Immunotherapy in Childhood Cancer:
Principles, clinical use and nursing considerations
Yan Yin Lim
Assistant Director, Nursing [email protected]
Objectives
• Define immunotherapy
• Identify the use and clinical indications of
immunotherapy in paediatric oncology setting
• Describe the process immunotherapy
• Examine the treatment related side effects and toxicity of immunotherapy
• Discuss the various aspect of nursing care of patients receiving immunotherapy
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What is Immunotherapy?
• A group of treatment that use the body’s own immune system to help identify and destroy cancer cells
- Unlike chemotherapy, healthy cells remain unharmed.
Goal: Optimse the immune system to fight disease while minimising toxicity.
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Chemotherapy VS Immunotherapy
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Toxicity
Classification of Immunotherapy
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Cancer
Vaccines
Monoclonal Antibodies
• Manufactured proteins that act as antibodies targeted to act on an antigen specific to a cancer cell
- The antibody bind to the targeted cancer cell and signal other immune cells to cause a cytotoxic effect
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• The antibody can be derived from
- human
- mouse (murine)
- a combination (chimeric)
Monoclonal Antibodies:
Common use in Paediatric Oncology
-
Rituximab (CD20): B-cell lymphoma, autoimmune cytopenias, rheumatologic conditions. (Infusion reactions – slow step-up infusion)
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Dinutuximab (GD2): High-risk neuroblastoma (Neuropathic pain due to nerve binding)
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Naxitimab (GD2): Relapsed/refractory
neuroblastoma (Outpatient infusion; pain, hypotension, infusion reactions)
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Blinatumomab (CD19/CD3): MRD+ or relapsed B-cell ALL (Neurotoxicity risk; CADD pump for infusion)
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Rituximab
Institutional guidelines to be shared - sensitive
Dinutuximab
•
Institutional guidelines to be shared - sensitive
Naxitimab
•
Institutional guidelines to be shared - sensitive
Blinatumomab
•
Institutional guidelines to be shared - sensitive
Checkpoint Inhibitors
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Increase activity of the T cell -> cause inflammatory reaction
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Checkpoint Inhibitors:
Common Use in Paediatric Oncology
➢ Nivolumab (anti-PD-1)
Used in relapsed/refractory Hodgkin lymphoma
➢ Pembrolizumab (anti-PD-1)
Used across a wide range of solid tumors, particularly those with high tumor mutational burden or mismatch repair deficiency
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Checkpoint Inhibitors:
Common Side Effects
Common Side Effects (Immune-Related Adverse Events)
•
Gastrointestinal: colitis, diarrhea•
Endocrine: thyroiditis, adrenalitis, pancreatitis•
Renal: nephritis•
Skin: rash, pruritus•
Liver: autoimmune hepatitis Management•
Treated with systemic corticosteroids•
Requires early recognition and escalation•
Side effects may appear weeks to months after therapyChimeric Antigen Receptor T lymphocyte (CAR-T) cells
•
T cells of the patients are isolated and modified to specifically target an antigen on a cancer cell.
•
Activate an immune response with direct cytotoxic effect on cancer cell.
•
Become part of the patient’s immune system, continue to
proliferate and remain in the immune system for a long
time.
Chimeric Antigen Receptor T lymphocyte (CAR-T) cells
1. Target 3. Expansion
2. Tumour-lysis
CAR-T Cells Therapy Process
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Cytokine Release Syndrome
Incidence and severity of CRS affected by:
•
CAR T-cell expansion and immune activation
- Cell dose - CAR design
- Infused cellular phenotypes - Conditioning chemotherapy
•
Disease burden at time of infusion
Median time to onset of CRS: 3 days
CRS: Management
Management Strategy
• Supportive care (fluids, oxygen, antipyretics)
• First-line: Tocilizumab (IL-6 receptor blocker)
▸ Rapidly reverses CRS symptoms
▸ Effects on CAR T-cell function still under study
• Alternative: Siltuximab (anti–IL-6 monoclonal antibody)
Corticosteroids
• Can reverse symptoms quickly
• Use cautiously: short courses are generally safe
• Avoid prolonged high-dose steroids
▸ May impair CAR T-cell persistence and long-term efficacy
• Not recommended as first-line treatment
CAR T-Related Encephalopathy Syndrome (CRES)
What is CRES?
• Stands for CAR T-Related Encephalopathy Syndrome
• A type of neurotoxicity seen after CAR T-cell therapy Common Symptoms
• Confusion, delirium, expressive aphasia
• Drowsiness/obtundation, myoclonus, seizures Pathophysiology
• Not fully understood
• IL-1 may play a more prominent role than IL-6 Clinical Course
• Often reversible, especially in patients treated with CD19-targeted CAR T-cells
Key Takeaways
• Immunotherapy enhances the body’s immune system to fight cancer with greater precision
• Monoclonal antibodies, checkpoint inhibitors, and CAR T-cell therapy are the main types used in pediatric oncology
• Each therapy has distinct mechanisms, indications, and toxicity profiles
• CRS and neurotoxicity are key complications of CAR T-cell therapy — early detection and nursing vigilance are essential
• Ongoing education, regional collaboration, and preparedness are key as access expands across Southeast Asia
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