Genetically Modified T Cells in Treating Patients With Stage III-IV Non-small Cell Lung Cancer or Mesothelioma
Genetically Modified T Cells in Treating Patients With Stage III-IV Non-small Cell Lung Cancer or Mesothelioma
This phase I/II trial studies the side effects and best dose of genetically modified T cells
 in treating patients with stage III-IV non-small cell lung cancer (NSCLC) or mesothelioma.
 Many types of cancer cells, including NSCLC and mesothelioma, but not most normal cells, have
 a protein called Wilms tumor (WT)1 on their surfaces. This study takes a type of immune cell
 from patients, called T cells, and modifies their genes in the laboratory so that they are
 programmed to find cells with WT1 and kill them. The T cells are then given back to the
 patient. Cyclophosphamide and aldesleukin may also stimulate the immune system to attack
 cancer cells. Giving cyclophosphamide and aldesleukin with laboratory-treated T cells may
 help the body build an immune response to kill tumor cells.
PRIMARY OBJECTIVES:

 I. Determine the safety, and potential toxicities associated with treating patients with
 metastatic NSCLC and mesothelioma with polyclonal autologous central memory and naive cluster
 of differentiation (CD)8+ T cells that have been transduced to express a WT1-specific T-cell
 receptor (TCR) (Arm 1 and Arm 2).

 II. Determine the feasibility of treating patients with metastatic NSCLC and mesothelioma
 with polyclonal autologous central memory and naive CD8+ T cells that have been transduced to
 express a WT1-specific TCR (Arm 1 and Arm 2).

 III. Determine and compare the in vivo persistence in blood and tumor of transferred
 polyclonal autologous central memory and naive CD8+ T cells that have been transduced to
 express a WT1-specific TCR (Arm 1 and Arm 2).

 SECONDARY OBJECTIVES:

 I. Determine the antitumor efficacy for patients with metastatic NSCLC and mesothelioma (Arm
 1), as measured by time to progression (TTP) based on the Response Evaluation Criteria in
 Solid Tumors (RECIST) 1.1 criteria.

 II. Determine the in vivo functional capacity of adoptively transferred polyclonal autologous
 CD8+ T cells that have been transduced to express a WT1-specific TCR, and assess the
 acquisition of phenotypic characteristics associated with T cell exhaustion (Arm 1 and Arm
 2).

 III. Determine the migration to tumor sites of adoptively transferred polyclonal autologous
 CD8+ T cells that have been transduced to express a WT1-specific TCR (Arm 2).

 IV. Evaluate the tumor response and T cell infiltration in tumors of patients with stage IIIA
 NSCLC treated in the neo-adjuvant setting.

 OUTLINE: This is a phase I, dose-escalation study of autologous WT1-TCRc4 gene-transduced
 CD8-positive Tcm/Tn lymphocytes followed by a phase II study. Patients are assigned to 1 of 3
 treatment arms.

 ARM I, STAGE I: Patients receive autologous WT1-TCRc4 gene-transduced CD8-positive Tcm/Tn
 lymphocytes intravenously (IV) on days 0 and 14, cyclophosphamide IV on days 11 and 12, and
 aldesleukin (IL-2) subcutaneously (SC) twice daily (BID) for 14 days. Patients who have
 received radiation to the chest/lung tissue may receive T lymphocytes 90 days after
 completion of radiation.

 ARM I, STAGE II: Patients receive cyclophosphamide IV on days -3 and -2, autologous WT1-TCRc4
 gene-transduced CD8-positive Tcm/Tn lymphocytes IV on day 0, and aldesleukin SC BID for 14
 days.

 ARM II: Patients receive autologous WT1-TCRc4 gene-transduced CD8-positive Tcm/Tn lymphocytes
 IV between 24-96 hours after the last dose of chemotherapy and receive aldesleukin SC BID for
 14 days. Patients then undergo surgery within 3-4 weeks after the T-cell infusion.

 After completion of study treatment, patients are followed up at 3, 6, and 12 months and then
 annually for 14 years.
Inclusion Criteria:

 -  ELIGIBILITY FOR ENROLLMENT/SCREENING (ARMS 1 AND 2): Histopathological documentation
 of NSCLC or mesothelioma

 -  ELIGIBILITY FOR ENROLLMENT/SCREENING (ARMS 1 AND 2): Patients must be able to give
 informed consent

 -  ELIGIBILITY FOR ENROLLMENT/SCREENING (ARMS 1 AND 2): Patients must be able to provide
 blood and tumor samples and undergo the procedures required for this protocol

 -  Arm 2 ONLY: Surgically operable NSCLC or mesothelioma

 -  ELIGIBILITY FOR TREATMENT ON ARM 1: Patients must express human leukocyte antigen
 (HLA)-A*0201

 -  ELIGIBILITY FOR TREATMENT ON ARM 1: Evidence of WT1 tumor expression

 -  ELIGIBILITY FOR TREATMENT ON ARM 1: Patients must have received at least one line of
 therapy for NSCLC or mesothelioma or previously documented to have declined therapy

 -  ELIGIBILITY FOR TREATMENT ON ARM 1: NSCLC patients with a mutation in epidermal growth
 factor receptor (EGFR) or anaplastic lymphoma kinase (ALK) must have demonstrated
 progression or intolerance to at least one of the corresponding targeted therapies
 (for example erlotinib or crizotinib)

 -  ELIGIBILITY FOR TREATMENT ON ARM 1: Bi-dimensionally measurable disease by palpation,
 clinical exam, or radiographic imaging (X-ray, computed tomography [CT] scan, positron
 emission tomography [PET] scan, magnetic resonance imaging [MRI], or ultrasound)

 -  ELIGIBILITY FOR TREATMENT ON ARM 1: Ninety days must have passed since the last doses
 of radiation or chemoradiation treatment involving lung tissue or thorax prior to T
 cell infusion (to avoid confounding pneumonitis)

 -  ELIGIBILITY FOR TREATMENT ON ARM 1: Patients treated with prior immunotherapy
 including and not limited to vaccines, cytokines, T cell stimulating agents, cytotoxic
 T lymphocyte antigen 4 (CTLA4) inhibitors and programmed death (PD)-1 check point
 inhibitors are allowed on therapy provided they did not have any severe grade 4
 toxicities due to prior therapy and any toxicities due to prior therapy should have
 resolved, if resolvable to less than or equal to grade 1

 -  ELIGIBILITY FOR TREATMENT ON ARM 2: Patients must express HLA-A*0201

 -  ELIGIBILITY FOR TREATMENT ON ARM 2: Evidence of WT1 tumor expression

 -  ELIGIBILITY FOR TREATMENT ON ARM 2: Ninety days must have passed since the last
 definitive doses of radiation or chemoradiation treatment prior to T cell infusion (to
 avoid confounding pneumonitis)

 Exclusion Criteria:

 -  EXCLUSION FOR ENROLLMENT/SCREENING (ARMS 1 AND 2)

 -  Eastern Cooperative Oncology Group (ECOG) performance status >= 2

 -  Active autoimmune disease (e.g., systemic lupus erythematosus, vasculitis,
 infiltrating lung disease, inflammatory bowel disease) in which possible progression
 during treatment would be considered unacceptable by the investigators

 -  Any condition or organ toxicity deemed by the principal investigator (PI) or the
 attending physician to place the patient at unacceptable risk for treatment on the
 protocol

 -  Men or women of reproductive ability who are unwilling to use effective contraception
 or abstinence; women of childbearing potential must have a negative urine pregnancy
 test within 2 weeks prior to first infusion

 -  Pregnant women and nursing mothers will be eligible for screening only to test HLA
 type by saliva or buccal swab and WT1 expression from previously collected tissue
 sample

 -  Clinically significant and ongoing immune suppression including, but not limited to,
 systemic immunosuppressive agents such as cyclosporine or corticosteroids, chronic
 lymphocytic leukemia (CLL), uncontrolled human immunodeficiency virus (HIV) infection,
 or solid organ transplantation

 -  EXCLUSION FOR TREATMENT (ARMS 1 AND 2)

 -  Exclusions for the leukapheresis procedure (this can be performed at a later time of
 symptoms resolve):

 -  Infection, with or without antibiotic treatment

 -  Recent hepatitis exposure (hepatitis B or C antigenemia)

 -  Pregnancy or nursing

 -  HIV or human T-lymphotropic virus (HTLV) infection

 -  Positive result on standard test for syphilis (STS)

 -  Unable to generate antigen-specific WT1-specific CD8+ T cells for infusions; however,
 the patient will have the option to receive WT1-specific T-cells if a lower than
 planned number of cells is available

 -  Documented infections or known oral temperature > 38.2 degrees Celsius (C) fewer than
 72 hours prior to receiving study treatment or systemic infection requiring chronic
 maintenance; the start of treatment may be delayed

 -  Systemic steroids should be stopped 2 weeks before the start of treatment; topical and
 inhaled steroids are allowed

 -  Untreated central nervous system (CNS) metastasis that are > 1 cm or symptomatic are
 not allowed; (patients with CNS metastases > 1 cm or symptomatic that have been
 treated and demonstrated to be radiologically and clinically stable for at least 4
 weeks are allowed)

 -  White blood cells (WBC) < 2,000/ul

 -  Hemoglobin (Hb) < 8 g/dL

 -  Absolute neutrophil count (ANC) < 1,000/ul

 -  Platelets < 50,000/ul

 -  New York Heart Association functional class III-IV heart failure, symptomatic
 pericardial effusion, stable or unstable angina, symptoms of coronary artery disease
 (CAD), congestive heart failure, clinically significant hypotension or history of an
 ejection fraction of =< 30% (echocardiogram or multi-gated acquisition scan [MUGA])

 -  Clinically significant pulmonary dysfunction, as determined by medical history and
 physical exam; patients so identified will undergo pulmonary functions testing and
 those with forced expiratory volume in 1 second (FEV1) < 2.0 L or diffusion capacity
 of the lungs for carbon monoxide (DLCO) (corrected for Hb) < 50% will be excluded

 -  Creatinine > 1.5 x the upper limit of normal

 -  Aspartate aminotransferase/alanine aminotransferase (AST/ALT) > 5 x upper limits of
 normal (ULN)

 -  Bilirubin > 3 x ULN that cannot be attributed to NSCLC metastasis

 -  HIV or HTLV infection