CAR T-cell therapy and critical care : A survival guide for medical emergency teams

Abstract

Chimeric antigen receptor (CAR) T‑cells are genetically engineered to give T‑cells the ability to attack specific cancer cells, and to improve outcome of patients with refractory/relapsed aggressive B‑cell malignancies. To date, several CAR T‑cell products are approved and additional products with similar indication or extended to other malignancies are currently being evaluated. Side effects of CAR T‑cell treatment are potentially severe or even life-threatening immune-related toxicities, specifically cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). Consequently, medical emergency teams (MET) are increasingly involved in the assessment and management of CAR T‑cell recipients. This article describes the principles of CAR T‑cell therapy and summarizes the main complications and subsequent therapeutic interventions aiming to provide a survival guide for METs with a proposed management algorithm.

Keywords: Chimeric antigen receptor T‑cells; Cytokine release syndrome; Immune effector cell associated neurotoxicity; Lymphoma; Medical emergency team.

Fig. 1

Medical emergency team (MET) algorithm for the assessment and management of CAR‑T related toxicities. Algorithm adapted from Lee et al. [10], Park et al. [12], and Maus et al. [21]. CRS cytokine release syndrome, ICANS immune effector cell-associated neurotoxicity syndrome, ICE immune effector cell-associated encephalopathy, cCT cerebral computed tomography, MRI magnetic resonance imaging, ICP intracranial pressure, LDH lactate dehydrogenase, EEG electroencephalogram