The immunosuppressive tumour microenvironment (TME) remains a central barrier to effective immunotherapy in solid tumours. We present a gene-therapeutic strategy that enables localized remodelling of the TME via tumour-intrinsic cytokine expression. Central to this approach is CancerPAM, a multi-omics bioinformatics pipeline that identifies and ranks patient-specific, tumour-exclusive CRISPR-Cas9 knock-in sites with high specificity and integration efficiency. Using neuroblastoma as a model, CancerPAM analysis of tumour sequencing data identifies optimal knock-in sites for pro-inflammatory cytokines (CXCL10, CXCL11, IFNG), and CancerPAM rankings correlate strongly with target-site specificity and knock-in efficiency, validating its predictive performance. CRISPR-mediated CXCL10 knock-in enhances CAR T cell infiltration and antitumour efficacy in vitro and in vivo, including humanized CD34⁺ HuNOG mice, where CXCL10-expressing tumours show stronger immune infiltration and prolonged tumour control within a reconstituted human immune microenvironment. Our findings establish a framework for safe and effective CRISPR-based cytokine delivery, integrating localized TME remodelling with cellular immunotherapies to enhance CAR T cells and other treatments in immune-refractory solid tumours.

Background: Use of real-time continuous glucose monitoring (rtCGM) systems has been shown to be a low-pain, safe, and effective method of preventing hypoglycemia and hyperglycemia in people with diabetes of various age groups. Evidence on rtCGM use in infants and in patients with conditions other than diabetes remains limited. Objective: This case study describes the off-label use of rtCGM and the use of an open-source app for glucose monitoring in a newborn with prolonged hypoglycemia secondary to transient congenital hyperinsulinism during the perinatal period. Methods: The Dexcom G6 rtCGM system (Dexcom, Inc) was introduced at 39 hours of age. Capillary blood glucose checks were performed regularly. In order to benefit from customizable alert settings and detect hypoglycemic episodes, the open-source rtCGM app xDrip+ was introduced at 9 days of age. Results: Time in range (45-180 mg/dL) for interstitial glucose remained consistently above 90%, whereas time in hypoglycemia (<45 mg/dL) decreased. Mean glucose was maintained above 70 mg/dL at 72 hours of life and thereafter. Daily sensor glucose profiles showed cyclic fluctuations that were less pronounced over time. Conclusions: While off-label use of medication is both common practice and a necessity in newborn infants, there are few examples of off-label uses of medical devices, rtCGM being a notable exception. Real-time information allowed us to better understand glycemic patterns and to improve the quality of glycemic control accordingly. Severe hypoglycemia was prevented, and measurement of serum levels of insulin and further lab diagnostics were performed much faster, while the patient’s individual burden caused by invasive procedures was reduced. Greater customizability of threshold and alert settings would be beneficial for user groups with glycemic instability other than people with diabetes, and for hospitalized newborn infants in particular. Further research in the field of personal and off-label rtCGM use, efficacy studies evaluating the accuracy of low glucose readings, and studies on the differences between algorithms in translating raw sensor data, as well as customization of commercially available rtCGM systems, is needed.

Exocrine pancreatic insufficiency (EPI) is suspected but remains understudied in immunosuppressed conditions such as post‐hematopoietic stem cell transplantation (HSCT). This prospective observational study aimed to investigate the incidence, impact, and risk factors of EPI in a cohort of 83 pediatric and young adult patients who underwent allogeneic HSCT at Charité ‐ Universitätsmedizin Berlin between 2020 and 2023. Fecal pancreatic elastase (PE) measurements and transabdominal ultrasound were utilized to evaluate pancreatic function over a one‐year period. Secondary analysis explored the association of EPI with clinical complications and included a multivariable regression analysis of potential risk factors. Low PE levels significantly correlated with pathological pancreatic imaging findings, independent of concurrent diarrhea. EPI was suspected in 45% (32/71) of patients (95%CI: [34.1%, 56.6%]), with 29% (13/45) (95%CI: [17.7%, 43.4%]) showing signs of prolonged EPI (pEPI) lasting at least 8 weeks. After excluding cases with confounding factors such as missing enteral nutrition and diarrhea, the cumulative incidence of prolonged EPI was 20% (8/41) (95%CI: 10.2%–34.0%) in the overall cohort. EPI was associated with weight loss, prolonged dependence on parenteral nutrition, and extended hospitalizations. Adenovirus (ADV) infection emerged as a significant risk factor for EPI (hazard ratio 3.22 [95%CI:1.26–8.2], p = 0.014), along with additional factors such as higher BMI pre‐HSCT, pre‐existing pancreatic damage and early post‐HSCT fasting. The persistence of pancreatic atrophy and EPI beyond two years post‐HSCT in individual cases suggests a potential for permanent pancreatic damage. This study underscores that EPI is a common complication following HSCT, with ADV infection being an important risk factor. The findings support routine PE measurements and early initiation of pancreatic enzyme replacement therapy (PERT), alongside aggressive treatment of ADV infections. Further research is necessary to evaluate the effects of PERT in this population and to explore the applicability of these findings in other immunosuppressed groups.

Hematopoietic stem cell transplantation (HSCT) serves as a therapeutic intervention for various pediatric diseases. Acute and chronic graft-versus-host disease (GVHD) are decisive determinants for allogeneic HSCT success. The immunosuppressive agent, ciclosporin A, is most often used to prevent GVHD in pediatric patients, but is known to be nephrotoxic. Acute kidney injury afflicts 21-84% of pediatric HSCT cases, compromising clinical outcomes. This retrospective single-institution analysis scrutinized the practice of substituting nephrotoxic ciclosporin A with an everolimus/mycophenolate mofetil combination as GVHD prophylaxis in 57 patients with acute kidney injury (n=53) or central nervous system side effects due to calcineurin inhibitor treatment (n=4) following first allogeneic HSCT. This retrospective cohort study analyzes clinical courses in 57 children switched from calcineurin inhibitor-based GVHD prophylaxis (ciclosporin A or tacrolimus in single cases) to the everolimus/mycophenolate mofetil combination (n=48) or everolimus alone (n=9) after first allogeneic HSCT at the Charité University Medicine Berlin. Serving as control cohort were 74 patients undergoing first allogeneic HSCT during the same period, who did not receive everolimus at any date post-transplantation. Patients undergoing mismatched family donor transplantation without subsequent calcineurin inhibitor treatment for GVHD prophylaxis were excluded. Study endpoints encompassed the retention parameter course subsequent to GVHD prophylaxis switch, overall survival, incidence of underlying disease relapse and acute and chronic GVHD in both treatment groups. Renal function significantly improved after switching from ciclosporin A treatment to the everolimus/mycophenolate mofetil combination. Crucially, the transition to everolimus did not adversely affect overall survival following HSCT (HR 1.6; 95% CI: 0.74 - 3.5; p=0.23), especially for patients afflicted with non-malignant diseases (HR 1.4; 95% CI: 0.34 - 5.9; p=0.64). Incidences of grade 3-4 acute GVHD (HR: 1.82; 95% CI: 0.45 - 7.4; p=0.40) and severe chronic GVHD (HR 2.76, 95% CI: 0.69 - 11.0; p=0.15) in patients treated with the everolimus/mycophenolate mofetil combination were comparable to standard ciclosporin A treatment in patients in the control group. Overall survival in patients with malignant underlying diseases was lower in the everolimus cohort (HR: 2.7; 95% CI: 1.1 - 6.9, P=0.03), however, event-free survival was similar in patients with an underlying malignant disease, who were treated with either the everolimus/mycophenolate mofetil combination or ciclosporin A (HR 0.87, 95% CI: 0.39-1.9, p=0.73). Among patients who switched immunosuppression regimen from cyclosporin A to everolimus, with or without mycophenolate mofetil co-treatment after diagnosis of AKI, renal function significantly improved. Patient outcomes in the everolimus cohort were comparable to those in the control cohort. This study provides compelling real-world clinical evidence to replace ciclosporin A with the everolimus/mycophenolate mofetil combination in the management of acute kidney injury following HSCT in children.

Extravasation can present serious accidental complication of intravenous drug application. While monoclonal antibodies do not show the necrotic potential of cytotoxic chemotherapy drugs, considerable inflammatory toxicity can occur, necessitating standardized operating procedures for the management of their extravasation. Here, we report the clinical course and management of dinutuximab beta extravasation in a 3-year-old child. Dinutuximab beta is a chimeric monoclonal antibody targeting the GD2 disialoganglioside on the surface of neuroblastoma cells that has in recent years gained significant importance in the treatment of high-risk neuroblastoma, now contributing to both first- and second-line therapy protocols. The dinutuximab beta extravasation reported here occurred when the patient received the antibody cycle as a continuous infusion over a 10-day period after haploidentical stem cell transplantation for relapsed high-risk neuroblastoma. The extravasated dinutuximab beta caused local pain, swelling, and hyperemia accompanied by fever and an overall deterioration in the general condition. Laboratory diagnostics demonstrated an increase in C-reactive protein level and total white blood cell count. Clinical complication management consisted of intravenous fluid therapy, local dabbing with dimethyl sulfoxide (DMSO), analgesia with dipyrone, as well as application of intravenous antibiotics to prevent bacterial superinfection in the severely immunocompromised host. The patient considerably improved after six days with this treatment regimen and fully recovered by day 20.