Case Presentation: Sequential CAR T-Cell Therapy in Relapsed/Refractory Multiple Myeloma Case Presentation
Patient Case:
Background:
65-year-old woman who initially presented with sternal pain and pancytopenia in 2017. She underwent bone marrow biopsy which demonstrated 70% kappa restricted plasma cells. FISH was positive for deletion 17p. She was anemic with hemoglobin of 7.8, beta 2 microglobulin (B2M) 2.3, albumin 3.2, immunoglobulin A (IgA) 4750, and kappa 1181. Lambda light chain urine protein electrophoresis (UPEP) showed 1.9 grams of Bence Jones proteinuria. Serum protein electrophoresis (SPEP) showed an IgA kappa M protein of 5.3. She was diagnosed with Revised International staging system (RISS) stage II disease.
She was started on bortezomib, lenalidomide, and dexamethasone at an outside institution and subsequently changed to carfilzomib, lenalidomide, and dexamethasone due to high-risk disease. She achieved a partial response (PR) and went to autologous stem cell transplantation with busulphan and melphalan. Post-transplant she was placed on a clinical trial with elotuzumab and lenalidomide. She remained on this for 26 months when she developed biochemical progression. At that time, she was placed on daratumumab, pomalidomide, and dexamethasone. She developed disease progression and received 5 additional lines of therapy.
She then went on a CAR T-cell trial with BB2121 and achieved a complete response (CR). She had a biochemical relapse 18 months post CAR-T and was started on therapy with isatuximab, pomalidomide, and dexamethasone with no response. Therapy was changed to selinexor, pomalidomide, and dexamethasone. She received CAR-T on clinical trial with a GPRC5D CAR T-cell product. She required bridging therapy and was placed on venetoclax and dexamethasone and had a very good partial response (VGPR).
Presentation of Symptoms:
Patient developed fevers on day 2 post cell infusion that persisted through day 4. Her ferritin went from 121 on day 1 to 2375 on day 7 post-cell infusion. Her c-reactive protein (CRP) went from 0.59 to 88.22 on day 4. Post-discharge she developed grade 2 dysgeusia and grade 1 dry mouth.
Management:
Fever work-up was initiated, and she was placed on antibiotics of vancomycin and cefepime. Cultures were negative. Due to persistent fevers and grade 1 cytokine release syndrome (CRS) she received a total of 3 doses of tociluzumab on days 4 and 5. On day 4 she started having visual hallucinations, so cefepime was discontinued and she was placed on meropenem. CT head and EEG were normal. We felt the hallucinations were due to cefepime as they resolved once antibiotic was stopped.
Patient was subsequently discharged and followed. She had neutropenia that persisted for 2 months post-cell infusion which required growth factor support. For dysgeusia she was started on zinc gluconate. Her dysgeusia started to improve around 4 months post-cell infusion but continues to persist. She initially lost 17 pounds but over the last 2 months has slowly gained her weight back. She continues to receive intravenous immunoglobulin (IVIG) monthly and remains on pneumocystis jirovecii pneumonia (PJP) prophylaxis. Her disease is currently in a stringent CR and minimal residual disease (MRD) negative.
65-year-old woman who initially presented with sternal pain and pancytopenia in 2017. She underwent bone marrow biopsy which demonstrated 70% kappa restricted plasma cells. FISH was positive for deletion 17p. She was anemic with hemoglobin of 7.8, beta 2 microglobulin (B2M) 2.3, albumin 3.2, immunoglobulin A (IgA) 4750, and kappa 1181. Lambda light chain urine protein electrophoresis (UPEP) showed 1.9 grams of Bence Jones proteinuria. Serum protein electrophoresis (SPEP) showed an IgA kappa M protein of 5.3. She was diagnosed with Revised International staging system (RISS) stage II disease.
She was started on bortezomib, lenalidomide, and dexamethasone at an outside institution and subsequently changed to carfilzomib, lenalidomide, and dexamethasone due to high-risk disease. She achieved a partial response (PR) and went to autologous stem cell transplantation with busulphan and melphalan. Post-transplant she was placed on a clinical trial with elotuzumab and lenalidomide. She remained on this for 26 months when she developed biochemical progression. At that time, she was placed on daratumumab, pomalidomide, and dexamethasone. She developed disease progression and received 5 additional lines of therapy.
She then went on a CAR T-cell trial with BB2121 and achieved a complete response (CR). She had a biochemical relapse 18 months post CAR-T and was started on therapy with isatuximab, pomalidomide, and dexamethasone with no response. Therapy was changed to selinexor, pomalidomide, and dexamethasone. She received CAR-T on clinical trial with a GPRC5D CAR T-cell product. She required bridging therapy and was placed on venetoclax and dexamethasone and had a very good partial response (VGPR).
Presentation of Symptoms:
Patient developed fevers on day 2 post cell infusion that persisted through day 4. Her ferritin went from 121 on day 1 to 2375 on day 7 post-cell infusion. Her c-reactive protein (CRP) went from 0.59 to 88.22 on day 4. Post-discharge she developed grade 2 dysgeusia and grade 1 dry mouth.
Management:
Fever work-up was initiated, and she was placed on antibiotics of vancomycin and cefepime. Cultures were negative. Due to persistent fevers and grade 1 cytokine release syndrome (CRS) she received a total of 3 doses of tociluzumab on days 4 and 5. On day 4 she started having visual hallucinations, so cefepime was discontinued and she was placed on meropenem. CT head and EEG were normal. We felt the hallucinations were due to cefepime as they resolved once antibiotic was stopped.
Patient was subsequently discharged and followed. She had neutropenia that persisted for 2 months post-cell infusion which required growth factor support. For dysgeusia she was started on zinc gluconate. Her dysgeusia started to improve around 4 months post-cell infusion but continues to persist. She initially lost 17 pounds but over the last 2 months has slowly gained her weight back. She continues to receive intravenous immunoglobulin (IVIG) monthly and remains on pneumocystis jirovecii pneumonia (PJP) prophylaxis. Her disease is currently in a stringent CR and minimal residual disease (MRD) negative.
Hear From the Expert:
The APP Institute is a new offering from the Oncology Learning Network that provides microburst education to oncology advanced practitioners. The platform offers year-round digital non-accredited learning modules through animated short videos, multimedia interviews with key opinion leaders, interactive content to test your knowledge, and more!
