(H-49235) Trivalent Autologous T-Lymphocytes Co-Expressing Three Chimeric Antigen Receptors Targeting CD19, CD20 AND CD22 in Acute B-lineage Leukemia (TRICAR-ALL)
This is a gene transfer study for patients with a type of blood cancer called Acute Lymphoblastic Leukemia (ALL) that has come back or has not gone away after treatment. The body has different ways of fighting infection and disease. No single way seems perfect for fighting cancers. This research study combines two different ways of fighting cancer: antibodies and T cells. Antibodies are types of proteins that protect the body from infectious diseases and possibly cancer. T cells, also called T lymphocytes, are special infection-fighting blood cells that can kill other cells, including cells infected with viruses and tumor cells. Both antibodies and T cells have been used to treat patients with cancers. They have shown promise but have not been strong enough to cure most patients. For example, T lymphocytes can kill cancer cells but there normally are not enough of them to kill all the cancer cells. Some researchers have taken T cells from a person's blood, grown more of them in the laboratory and then given them back to the person. The antibody used in this study targets CD19, CD20 and CD22. This antibody sticks to ALL cells because of a substance on the outside of these cells called CD19, CD20 and/or CD22. For this study, the antibody to CD19, CD20 and CD22 has been changed so that instead of floating free in the blood, it is now joined to the T cells. When T-cells contain an antibody that is joined to them, they are called chimeric antigen receptor- T cells or CAR-T cells. In the laboratory, we have also found that T cells work better if we also add proteins that stimulate them. One such protein is called 4-1BB. Adding the 4-1BB molecule makes the cells grow better and last longer in the body, giving them a better chance of killing the leukemia cells. In this study we are going to attach the CD19/CD20/CD22 chimeric receptor that has 4-1BB added to the patient's T cells. We will then test how long the cells last. These T cells, called TRICAR-ALL T cells are investigational products not approved by the Food and Drug Administration (FDA) outside the context of a clinical trial.
• Diagnosis of refractory or recurrent B cell Acute Lymphoblastic Leukemia (B-ALL) with expression of CD19, CD20 and/or CD22
• Age between 1 and 25 years.
• Life expectancy of ≥ 8 weeks
• Weight ≥ 10 kg
• Subjects ≥ 18 years of age must have the ability to give informed consent according to applicable regulatory and local institutional requirements. Legal guardian's consent must be obtained for subjects \< 18 years of age. Assent will be obtained from pediatric subjects and according to applicable regulatory and local institutional requirements. Adults with cognitive impairment who are unable to consent and those with Down's syndrome are also eligible for this protocol with consent/assent according to applicable regulatory and local institutional requirements.
• The subject must discontinue all anti-cancer agents and, in the opinion of the investigator, has recovered from significant acute toxic effects of: a) Chemotherapy and biologic agents: All chemotherapy and biologic therapy not specifically mentioned below must be discontinued ≥ 7 days prior to collection, with the exception of intrathecal chemotherapy and maintenance chemotherapy being discontinued ≥ 72 hours prior to collection (for the subset of subjects who relapse during maintenance); b) Steroid use: All systemic corticosteroid therapy (unless physiologic replacement dosing of ≤ 12mg/m2/day hydrocortisone or equivalent) must be discontinued ≥ 3 days prior to collection; c) Tyrosine Kinase Inhibitor (TKI) use: All TKIs must be discontinued ≥ 3 days prior to collection; d) Hydroxyurea: must be discontinued ≥ 1 day prior to collection; e) Prior CAR-T cell therapy: must be at least 30 days from most recent CAR-T cell infusion prior to collection; f) Immunotherapy directed at leukemia: No antibodies within three (3) half-lives prior to collection (or within 4 weeks) whichever is shorter. This includes Antithymocyte globulin (ATG) formulations; g) Anti T-cell Antibodies, Alemtuzumab: must be discontinued ≥ 8 weeks prior to collection
• Diagnosis of refractory or recurrent B cell Acute Lymphoblastic Leukemia (B-ALL) with expression of CD19, CD20 and/or CD22 and meeting any of the following conditions:
• B-ALL with no prior history of allo-HCT with one of the following:
‣ Second or subsequent marrow relapse
⁃ First marrow relapse if, at the end of re-induction, bone marrow showing ≥ 0.01% blasts by morphology \&/or flow cytometry
⁃ Primary refractory disease defined by having ≥ 5% blasts in the marrow by morphology and/or minimal residual (MRD) testing after 2 or more separate induction regimens (which may include CD19-targeting therapies)
⁃ Subject has an indication for allo-HCT but deemed ineligible (including subjects who have persistent MRD prior to allo-HCT)
⁃ CD19(+) or CD19(-) relapse or refractory ALL after infusion of CD19- CAR-T cells or other CD19-targeting immunotherapies. CD20 or CD22 expression is required for CD19(-) B-ALL.
∙ Or
• B-ALL recurrent after allo-HCT defined as having ≥ 0.01% marrow disease
• Available transduced T-cells with ≥ 15% expression of CD19, CD20 or CD22 CAR by flow cytometry.
• Prohibited medications - washout periods (prior to CAR-T cell product infusion): Radiation therapy including TBI and cranial radiation. Local/palliative radiation excluded: ≥ 4 weeks. Cytotoxic chemotherapy: ≥ 2 days. Tyrosine Kinase Inhibitors: ≥ 7 days
• Total Bilirubin: ≤ 3X upper limit of normal (ULN) for age OR conjugated bilirubin ≤ 2mg/dl, except in subjects with Gilbert's syndrome where a total bilirubin level of up to 5.3 mg/dL will be acceptable
• ALT ≤ 5 times upper limit of normal
• Adequate renal function defined as serum creatinine that is ≤ maximum based on age/gender (as indicated below) or Creatinine clearance or GFR (as measured or estimated by Cockcroft Gaultor Schwartz) ≥ 50 mL/min/1.73m2
∙ Maximum Serum Creatinine (mg/dL):
∙ Male and Female: Age 1 to \< 2 years: 0.6 Male and Female: Age 2 \< 6 years: 0.8 Male and Female: Age 6 to \< 10 years: 1.0 Male and Female: Age 10 to \< 13 years: 1.2 Male: Age 13 to \<16 years 1.5 Female: Age 13 to \<16 years 1.4 Male: Age equal to or \> 16 years 1.7 Female: Age equal to or \> 16 years 1.4
• Pulse oximetry of ≥ 90% on room air
• Left ventricular fractional shortening (LVFS) ≥ 28% confirmed by echocardiogram or left ventricular ejection fraction (LVEF) ≥ 45% confirmed by echocardiogram (MUGA or MRI heart may replace echocardiogram).
• Lansky score of ≥ 50% (age ≥1 and \< 16 years) or Karnofsky score of ≥ 50% (age ≥ 16 years)
• Donor lymphocyte infusions (DLI) completed \> 6 weeks prior to CAR-T cell infusion
• Subjects of childbearing/fathering potential must agree to use highly effective contraception (see Appendix IV for acceptable forms of contraception) from the time of initial T cell infusion through 12 months following the last T cell infusion
• Subjects \> 18 years of age must have the ability to give informed consent according to applicable regulatory and local institutional requirements. Legal guardian's consent must be obtained for subjects \< 18 years of age. Assent will be obtained from pediatric subjects and according to applicable regulatory and local institutional requirements. Adults with cognitive impairment who are unable to consent and those with Down's Syndrome are also eligible for this protocol with consent/assent according to applicable regulatory and local institutional requirements.
∙ Subject willing to participate in long term follow up for up to 15 years.