First-line anti-BCMA CAR-T cell therapy in a fragile patient with bi-clonal gammopathy and giantplasma cell tumor multiple myeloma with multiple comorbidities: a case report

Yi Fang Weiwei Lin Lijing Shen ^* Beiwen Ni Minyue Zhang Yongmei Cai Yi Zhou Jian Hou

• Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China

Background: Chimeric antigen receptor T (CAR-T) cells targeting B-cell maturation antigen (BCMA) have been used as an effective therapy against relapsed/refractory multiple myeloma (MM). However, the relapse rates in these patients are still high, which may be related to the poor quality of T cells after multiple chemotherapy. The case reported here demonstrated the effectiveness and safety of first-line anti-BCMA CAR-T cell therapy for high-risk MM patients, even in frailty with multiple comorbidities.2 Case presentation: A 75-year-old female was diagnosed with bi-clonal gammopathy and high-risk MM with extramedullary mass in the right caput femoris. The patient was fragile with multiple comorbidities, including pneumonia, left lower-limb deep venous thrombosis, and epilepsy secondary to cerebral hemorrhage. Considering the patient's fragility and comorbidities, commercial equecabtagene autoleucel, a fully human anti-BCMA CAR T-cells, as first-line CAR-T cell therapy, was proposed and accepted by the patient and her family. After one cycle of VCD regimen (bortezomib, cyclophosphamide, and dexamethasone), she reached very good partial response (VGPR). Then her leukapheresis was performed and the harvested cells were sent to the manufacturer for preparation. After lymphodepletion was performed using FC chemotherapy (fludarabine and cyclophosphamide), her equecabtagene autoleucel was transfused. On day 21 after infusion, she achieved stringent complete remission (sCR) with minimal residual disease (MRD) negative without severe toxicity. The CAR-T cells/CD3 + T cell ratio gradually increased, reaching a maximum of 54.97% on day 14, and gradually decreased, remaining at 0.03% on the 153 rd day. The patient received right hip replacement plus pelvic lesion curettage 7 months after CAR-T transfusion due to her pain in right hip, but no MM cells were found in postoperative pathology. Hitherto, her deep remission persisted for 12 months without any maintenance therapy.First-line anti-BCMA CAR-T cell therapy is effective and safe for high-risk MM patients, even in fragile patients with multiple comorbidities.