Phase Ib Study to Evaluate Humanized CD19-Specific CAR T Cells Following Lymphodepleting Chemotherapy in Adult Patients With Relapsed/Refractory CD19+ B-Cell Acute Lymphoblastic Leukemia
Trial Snapshot
- Phase
- Phase 1
- Status
- Suspended
- Sponsor
- Enrollment
- 24
- Locations
- 2
- Primary Endpoint
- Dose limiting toxicity (DLT)
Study Overview
Brief Summary
This phase Ib trial tests the safety, side effects, and effectiveness of humanized (hu)CD19-chimeric antigen receptor (CAR) T cell therapy in treating patients with CD19 positive B-cell acute lymphoblastic leukemia (ALL) that has come back after a period of improvement (relapsed) or that has not responded to previous treatment (refractory). CAR T-cell therapy is a treatment in which a patient's T cells (a type of immune system cell) are changed in the laboratory so they will attack cancer cells. T cells are taken from a patient's blood. Then the gene for a special receptor that binds to a certain protein, such as CD19, on the patient's cancer cells is added to the T cells in the laboratory. The special receptor is called a chimeric antigen receptor (CAR). Large numbers of the huCD19 positive CAR T cells are grown in the laboratory and given to the patient by infusion for treatment of certain cancers. Chemotherapy drugs, such as fludarabine and cyclophosphamide, work in different ways to stop the growth of cancer cells, either by killing the cells, by stopping them from dividing, or by stopping them from spreading. huCD19-CAR T cell therapy may be safe, tolerable and effective in treating patients with relapsed or refractory CD19 positive ALL.
Detailed Description
PRIMARY OBJECTIVES:
I. Assess the safety and tolerability of Tn/mem-enriched huCD19(VH4VK1)(dCH2)BBzeta/EGFRt+ T cells (huCD19 CAR T) as single-dose monotherapy by evaluation of toxicities including type, frequency, severity, attribution, time course and duration.
II. Determine the maximum feasible dose (MFD)/recommended phase 2 dose(s) schedule (RP2D) of huCD19 CAR T as single-dose monotherapy on relapsed/refractory (r/r) ALL patients.
SECONDARY OBJECTIVES:
I. Obtain preliminary estimates of complete remission (complete remission [CR] /complete response with incomplete bone marrow recovery [CRi]) rate(s).
Study Design
- Study Type
- Interventional
- Allocation
- Na
- Intervention Model
- Sequential
- Primary Purpose
- Treatment
- Masking
- None
Eligibility Criteria
- Ages
- 18 Years to — (Adult, Older Adult)
- Sex
- All
- Accepts Healthy Volunteers
- No
Inclusion Criteria
- •Documented informed consent of the participant
- •Agreement to allow the use of archival tissue from diagnostic tumor biopsies.
- •If unavailable, exceptions may be granted with study principal investigator (PI) approval
- •Note: For research participants who do not speak English, a short form consent may be used with a City of Hope (COH) certified interpreter/translator to proceed with screening and leukapheresis, while the request for a translated full consent is processed. However, the research participant is allowed to proceed with lymphodepletion and T cell infusion only after the translated full consent form is signed
- •Age: ≥ 18 years
- •Eastern Cooperative Oncology Group (ECOG) 0-2 / Karnofsky performance status (KPS) ≥ 70
- •Histologically confirmed CD19+ relapsed/refractory ALL with at least 2 prior lines of therapy
- •Prior alloHCT > 100 days prior to enrollment may be considered a prior line of therapy
- •Research participants with confirmed 1st or higher relapse of disease by morphology, cytogenetics or molecular, or research participants with refractory or residual disease
- •Participants with central nervous system (CNS) involvement by leukemia (CNS2 and CNS3) may be considered eligible after discussions with the study team
- •Patients with only MRD+ disease may be eligible
- •Patients with isolated extramedullary disease may also be eligible
- •Total bilirubin ≤ 2.0 X upper limit of normal (ULN) (unless has Gilbert's disease or related to leukemia involving the liver)
- •Aspartate aminotransferase (AST) ≤ 2.5 x ULN (unless related to leukemia involving the liver)
- •Alanine aminotransferase (ALT) ≤ 2.5 x ULN (unless related to leukemia involving the liver)
- •Creatinine clearance of ≥ 50 mL/min per 24-hour urine test or the Cockcroft-Gault formula
- •Left ventricular ejection fraction (LVEF) ≥ 45%
- •Note: To be performed within 28 days prior to start of protocol therapy
- •Cardiac function (12 lead-electrocardiogram [ECG]): Corrected QT interval (QTc) must be ≤ 480 msec
- •Oxygen (O2) saturation > 92% on room air
- •Note To be performed within 28 days prior to start of protocol therapy
- •Seronegative for HIV quantitative polymerase chain reaction (qPCR), hepatitis C virus (HCV), active hepatitis B virus (HBV) (surface antigen negative), and syphilis (rapid plasma reagin [RPR])
- •If positive, hepatitis C ribonucleic acid (RNA) quantitation must be performed. OR
- •If seropositive for HIV, HCV or HBV, nucleic acid quantitation must be performed. The viral load must be undetectable
- •Meets other institutional and federal requirements for infectious disease titer requirements
- •Note Infectious disease testing to be performed within 28 days prior to start of protocol therapy
- •Women of childbearing potential (WOCBP): negative urine or serum pregnancy test. If the urine test is positive or cannot be confirmed as negative, a serum pregnancy test will be required
- •Agreement by females and males of childbearing potential to use an effective method of birth control or abstain from heterosexual activity for the course of the study through at least 6 months after the last dose of protocol therapy
- •Childbearing potential defined as not being surgically sterilized (men and women) or have not been free from menses for > 1 year (women only)
- •ELIGIBILITY TO PROCEED WITH PERIPHERAL BLOOD MONONUCLEAR CELLS (PBMC) COLLECTION FOR CAR T CELL MANUFACTURING
- •Research participant has signed the 'screening and leukapheresis' informed consent
- •Research participant must have appropriate venous access, have a central line or be willing to undergo central or temporary line placement
- •The last dose of systemic chemotherapy must be at least 2 weeks before the leukapheresis procedure with the following exceptions:
- •Steroids and vincristine are allowed up to 7 days prior to leukapheresis.
- •Intrathecal chemotherapy is allowed up to 3 days prior to leukapheresis.
- •Tyrosine kinase inhibitors are allowed up to 48 hours prior to leukapheresis.
- •Hydrea is allowed up to 48 hours prior to leukapheresis.
- •The research participant cannot be on ≥ 7.5 mg prednisone or equivalent doses of other corticosteroids at the time of leukapheresis. Note: Topical and inhaled corticosteroids in standard doses and physiologic replacement for subjects with adrenal insufficiency are allowed
- •The last dose of prior targeted agents, immunotherapy or radiation must be at least 2 weeks before the leukapheresis procedure
- •If the research participant has undergone prior alloHCT, 100 days must have elapsed since allogeneic stem cell transplant to undergo PBMC collection for CAR T cell manufacturing
- •ELIGIBILITY TO UNDERGO LYMPHODEPLETION
- •Research participant's absolute leukemic blast count does not exceed 10,000 cells/uL
- •The last dose of chemotherapy, maintenance therapy, radiation therapy, biological therapy, and/or immunotherapy must have been 7 days prior to start of lymphodepletion
- •The following washout periods must be met:
- •Corticosteroids 3 days
- •Biologic agents 3 half lives
- •Oral chemotherapeutic agents 3 half lives
- •Intrathecal chemotherapy 3 days
- •Chemo and/or immunotherapy 2 weeks
- •Local radiation to sites 7 days
- +34 more not shown
Exclusion Criteria
- •Allogeneic stem cell transplant within 100 days at the time of enrollment
- •Received prior CAR T therapy within 90 days of enrollment
- •EXCEPTION: Participants who have previously received B-cell-activating factor receptor (BAFFR)-CAR T cells will be excluded from this study
- •Failure of research participant to understand the basic elements of the protocol and/or the risks/benefits of participating in this phase I study
- •History of allergic reactions attributed to compounds of similar chemical or biologic composition to study agent(s)
- •History or presence of clinically relevant CNS pathology such as uncontrolled seizure disorder, recent stroke, severe brain injuries, dementia, cerebellar disease or psychosis
- •Autoimmune disease or active graft versus host disease (GVHD) requiring systemic immunosuppressant therapy
- •Class III/IV cardiovascular disability according to the New York Heart Association (NYHA) Classification
- •History of other malignancies, except for malignancy surgically resected (or treated with other modalities) with curative intent, basal cell carcinoma of the skin or localized squamous cell carcinoma of the skin; non-muscle invasive bladder cancer; malignancy treated with curative intent with no known active disease present for ≥ 2 years
- •Clinically significant uncontrolled illness
- •Active systemic uncontrolled infection requiring antibiotics
- •Known history of immunodeficiency virus (HIV) or hepatitis B or hepatitis C infection
- •Subjects who are hepatitis B core antibody (anti-HBc) positive and who are surface antigen negative will need to have a negative polymerase chain reaction (PCR) result. Those who are hepatitis B surface antigen (HbsAg) positive or hepatitis B PCR positive will be excluded
- •Subjects who are hepatitis B core antibody positive (or have a known history of HBV infection) should be monitored quarterly with a quantitative PCR test for HBV deoxyribonucleic acid (DNA). HBV monitoring should last until 12 months after the last dose of study drug. Any subject with a rising viral load (above lower limit of detection) should discontinue study drug and have antiviral therapy instituted and a consultation with a physician with expertise in managing hepatitis B. Subjects who are core antibody (Ab) positive at study enrollment are strongly recommended to start Entecavir before start and until completion of study treatment
- •Subjects who are hepatitis C antibody positive will need to have a negative PCR result. Those who are hepatitis C PCR positive will be excluded
- •Females only: Pregnant or breastfeeding
- •Concurrent use of systemic steroids or chronic use of immunosuppressant medications. Recent or current use of topical or inhaled steroids is not exclusionary. Physiologic replacement of steroids (prednisone ≤ 7.5 mg /day or equivalent) is allowed
- •Any other condition that would, in the investigator's judgment, contraindicate the patient's participation in the clinical study due to safety concerns with clinical study procedures
- •Prospective participants who, in the opinion of the investigator, may not be able to comply with all study procedures (including compliance issues related to feasibility/logistics)
Arms & Interventions
Treatment (huCD19-CAR T)
Patients undergo leukapheresis then receive lymphodepletion chemotherapy with fludarabine IV and cyclophosphamide IV on days -5, -4 and -3 and huCD19-CAR T IV cells over 10-15 minutes on day 0. Patients may optionally receive cetuximab IV over 60-120 minutes at least 28 days post T cell infusion and undergo alloHCT. Additionally, patients undergo ECHO or MUGA, CT or PET/CT and optional MRI on study and bone marrow biopsy and aspiration and blood sample collection throughout the study.
Intervention: Echocardiography (Procedure)
Treatment (huCD19-CAR T)
Patients undergo leukapheresis then receive lymphodepletion chemotherapy with fludarabine IV and cyclophosphamide IV on days -5, -4 and -3 and huCD19-CAR T IV cells over 10-15 minutes on day 0. Patients may optionally receive cetuximab IV over 60-120 minutes at least 28 days post T cell infusion and undergo alloHCT. Additionally, patients undergo ECHO or MUGA, CT or PET/CT and optional MRI on study and bone marrow biopsy and aspiration and blood sample collection throughout the study.
Intervention: Cyclophosphamide (Drug)
Treatment (huCD19-CAR T)
Patients undergo leukapheresis then receive lymphodepletion chemotherapy with fludarabine IV and cyclophosphamide IV on days -5, -4 and -3 and huCD19-CAR T IV cells over 10-15 minutes on day 0. Patients may optionally receive cetuximab IV over 60-120 minutes at least 28 days post T cell infusion and undergo alloHCT. Additionally, patients undergo ECHO or MUGA, CT or PET/CT and optional MRI on study and bone marrow biopsy and aspiration and blood sample collection throughout the study.
Intervention: Fludarabine (Drug)
Treatment (huCD19-CAR T)
Patients undergo leukapheresis then receive lymphodepletion chemotherapy with fludarabine IV and cyclophosphamide IV on days -5, -4 and -3 and huCD19-CAR T IV cells over 10-15 minutes on day 0. Patients may optionally receive cetuximab IV over 60-120 minutes at least 28 days post T cell infusion and undergo alloHCT. Additionally, patients undergo ECHO or MUGA, CT or PET/CT and optional MRI on study and bone marrow biopsy and aspiration and blood sample collection throughout the study.
Intervention: Allogeneic Hematopoietic Stem Cell Transplantation (Procedure)
Treatment (huCD19-CAR T)
Patients undergo leukapheresis then receive lymphodepletion chemotherapy with fludarabine IV and cyclophosphamide IV on days -5, -4 and -3 and huCD19-CAR T IV cells over 10-15 minutes on day 0. Patients may optionally receive cetuximab IV over 60-120 minutes at least 28 days post T cell infusion and undergo alloHCT. Additionally, patients undergo ECHO or MUGA, CT or PET/CT and optional MRI on study and bone marrow biopsy and aspiration and blood sample collection throughout the study.
Intervention: Biospecimen Collection (Procedure)
Treatment (huCD19-CAR T)
Patients undergo leukapheresis then receive lymphodepletion chemotherapy with fludarabine IV and cyclophosphamide IV on days -5, -4 and -3 and huCD19-CAR T IV cells over 10-15 minutes on day 0. Patients may optionally receive cetuximab IV over 60-120 minutes at least 28 days post T cell infusion and undergo alloHCT. Additionally, patients undergo ECHO or MUGA, CT or PET/CT and optional MRI on study and bone marrow biopsy and aspiration and blood sample collection throughout the study.
Intervention: Bone Marrow Aspiration (Procedure)
Treatment (huCD19-CAR T)
Patients undergo leukapheresis then receive lymphodepletion chemotherapy with fludarabine IV and cyclophosphamide IV on days -5, -4 and -3 and huCD19-CAR T IV cells over 10-15 minutes on day 0. Patients may optionally receive cetuximab IV over 60-120 minutes at least 28 days post T cell infusion and undergo alloHCT. Additionally, patients undergo ECHO or MUGA, CT or PET/CT and optional MRI on study and bone marrow biopsy and aspiration and blood sample collection throughout the study.
Intervention: Bone Marrow Biopsy (Procedure)
Treatment (huCD19-CAR T)
Patients undergo leukapheresis then receive lymphodepletion chemotherapy with fludarabine IV and cyclophosphamide IV on days -5, -4 and -3 and huCD19-CAR T IV cells over 10-15 minutes on day 0. Patients may optionally receive cetuximab IV over 60-120 minutes at least 28 days post T cell infusion and undergo alloHCT. Additionally, patients undergo ECHO or MUGA, CT or PET/CT and optional MRI on study and bone marrow biopsy and aspiration and blood sample collection throughout the study.
Intervention: CD19CAR-CD28-CD3zeta-EGFRt-expressing Tn/mem-enriched T-lymphocytes (Biological)
Treatment (huCD19-CAR T)
Patients undergo leukapheresis then receive lymphodepletion chemotherapy with fludarabine IV and cyclophosphamide IV on days -5, -4 and -3 and huCD19-CAR T IV cells over 10-15 minutes on day 0. Patients may optionally receive cetuximab IV over 60-120 minutes at least 28 days post T cell infusion and undergo alloHCT. Additionally, patients undergo ECHO or MUGA, CT or PET/CT and optional MRI on study and bone marrow biopsy and aspiration and blood sample collection throughout the study.
Intervention: Computed Tomography (Procedure)
Treatment (huCD19-CAR T)
Patients undergo leukapheresis then receive lymphodepletion chemotherapy with fludarabine IV and cyclophosphamide IV on days -5, -4 and -3 and huCD19-CAR T IV cells over 10-15 minutes on day 0. Patients may optionally receive cetuximab IV over 60-120 minutes at least 28 days post T cell infusion and undergo alloHCT. Additionally, patients undergo ECHO or MUGA, CT or PET/CT and optional MRI on study and bone marrow biopsy and aspiration and blood sample collection throughout the study.
Intervention: Leukapheresis (Procedure)
Treatment (huCD19-CAR T)
Patients undergo leukapheresis then receive lymphodepletion chemotherapy with fludarabine IV and cyclophosphamide IV on days -5, -4 and -3 and huCD19-CAR T IV cells over 10-15 minutes on day 0. Patients may optionally receive cetuximab IV over 60-120 minutes at least 28 days post T cell infusion and undergo alloHCT. Additionally, patients undergo ECHO or MUGA, CT or PET/CT and optional MRI on study and bone marrow biopsy and aspiration and blood sample collection throughout the study.
Intervention: Magnetic Resonance Imaging (Procedure)
Treatment (huCD19-CAR T)
Patients undergo leukapheresis then receive lymphodepletion chemotherapy with fludarabine IV and cyclophosphamide IV on days -5, -4 and -3 and huCD19-CAR T IV cells over 10-15 minutes on day 0. Patients may optionally receive cetuximab IV over 60-120 minutes at least 28 days post T cell infusion and undergo alloHCT. Additionally, patients undergo ECHO or MUGA, CT or PET/CT and optional MRI on study and bone marrow biopsy and aspiration and blood sample collection throughout the study.
Intervention: Multigated Acquisition Scan (Procedure)
Treatment (huCD19-CAR T)
Patients undergo leukapheresis then receive lymphodepletion chemotherapy with fludarabine IV and cyclophosphamide IV on days -5, -4 and -3 and huCD19-CAR T IV cells over 10-15 minutes on day 0. Patients may optionally receive cetuximab IV over 60-120 minutes at least 28 days post T cell infusion and undergo alloHCT. Additionally, patients undergo ECHO or MUGA, CT or PET/CT and optional MRI on study and bone marrow biopsy and aspiration and blood sample collection throughout the study.
Intervention: Positron Emission Tomography (Procedure)
Treatment (huCD19-CAR T)
Patients undergo leukapheresis then receive lymphodepletion chemotherapy with fludarabine IV and cyclophosphamide IV on days -5, -4 and -3 and huCD19-CAR T IV cells over 10-15 minutes on day 0. Patients may optionally receive cetuximab IV over 60-120 minutes at least 28 days post T cell infusion and undergo alloHCT. Additionally, patients undergo ECHO or MUGA, CT or PET/CT and optional MRI on study and bone marrow biopsy and aspiration and blood sample collection throughout the study.
Intervention: Cetuximab (Biological)
Outcomes
Primary Outcomes
Dose limiting toxicity (DLT)
Time Frame: Up to 28 days after T cell infusion
Toxicity/ adverse events will be graded using Common Terminology Criteria for Adverse Events version 5.0. Cytokine release syndrome and neurotoxicity will be graded using American Society for Transplantation and Cellular Therapy Consensus Criteria. Toxicity will be summarized and tabulated by count and percentage of subjects stratified by severity (grade), relatedness, terms or organ level.
Secondary Outcomes
- Percentage of patients undergoing leukapheresis who get sufficient T cells manufactured and infused at assigned dose level(At time of infusion)
- Minimal residual disease (MRD)(Up to 2 years post infusion)
- Transplant OS(At days 30 and 100, 6 months, and years 1 and 2 post alloHCT)
- Overall response rate (ORR)(Up to 28 days post infusion)
- Overall survival (OS)(From start of protocol therapy to death, or last follow-up, whichever comes first, assessed up to 15 years)
- Transplant PFS(At days 30 and 100, 6 months, and years 1 and 2 post alloHCT)
- Non-relapse mortality (NRM)(At days 30 and 100, 6 months, and years 1 and 2 post alloHCT)
- Progression-free survival (PFS)(From the start of CD-19 CAR T cell infusion to the date of death or disease progression/relapse, whichever occurring first, assessed up to 15 years)
- Duration of response (DOR)(From the start of CD19-CAR T cell infusion to the date of death or disease progression/relapse, whichever occurring first, assessed up to 15 years)
- Extramedullary relapse(Up to 2 years post infusion)
- Transplant relapse/progression(At days 30 and 100, 6 months, and years 1 and 2 post alloHCT)