Grading of neurological toxicity in patients treated with tisagenlecleucel in the JULIET trial

Abstract

Chimeric antigen receptor-T (CAR-T) cell therapy achieves durable responses in patients with relapsed/refractory diffuse large B-cell lymphoma (r/r DLBCL), but may be associated with neurological toxicity (NT). We retrospectively assessed differences and concordance among 3 available grading scales (the National Cancer Institute Common Terminology Criteria for Adverse Events v4.03 [CTCAE], modified CAR-T Related Encephalopathy Syndrome [mCRES], and American Society for Transplantation and Cellular Therapy [ASTCT] scales) applied to the same set of NT data from the JULIET (A Phase 2, Single Arm, Multicenter Trial to Determine the Efficacy and Safety of CTL019 in Adult Patients With Relapsed or Refractory DLBCL) trial. Individual patient-level NT data from the phase 2, single-group, global, pivotal JULIET trial (NCT02445248) were retrospectively and independently graded, using CTCAE, ASTCT, and mCRES, by 4 medical experts with experience managing patients with 3 different CD19-targeted CAR constructs. According to the US Food and Drug Administration definition of NT using CTCAE, 62 of 106 patients infused with tisagenlecleucel had NT as of September 2017. Among 111 patients infused with tisagenlecleucel (as of December 2017), the 4 experts identified 50 patients (45%) who had any-grade NT per CTCAE, 19 (17%) per mCRES, and 19 (17%) per ASTCT. Reevaluation according to the mCRES/ASTCT criteria downgraded 31 events deemed NT by CTCAE to grade 0. This is the first study to retrospectively apply CTCAE, mCRES, and ASTCT criteria to the same patient data set. We conclude that CTCAE v4.03 was not designed for, and is suboptimal for, grading CAR-T cell therapy-associated NT. The CRES and ASTCT scales, which measure immune effector cell-associated neurotoxicity syndrome, offer more accurate assessments of NT after CAR-T cell therapy.

Conflict of interest statement

Conflict-of-interest disclosure: R.T.M. received honoraria, membership on the board of directors or advisory committees, and research funding from Novartis; consultancy and honoraria from CRSPR Therapeutics, Incyte, and Juno Therapeutics; honoraria from Kite Therapeutics; patents and royalties from Athersys, Inc.; and is employed by Oregon Health & Science University. R.T.M. also provided consultant services to and received payment from Novartis. This potential conflict of interest has been reviewed and managed by Oregon Health & Science University. S.J.S. received honoraria, membership on the board of directors or advisory committees, and research funding from Celgene; consultancy and honoraria from Dava Oncology; honoraria and research funding from Genentech; membership on the board of directors or advisory committees for Gilead; consultancy, honoraria, and research funding from Merck; honoraria, membership on the board of directors or advisory committees, and research funding from Novartis; and consultancy, honoraria, and membership on the board of directors or advisory committees for Nordic Nanovector. V.V.R. is employed by Novartis. E.S.R. is employed by Novartis. J.L. is employed by the Analysis Group, which received funding from Novartis. J.E.S. is employed by the Analysis Group, which received research funding from Novartis. D.G.M. receives research funding from Kite Pharma, a Gilead Company, and Celgene; he also receives research funding from and has patents licensed or pending with Juno Therapeutics, a Celgene/Bristol-Myers Squibb company; has participated in advisory board and/or data monitoring committee meetings for which he receives honoraria for BioLine RX, Kite Pharma, Gilead, Pharmacyclics, Novartis, Juno Therapeutics, and Celgene; and is a scientific advisory board member for which he receives honoraria from and has stock options in A2 Biotherapeutics. F.L.L. is a scientific advisor to Kite/Gilead, Novartis, Celgene/BMS, GammaDelta Therapeutics, and Wugen; and an allogene consultant with grant options for Cellular Biomedicine Group, Inc.

© 2020 by The American Society of Hematology.

Figures

Graphical abstract

Figure 1.

Regrade of JULIET trial patient-level data showed 50 patients as having any-grade NT by CTCAE, 19 patients by mCRES, and 19 patients by ASTCT criteria. (A) Classification of NT by CTCAE, mCRES, and ASTCT grading systems (N = 111). (B) Cross-classification of NT by 3 grading scales: CTCAE, ASTCT, and mCRES.