ABSTRACT
Introduction The clinical manifestations of COVID-19 infection in recipients of allogeneic hematopoietic stem cell transplantation (HSCT) have been reported in multiple retrospective cohorts of patients, but there have been no prospective studies to date. Previous studies report that HSCT recipients are at higher risk, with cumulative incidence of death between 17-35%. Although an excessive pro-inflammatory viral response has been documented in the general population, its role in the immune incompetent HSCT setting has not been documented. We present a combined prospective and retrospective national study run through the UK IMPACT trial network to characterize the clinical and immunological features of COVID-19 infection in 96 adult and pediatric recipients of HSCT in the United Kingdom. Methods HSCT recipients of any age and transplanted for any indication, with an RT-PCR-proven COVID-19 infection, were eligible for this study. Patients within 72 hours of COVID-19 diagnosis, who had not received cytokine-targeted treatment, were recruited to a prospective cohort. All other patients were eligible for a retrospective cohort. Prospective patients provided blood samples within 72 hours of COVID-19 diagnosis, and again within 72 hours of clinical deterioration (defined as requirement for oxygen administration) if applicable. Follow-up data were collected on patients 30 and 100 days after COVID-19 diagnosis. Results 100 patients were recruited from 16 sites across the UK between May 2020-June 2021, comprising 12 in a prospective cohort and 88 recruited retrospectively. 96 patients were evaluable, as 4 proved ineligible post-registration. Patients were diagnosed with COVID-19 at a median of 11 months after HSCT. Patient/HSCT characteristics are shown Table 1. The most common symptoms associated with the onset of COVID-19 were fever in 8 prospective (73%) and 35 (41%) retrospective patients, followed by cough in 5 (45%) prospective and 35 (41%) retrospective patients and dyspnea in 4 (36%) prospective and 16 (19%) retrospective patients. 8 (73%) prospective and 40 (47%) retrospective patients were actively immunosuppressed at the time of COVID-19 infection. 16% of the patients had moderate/severe disease at baseline. At day 30 (±2 days) after COVID-19 diagnosis, 2 prospective and 8 retrospective patients continued to demonstrate SARS-CoV-2 positivity on respiratory PCR testing. The median time to viral clearance was 40 (IQR 17-78) days for the prospective and 34 (IQR 15-70) days for the retrospective cohort. Prolonged (more than 14 days) neutropenia was reported in 4 (5%) patients in the retrospective cohort, prolonged thrombocytopenia in 2 (18%) prospective and 11 (13%) retrospective patients. 1 retrospective patient developed secondary hemophagocytic lymphohistiocytosis, and graft rejection was reported in 1 (1%) retrospective patient, within 30 days of COVID-19 diagnosis. In the prospective cohort, 3 (27%) patients died, all by day 30, and all due to COVID-19. In the retrospective cohort, 13 (17%) patients died by day 30, rising to 18 (21%) by day 100, 61% of deaths were attributed to COVID-19. Lower baseline platelets (p=0.013, Mann-Whitney U test), lymphocytes (p=0.012), albumin (p=0.028), and higher baseline CRP (p=0.007), were seen in patients who died following COVID-19 diagnosis. Additionally, exploratory univariate logistic regression of the retrospective cohort found mortality at day 100 to be associated with increased age at diagnosis (OR 1.04, 95% CI 1.01-1.08, p=0.04), and no requirement compared with requirement for invasive ventilation (OR 0.02, 95% CI 0.00-0.16, p=0.001). The 11 prospective patients showed normal levels of interleukin (IL)-2, -4, -10, interferon gamma and tumor necrosis factor alpha at COVID-19 presentation. IL-6 was minimally raised (up to 127 pg/ml, nv<50) in 3/11 pts at presentation. Respiratory deterioration was not associated with detectable cytokine storm. Conclusion Our study confirms a significant mortality rate in patients affected by COVID-19 post HSCT and confirms age as well s requirement for invasive ventilation to be independent risk factors associated with death at day 100. Baseline laboratory data at disease presentation can identify patients at higher risk of COVID-19 related death. In the prospective cohort of our study, pathophysiology of the viral disease did not seem related to cytokine storm-mediated inflammation. [Formula presented] Disclosures: Protheroe: Jazz Pharmaceuticals: Honoraria;Astellas: Honoraria;Kite Gilead: Honoraria. Peggs: Autolus: Consultancy, Current equity holder in publicly-traded company. Craddock: Novartis Pharmaceuticals: Other: Advisory Board;Celgene/BMS: Membership on an entity's Board of Directors or advisory committees, Research Funding. Nicholson: BMS/Celgene: Consultancy;Kite, a Gilead Company: Other: Conference fees, Speakers Bureau;Novartis: Consultancy, Other: Conference fees;Pfizer: Consultancy. Amrolia: ADC Therapeutics: Other: Named inventor on a patent which is being transferred to ADCT.;Autolus: Patents & Royalties.
ABSTRACT
Purpose or Objective CD19 CAR-T therapy is the most effective salvage treatment for relapsed/refractory DLBCL. However the manufacture of CAR-T cells takes several weeks and patients (pts) are at risk of progression during this time and usually require some form of bridging therapy to contain their disease. Radiotherapy (RT) is an attractive bridging option, as the chance of response to further conventional cytotoxic therapy is low. RT is generally delivered in the window between apheresis and infusion and requires careful scheduling. The aim of this study is to evaluate the feasibility, toxicity and early outcome of bridging RT in a cohort of pts undergoing CAR-T therapy for DLBCL. Materials and Methods This was a prospective analysis of pts receiving bridging RT since the start of CAR-T programme at our institution. We collected data on pt demographics, disease and RT details, as well as outcomes including early response, relapse, survival and toxicity. Results (Table presented.) Between April 2019 & January 2021 a total of 27 pts have received bridging RT. Of these 23 have been infused (1 not infused due to COVID19, 1 due to cardiac function & 2 pending). The CAR-T therapy was delivered in 1 Haematology Institution, but bridging RT in 9 different referring centres. Pt and disease characteristics and RT details are shown in table 1. The median time from CT planning scan to start of RT was 10 days (4-42). The median time between apheresis and start of RT was 5 days (-37-21;3 patients received RT prior to apheresis at -37,-35 &-29 days) and median time between end of RT and CAR-T infusion was 19 days (10-116). No pts were delayed due to RT toxicity. Toxicity data was available for 22 pts. 10 (45.5%) reported no toxicity. Only 1 pt had grade 3 toxicity (vomiting & diarrhoea) and RT was stopped. The most common toxicities were skin reaction (n=5) & fatigue (n=4). 25/27 (92.6%) pts underwent a PET-CT between bridging RT & infusion. In 22 (88%) pts there was response in treatment field (CMR=2, PMR=20). In 13 (59.1%) of those pts there was evidence of progressive disease (PD) outside the field, but none were prevented from receiving CAR-T infusion due to PD. With median FU of 8.8 (0.6-20.6) months from date of CAR-T infusion, 12/ 23 (52.2%) infused pts have relapsed, (2 infield, 5 out of field, 5 in both) with a local control rate of 69.6%;CMR (12;52.2%) and PMR (4;17.4%). 7 pts have died since infusion, 6 due to PD and 1 due to sepsis. Median PFS was 5.1 months (95% CI 0.0-11.9 months) and median OS 17.8 months (95% CI 12.7-22.9 months). 1 pt had infusion delayed due to COVID19 infection and died of PD. Conclusion RT was a safe and effective bridging option in this cohort of DLBCL pts pre CAR-T therapy. With close collaboration between Haematologists and Radiation Oncologists, it is possible to deliver a course of radical dose RT in the narrow window between apheresis and infusion, even across a wide geographical network. Further work is required to determine which pts benefit most from bridging RT and the optimal dose and schedule.
ABSTRACT
Background: Severe COVID-19 can result in pneumonia, with many patients (pts) requiring hospitalization andoxygen support. Severe COVID-19 may also be complicated by acute respiratory distress syndrome, sepsis andseptic shock, and/or multiorgan failure. Many of these pts have features consistent with cytokine release syndrome(CRS) and its associated hyperinflammation. Given their immunomodulatory effects, Janus kinase (JAK) inhibitorshave been suggested as a potential therapeutic option in pts with severe COVID-19. Ruxolitinib-a potentJAK1/JAK2 inhibitor approved for treating myelofibrosis, polycythemia vera, and steroid-refractory acute graft-vs.-host disease (GvHD;US only)-has been associated with reduced levels of inflammatory cytokines in disorderswhere cytokine dysregulation plays a role, including GvHD and secondary hemophagocytic lymphohistiocytosis.Additionally, findings from a small, randomized, phase 2 study (N = 43;Cao Y et al., J Allergy Clin Immunol 2020)showed that treatment with ruxolitinib plus standard of care (SOC) reduced CRS-associated hyperinflammation inpts with severe COVID-19 vs placebo plus SOC, with significant improvement seen in chest computed tomography(CT) features. Although no statistically significant differences were observed, ruxolitinib-treated pts also had anumerically shorter median time to clinical improvement, a lower proportion requiring intensive care/mechanicalventilation, and reduced mortality, with ruxolitinib having a favorable safety profile. Methods: RUXCOVID ( NCT04362137 ) is a global, randomized (2:1), double-blind, placebo-controlled, 29-day, phase 3 study evaluating the efficacy and safety of ruxolitinib plus SOC compared with placebo plus SOC in pts withCOVID-19. Pts are eligible for the study if they are ≥ 12 years old, have confirmed COVID-19, are hospitalized, andmeet ≥ 1 of the following: pulmonary infiltrates (by chest x-ray or CT scan), respiratory frequency ≥ 30 breaths/min, requirement of supplemental oxygen, oxygen saturation (SpO ) ≤ 94% on room air, or arterial oxygen partialpressure (PaO )/fraction of inspired oxygen (FiO ) < 300 mm Hg (1 mm Hg = 0.133 kPa). Pts with a need forintensive care or intubation are not eligible. Pts will be randomized to ruxolitinib 5 mg twice daily or placebo andtreated for 14 days. Pts may be treated for an additional 14 days if no improvement occurs and the potential benefitoutweighs the potential risk per investigator assessment. The primary endpoint is the proportion of pts who die, develop respiratory failure (require mechanical ventilation), or require intensive care by day 29. Secondaryendpoints include improvement in clinical status, in-hospital outcomes, change in National Early Warning Score, change in SpO :FiO ratio, mortality rate, change in inflammatory biomarkers, and safety. Target enrollment is 402pts. Sponsored by Novartis Pharmaceuticals and Incyte.