Patient case: 13-year-old male with acute myeloid leukemia; genetic feature: FLT3

Clinical trial: Laboratory-Treated T Cells in Treating Patients With High-Risk Relapsed Acute Myeloid Leukemia, Myelodysplastic Syndrome, or Chronic Myelogenous Leukemia Previously Treated With Donor Stem Cell Transplant

Summary: This phase I/II trial studies the side effects of laboratory-treated T cells and to see how well they work in treating patients with high-risk acute myeloid leukemia (AML), myelodysplastic syndrome (MDS), or chronic myelogenous leukemia (CML) that has returned after a period of improvement (relapsed), previously treated with donor stem cell transplant. Biological therapies, such as cellular adoptive immunotherapy, may stimulate the immune system in different ways and stop cancer cells from growing. Placing a gene that has been created in the laboratory into a person's T cells may make the body build an immune response to kill cancer cells.

Detailed description: PRIMARY OBJECTIVES:
  I. Determine the safety and potential toxicities associated with treating patients with high risk or relapsed AML, MDS, and CML after allogeneic hematopoietic cell transplantation (HCT) by adoptive transfer of virus-specific cluster of differentiation (CD)8 T cells genetically-modified to express a high affinity Wilms tumor 1 (WT1)-specific T cell receptor (TCR).
  II. Determine the anti-leukemic activity associated with treating patients with relapsed AML, MDS and CML after allogeneic HCT by adoptive transfer of virus-specific CD8 T cells genetically-modified to express a high affinity WT1-specific T cell receptor (TCR).
  SECONDARY OBJECTIVES:
  I. Determine the in vivo persistence of transferred T cells and ability to migrate to and accumulate in bone marrow.
  II. Determine the maintenance of TCR expression and function of transduced T cells.
  OUTLINE: Patients are assigned to 1 of 2 treatment arms.
  ARM I: Patients with no evidence of leukemia or MDS post-HCT receive WT1-sensitized T cells intravenously (IV) over 45 minutes (or longer for patients who are 15-30 kg) on days 0 and 14 and aldesleukin subcutaneously (SC) twice daily (BID) on days 14-28.
  ARM II: Patients with evidence of leukemia (AML or CML) or MDS (minimal residual disease or overt relapse) post-HCT receive WT1-sensitized T cells IV over 45 minutes (or longer for patients who are 15-30 kg) on days 0 and 14 and aldesleukin SC BID on days 14-28.
  After completion of study treatment, patients are followed up weekly for 4 weeks, at weeks 6 and 8, at 3, 6, 12 months, and then annually for up to 15 years.

Eligibility: Inclusion Criteria:
  -  Patients must express HLA-A*0201
  -  Patients who are currently undergoing or who previously underwent matched allogeneic HCT for:
  -  AML including:
  -  AML beyond first remission, therapy-related AML at any stage, primary refractory AML, AML in relapse (before or after HCT), AML with evidence of minimal residual disease (MRD) at time of HCT or after HCT (by multiparameter flow cytometry, cytogenetics, fluorescence in situ hybridization [FISH] or molecular studies); AML at any stage arising in a patient with an antecedent diagnosis of a hematologic disorder including myelodysplastic or myeloproliferative syndrome (e.g. chronic myelomonocytic leukemia, polycythemia vera, essential thrombocytosis, and agnogenic myeloid metaplasia with myelofibrosis)
  -  AML at any stage with unfavorable cytogenetic, FISH, or molecular abnormalities:
  -  Monosomal karyotype (presence of two or more distinct autosomal chromosome monosomies or a single autosomal monosomy associated with at least one structural abnormality)
  -  del(5q)/-5
  -  -abn7
  -  abn 3q
  -  abn 9q
  -  abn 11q, 11q23 (MLL gene rearrangement)
  -  abn 20q
  -  abn 21q
  -  abn 17p
  -  t(6;9)
  -  t(9;22)
  -  Complex karyotype (>= 3 unrelated abnormalities)
  -  Inv(3) or t(3;3)
  -  t(6;11)
  -  +8 sole
  -  +8 with 1 other abnormality/ies other than t(8;21), t(9;11), inv (16), t(16;16), t(15;17)
  -  FLT3-internal tandem duplication (ITD) mutation
  -  Other cytogenetics, FISH or molecular abnormalities per discussion and approval by patient care conference (PCC)
  -  Relapsed disease (overt relapse or minimal residual disease) at any time post HCT
  -  Other clinical manifestations consistent with high risk disease per discussion and approval by PCC
  -  MDS including:
  -  Intermediate-2 or high risk category patients according to the International Prognostic Scoring System (IPSS) >= 1.5, revised IPSS (IPSS-R) > 3, or poor risk karyotype defined as abnormalities involving chromosome 7 or complex karyotype (>= 3 unrelated abnormalities)
  -  Relapsed disease (overt relapse or minimal residual disease) at any time post HCT
  -  Other clinical manifestations consistent with high risk disease per discussion and approval by PCC
  -  CML including:
  -  CML beyond chronic phase
  -  Relapsed disease (overt relapse or minimal residual disease) at any time post HCT
  -  Other clinical manifestations consistent with high risk disease per discussion and approval by PCC
  -  Patients must have an HLA-matched donor of hematopoietic stem cells (related or unrelated)
  -  Patients must be able to provide blood and bone marrow samples and undergo the procedures required for this protocol
  -  Patients must be >= 15 kg
  -  Patients must be able to give informed consent; parent or legal representative will be asked to consent for patients younger than 18 year old
  -  DONOR: Patient and donor (related or unrelated) must be HLA-matched and express HLA-A*0201
  -  DONOR: Donor must be Epstein-Barr virus (EBV) or cytomegalovirus (CMV) seropositive
  -  DONOR: Donor must be age 18 or older
  -  DONOR: In good general health
  -  DONOR: Able to give informed consent
  Exclusion Criteria:
  -  Central nervous system (CNS) tumor refractory to intrathecal chemotherapy and/or cranio-spinal radiation
  -  In patients whose leukemic cells are available for evaluation, the expression of WT1 in the patient's bone marrow will be determined; if WT1 expression in the patient's bone marrow is not highly expressed by polymerase chain reaction (PCR), the patient will be excluded from the study; patients with no evaluable leukemia will be eligible for enrollment based on the high frequency of positive leukemias (> 90%), and leukemia will be evaluated for WT1 expression if recurrence is detected
  -  Human immunodeficiency virus (HIV) seropositive; testing for HIV should be within 6 months of enrollment
  -  Medical or psychological conditions that would make the patient unsuitable candidate for cell therapy at the discretion of the principal investigator (PI)
  -  Pregnancy or breast-feeding; women of childbearing potential must have a negative serum or urine beta-human chorionic gonadotropin (B-hCG) pregnancy test result within 14 days before the first dose of WT1-specific T cell infusion; woman of non-childbearing potential will be defined as being postmenopausal greater than one year or who have had a bilateral tubal ligation or hysterectomy; all recipients of WT1-specific T cells will be counseled to use effective birth control during participation in this study and for 12 months after the last T cell infusion
  -  DONOR: Less than 18 years old
  -  DONOR: Active infectious hepatitis
  -  DONOR: HIV or human T-lymphotropic virus (HTLV) seropositive
  -  DONOR: Pregnancy or nursing
  -  DONOR: Significant medical conditions (e.g. immunosuppressive therapy) that would make the donor an unsuitable T cell donor
  -  DONOR: Unable to give informed consent

Relevance to patient case: not relevant