CAR T cell therapy in advanced B-ALL with heavy disease burden

In recent years, CD19-directed chimeric antigen receptor (CAR) T cell therapy has exhibited significant potency for treating pediatric relapsed or refractory B-cell acute lymphoblastic leukemia (r/r B-ALL). Nonetheless, many patients with disease progressing rapidly may not benefit from this therapy. Actually, 10%–20% of these patients with rapidly progressive disease failed in CAR T cell manufacturing. Besides, some patients died of disease progression earlier than CAR T cells expanding in vivo. How to deal with the fast progressive disease and ensure successful manufacturing and expansion of CAR T cells are still very important questions for the clinicians. In this brief report, some clinical experience to handle these tough situations in our center will be introduced. Bridging chemotherapy and post-CAR antitumor managements help to control progressive blasts and contribute to the success of CAR T cell therapy. The optimal timing of apheresis and adjusted protocol for manufacturing CAR T cells are critical for advanced patients. Optimal treatment options and how they should be applied to advanced B-ALL with heavy disease burden still need to be discussed.