Recent Bendamustine Treatment Before Apheresis Has a Negative Impact on Outcomes in Patients With Large B-Cell Lymphoma Receiving Chimeric Antigen Receptor T-Cell Therapy

Author(s): Gloria Iacoboni, MD, PhD1,2,3; Víctor Navarro, BSc4; Ana África Martín-López, MD5,6; Kai Rejeski, MD7,8,9; Mi Kwon, MD, PhD10,11; Katarzyna Aleksandra Jalowiec, MD12,13; Paula Amat, MD14,15; Juan Luis Reguera-Ortega, MD16; Laura Gallur, MD1,2,3; Viktoria Blumenberg, MD7,8,9; Sara Gutiérrez-Herrero, PhD17; Claire Roddie, MD, PhD12; Ana Benzaquén, MD14,15; Javier Delgado-Serrano, MD16; Mario Andrés Sánchez-Salinas, MD1,2,3; Rebeca Bailén, MD, PhD10,11; Cecilia Carpio, MD1,2,3; Lucia López-Corral, MD5,6; Rafael Hernani, MD14,15; Mariana Bastos, MD, PhD10,11; Maeve O’Reilly, MD17; Lourdes Martín-Martín, PhD17; Marion Subklewe, MD, PhD7,8,9; Pere Barba, MD, PhD1,2,3
Anjan J Patel MD

Dr. Anjan Patel's Thoughts

This gives more credence to the idea of avoiding bendamustine before CAR T therapy. Patients exposed to bendamustine had about a 20% lower overall response rate (ORR), 50% shorter progression-free survival (PFS) and >50% shorter overall survival (OS) compared to those who were bendamustine naive. Although other factors may also play a role here, these seem to be significant differences and should make it clear that one should not use this drug before pursuing CAR T therapy.


Approximately 30%-40% of patients with relapsed/refractory (R/R) large B-cell lymphoma (LBCL) infused with CD19-targeted chimeric antigen receptor (CAR) T cells achieve durable responses. Consensus guidelines suggest avoiding bendamustine before apheresis, but specific data in this setting are lacking. We report distinct outcomes after CAR T-cell therapy according to previous bendamustine exposure.


The study included CAR T-cell recipients from seven European sites. Safety, efficacy, and CAR T-cell expansion kinetics were analyzed according to preapheresis bendamustine exposure. Additional studies on the impact of the washout period and bendamustine dose were performed. Inverse probability treatment weighting (IPTW) and propensity score matching (PSM) analyses were carried out for all efficacy comparisons between bendamustine-exposed and bendamustine-naïve patients.


The study included 439 patients with R/R LBCL infused with CD19-targeted commercial CAR T cells, of whom 80 had received bendamustine before apheresis. Exposed patients had significantly lower CD3+ cells and platelets at apheresis. These patients had a lower overall response rate (ORR, 53% v 72%; P < .01), a shorter progression-free survival (PFS, 3.1 v 6.2 months; P = .04), and overall survival (OS, 10.3 v 23.5 months; P = .01) in comparison with the bendamustine-naïve group. Following adjustment methods for baseline variables, these differences were mitigated. Focusing on the impact of bendamustine washout before apheresis, those with recent (<9 months) exposure (N = 42) displayed a lower ORR (40% v 72%; P < .01), shorter PFS (1.3 v 6.2 months; P < .01), and OS (4.6 v 23.5 months; P < .01) in comparison with bendamustine-naïve patients. These differences remained significant after IPTW and PSM analysis. Conversely, the cumulative dose of bendamustine before apheresis did not affect CAR-T efficacy outcomes.


Recent bendamustine exposure before apheresis was associated with negative treatment outcomes after CD19-targeted CAR T-cell therapy and should be therefore avoided in CAR T-cell candidates.

Author Affiliations

1Department of Hematology, University Hospital Vall d’Hebron, Barcelona, Spain; 2Experimental Hematology, Vall d’Hebron Institute of Oncology (VHIO), Barcelona, Spain; 3Department of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain; 4Oncology Data Science (ODySey) Group, Vall d’Hebron Institute of Oncology (VHIO), Barcelona, Spain; 5Hematology Department, Hospital Clínico Universitario de Salamanca, IBSAL, CIBERONC, Salamanca, Spain; 6Centro de Investigación del Cáncer-IBMCC, Salamanca, Spain; 7Department of Medicine III, University Hospital, LMU Munich, Munich, Germany; 8Laboratory for Translational Cancer Immunology, Gene Center of the LMU Munich, Munich, Germany; 9German Cancer Consortium (DKTK) and Bavarian Center for Cancer Research (BZKF), partner site Munich, Munich, Germany; 10Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; 11Gregorio Marañón Health Research Institute (IiSGM), Madrid, Spain; 12Hematology Department, University College London Cancer Institute, London, United Kingdom; 13Department of Hematology and Central Hematology Laboratory, University Hospital of Bern, Bern, Switzerland; 14Haematology Department, Hospital Clínico Universitario, Valencia, Spain; 15INCLIVA Research Institute, Valencia, Spain; 16Hematology Department, Hospital Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBIS)/CSIC, Universidad de Sevilla, Sevilla, Spain; 17Cancer Research Centre (IBMCC, USAL-CSIC), Institute for Biomedical Research of Salamanca (IBSAL) and Department of Medicine and Cytometry Service (NUCLEUS Research Support Platform), University of Salamanca (USAL), Salamanca, Spain

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