APHON Pediatric Chemotherapy-Biotherapy Renewal

Neurotoxicities of Biotherapy Immunotherapy

Chimeric antigen receptor T cells (CAR T cells). CAR T cells are a type of adoptive cellular therapy that involves apheresis and genetic engineering of autologous T cells. These T cells have been engineered to express the intracellular domain of a T-cell receptor fused to the antigen-binding domain of a B-cell receptor. The T cells are then expanded in the lab and subsequently reinfused into the patient. The reprogrammed cells are then able to recognize and attack tumor cells that bear the tumor-specific antigen they were genetically engineered to seek out (Kennedy & Salama, 2020) (see Figure 4 ).

Figure 4. T-Cell Transfer Therapy Cancer.gov, 2021. https://www.cancer.gov/publications/dictionaries/cancer-terms/def/car-t-cell-therapy. Copyright 2017 Terese Winslow LLC; U.S. government has certain rights.

Immune effector cell-associated neurotoxicity syndrome (ICANS) is a neurotoxicity that can develop after a patient receives CAR T-cell therapy. Patients may develop neurologic symptoms as soon as 1 day after CAR T-cell infusion or onset may be delayed and occur 3 or 4 weeks after infusion. Initial neurologic symptoms include tremor, dysgraphia, mild expressive aphasia, apraxia, and impaired attention. As time passes, the symptoms can evolve in severity and a global aphasia can result, with patients presenting both expressive and receptive difficulty. As the patient’s dysgraphia evolves, their ability to write intelligibly deteriorates, and patients may be found to be awake but mute and akinetic. Interestingly, this presentation may help the healthcare provider distinguish ICANS from other causes of encephalopathy (Kennedy & Salama, 2020). Neurotoxicity may progress to the point at which the patient develops subclinical or clinical seizures or even cerebral edema to the extent that the brain may herniate causing death—a rare but possible occurrence of which the nurse must be aware. Various risk factors