CAR T Cell Receptor Immunotherapy for Patients With B-cell Lymphoma
CAR T Cell Receptor Immunotherapy for Patients With B-cell Lymphoma
Background:

 The National Cancer Institute (NCI) Surgery Branch has developed an experimental therapy for
 treating patients with B cell lymphomas or leukemias 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-cluster of differentiation 19 (CD19) 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-CD19 cells) cause tumors to shrink.

 Eligibility:

 - Adults age 18-70 with B cell lymphomas or leukemias expressing the CD19 molecule.

 Design:

 Work up stage: Patients will be seen as an outpatient at the National Institutes of Health
 (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-CD19 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 and the anti-CD19 cells. They will stay in the hospital for about 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. Follow up visits will take up to 2 days.
BACKGROUND:

 -  We have constructed a retroviral vector that encodes an anti-cluster of differentiation
 19 (CD19) chimeric antigen receptor (CAR) that recognizes the CD19 antigen. This
 chimeric receptor also contains the signaling domains of cluster of differentiation 28
 (CD28) and cluster of differentiation 3 (CD3)-zeta. The retroviral vector can be used to
 mediate genetic transfer of this CAR to T cells with high efficiency (> 50%) without the
 need to perform any selection.

 -  In co-cultures with CD19-expressing target cells, anti-CD19-CAR-transduced T-cells
 secreted significant amounts of interferon gamma (IFN-y) and interleukin 2 (IL-2).

 -  We have developed a process for cryopreserving the cell product which may lead to the
 ability for this product to be manufactured at a central location and shipped to other
 institutions for treatment of a broader patient population

 OBJECTIVE:

 - Primary objective:

 --With the approval of amendment S, to determine the safety and feasibility of the
 administration of cryopreserved anti-CD19-CAR engineered peripheral blood lymphocytes with a
 non-myeloablative conditioning regimen in patients with Bcell lymphomas.

 ELIGIBILITY:

 Patients of 18 years of age or older must:

 -  Have a CD19-expressing B-cell lymphoma

 -  Be a non-responder to, or recurred after one or more standard chemotherapy-containing
 regimens for their malignancy

 -  Currently require treatment due to progressive malignancy

 -  Be deemed to be incurable by standard therapy

 Patients may not have:

 -  A history of allogeneic stem cell transplantation

 -  Central nervous system (CNS) disease

 DESIGN:

 -  Peripheral blood mononuclear cells (PBMC) obtained by leukapheresis (approximately 5.0x
 10^9 cells) will be cultured in the presence of anti-CD3 (muromonab-CD3 (OKT3)) and
 aldesleukin in order to stimulate T-cell proliferation.

 -  Transduction is initiated by exposure of approximately 1.0x 10^8 to 5.0x 10^8 cells to
 retroviral vector supernatant containing the anti-CD19 CAR.

 -  With the approval of Amendment S, patients will receive fludarabine and cyclophosphamide
 chemotherapy (NMA) for lymphodepletion, followed by cryopreserved
 anti-CD19-CAR-transduced T-cells.

 -  Patients will be followed until disease progression.

 -  Patients who have responded to treatment and then progress may receive one retreatment.
-  INCLUSION CRITERIA:

 1. Patient must have a cluster of differentiation 19 (CD19)-expressing B-cell
 lymphoma. Patients with diffuse large B-cell lymphoma, primary mediastinal B-cell
 lymphoma, and diffuse large B-cell lymphoma transformed from follicular lymphoma
 must have measurable disease after at least two prior chemotherapy regimens one
 of which must have contained doxorubicin and rituximab.

 2. Confirmation of diagnosis of B-cell malignancy and positivity for CD19 confirmed
 by the Laboratory of Pathology of the National Cancer Institute (NCI). The choice
 of whether to use flow cytometry or immunohistochemistry will be determined by
 what is the most easily available tissue sample in each patient.
 Immunohistochemistry will be used for lymph node biopsies, flow cytometry will be
 used for peripheral blood, fine needle aspirates and bone marrow samples.

 3. Patients must have indications for treatment for their B-cell malignancy at the
 time of enrollment on this trial.

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

 5. Willing to sign a durable power of attorney.

 6. Able to understand and sign the Informed Consent Document.

 7. Clinical performance status of Eastern Cooperative Oncology Group (ECOG) 0 or 1.

 8. Life expectancy of greater than three months.

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

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

 11. Serology:

 -  Seronegative for human immunodeficiency virus (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 hepatitis C antibody unless antigen
 negative. If hepatitis C antibody test is positive. Then patients must be
 tested for the presence of antigen by reverse transcription-polymerase chain
 reaction (RT-PCR) and be hepatitis C virus ribonucleic acid (HCV RNA)
 negative.

 12. Hematology:

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

 -  Platelet count greater than or equal to 50,000/mm^3.

 -  Hemoglobin greater than 8.0 g/dl.

 -  Lymphocyte count less than or equal to 4,000/ mm^3

 13. Chemistry:

 -  Serum alanine aminotransferase (ALT)/aspartate aminotransferase (AST) less
 or equal to 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 three weeks must have elapsed since any prior systemic therapy at the
 time the patient receives the preparative regimen, and patient toxicities must
 have recovered to a grade 1 or less (except for toxicities such as alopecia or
 vitiligo).

 15. Normal cardiac ejection fraction and no evidence of pericardial effusion as
 determined by an echocardiogram.

 EXCLUSION CRITERIA:

 1. Patients that require urgent therapy due to tumor mass effects such as bowel
 obstruction or blood vessel compression.

 2. Patients that have active hemolytic anemia.

 3. Patients with active brain metastases, or with a history of any central nervous system
 (CNS) metastases or cerebrospinal fluid malignant cells.

 Note: patients who are asymptomatic but are found to have malignant cells in the
 cerebrospinal fluid (CSF) on lumbar puncture prior to treatment will be considered
 eligible.

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

 5. Active systemic infections, coagulation disorders or other major medical illnesses of
 the cardiovascular, respiratory or immune system, myocardial infarction, cardiac
 arrhythmias, obstructive or restrictive pulmonary disease.

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

 7. 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).

 8. Concurrent systemic steroid therapy.

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

 10. History of allogeneic stem cell transplantation

 11. Patients with cardiac atrial or cardiac ventricular lymphoma involvement.

 Screening Evaluation:

 Within 4 weeks prior to starting the chemotherapy regimen:

 1. Complete history and physical examination, including, weight and vital signs, noting
 in detail the exact size and location of any lesions that exist. (Note: patient
 history may be obtained within 8 weeks.)

 2. Chest x-ray

 3. Electrocardiography (EKG)

 4. Baseline computed tomography (CT) of the chest, abdomen and pelvis, positron emission
 tomography (PET) scan, and brain magnetic resonance imaging (MRI) to evaluate the
 status of disease. Additional scans and x-rays may be performed if clinically
 indicated based on patient signs and symptoms.

 5. HIV antibody titer and Hepatitis B surface antigen (HbsAG) determination, and anti
 HCV, (Note: May be performed within 3 months of the chemotherapy start date).

 6. Anti cytomegalovirus (CMV) antibody titer, herpes simplex virus (HSV) serology, and
 Epstein-Barr virus (EBV) panel (Note: patients who are known to be positive for any of
 the above do not need to be retested; may be performed within 3 months of chemotherapy
 start date)

 7. Patients with a left ventricular ejection fraction (LVEF) of less than or equal to 55%
 will not proceed to treatment (Note: may be performed within 8 weeks of treatment).

 8. Cluster of differentiation 19 (CD19) staining of malignant cells by
 immunohistochemistry or flow cytometry (testing is permitted to be conducted at any
 time prior to this point).

 9. All patients must have a T cells, B cells, and natural killer cells (TBNK) for
 Peripheral blood cluster of differentiation 3 (CD3) count and CD19#.

 10. Patients with a history of leptomeningeal disease, or signs/symptoms suggestive of
 leptomeningeal involvement, or with symptoms of central nervous system malignancy such
 as new onset severe headaches, neck stiffness, or any focal neurologic findings on
 physical exam will have lumbar puncture for examination of cerebral spinal fluid.

 11. Patients may undergo lumbar puncture (LP) for flow cytometry of the CSF in order to
 assess the presence of CD19 positive lymphocytes for potential correlation with
 neurologic toxicity. Patients who have no neurologic symptoms at the time of LP will
 be eligible for enrollment regardless of the results of the flow cytometry.

 Within 14 days prior to starting the chemotherapy regimen:

 12. Chem 20: (Sodium (Na), Potassium (K), Chloride (Cl), Total carbon dioxide (CO2)
 (bicarbonate), Creatinine, Glucose, Urea nitrogen (BUN), Albumin, Calcium total,
 Magnesium total (Mg), Inorganic Phosphorus, Alkaline Phosphatase, ALT/glutamic pyruvic
 transaminase (GPT), AST/glutamic oxaloacetic (GOT), Total Bilirubin, Direct Bilirubin,
 lactate hydrogenase (LD), Total Protein, Total creatine kinase (CK), Uric Acid)

 13. Thyroid panel

 14. Complete blood count (CBC) with differential and platelet count

 15. Prothrombin time (PT)/partial thromboplastin time (PTT)

 16. Urinalysis and culture, if indicated

 Within 7 days prior to starting the chemotherapy regimen:

 17. Beta-human chorionic gonadotropin (βHCG) pregnancy test (serum or urine) on all women
 of child-bearing potential

 18. ECOG performance status of 0 or 1