Administration of Donor T Cells With the Caspase-9 Suicide Gene (DOTTI)
Patients will be receiving a stem cell transplant as treatment for their disease. As part of the stem cell transplant, patients will be given very strong doses of chemotherapy, which will kill all their existing stem cells.
A close relative of the patient will be identified, whose stem cells are not a perfect match for the patient's, but can be used. This type of transplant is called "allogeneic", meaning that the cells are from a donor. With this type of donor who is not a perfect match, there is typically an increased risk of developing GvHD, and a longer delay in the recovery of the immune system. Seventy to ninety percent of people who receive unchanged marrow or stem cells from this type of donor will develop severe GvHD.
GvHD is a serious and sometimes fatal side-effect of stem cell transplant. GvHD occurs when the new donor cells (graft) recognize that the body tissues of the patient (host) are different from those of the donor. When this happens, cells in the graft may attack the host organs, primarily the skin, liver and intestines, causing severe rashes, diarrhea, liver disease, and even death. GvHD is caused by a type of immune cell in the graft called T cells.
While this stem cell selection procedure will reduce the risk of GvHD, it will also result in slower recovery of the patient's immune system. As the immune system is responsible for fighting infections in your body, a longer recovery time after a transplant means that the patient may be at increased risk for infections which can become life-threatening. In some patients, the immune system can also fight leukemia cells and reduce the risk of relapse.
In this study, investigators are trying to see whether they can make special T cells in the laboratory that can be given to the patient to help their immune system recover faster. As a safety measure, we want to "program" the T cells so that if, after they have been given to the patient, they start to cause GvHD, we can destroy them ("suicide gene").
Investigators will obtain T cells from a donor, culture them in the laboratory, and then introduce the "suicide gene" which makes the cells sensitive to a specific drug called AP1903. If the specially modified T cells begin to cause GvHD, the investigators can kill the cells by administering AP1903 to the patient. We have had encouraging results in a previous study regarding the effective elimination of T cells causing GvHD in vitro, whilst sparing a sufficient number of T cells to fight infection and potentially cancer.
More specifically, T cells made to carry a gene called iCasp9 can be killed when they encounter the drug AP1903. To get the iCasp9 gene into T cells, we insert it using a virus called a retrovirus that has been made for this study. The drug (AP1903) that will be used to "activate" the iCasp9 is an experimental drug that has been tested in a study in normal donors with no bad side-effects. We hope we can use this drug to kill the T cells. Other drugs that kill or damage T cells have helped GvHD in many studies, but with a more profound reduction of immune defense. However, if the patient develops significant GvHD, they will also receive standard therapy for this complication, in addition to the experimental drug.
The major purpose of this study is to find a safe and effective dose of "iCasp9" T cells that can be given to patients who receive an allogeneic stem cell transplant. Another important purpose of this study is to find out whether these special T cells can help the patient's immune system recover faster after the transplant than they would have otherwise.
|Acute Lymphoblastic Leukemia Myelodysplastic Syndrome Acute Myeloid Leukemia Chronic Myelogenous Leukemia Non Hodgkin Lymphoma Hemophagocytic Lymphohistiocytosis Familial Hemophagocytic Lymphohistiocytosis Hemophagocytic Syndrome Epstein Barr Virus Infection X-linked Lymphoproliferative Disease||Biological: iCaspase9-transduced T cells Drug: AP1903||Phase 1|
|Study Design:||Intervention Model: Single Group Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
|Official Title:||Administration of Haploidentical Donor T Cells Transduced With the Inducible Caspase-9 Suicide Gene|
- Clinical and immunological effects of AP1903 administration. [ Time Frame: 14 days ]To evaluate the clinical and immunological effects of AP1903 administration, a dimerizer drug used to activate an iCaspase9 suicide gene mechanism, to subjects who have received escalating doses of T lymphocytes expressing the iCaspase9 gene and developed acute graft-versus-host-disease (GvHD).
- T cell dose that produces a greater than 25% risk of Grade II or greater GvHD. [ Time Frame: 42 days ]To discover the number of T cells/kg (up to 5 x 10^6/kg) that produce a greater than 25% risk of inducing Grade II or greater acute GvHD in these subjects.
- Immune reconstitution and relative contribution of iCaspase9-modified T cells post-infusion. [ Time Frame: Up to 15 years ]To measure the subsequent immune reconstitution of recipients of iCaspase9 modified T cells (and dimerizer drug), and assess the relative contribution of endogenous T cell recovery and infused gene-modified T cells.
- Overall and disease-free survival. [ Time Frame: 100 days and 1 year ]To measure the overall and disease-free survival of recipients of iCaspase9 T cells at 100 days and at 1 year post-transplant.
|Study Start Date:||November 2011|
|Estimated Study Completion Date:||May 2029|
|Estimated Primary Completion Date:||May 2029 (Final data collection date for primary outcome measure)|
Experimental: iCaspase9-transduced T cells
The 5 dose levels are:
Biological: iCaspase9-transduced T cells
Patients will receive the T cells between 30 and 90 days following transplantation. The T cells will be infused through a catheter line.Drug: AP1903
AP1903 will be administered if there is development of Grade 1 or greater GvHD.
Dose: 0.4 mg/kg by IV over 2 hours.
Up to 3 additional doses may be administered if the GvHD does not respond or gets worse.
If the patient is doing well after the stem cell transplant, and does not have severe GvHD, s/he will be eligible to receive the special "iCasp9" T cells from Day 30 to 90 after transplant. The specially selected and treated T cells will be given by vein (IV) once.
This is a dose escalation study. This means that at the beginning, patients will be started on the lowest dose (1 of 5 different levels) of T cells. Once that dose schedule proves safe, the next group of patients will be started at a higher dose. This process will continue until all 5 dose levels are studied. If the side-effects are too severe, the dose will be lowered or the T cell injections will be stopped.
If the patient develops GvHD after being given the specially treated T cells, we will prescribe AP1903, which has been shown to kill cells carrying the iCasp9 gene. This drug will be given as a 2-hour IV infusion.
We will continue to follow the patient weekly in the bone marrow transplant clinic for the first month after the infusion, to check for side-effects of the treatment and for GvHD. The patient will have the standard tests performed that all patients have after transplant, even when not receiving special T cells.
Please refer to this study by its ClinicalTrials.gov identifier: NCT01494103
|United States, Texas|
|Texas Children's Hospital|
|Houston, Texas, United States, 77030|
|The Methodist Hospital|
|Houston, Texas, United States, 77030|
|Principal Investigator:||Malcolm K Brenner, MB, PhD||Baylor College of Medicine|