EBMT and JACIE recommendations for the management of CAR T-cell therapy

To date, two chimeric antigen receptor (CAR) T-cell-based therapies have been approved for a number of hematological malignancies in USA and Europe, axicabtagene ciloleucel and tisagenlecleucel.^1,2 Despite the targeted nature of CAR T-cell therapies, life-threatening toxicities are still associated with their use. The main CAR T-cell-associated complications have been divided in to three broad categories. Short-term, medium-term and long-term follow-up (LTFU) complications are referred to as those occurring between day(s) zero and 28, 28 and 100 or 100 plus after CAR T-cell infusion, respectively. The necessary precautions required for a successful CAR T-cell regimen are complex, and the need for routine guidelines has become apparent.³

In December 2018, the Practice Harmonisation and Guidelines Subcommittee of the Chronic Malignancies Working Party (CMWP) of the European Society for Blood and Marrow Transplantation (EBMT) proposed a project to define practical clinical recommendations on the management of adults and children undergoing autologous CAR T-cell therapy. The EBMT board accepted the proposal and Ibrahim Yakoub-Agha, Lille University Hospital, Lille, FR, presented a summary of the first EBMT and Joint Accreditation Committee of ISCT and EBMT (JACIE) recommendations at the 2^nd European CAR T-Cell Meeting, Sitges, ES.^3,4 The guidelines are based on survey responses from active CART centers and a literature review performed by the authors. They aim to provide recommendations for individuals involved in the administration of CAR T therapies and act as a useful resource for other stakeholders, such as pharmacists and health service administrators. We hereby provide a comprehensive summary of these published guidelines.

Patient eligibility

• Eligibility (Table 1) for CAR T-cell therapy must be decided at a multi-disciplinary team meeting in a designated CAR T center

Table 1. EBMT CAR T-cell therapy eligibility criteria

ALL, acute lymphoblastic leukemia; allo-HCT, allogeneic hematopoietic cell transplantation; BiTE, bispecific monoclonal antibodies; CAR, chimeric antigen receptor; CNS, central nervous system; DLBCL, diffuse large B-cell lymphoma; EBMT, European Society for Blood And Marrow Transplantation; ECOG, Eastern Cooperative Oncology Group; GvHD, graft-versus-host disease; NHL, non-Hodgkin lymphoma; SPC, summary of product characteristics
Characteristics	EBMT recommendations	Comment
Age limit
NHL	No upper age limit	Decision should be based on physical condition rather than age
ALL	Follow SPC	Ability to collect sufficient cells by apheresis can be a limiting factor in infants and small children
ECOG performance status	>2 not recommended	Prognosis may be better if the decline in performance status is due to active disease
History of malignancy	Absence of history of malignancy other than carcinoma in situ unless disease-free and off therapy for at least three years
Previous treatment
Prior allo-HCT	Not a contra-indication	Active GvHD is listed as a reason to delay treatment with axicabtagene ciloleucel or tisagenlecleucel
Prior CD19-directed therapy/anti-CD3 BiTE antibodies	Not a contra-indication
Previous CAR T-cell therapy	Not a contra-indication	Further CAR T therapy outside of clinical trials is to be avoided
Current systemic immunosuppressive treatment	Contra-indication	Intermittent topical, inhaled or intranasal corticosteroids are allowed
History of autoimmune disease	Not recommended in active autoimmune disease resulting in end-organ injury or requiring systemic immunosuppression or systemic disease-modifying agents within the last two years	Individualized risk-benefit assessment required
Existing or suspected fungal, bacterial, viral, or other infection	Relative contra-indication; individualized risk-benefit assessment required	Active infection should be controlled and on treatment prior to leukapheresis

Screening laboratory tests and imaging

• The minimum required patient eligibility assessments are shown in Table 2

Table 2. Minimum required tests for patient eligibility

ALL, acute lymphoblastic leukemia; ANC, absolute neutrophil count; CAR, chimeric antigen receptor; CNS, central nervous system; EBMT, European Society for Blood And Marrow Transplantation; LVEF, left ventricular ejection fraction; MRI, magnetic resonance imaging; NHL, non-Hodgkin Lymphoma; SPC, summary of product characteristics; ULN, upper limit of normal *Leukapheresis material for tisagenlecleucel manufacturing will not be accepted from patients with a positive test for active HBV, HCV or HIV (SPC)
Test methods	EBMT recommendations	Comment
Disease confirmation	Histology only for NHL Immunophenotyping for ALL
Hematology
Hematology	ANC >1.0x109/L	Evidence of adequate bone marrow reserve
Chemistry
Bilirubin	<34umol/L; higher limit acceptable (< 43umol/L) with Gilbert’s syndrome	No trial data regarding patients outside of these parameters
AST/ALT	<5x ULN	Attempt to identify causes e.g. active infections
Creatinine clearance	>30ml/min	Caution is required in patients with CrCl of <60ml/min
Virology
Hepatitis B*	To be done within 30 days of leukapheresis and results must be available at the time of collection and shipment	As per national guidelines
Hepatitis C*	To be done within 30 days of leukapheresis and results must be available at the time of collection and shipment	As per national guidelines
HIV*	To be done within 30 days of leukapheresis and results must be available at the time of collection and shipment	Tisagenlecleucel is using a lentiviral vector whereas axicabtagene ciloleucel uses a retroviral vector
Other work-up
Cardiac function	LVEF >40%; assess for pericardial effusion by echocardiography; ECG	Work-up of effusions required to identify causes
CNS imaging	MRI not required except in those with a history of CNS disease or current neurological symptoms of concern	A baseline MRI can be helpful, should severe neurological toxicities arise
Lumbar puncture	Lumbar puncture not required except in those with a history ofCNS disease or current neurological symptoms of concern
Fertility	Must have a negative serum or urine pregnancy test	Test must be repeated and confirmed negative within eight days of the CAR T-cell cell infusion

Minimum required laboratory tests before apheresis

• Prior to the guidelines, regulations were based on the donor-recipient relationship irrespective of the intended use
• The novel guidelines regarding the necessary procedures prior to apheresis are given in Table 3

Table 3. Apheresis checklist

ALC, absolute lymphocyte count; ANC, absolute neutrophil count; ECOG, Eastern Cooperative Oncology Group; EBMT, European Society for Blood And Marrow Transplantation; FBC, full blood count; HIV, human immunodeficiency virus; HTLV, human T-cell lymphotropic virus; NAT, nucleic acid testing; SPC, summary of product characteristics
Prior to Apheresis	EBMT recommendations	Comment
ECOG performance status score	ECOG ≤2	At discretion of apheresis practitioner
Days after last chemotherapy	Allow for recovery from cytotoxic chemotherapy	Need for marrow recovery from prior chemotherapy
Days off corticosteroids	Ideally, seven days to minimize effect on lymphocyte collection	Physiological replacement doses of hydrocortisone permitted
Blood tests
Hepatitis B, hepatitis C, HIV, syphilis, and HTLV	To be done within 30 days of leukapheresis and results must be available at the time of collection and shipment	NAT is not necessary if all serological testing is negative
C-reactive protein	Recommended to assess for ongoing infection	Eligibility for apheresis will need to be decided on a case-by-case basis in the instance of active infection
Standard electrolytes and renal function	Required	Apheresis may predispose to electrolyte imbalance and limit fluid tolerance
Blood values required for optimal apheresis performance
Hemoglobin	Hemoglobin >80g/L Hematocrit >0.24	To establish a good interface during collection
ANC	>1.0x109/L	Consistent with recovery from prior chemotherapy
ALC	>0.2x109/L	Higher count required in small children. Of note, 0.2x109/L CD3+ count is the minimum threshold
Platelet count	>30x109/L
FBC	To be repeated at the end of the apheresis procedure	Apheresis can remove >30% of circulating platelets

Performing leukapheresis

• Leukapheresis must be coordinated with the manufacturing company prior to start date confirmation
• A pre-existing quality management system (QMS) must be confirmed prior to leukapheresis
  • The QMS must comply with the 7^th edition of the FACT-JACIE standards for hematopoietic cellular therapies or FACT standards for immune effector cells
• Identification of infectious disease markers in peripheral blood, sterility testing, and hemocytometry should be carried out on the day-of-collection

Bridging therapy

• Although the ideal bridging therapy regimen is disease- and patient-specific, there are a number of uniform factors for consideration:

• Patients receiving chemotherapy will be at risk of developing cytokine release syndrome (CRS), encephalopathy or tumor lysis syndrome following lymphodepletion (LD)
• Bridging therapy should not induce infections, bleeding or organ dysfunction that could interfere with LD and CAR T-cell infusion
• Immunotherapeutic drugs with a longer half-life may interfere with the expansion or persistence of the infused CAR T-cells
• Bridging therapy should be given after leukapheresis to prevent interference with T-cell therapy
• Frequent monitoring of patients after leukapheresis as well as during and following bridging therapy at specialist centers is compulsory

LD conditioning

• Factors to consider prior to LD conditioning are shown in Table 4
• Factors requiring laboratory testing prior to LD conditioning are shown in Table 5

Table 4. Considerations prior to LD conditioning

ALC, absolute lymphocyte count; CAR, chimeric antigen receptor; EBMT, European Society for Blood And Marrow Transplantation; LD, lymphodepletion; SPC, summary of product characteristics; WBC, white blood cell count
	EBMT recommendations
CAR T-cell product	LD conditioning should only be administered following receipt of CAR T product on site
Clinical conditions	Active infections must be excluded or under control before starting LD conditioning
WBC	Administer LD conditioning to all patients regardless of WBC or ALC

Table 5. Routine laboratory testing prior to LD conditioning

CC, creatinine clearance; EBMT, European Society for Blood and Marrow Transplantation; ECG, electrocardiogram; LD, lymphodepletion; LVFE, left ventricular ejection fraction; SPC, summary of product characteristics; ULN, upper limit of normal
Test methods	EBMT recommendations	Comment
Chemistry
C-reactive protein and/or fibrinogen level	Required to rule out ongoing infection	Active infection must be excluded or under control before starting LD
Bilirubin	<34umol/L; higher limit acceptable (>43umol/L) with Gilbert’s syndrome	No trial data regarding patients outside of these parameters
AST/ALT	<5xULN	Attempt to identify causes e.g. active infections
CC	>30 ml/min	Modify drug doses according to CC
Other work-up
Cardiac function	Repeat cardiac investigations if clinically indicated	LVEF >40%; assess for pericardial effusion by echocardiography; ECG

CAR T- cell infusion

• CAR T-cell infusion should be carried out using a transfusion filter set with a 50-200μm pore size
• Fluid infusion sets and transfusion sets with leukocyte depletion filters should not be used
• Pre-medication to prevent adverse reactions is acceptable, however, corticosteroids must be avoided as they may damage the CAR T product
• Concurrent medication must not be given during CAR T-cell infusion
• Patients must be assessed before the onset of CAR T product thawing, and CAR T-cell infusion may be delayed in the case of:
  • Active infection
  • Cardiac arrhythmia not controlled with medical management
  • Hypotension requiring vasopressor support
  • Non-hematologic organ dysfunction
  • Significant worsening of the clinical condition since the start of LD

Management of short-term complications

• Patients must be able to access a trained coordinator 24 hours a day, seven days a week
• 14 days of hospitalization following CAR T-cell therapy
• Patients must be located within 60 minutes of the treating unit following hospital discharge until day 28 following CAR T infusion
• Anti-infective prophylaxis following CAR T-cell therapy is infection-dependent

CRS and neurotoxicity

• As the most common complications following CAR T-cell infusion, CRS and neurotoxicity must be monitored daily using both behavioral observations and laboratory testing methods
• First- and second-line treatment for severe cases of CRS are tocilizumab plus corticosteroids and siltuximab respectively
• Daily writings tests following CAR T-cell infusion should be used to detect incipient immune effector cell-associated neurotoxicity syndrome (ICANS)
• Cross-sectional imaging, electroencephalography, and cerebrospinal fluid examination should be used in the management of patients with severe neurotoxicity
• Anti-epileptic prophylaxis is only recommended in patients with a history of seizures or central nervous system disease
• ICANS severity has been associated with the severity and early onset of CRS
• The American Society for Transplantation and Cellular Therapy (ASTCT) consensus panel replaced the CARTOX scoring system with the ICE score
• Table 6 illustrates the measures for screening delirium in children
• CRP and ferritin levels should be monitored daily as they are indicative of CRS and neurotoxicity development

Table 6. Encephalopathy assessment in children < 12 years

	Always	Often	Sometimes	Rarely	Never
Eye contact with caregiver	0	1	2	3	4
Purposeful actions	0	1	2	3	4
Aware of their surroundings	0	1	2	3	4
Being restless	4	3	2	1	0
Being inconsolable	4	3	2	1	0
Being underactive	4	3	2	1	0
Slow response to interactions	4	3	2	1	0
Communicating needs and wants	4	3	2	0	0

 Management of medium-term complications

• The guidelines for testing and managing medium-term complications are shown in Table 7

Table 7. Management of medium-term complications

CAR T, chimeric antigen receptor; CMV, cytomegalovirus; CRP, C-reactive protein; EBV, Epstein-Barr virus; FBC, full blood count; IV, intravenous; LDL, lactate dehydrogenase
Test	Purpose	Frequency	Comment
FBC, biochemistry panel, LDH, fibrinogen, CRP	Standard follow-up	At every visit and as clinically indicated
CMV, EBV, adenovirus	Viral reactivation	As clinically indicated
Quantitative immunoglobulins or serum protein electrophoresis	Immune reconstitution	Monthly	Consider IV immunoglobulins
Peripheral blood immunophenotyping: CD3/4/8/16+56/19+	Immune recovery	Once monthly for first three months, thrice monthly thereafter in first year	Guide to anti-infective prophylaxis
CAR T monitoring where kits are available for routine monitoring of anti-CD19 CAR T	CAR T persistence	Peripheral blood flow cytometry or transgene by molecular methods as clinically indicated	Not recommended by CAR T manufacturers

LTFU

• The clinic should routinely measure cardiovascular, gastrointestinal, liver, respiratory, endocrine, reproductive and bone health, disease status, further treatments, infections, immunological status, new cancers, autoimmunity and neurological and psychological status
• To address the uncertainty surrounding long-term effects of CAR T-cell therapy the guidelines in Table 8 have been put in place

Table 8. Tests to be performed at the LTFU clinic

CAR, chimeric antigen receptor; FBC, full blood count; NPA, naso-pharyngeal aspirate; LTFU, long-term follow-up; PB, peripheral blood; PCR, polymerase chain reaction
Test	Purpose	Frequency	Comment
FBC, biochemistry panel	Standard follow-up	At every visit
Viral infection (PB PCR, NPA)	Viral reactivation	As clinically indicated
Quantitative immunoglobulins with or without serum protein electrophoresis	Immune reconstitution	At every visit
Peripheral blood immunophenotyping	Immune reconstitution	Every second visit	Discontinuation following normalization
CAR T monitoring where kits are available for routine monitoring of anti-CD19 CAR T	CAR T persistence	Every visit	Discontinuation when absent for two consecutive tests
Endocrine function	Standard follow-up	As clinically indicated

Conclusions:

• Until now, management of patients receiving CAR T-cell therapy has been clinical trial-, location- and product-specific
• The novel guidelines provide the first routine measures to enhance global uniformity of CAR T-cell therapy