Molecular monitoring of T-cell kinetics and migration in severe neurotoxicity after real-world CD19-specific chimeric antigen receptor T cell therapy.

CD19-specific chimeric antigen receptor (CD19-CAR) T-cell therapies mediate durable responses in late-stage B-cell malignancies, but can be complicated by a potentially severe immune effector cell-associated neurotoxicity syndrome (ICANS). Despite broad efforts, the precise mechanisms of ICANS are not entirely known, and resistance to current ICANSdirected therapies (especially corticosteroids) has been observed. Recent data suggest that inflammatory cytokines and/or targeting of cerebral CD19-expressing pericytes can disrupt the blood-brain barrier and facilitate influx of immune cells, including CAR T cells. However, specific tools for CD19-CAR T-cell analysis within often minute samples of cerebrospinal fluid (CSF) are not broadly available. Here, we applied our recently developed digital polymerase chain reaction assays to monitor CD19-CAR T-cell kinetics in CSF and blood in real-world patients with neurotoxicity. Consistently, we observed a CAR T-cell enrichment within CSF in ICANS patients with further progressive accumulation despite intense corticosteroid- containing immuno-chemotherapies in a subset of patients with prolonged and therapy-resistant grade 3-4 neurotoxicity. We used next-generation T-cell receptor-b sequencing to assess the repertoire of treatment-refractory cells. Longitudinal analysis revealed a profound skewing of the T-cell receptor repertoire, which at least partly reflected selective expansion of infused T-cell clones. Interestingly, a major fraction of eventually dominating hyperexpanded T-cell clones were of non-CAR T-cell derivation. These findings hint to a role of therapy-refractory T-cell clones in severe ICANS development and prompt future systematic research to determine if CAR T cells may serve as 'door openers' and to further characterize both CAR-positive and non-CAR T cells to interrogate the transcriptional signature of these possibly pathologic T cells.

Approaches of stem cell mobilization in a large cohort of metastatic germ cell cancer patients.

High-dose chemotherapy (HD-Cx) in refractory germ cell cancer (GCC) is effective but limited data are available concerning the optimal approach for stem cell mobilization (SCM) in these patients. In this analysis 102 patients undergoing SCM during first (n = 25) or subsequent treatment lines (n = 77) were analyzed. Subcutaneous injections of granulocyte colony-stimulating factor (G-CSF) were given once daily (group 1) in 52 patients (51%), twice daily (group 2) in 39 patients (38%) or one injection Pegylated-G-CSF (PegG-CSF) (group 3) in eleven patients (11%) after one cycle of mobilization chemotherapy. Plerixafor was administered 13 times in group 1, seven times in group 2 and once in group 3. Overall, 77 (75%) patients achieved successful SCM defined as ≥8*106 CD34+ cells/kg body weight for three consecutive HD-Cx plus one backup dose. In group 1, 40 of 52 patients (77%) achieved successful SCM with a median of 11 G-CSF injections, in group 2, 27 of 39 patients (69%) with a median of 14 G-CSF injections and in group 3, 10 of 11 patients (91%) with one injection of PegG-CSF. SCM was more successful if conducted during first-line chemotherapy (p = 0.016) and associated with a beneficial outcome concerning overall survival (p = 0.02) if performed satisfactorily.

[Neoehrlichiosis as a cause of feaver of unknown origin]. / Neoehrlichiose als Ursache eines Fiebers unklarer Genese.

Establishing a diagnosis in cases of fever of unknown origin (FUO) in immunocompromised patients can be difficult. In 25-35% infectious diseases are the underlying cause. This article reports the case of a 74-year-old woman with a 5-month history of fever. Through open biopsy of the femoral shaft and microbiological analysis, a diagnosis of neoehrlichiosis could be established. After initiation of treatment with doxycycline, the symptoms quickly resolved resulting in a complete recovery.

Outcome of a Real-World Patient Cohort with Secondary CNS Lymphoma Treated with High-Intensity Chemoimmunotherapy and Autologous Stem Cell Transplantation.

BACKGROUND: Aggressive non-Hodgkin lymphomas with secondary central nervous system (CNS) involvement bear a dismal prognosis. Optimal treatment remains so far unclear, and effective treatment options remain an unmet clinical need. Remission rates are in general low, resulting in rapid relapses and palliative care in the majority of patients. High-intensity treatment combining effective CNS-directed chemoimmunotherapy with autologous stem cell transplantation was shown in a recent phase 2 trial to induce durable remissions. Here, we report the outcome of the first real-world patient cohort treated according to the published protocol. METHODS: We retrospectively identified 17 HIV-negative lymphoma patients with secondary CNS involvement, either at first diagnosis or at relapse of lymphoma, treated according to the study protocol published by Ferreri et al. [J Clin Oncol. 2015] at two university medical centers in Germany. Treatment consisted of four cycles of chemoimmunotherapy with a consolidating autologous stem cell transplantation. Adverse events and overall outcome were assessed. RESULTS: Five patients had CNS involvement at first diagnosis and 12 patients at relapse of lymphoma. A complete response was achieved in 9 patients. Median survival was 11 months. Five patients died of septic complications and 4 patients succumbed to progression or relapse of disease. CONCLUSIONS: The outcome of our real-world cohort emphasizes the possible toxic character of the treatment protocol by Ferreri et al. [J Clin Oncol. 2015]. Further improvement in treatment regimens is still an unmet need.

Axicabtagene ciloleucel in vivo expansion and treatment outcome in aggressive B-cell lymphoma in a real-world setting.

Data on the association between chimeric antigen receptor (CAR)-T-cell kinetics and patient outcome in the nontrial setting are missing, mainly due to the lack of broadly available CAR-T-cell diagnostic quantification tools. We performed prospective quantification of axicabtagene ciloleucel (axi-cel) in 21 patients treated for aggressive B-cell lymphoma at our clinic. Median peak CAR-T-cell count was 16.14 CAR-T cells/µL. Patients with 16.14/µL or higher peak CAR-T cells (strong expanders) had more day-30 objective responses (91% vs 40%, P = .02). In univariate analysis, peak CAR-T cell ≥ 16.14 (P < .001), normal platelet counts at start of lymphodepletion (P < .001), no prior stem cell transplant (P = .04), and peak CAR-T cells as continuous variable (P = .03) were associated with better progression-free survival (PFS). After adjusting for platelet counts and prior stem cell transplantation, peak CAR-T cells below median was still associated with shorter PFS (relative risk, 0.15, 95% confidence interval, 0.04-0.59, P = .007). Low platelet counts also maintained significant impact on PFS. Our data demonstrate association of axi-cel levels and outcome in a nontrial setting and for the first time use a cutoff to segregate weak and strong expanders with respective outcomes.

Standardized Supportive Care Documentation Improves Safety of High-Dose Methotrexate Treatment.

BACKGROUND: High-dose (HD) methotrexate (MTX) is an essential component of treatment protocols in acute lymphoblastic leukemia, aggressive lymphoma, and osteosarcoma. However, delayed MTX clearance may lead to life-threatening toxicities. Administration of supportive therapy for HD-MTX is complex, and insufficient supportive care increases the risk of MTX toxicity. To improve patient safety, we investigated the implementation of a checklist and urine alkalinization protocol in addition to standard supportive care during HD-MTX therapy. MATERIALS AND METHODS: The intervention included individualized patient checklists for control of adequate supportive care for every HD-MTX treatment cycle and a urine alkalinization protocol for documentation and guidance during urine alkalinization therapy. The impact of these tools on the rate of adverse events (acute renal injury, delayed MTX clearance) was retrospectively assessed in patients treated from April 2017 to April 2019 (intervention group) and compared with patients treated from January 2015 to March 2017 who received standard supportive care for HD-MTX according to a standard operating procedure (SOP). RESULTS: In total, 118 patients received 414 HD-MTX cycles in the intervention group compared with 108 patients with 332 treatment cycles in the SOP group. Delayed MTX clearance was observed in 2.6% of treatment cycles in the intervention cohort opposed to 15.2% of cycles in the SOP group. The rate of acute kidney injury was also significantly reduced in the intervention group (6.2%. vs. 0.7%). The use of carboxypeptidase as rescue treatment for severe renal impairment and insufficient MTX clearance was necessary in five cases in the SOP group and in only two cycles within the intervention group. CONCLUSION: The use of standardized documentation for supportive care during HD-MTX therapy is recommended to minimize the risk of adverse events. IMPLICATIONS FOR PRACTICE: High-dose methotrexate (HD-MTX) is a commonly used treatment in several cancer types. Distinct supportive measures are necessary to minimize the risk of HD-MTX side effects, which can be life-threatening. Supportive care consists of certain examinations and interventions before starting HD-MTX and permanent alkalinization of the urine, as this greatly increases the elimination of MTX and decreases the risk of kidney injury. After implementing a checklist for control of supportive care and a urine alkalinization protocol to optimize urine alkalinization, a significant decrease of side effects was observed in comparison to the standard of care; therefore, the use of a safety checklist and alkalinization protocol is recommended for all patients who receive HD-MTX.

Undifferentiated embryonal sarcoma of the liver treated with associating liver partition and portal vein ligation for staged hepatectomy in a young adult: A case report.

INTRODUCTION: Embryonal sarcomas of the liver (ESL) are extremely rare solid tumors appearing mainly in children. The therapeutic standard for an ESL is a margin free resection combined with chemotherapy. The Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) procedure as a surgical therapy offers a curative approach for liver tumors of various origins where the future liver remnant (FLR) would be insufficient after a one-staged (extended) hemihepatectomy. PRESENTATION OF CASE: A 19-year-old patient was diagnosed with an undifferentiated embryonal sarcoma of the liver (UESL) in the right liver lobe with oligometastatic spread to the lungs. After neoadjuvant chemotherapy remission was enough to plan a resection of the liver tumor. During the operation we changed our strategy from one-stage hepatectomy to ALPPS because of borderline FLR and macroscopic and histologic liver damage to avoid posthepatectomy liver failure. The interstage and postoperative course of the patient was uneventful beside postoperative bile leakage, which was treated by interventional drainage and stenting. DISCUSSION: The ALPPS-procedure as a comparatively new surgery was considered over a portal vein ligation or embolization. ALPPS shows a faster hypertrophy compared to standard one-staged hemihepatectomy with decreased or similar proliferation, apoptosis or angiogenesis (at least for CRLM) CONCLUSION: In experienced centers the ALPPS-procedure is evolving as the safer approach in hemihepatectomys where the FLR is critical. Additionally, ALPPS can serve as an intraoperative option when liver volume and quality seem not to be sufficient and is to be considered when facing new tumor-entities.

Fatal Myelotoxicity Following Palliative Chemotherapy With Cisplatin and Gemcitabine in a Patient With Stage IV Cholangiocarcinoma Linked to Post Mortem Diagnosis of Fanconi Anemia.

Unrecognized genome instability syndromes can potentially impede the rational treatment of cancer in rare patients. Identification of cancer patients with a hereditary condition is a compelling necessity for oncologists, giving varying hypersensitivities to various chemotherapeutic agents or radiation, depending on the underlying genetic cause. Omission of genetic testing in the setting of an overlooked hereditary syndrome may lead to unexpected and unbearable toxicity from oncological standard approaches. We present a case of a 33-year-old man with an early-onset stage IV intrahepatic cholangiocarcinoma, who experienced unusual bone marrow failure and neutropenic fever syndrome as a consequence of palliative chemotherapy containing cisplatin and gemcitabine, leading to a fatal outcome on day 25 of his first chemotherapeutic cycle. The constellation of bone marrow failure after exposure to the platinum-based agent cisplatin, the presence of an early-onset solid malignancy and the critical appraisal of further phenotypical features raised suspicion of a hereditary genome instability syndrome. Whole-exome sequencing from buccal swab DNA enabled the post mortem diagnosis of Fanconi anemia, most likely linked to the fatal outcome due to utilization of the DNA crosslinking agent cisplatin. The patient's phenotype was exceptional, as he never displayed significant hematologic abnormalities, which is the hallmark of Fanconi anemia. As such, this case stresses the importance to at least question the possibility of a hereditary basis in cases of relatively early-onset malignancy before defining an oncological treatment strategy.

Drug induced liver injury: accuracy of diagnosis in published reports.

The diagnosis of drug induced liver injury (DILI) is based primarily on the exclusion of alternative causes. To assess the frequency of alternative causes in initially suspected DILI cases, we searched the Medline database with the following terms: drug hepatotoxicity, drug induced liver injury, and hepatotoxic drugs. For each term, we used the first 100 publications. We reviewed references, selected those reports relevant to our study, and retrieved finally 15 publications related to DILI and alternative causes. A total of 2,906 cases of initially assumed DILI were analyzed in these 15 publications, with diagnoses missed in 14% of the cases due to overt alternative causes. In another 11%, the diagnosis of DILI could not be established because of confounding variables. Alternative diagnoses included hepatitis B, C, and E, CMV, EBV, ischemic hepatitis, autoimmune hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis, hemochromatosis, Wilson's disease, Gilbert's syndrome, fatty liver, non alcoholic steatohepatitis, alcoholic liver diseases, cardiac and thyroid causes, rhabdomyolysis, polymyositis, postictal state, tumors, lymphomas, chlamydial and HIV infections. Causality assessment methods applied in these 15 publications were the CIOMS (Council for International Organizations of Medical Sciences) scale alone (n = 5) or combined with the Maria and Victorino (MV) scale (n = 1), the DILIN (Drug-Induced Liver Injury Network) method (n = 4), or the Naranjo scale (n = 1); the qualitative CIOMS method alone (n = 3) or combined with the MV scale (n = 1). In conclusion, alternative diagnoses are common in primarily suspected DILI cases and should be excluded early in future cases, requiring a thorough clinical and causality assessment.

Drug induced liver injury: do we still need a routine liver biopsy for diagnosis today?

For the pathologist, the diagnosis of drug induced liver injury (DILI) is challenging, because histopathological features mimic all primary hepatic and biliary diseases, lacking changes that are specific for DILI. Therefore, in any patient of suspected DILI who underwent liver biopsy, the pathologist will assure the clinician that the observed hepatic changes are compatible with DILI, but this information is less helpful due to lack of specificity. Rather, the pathologist should assess liver biopsies blindly, without knowledge of prior treatment by drugs. This will result in a detailed description of the histological findings, associated with suggestions for potential causes of these hepatic changes. Then, it is up to the physician to reassess carefully the differential diagnoses, if not done before. At present, liver histology is of little impact establishing the diagnosis of DILI with the required degree of certainty, and this shortcoming also applies to herb induced liver injury (HILI). To reach at the correct diagnoses of DILI and HILI, clinical and structured causality assessments are therefore better approaches than liver histology results obtained through liver biopsy, an invasive procedure with a low complication rate.

Complications and risk factors in 2731 diagnostic mini-laparoscopies in patients with liver disease.

BACKGROUND/AIMS: Mini-laparoscopy (ML) allows macroscopic assessment and biopsy under direct vision and therefore is a valuable technique in the diagnosis of liver disease. Herein we report procedure-related complications and risk factors. METHODS: A total of 2731 consecutive patients underwent diagnostic ML at two university hospitals (June 1996-December 2007). ML was performed using standard technique with a 1.9mm optical instrument. Coagulation of the liver biopsy site was performed with APC. The following variables were analysed as risk factors for complications: platelet count (<50/nL), international normalized ratio (INR) (>1.5), Cirrhosis, signs of portal hypertension, prior abdominal surgery. RESULTS: Major complications occurred in 1.0% (n=27) of patients and these were, delayed bleeding from the liver biopsy site or abdominal wall (in 0.7% of patients) and intestinal perforation (in 0.3% of patients). Two patients died after severe haemorrhage (mortality 0.07%); the other patients recovered without sequelae. Bleeding risk was increased in patients with low platelets (OR=6.1), increased INR (OR=8.9), cirrhosis (OR=1.9) and portal hypertension (OR=2.1). Logistic regression showed a significant correlation only for the concurrence of low platelets and increased INR (P = 0.001; OR=14.1); bootstrap analysis identified INR >1.5 as significant predictor (P = 0.0002). Prior abdominal surgery did not carry a significant risk for intestinal perforation (OR=1.1; P = 0.142), unless abdominal adhesions were present (OR=9.5; P = 0.0002). None of the patients required surgery for intestinal perforation. CONCLUSION: Mini-laparoscopy is a diagnostic technique with a low complication rate. However, in patients with increased INR, low platelets or after extensive abdominal surgery, complications may occur in up to 5%.

Effectiveness and safety of minilaparoscopy-guided spleen biopsy: a retrospective series of 57 cases.

BACKGROUND: Minilaparoscopy is an accepted method for liver biopsy. We report our experience with minilaparoscopy for splenic biopsy. METHODS: We reviewed the records of all minilaparoscopy procedures performed from 1996 to 2004 at the University of Mainz Medical Center and from 2005 to mid-2011 at the University of Hamburg Medical Center to identify patients who underwent a minilaparoscopy-guided splenic biopsy. All procedures were performed using the previously described method (2.75-mm trocar, 2.3-mm Veress needle, 1.9-mm laparoscope) with the patient under conscious sedation (midazolam/meperidine/propofol). Splenic biopsies were performed using a second trocar with an 18-G Tru-Cut needle. Argon plasma coagulation (APC) and/or fibrin glue (FG) were used to control postbiopsy bleeding. RESULTS: Fifty-seven patients underwent minilaparoscopy-guided biopsy of the spleen (27 females, 30 males; median age = 41 years, range = 16-76). A specimen suitable for histopathologic evaluation was obtained in all patients. Grouped by preprocedure indication, a definitive diagnosis was obtained in 70% (7/10) of patients who had splenic mass lesions in prior imaging (3 B-NHL, 2 hemangioma, 1 tuberculosis, 1 sarcoidosis; p < 0.01) compared to 29% (10/34) in the group with unexplained fever or suspected lymphoma (3 tuberculosis, 2 B-NHL, 1 hepatosplenic T-cell lymphoma, 1 sarcoidosis, 1 Still's disease, 1 EBV, 1 Q-fever) and 0/13 with unexplained splenomegaly. Focal lesions noted at laparoscopy yielded to a histologic diagnosis in 38% (11/29) of 42 patients compared to 21% (6/28) without laparoscopic abnormality (p = 0.25). Bleeding from the biopsy site was noted in 96.5% (55/57) and was classified as brisk in 9. Control of hemorrhage was achieved in all patients (APC: 47, FG: 1, APC/FG: 7). There was no postprocedure bleeding or other complications. CONCLUSION: Splenic biopsy guided by minilaparoscopy can be performed safely. Postprocedure bleeding is readily controlled with APC with or without fibrin glue. The highest diagnostic yield is in patients with focal splenic lesions.

Serologic markers compared with liver biopsy for monitoring disease activity in autoimmune hepatitis.

GOALS/BACKGROUND: Disease activity and response to treatment in autoimmune hepatitis is assessed best by liver biopsy, which does not suit for regular disease monitoring. It is frequent clinical practice to follow disease by assessment of serologic markers. Here, we assessed the diagnostic fidelity of this clinical practice. STUDY: One hundred thirty-one biopsies from 82 patients with autoimmune hepatitis were analyzed for histologic activity. Serum samples, taken at the time of biopsy, were analyzed for aminotransferases [alanine aminotransferase (ALT), aspartate aminotransferase], IgG, and gamma-globulin levels and compared with histology. RESULTS: All serum parameters were significantly associated with histologic activity (P<0.0075); ALT and IgG were most complementary. Presence of both elevated ALT and IgG were associated with high inflammatory activity (histologic activity scores >/=6) with 99% sensitivity. Elevation of either IgG or ALT was associated with residual inflammatory activity in almost all patients. Histologic remission is reliably indicated by normalization of both serum parameters, but about half of the patients with normal serum parameters still showed residual histologic activity of histologic activity index (HAI) 4 or 5. However, our patients with HAI scores 4 or 5 were at significantly lower risk of fibrosis progression than patients with scores >/=6 (P<0.02; odds ratio 14.2). CONCLUSIONS: Histologic activity seems to be reliably indicated by elevated serum parameters. Normalization of serum parameters is not a reliable marker for complete histologic remission (HAI 1 to 3); however, normalized serum parameters identified patients at low risk of fibrosis progression. Thus, the common clinical practice of disease monitoring by serum markers seems to be suitable for regular follow-up.