Description:
This phase I/2 trial studies the side effects and best dose of activated natural killer cells
in treating patients with relapsed or refractory acute myeloid leukemia and myeloid
dysplastic syndromes. Giving chemotherapy before a donor natural killer cell infusion helps
stop the growth of cancer cells. It may also stop the patient's immune system from rejecting
the donor's natural killer cells. Modified natural killer cells may help the body build an
immune response to kill cancer cells. Aldesleukin (interleukin-2) may stimulate the white
blood cells (including natural killer cells) to kill leukemia cells.
In the phase II and pediatric portion of the study, the investigators intend to use maximal
tolerated or tested (MT/TD) CIML NK cell dose as determined from the phase I part of this
study. The phase II portion of the study also replaces IL-2 with ALT-803. The rationale for
this change is to support the donor derived NK cells in vivo after adoptive transfer.
PLEASE NOTE: THE PEDIATRIC PORTION OF THE STUDY IS CLOSED TO FURTHER ENROLLMENT.
Title
- Brief Title: Cytokine-induced Memory-like NK Cells in Patients With Acute Myeloid Leukemia (AML) or Myelodysplastic Syndrome (MDS)
- Official Title: A Phase 1/2 Study of Cytokine-Induced Memory-Like NK Cells in Patients With AML or MDS
Clinical Trial IDs
- ORG STUDY ID:
201401085
- SECONDARY ID:
5F32CA200253-02
- NCT ID:
NCT01898793
Conditions
Interventions
Drug | Synonyms | Arms |
---|
Fludarabine | 2-F-ara-AMP, 75607-67-9, 9H-purin-6-amine, 2-fluoro-9-(5-O-phosphono-.beta.-D-arabinofuranosyl), Beneflur, Fludara, fludarabine-5'-monophosphate | Lead-in Cohort & Phase II (ALT-803): Maximum NK cell/number kg |
Cyclophosphamide | Cytoxan®, CPM | Lead-in Cohort & Phase II (ALT-803): Maximum NK cell/number kg |
Cytokine-induced killer cells | CIK cells | Lead-in Cohort & Phase II (ALT-803): Maximum NK cell/number kg |
IL-2 | Proleukin, recombinant human interleukin-2, recombinant interleukin-2, Ro-236019, T-cell growth factor, TCGF, TCGF,, interleukin, Aldesleukin | Pediatric Cohort: Maximum NK cell/number kg |
ALT-803 | | Lead-in Cohort & Phase II (ALT-803): Maximum NK cell/number kg |
Purpose
This phase I/2 trial studies the side effects and best dose of activated natural killer cells
in treating patients with relapsed or refractory acute myeloid leukemia and myeloid
dysplastic syndromes. Giving chemotherapy before a donor natural killer cell infusion helps
stop the growth of cancer cells. It may also stop the patient's immune system from rejecting
the donor's natural killer cells. Modified natural killer cells may help the body build an
immune response to kill cancer cells. Aldesleukin (interleukin-2) may stimulate the white
blood cells (including natural killer cells) to kill leukemia cells.
In the phase II and pediatric portion of the study, the investigators intend to use maximal
tolerated or tested (MT/TD) CIML NK cell dose as determined from the phase I part of this
study. The phase II portion of the study also replaces IL-2 with ALT-803. The rationale for
this change is to support the donor derived NK cells in vivo after adoptive transfer.
PLEASE NOTE: THE PEDIATRIC PORTION OF THE STUDY IS CLOSED TO FURTHER ENROLLMENT.
Detailed Description
Amendment 16: Based on the data indicating that ALT-803/IL-15 result in more modulation of
the NK cells in vivo, the investigators performed a lead in cohort with ALT-803 replacing
IL-2 at a dose of 10 mcg/kg SQ administered q5 days starting on the date of NK cell infusion.
The first two patients treated in the ALT-803 lead in cohort experienced a set of symptoms
consistent with cytokine release syndrome (CRS) including fevers, elevated markers of
inflammation between days 10-14 after ML NK cell infusion.
Based on the evidence of increased CD8 T cell activation, the in vitro data indicating that
ALT-803 promoted recipient CD8 T cell expansion and killing of donor ML NK cells, and the
lack of clinical responses using ALT-803, the lead in cohort was closed, and a decision was
made to return to rhIL-2 support, mimicking the cytokine support utilized in the phase 2
portion of the trial.
PLEASE NOTE: THE PEDIATRIC PORTION OF THE STUDY IS CLOSED TO FURTHER ENROLLMENT.
Trial Arms
Name | Type | Description | Interventions |
---|
Phase I: 0.5 x 10^6/kg CIML NK cells (Dose Levels 1-3) | Experimental | Lymphodepleting Preparative Regimen: Patients receive fludarabine phosphate IV over 1 hour on days -6 to -2 and cyclophosphamide IV over 2 hours on days -5 and -4.
Donor Leukapheresis: Peripheral blood cells are collected from haploidentical related donors over 5 hours on day -1.
CIML NK Cells: Patients undergo CIML NK cell infusion over 15-60 minutes on day 0.
Interleukin-2: Patients receive aldesleukin SC every other day for 2 weeks starting on day 1 (total of 7 doses) | - Fludarabine
- Cyclophosphamide
- Cytokine-induced killer cells
- IL-2
|
Lead-in Cohort & Phase II (ALT-803): Maximum NK cell/number kg | Experimental | Lymphodepleting Preparative Regimen: Patients receive fludarabine phosphate IV over 1 hour on days -6 to -2 and cyclophosphamide IV over 2 hours on days -5 and -4.
Donor Leukapheresis: Peripheral blood cells are collected from haploidentical related donors on Day -1.
CIML NK Cells: Patients undergo CIML NK cell infusion on Day 0.
Subcutaneous ALT-803 will begin approximately 4 hours after the infusion and will continue for a total of 2 doses (Days 0 and 5). | - Fludarabine
- Cyclophosphamide
- Cytokine-induced killer cells
- ALT-803
|
Pediatric Cohort: Maximum NK cell/number kg | Experimental | Lymphodepleting Preparative Regimen: Patients receive fludarabine phosphate IV over 1 hour on days -6 to -2 and cyclophosphamide IV over 2 hours on days -5 and -4.
Donor Leukapheresis: Peripheral blood cells are collected from haploidentical related donors on Day -1
CIML NK Cells: Patients undergo CIML NK cell infusion on Day 0
Subcutaneous IL-2 will begin approximately 2-4 hours after infusion and will continue every other day through Day 12 for a total of 7 doses | - Fludarabine
- Cyclophosphamide
- Cytokine-induced killer cells
- IL-2
|
Phase II (IL-2): Maximum NK cell/number kg | Experimental | The recipient will begin a lymphodepleting preparative regimen of fludarabine and cyclophosphamide on Day -6. The haploidentical donor identified by HLA matching of the immediate family members will undergo non-mobilized large volume (20-L) leukapheresis on Day -1, and the NK cell product will be infused into the recipient on Day 0. Subcutaneous IL-2 will begin approximately 2-4 hours after infusion and will continue every other day through Day 12 for a total of 7 doses. | - Fludarabine
- Cyclophosphamide
- Cytokine-induced killer cells
- IL-2
|
Eligibility Criteria
Inclusion Criteria:
- Diagnosis requirement for phase I patients:
- Refractory AML without complete remission (CR) after induction therapy (primary
induction failure) or relapsed AML after obtaining a CR.
- OR High-risk AML (by ELN criteria; See Appendix C) in complete remission (CR) and
has either refused hematopoietic stem cell transplantation OR is currently not
eligible for hematopoietic stem cell transplantation OR for whom hematopoietic
stem cell transplantation is being reserved for later relapse. This is inclusive
of patients with minimal residual disease evidenced by cytogenetics, molecular
testing, and/or flow cytometry.
- OR Myelodysplastic syndrome (MDS) with excess blasts (>5%) and progressive
disease at any time after initiation of DNA hypomethylator treatment during the
past 2 years, OR failure to achieve complete or partial response or hematological
improvement (see section 12.4) after at least six cycles of azacytidine or four
cycles of decitabine administered during the past 2 years, OR intolerance to
azacytidine or decitabine. MDS patients with isolated 5q- abnormalities that meet
these criteria after lenalidomide therapy and DNA hypomethylator therapy are also
eligible.
- Diagnosis requirement for phase II patients:
*Refractory AML without CR after induction therapy (primary induction failure) or
relapsed AML after obtaining a CR. Favorable-risk core binding factor (CBF) mutated
AML and acute promyelocytic leukemia (APL) will be excluded.
- Diagnosis requirement for pediatric cohort patients:
*Refractory AML without complete remission (CR) after induction therapy (primary
induction failure) or relapsed AML after obtaining a CR.
- Age requirement for phase I and phase II patients: At least 18 years of age.
- Age requirement for pediatric cohort: 2-17 years of age.
- Available HLA-haploidentical donor that meets the following criteria:
- Related donor (parent, sibling, offspring, or offspring of sibling)
- At least 18 years of age
- HLA-haploidentical donor/recipient match by at least Class I serologic typing at
the A&B locus.
- In general good health, and medically able to tolerate leukapheresis required for
harvesting the NK cells for this study.
- Negative for hepatitis, HTLV, and HIV on donor viral screen
- Not pregnant
- Voluntary written consent to participate in this study
- Patients with known CNS involvement with AML are eligible provided that they have been
treated and CSF is clear for at least 2 weeks prior to enrollment into the study. CNS
therapy (chemotherapy or radiation) should continue as medically indicated during the
study treatment.
- Karnofsky/Lansky performance status ≥ 50 %
- Adequate organ function as defined below:
- Total bilirubin ≤ 2 mg/dL
- AST(SGOT)/ALT(SGPT) ≤ 3.0 x IULN
- Creatinine within normal institutional limits OR creatinine clearance ≥ 50
mL/min/1.73 m2 by Cockcroft-Gault Formula (adults) or Schwartz formula (pediatric
cohort)
- Oxygen saturation ≥90% on room air
- Ejection fraction ≥35%
- Able to be off corticosteroids and any other immune suppressive medications beginning
on Day -3 and continuing until 30 days after the infusion of the CIML NK cells.
However, use of low-level corticosteroids is permitted if deemed medically necessary.
Low-level corticosteroid use is defined as 10mg or less of prednisone (or equivalent
for other steroids) per day.
- Women of childbearing potential must have a negative pregnancy test within 28 days
prior to study registration. Female and male patients (along with their female
partners) must agree to use two forms of acceptable contraception, including one
barrier method, during participation in the study and throughout the DLT evaluation
period.
- Ability to understand and willingness to sign an IRB approved written informed consent
document (or that of legally authorized representative, if applicable).
Exclusion Criteria:
- Relapsed after allogeneic transplantation.
- Isolated extramedullary relapse (phase II only).
- More than one course of salvage chemotherapy for primary induction failure or AML
relapsing after CR1 (phase II only).
- Circulating blast count ≥30,000/µL by morphology or flow cytometry (cytoreductive
therapies including leukapheresis or hydroxyurea are allowed).
- Uncontrolled bacterial or viral infections, or known HIV, Hepatitis B or C infection.
- Uncontrolled angina, severe uncontrolled ventricular arrhythmias, or EKG suggestive of
acute ischemia or active conduction system abnormalities.
- New progressive pulmonary infiltrates on screening chest x-ray or chest CT scan that
have not been evaluated with bronchoscopy. Infiltrates attributed to infection must be
stable/ improving after 1 week of appropriate therapy (4 weeks for presumed or proven
fungal infections).
- Known hypersensitivity to one or more of the study agents.
- Received any investigational drugs within the 14 days prior to the first dose of
fludarabine.
- Pregnant and/or breastfeeding.
Maximum Eligible Age: | N/A |
Minimum Eligible Age: | 2 Years |
Eligible Gender: | All |
Healthy Volunteers: | No |
Primary Outcome Measures
Measure: | Maximal tolerated or tested dose (MT/TD) of CIML-NK cells (Phase I) |
Time Frame: | 35 days |
Safety Issue: | |
Description: | Defined as the dose level immediately below the dose level at which 2 patients of a cohort (of 2 to 6 patients) experience dose-limiting toxicity (DLT) or the maximum dose if less than or equal to 1 patient suffers a DLT at the maximum dose. Summary statistics including proportions and their 95% confidence interval will be calculated. |
Secondary Outcome Measures
Measure: | Response assessed according to IWG criteria (Phase 1, Phase II, and Pediatric) |
Time Frame: | 35 days |
Safety Issue: | |
Description: | Reported with 95% confidence intervals. |
Measure: | Duration of remission (DOR) (Phase I, Phase II, and Pediatric) |
Time Frame: | Up to 3 years |
Safety Issue: | |
Description: | DOR is defined only for patients who achieve a CR or PR, and is measured from the first date of attaining CR or PR until the date of disease progression or death. |
Measure: | Time to progression (Phase I, Phase II, and Pediatric) |
Time Frame: | Up to 3 years |
Safety Issue: | |
Description: | TTP is defined as the time from date of first dose of fludarabine until evidence of disease progression. |
Measure: | Disease free survival (DFS) (Phase I, Phase II, and Pediatric) |
Time Frame: | Up to 3 years |
Safety Issue: | |
Description: | DFS is defined as the time from the day CR or CRi is documented until disease progression or death. |
Measure: | Overall survival (OS) (Phase I, Phase II, and Pediatric) |
Time Frame: | Up to 3 years |
Safety Issue: | |
Description: | OS is defined from the date of first dose of fludarabine on this study until death. |
Measure: | Toxicity as measured by the frequency and incidence of serious adverse events (Phase I and Phase II) |
Time Frame: | Through Day 100 |
Safety Issue: | |
Description: | Graded using the National Cancer (NCI) Common Terminology Criteria for Adverse Events (CTCAE) version 4.0
AEs will be collected from Day 0 to Day +35; however, bone marrow suppression (ANC < 500/uL/µL) and AEs of GVHD involving the liver, skin, or GI tract will be recorded to Day 100. |
Details
Phase: | Phase 1/Phase 2 |
Primary Purpose: | Interventional |
Overall Status: | Recruiting |
Lead Sponsor: | Washington University School of Medicine |
Last Updated
May 21, 2021