Diagnostic workup
| Diagnostic category . | Included diagnostic tests . | When to initiate . | Additional comments . |
|---|---|---|---|
| Basis workup (tier 1) | • Check medication list for myelotoxic co-medications • Rule out active infections: blood cultures, procalcitonin • Vitamin deficiency: B12, folic acid • Consider secondary HLH/MAS: serum ferritin | In case of severe neutropenia (ANC <500/µL) beyond day +7 after CAR-T infusion | Low threshold to perform (minimal workup) |
| Advanced workup in case of severe ICAHT (tier 2) | • Bone marrow aspiration and biopsy • Advanced viral studies (parvovirus B19, CMV) | Grade 3 or higher ICAHT beyond day +14 | Especially in patients with underlying marrow infiltration |
| Clinical suspicion for therapy-related myeloid neoplasm | Immunohistochemistry, flow cytometry, cytogenetics; next-generation sequencing (myeloid panel) | In case of persistent bone marrow aplasia beyond 1 month; unclear and/or new-onset cytopenia; cytopenia refractory to therapeutic measures | t-MN after CAR-T therapy is an emerging field of study* |
| Diagnostic category . | Included diagnostic tests . | When to initiate . | Additional comments . |
|---|---|---|---|
| Basis workup (tier 1) | • Check medication list for myelotoxic co-medications • Rule out active infections: blood cultures, procalcitonin • Vitamin deficiency: B12, folic acid • Consider secondary HLH/MAS: serum ferritin | In case of severe neutropenia (ANC <500/µL) beyond day +7 after CAR-T infusion | Low threshold to perform (minimal workup) |
| Advanced workup in case of severe ICAHT (tier 2) | • Bone marrow aspiration and biopsy • Advanced viral studies (parvovirus B19, CMV) | Grade 3 or higher ICAHT beyond day +14 | Especially in patients with underlying marrow infiltration |
| Clinical suspicion for therapy-related myeloid neoplasm | Immunohistochemistry, flow cytometry, cytogenetics; next-generation sequencing (myeloid panel) | In case of persistent bone marrow aplasia beyond 1 month; unclear and/or new-onset cytopenia; cytopenia refractory to therapeutic measures | t-MN after CAR-T therapy is an emerging field of study* |
ANC, absolute neutrophil count; CMV, cytomegaly virus; HLH/MAS, hemophagocytic lymphohistiocytosis/macrophage activation syndrome; ICAHT, immune effector cell-associated hematotoxicity; t-MN, therapy-related myeloid neoplasm.
Incidence rate as high as 6% of t-MN after CAR T-cell infusion (see Gurney et al., EHA 2023; abstract number S26387 ).