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.
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). II. Overall response rate (CR, CRi): best response. III. Duration of response (CR, CRi). IV. Minimal residual disease (MRD)- negative CR/CRi. V. The number and rate of bridging to transplant. VI. Estimate the progression free survival (PFS) and overall survival (OS) rate, at 6-months and 1-year post (first) huCD19 CAR T cell infusion. EXPLORATORY OBJECTIVES: I. Access the expansion and persistence of T cell via flow cytometry in blood, bone marrow (BM) and cerebrospinal fluid (CSF). II. Assess the phenotype and activation status of CAR T via flow cytometry, polymerase chain reaction (PCR), and cytokine analysis. III. Assess CAR T cell clonal expansion and repertoires of endogenous T cells. IV. Assess immunophenotyping and functional analyses of CAR T cell products. V. Determine the role of the immunologic milieu. VI. Evaluation of B cell aplasia. VII. Serum cytokine measurement. VIII. Tumor antigen analysis. XIV. Evaluation of Immunogenicity by enzyme-linked immunosorbent assay (ELISA). X. For subjects who receive cetuximab for CAR T cell ablation, assess the activity of infusional cetuximab to eliminate transferred huCD19-CAR T cells. OUTLINE: This is a dose-escalation study of huCD19-CAR T, followed by a dose-expansion study. Patients undergo leukapheresis then receive lymphodepletion chemotherapy with fludarabine ntravenously (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 allogeneic hematopoietic cell transplantation (alloHCT). Additionally, patients undergo echocardiography (ECHO) or multigated acquisition scan ((MUGA), computed tomography (CT) or positron emission tomography (PET)/CT and optional magnetic resonance imaging (MRI) on study and bone marrow biopsy and aspiration and blood sample collection throughout the study. After completion of study treatment, patients are followed up monthly for 1 year then yearly for up to 15 years.
Study Type
INTERVENTIONAL
Allocation
NA
Purpose
TREATMENT
Masking
NONE
Enrollment
24
Undergo alloHCT
Undergo blood sample collection
Undergo bone marrow biopsy and aspiration
Undergo bone marrow biopsy and aspiration
Given IV
Given IV
Undergo CT and PET
Given IV
Undergo ECHO
Given IV
Undergo leukapheresis
Undergo MRI
Undergo MUGA
Undergo PET/CT
City of Hope Medical Center
Duarte, California, United States
RECRUITINGDose limiting toxicity (DLT)
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.
Time frame: Up to 28 days after T cell infusion
Percentage of patients undergoing leukapheresis who get sufficient T cells manufactured and infused at assigned dose level
Time frame: At time of infusion
Overall response rate (ORR)
ORR will be defined as the percentage of subjects who experience a best response of either complete response (CR) or complete response with incomplete bone marrow recovery (CRi). Exact 95% confidence intervals will be calculated.
Time frame: Up to 28 days post infusion
Progression-free survival (PFS)
PFS over time will be assessed by Kaplan-Meier method.
Time frame: 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)
DOR will be defined as the time from the first achievement of CR or CRi after infusion through disease relapse or progression or death.
Time frame: 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
Overall survival (OS)
OS over time will be assessed by Kaplan-Meier method.
Time frame: From start of protocol therapy to death, or last follow-up, whichever comes first, assessed up to 15 years
Minimal residual disease (MRD)
MRD relapse will be defied as detectable of leukemic cells at \> 0.01% in morphological remission bone marrow.
Time frame: Up to 2 years post infusion
Extramedullary relapse
Extramedullary relapse will be defined as documented relapse outside the bone marrow.
Time frame: Up to 2 years post infusion
Transplant OS
Transplant OS will be defined as the duration of time from start of allogeneic hematopoietic cell transplant (alloHCT) to time of death (due to any cause). OS over time will be assessed by Kaplan-Meier method.
Time frame: At days 30 and 100, 6 months, and years 1 and 2 post alloHCT
Transplant PFS
Transplant PFS will be defined as the duration of time from start of alloHCT treatment to time of progression or death, whichever comes first. PFS over time will be assessed by Kaplan-Meier method.
Time frame: At days 30 and 100, 6 months, and years 1 and 2 post alloHCT
Transplant relapse/progression
Time frame: At days 30 and 100, 6 months, and years 1 and 2 post alloHCT
Non-relapse mortality (NRM)
NRM will be defined as death occurring in a patient from causes other than relapse or progression. NRM will be measured from start of treatment until non-disease related death or last follow up, whichever comes first.
Time frame: At days 30 and 100, 6 months, and years 1 and 2 post alloHCT
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