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Background/Aim: Chimeric antigen receptor (CAR) T-cell therapy has revolutionized the treatment of various B-cell malignancies. However, it can cause serious adverse effects like immune effector cell-associated neurotoxicity syndrome (ICANS). ICANS is attributed to disruption of the blood-brain barrier due to inflammatory cytokines and increased levels of immune effector cells (IECs) in the cerebrospinal fluid (CSF). Corticosteroids and supportive management are the mainstays of ICANS treatment. However, no guidelines exist for the treatment of steroid-refractory ICANS. Some reports have shown favorable outcomes with no long-term complications in patients with steroid-refractory ICANS treated with intrathecal (IT) chemotherapy. Case Report: We describe the outcomes of two patients with steroid-refractory ICANS treated with IT chemotherapy. Both patients had refractory large B-cell lymphoma and were not candidates for autologous transplant. They developed steroid-refractory ICANS after CAR T-cell infusion. IT chemotherapy with 12 mg methotrexate and 50 mg hydrocortisone resulted in prompt neurological improvement in both patients. One of them passed away due to multiple other comorbidities, and the other patient continues to do well without any complications. Conclusion: IT chemotherapy could be considered as a potential approach for the management of steroid-refractory ICANS based on our experience. Prospective studies are needed to validate this approach.Chimeric antigen receptor (CAR) T-cell therapy is a novel therapeutic modality that uses genetically modified T cells to target tumor cells. CAR T-cells get activated after binding to a specific antigen on tumor cells to proliferate, secrete cytokines and kill the targeted cancer cells (1). CD-19 targeting CAR T-cells (tisagenlecleucel/tisa-cel and axicabtagene cilileucel/axi-cel) are approved to treat relapsed or refractory (R/R) B cell acute lymphoblastic leukemia (B-ALL) and large B cell lymphomas (2-3).CAR T-cell therapy has revolutionized the treatment of hematologic malignancies. However, it is associated with adverse events like cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity (ICANS). CRS is caused by the systemic release of inflammatory cytokines through activated lymphocytes and myeloid cells, which can result in a clinical syndrome consisting of fever, hypotension, and widespread organ dysfunction (4). ICANS may occur with or without CRS, and onset is variable ranging from days to weeks after cell infusion. Its presentation is diverse, ranging from encephalopathy (most common), focal weakness/numbness to tremors, seizures, and cerebral edema.Management of CRS and ICANS depends on the severity of the toxicity, with supportive care, corticosteroids, and IL-6-directed therapy (tocilizumab) being the mainstay of treatment (5). Tocilizumab was approved by FDA in August 2017 for the treatment of CRS as a first-line pharmacotherapy (6). However, it is unclear if it helps treat ICANS without CRS. Corticosteroids are indicat...

Venetoclax, a highly selective Bcl-2 inhibitor, is an orally bioavailable drug that has been approved as firstline therapy for chronic lymphocytic leukemia (CLL) in combination with obinutuzumab, as well as monotherapy in the setting of relapsed CLL. Although some of its lifethreatening side effects are well known, including tumor lysis syndrome and cytopenias, others less known side effects include skin reactions. Skin rash is commonly reported in literature, which is often mild and not lifethreatening. In this case report, the authors describe what is potentially the second case of venetoclax-induced vitiligo reported in literature. A 77-year-old man with CLL Rai stage II with cytogenetics showed 11 q23 deletion in 14% of cells, and 14q32 partial deletion in 9% of cells developed vitiligo in his extremities 2 years into treatment. A decision was made to continue venetoclax with close monitoring as the side effect was mild and not debilitating. The patient continued to do well. Although vitiligo is not associated with increased mortality risk, its development is associated with increased psychological stress. The mechanism by which vitiligo develops remains unclear. There may be an association between drug-induced vitiligo and improved cancer prognosis; however, larger studies need to be carried out to prove this hypothesis.

Background/Aim: Extramedullary plasmacytoma (EMP) is defined as a localized plasma cell neoplasm that arises in tissues other than the bone. The most common sites of involvement of EMP are the upper airways followed by lymph nodes, gastrointestinal tract, thyroid gland, skin, brain, liver, and lungs. Testicular plasmacytoma has a very rare occurrence with about 70 cases reported in literature to date. Case Report: We describe a 52-year-old-male with a diagnosis of multiple myeloma presenting with lytic lesions of the axial skeleton. He had lambda light chain restricted, R-ISS stage II with high risk cytogenetics as he tested positive for t(4;14). He underwent four cycles of cyclophosphamide, bortezomib and dexamethasone followed by auto-peripheral stem cell transplantation. He was kept on ixazomib, lenalidomide and dexamethasone maintenance therapy, but relapsed soon after and was diagnosed with plasmacytoma of the left lung. Therapy was switched to daratumumab, carfilzomib and dexamethasone and the patient received radiation of his left lung. He then developed left painless testicular mass which was treated with six weeks course of antibiotics. However due to persistence of concerning features on scrotal ultrasound post-treatment, the patient underwent radical orchiectomy with pathology coming back positive for plasma cells. Conclusion: The testes serve as a sanctuary site for hematological malignancies due to the presence of the testicular-blood barrier. Hence, it is imperative to keep a high index of suspicion for testicular plasmacytoma in the right clinical context when evaluating a patient with known multiple myeloma.