Table 2 Recommendations for diagnosing and managing IEC-associated enterocolitis.
Diagnosing IEC-associated enterocolitis | |
|---|---|
Recommendation | Rationale |
Consider this entity in patients with unexplained diarrhea following CAR-T, particularly if > 1 month afterward | In our series, the median time to symptom onset (typically Grade 3+ non-bloody diarrhea) was 3 months after CAR-T infusion |
(If applicable) Re-refer the patient to the CAR-T treatment center if no longer being followed there actively | Diagnosis of this delayed toxicity requires close consultation between the patient’s primary oncologist and the CAR-T treatment center |
Perform endoscopic evaluation with biopsies that are specifically reviewed by a hematopathologist | Infectious causes (e.g., CMV colitis) can occur without viremia, and enteral T-cell malignancies have been reported in this setting [9] |
(If applicable) Work with product manufacturers to test for CAR presence on enteral biopsies | If a lymphoproliferative process is suspected, the product manufacturer will be able to assist with CAR staining to evaluate causality |
Managing IEC-associated enterocolitis | |
|---|---|
Recommendation | Rationale |
Consult with GI and ID specialists on management and strategies to avoid treatment-related infections | Given the rarity of this toxicity and the immunosuppressive nature of its management, a collaborative approach is imperative |
Consider minimizing the use of long-term corticosteroids, particularly if symptoms do not resolve quickly | Long-term corticosteroids can potentially predispose patients to complications such as adrenal insufficiency or bowel perforation |
Consider irAE-type management with early infliximab or vedolizumab if symptoms do not resolve quickly | In our series, these biological agents occasionally led to symptom resolution in steroid-refractory cases after 1–3 doses |
If symptoms do not resolve with the above steps, revisit the diagnosis of a potential lymphoproliferative process | For patients with lymphoproliferative T-cell processes involving the gut, drugs like cyclosporine may be more effective [12] |
For life-threatening cases, consider IEC-HS management strategies including ruxolitinib or chemotherapy | While these agents have not been studied in this setting, they are options in refractory cases of IEC-HS based on expert opinion [4] |
