JL503. Chimeric Antigen Receptor T-Cell Therapy: Management of Toxicities
Harolynn K. Adeniran, FNP-C, Karla Ow, FNP-C, and Evelyn Acosta, FNP-C; The University of Texas MD Anderson Cancer Center, Houston, Texas
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JADPRO Live at APSHO 2017
Marriott Marquis, Houston, Texas • November 2–5, 2017
The posters for the abstracts below can be found at:
Introduction: Relapsed and/or refractory aggressive non-Hodgkin lymphoma can be devastating news to the lymphoma patient. In fact, outcomes for patients with refractory diffuse large B-cell lymphoma (DLBCL) are poor. The median overall survival with salvage chemotherapy is 6.6 months. Considerable effort has been given to the development of immunotherapy in this patient population. In particular, chimeric antigen receptor T (CAR-T) cell therapy targeting CD19 is being evaluated for various disease states including non-Hodgkin lymphoma. Phase 1 and 2 trials have demonstrated that CD19-specific CAR-T cell therapy is emerging as a potential new tool in the management of B-cell malignancies. CAR-T cells are generated by genetically programming autologous T cells to express CAR molecules that target CD19 antigen on tumor cells. While it is highly efficacious, CAR-T cell therapy can be associated with potentially life threatening toxicities. These toxicities result from T cell activation leading to a profound inflammatory response and cytokine release. Cytokine release syndrome (CRS) most commonly manifests as fever, hypotension, neurotoxicity, coagulopathy, and multi-organ dysfunction.
Description: 67-year-old male diagnosed with stage IIE DLBCL in 2003 with mesenteric and small bowel disease. He later relapsed and underwent autologous stem cell transplant with R-BEAM in 2/2014. In 12/2014 he again relapsed with mesenteric lymph node involvement and was later enrolled on CD19 CAR-T cell study. Following conditioning therapy with cyclophosphamide and fludarabine, he received CAR-T cells by intravenous infusion. His course was complicated by CRS symptoms including fever, hypotension, and altered mental status. He received supportive care for fevers with acetaminophen and cooling blanket. Antibiotics were given for neutropenia and urinary tract infection. Tocilizumab, an anti-IL-6 receptor antibody was given for grade 2 CRS. Fluid blouses were given for hypotension. He was also started on dexamethasone for neurotoxicity. He also received intrathecal hydrocortisone. His mentation returned to baseline on day 10. Patient achieved complete remission by PET-CT scan at 30 days after CAR-T infusion and remains in remission 2 years later.
Conclusion: Chemotherapy–refractory DLBCL is considered incurable and universally fatal, except for those who successfully undergo allogenic stem cell transplant. CAR-T cell therapy has shown promising treatment in refractory B-cell malignancies. This new therapy presents unique challenges in toxicity management. Advance nurse practitioners are at the forefront of this emerging therapy and must be familiar with the hallmark side effects and be prepared to manage them effectively in a timely manner to improve patient outcomes.
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