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Keijzer K, de Boer JW, van Doesum JA, Noordzij W, Huls GA, van Dijk LV, van Meerten T, Niezink AGH. Reducing and controlling metabolic active tumor volume prior to CAR T-cell infusion can improve survival outcomes in patients with large B-cell lymphoma. Blood Cancer J 2024; 14:41. [PMID: 38448432 PMCID: PMC10917787 DOI: 10.1038/s41408-024-01022-w] [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: 11/21/2023] [Revised: 02/26/2024] [Accepted: 02/27/2024] [Indexed: 03/08/2024] Open
Abstract
Bridging therapy before CD19-directed chimeric antigen receptor (CAR) T-cell infusion is frequently applied in patients with relapsed or refractory Large B-cell lymphoma (r/r LBCL). This study aimed to assess the influence of quantified MATV and MATV-dynamics, between pre-apheresis (baseline) and pre-lymphodepleting chemotherapy (pre-LD) MATV, on CAR T-cell outcomes and toxicities in patients with r/r LBCL. MATVs were calculated semi-automatically at baseline (n = 74) and pre-LD (n = 68) in patients with r/r LBCL who received axicabtagene ciloleucel. At baseline, patients with a low MATV (< 190 cc) had a better time to progression (TTP) and overall survival (OS) compared to high MATV patients (p < 0.001). High MATV patients who remained stable or reduced upon bridging therapy showed a significant improvement in TTP (p = 0.041) and OS (p = 0.015), compared to patients with a high pre-LD MATV (> 480 cc). Furthermore, high MATV baseline was associated with severe cytokine release syndrome (CRS, p = 0.001). In conclusion, patients with low baseline MATV had the best TTP/OS and effective reduction or controlling MATV during bridging improved survival outcomes in patients with a high baseline MATV, providing rationale for the use of more aggressive bridging regimens.
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Affiliation(s)
- Kylie Keijzer
- Department of Hematology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713GZ, Groningen, The Netherlands
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713GZ, Groningen, The Netherlands
| | - Janneke W de Boer
- Department of Hematology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713GZ, Groningen, The Netherlands
| | - Jaap A van Doesum
- Department of Hematology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713GZ, Groningen, The Netherlands
| | - Walter Noordzij
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713GZ, Groningen, The Netherlands
| | - Gerwin A Huls
- Department of Hematology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713GZ, Groningen, The Netherlands
| | - Lisanne V van Dijk
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713GZ, Groningen, The Netherlands
| | - Tom van Meerten
- Department of Hematology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713GZ, Groningen, The Netherlands
| | - Anne G H Niezink
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713GZ, Groningen, The Netherlands.
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de Boer JW, Keijzer K, Pennings ERA, van Doesum JA, Spanjaart AM, Jak M, Mutsaers PGNJ, van Dorp S, Vermaat JSP, van der Poel MWM, van Dijk LV, Kersten MJ, Niezink AGH, van Meerten T. Population-Based External Validation of the EASIX Scores to Predict CAR T-Cell-Related Toxicities. Cancers (Basel) 2023; 15:5443. [PMID: 38001703 PMCID: PMC10670876 DOI: 10.3390/cancers15225443] [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: 09/29/2023] [Revised: 11/14/2023] [Accepted: 11/14/2023] [Indexed: 11/26/2023] Open
Abstract
Cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS) can hamper the clinical benefit of CAR T-cell therapy in patients with relapsed/refractory large B-cell lymphoma (r/r LBCL). To assess the risk of CRS and ICANS, the endothelial activation and stress index (EASIX), the modified EASIX (m-EASIX), simplified EASIX (s-EASIX), and EASIX with CRP/ferritin (EASIX-F(C)) were proposed. This study validates these scores in a consecutive population-based cohort. Patients with r/r LBCL treated with axicabtagene ciloleucel were included (n = 154). EASIX scores were calculated at baseline, before lymphodepletion (pre-LD) and at CAR T-cell infusion. The EASIX and the s-EASIX at pre-LD were significantly associated with ICANS grade ≥ 2 (both p = 0.04), and the EASIX approached statistical significance at infusion (p = 0.05). However, the predictive performance was moderate, with area under the curves of 0.61-0.62. Validation of the EASIX-FC revealed that patients in the intermediate risk group had an increased risk of ICANS grade ≥ 2 compared to low-risk patients. No significant associations between EASIX scores and CRS/ICANS grade ≥ 3 were found. The (m-/s-) EASIX can be used to assess the risk of ICANS grade ≥ 2 in patients treated with CAR T-cell therapy. However, due to the moderate performance of the scores, further optimization needs to be performed before broad implementation as a clinical tool, directing early intervention and guiding outpatient CAR T-cell treatment.
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Affiliation(s)
- Janneke W. de Boer
- Department of Hematology, University of Groningen, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands; (J.W.d.B.); (K.K.); (J.A.v.D.)
| | - Kylie Keijzer
- Department of Hematology, University of Groningen, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands; (J.W.d.B.); (K.K.); (J.A.v.D.)
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands; (L.V.v.D.); (A.G.H.N.)
| | - Elise R. A. Pennings
- Department of Hematology, Amsterdam UMC Location University of Amsterdam, 1007 MB Amsterdam, The Netherlands (M.J.K.)
- Cancer Center Amsterdam, 1105 AZ Amsterdam, The Netherlands
- LYMMCARE (Lymphoma and Myeloma Center Amsterdam), 1105 AZ Amsterdam, The Netherlands
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, 3062 PA Rotterdam, The Netherlands
| | - Jaap A. van Doesum
- Department of Hematology, University of Groningen, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands; (J.W.d.B.); (K.K.); (J.A.v.D.)
| | - Anne M. Spanjaart
- Department of Hematology, Amsterdam UMC Location University of Amsterdam, 1007 MB Amsterdam, The Netherlands (M.J.K.)
- Cancer Center Amsterdam, 1105 AZ Amsterdam, The Netherlands
- LYMMCARE (Lymphoma and Myeloma Center Amsterdam), 1105 AZ Amsterdam, The Netherlands
| | - Margot Jak
- Department of Hematology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands;
| | - Pim G. N. J. Mutsaers
- Department of Hematology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands;
| | - Suzanne van Dorp
- Department of Hematology, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands;
| | - Joost S. P. Vermaat
- Department of Hematology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands;
| | - Marjolein W. M. van der Poel
- Department of Internal Medicine, Division of Hematology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, 6229 HX Maastricht, The Netherlands;
| | - Lisanne V. van Dijk
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands; (L.V.v.D.); (A.G.H.N.)
| | - Marie José Kersten
- Department of Hematology, Amsterdam UMC Location University of Amsterdam, 1007 MB Amsterdam, The Netherlands (M.J.K.)
- Cancer Center Amsterdam, 1105 AZ Amsterdam, The Netherlands
- LYMMCARE (Lymphoma and Myeloma Center Amsterdam), 1105 AZ Amsterdam, The Netherlands
| | - Anne G. H. Niezink
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands; (L.V.v.D.); (A.G.H.N.)
| | - Tom van Meerten
- Department of Hematology, University of Groningen, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands; (J.W.d.B.); (K.K.); (J.A.v.D.)
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Keijzer K, Niezink AG, de Boer JW, van Doesum JA, Noordzij W, van Meerten T, van Dijk LV. Semi-automated 18F-FDG PET segmentation methods for tumor volume determination in Non-Hodgkin lymphoma patients: a literature review, implementation and multi-threshold evaluation. Comput Struct Biotechnol J 2023; 21:1102-1114. [PMID: 36789266 PMCID: PMC9900370 DOI: 10.1016/j.csbj.2023.01.023] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 01/18/2023] [Accepted: 01/18/2023] [Indexed: 01/21/2023] Open
Abstract
In the treatment of Non-Hodgkin lymphoma (NHL), multiple therapeutic options are available. Improving outcome predictions are essential to optimize treatment. The metabolic active tumor volume (MATV) has shown to be a prognostic factor in NHL. It is usually retrieved using semi-automated thresholding methods based on standardized uptake values (SUV), calculated from 18F-Fluorodeoxyglucose Positron Emission Tomography (18F-FDG PET) images. However, there is currently no consensus method for NHL. The aim of this study was to review literature on different segmentation methods used, and to evaluate selected methods by using an in house created software tool. A software tool, MUltiple SUV Threshold (MUST)-segmenter was developed where tumor locations are identified by placing seed-points on the PET images, followed by subsequent region growing. Based on a literature review, 9 SUV thresholding methods were selected and MATVs were extracted. The MUST-segmenter was utilized in a cohort of 68 patients with NHL. Differences in MATVs were assessed with paired t-tests, and correlations and distributions figures. High variability and significant differences between the MATVs based on different segmentation methods (p < 0.05) were observed in the NHL patients. Median MATVs ranged from 35 to 211 cc. No consensus for determining MATV is available based on the literature. Using the MUST-segmenter with 9 selected SUV thresholding methods, we demonstrated a large and significant variation in MATVs. Identifying the most optimal segmentation method for patients with NHL is essential to further improve predictions of toxicity, response, and treatment outcomes, which can be facilitated by the MUST-segmenter.
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Key Words
- 18F-FDG PET
- AT, adaptive thresholding methods
- CAR, chimeric antigen receptor
- CT, computed tomography
- DICOM, Digital Imaging and Communications in Medicine
- DLBCL, Diffuse large B-cell lymphoma
- EANM, European Association of Nuclear Medicine
- EARL, EANM Research Ltd.
- FDG, fluorodeoxyglucose
- HL, Hodgkin lymphoma
- IMG, robustness across image reconstruction methods
- IQR, interquartile range
- LBCL, Large B-cell lymphoma
- LDH, lactate dehydrogenase
- MAN, clinician based evaluation using manual segmentations
- MATV, Metabolic active tumor volume
- MIP, Maximum Intensity Projection
- MUST, Multiple SUV Thresholding
- Metabolic tumor volume
- NHL, Non-Hodgkin lymphoma
- Non-Hodgkin lymphoma
- OBS, robustness across observers
- OS, overall survival
- PD-L1, programmed cell death ligand-1
- PET segmentation
- PET, positron emission tomography
- PFS, progression free survival
- PROG, progression vs non-progression
- PTCL, Peripheral T-cell lymphoma
- PTLD, Post-transplant lymphoproliferative disorder
- QS, quality scores
- SOFT, robustness across software
- SUV thresholding
- SUV, standardized uptake value
- Segmentation software
- TCL, T-cell lymphoma
- UMCG, University Medical Center Groningen
- VOI, volume of interest
- cc, cubic centimeter
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Affiliation(s)
- Kylie Keijzer
- Department of Hematology, University Medical Center Groningen, Hanzeplein 1, 9713GZ Groningen, the Netherlands,Department of Radiation Oncology, University Medical Center Groningen, Hanzeplein 1, 9713GZ Groningen, the Netherlands
| | - Anne G.H. Niezink
- Department of Radiation Oncology, University Medical Center Groningen, Hanzeplein 1, 9713GZ Groningen, the Netherlands
| | - Janneke W. de Boer
- Department of Hematology, University Medical Center Groningen, Hanzeplein 1, 9713GZ Groningen, the Netherlands
| | - Jaap A. van Doesum
- Department of Hematology, University Medical Center Groningen, Hanzeplein 1, 9713GZ Groningen, the Netherlands
| | - Walter Noordzij
- Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, Hanzeplein 1, 9713GZ Groningen, the Netherlands
| | - Tom van Meerten
- Department of Hematology, University Medical Center Groningen, Hanzeplein 1, 9713GZ Groningen, the Netherlands
| | - Lisanne V. van Dijk
- Department of Radiation Oncology, University Medical Center Groningen, Hanzeplein 1, 9713GZ Groningen, the Netherlands,Corresponding author.
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