T Cells Expressing a Fully-human AntiCD19 Chimeric Antigen Receptor for Treating B-cell Malignancies
T Cells Expressing a Fully-human AntiCD19 Chimeric Antigen Receptor for Treating B-cell Malignancies
Background:

 The immune system fights infection and can affect cancer cells. T cells are white blood cells
 that are a major part of the immune system. T cells can destroy tumors. Researchers want to
 try to manipulate the immune system to better recognize and kill tumor cells.

 Objective:

 To test the safety of giving T cells expressing a novel fully-human anti-CD19 chimeric
 antigen receptor (CAR) to people with advanced B-cell cancer.

 Eligibility:

 People ages 18 73 with a B-cell cancer that has not been controlled by other therapies.

 Design:

 Participants will be screened with:

 Physical exam

 Blood and urine tests

 Heart tests

 Bone marrow sample taken

 Scans in machines that take pictures

 Participants will have apheresis. Blood is removed through a needle in an arm. T cells are
 removed. The rest of the blood is returned through a needle in the other arm.

 The cells will be changed in a laboratory.

 Participants will get 2 chemotherapy drugs over 3 days.

 Two days later, participants will check into the hospital. They will get an intravenous (IV)
 catheter in an arm or chest vein. They will get the T cells through the IV in 1 infusion.

 After this, participants will stay in the hospital for at least 9 days and stay nearby for 2
 weeks. Then they will have blood tests and see a doctor.

 Participants will have visits 6 visits for 1 year after the infusion. Some may have more
 follow-up visits.

 Participants may samples taken of spinal fluid, bone marrow, and tumors.

 ...
Background:

 -  Improved treatments for a variety of treatment-resistant B-cell malignancies including
 Bcell lymphomas and chronic lymphocytic leukemia (CLL), are needed.

 -  A particular need is development of new treatments for chemotherapy-refractory B-cell
 malignancies.

 -  T cells can be genetically modified to express chimeric antigen receptors (CARs) that
 specifically target malignancy-associated antigens.

 -  Autologous T cells genetically modified to express CARs targeting the B-cell antigen
 CD19 have caused complete remissions in a small number of patients with leukemia or
 lymphoma. These results demonstrate that anti-CD19 CAR-expressing T cells have
 antimalignancy activity in humans.

 -  The vast majority of B-cell malignancies express CD19.

 -  CD19 is not expressed by normal cells except for B cells.

 -  We have constructed a novel fully-human anti-CD19 CAR that can specifically recognize
 CD19-expressing target cells in vitro and eradicate CD19-expressing tumors in mice.

 -  This fully-human CAR targeting CD19 has not been tested in humans before.

 -  Possible toxicities include cytokine-associated toxicities such as fever, hypotension,
 and neurological toxicities. Elimination of normal B cells is probable, and unknown
 toxicities are also possible.

 Objectives:

 Primary

 -Determine the safety and feasibility of administering T cells expressing a novel fully-human
 anti-CD19 CAR to patients with advanced B-cell malignancies.

 Secondary

 -  Evaluate the in vivo persistence and peak blood levels of anti-CD19 CAR T cells after
 initial and repeated CAR T-cell infusions. CAR T-cell blood levels will be compared
 retrospectively to results with an anti-CD19 CAR containing an antigen-recognition
 moiety derived from a murine antibody.

 -  Assess for evidence of anti-malignancy activity by anti-CD19 CAR T cells

 -  Assess the impact of repeated CAR T-cell infusions on residual malignancy after an
 initial CAR T-cell infusion.

 -  Assess the immunogenicity of the CAR used in this protocol.

 Eligibility:

 -  Patients must have any B-cell lymphoma, or CLL/SLL. Lower grade lymphomas transformed to
 DLBCL are potentially eligible as is primary mediastinal B-cell lymphoma and all other
 subtypes of DLBCL.

 -  Patients must have malignancy that is measurable on a CT scan or by flow cytometry of
 bone marrow or blood.

 -  Patients must have a creatinine of 1.4 mg/dL or less and a normal cardiac ejection
 fraction.

 -  An ECOG performance status of 0-1 is required.

 -  No active infections are allowed including any history of hepatitis B or hepatitis C.

 -  Absolute neutrophil count greater than or equal to1000/microliter, platelet count
 greater than or equal to 45,000/microliter, hemoglobin greater than or equal to 8g/dL

 -  Serum ALT and AST less or equal to 3 times the upper limit of the institutional normal
 unless liver involvement by malignancy is demonstrated.

 -  At least 14 days must elapse between the time of any prior systemic treatment (including
 corticosteroids) and initiation of protocol enrollment.

 -  The patient s malignancy will need to be assessed for CD19 expression by flow cytometry
 or immunohistochemistry performed at the NIH. If unstained, paraffinembedded bone marrow
 or lymphoma sections are available from prior biopsies, these can be used to determine
 CD19 expression by immunohistochemistry; otherwise, patients will need to come to the
 NIH for a biopsy to determine CD19 expression. The sample for CD19 expression can come
 from a biopsy obtained at any time before enrollment.

 -  Patients who have never had an allogeneic hematopoietic stem cell transplant are
 potentially eligible.

 Design:

 -  This is a phase I dose-escalation trial

 -  Patients will undergo leukapheresis

 -  T-cells obtained by leukapheresis will be genetically modified to express an anti-CD19
 CAR

 -  Patients will receive a lymphocyte-depleting chemotherapy conditioning regimen with the
 intent of enhancing the activity of the infused anti-CD19-CAR-expressing T cells.

 -  The chemotherapy conditioning regimen is cyclophosphamide 300 mg/m(2) daily for 3 days
 and fludarabine 30 mg/m(2) daily for 3 days. Fludarabine will be given on the same days
 as the cyclophosphamide.

 -  Two days after the chemotherapy ends, patients will receive an infusion of
 anti-CD19-CAR-expressing T cells.

 -  The initial dose level of this dose-escalation trial will be 0.66x10(6) CAR+ T cells/kg
 of recipient bodyweight.

 -  The cell dose administered will be escalated until a maximum tolerated dose is
 determined.

 -  Following the T-cell infusion, there is a mandatory 9-day inpatient hospitalization to
 monitor for toxicity.

 -  Outpatient follow-up is planned for 2 weeks, and 1, 2, 3, 6, 9, and 12 months after the
 CAR T-cell infusion. Long-term gene-therapy follow-up consisting of yearly visits to a
 doctor near the patient s home for 4 more years and then yearly telephone contact for 10
 additional years will be required.

 -  Repeat treatments consisting of the conditioning chemotherapy followed by a CAR T-cell
 infusion are planned for eligible patients with any best responses except continuing
 complete remission or progressive malignancy.

 -  Re-enrollment will be allowed for a small number of subjects.
-  INCLUSION CRITERIA:

 -  Malignancy criteria:

 -  Patients with the following malignancies are potentially eligible: any B-cell
 lymphoma, and chronic lymphocytic leukemia (CLL). Patients with indolent
 malignancies that have transformed to diffuse large B-cell lymphoma are eligible.

 -  Clear CD19 expression must be uniformly detected on 75% or more of malignant
 cells from either bone marrow or a leukemia or lymphoma mass by flow cytometry or
 immunohistochemistry. These assays must be performed at the National Institutes
 of Health. It is preferable but not required that the specimen used for CD19
 determination comes from a sample that was obtained after the patient s most
 recent treatment. If paraffin embedded unstained samples of bone marrow involved
 with malignancy or a lymphoma mass are available, these can be shipped to the NIH
 for CD19 staining; otherwise, new biopsies will need to be performed for
 determination of CD19 expression.

 -  DLBCL patients must have received at least two prior chemotherapy-containing
 regimens at least one of which must have contained doxorubicin and a monoclonal
 antibody. Follicular lymphoma patients must have received at least 2 prior
 regimens including at least 1 regimen with chemotherapy. All other lymphoma and
 leukemia patients must have had at least 1 prior chemotherapy-containing regimen.
 All patients with CLL or small lymphocytic lymphoma must have had prior treatment
 with ibrutinib or another signal transduction inhibitor.

 -  Patients must have measurable malignancy as defined by at least one of the
 criteria below.

 -  Lymphoma or leukemia masses that are measurable (minimum 1.5 cm in largest
 diameter) by CT scan is required for all diagnoses except CLL. All masses
 must be less than 10 cm in the largest diameter.

 -  For a lymphoma mass to count as measurable malignancy, it must have
 abnormally increased metabolic activity when assessed by positron emission
 tomography (PET) scan.

 -  For CLL and lymphoma with only bone marrow involvement no mass is necessary,
 but if a mass is not present, bone marrow malignancy must be detectable by
 flow cytometry in lymphoma and CLL.

 -  Other inclusion criteria:

 -  Greater than or equal to 18 years of age and less than or equal to age 73.

 -  Able to understand and sign the Informed Consent Document.

 -  Clinical performance status of ECOG 0-1

 -  Room air oxygen saturation of 92% or greater

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

 -  Women of child bearing potential must have a negative pregnancy test because of
 the potentially dangerous effects of the preparative chemotherapy on the fetus.
 Women of child-bearing potential are defined as all women except women who are
 post-menopausal

 or who have had a hysterectomy. Postmenopausal will be defined as women over the age of 55
 who have not had a menstrual period in at least 1 year.

 -  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 are less responsive to the experimental
 treatment and more susceptible to its toxicities.)

 -  Patients with a known history of hepatitis B or hepatitis C are not eligible due to
 the risk of re-activation of hepatitis after prolonged B-cell depletion due to
 anti-CD19 CAR T cells.

 -  Seronegative for hepatitis B antigen, positive hepatitis B tests can be further
 evaluated by confirmatory tests, and if confirmatory tests are negative, the patient
 can be enrolled. Patients with a known history of hepatitis B are not eligible.

 -  Seronegative for hepatitis C antibody unless antigen negative. If hepatitis C antibody
 test is positive, then patients must be tested for the presence of RNA by RT-PCR and
 be HCV RNA negative. Patients with a known history of hepatitis C are not eligible.

 -  Absolute neutrophil count greater than or equal to 1000/mm(3) without the support of
 filgrastim or other growth factors.

 -  Platelet count greater than or equal to 45,000/mm(3) without transfusion support

 -  Hemoglobin greater than 8.0 g/dl.

 -  Less than 5% malignant cells in the peripheral blood leukocytes

 -  Serum ALT and AST less or equal to 3 times the upper limit of the institutional normal
 unless liver involvement by malignancy is demonstrated.

 -  Serum creatinine less than or equal to 1.4 mg/dL.

 -  Total bilirubin less than or equal to 2.0 mg/dl.

 -  At least 14 days must have elapsed since any prior systemic therapy prior to apheresis
 and prior to the initiation of chemotherapy (including systemic corticosteroids at any
 dose). Because this protocol requires collection of autologous blood cells by
 leukapheresis

 in order to prepare CAR T cells, systemic anti-malignancy therapy including systemic
 corticosteroid therapy of any dose are not allowed within 14 days prior to the required
 leukapheresis. NOTE: Because of the long half-life and potential to affect CAR T cells, 60
 days must elapse from the time of administration of anti-PD-1 or anti-PD-L1 antibodies or
 other agents that in the opinion of the PI can stimulate immune activity and infusion of
 CAR T cells.

 -  Normal cardiac ejection fraction (greater than or equal to 55% by echocardiography)
 and no evidence of hemodynamically significant pericardial effusion as determined by
 an echocardiogram within 4 weeks of the start of the treatment protocol.

 -  Patients must not take corticosteroids including prednisone, dexamethasone or any
 other corticosteroid for 14 days before apheresis and CAR T-cell infusion. Patients
 must also not take corticosteroids at doses higher than 5 mg/day of prednisone or
 equivalent at any

 time after the CAR T cell infusion.

 --Patients who have been treated on other protocols of genetically-modified T cells at the
 NIH only are potentially eligible under these conditions:

 ---At least 6 months have elapsed since the last genetically-modified T-cell therapy that
 the patient received and there is no evidence of replication-competent retroviruses
 (evidence must be provided from prior NIH gene-therapy protocol Principal Investigator) and
 persisting genetically-modified T cells are not detectable in the patient s blood (evidence
 must be provided by prior NIH gene-therapy protocol Principal Investigator).

 EXCLUSION CRITERIA:

 -  Patients that require urgent therapy due to tumor mass effects or spinal cord
 compression.

 -  Patients that have active hemolytic anemia.

 -  Patients with second malignancies in addition to their B-cell malignancy are not
 eligible if the second malignancy has required treatment (including maintenance
 therapy) within the past 4 years or is not in complete remission. There are two
 exceptions to this

 criterion: successfully treated non-metastatic basal cell or squamous cell skin carcinoma.

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

 -  Active uncontrolled systemic infections (defined as infections causing fevers and
 infections requiring intravenous antibiotics when intravenous antibiotics have been
 administered for less than 72 hours), active coagulation disorders or other major
 uncontrolled medical illnesses of the cardiovascular, respiratory, endocrine, renal,
 gastrointestinal, genitourinary or immune system, history of myocardial infarction,
 history of ventricular tachycardia or ventricular fibrillation, active cardiac
 arrhythmias (active atrial fibrillation is not allowed, resolved atrial fibrillation
 not requiring current treatment is allowed (anticoagulants count as current treatment)
 ), active obstructive or restrictive pulmonary disease, active autoimmune diseases
 such as rheumatoid arthritis.

 -  Patients will not be seen for screening appointments or enrolled on the protocol if
 they have been hospitalized within the 7 days prior to the screening appointment or
 the date of protocol enrollment.

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

 -  Systemic corticosteroid steroid therapy of any dose is not allowed within 14 days
 prior to the required leukapheresis, or the initiation of the conditioning
 chemotherapy regimen. Corticosteroid creams, ointments, and eye drops are allowed.

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

 -  Patients with current CNS involvement by malignancy (either by imaging or
 cerebrospinal fluid involvement or biopsy-proven).