Patient case: 18-year-old male with anaplastic large cell lymphoma; genetic feature: ALK

Clinical trial: T Cells Expressing a Fully-Human Anti-CD30 Chimeric Antigen Receptor for Treating CD30-Expressing Lymphomas

Summary: Background:
  -  Improved treatments for a variety of treatment-resistant, CD30-expressing malignancies including Hodgkin lymphoma, anaplastic large cell lymphoma, and other CD30- expressing lymphomas are needed.
  -  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 lymphoma. These results demonstrate that CAR-expressing T cells can have anti-lymphoma activity in humans.
  -  CD30 expression can be easily detected by immunohistochemistry on lymphoma cells, which allows selection of CD30-expressing malignancies for treatment.
  -  CD30 is not known to be expressed by normal cells except for a small number of activated lymphocytes and decidual cells in the pregnant uterus.
  -  We have constructed a novel fully-human anti-CD30 CAR that can specifically recognize CD30-expressing target cells in vitro and eradicate CD30-expressing tumors in mice.
  -  This particular CAR has not been tested before in humans.
  -  Possible toxicities include cytokine-associated toxicities such as fever, hypotension, and neurological toxicities. Elimination of a small number of normal activated lymphocytes is possible, and unknown toxicities are also possible.
  Objectives:
  Primary
  -Determine the safety and feasibility of administering T-cells expressing a novel fullyhuman anti-CD30 CAR to patients with advanced CD30-expresssing lymphomas.
  Eligibility:
  -  Patients must have Hodgkin lymphoma, anaplastic large cell lymphoma, peripheral T-cell lymphoma not otherwise specified, diffuse large B-cell lymphoma not otherwise specified, primary mediastinal B-cell lymphoma, grey zone lymphoma, enteropathyassociated T-cell lymphoma, or extranodal NK/T-cell lymphoma, nasal type
  -  Patients must have malignancy that is both measurable on a CT scan with a largest diameter of at least 1.5 cm and possessing increased metabolic activity detectable by PET scan. Alternatively patients with lymphoma detected by flow cytometry of bone marrow
  are eligible.
  -  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 HIV, hepatitis B, or hepatitis C. Patients must be seronegative for CMV by blood PCR.
  -  Absolute neutrophil count greater than or equal to 1000/micro L, platelet count greater than or equal to 45,000/micro L, 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.
  -  Clear CD30 expression must be detected on 75% or more of malignant cells from either bone marrow or lymphoma mass by flow cytometry or immunohistochemistry. The patient s malignancy will need to be assessed for CD30 expression by flow cytometry or immunohistochemistry performed at the NIH. If unstained, paraffin-embedded bone marrow or lymphoma sections are available from prior biopsies, these can be used to determine CD30 expression by immunohistochemistry; otherwise, patients will need to come to the NIH for a biopsy to determine CD30 expression. The sample for CD30 expression can come from a biopsy obtained at any time before enrollment, unless the patient has received a prior anti-CD30 monoclonal antibody, in which case the sample must come from a biopsy following completion of the most recent anti-CD30 monoclonal antibody treatment.
  -  Eligible patients with Hodgkin lymphoma must fulfill one of the following criteria: 1) have received two prior therapies, one of which must be an autologous stem cell transplant, or 2) have received three prior lines of therapy. Eligible patients with any of the listed peripheral T cell lymphomas or non-Hodgkin lymphomas must have received two lines of prior therapy, at least one of which must contain cytotoxic
  chemotherapyPatients with diffuse large B-cell lymphoma or primary mediastinal B-cell lymphoma must have received 2 prior treatment regimens at least 1 of which included an anthracycline and an anti-CD20 monoclonal antibody.
  -  Patients who have never had an allogeneic hematopoietic stem cell transplant as well as patients who have had an HLA-matched sibling or a 8/8 HLA-matched unrelated donor hematopoietic stem cell transplant are potentially eligible.
  -  Women who are pregnant or plan to become pregnant will be excluded. Due to the risk of damage to normal uterine tissue during the secretory phase of menstruation, w......

Detailed description: Background:
  -  Improved treatments for a variety of treatment-resistant, CD30-expressing malignancies including Hodgkin lymphoma, anaplastic large cell lymphoma, and other CD30- expressing lymphomas are needed.
  -  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 lymphoma. These results demonstrate that CAR-expressing T cells can have anti-lymphoma activity in humans.
  -  CD30 expression can be easily detected by immunohistochemistry on lymphoma cells, which allows selection of CD30-expressing malignancies for treatment.
  -  CD30 is not known to be expressed by normal cells except for a small number of activated lymphocytes and decidual cells in the pregnant uterus.
  -  We have constructed a novel fully-human anti-CD30 CAR that can specifically recognize CD30-expressing target cells in vitro and eradicate CD30-expressing tumors in mice.
  -  This particular CAR has not been tested before in humans.
  -  Possible toxicities include cytokine-associated toxicities such as fever, hypotension, and neurological toxicities. Elimination of a small number of normal activated lymphocytes is possible, and unknown toxicities are also possible.
  Objectives:
  Primary
  -Determine the safety and feasibility of administering T-cells expressing a novel fullyhuman anti-CD30 CAR to patients with advanced CD30-expresssing lymphomas.
  Eligibility:
  -  Patients must have Hodgkin lymphoma, anaplastic large cell lymphoma, peripheral T-cell lymphoma not otherwise specified, diffuse large B-cell lymphoma not otherwise specified, primary mediastinal B-cell lymphoma, grey zone lymphoma, enteropathyassociated T-cell lymphoma, or extranodal NK/T-cell lymphoma, nasal type
  -  Patients must have malignancy that is both measurable on a CT scan with a largest diameter of at least 1.5 cm and possessing increased metabolic activity detectable by PET scan. Alternatively patients with lymphoma detected by flow cytometry of bone marrow
  are eligible.
  -  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 HIV, hepatitis B, or hepatitis C. Patients must be seronegative for CMV by blood PCR.
  -  Absolute neutrophil count greater than or equal to 1000/micro L, platelet count greater than or equal to 45,000/micro L, 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.
  -  Clear CD30 expression must be detected on 75% or more of malignant cells from either bone marrow or lymphoma mass by flow cytometry or immunohistochemistry. The patient s malignancy will need to be assessed for CD30 expression by flow cytometry or immunohistochemistry performed at the NIH. If unstained, paraffin-embedded bone marrow or lymphoma sections are available from prior biopsies, these can be used to determine CD30 expression by immunohistochemistry; otherwise, patients will need to come to the NIH for a biopsy to determine CD30 expression. The sample for CD30 expression can come from a biopsy obtained at any time before enrollment, unless the patient has received a prior anti-CD30 monoclonal antibody, in which case the sample must come from a biopsy following completion of the most recent anti-CD30 monoclonal antibody treatment.
  -  Eligible patients with Hodgkin lymphoma must fulfill one of the following criteria: 1) have received two prior therapies, one of which must be an autologous stem cell transplant, or 2) have received three prior lines of therapy. Eligible patients with any of the listed peripheral T cell lymphomas or non-Hodgkin lymphomas must have received two lines of prior therapy, at least one of which must contain cytotoxic
  chemotherapyPatients with diffuse large B-cell lymphoma or primary mediastinal B-cell lymphoma must have received 2 prior treatment regimens at least 1 of which included an anthracycline and an anti-CD20 monoclonal antibody.
  -  Patients who have never had an allogeneic hematopoietic stem cell transplant as well as patients who have had an HLA-matched sibling or a 8/8 HLA-matched unrelated donor hematopoietic stem cell transplant are potentially eligible.
  -  Women who are pregnant or plan to become pregnant will be excluded. Due to the risk of damage to normal uterine tissue during the secretory phase of menstruation, women who have had menstrual periods in the last six months will be excluded. Participating women
  must have a serum FSH greater than 22 units/Liter and an estradiol level <10 pg/mL and not be taking progestin-containing drugs. If women are currently achieving effective menstrual suppression on Lupron or similar gonadotropin-releasing hormone (GnRH) analogues and have not had a menstrual period for the last six months on a stable dose of GnRH analogue, they may participate in the trial without meeting the FSH and serum estradiol criteria and with continuation of the GnRH analogue during the trial and for at least 3 months following the final CAR T-cell infusion. All pre-menopausal women will be asked to have a consultation with NIH gynecology prior to trial participation.
  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-CD30 CAR.
  -  Patients will receive a lymphocyte-depleting chemotherapy conditioning regimen with the intent of enhancing the activity of the infused anti-CD30 CAR-expressing T cells.
  -  The chemotherapy conditioning regimen is cyclophosphamide 300 mg/m2 daily for 3 days and fludarabine 30 mg/m2 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-CD30-CAR-expressing T cells.
  -  The initial dose level of this dose-escalation trial will be 0.3x106 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.
  -  Re-enrollment will be allowed for a small number of subjects.

Eligibility: -  INCLUSION CRITERIA:
  Malignancy Criteria:
  -  Patients must have Hodgkin lymphoma, anaplastic large cell lymphoma, peripheral T-cell lymphoma not otherwise specified, diffuse large B-cell lymphoma not otherwise specified, primary mediastinal B-cell lymphoma, grey zone lymphoma, enteropathy-associated T-cell lymphoma, or extranodal NK/T-cell lymphoma, nasal type
  -  Clear CD30 expression must be detected on 75% or more of malignant cells from either bone marrow or lymphoma mass by flow cytometry or immunohistochemistry. The patient s malignancy will need to be assessed for CD30 expression by flow cytometry or immunohistochemistry performed at the NIH. If unstained, paraffin-embedded bone marrow or lymphoma sections are available from prior biopsies, these can be used to determine CD30 expression by immunohistochemistry; otherwise, patients will need to come to the NIH for a biopsy to determine CD30 expression. The sample for CD30 expression can come from a biopsy obtained at any time before enrollment, unless the patient has received a prior anti-CD30 monoclonal antibody, in which case the sample must come from a biopsy following completion of the most recent anti-CD30 monoclonal antibody treatment.
  -  Eligible patients with Hodgkin lymphoma must fulfill one of the following criteria: 1) have received two prior therapies, one of which must be an autologous stem cell transplant, or 2) have received three prior lines of therapy. Eligible patients with any of the listed peripheral T- cell lymphomas or non-Hodgkin lymphomas must have received two lines of prior therapy, at least one of which must contain cytotoxic chemotherapy. Patients with diffuse large B-cell lymphoma or primary mediastinal B-cell lymphoma must have received 2 prior treatment regimens at least 1 of which included an anthracycline and an anti-CD20 monoclonal antibody.
  -  Patients must have measurable malignancy as defined by at least one of the criteria below.
  -  Lymphoma mass that is measurable (minimum 1.5 cm in largest diameter) by CT scan is required unless bone marrow lymphoma is detectable.
  -  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 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.
  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
  -  Male patients and must be willing to practice birth control from the time of enrollment on this study and for four months following the final CAR T-cell infusion. Pre-menopausal patients (female patients who have had a menstrual period within the last year) must be willing to practice birth control from the time of enrollment and for one year following the final CAR T cell infusion.
  -  Women of child-bearing potential must have a negative pregnancy test because of the potentially dangerous effects of the preparative chemotherapy on the fetus or infant. Women of child-bearing potential are defined as all women except women who are postmenopausal 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.
  -  For safety reasons women must have had no menstrual periods in the six months prior to enrollment. A menstrual period will be defined as any vaginal bleeding or spotting lasting for more than one day. Participating women must have a serum FSH greater than 22 units/Liter and a serum estradiol level <10 pg/mL and not be taking progestin-containing drugs. If women are currently achieving effective menstrual suppression on Lupron or similar gonadotropin-releasing hormone (GnRH) analogues and have not had a menstrual
  period for the last six months on a stable dose of GnRH analogue, they may participate in the trial without meeting the FSH and serum estradiol criteria and with continuation of the GnRH analogue during the trial and for at least 3 months following the final CAR Tcell infusion. All pre-menopausal women will be asked to have a consultation with NIH gynecology prior to trial participation.
  -  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 possible immunosuppression due to anti-CD30 CAR T-cells and chemotherapy administered on this protocol.
  -  Seronegative for HTLV-1.
  -  Negative for hepatitis B surface 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.
  -  Seronegative for CMV and JC virus by blood PCR.
  -  Absolute neutrophil count greater than or equal to 1000/mm3 without the support of filgrastim or other growth factors.
  -  Platelet count greater than or equal to 45,000/mm3 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 is not allowed within 14 days prior to the required leukapheresis. NOTE: Because of the long half-life and potential to affect CAR T-cells, 30 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 must be willing to undergo endotracheal intubation, mechanical ventilation, dialysis, CPR, and electrical defibrillation. Patients must be willing to receive vasopressor drugs and all other standard intensive care unit interventions. Any living will must be amended to allow these interventions or the patient will not eligible.
  -  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).
  Additional Inclusion Criteria Pertinent Only for Patients with Prior Allogeneic Transplantation:
  -  Recipients must have received an HLA-identical sibling allogeneic hematopoietic stem cell transplant or a 8/8-matched (HLA-A, B, C, DR) unrelated donor (URD) allo-HSCT for an eligible CD30+ lymphoma Donor T cell engraftment after allo-HSCT (>90% donor chimerism of the T-cell compartment at the time of protocol enrollment).
  -  Patients must be at least 90 days post-transplant.
  -  Patients must be off all systemic immunosuppressive drugs including corticosteroids at any dose for at least 28 days prior to protocol enrollment and must remain off immunosuppressive drugs while enrolled on the protocol. Patients must not be taking any systemic steroids at all for 14 days prior to apheresis and initiation of chemotherapy. Topical corticosteroid preparations applied to the skin such as solutions, creams, and ointments are allowed. Inhaled corticosteroids are allowed, and corticosteroid eye drops are allowed.
  -  Prior DLIs are not necessary.
  -  Either no evidence of GVHD or minimal clinical evidence of acute GVHD and chronic GVHD while off of systemic immunosuppressive therapy for at least 28 days. Minimal clinical evidence of acute GVHD defined as grade 0 to I acute GVHD 109 Minimal evidence of chronic GVHD is defined as mild global score chronic GVHD (as defined by the 2005 NIH consensus project) or no chronic GVHD .107 Subjects with disease that is controlled to stage I acute GVHD or to mild global score chronic GVHD with local topical cutaneous steroids will be eligible for enrollment.
  EXCLUSION CRITERIA:
  -  Patients that require urgent therapy due to tumor mass effects or spinal cord compression.
  -  Patients with lymphoma masses 10.0 cm or larger in longest diameter will not be eligible.
  -  Patients that have active hemolytic anemia.
  -  Patients who are currently taking any medications for systemic anticoagulation other than aspirin will not be eligible.
  -  Patients with second malignancies in addition to their lymphoma 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. Women of child-bearing potential are defined as all women except women who are postmenopausal 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.
  -  Active uncontrolled systemic infections (defined as infections causing fevers and infections requiring intravenous antibiotics when the 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, but resolved atrial fibrillation is allowed.); active obstructive or restrictive pulmonary disease; or 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 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).

Relevance to patient case: not relevant