Background:
- Although progress has been made in treating children with B-cell cancers such as leukemia
or lymphoma, many children do not respond to the standard treatments. One possible treatment
involves collecting white blood cells called T cells from the person with cancer and
modifying the cells to attack the B-cell cancer. The cells can then be given back to the
participant. This study will use T cells that have been modified to attack the cluster of
differentiation 19 (CD19) protein, which is found on the surface of some B-cell cancers.
Objectives:
- To see if anti-CD19 modified white blood cells are a safe and effective treatment for
children and young adults with advanced B-cell cancer.
Eligibility:
- Children and young adults between 1 and 30 years of age who have B-cell cancer (leukemia
or lymphoma) that has not responded to standard treatments.
- The leukemia or the lymphoma must have the CD19 protein.
- There must be adequate organ function.
Design:
- Participants will be screened with a physical exam and medical history. Blood and urine
samples will be collected. Imaging studies or bone marrow biopsies may be performed
depending on the type of cancer.
- Participants will undergo a process where white blood cells are collected, called
apheresis. These cells will be modified to contain the anti-CD19 gene.
- Participants will have 3 days of chemotherapy to prepare their immune system to accept
the modified cells.
- Participants will receive an infusion of their own modified white blood cells. They will
remain in the hospital until they have recovered from the treatment.
- Participants will have frequent follow-up visits to monitor the outcome of the
treatment.
- If the participant benefits from the treatment, then he/she may have the option for
another round of treatment.
Background:
Chimeric antigen receptors (CAR) that recognize the cluster of differentiation 19(CD19)
antigen have been constructed and are in clinical trials at several institutions. In this
trial, the Pediatric Oncology Branch (POB) will utilize a chimeric receptor containing the
signaling domains of cluster of differentiation 28 (CD28) and cluster of differentiation 3
(CD3)-zeta, currently under study in the Center for Cancer Research (CCR) in adults, for
children and young adults with CD19 expressing malignancies.
In co-cultures with CD19-expressing acute lymphoblastic leukemia cells,
anti-CD19-CAR-transduced T cells show robust killing, and in xenograft models, can rapidly
clear CD19- expressing ALL cell lines.
Objectives:
1. Primary: To determine the safety and feasibility of administering escalating doses of
anti-CD19-CAR engineered peripheral blood lymphocytes in two strata (prior allogeneic
stem cell transplant [SCT] vs. no prior SCT) of children and young adults with B cell
malignancies following a cyclophosphamide/fludarabine preparative regimen. COMPLETED
March 2014.
2. Primary: To determine the safety of administering cells in two groups of children and
young adults with B-cell malignancies expressing CD19:
- Arm 1 - Patients without high-burden disease or patients for whom chemotherapy
toxicity is a concern will receive standard preparative regimen.
- Arm 2 - Patients with high-burden disease who receive standard chemotherapy to
reduce burden, (defined as patients with ALL who have M3 bone marrow blasts and/or
presence of peripheral blood blasts on routine complete blood count (CBC), or
patients with lymphoma).
3. Primary: To determine the feasibility of administering anti-CD19 CAR transduced T cells
within 21 days of the target date in children and young adults with B-cell malignancies
expressing CD19 enrolled on arm 2: Patients with high-burden disease who receive
standard chemotherapy to reduce burden.
1) Secondary: 1) To determine if the administration of anti-CD19-CAR engineered peripheral
blood lymphocytes can mediate antitumor effects in children with B cell high-burden disease
after standard chemotherapy, or in patients without high-burden disease who receive standard
preparative regimen. 2) To evaluate the ability of CRS treatment algorithm to reduce the
incidence of Grade 4 Cytokine Release Syndrome (CRS) to less than or equal to 10% of
patients. 3) To measure persistence of adoptively-transferred anti-CD19-CAR-transduced T
cells in the blood, bone marrow and cerebrospinal fluid (CSF) of patients. 4) To describe the
toxicity of administration of anti-CD19-CAR engineered peripheral blood lymphocytes in
children and young adults with central nervous system (CNS) disease.
Eligibility:
Patients 1-30 years of age, at least 15 kg, with a CD19-expressing B-cell malignancy that has
recurred after or not responded to one or more standard chemotherapy-containing regimens for
their malignancy and is deemed incurable by standard therapy. Patients with a history of
allogeneic stem cell transplant who meet all eligibility criteria are eligible to
participate.
Design:
- PBMC will be obtained by leukapheresis. Anti-CD19 CAR T cells will be manufactured from
fresh or frozen peripheral blood mononuclear cells (PBMCs). On Day -7, PBMC will be
enriched for cluster of differentiation 3 (CD3)+ cells and cultured in the presence of
anti-CD3/-cluster of differentiation 28 (CD28) beads followed by retroviral vector
supernatant containing the anti-cluster of differentiation 19 (CD19) CAR. Total culture
time is approximately 7-14 days.
- Patients will be divided into the 2 groups listed above.
Arm 1: Patients will begin preparative regimen comprising fludarabine 25 mg/m(2) on Days -4,
-3 and -2 and cyclophosphamide 900 mg/m(2) on day -2.
Arm 2: Patients with high-disease burden will be treated with intensive standard of care
chemotherapy to decrease disease burden during cell manufacturing.
- All patients: The CD19-CAR cells will be infused on Day 0, with up to a 72h delay
allowed for fresh cells or a 21 day delay if cells are cryopreserved, if needed for
resolution of clinical toxicities or to generate adequate cell numbers.
- The previously determined maximum tolerated dose (MTD) of 1 X 10(6) will be administered
intravenously.
- Patients will be monitored for toxicity, response and T cell persistence.
- INCLUSION CRITERIA
- Patient must have a cluster of differentiation 19 (CD19)-expressing B cell ALL or
lymphoma and must have relapsed or refractory disease after at least one standard
chemotherapy and one salvage regimen. In view of the principal investigator (PI) and
the primary oncologist, there must be no available alternative curative therapies and
subjects must be either ineligible for allogeneic stem cell transplant (SCT), have
refused SCT, or have disease activity that prohibits SCT at this time.
- CD19 expression must be detected on greater than 15% of the malignant cells by
immunohistochemistry or greater than 30% by flow cytometry in a Clinical Laboratory
Improvement Amendments (CLIA) approved test in the Laboratory of Pathology, Center for
Cancer Research (CCR), National Cancer Institute (NCI), National Institutes of Health
(NIH), or from the referring institution or reference laboratory. The choice of
whether to use flow cytometry or immunohistochemistry will be determined by what is
the most easily available tissue sample in each patient. In general
immunohistochemistry will be used for lymph node biopsies, flow cytometry will be used
for peripheral blood and bone marrow samples.
- Patients must have measurable or evaluable disease at the time of enrollment, which
may include any evidence of disease including minimal residual disease detected by
flow cytometry, cytogenetics, or polymerase chain reaction (PCR) analysis.
- Greater than or equal to 1 year of age (and at least 15 kg) and less than or equal to
30 years of age.
- Adequate absolute CD3 count estimated to be required to obtain target cell dose based
on discussion with Department of Transfusion Medicine (DTM) apheresis and Cell
Processing Section, DTM.
- Subjects with the following central nervous system (CNS) status are eligible only in
the absence of neurologic symptoms suggestive of CNS leukemia, such as cranial nerve
palsy:
- CNS 1, defined as absence of blasts in cerebral spinal fluid (CSF) on cytospin
preparation, regardless of the number of WBCs;
- CNS 2, defined as presence of < 5/uL white blood cells (WBCs) in CSF and cytospin
positive for blasts, or > 5/uL WBCs but negative by Steinherz/Bleyer algorithm
- CNS3 with marrow disease who has failed salvage systemic and intensive IT
chemotherapy (and therefore not eligible for radiation)
- Patients with isolated CNS relapse will be eligible if they have previously been
treated with cranial radiation (at least centigray (cGy)).
- Ability to give informed consent. For subjects <18 years old their legal guardian must
give informed consent. Pediatric subjects will be included in age appropriate
discussion and verbal assent will be obtained for those greater than or equal to 12
years of age, when appropriate.
- Clinical performance status: Patients > 10 years of age: Karnofsky greater than or
equal to 50%; Patients less than or equal to 10 years of age: Lansky scale greater
than or equal to 50%. Subjects who are unable to walk because of paralysis, but who
are upright in a wheelchair will be considered ambulatory for the purpose of
calculating the performance score.
- Patients of child-bearing or child-fathering potential must be willing to practice
birth control from the time of enrollment on this study and for four months after
receiving the preparative regimen.
- Females of child-bearing potential must have a negative pregnancy test because of the
potentially dangerous effects on the fetus.
- Cardiac function: Left ventricular ejection fraction greater than or equal to 40% by
multi-gated acquisition scan (MUGA) or cardiac magnetic resonance imaging (MRI), or
fractional shortening greater than or equal to 28% by echocardiogram (ECHO) or left
ventricular ejection fraction greater than or equal to 50% by ECHO.
- Patients with history of allogeneic stem cell transplantation are eligible if at least
100 days post-transplant, if there is no evidence of active graft versus host disease
(GVHD) and no longer taking immunosuppressive agents for at least 30 days prior to
enrollment.
EXCLUSION CRITERIA
Subjects meeting any of the following criteria are not eligible for participation in the
study:
- Recurrent or refractory ALL limited to isolated testicular disease.
- Hepatic function: Inadequate liver function defined as total bilirubin > 2x upper
limit of normal (ULN) (except in the case of subjects with documented Gilbert's
disease > 3x ULN) or transaminase (alanine aminotransferase (ALT) and aspartate
aminotransferase (AST) > 20x ULN based on age and laboratory specific normal ranges;
- Renal function: Greater than age-adjusted normal serum creatinine (see below) and a
creatinine clearance < 60 mL/min/1.73 m^2.
- Age:
- <= 5 yrs (Maximum Serum Creatinine = 0.8 mg/dL)
- 5 < age <=10 yrs (Maximum Serum Creatinine =1.0 mg/dL)
- > 10 yrs (Maximum Serum Creatinine = 1.2 mg/dL)
- Hematologic function:
- Absolute neutrophil count (ANC) < 750/microliter, or platelet count <
50,000/microliter, if these cytopenias are not judged by the investigator to be
due to underlying disease (i.e. potentially reversible with anti-neoplastic
therapy);
- A subject will not be excluded because of pancytopenia greater than or equal to
Grade 3 if it is due to disease, based on the results of bone marrow studies.
- Hyperleukocytosis (greater than or equal to 50,000 blasts/microliter) or rapidly
progressive disease that in the estimation of the investigator and sponsor would
compromise ability to complete study therapy;
- Pregnant or breast-feeding females;
- Recent prior therapy:
- Systemic chemotherapy less than or equal to 2 weeks (6 weeks for nitrosoureas) or
radiation therapy less than or equal to 3 weeks prior to apheresis;
Exceptions:
- There is no time restriction in regard to prior intrathecal chemotherapy provided
there is complete recovery from any acute toxic effects of such;
- Subjects receiving hydroxyurea may be enrolled provided there has been no increase in
dose for at least 2 weeks prior to starting apheresis;
- Patients who relapse while receiving standard ALL maintenance chemotherapy will not be
required to have a waiting period before entry onto this study provided they meet all
other eligibility criteria;
- Subjects receiving steroid therapy at physiologic replacement doses only are allowed
provided there has been no increase in dose for at least 2 weeks prior to starting
apheresis;
- For radiation therapy: Radiation therapy must have been completed at least 3 weeks
prior to enrollment, with the exception that there is no time restriction if the
volume of bone marrow treated is less than 10% and also the subject has
measurable/evaluable disease outside the radiation port.
- Other anti-neoplastic investigational agents currently or within 30 days prior to
apheresis (i.e. start of protocol therapy);
- Subjects must have recovered from the acute side effects of their prior therapy,
such that eligibility criteria are met. Cytopenias deemed to be disease-related
and not therapy-related are exempt from this exclusion.
- Human immunodeficiency virus/hepatitis B virus/Hepatitis C virus
(HIV/HBV/HCV) Infection:
- Seropositive for HIV antibody. (Patients with HIV are at increased risk of lethal
infections when treated with marrow-suppressive therapy. Appropriate studies will be
undertaken in patients receiving combination antiretroviral therapy in the future
should study results indicate effectiveness.)
- Seropositive for hepatitis C or positive for Hepatitis B surface antigen (HbsAG).
- Monoclonal antibody therapy administered within 30 days of the agent prior to
apheresis;
- Uncontrolled, symptomatic, intercurrent illness including but not limited to
infection, congestive heart failure, unstable angina pectoris, cardiac
arrhythmia, psychiatric illness, or social situations that would limit compliance
with study requirements or in the opinion of the principal investigator (PI)
would pose an unacceptable risk to the subject;
- Second malignancy other than in situ carcinoma of the cervix, unless the tumor
was treated with curative intent at least two years previously and subject is in
remission;
- History of severe, immediate hypersensitivity reaction attributed to compounds of
similar chemical or biologic composition to any agents used in study or in the
manufacturing of the cells (i.e. gentamicin);
