Phase I Dose Escalation Study of CD19/CD22 Chimeric Antigen Receptor (CAR) T Cells in Children and Young Adults With Recurrent or Refractory B Cell Malignancies
Phase I Dose Escalation Study of CD19/CD22 Chimeric Antigen Receptor (CAR) T Cells in Children and Young Adults With Recurrent or Refractory B Cell Malignancies
This phase I trial studies the best dose and side effects of CD19/CD22 chimeric antigen
 receptor (CAR) T cells when given together with chemotherapy, and to see how well they work
 in treating children or young adults with CD19 positive B acute lymphoblastic leukemia that
 has come back or does not respond to treatment. A CAR is a genetically-engineered receptor
 made so that immune cells (T cells) can attack cancer cells by recognizing and responding to
 the CD19/CD22 proteins. These proteins are commonly found on B acute lymphoblastic leukemia.
 Drugs used in chemotherapy, such as fludarabine phosphate 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. Giving CD19/CD22-CAR T cells and
 chemotherapy may work better in treating children or young adults with B acute lymphoblastic
 leukemia.
PRIMARY OBJECTIVES:

 I. Determine the feasibility of producing CD19/CD22-CAR T cells meeting the established
 release criteria.

 II.Assess the safety of administering escalating doses of autologous CD19/CD22-CAR T cells
 that meet established release specifications in children and young adults with B-cell
 hematologic malignancies following a cyclophosphamide/fludarabine conditioning regimen. The
 following dose escalation will be used in two disease groups: 1) children and young adults
 with relapsed/refractory low disease burden ALL (< 5% blasts), and 2) children and young
 adults with relapsed/refractory high disease burden ALL (≥5% blasts) or lymphoma:

 1. Dose Level -1: 3 x 105 transduced T cells/kg (± 20%)

 2. Dose Level 1: 1 x 106 transduced T cells/kg (± 20%)

 3. Dose Level 2: 3 x 106 transduced T cells/kg (± 20%)

 4. Dose Level 3: 1 x 107 transduced T cells/kg (± 20%)

 SECONDARY OBJECTIVES:

 I. Evaluate the ability of CD19/CD22-CAR T cells to mediate clinical activity in children and
 young adults with B-acute lymphoblastic leukemia (ALL).

 TERTIARY OBJECTIVES:

 I. Analyze alterations in early B cell development induced by immune pressure exerted via
 CD19/CD22-CAR T cells.

 II. Evaluate whether subjects receiving CD19/CD22-CAR T cells relapse with loss or diminished
 expression of CD19 and/or CD22, when feasible.

 III. Measure persistence of CD19/CD22-CAR T cells in the blood, bone marrow and cerebral
 spinal fluid (CSF), and explore correlations between CD19/CD22-CAR T cell properties and CAR
 T cell efficacy and persistence.

 IV. Establish the utility of chromatin structure and epigenomic technology to characterize
 CAR T cell therapies.

 V. Explore the ability of CD19/CD22-CAR T cells to mediate clinical activity in children and
 young adults with refractory B cell lymphoma in a non-statistical cohort due to expectations
 of low accrual.

 OUTLINE: This is a dose-escalation study of CD19/CD22-CAR T cells.

 Patients receive fludarabine phosphate intravenously (IV) over 30 minutes on days -4 to -2
 and cyclophosphamide IV over 60 minutes on day -2. Patients then receive CD19/CD22-CAR T
 cells IV over 10-20 minutes on day 0. Patients that benefited from the first dose of
 CD19/CD22-CAR T cells, had no unacceptable side effects, and have enough cells left over may
 receive 2 or 3 additional doses of CD19/CD22-CAR T cells.

 After completion of study treatment, patients are followed up daily until day 14, twice
 weekly until day 28, at 2 and 3 months, every 3 months until month 12, every 6-12 months up
 to year 5, and then annually for years 6-15.
1.1 INCLUSION CRITERIA

 1. Diagnosis: ALL In view of the PI and the primary oncologist, there must be no
 available alternative curative therapies or subject has declined to pursue alternative
 therapy; and subjects must be either ineligible for allogeneic stem cell transplant
 (SCT), have refused SCT, recurred after SCT, or have disease activity that prohibits
 SCT at the time of enrollment.

 1. Chemotherapy refractory disease in subjects with B-ALL is defined as progression
 or stable disease after two lines of therapies

 2. Recurrence of disease after achieving a complete response (CR).

 3. Subjects with persistent or relapsed minimal residual disease (MRD) (by flow
 cytometry, PCR, FISH, or next generation sequencing) require verification of MRD
 positivity on two occasions at least 4 weeks apart.

 4. Subjects with Philadelphia Chromosome positive acute lymphoblastic leukemia
 (Ph+ALL) subjects are eligible if they progressed, had stable disease or relapsed
 after two lines of therapy, including tyrosine kinase inhibitors (TKIs).

 5. Subjects with recurrence of isolated CNS relapse after achieving complete
 remission (CR); if relapsed with MRD, will require verification of MRD positivity
 on two occasions at least 4 weeks apart.

 2. Diagnosis: Lymphoma Subjects with lymphoma must have progressed, had SD, or recurred
 after initial treatment regimens that include an anthracycline and an anti CD20
 monoclonal antibody. Subjects who relapse ≥12 months after therapy should have
 progressed after autologous transplant or been ineligible for autologous transplant.

 3. CD19 expression CD19 expression is required at any time since diagnosis. If patient
 has received anti-CD19 targeted therapy (i.e. Blinatumomab), then CD19 expression must
 be subsequently demonstrated. CD19 expression. must be detected on greater than 50% of
 the malignant cells by immunohistochemistry or ≥ 90% by flow cytometry. The choice of
 whether to use flow cytometry or immunohistochemistry will be determined by what is
 the most easily available tissue sample in each subject. In general,
 immunohistochemistry will be used for lymph node biopsies, flow cytometry will be used
 for peripheral blood and bone marrow samples.

 4. Subjects who have undergone autologous SCT with disease progression or relapse
 following SCT will be eligible if all other eligibility criteria are met. Subjects who
 have undergone allogeneic SCT will be eligible if, in addition to meeting other
 eligibility criteria, they are at least 100 days post-transplant, they have no
 evidence of active GVHD and have been without immunosuppressive agents for at least 30
 days.

 5. Subjects who have undergone prior anti-CD19 or anti-CD22 CAR therapy will be eligible
 if < 5% of circulating levels of CD3+ cells express the previous CAR by flow
 cytometry.

 6. Must have evaluable or measurable disease; subjects with lymphoma must have evaluable
 or measurable disease according to the revised IWG Response Criteria for Malignant
 Lymphoma[66] must be present. Lesions that have been previously irradiated will be
 considered measurable only if progression has been documented following completion of
 radiation therapy.

 7. At least 2 weeks or 5 half-lives, whichever is shorter, must have elapsed since any
 prior systemic therapy at the time the subject is planned for leukapheresis, except
 for systemic inhibitory/stimulatory immune checkpoint therapy, which requires 5
 half-lives.

 Exceptions:

 f. There is no time restriction with regard to prior intrathecal chemotherapy (incl.
 steroids) provided there is complete recovery from any acute toxic effects of such; g.
 Subjects receiving hydroxyurea may be enrolled provided there has been no increase in
 dose for at least 2 weeks prior to starting apheresis; h. Subjects who are on standard
 ALL maintenance type chemotherapy (vincristine, 6-mercaptopurine or oral methotrexate)
 may be enrolled provided that chemotherapy is discontinued at least 1 week prior to
 apheresis.

 i. Subjects receiving steroid therapy at physiologic replacement doses (≤ 5 mg/day of
 prednisone or equivalent doses of other corticosteroids) only are allowed provided
 there has been no increase in dose for at least 2 weeks prior to starting apheresis;
 j. For radiation therapy: Radiation therapy must have been completed at least 3 weeks
 prior to enrollment, with the exception that there is no time restriction if the
 volume of bone marrow treated is less than 10% and also the subject has
 measurable/evaluable disease outside the radiation port.

 8. Toxicities due to prior therapy must be stable and recovered to ≤ Grade 1 (except for
 clinically non-significant toxicities, such as alopecia, nutritional support measures,
 electrolyte abnormalities, or those not impacting the investigator's ability to assess
 treatment emergent toxicities)

 9. Age Greater than or equal to 1 year of age and less than or equal to 30 years of age
 at time of enrollment; must meet parameters for apheresis per institutional
 guidelines. NOTE: The first subject in the first dose cohort must be ≥ 18 years of age
 if an adult has not been treated at that dose cohort on the companion Stanford
 protocol "Phase 1 Dose Escalation Study of CD19/CD22 Chimeric Antigen Receptor (CAR) T
 Cells in Adults with Recurrent or Refractory B Cell Malignancies" and undergone safety
 evaluation at Day 28 without evidence of DLT.

 10. Performance Status: Subjects > 10 years of age: Karnofsky ≥ 50%; Subjects ≤ 10 years
 of age: Lansky scale ≥ 50% (See Appendix B Section 14.2)

 11. Normal Organ and Marrow Function (supportive care is allowed per institutional
 standards, i.e. filgrastim, transfusion)

 1. ANC ≥750/uL*

 2. Platelet count ≥50,000/uL*

 3. Absolute lymphocyte count ≥150/uL*

 4. Adequate renal, hepatic, pulmonary and cardiac function defined as:

 -  Serum ALT/AST ≤10 ULN (unless elevated ALT/AST is attributed to leukemia or
 lymphoma involvement of the liver, in which case this criterion will be
 waived and not disqualify a patient).

 -  Total bilirubin ≤1.5 mg/dl, except in subjects with Gilbert's syndrome.

 -  Cardiac ejection fraction ≥ 45%, no evidence of physiologically significant
 pericardial effusion as determined by an ECHO, and no clinically significant
 ECG findings

 -  No clinically significant pleural effusion

 -  Baseline oxygen saturation >92% on room air at rest

 -  creatinine: within age adjusted normal institutional limits (see table
 below) OR

 -  creatinine clearance ≥60 mL/min/1.73 m2 (as estimated by Cockcroft Gault
 Equation) for subjects with creatinine levels above institutional normal.

 Age (Years) Maximum Serum Creatinine (mg/dL)

 ≤5 0.8 5 < age ≤ 10 1.0 >10 1.2

 * if these cytopenias are not judged by the investigator to be due to underlying
 disease (i.e. potentially reversible with anti-neoplastic therapy); A subject will not
 be excluded because of pancytopenia ≥ Grade 3 if it is due to disease, based on the
 results of bone marrow studies.

 12. CNS Status

 1. Subjects with ALL

 Subjects with the following CNS status are eligible only in the absence of
 neurologic symptoms suggestive of CNS leukemia, such as cranial nerve palsy:

 -  CNS 1, defined as absence of blasts in cerebral spinal fluid (CSF) on
 cytospin preparation, regardless of the number of WBCs;

 -  CNS 2, defined as presence of < 5/µL WBCs in CSF and cytospin positive for
 blasts, or > 5/µL WBCs but negative by Steinherz/Bleyer algorithm:

 -  CNS 2a: <10/µL RBCs; < 5/µL WBCs and cytospin positive for blasts;

 -  CNS 2b: ≥10/µL RBCs; < 5/µL WBCs and cytospin positive for blasts;

 -  CNS 2c: ≥10/µL RBCs; ≥5/µL WBCs and cytospin positive for blasts but
 negative by Steinherz/Bleyer algorithm.

 2. Subjects with lymphoma

 Subjects must have no signs or symptoms of CNS disease or detectable evidence of CNS
 disease on MRI at the time of screening. Subjects who have previously been treated for
 CNS disease and who have the following CNS status will be eligible:

 -  CNS 1, defined as absence of blasts in cerebral spinal fluid (CSF) on cytospin
 preparation, regardless of the number of WBCs;

 -  CNS 2, defined as presence of < 5/µL WBCs in CSF and cytospin positive for
 blasts, or > 5/µL WBCs but negative by Steinherz/Bleyer algorithm:

 -  CNS 2a: < 10/µL RBCs; < 5/µL WBCs and cytospin positive for blasts;

 -  CNS 2b: ≥ 10/µL RBCs; < 5/µL WBCs and cytospin positive for blasts;

 -  CNS 2c: ≥ 10/µL RBCs; ≥ 5/µL WBCs and cytospin positive for blasts but
 negative by Steinherz/Bleyer algorithm.

 13. Females of childbearing potential must have a negative serum or urine pregnancy test
 (females who have undergone surgical sterilization or who have been postmenopausal for
 at least 2 years are not considered to be of childbearing potential)

 14. Contraception Subjects of child-bearing or child-fathering potential must be willing
 to practice birth control from the time of enrollment on this study and for four (4)
 months after receiving the preparative regimen.

 Females of child-bearing potential must have a negative pregnancy test because of the
 potentially dangerous/unknown effects on the fetus.

 15. Ability to give informed consent. All subjects ≥ 18 years of age must be able to give
 informed consent. For subjects <18 years old their legal authorized representative
 (LAR) (i.e. parent or guardian) must give informed consent. Pediatric subjects will be
 included in age appropriate discussion and verbal assent will be obtained for those >
 7 years of age, when appropriate.

 1.2 EXCLUSION CRITERIA

 Subjects meeting any of the following criteria are not eligible for participation in the
 study:

 1. Recurrent or refractory ALL limited to isolated testicular.

 2. Subjects with radiologically-detected CNS lymphoma or CNS 3 disease (presence of ≥
 5/µL WBCs in CSF and cytospin positive for blasts [in the absence of a traumatic
 lumbar puncture] and/or clinical signs of CNS leukemia).

 3. Hyperleukocytosis (≥ 50,000 blasts/µL) or rapidly progressive disease that in the
 estimation of the investigator and sponsor would compromise ability to complete study
 therapy.

 4. History of malignancy other than non-melanoma skin cancer or carcinoma in situ (e.g.
 cervix, bladder, breast) unless disease free for at least 3 years.

 5. Presence of fungal, bacterial, viral, or other infection that is uncontrolled or
 requiring IV antimicrobials for management. Simple UTI and uncomplicated bacterial
 pharyngitis are permitted if responding to active treatment.

 Ongoing infection with HIV or hepatitis B (HBsAg positive) or hepatitis C virus
 (anti-HCV positive) as the immunosuppression contained in this study will pose
 unacceptable risk. A history of hepatitis B or hepatitis C is permitted if the viral
 load is undetectable per quantitative PCR and/or nucleic acid testing.

 6. CNS disorder such as cerebrovascular ischemia/hemorrhage, dementia, cerebellar
 disease, or autoimmune disease with CNS involvement that in the judgment of the
 investigator may impair the ability to evaluate neurotoxicity.

 7. History of myocardial infarction, cardiac angioplasty or stenting, unstable angina, or
 other clinically significant cardiac disease within 12 months of enrollment, or have
 cardiac atrial or cardiac ventricular lymphoma involvement.

 8. Subjects receiving anticoagulation therapy.

 9. Any medical condition that in the judgement of the principal investigator is likely to
 interfere with assessment of safety or efficacy of study treatment

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

 11. Women of child-bearing potential who are pregnant or breastfeeding because of the
 potentially dangerous effects of the conditioning lymphodepletion chemotherapy on the
 fetus or infant. Females who have undergone surgical sterilization or who have been
 postmenopausal for at least 2 years are not considered to be of childbearing
 potential.

 12. In the investigator's judgment, the subject is unlikely to complete all
 protocol-required study visits or procedures, including follow-up visits, or comply
 with the study requirements for participation.

 13. May not have primary immunodeficiency or history of systemic autoimmune disease (e.g.
 Crohns, rheumatoid arthritis, systemic lupus) resulting in end organ injury or
 requiring systemic immunosuppression/systemic disease modifying agents within the last
 2 years.