Chimeric Antigen Receptor T-cells for The Treatment of AML Expressing CLL-1 Antigen
Chimeric Antigen Receptor T-cells for The Treatment of AML Expressing CLL-1 Antigen
Patients eligible for this study have a type of blood cancer Acute Myeloid Leukemia (AML)
 which has come back or has not gone away after treatment.

 The body has different ways of fighting disease and infection, and this research study
 combines two different ways of fighting cancer with antibodies and T cells with the hope that
 they will work together. T cells (also called T lymphocytes) are special infection-fighting
 blood cells that can kill other cells including tumor cells. Antibodies are types of proteins
 that protect the body from bacterial and other infectious diseases. Both antibodies and T
 cells have been used to treat patients with cancers; they have shown promise, but have not
 been strong enough to cure most patients when used alone.

 T lymphocytes can kill tumor cells but there normally are not enough of them to kill all the
 tumor cells. Some researchers have taken T cells from a person's blood, grown more of them in
 the laboratory and then given them back to the person. The antibody used in this study
 targets CLL-1. This antibody sticks to AML cells because of a substance (protein) on the
 outside of these cells called CLL-1. For this study, the antibody to CLL-1 has been changed
 so that instead of floating free in the blood, it is now joined to the T cells. When T-cells
 contain an antibody that is joined to them, they are called chimeric antigen receptor T-cells
 or CAR-T cells.

 In the laboratory, the investigators have also found that T cells work better if proteins
 that stimulate T cells are also added, such as one called CD28. Adding the CD28 makes the
 cells grow better and last longer in the body, thus giving the cells a better chance of
 killing the leukemia or lymphoma cells. In this study we are going to attach the CLL-1
 chimeric receptor that has CD28 added to it to the patient's T cells. We will then test how
 long the cells last.

 These CLL-1 chimeric antigen receptor T cells with CD28 are investigational products not
 approved by the Food and Drug Administration.
To make the CLL1-CD28 chimeric antigen receptor T cells, the investigators will collect the
 patient's blood and stimulate them with growth factors to make the cells grow. To get the
 CLL-1 antibody and CD28 to attach to the surface of the T cell, we put the antibody gene into
 the T cell. This is done using a virus called a retrovirus that has been made for this study
 and will carry the antibody gene into the T cell. This virus also helps investigators find
 the T cells in the patient's blood after they are injected. Because the patient will have
 received cells with a new gene in them the patient will be followed for a total of 15 years
 to see if there are any long term side effects of gene transfer.

 When the patient enrolls on this study, the patient will be assigned a dose of CLL-1 chimeric
 antigen receptor- T cells. Several studies suggest that the T cells that we give to the
 patient need room to be able to grow and work well and that this may not happen if there are
 too many other T cells already in circulation the patient's body. Because of that, the
 patient will receive two chemotherapy medications before receiving the CLL-1 chimeric antigen
 receptor- T cells.

 One medication is called cyclophosphamide and the other fludarabine. The patient will receive
 3 daily doses of each drug, ending at least one day before receiving the chimeric antigen
 receptor- T cells. These drugs will lower the numbers of the patient's T cells before we give
 them the CLL-1 chimeric antigen receptor T cells and will also help lower the number of other
 cells that may block the chimeric antigen receptor- T cells from working well. Although we do
 not expect any effect on the patient's cancer with the doses that will be received, these
 drugs are part of many treatment plans that are used to treat leukemia.

 Patients will be given an injection of cells into the vein through an IV at the assigned
 dose. The injection will take from 1 to 10 minutes. Before patients receive the injection,
 they may be given a dose of Benadryl and Tylenol. The treatment will be given by the Center
 for Cell and Gene Therapy at Texas Children's Hospital or Houston Methodist Hospital.

 Investigators will monitor patients in the clinic after the injection for up to 3 hours, and
 they will have to remain locally for at least 3 weeks after the infusion. If patients have
 any side effects, they may have to be admitted to the hospital for evaluation and management.
 If after a 4 week evaluation period following the infusion, the patient has achieved a
 complete response, his/her cancer doctors may decide if you should go on to have a bone
 marrow transplant, at which time the patient will be removed from the treatment portion of
 the study.

 BEFORE BEING TREATED, PATIENTS WILL RECEIVE A SERIES OF STANDARD MEDICAL TESTS:

 -  Physical exam and History

 -  Blood tests to measure blood cells, kidney and liver function

 -  Pregnancy test for female patients who are of child bearing potential -Measurements of
 your tumor by bone marrow studies

 -  Imaging such as PET scans, CT scans or MRIs will be obtained if needed

 PATIENTS WILL RECEIVE STANDARD MEDICAL TESTS DURING TREATMENT AND AFTER:

 -  Physical exams and History

 -  Blood tests to measure blood cells, kidney and liver function

 -  Measurements of your tumor by bone marrow studies 4-6 weeks after the infusion, possibly
 12 weeks after the infusion and then per standard of care.

 -  Imaging such as PET scans, CT scans or MRIs will be obtained if needed 4-6 weeks
 following the infusion

 To learn more about the way the CLL-1 chimeric receptor-T cells are working and how long they
 last in the body, extra blood will be drawn. The total amount on any day is about 10
 teaspoons (50 mL) or no more than 3 mL per 2.2 pounds body weight in children. This amount is
 considered safe but may be lowered if you are anemic. This blood may be taken from a central
 line if you have one. Blood will be taken before the chemotherapy drugs, several hours after
 the T cell infusion, at 1 week, 2 weeks, 3 weeks, 4 weeks, 6 weeks, and 8 weeks after the
 infusion, at 3 months, 6 months, 9 months, at 1 year, every 6 months for 4 years, then yearly
 for a total of 15 years.

 If patients have a bone marrow exam while they are on this study, we may ask to have a sample
 of bone marrow to look for CLL-1 chimeric receptor- T cells.

 If a patient decides to withdraw at any time during the study, both samples and data
 collected during his/her participation will be kept.
PROCUREMENT

 Inclusion Criteria:

 1. Diagnosis of primary refractory or relapsed Acute Myeloid Leukemia (AML) AND suitable
 for consideration of allogeneic Hematopoietic Stem Cell Transplant with confirmation
 of an identified eligible donor by a FACT accredited transplant center and with
 confirmation that the center plans to proceed with transplant if CLL-1.CAR treatment
 induces response they consider adequate to proceed to allogeneic HSCT

 2. CLL-1 positive tumor with at least 30% CLL-1 blasts by flow cytometry or
 immunohistochemistry (tissue) assessed by a CLIA certified Flow Cytometry/Pathology
 laboratory

 3. Age ≤75 years NOTE: The first six (6) patients treated on the study will be adults
 (≥18 yrs of age).

 4. Hgb ≥ 7.0 g/dL(can be transfused)

 5. Life expectancy greater than 12 wks

 6. If apheresis required to collect blood

 -  PT and APTT <1.5x ULN

 -  Serum Creatinine < 1.5 x ULN

 -  AST < 1.5 x ULN

 7. Informed consent

 Exclusion Criteria:

 1. Active infection (bacterial, fungal or viral) requiring ongoing treatment without
 improvement.

 2. Active infection with HIV or HTLV

 3. Active second cancer (except non-melanoma skin cancer or in situ breast cancer or
 cervix cancer)or other cancer treated ≤ 2 years prior to enrollment

 4. Ongoing treatment with immune suppression for prophylaxis or treatment of GVHD
 including high dose steroids (eg prednisone > 0.25mg/kg)

 -

 TREATMENT

 Inclusion Criteria:

 1. Diagnosis of primary refractory or relapsed Acute Myeloid Leukemia (AML). Patients
 with targetable mutations should have failed or be ineligible for targeted therapies
 (e.g. FLT3 inhibitors, IDH inhibitors, or anti-CD33 drug conjugate). AND patients
 should be suitable for consideration of allogeneic Hematopoietic Stem Cell Transplant
 with confirmation of an identified eligible donor by a FACT accredited transplant
 center and with confirmation that the center plans to proceed with transplant if
 CLL-1.CAR treatment induces a response they consider adequate to proceed to allogeneic
 HSCT.

 2. CLL-1 positive tumor with at least 30% CLL-1 blasts by flow cytometry or
 immunohistochemistry (tissue) assessed by a CLIA certified Flow Cytometry/Pathology
 laboratory

 3. Age ≤75 years NOTE: The first six (6) patients treated on the study will be adults
 (≥18 yrs of age).

 4. AST/ALT less than 5 times the upper limit of normal

 5. Bilirubin less than 3 times the upper limit of normal

 6. Estimated GFR ≥ 60ml/min

 7. Pulse oximetry of > 92% on room air

 8. Karnofsky/Lansky ≥ 60

 9. Recovered from all acute toxic effects of prior chemotherapy at least one week before
 study entry and off systemic chemotherapy at least 2 weeks prior to study entry

 10. Available autologous transduced activated peripheral blood T-cell product with ≥ 20%
 expression of CLL-1.CAR.28z by flow cytometry

 11. Life expectancy > 12 weeks

 12. Sexually active patients must be willing to utilize one of the more effective birth
 control methods during the study and for 6 months after the study is concluded. The
 male partner should use a condom

 13. Informed consent explained to, understood by, and signed by patient/guardian.
 Patient/guardian given copy of informed consent.

 Exclusion Criteria:

 1. Currently receiving any investigational agents or having received any tumor vaccines
 within the previous 6 weeks.

 2. History of hypersensitivity reactions to murine protein-containing products.

 3. Pregnant or lactating.

 4. Active infection with HIV or HTLV.

 5. Clinically significant bacterial, viral or fungal infection requiring ongoing
 antifungal therapy without improvement,.

 6. Cardiac criteria: Prolonged QTc with maximum interval as defined by age with ;
 Uncontrolled atrial fibrillation/flutter; Myocardial infarction within the last 6
 months; Cardiac echocardiography with LVSF<30% or LVEF<50% or clinically significant
 pericardial effusion; Cardiac dysfunction NYHA III or IV; CNS abnormalities: Presence
 of CNS disease defined as detectable cerebrospinal blast cells in a sample of CSF with
 ≥ 5 WBCs per mm3 or chloroma on imaging, History or presence of an underlying CNS
 disorder such as a seizure disorder requiring current use of antiepileptic
 medications, cerebrovascular ischemia/hemorrhage within prior 6 months, dementia,
 cerebellar disease, or any autoimmune disease with CNS involvement.

 7. Use of serotherapy with Campath or Anti-Thymocyte Globulin (ATG) within the last 28
 days

 8. Use of Donor Lymphocyte Infusion (DLI) or other cellular therapy product within 30
 days

 9. Acute GVHD ≥ Grade 2 or moderate to severe (formerly extensive) chronic GVHD

 10. Aministration of high dose steroids >1 mg/kg within the preceding 5 days or currently
 receiving > 0.25 mg/kg of Prednisone equivalent

 11. Hyperleukocytosis (WBC ≥50K) or rapidly progressive disease that in the estimation of
 the investigator would compromise the ability of the patient to complete the study.