumor effects in brain metastases from lung cancer. Strategies improving the intratumoral CAR T-cell persistence may further boost the therapeutic success.
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Affiliation(s)
- Tao Xu
- Department of Neurology, University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany
| | - Philipp Karschnia
- Department of Neurosurgery, University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany,German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany,CONTACT Philipp Karschnia
| | - Bruno Loureiro Cadilha
- Department of Medicine IV, Division of Clinical Pharmacology and Center of Integrated Protein Science Munich, University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany
| | - Sertac Dede
- Department of Neurology, University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany
| | - Michael Lorenz
- Department of Medicine I, University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany
| | - Niklas Seewaldt
- Department of Neurosurgery, University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany
| | - Elene Nikolaishvili
- Department of Neurosurgery, University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany
| | - Katharina Müller
- Department of Neurology, University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany
| | - Jens Blobner
- Department of Neurosurgery, University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany,German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Nico Teske
- Department of Neurosurgery, University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany,German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Julika J. Herold
- Department of Neurosurgery, University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany
| | - Kai Rejeski
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany,Department of Medicine III, University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany
| | - Sigrid Langer
- Department of Neurology, University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany
| | - Hannah Obeck
- Department of Medicine IV, Division of Clinical Pharmacology and Center of Integrated Protein Science Munich, University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany
| | - Theo Lorenzini
- Department of Medicine IV, Division of Clinical Pharmacology and Center of Integrated Protein Science Munich, University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany
| | - Matthias Mulazzani
- Immunology Division, Walter and Eliza Hall Institute of Medical Research, Parkville, Australia
| | - Wenlong Zhang
- Department of Neurology, University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany
| | - Hellen Ishikawa-Ankerhold
- Department of Medicine I, University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany
| | - Veit R. Buchholz
- Institute for Medical Microbiology, Immunology and Hygiene, Technische Universitaet Muenchen (TUM), Munich, Germany
| | - Marion Subklewe
- Department of Medicine III, University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany
| | - Niklas Thon
- Department of Neurosurgery, University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany,German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Andreas Straube
- Department of Neurology, University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany
| | - Joerg-Christian Tonn
- Department of Neurosurgery, University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany,German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Sebastian Kobold
- Department of Medicine IV, Division of Clinical Pharmacology and Center of Integrated Protein Science Munich, University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany
| | - Louisa von Baumgarten
- Department of Neurology, University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany,Department of Neurosurgery, University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany,German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany,Louisa von Baumgarten Department of Neurosurgery, Division of Neuro-Oncology, University Hospital of the Ludwig-Maximilians-University Munich, Marchioninistrasse 15/81377, Munich, Germany
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29
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Stoecklein S, Wunderlich S, Papazov B, Winkelmann M, Kunz WG, Mueller K, Ernst K, Stoecklein VM, Blumenberg V, Karschnia P, Bücklein VL, Rejeski K, Schmidt C, von Bergwelt-Baildon M, Tonn JC, Ricke J, Liu H, Remi J, Subklewe M, von Baumgarten L, Schoeberl F. Functional connectivity MRI provides an imaging correlate for chimeric antigen receptor T-cell-associated neurotoxicity. Neurooncol Adv 2023; 5:vdad135. [PMID: 38024243 PMCID: PMC10673700 DOI: 10.1093/noajnl/vdad135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Abstract
Background Treatment of hematological malignancies with chimeric antigen receptor modified T cells (CART) is highly efficient, but often limited by an immune effector cell-associated neurotoxicity syndrome (ICANS). As conventional MRI is often unremarkable during ICANS, we aimed to examine whether resting-state functional MRI (rsfMRI) is suitable to depict and quantify brain network alterations underlying ICANS in the individual patient. Methods The dysconnectivity index (DCI) based on rsfMRI was longitudinally assessed in systemic lymphoma patients and 1 melanoma patient during ICANS and before or after clinical resolution of ICANS. Results Seven lymphoma patients and 1 melanoma patient (19-77 years; 2 female) were included. DCI was significantly increased during ICANS with normalization after recovery (P = .0039). Higher ICANS grades were significantly correlated with increased DCI scores (r = 0.7807; P = .0222). DCI increase was most prominent in the inferior frontal gyrus and the frontal operculum (ie, Broca's area) and in the posterior parts of the superior temporal gyrus and the temporoparietal junction (ie, Wernicke's area) of the language-dominant hemisphere, thus reflecting the major clinical symptoms of nonfluent dysphasia and dyspraxia. Conclusions RsfMRI-based DCI might be suitable to directly quantify the severity of ICANS in individual patients undergoing CAR T-transfusion. Besides ICANS, DCI seems a promising diagnostic tool to quantify functional brain network alterations during encephalopathies of different etiologies, in general.
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Affiliation(s)
- Sophia Stoecklein
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Stephan Wunderlich
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Boris Papazov
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Michael Winkelmann
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Wolfgang G Kunz
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Katharina Mueller
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Katharina Ernst
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Veit M Stoecklein
- Department of Neurosurgery, University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), partner site Munich, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Viktoria Blumenberg
- German Cancer Consortium (DKTK), partner site Munich, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, Gene Center, LMU Munich, Munich, Germany
| | - Philipp Karschnia
- Department of Neurosurgery, University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), partner site Munich, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Veit L Bücklein
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, Gene Center, LMU Munich, Munich, Germany
- Bavarian Cancer Research Center (BZKF), Erlangen, Germany
| | - Kai Rejeski
- German Cancer Consortium (DKTK), partner site Munich, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Laboratory for Translational Cancer Immunology, Gene Center, LMU Munich, Munich, Germany
- Bavarian Cancer Research Center (BZKF), Erlangen, Germany
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Christian Schmidt
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Michael von Bergwelt-Baildon
- German Cancer Consortium (DKTK), partner site Munich, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Bavarian Cancer Research Center (BZKF), Erlangen, Germany
| | - Joerg-Christian Tonn
- Department of Neurosurgery, University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), partner site Munich, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jens Ricke
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Hesheng Liu
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
- Department of Neuroscience, Medical University of South Carolina, Charleston, SC, USA
| | - Jan Remi
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Marion Subklewe
- German Cancer Consortium (DKTK), partner site Munich, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, Gene Center, LMU Munich, Munich, Germany
- Bavarian Cancer Research Center (BZKF), Erlangen, Germany
| | - Louisa von Baumgarten
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
- Department of Neurosurgery, University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), partner site Munich, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Bavarian Cancer Research Center (BZKF), Erlangen, Germany
| | - Florian Schoeberl
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Munich, Germany
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Katzendobler S, Do A, Weller J, Rejeski K, Dorostkar MM, Albert NL, Forbrig R, Niyazi M, Egensperger R, Tonn JC, Baumgarten LV, Quach S, Thon N. The value of stereotactic biopsy of primary and recurrent brain metastases in the era of precision medicine. Front Oncol 2022; 12:1014711. [PMID: 36605448 PMCID: PMC9808072 DOI: 10.3389/fonc.2022.1014711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 11/30/2022] [Indexed: 12/24/2022] Open
Abstract
Background Brain metastases (BM) represent the most frequent intracranial tumors with increasing incidence. Many primary tumors are currently treated in protocols that incorporate targeted therapies either upfront or for progressive metastatic disease. Hence, molecular markers are gaining increasing importance in the diagnostic framework of BM. In cases with diagnostic uncertainty, both in newly diagnosed or recurrent BM, stereotactic biopsy serves as an alternative to microsurgical resection particularly whenever resection is not deemed to be safe or feasible. This retrospective study aimed to analyze both diagnostic yield and safety of an image-guided frame based stereotactic biopsy technique (STX). Material and methods Our institutional neurosurgical data base was searched for any surgical procedure for suspected brain metastases between January 2016 and March 2021. Of these, only patients with STX were included. Clinical parameters, procedural complications, and tissue histology and concomitant molecular signature were assessed. Results Overall, 467 patients were identified including 234 (50%) with STX. Median age at biopsy was 64 years (range 29 - 87 years). MRI was used for frame-based trajectory planning in every case with additional PET-guidance in 38 cases (16%). In total, serial tumor probes provided a definite diagnosis in 230 procedures (98%). In 4 cases (1.7%), the pathological tissue did not allow a definitive neuropathological diagnosis. 24 cases had to be excluded due to non-metastatic histology, leaving 206 cases for further analyses. 114 patients (49%) exhibited newly diagnosed BM, while 46 patients (20%) displayed progressive BM. Pseudoprogression was seen in 46 patients, a median of 12 months after prior therapy. Pseudoprogression was always confirmed by clinical course. Metastatic tissue was found most frequently from lung cancer (40%), followed by breast cancer (9%), and malignant melanoma (7%). Other entities included gastrointestinal cancer, squamous cell cancer, renal cell carcinoma, and thyroid cancer, respectively. In 9 cases (4%), the tumor origin could not be identified (cancer of unknown primary). Molecular genetic analyses were successful in 137 out of 144 analyzed cases (95%). Additional next-generation sequencing revealed conclusive results in 12/18 (67%) cases. Relevant peri-procedural complications were observed in 5 cases (2.4%), which were all transient. No permanent morbidity or mortality was noted. Conclusion In patients with BM, frame-based stereotactic biopsy constitutes a safe procedure with a high diagnostic yield. Importantly, this extended to discerning pseudoprogression from tumor relapse after prior therapy. Thus, comprehensive molecular characterization based on minimal-invasive stereotactic biopsies lays the foundation for precision medicine approaches in the treatment of primary and recurrent BM.
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Affiliation(s)
- Sophie Katzendobler
- Department of Neurosurgery, University Hospital, Ludwig-Maximilians-Universität (LMU) Munich, Munich, Germany
| | - Anna Do
- Department of Neurosurgery, University Hospital, Ludwig-Maximilians-Universität (LMU) Munich, Munich, Germany
| | - Jonathan Weller
- Department of Neurosurgery, University Hospital, Ludwig-Maximilians-Universität (LMU) Munich, Munich, Germany
| | - Kai Rejeski
- Department of Medicine III, Hematology and Oncology, University Hospital, Ludwig-Maximilians-Universität (LMU) Munich, Munich, Germany,German Cancer Consortium (DKTK), Partner Site Munich, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Mario M. Dorostkar
- Center for Neuropathology and Prion Research, Ludwig-Maximilians-Universität (LMU) Munich, Munich, Germany
| | - Nathalie L. Albert
- German Cancer Consortium (DKTK), Partner Site Munich, German Cancer Research Center (DKFZ), Heidelberg, Germany,Department of Nuclear Medicine, University Hospital, Ludwig-Maximilians-Universität (LMU) Munich, Munich, Germany
| | - Robert Forbrig
- Institute of Neuroradiology, University Hospital, Ludwig-Maximilians-Universität (LMU) Munich, Munich, Germany
| | - Maximilian Niyazi
- German Cancer Consortium (DKTK), Partner Site Munich, German Cancer Research Center (DKFZ), Heidelberg, Germany,Department of Radiation Oncology, University Hospital, Ludwig-Maximilians-Universität (LMU) Munich, Munich, Germany
| | - Rupert Egensperger
- Center for Neuropathology and Prion Research, Ludwig-Maximilians-Universität (LMU) Munich, Munich, Germany
| | - Joerg-Christian Tonn
- Department of Neurosurgery, University Hospital, Ludwig-Maximilians-Universität (LMU) Munich, Munich, Germany,German Cancer Consortium (DKTK), Partner Site Munich, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Louisa v. Baumgarten
- Department of Neurosurgery, University Hospital, Ludwig-Maximilians-Universität (LMU) Munich, Munich, Germany,German Cancer Consortium (DKTK), Partner Site Munich, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Stefanie Quach
- Department of Neurosurgery, University Hospital, Ludwig-Maximilians-Universität (LMU) Munich, Munich, Germany
| | - Niklas Thon
- Department of Neurosurgery, University Hospital, Ludwig-Maximilians-Universität (LMU) Munich, Munich, Germany,German Cancer Consortium (DKTK), Partner Site Munich, German Cancer Research Center (DKFZ), Heidelberg, Germany,*Correspondence: Niklas Thon,
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31
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Winkelmann M, Bücklein VL, Blumenberg V, Rejeski K, Ruzicka M, Unterrainer M, Schmidt C, Dekorsy FJ, Bartenstein P, Ricke J, von Bergwelt-Baildon M, Subklewe M, Kunz WG. Lymphoma tumor burden before chimeric antigen receptor T-Cell treatment: RECIL vs. Lugano vs. metabolic tumor assessment. Front Oncol 2022; 12:974029. [PMID: 36158658 PMCID: PMC9492918 DOI: 10.3389/fonc.2022.974029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 08/23/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose High tumor burden has emerged as a negative predictor of efficacy in chimeric antigen receptor T-cell therapy (CART) in patients with refractory or relapsed large B-cell lymphoma. This study analyzed the deviation among imaging-based tumor burden (TB) metrics and their association with progression-free (PFS) and overall survival (OS). Materials and methods In this single-center observational study, we included all consecutively treated patients receiving CD19 CART with available baseline PET-CT imaging. Imaging-based TB was determined based on response evaluation criteria in lymphoma (RECIL), the Lugano criteria, and metabolic tumor volume. Total, nodal and extranodal TB were represented, according to the respective criteria, by sum of longest diameters (TBRECIL), sum of product of perpendicular diameters (TBLugano), and metabolic tumor volume (TBMTV). Correlation statistics were used for comparison. Proportional Cox regression analysis studied the association of TB metrics with PFS and OS. Results 34 consecutive patients were included (median age: 67 years, 41% female) with total median baseline TBRECIL of 12.5 cm, TBLugano of 4,030 mm2 and TBMTV of 330 mL. The correlation of TBRECIL and TBLugano with TBMTV was strong (ρ=0.744, p<0.001 and ρ=0.741, p<0.001), with lowest correlation for extranodal TBRECIL with TBMTV (ρ=0.660, p<0.001). Stratification of PFS was strongest by total TBMTV>50% (HR=2.915, p=0.042), whereas total TBRECIL>50% and total TBLugano>50% were not significant (both p>0.05). None of the total TB metrics were associated with OS (all p>0.05). Conclusion Pre-CART TB metrics vary significantly based on the assessment method, impacting their association with survival outcomes. The correlation between TBRECIL, TBLugano and TBMTV was influenced by disease phenotype and prior bridging therapy. TB method of assessment must be considered when interpreting the impact of TB on outcomes in clinical trials. Considering the heterogeneity, our results argue for standardization and harmonization across centers.
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Affiliation(s)
- Michael Winkelmann
- Department of Radiology, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany
| | - Veit L. Bücklein
- Department of Medicine III, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany
| | - Viktoria Blumenberg
- Department of Medicine III, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany
| | - Kai Rejeski
- Department of Medicine III, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany
| | - Michael Ruzicka
- Department of Medicine III, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany
| | - Marcus Unterrainer
- Department of Radiology, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany
| | - Christian Schmidt
- Department of Medicine III, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany
| | - Franziska J. Dekorsy
- Department of Nuclear Medicine, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany
- Comprehensive Cancer Center München-LMU (CCCM), Ludwig Maximilian University (LMU) Munich, Munich, Germany
| | - Peter Bartenstein
- Department of Nuclear Medicine, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany
- Comprehensive Cancer Center München-LMU (CCCM), Ludwig Maximilian University (LMU) Munich, Munich, Germany
| | - Jens Ricke
- Department of Radiology, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany
- Comprehensive Cancer Center München-LMU (CCCM), Ludwig Maximilian University (LMU) Munich, Munich, Germany
| | - Michael von Bergwelt-Baildon
- Department of Medicine III, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany
- Comprehensive Cancer Center München-LMU (CCCM), Ludwig Maximilian University (LMU) Munich, Munich, Germany
| | - Marion Subklewe
- Department of Medicine III, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany
- Comprehensive Cancer Center München-LMU (CCCM), Ludwig Maximilian University (LMU) Munich, Munich, Germany
| | - Wolfgang G. Kunz
- Department of Radiology, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany
- Comprehensive Cancer Center München-LMU (CCCM), Ludwig Maximilian University (LMU) Munich, Munich, Germany
- *Correspondence: Wolfgang G. Kunz,
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32
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Philipp N, Kazerani M, Nicholls A, Vick B, Wulf J, Straub T, Scheurer M, Muth A, Hänel G, Nixdorf D, Sponheimer M, Ohlmeyer M, Lacher SM, Brauchle B, Marcinek A, Rohrbacher L, Leutbecher A, Rejeski K, Weigert O, von Bergwelt-Baildon M, Theurich S, Kischel R, Jeremias I, Bücklein V, Subklewe M. T-cell exhaustion induced by continuous bispecific molecule exposure is ameliorated by treatment-free intervals. Blood 2022; 140:1104-1118. [PMID: 35878001 PMCID: PMC10652962 DOI: 10.1182/blood.2022015956] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/07/2022] [Indexed: 11/20/2022] Open
Abstract
T-cell-recruiting bispecific molecule therapy has yielded promising results in patients with hematologic malignancies; however, resistance and subsequent relapse remains a major challenge. T-cell exhaustion induced by persistent antigen stimulation or tonic receptor signaling has been reported to compromise outcomes of T-cell-based immunotherapies. The impact of continuous exposure to bispecifics on T-cell function, however, remains poorly understood. In relapsed/refractory B-cell precursor acute lymphoblastic leukemia patients, 28-day continuous infusion with the CD19xCD3 bispecific molecule blinatumomab led to declining T-cell function. In an in vitro model system, mimicking 28-day continuous infusion with the half-life-extended CD19xCD3 bispecific AMG 562, we identified hallmark features of exhaustion arising over time. Continuous AMG 562 exposure induced progressive loss of T-cell function (day 7 vs day 28 mean specific lysis: 88.4% vs 8.6%; n = 6; P = .0003). Treatment-free intervals (TFIs), achieved by AMG 562 withdrawal, were identified as a powerful strategy for counteracting exhaustion. TFIs induced strong functional reinvigoration of T cells (continuous vs TFI-specific lysis on day 14: 34.9% vs 93.4%; n = 6; P < .0001) and transcriptional reprogramming. Furthermore, use of a TFI led to improved T-cell expansion and tumor control in vivo. Our data demonstrate the relevance of T-cell exhaustion in bispecific antibody therapy and highlight that T cells can be functionally and transcriptionally rejuvenated with TFIs. In view of the growing number of bispecific molecules being evaluated in clinical trials, our findings emphasize the need to consider and evaluate TFIs in application schedules to improve clinical outcomes.
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Affiliation(s)
- Nora Philipp
- Department of Medicine III, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
| | - Maryam Kazerani
- Department of Medicine III, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
| | - Alyssa Nicholls
- Department of Medicine III, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
| | - Binje Vick
- German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Helmholtz Zentrum München, German Research Center for Environmental Health (HMGU), Munich, Germany
| | - Jan Wulf
- Department of Medicine III, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
| | - Tobias Straub
- Bioinformatics Unit, Biomedical Center, LMU Munich, Martinsried, Germany
| | - Michaela Scheurer
- Department of Medicine III, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
| | - Amelie Muth
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
| | - Gerulf Hänel
- Department of Medicine III, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
| | - Daniel Nixdorf
- Department of Medicine III, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
| | - Monika Sponheimer
- Department of Medicine III, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
| | - Malte Ohlmeyer
- Department of Medicine III, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
| | - Sonja M. Lacher
- Department of Medicine III, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
| | - Bettina Brauchle
- Department of Medicine III, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
| | - Anetta Marcinek
- Department of Medicine III, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
| | - Lisa Rohrbacher
- Department of Medicine III, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
| | - Alexandra Leutbecher
- Department of Medicine III, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
| | - Kai Rejeski
- Department of Medicine III, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
| | - Oliver Weigert
- Department of Medicine III, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany
- German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Experimental Leukemia and Lymphoma Research, Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | | | - Sebastian Theurich
- Department of Medicine III, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany
| | - Roman Kischel
- AMGEN Research Munich GmbH, Munich, Germany
- AMGEN Inc., Thousand Oaks, CA
| | - Irmela Jeremias
- German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Helmholtz Zentrum München, German Research Center for Environmental Health (HMGU), Munich, Germany
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, LMU, Munich, Germany
| | - Veit Bücklein
- Department of Medicine III, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
| | - Marion Subklewe
- Department of Medicine III, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany
- German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Heidelberg, Germany
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Rejeski K, Perez A, Iacoboni G, Penack O, Bücklein V, Jentzsch L, Mougiakakos D, Johnson G, Arciola B, Carpio C, Blumenberg V, Hoster E, Bullinger L, Locke FL, von Bergwelt-Baildon M, Mackensen A, Bethge W, Barba P, Jain MD, Subklewe M. The CAR-HEMATOTOX risk-stratifies patients for severe infections and disease progression after CD19 CAR-T in R/R LBCL. J Immunother Cancer 2022; 10:jitc-2021-004475. [PMID: 35580927 PMCID: PMC9114843 DOI: 10.1136/jitc-2021-004475] [Citation(s) in RCA: 52] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2022] [Indexed: 01/18/2023] Open
Abstract
Background CD19-directed chimeric antigen receptor T-cell therapy (CAR-T) represents a promising treatment modality for an increasing number of B-cell malignancies. However, prolonged cytopenias and infections substantially contribute to the toxicity burden of CAR-T. The recently developed CAR-HEMATOTOX (HT) score—composed of five pre-lymphodepletion variables (eg, absolute neutrophil count, platelet count, hemoglobin, C-reactive protein, ferritin)—enables risk stratification of hematological toxicity. Methods In this multicenter retrospective analysis, we characterized early infection events (days 0–90) and clinical outcomes in 248 patients receiving standard-of-care CD19 CAR-T for relapsed/refractory large B-cell lymphoma. This included a derivation cohort (cohort A, 179 patients) and a second independent validation cohort (cohort B, 69 patients). Cumulative incidence curves were calculated for all-grade, grade ≥3, and specific infection subtypes. Clinical outcomes were studied via Kaplan-Meier estimates. Results In a multivariate analysis adjusted for other baseline features, the HT score identified patients at high risk for severe infections (adjusted HR 6.4, 95% CI 3.1 to 13.1). HThigh patients more frequently developed severe infections (40% vs 8%, p<0.0001)—particularly severe bacterial infections (27% vs 0.9%, p<0.0001). Additionally, multivariate analysis of post-CAR-T factors revealed that infection risk was increased by prolonged neutropenia (≥14 days) and corticosteroid use (≥9 days), and decreased with fluoroquinolone prophylaxis. Antibacterial prophylaxis significantly reduced the likelihood of severe bacterial infections in HThigh (16% vs 46%, p<0.001), but not HTlow patients (0% vs 2%, p=n.s.). Collectively, HThigh patients experienced worse median progression-free (3.4 vs 12.6 months) and overall survival (9.1 months vs not-reached), and were hospitalized longer (median 20 vs 16 days). Severe infections represented the most common cause of non-relapse mortality after CAR-T and were associated with poor survival outcomes. A trend toward increased non-relapse mortality in HThigh patients was observed (8.0% vs 3.7%, p=0.09). Conclusions These data demonstrate the utility of the HT score to risk-stratify patients for infectious complications and poor survival outcomes prior to CD19 CAR-T. High-risk patients likely benefit from anti-infective prophylaxis and should be closely monitored for potential infections and relapse.
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Affiliation(s)
- Kai Rejeski
- Department of Medicine III, Hematology and 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
| | - Ariel Perez
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida, USA.,Blood & Marrow Transplant Program, Miami Cancer Institute, Miami, Florida, USA
| | - Gloria Iacoboni
- Department of Hematology, Vall d'Hebron Institute of Oncology (VHIO), University Hospital Vall d'Hebron, Universitat Autònoma of Barcelona (UAB), Department of Medicin, Barcelona, Spain
| | - Olaf Penack
- Department of Hematology, Oncology and Tumorimmunology, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,German Cancer Consortium (DKTK) Berlin Site, and German Cancer Research Center, Heidelberg, Germany
| | - Veit Bücklein
- Department of Medicine III, Hematology and Oncology, University Hospital, LMU Munich, Munich, Germany.,Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
| | - Liv Jentzsch
- Department of Hematology, Oncology, Clinical Immunology and Rheumatology, University Hospital Tübingen, Tübingen, Germany
| | - Dimitrios Mougiakakos
- Department of Internal Medicine 5, Hematology and Oncology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Grace Johnson
- USF Morsani College of Medicine, Tampa, Florida, USA
| | - Brian Arciola
- USF Morsani College of Medicine, Tampa, Florida, USA
| | - Cecilia Carpio
- Department of Hematology, Vall d'Hebron Institute of Oncology (VHIO), University Hospital Vall d'Hebron, Universitat Autònoma of Barcelona (UAB), Department of Medicin, Barcelona, Spain
| | - Viktoria Blumenberg
- Department of Medicine III, Hematology and Oncology, University Hospital, LMU Munich, Munich, Germany.,Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
| | - Eva Hoster
- Institute for Medical Information Processing, Biometry and Epidemiology (IBE), LMU Munich, Munich, Germany
| | - Lars Bullinger
- Department of Hematology, Oncology and Tumorimmunology, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,German Cancer Consortium (DKTK) Berlin Site, and German Cancer Research Center, Heidelberg, Germany
| | - Frederick L Locke
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida, USA
| | - Michael von Bergwelt-Baildon
- Department of Medicine III, Hematology and Oncology, University Hospital, LMU Munich, Munich, Germany.,German Cancer Consortium (DKTK) Munich Site, and German Cancer Research Center, Heidelberg, Germany
| | - Andreas Mackensen
- Department of Internal Medicine 5, Hematology and Oncology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Wolfgang Bethge
- Department of Hematology, Oncology, Clinical Immunology and Rheumatology, University Hospital Tübingen, Tübingen, 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 Medicin, Barcelona, Spain
| | - Michael D Jain
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida, USA
| | - Marion Subklewe
- Department of Medicine III, Hematology and 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
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34
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Karschnia P, Rejeski K, Winkelmann M, Schöberl F, Bücklein VL, Blumenberg V, Schmidt C, Blobner J, von Bergwelt-Baildon M, Tonn JC, Kunz WG, Subklewe M, von Baumgarten L. Toxicities and Response Rates of Secondary CNS Lymphoma After Adoptive Immunotherapy With CD19-Directed Chimeric Antigen Receptor T Cells. Neurology 2022; 98:884-889. [PMID: 35351785 PMCID: PMC9169944 DOI: 10.1212/wnl.0000000000200608] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 03/11/2022] [Indexed: 11/15/2022] Open
Abstract
Background and Objectives Secondary CNS involvement in systemic B-cell lymphoma (SCNSL) is difficult to treat and displays dismal clinical outcomes. Chimeric antigen receptor (CAR) T cells emerged as a powerful treatment for systemic lymphoma. We aimed to evaluate whether CAR T cells also represent a safe and effective therapy for SCNSL. Methods We retrospectively searched our institutional database for patients with SCNSL treated with CD19-directed CAR T cells. Results We identified 10 cases, including 7 patients with intraparenchymal lesions and 3 patients with leptomeningeal disease. CNS staging at 1 month after CAR T-cell transfusion showed disease response (stable disease, partial response, and complete response) in 7 patients (70%), including 2 cases of long-lasting complete response (20%). One patient developed pseudoprogression, which resolved under steroids. Response of CNS disease was associated with systemic 1-month response. With a median follow-up of 6 months, median overall and systemic progression-free survival was 7 and 3 months, respectively. Neurotoxic symptoms occurred in 6 patients, with 3 patients developing severe neurotoxicity (American Society for Transplantation and Cellular Therapy grade ≥3). Discussion CAR T cells induce considerable antitumor effects in SCNSL, and CNS response reflects systemic response. Neurotoxicity appears similar to previous reports on patients with lymphoma without CNS involvement. CAR T cells may therefore represent an effective and safe therapy for SCNSL.
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Affiliation(s)
- Philipp Karschnia
- From the Department of Neurosurgery (P.K., J.B., J.-C.T., L.B.), University Hospital, LMU (Ludwig-Maximilians-University) Munich; German Cancer Consortium (DKTK) (P.K., K.R., V.B., C.S., J.B., M.B.-B., J.-C.T., M.S., L.B.), Partner Site Munich; Department of Medicine III - Hematology/Oncology (K.R., V.L.B., V.B., C.S., M.B.-B., M.S.), University Hospital, LMU (Ludwig-Maximilians-University) Munich; Department of Radiology (M.W., W.G.K.), University Hospital, LMU (Ludwig-Maximilians-University) Munich; and Department of Neurology (F.S., L.B.), University Hospital, LMU (Ludwig-Maximilians-University) Munich, Germany
| | - Kai Rejeski
- From the Department of Neurosurgery (P.K., J.B., J.-C.T., L.B.), University Hospital, LMU (Ludwig-Maximilians-University) Munich; German Cancer Consortium (DKTK) (P.K., K.R., V.B., C.S., J.B., M.B.-B., J.-C.T., M.S., L.B.), Partner Site Munich; Department of Medicine III - Hematology/Oncology (K.R., V.L.B., V.B., C.S., M.B.-B., M.S.), University Hospital, LMU (Ludwig-Maximilians-University) Munich; Department of Radiology (M.W., W.G.K.), University Hospital, LMU (Ludwig-Maximilians-University) Munich; and Department of Neurology (F.S., L.B.), University Hospital, LMU (Ludwig-Maximilians-University) Munich, Germany
| | - Michael Winkelmann
- From the Department of Neurosurgery (P.K., J.B., J.-C.T., L.B.), University Hospital, LMU (Ludwig-Maximilians-University) Munich; German Cancer Consortium (DKTK) (P.K., K.R., V.B., C.S., J.B., M.B.-B., J.-C.T., M.S., L.B.), Partner Site Munich; Department of Medicine III - Hematology/Oncology (K.R., V.L.B., V.B., C.S., M.B.-B., M.S.), University Hospital, LMU (Ludwig-Maximilians-University) Munich; Department of Radiology (M.W., W.G.K.), University Hospital, LMU (Ludwig-Maximilians-University) Munich; and Department of Neurology (F.S., L.B.), University Hospital, LMU (Ludwig-Maximilians-University) Munich, Germany
| | - Florian Schöberl
- From the Department of Neurosurgery (P.K., J.B., J.-C.T., L.B.), University Hospital, LMU (Ludwig-Maximilians-University) Munich; German Cancer Consortium (DKTK) (P.K., K.R., V.B., C.S., J.B., M.B.-B., J.-C.T., M.S., L.B.), Partner Site Munich; Department of Medicine III - Hematology/Oncology (K.R., V.L.B., V.B., C.S., M.B.-B., M.S.), University Hospital, LMU (Ludwig-Maximilians-University) Munich; Department of Radiology (M.W., W.G.K.), University Hospital, LMU (Ludwig-Maximilians-University) Munich; and Department of Neurology (F.S., L.B.), University Hospital, LMU (Ludwig-Maximilians-University) Munich, Germany
| | - Veit L Bücklein
- From the Department of Neurosurgery (P.K., J.B., J.-C.T., L.B.), University Hospital, LMU (Ludwig-Maximilians-University) Munich; German Cancer Consortium (DKTK) (P.K., K.R., V.B., C.S., J.B., M.B.-B., J.-C.T., M.S., L.B.), Partner Site Munich; Department of Medicine III - Hematology/Oncology (K.R., V.L.B., V.B., C.S., M.B.-B., M.S.), University Hospital, LMU (Ludwig-Maximilians-University) Munich; Department of Radiology (M.W., W.G.K.), University Hospital, LMU (Ludwig-Maximilians-University) Munich; and Department of Neurology (F.S., L.B.), University Hospital, LMU (Ludwig-Maximilians-University) Munich, Germany
| | - Viktoria Blumenberg
- From the Department of Neurosurgery (P.K., J.B., J.-C.T., L.B.), University Hospital, LMU (Ludwig-Maximilians-University) Munich; German Cancer Consortium (DKTK) (P.K., K.R., V.B., C.S., J.B., M.B.-B., J.-C.T., M.S., L.B.), Partner Site Munich; Department of Medicine III - Hematology/Oncology (K.R., V.L.B., V.B., C.S., M.B.-B., M.S.), University Hospital, LMU (Ludwig-Maximilians-University) Munich; Department of Radiology (M.W., W.G.K.), University Hospital, LMU (Ludwig-Maximilians-University) Munich; and Department of Neurology (F.S., L.B.), University Hospital, LMU (Ludwig-Maximilians-University) Munich, Germany
| | - Christian Schmidt
- From the Department of Neurosurgery (P.K., J.B., J.-C.T., L.B.), University Hospital, LMU (Ludwig-Maximilians-University) Munich; German Cancer Consortium (DKTK) (P.K., K.R., V.B., C.S., J.B., M.B.-B., J.-C.T., M.S., L.B.), Partner Site Munich; Department of Medicine III - Hematology/Oncology (K.R., V.L.B., V.B., C.S., M.B.-B., M.S.), University Hospital, LMU (Ludwig-Maximilians-University) Munich; Department of Radiology (M.W., W.G.K.), University Hospital, LMU (Ludwig-Maximilians-University) Munich; and Department of Neurology (F.S., L.B.), University Hospital, LMU (Ludwig-Maximilians-University) Munich, Germany
| | - Jens Blobner
- From the Department of Neurosurgery (P.K., J.B., J.-C.T., L.B.), University Hospital, LMU (Ludwig-Maximilians-University) Munich; German Cancer Consortium (DKTK) (P.K., K.R., V.B., C.S., J.B., M.B.-B., J.-C.T., M.S., L.B.), Partner Site Munich; Department of Medicine III - Hematology/Oncology (K.R., V.L.B., V.B., C.S., M.B.-B., M.S.), University Hospital, LMU (Ludwig-Maximilians-University) Munich; Department of Radiology (M.W., W.G.K.), University Hospital, LMU (Ludwig-Maximilians-University) Munich; and Department of Neurology (F.S., L.B.), University Hospital, LMU (Ludwig-Maximilians-University) Munich, Germany
| | - Michael von Bergwelt-Baildon
- From the Department of Neurosurgery (P.K., J.B., J.-C.T., L.B.), University Hospital, LMU (Ludwig-Maximilians-University) Munich; German Cancer Consortium (DKTK) (P.K., K.R., V.B., C.S., J.B., M.B.-B., J.-C.T., M.S., L.B.), Partner Site Munich; Department of Medicine III - Hematology/Oncology (K.R., V.L.B., V.B., C.S., M.B.-B., M.S.), University Hospital, LMU (Ludwig-Maximilians-University) Munich; Department of Radiology (M.W., W.G.K.), University Hospital, LMU (Ludwig-Maximilians-University) Munich; and Department of Neurology (F.S., L.B.), University Hospital, LMU (Ludwig-Maximilians-University) Munich, Germany
| | - Joerg-Christian Tonn
- From the Department of Neurosurgery (P.K., J.B., J.-C.T., L.B.), University Hospital, LMU (Ludwig-Maximilians-University) Munich; German Cancer Consortium (DKTK) (P.K., K.R., V.B., C.S., J.B., M.B.-B., J.-C.T., M.S., L.B.), Partner Site Munich; Department of Medicine III - Hematology/Oncology (K.R., V.L.B., V.B., C.S., M.B.-B., M.S.), University Hospital, LMU (Ludwig-Maximilians-University) Munich; Department of Radiology (M.W., W.G.K.), University Hospital, LMU (Ludwig-Maximilians-University) Munich; and Department of Neurology (F.S., L.B.), University Hospital, LMU (Ludwig-Maximilians-University) Munich, Germany
| | - Wolfgang G Kunz
- From the Department of Neurosurgery (P.K., J.B., J.-C.T., L.B.), University Hospital, LMU (Ludwig-Maximilians-University) Munich; German Cancer Consortium (DKTK) (P.K., K.R., V.B., C.S., J.B., M.B.-B., J.-C.T., M.S., L.B.), Partner Site Munich; Department of Medicine III - Hematology/Oncology (K.R., V.L.B., V.B., C.S., M.B.-B., M.S.), University Hospital, LMU (Ludwig-Maximilians-University) Munich; Department of Radiology (M.W., W.G.K.), University Hospital, LMU (Ludwig-Maximilians-University) Munich; and Department of Neurology (F.S., L.B.), University Hospital, LMU (Ludwig-Maximilians-University) Munich, Germany
| | - Marion Subklewe
- From the Department of Neurosurgery (P.K., J.B., J.-C.T., L.B.), University Hospital, LMU (Ludwig-Maximilians-University) Munich; German Cancer Consortium (DKTK) (P.K., K.R., V.B., C.S., J.B., M.B.-B., J.-C.T., M.S., L.B.), Partner Site Munich; Department of Medicine III - Hematology/Oncology (K.R., V.L.B., V.B., C.S., M.B.-B., M.S.), University Hospital, LMU (Ludwig-Maximilians-University) Munich; Department of Radiology (M.W., W.G.K.), University Hospital, LMU (Ludwig-Maximilians-University) Munich; and Department of Neurology (F.S., L.B.), University Hospital, LMU (Ludwig-Maximilians-University) Munich, Germany
| | - Louisa von Baumgarten
- From the Department of Neurosurgery (P.K., J.B., J.-C.T., L.B.), University Hospital, LMU (Ludwig-Maximilians-University) Munich; German Cancer Consortium (DKTK) (P.K., K.R., V.B., C.S., J.B., M.B.-B., J.-C.T., M.S., L.B.), Partner Site Munich; Department of Medicine III - Hematology/Oncology (K.R., V.L.B., V.B., C.S., M.B.-B., M.S.), University Hospital, LMU (Ludwig-Maximilians-University) Munich; Department of Radiology (M.W., W.G.K.), University Hospital, LMU (Ludwig-Maximilians-University) Munich; and Department of Neurology (F.S., L.B.), University Hospital, LMU (Ludwig-Maximilians-University) Munich, Germany
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35
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Dos Santos DMC, Rejeski K, Winkelmann M, Liu L, Trinkner P, Günther S, Bücklein VL, Blumenberg V, Schmidt C, Kunz WG, Von Bergwelt-Baildon M, Theurich S, Subklewe M. Increased visceral fat distribution and body composition impact cytokine release syndrome onset and severity after CD19 CAR-T in advanced B-cell malignancies. Haematologica 2022; 107:2096-2107. [PMID: 35172565 PMCID: PMC9425325 DOI: 10.3324/haematol.2021.280189] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Indexed: 11/23/2022] Open
Abstract
Chimeric antigen receptor T-cell (CAR-T) therapy is associated with a distinct toxicity profile that includes cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). CRS is characterized by the release of pro-inflammatory cytokines such as interleukin 6 (IL-6) and is closely linked to CAR-T expansion and bystander cells like monocytes/macrophages. In other hyperinflammatory states, obesity contributes to inflammatory cascades and acts as a risk factor for disease severity. We aimed to study the influence of anthropometric and body composition (BC) measurements on CAR-T-related immunotoxicity in 64 patients receiving CD19-directed CAR-T for relapsed/refractory B-cell malignancies. Patients with grade ≥2 CRS presented with a significantly higher median body mass index (BMI), waist circumference, waist-to-height ratio (WtHR) and visceral adipose tissue (VAT). These parameters were also found to be associated with an earlier CRS onset. Other adipose deposits and muscle mass did not differ between patients with grade 0-1 CRS versus grade ≥2 CRS. Moreover, BC parameters did not influence ICANS severity or onset. In a multivariate binary logistic regression incorporating known risk factors of immunotoxicity, the factors BMI, waist circumference, WtHR and VAT increased the probability of grade ≥2 CRS. Receiver operating characteristic analyses were utilized to determine optimal discriminatory thresholds for these parameters. Patients above these thresholds displayed markedly increased peak IL-6 levels. Our data imply that increased body composition and VAT in particular represent an additional risk factor for severe and early CRS. These findings carry implications for risk-stratification prior to CD19 CAR-T and may be integrated into established risk models.
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Affiliation(s)
- David M Cordas Dos Santos
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany; Cancer- and Immunometabolism Research Group, LMU Gene Center, Munich, Germany; German Cancer Consortium (DKTK), Munich Site, and German Cancer Research Center, Heidelberg
| | - Kai Rejeski
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany; German Cancer Consortium (DKTK), Munich Site, and German Cancer Research Center, Heidelberg, Germany; Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich
| | | | - Lian Liu
- Comprehensive Cancer Center Munich, LMU Munich, Munich
| | - Paul Trinkner
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany; Cancer- and Immunometabolism Research Group, LMU Gene Center, Munich
| | - Sophie Günther
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany; Cancer- and Immunometabolism Research Group, LMU Gene Center, Munich
| | - Veit L Bücklein
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany; Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich
| | - Viktoria Blumenberg
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany; German Cancer Consortium (DKTK), Munich Site, and German Cancer Research Center, Heidelberg, Germany; Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich
| | | | | | - Michael Von Bergwelt-Baildon
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany; German Cancer Consortium (DKTK), Munich Site, and German Cancer Research Center, Heidelberg, Germany; Comprehensive Cancer Center Munich, LMU Munich, Munich
| | - Sebastian Theurich
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany; Cancer- and Immunometabolism Research Group, LMU Gene Center, Munich, Germany; German Cancer Consortium (DKTK), Munich Site, and German Cancer Research Center, Heidelberg.
| | - Marion Subklewe
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany; German Cancer Consortium (DKTK), Munich Site, and German Cancer Research Center, Heidelberg, Germany; Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich.
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36
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Karschnia P, Weller J, Blobner J, Stoecklein VM, Dorostkar MM, Rejeski K, Forbrig R, Niyazi M, von Baumgarten L, Dietrich J, Tonn JC, Thon N. Subventricular zone involvement is associated with worse outcome in glioma WHO grade 2 depending on molecular markers. Sci Rep 2021; 11:20045. [PMID: 34625590 PMCID: PMC8501091 DOI: 10.1038/s41598-021-97714-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 08/26/2021] [Indexed: 02/06/2023] Open
Abstract
Neural stem cells within the subventricular zone were identified as cells of origin driving growth of high-grade gliomas, and anatomical involvement of the subventricular zone has been associated with an inferior clinical outcome. Whether the association between poor outcome and subventricular zone involvement also applies to glioma of lower grades is unclear. We therefore analysed a retrospective cohort of 182 patients with glioma grade 2 (according to the WHO 2016 classification) including 78 individuals (43%) with subventricular zone involvement. Patients with and without subventricular zone involvement did not differ in regard to demographics, histopathology, and molecular markers. Notably, subventricular zone involvement was a negative prognostic marker for malignant progression and overall survival on uni- and multivariate analysis. When patients were stratified according to the cIMPACT-NOW update 6, subventricular zone involvement was negatively associated with outcome in IDH-wildtype astrocytomas and 1p19q-codeleted oligodendrogliomas but not in IDH-mutant astrocytomas. Collectively, subventricular zone involvement may represent a risk factor for worse outcome in glioma WHO grade 2 depending on the molecular tumor signature. The present data confirm the relevance of molecular glioma classifications as proposed by the cIMPACT-NOW update 6. These findings warrant evaluation in prospective cohorts.
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Affiliation(s)
- Philipp Karschnia
- Department of Neurosurgery, Ludwig Maximilians University, Marchioninistrasse 15, 81377, Munich, Germany. .,German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany. .,Department of Neurology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA.
| | - Jonathan Weller
- Department of Neurosurgery, Ludwig Maximilians University, Marchioninistrasse 15, 81377, Munich, Germany.,German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Jens Blobner
- Department of Neurosurgery, Ludwig Maximilians University, Marchioninistrasse 15, 81377, Munich, Germany.,German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Veit M Stoecklein
- Department of Neurosurgery, Ludwig Maximilians University, Marchioninistrasse 15, 81377, Munich, Germany.,German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Mario M Dorostkar
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany.,Center for Neuropathology and Prion Research, Ludwig-Maximilians-University, Munich, Germany
| | - Kai Rejeski
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany.,Department of Medicine III, Ludwig-Maximilians-University, Munich, Germany
| | - Robert Forbrig
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany.,Department of Neuroradiology, Ludwig-Maximilians-University, Munich, Germany
| | - Maximilian Niyazi
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany.,Department of Radiation Oncology, Ludwig-Maximilians-University, Munich, Germany
| | - Louisa von Baumgarten
- Department of Neurosurgery, Ludwig Maximilians University, Marchioninistrasse 15, 81377, Munich, Germany.,German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany.,Department of Neurology, Ludwig-Maximilians-University, Munich, Germany
| | - Jorg Dietrich
- Department of Neurology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Joerg-Christian Tonn
- Department of Neurosurgery, Ludwig Maximilians University, Marchioninistrasse 15, 81377, Munich, Germany.,German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Niklas Thon
- Department of Neurosurgery, Ludwig Maximilians University, Marchioninistrasse 15, 81377, Munich, Germany.,German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
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37
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Rejeski K, Duque-Afonso J, Lübbert M. AML1/ETO and its function as a regulator of gene transcription via epigenetic mechanisms. Oncogene 2021; 40:5665-5676. [PMID: 34331016 PMCID: PMC8460439 DOI: 10.1038/s41388-021-01952-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 06/11/2021] [Accepted: 07/07/2021] [Indexed: 01/10/2023]
Abstract
The chromosomal translocation t(8;21) and the resulting oncofusion gene AML1/ETO have long served as a prototypical genetic lesion to model and understand leukemogenesis. In this review, we describe the wide-ranging role of AML1/ETO in AML leukemogenesis, with a particular focus on the aberrant epigenetic regulation of gene transcription driven by this AML-defining mutation. We begin by analyzing how structural changes secondary to distinct genomic breakpoints and splice changes, as well as posttranscriptional modifications, influence AML1/ETO protein function. Next, we characterize how AML1/ETO recruits chromatin-modifying enzymes to target genes and how the oncofusion protein alters chromatin marks, transcription factor binding, and gene expression. We explore the specific impact of these global changes in the epigenetic network facilitated by the AML1/ETO oncofusion on cellular processes and leukemic growth. Furthermore, we define the genetic landscape of AML1/ETO-positive AML, presenting the current literature concerning the incidence of cooperating mutations in genes such as KIT, FLT3, and NRAS. Finally, we outline how alterations in transcriptional regulation patterns create potential vulnerabilities that may be exploited by epigenetically active agents and other therapeutics.
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Affiliation(s)
- Kai Rejeski
- Department of Hematology, Oncology and Stem Cell Transplantation, University of Freiburg Medical Center, Freiburg, Germany.,Department of Hematology and Oncology, University Hospital of the LMU Munich, Munich, Germany.,German Cancer Consortium (DKTK) Freiburg Partner Site, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jesús Duque-Afonso
- Department of Hematology, Oncology and Stem Cell Transplantation, University of Freiburg Medical Center, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Michael Lübbert
- Department of Hematology, Oncology and Stem Cell Transplantation, University of Freiburg Medical Center, Freiburg, Germany. .,German Cancer Consortium (DKTK) Freiburg Partner Site, German Cancer Research Center (DKFZ), Heidelberg, Germany. .,Faculty of Medicine, University of Freiburg, Freiburg, Germany.
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38
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Rejeski K, Perez A, Sesques P, Berger C, Jentzsch L, Mougiakakos D, Frölich L, Ackermann J, Bücklein V, Blumenberg V, Schmidt C, Jallades L, Fehse B, Faul C, Karschnia P, Weigert O, Dreyling M, Hoster E, Locke F, Bergwelt‐Baildon M, Mackensen A, Bethge W, Ayuk F, Bachy E, Salles G, Jain M, Subklewe M. CAR‐HEMATOTOX: A DISCRIMINATIVE MODEL FOR CAR T‐CELL RELATED HEMATOTOXICITY IN RELAPSED/REFRACTORY LARGE B‐CELL LYMPHOMA. Hematol Oncol 2021. [DOI: 10.1002/hon.82_2879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- K. Rejeski
- University Hospital of the LMU Munich Department of Hematology/Oncology Munich Germany
| | - A. Perez
- Moffitt Cancer Center Department of Blood and Marrow Transplant and Cellular Immunotherapy Moffitt Cancer Center, Tampa, USA Tampa USA
| | - P. Sesques
- Hospices Civils de Lyon Institut National de la Santé et de la Recherche Médicale (INSERM) Lyon France
| | - C. Berger
- University Hospital Hamburg‐Eppendorf Department of Hematology, Oncology and Pulmonology Hamburg Germany
| | - L. Jentzsch
- University Hospital Tübingen Department of Hematology, Oncology, Immunology and Rheumatology Tübingen Germany
| | - D. Mougiakakos
- University Hospital of Erlangen Department of Internal Medicine 5, Hematology and Oncology Erlangen Germany
| | - L. Frölich
- University Hospital of the LMU Munich Department of Hematology/Oncology Munich Germany
| | - J. Ackermann
- University Hospital of the LMU Munich Department of Hematology/Oncology Munich Germany
| | - V. Bücklein
- University Hospital of the LMU Munich Department of Hematology/Oncology Munich Germany
| | - V. Blumenberg
- University Hospital of the LMU Munich Department of Hematology/Oncology Munich Germany
| | - C. Schmidt
- University Hospital of the LMU Munich Department of Hematology/Oncology Munich Germany
| | - L. Jallades
- Hospices Civils de Lyon Institut National de la Santé et de la Recherche Médicale (INSERM) Lyon France
| | - B. Fehse
- University Hospital Hamburg‐Eppendorf Department of Hematology, Oncology and Pulmonology Hamburg Germany
| | - C. Faul
- University Hospital Tübingen Department of Hematology, Oncology, Immunology and Rheumatology Tübingen Germany
| | - P. Karschnia
- University Hospital of the LMU Munich Department of Neurosurgery Munich Germany
| | - O. Weigert
- University Hospital of the LMU Munich Department of Hematology/Oncology Munich Germany
| | - M. Dreyling
- University Hospital of the LMU Munich Department of Hematology/Oncology Munich Germany
| | - E. Hoster
- LMU Munich Institute for Medical Informatics Biometry and Epidemiology Munich Germany
| | - F. Locke
- Moffitt Cancer Center Department of Blood and Marrow Transplant and Cellular Immunotherapy Moffitt Cancer Center, Tampa, USA Tampa USA
| | - M. Bergwelt‐Baildon
- University Hospital of the LMU Munich Department of Hematology/Oncology Munich Germany
| | - A. Mackensen
- University Hospital of Erlangen Department of Internal Medicine 5, Hematology and Oncology Erlangen Germany
| | - W. Bethge
- University Hospital Tübingen Department of Hematology, Oncology, Immunology and Rheumatology Tübingen Germany
| | - F. Ayuk
- University Hospital Hamburg‐Eppendorf Department of Hematology, Oncology and Pulmonology Hamburg Germany
| | - E. Bachy
- Hospices Civils de Lyon Institut National de la Santé et de la Recherche Médicale (INSERM) Lyon France
| | - G. Salles
- MSKCC, Lymphoma Service Department of Medicine NYC New York USA
| | - M. Jain
- Moffitt Cancer Center Department of Blood and Marrow Transplant and Cellular Immunotherapy Moffitt Cancer Center, Tampa, USA Tampa USA
| | - M. Subklewe
- University Hospital of the LMU Munich Department of Hematology/Oncology Munich Germany
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39
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Bücklein V, Blumenberg V, Ackermann J, Frölich L, Winkelmann M, Schmidt C, Rejeski K, Ruzicka M, Müller N, von Baumgarten L, Schöberl F, Hildebrandt M, Humpe A, Kunz W, Hoster E, von Bergwelt M, Subklewe M. EXTRANODAL DISEASE IS ASSOCIATED WITH SHORTER PROGRESSION‐FREE SURVIVAL AFTER CD19‐CAR T‐CELL THERAPY FOR RELAPSED/REFRACTORY DIFFUSE LARGE B‐CELL LYMPHOMA. Hematol Oncol 2021. [DOI: 10.1002/hon.183_2880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- V. Bücklein
- University Hospital LMU Munich Department of Medicine III Munich Germany
| | - V. Blumenberg
- University Hospital LMU Munich Department of Medicine III Munich Germany
| | - J. Ackermann
- University Hospital LMU Munich Department of Medicine III Munich Germany
| | - L. Frölich
- University Hospital LMU Munich Department of Medicine III Munich Germany
| | - M. Winkelmann
- University Hospital LMU Munich Department of Radiology Munich Germany
| | - C. Schmidt
- University Hospital LMU Munich Department of Medicine III Munich Germany
| | - K. Rejeski
- University Hospital LMU Munich Department of Medicine III Munich Germany
| | - M. Ruzicka
- University Hospital LMU Munich Department of Medicine III Munich Germany
| | - N. Müller
- University Hospital LMU Munich Department of Medicine III Munich Germany
| | - L. von Baumgarten
- University Hospital LMU Munich Department of Neurosurgery Munich Germany
| | - F. Schöberl
- University Hospital LMU Munich Department of Neurology Munich Germany
| | - M. Hildebrandt
- University Hospital LMU Munich Department of Transfusion Medicine Munich Germany
| | - A. Humpe
- University Hospital LMU Munich Department of Transfusion Medicine Munich Germany
| | - W. Kunz
- University Hospital LMU Munich Department of Radiology Munich Germany
| | - E. Hoster
- LMU Munich Institute for Medical Information Processing, Biometry, and Epidemiology Munich Germany
| | - M. von Bergwelt
- University Hospital LMU Munich Department of Medicine III Munich Germany
| | - M. Subklewe
- University Hospital LMU Munich Department of Medicine III Munich Germany
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Rejeski K, Kunz WG, Rudelius M, Bücklein V, Blumenberg V, Schmidt C, Karschnia P, Schöberl F, Dimitriadis K, von Baumgarten L, Stemmler J, Weigert O, Dreyling M, von Bergwelt-Baildon M, Subklewe M. Severe Candida glabrata pancolitis and fatal Aspergillus fumigatus pulmonary infection in the setting of bone marrow aplasia after CD19-directed CAR T-cell therapy - a case report. BMC Infect Dis 2021; 21:121. [PMID: 33509115 PMCID: PMC7841988 DOI: 10.1186/s12879-020-05755-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 12/28/2020] [Indexed: 01/04/2023] Open
Abstract
Background Prolonged myelosuppression following CD19-directed CAR T-cell transfusion represents an important, yet underreported, adverse event. The resulting neutropenia and multifactorial immunosuppression can facilitate severe infectious complications. Case presentation We describe the clinical course of a 59-year-old patient with relapsed/refractory DLBCL who received Axicabtagene-Ciloleucel (Axi-cel). The patient developed ASTCT grade I CRS and grade IV ICANS, necessitating admission to the neurological ICU and prolonged application of high-dose corticosteroids and other immunosuppressive agents. Importantly, neutropenia was profound (ANC < 100/μl), G-CSF-refractory, and prolonged, lasting more than 50 days. The patient developed severe septic shock 3 weeks after CAR transfusion while receiving anti-fungal prophylaxis with micafungin. His clinical status stabilized with broad anti-infective treatment and intensive supportive measures. An autologous stem cell backup was employed on day 46 to support hematopoietic recovery. Although the counts of the patient eventually started to recover, he developed an invasive pulmonary aspergillosis, which ultimately lead to respiratory failure and death. Postmortem examination revealed signs of Candida glabrata pancolitis. Conclusions This case highlights the increased risk for fatal infectious complications in patients who present with profound and prolonged cytopenia after CAR T-cell therapy. We describe a rare case of C. glabrata pancolitis associated with multifactorial immunosuppression. Although our patient succumbed to a fatal fungal infection, autologous stem cell boost was able to spur hematopoiesis and may represent an important therapeutic strategy for DLBCL patients with CAR T-cell associated bone marrow aplasia who have underwent prior stem cell harvest.
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Affiliation(s)
- Kai Rejeski
- Department of Hematology and Oncology, University Hospital, LMU Munich, Munich, Germany. .,Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany. .,German Cancer Consortium (DKTK) and German Cancer Research Center, Heidelberg, Germany.
| | - Wolfgang G Kunz
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Martina Rudelius
- Department of Pathology, University Hospital, LMU Munich, Munich, Germany
| | - Veit Bücklein
- Department of Hematology and Oncology, University Hospital, LMU Munich, Munich, Germany.,Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
| | - Viktoria Blumenberg
- Department of Hematology and Oncology, University Hospital, LMU Munich, Munich, Germany.,Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
| | - Christian Schmidt
- Department of Hematology and Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Philipp Karschnia
- Department of Neurosurgery, University Hospital, LMU Munich, Munich, Germany
| | - Florian Schöberl
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | | | | | - Joachim Stemmler
- Department of Hematology and Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Oliver Weigert
- Department of Hematology and Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Martin Dreyling
- Department of Hematology and Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Michael von Bergwelt-Baildon
- Department of Hematology and Oncology, University Hospital, LMU Munich, Munich, Germany.,German Cancer Consortium (DKTK) and German Cancer Research Center, Heidelberg, Germany
| | - Marion Subklewe
- Department of Hematology and Oncology, University Hospital, LMU Munich, Munich, Germany.,Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany.,German Cancer Consortium (DKTK) and German Cancer Research Center, Heidelberg, Germany
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Winkelmann M, Rejeski K, Unterrainer M, Schmidt C, Ruzicka M, Ricke J, Rudelius M, Subklewe M, Kunz WG. Transformation of diffuse large B cell lymphoma into dendritic sarcoma under CAR T cell therapy detected on 18F-FDG PET/CT. Eur J Nucl Med Mol Imaging 2020; 48:1692-1693. [PMID: 32814980 PMCID: PMC8113144 DOI: 10.1007/s00259-020-05000-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 08/11/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Michael Winkelmann
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Kai Rejeski
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Marcus Unterrainer
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Christian Schmidt
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Michael Ruzicka
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Jens Ricke
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Martina Rudelius
- Department of Pathology, University Hospital, LMU Munich, Munich, Germany
| | - Marion Subklewe
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Wolfgang G Kunz
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.
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Liang Y, Daubner G, Tebaldi T, Li Y, Stefani G, Taylor A, Maziarz J, Rejeski K, Vasic R, Modis Y, Allain F, Halene S. 22 MUTATIONS IN SRSF2 IDENTIFIED IN MYELODYSPLASIA AFFECT RNA BINDING AFFINITY, SPECIFICITY, AND SPLICING. Leuk Res 2015. [DOI: 10.1016/s0145-2126(15)30023-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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