How can myeloma patients enhance the outcome of CAR-T cell therapy?
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PET/CT, EMD and CAR-T Outcomes
How do PET/CT, EMD, and CAR-T relate to each other in the treatment of multiple myeloma? To clarify, PET is short for Positron Emission Tomography. CT is short for computed tomography. EMD is short for extramedullary disease, and CAR is short for chimeric antigen receptor.
You have undergone CAR-T cell therapy. You have read that this revolutionary therapy for MM can result in long remissions, but it often results in short remissions. You want to identify your prognosis as best you can.
The research linked below explains how PET/CT imaging before and after CAR-T therapy can identify EMD and therefore can identify which patients can relapse soon after CAR-T therapy concludes.
The role of PET/CT in multiple myeloma
To enhance the outcomes of CAR-T cell therapy in multiple myeloma, patients can take proactive steps before, during, and after treatment. These strategies aim to improve T-cell health, reduce disease burden, manage toxicities, and support long-term immune recovery.
🔬1. Optimize T-cell Health Before Apheresis (Collection)
Why it matters:
CAR-T therapy relies on the patient’s own T-cells. If these are exhausted, dysfunctional, or suppressed, the CAR-T product may be less effective.
Strategies:
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Early Collection: Collect T-cells before multiple lines of therapy, especially before alkylators or daratumumab, which impair T-cell function.
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Avoid recent steroid use: Corticosteroids before apheresis can suppress T-cell yield and function.
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Exercise (moderate intensity): Shown to enhance T-cell responsiveness and reduce exhaustion markers.
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Nutritional Support:
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Adequate vitamin D, omega-3s, and antioxidants (e.g., vitamins A, C, E).
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Avoiding malnutrition supports immune cell health.
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Microbiome balance: A healthy gut microbiome may support T-cell fitness. This includes:
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High-fiber, plant-rich diet
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Probiotics (e.g., Lactobacillus, Bifidobacterium)
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Avoiding unnecessary antibiotics
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⚔️2. Minimize Disease Burden Before Infusion
Why it matters:
High disease burden is linked to increased toxicity and poorer response.
Strategies:
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Use bridging therapy effectively to reduce disease before lymphodepletion and infusion.
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Monitor MRD status (if available) to time infusion during low burden.
💉3. Prepare for and Manage Toxicities
Key toxicities:
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Cytokine Release Syndrome (CRS)
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Neurotoxicity (ICANS)
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Infections (due to prolonged cytopenias and hypogammaglobulinemia)
Strategies:
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Early recognition and reporting of symptoms
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Prophylactic antibiotics/antivirals/antifungals
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IVIG replacement for hypogammaglobulinemia
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Consider tocilizumab or steroids under physician guidance for CRS/ICANS
🧬4. Support Immune Recovery and CAR-T Persistence
Why it matters:
Long-term remission is linked to CAR-T cell persistence and immune reconstitution.
Strategies:
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Avoid immunosuppressants unless needed for CRS/ICANS
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Vaccination strategy: Reimmunize when CD4+ counts recover (usually 3–6 months post-infusion)
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Monitor for infections long-term
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Investigational: IL-7/IL-15 support (cytokines that help T-cell survival and expansion)
🌱5. Consider Clinical Trials or Novel Strategies
Investigational enhancements:
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Dual-targeted CAR-T (e.g., BCMA + GPRC5D or CD19)
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CAR-T plus checkpoint inhibitors
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Off-the-shelf allogeneic CAR-T
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Early-line CAR-T (before T-cell exhaustion)
🧘6. Psychosocial and Functional Wellness
Why it matters:
Psychological distress and physical deconditioning can reduce resilience and recovery.
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Counseling and peer support reduce anxiety, improve adherence
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Rehabilitation or PT to regain function post-treatment
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Sleep, hydration, and mental health support immune regulation
Summary Table
| Goal | Strategy |
|---|---|
| T-cell fitness | Early collection, no steroids, nutrition, gut health |
| Disease control | Bridging therapy, MRD-based timing |
| Reduce toxicities | Prophylaxis, early management of CRS/ICANS |
| Immune recovery | Re-vaccination, monitor infections, IVIG |
| Long-term remission | Persistence support, novel CARs, trials |
| Overall wellness | Exercise, sleep, psychosocial care |
The study below is quick to point out that it can be difficult to read PET/CT scans properly. Or I should say that it can be difficult to identify EMD in your PET/CT images. I would discuss this possibility with your oncologist.
I am a long-term MM survivor. Image studies for MM have come a long way over the past 30-plus years.
Email me at David.PeopleBeatingCancer@gmail.com to learn more about managing your MM with both conventional and non-conventional MM therapies.
David Emerson
- MM Survivor
- MM Cancer Coach
- Director PeopleBeatingCancer
PET/CT Helps Predict Relapse in Patients With Myeloma Undergoing CAR T-Cell Therapy
Key Takeaways
- PET/CT scans are crucial for staging, treatment response monitoring, and detecting extramedullary disease in multiple myeloma patients undergoing CAR T-cell therapy.
- Bone-independent extramedullary disease is associated with significantly inferior progression-free survival compared to those without it.
“PET/CT scans can help identify patients with multiple myeloma (MM) who are at risk of adverse outcomes following treatment with chimeric antigen receptor (CAR) T-cell therapies, according to a new report published in HemaSphere.1 The authors of the study said their findings could help clinicians tailor therapeutic regimens to high-risk patients, for example, by incorporating concomitant radiation therapy.
PET/CT is a critical tool for MM staging, treatment response monitoring, and the detection of extramedullary disease (EMD), the authors explained. PET/CT has also been found to be a valuable prognostic indicator for patients with MM who undergo autologous stem cell transplantation (ASCT).2…
In an effort to better understand potential associations between PET/CT imaging and outcomes for patients undergoing CAR T-cell therapy, the investigators identified 61 patients with MM who were treated with either idecabtagenevicleucel (ide-cel; Abecma) or ciltacabtageneautoleucel (cilta-cel; Carvykti).
Of the 61 patients, 53 patients had imaging performed prior to CAR T infusion, and 43 had imaging available from 30 days after infusion. The investigators compared those data to other biomarkers and patient outcomes to see whether PET/CT had prognostic value.
Patients who had bone-independent EMD had progression-free survival of just 3 months, compared to 15 months for those without bone-independent EMD (P = .01). The investigators found that EMD was associated with inferior progression-free survival (PFS), but the number of lesions was not, nor was metabolic tumor volume (MTV)…
In follow-up PET/CTs, the investigators said those with complete metabolic remissions tended to have superior PFS.
“By evaluating PET/CT findings before and after treatment, we elucidated the complex interplay between tumor burden, metabolic activity, and patient outcomes, revealing novel insights into the stratification of high-risk individuals and potential avenues for optimizing therapeutic interventions,” the authors wrote…
The authors noted that a significant downside of the use of PET/CT is that it is open to interpretation, and thus inter-observer variability occurs. However, they said incorporating the Italian Myeloma criteria for PET Use (IMPeTUs) led to a more standardized interpretation of PET/CT findings, which showed that patients with diffuse bone marrow uptake (>Deauville 3) had worse outcomes.
“Combining IMPeTUs-defined risk factors—EMD and marrow infiltration—proved highly effective in stratifying patients, enabling identification of individuals at risk for early relapse or extended survival,” they wrote.
Only 37% of patients achieved complete metabolic remission on follow-up, which the authors noted is an indication of why PET/CT can be valuable in detecting residual disease not captured by traditional biochemical markers.”
The authors said their 30-day follow-up might be too short to fully capture treatment response and progression, and future studies are necessary to better understand how to use PET/CT in patient risk stratification and monitoring.
PET/CT EMD and CAR-T PET/CT EMD and CAR-T PET/CT EMD and CAR-T