Abstract Details

Title Central Meningioma Necrosis after CAR T-Cell Therapy

Topic Neuro-oncology

Presentation(s) P2 - Poster Session 2 (5:30 PM-6:30 PM)

Poster/Presentation
Number 7-001

Objective To describe the clinical course, neuroimaging, and histopathologic findings of a patient with a presumed meningioma, who underwent Chimeric Antigen Receptor (CAR) T-Cell therapy for diffuse large B-cell lymphoma (DLBCL).

Background Genetically engineered T-Cells are a promising treatment for refractory malignancies, but are associated with CAR T cell related encephalopathy syndrome (CRES). CRES occurs in at least 80% of patients, and is characterized by impairments in attention, language, and arousal. As clinical trials excluded patients with underlying neurologic abnormalities, the safety of CAR T-cells in these patients warrants further investigation.

Design/Methods Neurologic assessments were performed every 8 hours using the CARTOX-10 rating scale. CRES was graded on a scale of 1-4, representing mild to critical neurotoxicity (Neelapu et al. Nat Rev Clin Onc 2018).

Results A 71 year-old woman with refractory DLBCL received CD19-targeting CAR T-cells (axicabtagene ciloleucel). Baseline brain MRI revealed a uniformly enhancing 1.9 x 2.9 x 2.3 cm extra-axial mass and peri-tumoral edema in the inferior frontal lobe, consistent with an olfactory groove meningioma. On hospital day 5, she developed severe obtundation (CRES grade 4), prompting initiation of high-dose steroids and transfer to the neuro-ICU for 48 hours. MRI brain, EEG monitoring and CSF analysis during the acute phase were unrevealing. Although her mental status initially improved, she became inattentive and abulic every time steroids were tapered off. On day 50, a follow-up brain MRI showed increased vasogenic edema and new necrosis within the extra-axial mass. Neurosurgical resection of the tumor led to marked improvement in cognition. Final histopathology revealed a WHO grade II meningioma with infiltration by CD8+ cytotoxic T-cells.

Conclusions We present a unique case of CRES related to meningioma necrosis and T-cell invasion. Although CAR T-cells are feasible in patients with underlying intracranial mass lesions, the risk for severe neurotoxicity is high, requiring close-monitoring and vigilance.

Authors/Disclosures
Seth N. Levin, MD (Biogen) PRESENTER	Dr. Levin has received personal compensation for serving as an employee of Biogen. Dr. Levin has received stock or an ownership interest from Biogen.
Claudiu I. Diaconu, MD (White Plains Hospital Physician Associates)	No disclosure on file
Rebecca G. Straus Farber, MD (Columbia University Irving Medical Center)	Dr. Straus Farber has received personal compensation in the range of $500-$4,999 for serving as a Consultant for TG Therapeutics.
Philip De Jager, MD, PhD (Columbia University Irving Medical Center)	Dr. De Jager has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Puretech. Dr. De Jager has received personal compensation in the range of $5,000-$9,999 for serving on a Scientific Advisory or Data Safety Monitoring board for roche. Dr. De Jager has received personal compensation in the range of $5,000-$9,999 for serving on a Scientific Advisory or Data Safety Monitoring board for biogen. The institution of Dr. De Jager has received research support from roche. The institution of Dr. De Jager has received research support from puretech.
Ran Reshef	Ran Reshef has nothing to disclose.
Claire Riley, MD, FAAN	Dr. Riley has received personal compensation for serving as an employee of AstraZeneca. Dr. Riley has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Genentech. Dr. Riley has received personal compensation in the range of $10,000-$49,999 for serving on a Scientific Advisory or Data Safety Monitoring board for EMD Serono. Dr. Riley has received personal compensation in the range of $10,000-$49,999 for serving on a Scientific Advisory or Data Safety Monitoring board for TG Therapeutics. Dr. Riley has received personal compensation in the range of $10,000-$49,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Horizon. Dr. Riley has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Roche. Dr. Riley has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Amgen. Dr. Riley has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Immunic AG. Dr. Riley has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Cabaletta Bio. Dr. Riley has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Bristol Myers Squibb. Dr. Riley has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Novartis. Dr. Riley has received personal compensation in the range of $10,000-$49,999 for serving on a Scientific Advisory or Data Safety Monitoring board for TG Therapeutics.

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