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Next Generation of Cancer Treatments: Chimeric Antigen Receptor T-Cell Therapy and Its Related Toxicities: A Review for Perioperative Physicians

Echeverry, Germán MD; Fischer, Gregory W. MD; Mead, Elena MD

doi: 10.1213/ANE.0000000000004201
Critical Care and Resuscitation

Cancer immunotherapy has entered a new era with the recent introduction of genetically engineered T-cells that express chimeric antigen receptors (CARs) capable of recognizing and destroying tumor cells. Several clinical trials in patients with relapsed or refractory B-cell malignancies have demonstrated complete remission rates ranging from 50% to 90%, with long-term data suggestive of a possible curative response. CAR T-cell therapy is currently under investigation for earlier use in these disease processes and in various other solid and liquid tumors. CAR T-cell therapy is associated with a unique postinfusion toxicity profile including cytokine-release syndrome and neurotoxicity. These toxicities are usually reversible but can be fatal, requiring close vigilance and prompt treatment often in an intensive care unit (ICU) setting. CAR T-cell therapy is currently restricted to designated centers possessing expertise in acute toxicity management, but wider use is likely if early therapeutic successes are replicated. As perioperative and critical care physicians, anesthesiologists may encounter such patients in the perioperative or ICU setting and should become familiar with this unique and novel therapeutic modality capable of causing extreme cardiovascular and respiratory compromise. This review will describe the immunobiology of CAR T-cells, their relevance to cancer treatment, clinical aspects of their therapeutic use in cancer chemotherapy, toxicities related to CAR T-cell use, and their therapeutic management.

From the Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.

Published ahead of print 27 March 2019.

Accepted for publication March 27, 2019.

Funding: This manuscript was funded in part through the National Institutes of Health/National Cancer Institute (NIH/NCI), Memorial Sloan Kettering Cancer Center, Support Grant P30 CA008748.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Germán Echeverry, MD, Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Suite C 11–79, New York, NY 10065. Address e-mail to

Copyright © 2019 International Anesthesia Research Society
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