Description:
Background:
- Allogeneic hematopoietic stem cell transplantation (alloHSCT) is a procedure that
transplants bone marrow cells (stem cells) from a matching donor into a recipient in
order to allow the donor stem cells to produce cells that will attack the recipient s
cancer cells. AlloHSCT is performed when chemotherapy, immunotherapy, or radiation
therapy do not adequately control cancer growth. However, cancers that are not
controlled by alloHSCT frequently become resistant to other standard treatment options.
- The outcomes of alloHSCT might be improved if certain kinds of white blood cells (T
cells) could be manipulated so that they generate a more potent effect against the
cancer cells. This effect can be augmented by genetically engineering donor T cells to
specifically recognize cancerous cells in order to attack them. For this purpose,
researchers are studying a specific kind of genetically engineered T cell known as the
anti-CD19-CAR-transduced T cell. More research is needed to determine if this T cell
will be an effective treatment for certain kinds of B cell cancer (such as non-Hodgkin s
lymphoma and chronic lymphocytic leukemia) that has not been controlled with alloHSCT.
Objectives:
- To assess the safety and effectiveness of administering allogeneic anti-CD19-CAR-transduced
T cells to patients with B-cell cancer that has not responded to alloHSCT.
Eligibility:
- Individuals between 18 and 75 years of age who have received allogeneic hematopoietic
stem cell transplantation for a B cell cancer, but whose cancer has either not responded
to or recurred after the transplant.
- Recipients must have the same stem cell donor from their previous procedure.
Design:
- Before the start of the study, all participants will be screened with a medical history
and blood tests. Recipients will have tumor imaging scans, additional blood tests, and
other tests as directed by the study doctors.
- Donor participants will undergo apheresis to provide white blood cells for researchers
to use in the treatment.
- Recipients will have dose escalation to determine the most effective yet safe dose of
anti-CD19 T cells. There will be six dose levels of anti-CD19 T cells. The first
patients enrolled will have the smallest dose, and the dose will be increased when a
level has been determined to be safe. .
- Recipients will be hospitalized for at least 9 days after receiving the cell infusion,
and will need to come to clinic for follow-up visits 2, 4, 8, and 12 weeks after the
infusion.
- Additional scans and frequent blood tests will be required for the first 3 months after
the infusion, followed by less frequent visits over time.
- Recipients will be followed for a maximum of 15 years after receiving the infusion.
Title
- Brief Title: Administration of Anti-CD19-chimeric-antigen-receptor-transduced T Cells From the Original Transplant Donor to Patients With Recurrent or Persistent B-cell Malignancies After Allogeneic Stem Cell Transplantation
- Official Title: Administration of Anti-CD19-Chimeric-Antigen-Receptor-Transduced T Cells From the Original Transplant Donor to Patients With Recurrent or Persistent B-Cell Malignancies After Allogeneic Stem Cell Transplantation
Clinical Trial IDs
- ORG STUDY ID:
100054
- SECONDARY ID:
10-C-0054
- NCT ID:
NCT01087294
Conditions
- Leukemia, B-cell
- Lymphoma, Hodgkins
- Lymphoma, Non-hodgkins
- Lymphoma, B-Cell
Interventions
Drug | Synonyms | Arms |
---|
Anti-CD19-chimeric-antigen-receptor-transduced T cells | | 1A/T cell Arm (closed) |
Purpose
Background:
- Allogeneic hematopoietic stem cell transplantation (alloHSCT) is a procedure that
transplants bone marrow cells (stem cells) from a matching donor into a recipient in
order to allow the donor stem cells to produce cells that will attack the recipient s
cancer cells. AlloHSCT is performed when chemotherapy, immunotherapy, or radiation
therapy do not adequately control cancer growth. However, cancers that are not
controlled by alloHSCT frequently become resistant to other standard treatment options.
- The outcomes of alloHSCT might be improved if certain kinds of white blood cells (T
cells) could be manipulated so that they generate a more potent effect against the
cancer cells. This effect can be augmented by genetically engineering donor T cells to
specifically recognize cancerous cells in order to attack them. For this purpose,
researchers are studying a specific kind of genetically engineered T cell known as the
anti-CD19-CAR-transduced T cell. More research is needed to determine if this T cell
will be an effective treatment for certain kinds of B cell cancer (such as non-Hodgkin s
lymphoma and chronic lymphocytic leukemia) that has not been controlled with alloHSCT.
Objectives:
- To assess the safety and effectiveness of administering allogeneic anti-CD19-CAR-transduced
T cells to patients with B-cell cancer that has not responded to alloHSCT.
Eligibility:
- Individuals between 18 and 75 years of age who have received allogeneic hematopoietic
stem cell transplantation for a B cell cancer, but whose cancer has either not responded
to or recurred after the transplant.
- Recipients must have the same stem cell donor from their previous procedure.
Design:
- Before the start of the study, all participants will be screened with a medical history
and blood tests. Recipients will have tumor imaging scans, additional blood tests, and
other tests as directed by the study doctors.
- Donor participants will undergo apheresis to provide white blood cells for researchers
to use in the treatment.
- Recipients will have dose escalation to determine the most effective yet safe dose of
anti-CD19 T cells. There will be six dose levels of anti-CD19 T cells. The first
patients enrolled will have the smallest dose, and the dose will be increased when a
level has been determined to be safe. .
- Recipients will be hospitalized for at least 9 days after receiving the cell infusion,
and will need to come to clinic for follow-up visits 2, 4, 8, and 12 weeks after the
infusion.
- Additional scans and frequent blood tests will be required for the first 3 months after
the infusion, followed by less frequent visits over time.
- Recipients will be followed for a maximum of 15 years after receiving the infusion.
Detailed Description
Background:
Many patients with advanced B-cell malignancies that cannot be cured by chemotherapy and
monoclonal antibodies have prolonged relapse-free survival after allogeneic hematopoietic
stem cell transplantation (alloHSCT); however, a substantial fraction of patients with B-cell
malignancies relapse following alloHSCT.
The first therapeutic maneuver attempted when patients without graft-versus-host disease
(GVHD) relapse after alloHSCT is usually withdrawal of immunosuppressive drugs. If a
remission does not occur after withdrawal of immunosuppression, patients are often treated
with lymphocyte -DCI. Withdrawal of immunosuppression and DCI can lead to complete remissions
in patients with B-cell malignancies that relapse after alloHSCT. Unfortunately, a
substantial fraction of patients do not enter a complete remission after withdrawal of
immunosuppression followed by DCI, and these therapies are often complicated by GVHD.
The outcomes of alloHSCT might be improved if T cells could be manipulated so that they
generate a more potent graft-versus-malignancy (GVM) effect than unmanipulated T cells.
We hypothesize that the GVM effect against B-cell malignancies can be augmented by
genetically engineering donor T cells to express receptors that specifically recognize
antigens expressed by malignant B cells.
Chimeric antigen receptors (CARs) consist of an antigen recognition moiety combined with
T-cell signaling domains. CARs are capable of activating T cells in an antigen-specific
manner.
Expression of the CD19 antigen is limited to B cells and perhaps follicular dendritic cells.
Most malignant B cells express CD19.
We have constructed a retroviral vector encoding an anti-CD19 CAR. Large numbers of T cells
that have been transduced with this retroviral vector can be generated in vitro for clinical
adoptive T cell therapy. These anti-CD19-CAR-transduced T cells specifically recognize a
variety of CD19+ target cells and kill primary chronic lymphocytic leukemia (CLL) cells in
vitro.
Primary Objective:
To assess the safety of administering allogeneic anti-CD19-CAR-transduced T cells to patients
with B-cell malignancies that are persistent or relapsed after alloHSCT. The allogeneic
anti-CD19-CAR-transduced T cells will be derived from the original allogeneic transplant
donor.
Eligibility:
Patients with any CD19-expressing malignancy that is persistent or recurrent following
successful engraftment after HLA-identical or >=9/10 matched sibling, 1-antigen mismatched
sibling, or 9/10-matched unrelated donor (URD) alloHSCT and withdrawal of immunosuppression.
The same donor that provided cells for the alloHSCT must be willing and able to undergo
leukapheresis so that cells can be obtained to prepare the anti-CD19-CAR-transduced T cells.
The recipient must have at most grade I acute GVHD or chronic GVHD with no organ site with a
score exceeding 1, except for the skin, for which a score of 1 or 2 will be allowable. The
recipient must not have received systemic immunosuppressive drugs given for graft versus host
disease for at least 28 days at the time of study enrollment. Patients must be on a dose of
corticosteroids of an equivalent of 5 mg/day or less of prednisone. Corticosteroid creams,
ointments, and eye drops are allowed.
Design:
The alloHSCT donor will undergo leukapheresis.
Patients will undergo apheresis to obtain peripheral blood mononuclear cells. These cells
will be processed to produce anti-CD19 CAR stem memory T cells (anti-CD19 CAR Tscm). This
process involves sorting the cells and then culturing the cells in vitro for 9 days. During
the 9-day culture period, the cells will be transduced with gammaretroviruses encoding the
FMC63-28Z.
CAR recipients will be monitored for development of acute treatment-related toxicities for at
least 9 days after cell infusion as inpatients. Dose-limiting toxicities (DLTs) will include
severe acute GVHD and Grade 4 toxicities not associated with GVHD.
A maximum of 126 evaluable patients (donors plus recipients) will be treated.
Assessment of safety is a primary objective of this clinical trial. Safety will be defined as
a lack of severe acute post-infusional toxicities and an incidence of GVHD that is not higher
than historical rates of GVHD occurring after standard DCI.
Anti-CD19-CAR-transduced T-cell persistence in the peripheral blood will be measured at
multiple time points from 1 week to 1 year after anti-CD19-CAR-transduced T cell infusion by
flow cytometry.
To assess for an anti-malignancy effect of the infused cells, patients will be staged using
standard staging systems.
Trial Arms
Name | Type | Description | Interventions |
---|
1A/T cell Arm (closed) | Experimental | Dose escalation of CAR+ T cells based on the patients actual body-weight | - Anti-CD19-chimeric-antigen-receptor-transduced T cells
|
1B/T memory stem cell arm | Experimental | Dose Escalation with 5 dose levels of CAR+ T memory cells based on the patients actual body-weight | - Anti-CD19-chimeric-antigen-receptor-transduced T cells
|
2/Donor arm | Other | Leukapheresis | |
Eligibility Criteria
- INCLUSION CRITERIA:
Inclusion Criteria: Recipient
1. Recipients (patients with B-cell malignancy) must have received an HLA-identical or
9/10 matched sibling allogeneic hematopoietic stem cell transplant, a 1-antigen
mismatched related transplant, or a greater than or equal to 9/10-matched unrelated
donor (URD) alloHSCT for any CD19+ B-cell malignancy. Patients with any CD19+ B-cell
malignancy that is persistent or relapsed after all of the following interventions are
eligible:
1. Donor T cell engraftment after alloHSCT (>50% donor chimerism of the T cell
compartment and a peripheral blood T cell number from the NIH, CC clinical lab of
at least 50 CD3+ cells/uL).
2. A trial of withdrawal of immunosuppressive therapy.
Exception: Prior (DCI) DLI is not an eligibility requirement for patients with ALL,
Burkitt lyphoma, ALL like high-grade lymphomas, or diffuse large B-cell lymphoma.
At least 28 days weeks must have elapsed since the latest trial of withdraw of
immunosuppression or DLI until the patient can be deemed to have persistent disease.
2. CD19 expression must be detected on the majority of the malignant cells by
immunohistochemistry or by flow cytometry in the Laboratory of Pathology, CCR, NCI,
NIH. Definition of which cells are malignant must be determined for each patient by
the Laboratory of Pathology using techniques to demonstrate monoclonality such as
kappa/lambda restriction (other techniques can be used to determine monoclonality at
the discretion of the Laboratory of Pathology). The choice of whether to use flow
cytometry or immuohistochemistry will be determined by what is the most easily
available tissue sample in each patient. Immunohistochemistry will be used for lymph
node biopsies and bone marrow biopsies. Flow cytometry will be used for peripheral
blood, fine needle aspirate, and bone marrow aspirate samples.
3. Patients must be 18-75 years of age.
4. Performance status: ECOG less than or equal to 2
5. Either no evidence of GVHD or minimal clinical evidence of acute GVHD and chronic GVHD
while off of systemic immunosuppressive therapy for at least 28 days. Minimal clinical
evidence of acute GVHD is defined as grade 0 to I acute GVHD. Minimal evidence of
chronic GVHD is defined as chronic GVHD with no organ site with a score exceeding 1,
except for the skin, for which a score of 1 or 2 will be allowable (as defined by the
2005 NIH consensus project) or no chronic GVHD. Subjects with disease that is
controlled to stage I acute GVHD or chronic GVHD meeting the above criteria with local
therapy only, e.g., topical cutaneous steroids, will be eligible for enrollment.
6. Ability to give informed consent.
7. Prior Therapy: Therapy with monoclonal antibodies and/or chemotherapy must be stopped
at least 7 days prior to anti-CD19 CAR-transduced T cell infusion, and recovery of
treatment-associated toxicity to less than or equal to grade 2 is required prior to
infusion of cells. For patients that have received prior DLI, the last dose must be at
least 28 days prior to anti-CD19 CAR-transduced T cell administration. Note that
patients can be enrolled on this study at any time after or during therapy, but at
least 14 days must elapse from the time of prior monoclonal antibody administration or
chemotherapy until anti-CD19 CAR-transduced T cells are infused, and at least 28 days
must elapse from the time of withdraw of immunosuppression, or DLI, or other
immunomodulatory therapies such as lenalidomide until anti-CD19 CAR-transduced T cells
are infused. Systemic immunosuppression given for graft versus host disease must be
stopped at least 28 days prior to protocol entry. There is no time restriction in
regard to prior intrathecal chemotherapy provided there is complete recovery from any
acute toxic effects of such.
8. Recipients of unrelated donor transplants from a National Marrow Donor Program (NMDP)
Center must sign a release of information form to authorize NMDP transfer of
information to the NIH.
9. Previous allogeneic donor must be willing and available to donate again.
10. Patients of childbearing or child-fathering potential must be willing use an effective
method of contraception while being treated on this study and for 4 months after the
last cell infusion.
11. Normal left ventricular function as evaluated by echocardiograph within 4 weeks of
anti- CD19-CAR-transduced T cell infusion
Inclusion Criteria: Donor
1. Donors greater than or equal to 18 years of age must be the same individual whose
cells were used as the source for the patient s original stem cell transplant.
2. Adequate venous access for peripheral leukapheresis, or consent to use a temporary
central venous catheter for leukapheresis.
3. Donors must be HIV negative, hepatitis B surface antigen negative, and hepatitis C
antibody negative.
4. Ability to give informed consent.
5. Donor selection will be in accordance with NIH/CC Department of Transfusion Medicine
(DTM) criteria and, in the case of an unrelated donor from a Transplant Center, the
National Marrow Donor Program (NMDP) standards. When a potentially eligible recipient
of an unrelated donor product from an NMDP Center is identified, the recipient will
complete an NMDP search transfer request to allow NIH NMDP staff to contact the NMDP
Coordinating Center, who will, in turn, contact the donor s prior Donor Center. The
NMDP Policy for Subsequent Donation Requests will be followed and the appropriate
forms (Subsequent Donation Request form) and Therapeutic T Cell Collection
Prescription will be submitted as required.
EXCLUSION CRITERIA:
Exclusion Criteria: Recipients
1. Active infection that is not responding to antimicrobial therapy.
2. Sero positive for HIV antibody. (The experimental treatment being evaluated in this
protocol depends on an intact immune system. Patients who are HIV seropositive can
have decreased immune -competence and thus are less responsive to the experimental
treatment and more susceptible to its toxicities.)
3. Sero positive for hepatitis B antigen, positive hepatitis B tests can be further
evaluated by confirmatory tests (HBV DNA), and if confirmatory tests are negative, the
patient can be enrolled.
4. Sero positive for hepatitis C antibody unless antigen negative. If hepatitis C
antibody test is positive, then patients must be tested for the presence of RNA by
RT-PCR and be HCV RNA negative.
5. Active psychiatric disorder which may compromise compliance with the treatment
protocol, or which does not allow for appropriate informed consent (as determined by
Principal Investigator and/or his designee).
6. Pregnant or lactating. The effects of the immunosuppressive medications that could be
required to treat GHVD are likely to be harmful to a fetus. The effects upon breast
milk are also unknown and may be harmful to an infant.
7. Serum total bilirubin > 2.5 mg/dl, serum ALT and AST values greater than or equal to
2.5 times the upper limit of normal based on age-specific normal values. If the
abnormal liver function is attributable to liver involvement by malignancy, patients
may be eligible with serum total bilirubin up to 5.0 mg/dl, and serum ALT and AST
values up to 5.0 times the upper limit of normal, provided the patient has no evidence
of impending hepatic failure (encephalopathy or prothrombin time >2 times the upper
limit of normal).
8. Serum creatinine greater than 1.6 mg/dL
9. Absolute neutrophil count of less than 1000 cells/microL unless low neutrophil count
is thought to be due to malignancy in the bone marrow and malignancy is documented in
the bone marrow.
10. Active cerebrospinal fluid involvement with malignancy or brain metastasis.
11. Platelet count less than 30,000/microL unless low platelet count is thought to be due
to malignancy in the bone marrow and malignancy is documented in the bone marrow.
12. Hemoglobin less than 8.0 g/dL.
13. Receiving systemic corticosteroids including prednisone, dexamethasone or any other
corticosteroid at doses of higher than 5 mg/day of prednisone within 28 days prior to
anti-CD19-CAR-transduced T cell administration. Corticosteroid creams, ointments, and
eye drops are allowed.
14. Blood blast percentage higher than 5%.
Exclusion Criteria: Donors
1. History of psychiatric disorder which may compromise compliance with this protocol or
which does not allow for appropriate informed consent.
2. History of hypertension that is not controlled by medication, stroke, or severe heart
disease (donors with symptomatic angina will be excluded). Donors with a history of
coronary artery bypass grafting or angioplasty who are symptom free will receive a
cardiology evaluation and be considered on a case-by-case basis.
3. Donors must not be pregnant.
4. Anemia (Hb < 11 gm/dl) or thrombocytopenia (platelets < 100,000 per microL). However,
potential donors with Hb levels < 11 gm/dl that is due to iron deficiency will be
eligible as long as the donor is initiated on iron replacement therapy. The NIH
Clinical Center, Department of Transfusion Medicine/NMDP physicians will determine the
appropriateness of individuals as donors.
Maximum Eligible Age: | 75 Years |
Minimum Eligible Age: | 18 Years |
Eligible Gender: | All |
Healthy Volunteers: | Accepts Healthy Volunteers |
Primary Outcome Measures
Measure: | To assess the safety of allogeneic anti-CD19 CAR |
Time Frame: | 4-5 weeks after first dose |
Safety Issue: | |
Description: | List of adverse event frequency |
Secondary Outcome Measures
Measure: | To measure the persistence of anti-CD19-CAR- transduced T cells in the blood of patients after infusion |
Time Frame: | Until the patient goes off-study for malignancy response assessment. |
Safety Issue: | |
Description: | Amount of anti-CD19-CAR- transduced T cells in the blood of patients after infusion. |
Measure: | To determine if administering anti-CD19-CAR-transduced T cells from the original transplant donor can cause regression of B-cell malignancies that are relapsed or persistent after alloHSCT |
Time Frame: | at progression |
Safety Issue: | |
Description: | Median amount of time subject survives without disease progression after treatment |
Details
Phase: | Phase 1 |
Primary Purpose: | Interventional |
Overall Status: | Recruiting |
Lead Sponsor: | National Cancer Institute (NCI) |
Trial Keywords
- CD19
- Chimeric-Antigen-Receptor
- Gene Therapy
- Adoptive T Cell Therapy
- Allogeneic Stem Cell Transplantation
Last Updated
August 26, 2021