Immunotherapy for Lymphoma in Children

Immunotherapy is the use of medicines to help a person’s own immune system recognize and destroy cancer cells. It may be used as part of treatment for some types of lymphoma in children. Not all lymphomas are treated with immunotherapy.

Monoclonal antibodies

Monoclonal antibodies are currently used to treat some B-cell lymphomas.

Monoclonal antibodies attach to specific proteins on the surface of some types of cancer cells, which causes the cells to die.

Rituximab (Rituxan)

Rituximab finds cells with CD20 on their surface. CD20 is commonly found on B cells, so it is often used with chemotherapy as part of treatment for some B-cell lymphomas. Treatment is typically given through a vein (IV).

Blinatumomab (Blincyto)

Blinatumomab is a special kind of monoclonal antibody known as a bispecific T-cell engager (BiTE). It attaches to 2 different proteins at the same time.

One part of blinatumomab attaches to the CD19 protein, which is found on some B cells, including some lymphoma cells. Another part attaches to CD3, a protein found on immune cells called T cells. By binding to both proteins, this drug brings the lymphoma cells and immune cells together, which helps the immune system attack the cancer.

Blinatumomab is given into a vein (IV) as a continuous infusion over 28 days.

Serious side effects, such as cytokine release syndrome (see below), may happen during the infusion, especially in the first few days of an infusion. Because of this, a child or teen usually needs to stay in the hospital for the first few days of the infusion.

Immune checkpoint inhibitors

Immune checkpoint inhibitors are currently used to treat Hodgkin lymphoma and lymphomas that come back after treatment.

The immune system is designed to attack foreign cells, such as germs and cancer cells. But it needs a way to tell the difference between normal cells and those it sees as foreign. It does this by using checkpoint proteins on immune cells.

These checkpoints act like switches that turn immune responses on or off, helping the body avoid attacking its own tissues. Some cancer cells find ways to use these checkpoints to avoid being recognized and destroyed.

Immune checkpoint inhibitors block the signals from these checkpoints, allowing the immune system to find and attack cancer cells.

PD-1 inhibitors

PD-1 is a checkpoint protein on immune cells called T cells. It normally acts as an “off switch” to help keep T cells from attacking normal cells. When it is blocked, this may allow the immune system to see the cancer cells and destroy them.

Examples of PD-1 inhibitors include:

• Nivolumab (Opdivo)
• Pembrolizumab (Keytruda)

These drugs can be given through a vein (IV) or by injection (pembrolizumab).

CAR T-cell therapy

CAR T-cell therapy is a treatment that targets specific proteins on cancer cells. It can be used to treat childhood lymphoma that has come back after treatment or that is no longer responding to treatment.

For this treatment, immune cells called T cells are removed from the child’s blood through an IV line that goes into a machine during a process called leukapheresis. The remaining blood then goes back into the body. This typically takes a few hours, and it might need to be repeated.

The T cells are then genetically altered in the lab to have specific receptors, called chimeric antigen receptors or CARs, on their surface. These receptors can attach to proteins on cancer cells. The T cells are then multiplied in the lab and given back into the child’s blood, where they can seek out the lymphoma cells and attack them. This process can take a few weeks.

For the treatment itself, a child typically gets chemo for a few days to help prepare their body. The CAR T cells are then infused into a vein.

Possible side effects of CAR T-cell therapy

This treatment can have serious or even life-threatening side effects. It needs to be given in a medical center that is specially trained in its use.

Cytokine release syndrome (CRS): CRS happens when the body releases chemicals (cytokines) that ramp up the immune system. Symptoms can include high fever and chills, trouble breathing, low blood pressure, heart problems, kidney problems, severe nausea, vomiting, and/or diarrhea, severe muscle or joint pain, and feeling dizzy or lightheaded.

Nervous system problems: CAR T-cell therapy can have serious effects on the nervous system. This could result in symptoms such as headaches, changes in consciousness, confusion or agitation, seizures, trouble speaking and understanding, loss of balance.

Other possible serious side effects can include serious infections and low blood cell counts which can increase the risk of infections, fatigue, and bruising or bleeding.

It is very important to report any side effects to your child’s health care team right away. There are often medicines that can help treat these side effects.