Acute Lymphoblastic Leukemia, Acute Lymphocytic Leukemia, Acute Lymphoid Leukemia, B-All, B-Cell Leukemia, B-Cell Lymphoma, B-NHL, B-Non Hodgkin Lymphoma, B-precursor ALL, Leukemia, Lymphocytic, B Cell, Lymphoma, Non-Hodgkin
Conditions
Keywords
Philadelphia chromosome + ALL, Lymphoma, CD-22 Expressing Tumor, CD-19 expressing tumor, Adoptive Immunotherapy, B-All, B-precursor ALL, Acute Lymphoblastic Leukemia, Acute Lymphocytic Leukemia, B-Non Hodgkin Lymphoma
Brief summary
Background: Acute lymphoblastic leukemia (ALL) is the most common cancer in children. About 90% of children and young adults who are treated for ALL can now be cured. But if the disease comes back, the survival rate drops to less than 50%. Better treatments are needed for ALL relapses. Objective: To test chimeric antigen receptor (CAR) therapy. CARs are genetically modified cells created from each patient s own blood cells. his trial will use a new type of CAR T-cell that is targeting both CD19 and CD22 at the same time. CD19 and CD22 are proteins found on the surface of most types of ALL. Eligibility: People aged 3 to 39 with ALL or related B-cell lymphoma that has not been cured by standard therapy. Design: Participants will be screened. This will include: Physical exam Blood and urine tests Tests of their lung and heart function Imaging scans Bone marrow biopsy. A large needle will be inserted into the body to draw some tissues from the interior of a bone. Lumbar puncture. A needle will be inserted into the lower back to draw fluid from the area around the spinal cord. Participants will undergo apheresis. Their blood will circulate through a machine that separates blood into different parts. The portion containing T cells will be collected; the remaining cells and fluids will be returned to the body. The T cells will be changed in a laboratory to make them better at fighting cancer cells. Participants will receive chemotherapy starting 4 or 5 days before the CAR treatment. Participants will be admitted to the hospital. Their own modified T cells will be returned to their body. Participants will visit the clinic 2 times a week for 28 days after treatment. Follow-up will continue for 15 years....
Detailed description
Background: * Despite improvements in therapy, acute lymphoblastic leukemia (ALL) contributes to significant morbidity and mortality for children and young adults with cancer. CD19-CAR and CD22-CAR therapy have proven highly effective in inducing remission in patients with relapsed/refractory disease. * Immune escape has been observed by several groups following CD19-CAR and CD22- CAR therapy for B-ALL. Investigation of this phenomenon reveals a complex biology responsible for loss or downregulation of CD19 and/or CD22 expression observed in these cases. * The challenges encountered with currently available CD19- and CD22-directed CAR T cells in B-ALL demonstrates the need for combinatorial treatment strategies simultaneously targeting two antigens, such as CD19 and CD22, to enhance the long-term effectiveness of CARs. * We have previously treated patients with B-ALL on a phase 1/2 clinical trial using a bivalent CD19/22 CAR T-cell as a first combinatorial treatment strategy. This CAR T-cell construct is well-tolerated and has yielded responses however there has been limited CAR T cell expansion and persistence. Additionally, the previously tested CD19/CD22 bivalent CAR T-cell construct is limited in its ability to target CD22. * This new CD19/22 targeted construct being tested in this clinical trial has improved dual targeting capability based on preclinical data/evaluation. Objectives: * Phase I: Assess the safety of administering escalating doses of autologous CD19/CD22- CAR engineered T cells in children and young adults with B cell ALL or lymphoma following a cyclophosphamide/fludarabine conditioning regimen. * Phase II: Determine the efficacy of CD19/CD22 therapy in participants with B-ALL/ B-LBL.. Eligibility: -Participants between \>= 3 years and \<= 39 years of age, with CD19+ and/or CD22+ B cell ALL or lymphoma who have relapsed or have refractory disease after at least one standard chemotherapy regimen and one salvage regimen, with no alternative curative options. Design: * Phase I, 3 + 3 dose escalation design across 4 cohorts (B-ALL/B-cell lymphoblastic lymphoma: A: low-disease burden (\<25 % marrow blasts without extramedullary disease) vs. B: high-disease burden (\>= 25 % marrow blasts or with EMD). C: B-cell non-Hodgkin lymphoma D: CD19+ or CD22+ single antigen positivity using the following dose levels: -2: 1 x 10\^5 transduced T cells/kg (+/- 20%); -1: 3 x 10\^5 transduced T cells/kg (+/- 20%); 1: 1 x 10\^6 transduced T cells/kg (+/- 20%); and 2: 3x 10\^6 transduced T cells/kg (+/- 20%). Cohorts will enroll concurrently. * Participants will be treated based on disease burden and will receive 1 of 2 lymphodepleting preparative regimens: * Lymphodepleting preparative regimen # 1: Fludarabine (30 mg/m\^2/d x 3 on Days -4, -3, -2) and cyclophosphamide (900 mg/m\^2/d x 1 on Day -2) followed by infusion of CD19/CD22-CAR T-cells on D0. * Lymphodepleting preparative regimen #2: Fludarabine (30 mg/m2/d x 4 on Days -5, -4, -3, -2) and cyclophosphamide (600 mg/m2/d x 2 on Days -3, -2) followed by infusion of CD19/CD22-CAR T-cells on D0. * Determination for use of LD regimen #1 versus #2 will be based on pre-treatment absolute lymphocyte count, pre-existing cytopenias, receipt of prior CAR T-cell therapy, high disease burden and assessment of infection risk. * Participants will be evaluated sequentially for toxicity, antitumor effects, CAR expansion and persistence, and other biologic correlatives.
Interventions
BIOLOGICALCD19/CD22-CAR-transduced T cells
CD19/CD22-CAR-transduced T cells on D0 after lymphodepleting preparative regimen
DRUGcyclophosphamide
Cyclophosphamide will be diluted in an appropriate solution and infused over one hour. The dose will be based on the patient s body weight, at 900 mg/m2/dose after fludarabine infusion.
DRUGfludarabine
Fludarabine is administered as an IV infusion in an appropriate solution over 30 minutes. To prevent undue toxicity the dose will be based on BSA (25 mg/m2/dose).
Sponsors
National Cancer Institute (NCI)
Study design
Allocation
NON_RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
3 Years to 39 Years
Healthy volunteers
No
Inclusion criteria
* INCLUSION CRITERIA: * Diagnosis * Participant must: * Have pathology confirmed B cell ALL (not isolated to the testis or CNS), CML with ALL transformation, or high-grade lymphoma (e.g., Burkitt's lymphoma, B-lymphoblastic lymphoma, diffuse large B-cell lymphoma, inclusive of low-grade lymphoma that has transformed to high grade disease); and * Have relapsed or been refractory after at least one standard chemotherapy regimen and at least one salvage treatment. Participants with Philadelphia chromosome + ALL must have failed prior tyrosine kinase inhibitor; and * Be ineligible for allogeneic stem cell transplant (SCT), have refused SCT, or have recurred after SCT; and * Be unable to access (in a timely manner), ineligible for, or have relapsed/failed after or not responded to a commercially available CD19 CAR T-cell construct; and * Have evidence of at least minimal residual disease or PET-avid disease (lymphoma) at the time of enrollment. * CD22/CD19 expression * Cohorts A1b, B1b, C2b * CD19 must be detected on \>15% of the malignant cells by immunohistochemistry or \> 80% by flow cytometry. * CD22 positivity must be confirmed. * Cohorts D1b, 2 B-ALL * CD19 or CD22 positivity must be confirmed * Age \>= 3 years of age and \<=39 years of age at time of enrollment. * Clinical Performance status: Participants \>= 16 years of age: Karnofsky \>= 50%; Participants \< 16 years of age: Lansky scale \>= 50%. * Participants must have adequate organ and marrow function as defined below: * leukocytes \>= 750/mcL\* * platelets \>= 50,000/mcL\* * total bilirubin \<=2 X ULN (except in the case of participants with documented Gilbert's disease \> 3x ULN) * AST(SGOT)/ALT(SGPT) \<=10 X institutional upper limit of normal * creatinine \<= the maximum for age listed in the table below OR * measured creatinine clearance \>=60 mL/min/1.73 m\^2 for participants with creatinine levels above the max listed below per age. * Age (Years) \<= 5 / Maximum Serum Creatinine (mg/dL) \<= 0.8 * Age (Years) 6 to \<= 10 / Maximum Serum Creatinine (mg/dL) \<= 1.0 * Age (Years) \>10 / Maximum Serum Creatinine (mg/dL) \<= 1.2 * a participant will not be excluded because of pancytopenia \>= Grade 3 if it is due to underlying bone marrow involvement by leukemia * Central nervous system (CNS) Status * Participants with leukemia with CNS 1 and 2 disease are eligible in the absence of
Exclusion criteria
* Participants of child-bearing or child-fathering potential must be willing to practice effective birth control from the time of enrollment until 12 months following completion of study treatment for women and for 4 months following completion of study treatment for men. * Participants who are breastfeeding or plan to breastfeed must agree to discontinue/postpone breastfeeding while on study therapy and until 1 month after the administration of CAR. * Cardiac function: Left ventricular ejection fraction \>= 45% or fractional shortening \>=28% * Pulmonary Function * Baseline oxygen saturation \>92% on room air at rest * Ability of participant or Legally Authorized Representative (LAR) to understand and the willingness to sign a written informed consent document. * Ability and willingness of participant or Legally Authorized Representative (LAR) to co- enroll on 15-C-0028: Follow-up Evaluation for Gene-Therapy Related Delayed Adverse Events after Participation in Pediatric Oncology Branch Clinical Trials.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Safety | 30 days post CAR T infusion | Assess the safety of administering escalating doses of autologous CD19/CD22-CAR engineered T cells in children and young adult with B cell ALL or lymphoma following a cyclophosphamide/fludarabine LD. |
| Efficacy | Monthly until 3 months post CAR T infusion and then at 6 months and every 6 months after that, for 2 years post-infusion for each participant, up to 2 years after the entry date of the last participant. | Determine the efficacy of CD19/CD22 therapy in participants with B-ALL/B-LBL. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Assess response and toxicity (CRS grade) | Up to two years after last participant has entered | Assess overall response rate and CRS grades (toxicity) in participants who received subsequent infusion |
| Overall response rate | Monthly until 3 months post infusion and then at 6 months and every 6 months after that, for 2 years post-infusion for each participant, for up to two years from the entry date of the last participant | Phase I: Evaluate the ability of CD19/CD22-CAR T cells to mediate clinical activity in children and young adults with CD19+ and/or CD22+ B cell ALL or lymphoma. |
| Progression free survival (PFS) and Overall survival (OS) | Up to two years after the last participant has entered. | Evaluate PFS and OS in participants, in the phase II cohort (inclusive of those treated in the phase 1 arms at the RP2D) |
| Persistence and expansion | Up to two years after the last participant has entered. | Evaluate persistence and expansion of CD19/CD22-CAR T cells in children and young adults with CD19+ and/or CD22+ B-ALL or lymphoma |
| Adverse Events | 30 days post CAR T infusion | Phase II: Assess the safety of CD19/CD22 therapy in participants with B-ALL/B-LBL regardless of disease burden and antigen expression. |
| Feasibility | Up to two years after the last participant has entered. | Determine the feasibility of producing CD19/CD22-CAR T cells meeting the established release criteria. |
Countries
United States
Contacts
CONTACTNCI Ped LeukemiaLymph Cell Tx Tm
CONTACTSara K Silbert, M.D.
PRINCIPAL_INVESTIGATORSara K Silbert, M.D.
National Cancer Institute (NCI)
Outcome results
None listed