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Administration of Autologous T-Cells Genetically Engineered to Express T-Cell Receptors Reactive Against Mutated Neoantigens in People With Metastatic Cancer

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ClinicalTrials.gov Identifier: NCT03412877
Recruitment Status : Recruiting
First Posted : January 29, 2018
Last Update Posted : April 20, 2020
Sponsor:
Information provided by (Responsible Party):
National Institutes of Health Clinical Center (CC) ( National Cancer Institute (NCI) )

Tracking Information
First Submitted Date  ICMJE January 26, 2018
First Posted Date  ICMJE January 29, 2018
Last Update Posted Date April 20, 2020
Actual Study Start Date  ICMJE September 6, 2018
Estimated Primary Completion Date March 23, 2027   (Final data collection date for primary outcome measure)
Current Primary Outcome Measures  ICMJE
 (submitted: December 31, 2019)
Response rate [ Time Frame: 6 and 12 weeks after cell infusion, then every 3 months x3, then every 6 months x 2 years, then per PI discretion ]
Percentage of patients who receive pembrolizumab as part of the treatment regimen that have a clinical response to treatment (objective tumor regression)
Original Primary Outcome Measures  ICMJE
 (submitted: January 26, 2018)
Response rate [ Time Frame: 6 and 12 weeks after cell infusion, then every 3 months x3, then every 6 months x 2 years, then per PI discretion ]
Percentage of patients who have a clinical response to treatment
Change History
Current Secondary Outcome Measures  ICMJE
 (submitted: December 28, 2019)
Safety and tolerance [ Time Frame: 6 weeks ( 2 weeks) following administration of the cell product or 30 days following the last dose of pembrolizumab ]
Using standard CTCAE 5.0
Original Secondary Outcome Measures  ICMJE Not Provided
Current Other Pre-specified Outcome Measures Not Provided
Original Other Pre-specified Outcome Measures Not Provided
 
Descriptive Information
Brief Title  ICMJE Administration of Autologous T-Cells Genetically Engineered to Express T-Cell Receptors Reactive Against Mutated Neoantigens in People With Metastatic Cancer
Official Title  ICMJE Administration of Autologous T-Cells Genetically Engineered to Express T-Cell Receptors Reactive Against Mutated Neoantigens in People With Metastatic Cancer
Brief Summary

Background:

In gene transfer therapy, cells are taken from a person s tumor to isolate mutations. White blood cells are then taken from the person's body, changed with a type of virus to attack the tumor cells, and returned to the person.

Objective:

To see if gene transfer therapy shrinks tumors.

Eligibility:

People with certain metastatic cancer for which standard treatments have not worked

Design:

Participants will complete screening and stages 1-3 under another protocol. Screening includes:

Undergoing a biopsy or surgery at the NIH to obtain pieces of tumor in order to grow tumor cells

Medical history

Physical exam

Scans

Blood, urine, heart, and lung tests

The study has 7 stages:

  1. Screening tests repeated over 1-2 weeks. Participants will have leukapheresis: Blood is removed by a needle in one arm. A machine removes white blood cells. The rest of the blood is returned by a needle in the other arm. An IV catheter will be placed in the chest.
  2. Care at home over 6-12 weeks.
  3. Stopping therapy for 4-6 weeks while their cells are changed in a lab.
  4. Hospital stay for 1 week to get chemotherapy by IV.
  5. Receiving changed cells by catheter. Then getting a drug over 1-5 days to help the cells live longer.
  6. Recover in the hospital for 1 2 weeks. Participants will get drugs and have blood and urine tests.
  7. Participants will take an antibiotic and maybe an antiviral for at least 6 months after treatment. They will have repeat screening tests at visits every few months for the first year, every 6 months for the second year, then as determined.

    ...

Detailed Description

Background:

  • The administration of autologous tumor-infiltrating lymphocytes (TIL) can mediate complete, durable regressions in 20-25% of patients with metastatic melanoma. Recent studies have shown that these TIL predominantly recognize unique mutated neoantigens expressed by the cancer not shared by other melanomas.
  • Administration of bulk autologous TIL to patients with a variety of other solid cancers, including cancers of the gastrointestinal tract and genitourinary tract, have little if any therapeutic impact.
  • Recent studies in the National Cancer Institute Surgery Branch, (NCI-SB), have shown that TIL from non-melanoma solid cancers can also contain T-cells reactive against non-shared unique mutated neoantigens expressed in the cancer. The frequency of these T-cells is very low (often < 0.1%) and it is thus difficult to isolate and grow mutation reactive T-cells to levels required for effective therapy.
  • In a single patient with chemo-refractory metastatic cholangiocarcinoma we were able to grow a relatively pure population of neoantigen reactive TIL and administration of these cells mediated a near-complete regression of all metastatic disease now lasting 2.5 years.
  • We have developed approaches to identify these rare neoantigen reactive T-cells from common non-melanoma cancers, to isolate their T-cell receptors (TCR), and to genetically engineer autologous peripheral blood lymphocytes (PBL) to express these TCRs with high efficiency. The neoantigen TCR gene-modified cells can recognize and destroy the autologous cancer in vitro.
  • With these techniques, we have isolated a number of TCRs selectively recognizing shared mutated oncogenes (e.g., KRAS, TP53) in the context of several major histocompatibility complexes (MHC-I and MHC-II).
  • This clinical protocol will treat patients with refractory solid cancers using the adoptive transfer of autologous PBL transduced with genes encoding TCRs that recognize unique mutated neoantigens expressed by the cancer.

Objectives:

-Primary objective:

--Determine the rate of objective response (using RECIST v1.1 criteria) of patients with solid cancers who receive pembrolizumab plus autologous PBL (Arm 2) that have been transduced with genes encoding T-cell receptors that recognize mutated neoantigens in the autologous cancer

Eligibility:

-Patients must be/have:

  • Age greater than or equal to 18 years and less than or equal to 70 years
  • Solid cancer with at least one lesion that can be measured, that falls into one of four cohorts: (1) gastrointestinal and genitourinary cancers; (2) breast, ovarian, and other solid cancers; (3) non-small cell lung cancer (NSCLC); and, (4) glioblastoma. Metastatic disease is required for cohorts 1-3, but not for cohort 4.
  • Evaluable solid cancer that has recurred following standard chemotherapy or standard systemic therapy
  • Normal basic laboratory values.
  • No allergies or hypersensitivity to high-dose aldesleukin administration
  • No concurrent major medical illnesses or any form of immunodeficiency.

Design:

  • Patients will have already undergone resection or biopsy to obtain tumor for generation of autologous TIL cultures. This will have been conducted under the NCI-SB cell harvest protocol 03-C-0277 (Cell Harvest and Preparation for Surgery Branch Adoptive Cell Therapy Protocols).
  • Exomic sequencing, and often RNA-Seq will be performed to identify the mutations expressed in the patient s cancer. Multiple autologous TIL cultures will be grown and tested for reactivity against mutations from the autologous tumor using assays we have developed that involve the exposure of autologous antigen-presenting cells to long peptides containing the mutation or tandem mini-genes encoding the mutation.
  • T-cell cultures with reactivity against mutations will be identified and the individual T-cell receptors that recognize the mutation will be synthesized and used to create a retrovirus for transduction of the TCR into the patient s autologous PBL.
  • Patients that present with tumors expressing mutated shared oncogenes (KRAS or TP53) that also express the appropriate restriction element may be treated with autologous PBLs retrovirally -transduced with TCR(s) previously isolated in the Surgery Branch targeting the shared mutated antigen. These patients will be administered a cell infusion product of TCRs targeting mutated shared oncogenes (KRAS or TP53). Their cell infusion product will not include PBL transduced with unique (i.e., non-shared) TCR(s).
  • Patients will be enrolled into one of four cohorts: (1) gastrointestinal and genitourinary cancers; (2) breast, ovarian, and other solid cancers; (3) non-small cell lung cancer (NSCLC); and, (4) glioblastoma. Autologous PBL (transduced with either TCR(s) targeting mutated shared oncogenes TP53 or KRAS, or, TCR(s) targeting individual neoantigens) will then be expanded to large numbers using our standard rapid expansion protocol.
  • Patients enrolled on Arm 1 and Arm 2 will receive a non-myeloablative, lymphodepleting preparative regimen consisting of cyclophosphamide and fludarabine followed by the infusion of autologous transduced PBL and high-dose aldesleukin. At the discretion of the Principal Investigator (PI), patients enrolled in Cohort 3 (NSCLC) may receive lowdose aldesleukin
  • Patients enrolled on Arm 2 will receive pembrolizumab prior to cell administration and three additional doses every three weeks following the cell infusion. Patients who have experienced major organ toxicity due to previous treatment with pembrolizumab (or equivalent PD-1/PD-L1 blockade) will be enrolled on Arm 1.
  • Clinical and immunologic response will be evaluated about 4-6 weeks after cell infusion and periodically thereafter.
  • It is anticipated that approximately one patient per month may enroll on the trial for each of the four histologic cohorts for Arm 2. There will be a limit of 15 patients per cohort to enroll on Arm 1 (60 patients for Arm 1), and accrual of up to 4 x 50 = 200 total evaluable

patients on Arm 2. It is expected that once full manufacturing capability is reached, that the accrual may be completed in approximately 4-5 years. In order to allow for a small number of inevaluable patients, the accrual ceiling will be set to 270.

Study Type  ICMJE Interventional
Study Phase  ICMJE Phase 2
Study Design  ICMJE Allocation: Non-Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
Condition  ICMJE
  • Glioblastoma
  • Non-Small Cell Lung Cancer
  • Ovarian Cancer
  • Breast Cancer
  • Gastrointestinal/Genitourinary Cancer
Intervention  ICMJE
  • Drug: Cyclophosphamide
    Days -7 and -6: Cyclophosphamide 60 mg/kg/day x 2 days IV in 250 mL D5W infused simultaneously with mesna 15 mg/kg/day over 1 hour x 2 days.
  • Drug: Fludarabine
    Days -7 to -3: Fludarabine 25 mg/m2/day IVPB daily over 30 minutes for 5 days.
  • Drug: Aldesleukin
    Aldesleukin 720,000 IU/kg IV over 15 minutes approximately every 8 hours beginning within 24 hours of cell infusion and continuing for up to 4 days (maximum 10 doses). Patients in cohort 3 may receive 72,000 IU/kg IV.
  • Biological: Individual Patient TCR-Transduced PBL
    Day 0: Cells will be infused intravenously on the Patient Care Unit over 20-30 minutes (2-4 days after the last dose of fludarabine)..
  • Drug: Pembrolizumab (KEYTRUDA )
    Arm 2: Pembrolizumab 2 mg /kg IV over approximately 30 minutes on Days -2, 21, 42, and 63.
Study Arms  ICMJE
  • Experimental: 1/iTCR
    Non-myeloablative lymphocyte depleting preparative regimen of cyclophosphamide and fludarabine + Individual Patient TCR-Transduced PBL + high or low-dose aldesleukin
    Interventions:
    • Drug: Cyclophosphamide
    • Drug: Fludarabine
    • Drug: Aldesleukin
    • Biological: Individual Patient TCR-Transduced PBL
  • Experimental: 2/iTCR + Pembro
    Non-myeloablative, lymphodepleting preparative regimen of cyclophosphamide and fludarabine + Individual Patient TCRTransduced PBL + high- or low-dose aldesleukin + pembrolizumab prior to cell administration and 3 additional doses every 3 weeksfollowing cell infusion
    Interventions:
    • Drug: Cyclophosphamide
    • Drug: Fludarabine
    • Drug: Aldesleukin
    • Biological: Individual Patient TCR-Transduced PBL
    • Drug: Pembrolizumab (KEYTRUDA )
Publications *

*   Includes publications given by the data provider as well as publications identified by ClinicalTrials.gov Identifier (NCT Number) in Medline.
 
Recruitment Information
Recruitment Status  ICMJE Recruiting
Estimated Enrollment  ICMJE
 (submitted: December 28, 2019)
270
Original Estimated Enrollment  ICMJE
 (submitted: January 26, 2018)
210
Estimated Study Completion Date  ICMJE March 23, 2028
Estimated Primary Completion Date March 23, 2027   (Final data collection date for primary outcome measure)
Eligibility Criteria  ICMJE
  • INCLUSION CRITERIA:
  • Solid cancer that can be measured, that falls into one of four cohorts: (1) gastrointestinal and genitourinary cancers; (2) breast, ovarian, and other solid cancers; (3) non-small cell lung cancer (NSCLC); and, (4) glioblastoma.

    --Note: Metastatic disease is required for Cohorts 1-3, but not required for cohort 4. NSCLC includes but is not limited to squamous cell carcinoma, adenosquamous carcinoma or adenocarcinomas. Neuroendocrine tumors are not eligible.

  • Confirmation of diagnosis of cancer by the NCI Laboratory of Pathology.
  • Refractory to approved standard systemic therapy. Specifically:

    • Patients with metastatic colorectal cancer must have received oxaliplatin or irinotecan.
    • Patients with breast and ovarian cancer must be refractory to both first and second line treatments.
    • Patients with NSCLC must have received at least one platinum-based chemotherapy regimen and at least one FDA approved targeted treatment (when appropriate).
    • Patients with glioblastoma must have progression of disease after radiotherapy (including patients that undergo surgery for recurrent disease and are rendered NED). This includes recurrent glioblastoma after receiving all standard first-line treatment, including surgery (if feasible due to neurosurgical and neuro-anatomical considerations) and adjuvant radiotherapy +/- chemotherapy.
  • For Cohorts 1-3: patients with 3 or fewer brain metastases that are less than or equal to 1 cm in diameter and asymptomatic are eligible. Lesions that have been treated with stereotactic radiosurgery must be clinically stable for one month after treatment for the patient to be eligible. Patients with surgically resected brain metastases are eligible.
  • Age greater than or equal to 18 years and less than or equal to 70 years.
  • For Cohorts 1-3: clinical performance status of ECOG 0 or 1.
  • For cohort 4: Patients must have Karnofsky performance status greater than or equal to 60.
  • Patients of both genders must be willing to practice birth control from the time of enrollment on this studyand for four months after treatment.
  • Women of child-bearing potential must have a negative pregnancy test because of the potentially dangerous effects of the treatment on the fetus.
  • Serology:

    • Seronegative for HIV antibody. (The experimental treatment being evaluated in this protocol depends on an intact immune system. Patients who are HIV seropositive may have decreased immune-competence and thus be less responsive to the experimental treatment and more susceptible to its toxicities.)
    • Seronegative for hepatitis B antigen, and seronegative for hepatitis C antibody. If hepatitis C antibody test is positive, then patient must be tested for the presence of antigen by RT-PCR and be HCV RNA negative.
  • Hematology:

    • ANC > 1000/mm^3 without the support of filgrastim
    • WBC greater than or equal to 3000/mm^3
    • Platelet count greater than or equal to 100,000/mm^3
    • Hemoglobin > 8.0 g/dl. Subjects may be transfused to reach this cut-off.
  • Chemistry:

    • Serum ALT/AST less than or equal to 5.0 x ULN
    • Serum creatinine less than or equal to 1.6 mg/dl.
    • Total bilirubin less than or equal to 2.0 mg/dl, except in patients with Gilbert's Syndrome, who must have a total bilirubin less than or equal to 3.0 mg/dl.
  • More than four weeks must have elapsed since completion of any prior systemic therapy at the time of enrollment .

Note: Patients may have undergone minor surgical procedures or limited field radiotherapy within the four weeks prior to enrollment, as long as related major organ toxicities have recovered to grade 1 or less.

  • For cohort 3: more than two weeks must have elapsed since any prior palliation for major bronchial occlusion or bleeding at the time the patient receives the preparative regimen, and patient s toxicities must have recovered to a grade 1 or less.
  • For cohort 4: patients must be at least four weeks from radiation therapy. Additionally, patients must be at least six weeks from nitrosoureas, four weeks from temozolomide, three weeks from procarbazine, two weeks from vincristine and four weeks from last bevacizumab administration. Patients must be at least four weeks from other cytotoxic therapies not listed above and two weeks for non-cytotoxic agents (e.g., interferon) including investigative agents.
  • For Cohort 4: Patients must either not be receiving steroids, or be on a stable dose of steroids, for at least five days prior to registration.
  • Ability of subject to understand and the willingness to sign a written informed consent document.
  • Willing to sign a durable power of attorney.
  • Subjects must be co-enrolled on protocol 03-C-0277.

EXCLUSION CRITERIA:

  • Women of child-bearing potential who are pregnant or breastfeeding because of the potentially dangerous effects of the treatment on the fetus or infant.
  • Concurrent systemic steroid therapy, except for patients with glioblastoma (cohort 4).
  • Active systemic infections requiring anti-infective treatment, coagulation disorders, or any other active or uncompensated major medical illnesses.
  • For cohort 3: Any major bronchial occlusion or bleeding not amenable to palliation.
  • For cohort 4: Clinically significant hemorrhagic or ischemic stroke, including transient ischemic attacks and other central nervous system bleeding in the preceding six months that were not related to glioma surgery.

Note: History of prior intratumoral bleeding is not an exclusion criterion; however, patients with a history of prior intratumoral bleeding, will need to undergo a non-contrast head CT to exclude acute bleeding.

  • Any form of primary immunodeficiency (such as Severe Combined Immunodeficiency Disease and AIDS).
  • For Arm 2: History of major organ autoimmune disease.

Note: Patients with a history of major organ autoimmune disease may be enrolled on Arm 1 if all other eligibility criteria are met.

-For Arm 2: Grade 3 or 4 major organ irAEs following treatment with anti-PD-1/PD-L1, including but not limited to myocarditis and pneumonitis.

Note: Patients with grade 3 or 4 major organ irAEs may be enrolled on Arm 1 if all other eligibility criteria are met.

-Concurrent opportunistic infections (The experimental treatment being evaluated in this protocol depends on an intact immune system. Patients who have decreased immune competence may be less responsive to the experimental treatment and more susceptible to its

toxicities.)

  • History of severe immediate hypersensitivity reaction to cyclophosphamide, fludarabine, or aldesleukin.
  • For Cohorts 1, 2, or 4: Clinically significant patient history which in the judgment of the Principal Investigator (PI) would compromise the patients' ability to tolerate high-dose aldesleukin.

Note: At the discretion of the PI, patients enrolled in cohort 3 may receive low-dose aldesleukin.

  • History of coronary revascularization or ischemic symptoms.
  • Any patient known to have an LVEF less than or equal to 45%.
  • Documented LVEF less than or equal to 45% tested in patients:

    • Age greater than or equal to 65 years
    • With clinically significant atrial and/or ventricular arrhythmias including but not limited to: atrial fibrillation, ventricular tachycardia, second- or third-degree heart block or have a history of ischemic heart disease and/or chest pain
  • Documented FEV1 less than or equal to 50% predicted tested in patients with:

    • A prolonged history of cigarette smoking (greater than or equal to 20 pack-year smoking history, within the past two years).
    • Symptoms of respiratory dysfunction
  • Patients who are receiving any other investigational agents.
Sex/Gender  ICMJE
Sexes Eligible for Study: All
Ages  ICMJE 18 Years to 70 Years   (Adult, Older Adult)
Accepts Healthy Volunteers  ICMJE No
Contacts  ICMJE
Contact: Recruitment Center - SB (866) 820-4505 IRC@nih.gov
Listed Location Countries  ICMJE United States
Removed Location Countries  
 
Administrative Information
NCT Number  ICMJE NCT03412877
Other Study ID Numbers  ICMJE 180049
18-C-0049
Has Data Monitoring Committee Not Provided
U.S. FDA-regulated Product
Studies a U.S. FDA-regulated Drug Product: Yes
Studies a U.S. FDA-regulated Device Product: No
IPD Sharing Statement  ICMJE Not Provided
Responsible Party National Institutes of Health Clinical Center (CC) ( National Cancer Institute (NCI) )
Study Sponsor  ICMJE National Cancer Institute (NCI)
Collaborators  ICMJE Not Provided
Investigators  ICMJE
Principal Investigator: Steven A Rosenberg, M.D. National Cancer Institute (NCI)
PRS Account National Institutes of Health Clinical Center (CC)
Verification Date January 8, 2020

ICMJE     Data element required by the International Committee of Medical Journal Editors and the World Health Organization ICTRP