Facial Nerve Palsy After Chimeric Antigen Receptor T-Cell Therapy.

A man in his 60s with relapsed/refractory IgG lambda multiple myeloma underwent chimeric antigen receptor T (CART) cell therapy. Twenty-five days after infusion, he presented with new right-sided facial numbness. Physical examination showed right-sided facial paralysis (Figure 1). A magnetic resonance image of the brain with and without contrast enhancement showed new increased enhancement of the bilateral facial nerves (Figure 2). Despite bilateral enhancement on imaging, clinically his facial palsy manifested unilaterally to the right side. The patient was prescribed corticosteroids with clinical improvement. At 3-month follow-up, his symptoms had resolved.Figure 2A, Axial T1 sequence at the level of the facial nerve following intravenous administration of gadolinium contrast medium demonstrates a normal appearance of bilateral facial nerves. B, Follow-up axial T1 sequence at the level of the facial nerve following intravenous administration of gadolinium contrast medium after development of right facial nerve palsy demonstrates new abnormal enhancement of the anterior genu and horizontal segment of bilateral facial nerve (arrows).View Large Image Figure ViewerDownload Hi-res image Download (PPT) Multiple myeloma is a malignant neoplasm of abnormal plasma cells in the bone marrow.1Feng D. Sun J. Overview of anti-BCMA CAR-T immunotherapy for multiple myeloma and relapsed/refractory multiple myeloma.Scand J Immunol. 2020; 92e12910Crossref Scopus (18) Google Scholar There have been significant advances in treatment and overall survival of myeloma, including CART cell therapy. Chimeric antigen receptors are engineered synthetic receptors that redirect lymphocytes to recognize and eliminate cells expressing a specific target antigen.1Feng D. Sun J. Overview of anti-BCMA CAR-T immunotherapy for multiple myeloma and relapsed/refractory multiple myeloma.Scand J Immunol. 2020; 92e12910Crossref Scopus (18) Google Scholar Common adverse effects of CART cell therapy include cytokine release syndrome and neurotoxicity.2Cohen A.D. Parekh S. Santomasso B.D. et al.Incidence and management of CAR-T neurotoxicity in patients with multiple myeloma treated with ciltacabtagene autoleucel in CARTITUDE studies.Blood Cancer J. 2022; 12: 32Crossref PubMed Scopus (39) Google Scholar Neurotoxicity can manifest as aphasia, confusion, or lethargy and can eventually lead to seizures and fatal cerebral edema if untreated.2Cohen A.D. Parekh S. Santomasso B.D. et al.Incidence and management of CAR-T neurotoxicity in patients with multiple myeloma treated with ciltacabtagene autoleucel in CARTITUDE studies.Blood Cancer J. 2022; 12: 32Crossref PubMed Scopus (39) Google Scholar Cranial nerve disorders, including the third, fifth, sixth, and seventh nerves, have been reported.3Berdeja J.G. Madduri D. Usmani S.Z. et al.Ciltacabtagene autoleucel, a B-cell maturation antigen-directed chimeric antigen receptor T-cell therapy in patients with relapsed or refractory multiple myeloma (CARTITUDE-1): a phase 1b/2 open-label study.Lancet. 2021; 398 (Published correction appears in Lancet. 2021;398(10307):1216): 314-324Abstract Full Text Full Text PDF PubMed Scopus (448) Google Scholar,4CARVYKTI. Package insert. Janssen Biotech, Inc, 2023https://www.fda.gov/media/156560/downloadDate accessed: April 20, 2023Google Scholar In the CARTITUDE-1 trial, 5% of patients reported movement and neurocognitive treatment-emergent adverse events that were associated with several variables including high tumor burden and high CART expansion/persistence.2Cohen A.D. Parekh S. Santomasso B.D. et al.Incidence and management of CAR-T neurotoxicity in patients with multiple myeloma treated with ciltacabtagene autoleucel in CARTITUDE studies.Blood Cancer J. 2022; 12: 32Crossref PubMed Scopus (39) Google Scholar, 3Berdeja J.G. Madduri D. Usmani S.Z. et al.Ciltacabtagene autoleucel, a B-cell maturation antigen-directed chimeric antigen receptor T-cell therapy in patients with relapsed or refractory multiple myeloma (CARTITUDE-1): a phase 1b/2 open-label study.Lancet. 2021; 398 (Published correction appears in Lancet. 2021;398(10307):1216): 314-324Abstract Full Text Full Text PDF PubMed Scopus (448) Google Scholar As the use of cellular therapies in cancer care increases, clinicians need to remain cognizant of these nervous system disorders, including facial nerve palsy, when treating patients undergoing CART cell therapy. The authors report no competing interests.