T Cell Receptor Immunotherapy Targeting MAGE-A3 for Patients With Metastatic Cancer Who Are HLA-DP0401 Positive
T Cell Receptor Immunotherapy Targeting MAGE-A3 for Patients With Metastatic Cancer Who Are HLA-DP0401 Positive
Background:

 The NCI Surgery Branch has developed an experimental therapy for treating patients with
 metastatic cancer that involves taking white blood cells from the patient, growing them in
 the laboratory in large numbers, genetically modifying these specific cells with a type of
 virus (retrovirus) to attack only the tumor cells, and then giving the cells back to the
 patient. This type of therapy is called gene transfer. In this protocol, we are modifying the
 patient s white blood cells with a retrovirus that has the gene for anti-MAGE-A3-DP0401/0402
 incorporated in the retrovirus.

 Objective:

 The purpose of this study is to determine a safe number of these cells to infuse and to see
 if these particular tumor-fighting cells (anti-MAGE-A3-DP0401/0402 cells) cause tumors to
 shrink and to be certain the treatment is safe.

 Eligibility:

 - Adults age 18-70 with metastatic cancer expressing the MAGE-A3 molecule.

 Design:

 -  Work up stage: Patients will be seen as an outpatient at the NIH clinical Center and
 undergo a history and physical examination, scans, x-rays, lab tests, and other tests as
 needed

 -  Leukapheresis: If the patients meet all of the requirements for the study they will
 undergo leukapheresis to obtain white blood cells to make the anti-MAGE-A3-DP0401/0402
 cells. {Leukapheresis is a common procedure, which removes only the white blood cells
 from the patient.}

 -  Treatment: Once their cells have grown, the patients will be admitted to the hospital
 for the conditioning chemotherapy, the anti-MAGE-A3-DP0401/0402 cells and aldesleukin.
 They will stay in the hospital for approximately 4 weeks for the treatment.

 -  Follow up: Patients will return to the clinic for a physical exam, review of side
 effects, lab tests, and scans about every 1-3 months for the first year, and then every
 6 months to 1 year as long as their tumors are shrinking.
Background:

 -  We have constructed a single retroviral vector that contains both and $ <= chains of a T
 cell receptor (TCR) that recognizes the DP0401/0402 restricted MAGE-A3 tumor antigen,
 which can be used to mediate genetic transfer of this TCR with high efficiency.

 -  In co-cultures with HLA-DP0401/0402 and MAGE-A3 double positive tumors, the anti-
 MAGE-A3- DP0401/0402 restricted (anti-MAGE-A3-DP4) TCR transduced T cells secreted
 significant amounts of IFN-y with high specificity.

 Objectives:

 Primary objectives:

 -  Determine a safe dose of the administration of autologous CD4 cells transduced with an
 anti- MAGE-A3-DP0401/0402 restricted (MAGE-A3-DP4) TCR and aldesleukin to patients
 following a nonmyeloablative but lymphoid depleting preparative regimen.

 -  Determine if this approach will result in objective tumor regression in patients with
 metastatic cancer expressing MAGE-A3-DP4.

 -  Determine the toxicity profile of this treatment regimen.

 Eligibility:

 Patients who are HLA-DP0401/0402 positive and 18 years of age or older must have

 -  Metastatic cancer whose tumors express the MAGE-A3-DP4 antigen;

 -  Previously received and have been a non-responder to or recurred following at least one
 first line treatment for metastatic disease;

 Patients may not have:

 - Contraindications for high dose aldesleukin administration.

 Design:

 -  PBMC obtained by leukapheresis will be enriched for CD4 cells and transduced with the
 retroviral vector supernatant encoding the anti-MAGE-A3-DP4 TCR.

 -  The study will begin in a standard phase 1 dose escalation. After the MTD cell dose has
 been determined, patients will be enrolled into the phase 2 portion of the trial at the
 MTD established during the phase 1 portion of the study. In the phase 2 portion,
 patients will be entered into two cohorts: cohort 1 will include patients with
 metastatic melanoma; cohort 2 will include patients with renal cancer and other types of
 metastatic cancer.

 -  Patients will receive a nonmyeloablative but lymphocyte depleting preparative regimen
 consisting of cyclophosphamide and fludarabine followed by intravenous infusion of ex
 vivo tumor reactive, TCR gene-transduced PBMC plus IV aldesleukin.

 -  Patients will undergo complete evaluation of tumor response every 1-6 months until off
 study criteria are met.

 -  For each of the 2 strata evaluated in the phase 2 portion, the study will be conducted
 using a phase 2 optimal design where initially 21 evaluable patients will be enrolled.
 For each of these two arms of the trial, if 0 or 1 of the 21 patients experiences a
 clinical response, then no further patients will be enrolled but if 2 or more of the
 first 21 evaluable patients enrolled have a clinical response, then accrual will
 continue until a total of 41 evaluable patients have been enrolled in that stratum.

 -  For both strata, the objective will be to determine if the treatment regimen is able to
 be associated with a clinical response rate that can rule out 5% (p0=0.05) in favor of a
 modest 20% PR + CR rate (p1=0.20).
-INCLUSION CRITERIA:

 1. Metastatic or locally advanced refractory/recurrent cancer that expresses MAGE-A3 as
 assessed by one of the following methods: RT-PCR on tumor tissue defined as 30,000
 copies of MAGE-A3 per 10^6 GAPDH copies, or by immunohistochemistry of resected tissue
 defined as 10% or greater of tumor cells being 2-3+ for MAGE-A3, or serum antibody
 reactive with MAGE-A3. Metastatic cancer diagnosis will be confirmed by the Laboratory
 of Pathology at the NCI.

 2. Patients must have previously received prior first line standard therapy (or effective
 salvage chemotherapy regimens) for their disease, if known to be effective for that
 disease, and have been either non-responders (progressive disease) or have recurred.

 3. Patients must be HLA-DP4 positive.

 4. Patients with 3 or fewer brain metastases that are less than 1 cm in diameter and
 asymptomatic are eligible. Lesions that have been treated with stereotactic
 radiosurgery must be clinically stable for 1 month after treatment for the patient to
 be eligible. Patients with surgically resected brain metastases are eligible.

 5. Greater than or equal to 18 years of age and less than or equal to age 70.

 6. Ability of subject to understand and the willingness to sign the Informed Consent
 Document.

 7. Willing to sign a durable power of attorney

 8. Clinical performance status of ECOG 0 or 1

 9. Patients of both genders must be willing to practice birth control from the time of
 enrollment on this study and for up to four months after treatment.

 10. Serology:

 -  Seronegative for HIV antibody. (The experimental treatment being evaluated in
 this protocol depends on an intact immune system. Patients who are HIV
 seropositive can have decreased immune-competence and thus be less responsive to
 the experimental treatment and more susceptible to its toxicities.)

 -  Seronegative for hepatitis B antigen, and seronegative for hepatitis C antibody.
 If hepatitis C antibody test is positive, then patient must be tested for the
 presence of antigen by RT-PCR and be HCV RNA negative.

 11. Women of child-bearing potential must have a negative pregnancy test because of the
 potentially dangerous effects of the treatment on the fetus.

 12. Hematology

 -  Absolute neutrophil count greater than 1000/mm^3 without the support of
 filgrastim

 -  WBC greater than or equal to 3000/mm^3

 -  Platelet count greater than or equal to 100,000/mm^3

 -  Hemoglobin > 8.0 g/dl

 13. Chemistry:

 -  Serum ALT/AST less than or equal to 2.5 times the upper limit of normal

 -  Serum creatinine less than or equal to 1.6 mg/dl

 -  Total bilirubin less than or equal to 1.5 mg/dl, except in patients with Gilbert
 s Syndrome who must have a total bilirubin less than 3.0 mg/dl.

 14. More than four weeks must have elapsed since any prior systemic therapy at the time
 the patient receives the preparative regimen, and patients' toxicities must have
 recovered to a grade 1 or less (except for toxicities such as alopecia or vitiligo).
 Patients must have

 progressing disease after prior treatment. Note: Patients who have previously received
 ipilimumab and have documented GI toxicity must have a normal colonoscopy with normal
 colonic biopsies.

 15. Subjects must be co-enrolled in protocol 03-C-0277.

 EXCLUSION CRITERIA:

 1. Women of child-bearing potential who are pregnant or breastfeeding because of the
 potentially dangerous effects of the treatment on the fetus or infant.

 2. Active systemic infections, (e.g.: requiring anti-infective treatment), coagulation
 disorders or any other active major medical illnesses

 3. Any form of primary immunodeficiency (such as Severe Combined Immunodeficiency
 Disease).

 4. Concurrent opportunistic infections (The experimental treatment being evaluated in
 this protocol depends on an intact immune system. Patients who have decreased immune
 competence may be less responsive to the experimental treatment and more susceptible
 to its toxicities).

 5. Concurrent systemic steroid therapy.

 6. History of severe immediate hypersensitivity reaction to any of the agents used in
 this study.

 7. History of any cardiac events including coronary revascularization or ischemic
 symptoms.

 8. Documented LVEF of less than or equal to 45% testing is required in patients who are

 -  greater than or equal to 65 years old

 -  Clinically significant atrial and or ventricular arrhythmias including but not
 limited to: atrial fibrillation, ventricular tachycardia, second or third degree
 heart block or have a history of ischemic heart disease, or chest pain.

 9. Documented FEV1 less than or equal to 60% predicted tested in patients with:

 -  A prolonged history of cigarette smoking (20 pk/year of smoking within the past 2
 years).

 -  Symptoms of respiratory dysfunction

 10. Patients who are receiving any other investigational agents.