Patient case: 73-year-old female with breast cancer; genetic feature: CDKN2A

Clinical trial: Genetically Modified T-Cell Therapy in Treating Patients With Advanced ROR1+ Malignancies

Summary: This phase I trial studies the side effects and best dose of genetically modified T-cell therapy in treating patients with receptor tyrosine kinase-like orphan receptor 1 positive (ROR1+) chronic lymphocytic leukemia (CLL), mantle cell lymphoma (MCL), acute lymphoblastic leukemia (ALL), stage IV non-small cell lung cancer (NSCLC), or triple negative breast cancer (TNBC) that has spread to other places in the body and usually cannot be cured or controlled with treatment (advanced). Genetically modified therapies, such as ROR1 specific chimeric antigen receptor (CAR) T-cells, are taken from a patient's blood, modified in the laboratory so they specifically may kill cancer cells with a protein called ROR1 on their surfaces, and safely given back to the patient after conventional therapy. The "genetically modified" T-cells have genes added in the laboratory to make them recognize ROR1.

Detailed description: PRIMARY OBJECTIVES:
  I. To evaluate the safety of adoptive T cell therapy using ex vivo expanded autologous cluster of differentiation (CD)8+ and CD4+ ROR1 CAR-T cells for patients with advanced ROR1+ hematologic (Cohort A) and epithelial (Cohort B) malignancies.
  SECONDARY OBJECTIVES:
  I. To determine duration of in vivo persistence of adoptively transferred T cells, and the phenotype of persisting T cells.
  II. To determine trafficking of adoptively transferred T cells traffic to the bone marrow or other tumor site and function in vivo.
  III. To determine preliminary antitumor activity of the adoptive transfer of ROR1 CAR-T cells in patients with measurable tumor burden prior to T cell transfer.
  OUTLINE: This is a phase I, dose escalation study of ROR1 CAR-specific autologous T-lymphocytes followed by a phase II study.
  Patients receive chemotherapy comprising fludarabine phosphate and cyclophosphamide as determined by the referring physician in consultation with the protocol principal investigator (PI). Beginning within 36-96 hours after completion of lymphodepleting chemotherapy, patients receive ROR1 CAR-specific autologous T-lymphocytes intravenously (IV) over 20-30 minutes. Patients may receive a second infusion of ROR1 CAR-specific autologous T-lymphocytes with or without additional cytoreductive therapy at the same (for those that received the highest cell dose) or up to the next highest dose level and there is persistent disease, there were no toxicities attributed to the first infusion, and the patient is at least 21 days from the first T cell infusion.
  After completion of study treatment, patients are followed up for at least 15 years.

Eligibility: Inclusion Criteria:
  INCLUSION CRITERIA FOR PATIENTS WITH CLL, MCL OR ALL (COHORT A)
  -  CLL who are beyond first remission and who have failed combination chemoimmunotherapy with regimens containing a purine analogue and anti-CD20 antibody, or who have failed tyrosine kinase or phosphatidylinositol 3 (PI3) kinase inhibitors, or who were not eligible for or declined such therapy; patients with fludarabine refractory disease are eligible
  -  Mantle cell lymphoma patients who are beyond first remission and previously treated with chemoimmunotherapy; patients who have relapsed following autologous hematopoietic cell transplant (HCT) are eligible
  -  ALL patients who have relapsed or have residual disease following treatment with curative intent; ALL patients must have ROR1 expressed on > 90% of the leukemia blasts to be eligible
  -  Confirmation of diagnosis by internal pathology review of initial or subsequent biopsy or other pathologic material at the Fred Hutchinson Cancer Research Center (FHCRC)/Seattle Cancer Care Alliance (SCCA)
  -  Evidence of ROR1 expression by immunohistochemistry or flow cytometry on any prior or current tumor specimen
  -  Karnofsky performance status >= 70%
  -  Negative pregnancy test for women of childbearing potential; subjects of childbearing potential are those who have not been surgically sterilized or have not been free from menses for > 1 year
  -  Fertile male and female patients must be willing to use a contraceptive method before, during, and for at least two months after the T cell infusion
  -  Ability to understand and provide informed consent
  INCLUSION CRITERIA FOR PATIENTS WITH NSCLC OR TNBC (COHORT B):
  -  INCLUSION CRITERIA FOR PATIENTS WITH NSCLC OR TNBC (COHORT B): Patients with stage IV non-small cell lung cancer who have been treated with at least one line of prior therapy or declined conventional therapy
  -  INCLUSION CRITERIA FOR PATIENTS WITH NSCLC OR TNBC (COHORT B): Patients with known epidermal growth factor receptor (EGFR) or anaplastic lymphoma kinase (ALK) mutations must have been treated on at least one line of molecularly targeted therapy (e.g., erlotinib, crizotinib)
  -  INCLUSION CRITERIA FOR PATIENTS WITH NSCLC OR TNBC (COHORT B): Patients must have measurable disease by at least one of the criteria below:
  -  Extra skeletal disease that can be accurately measured in at least one dimension as >= 10 mm with conventional computed tomography (CT) techniques as defined by Response Evaluation Criteria in Solid Tumors (RECIST) 1.1
  -  Skeletal or bone-only disease measurable by fludeoxyglucose F 18 (FDG) positron emission tomography (PET) imaging
  -  INCLUSION CRITERIA FOR PATIENTS WITH NSCLC OR TNBC (COHORT B): ROR1 expression in > 20% of the primary tumor or metastasis by immunohistochemistry (IHC)
  -  INCLUSION CRITERIA FOR PATIENTS WITH NSCLC OR TNBC (COHORT B): Karnofsky performance status of >= 70%
  -  INCLUSION CRITERIA FOR PATIENTS WITH NSCLC OR TNBC (COHORT B): Patients must be off chemotherapy for a minimum of 3 weeks prior to start of treatment; targeted therapies must be stopped at least 3 days prior to start of lymphodepletion
  -  INCLUSION CRITERIA FOR PATIENTS WITH NSCLC OR TNBC (COHORT B): Negative pregnancy test for women of childbearing potential; subjects of childbearing potential are those who have not been surgically sterilized or have not been free from menses for > 1 year
  -  INCLUSION CRITERIA FOR PATIENTS WITH NSCLC OR TNBC (COHORT B): Fertile male and female patients must be willing to use a contraceptive method before, during and for at least two months after the T cell infusion
  -  INCLUSION CRITERIA FOR PATIENTS WITH NSCLC OR TNBC (COHORT B): Ability to understand and provide informed consent
  INCLUSION CRITERIA FOR TNBC
  -  INCLUSION CRITERIA FOR TNBC: Histologically confirmed diagnosis of metastatic TNBC; i.e. breast cancer that is estrogen receptor (ER) negative (=< 10%), progesterone receptor (PR) negative (=< 10%), and human epidermal growth factor receptor 2 (HER2) negative (0 or 1+ by immunohistochemistry or negative for gene amplification by fluorescence in situ hybridization [FISH])
  -  INCLUSION CRITERIA FOR TNBC: Patients must have measurable disease by at least one of the criteria below:
  -  Extra skeletal disease that can be accurately measured in at least one dimension as >= 10 mm with conventional CT techniques as defined by RECIST 1.1
  -  Skeletal or bone-only disease measurable by FDG PET imaging
  -  INCLUSION CRITERIA FOR TNBC: Patients must have received standard adjuvant, neoadjuvant, and/or metastatic chemotherapy per National Comprehensive Cancer Network (NCCN) or institutional practice; no maximum on number of prior systemic treatment regimens
  -  INCLUSION CRITERIA FOR TNBC: Patients may receive agents to protect against skeletal related complications such as zolendronic acid or denosumab
  -  INCLUSION CRITERIA FOR TNBC: ROR1 expression in > 20% of the primary tumor or metastasis by IHC
  -  INCLUSION CRITERIA FOR TNBC: Karnofsky performance status of >= 70%
  -  INCLUSION CRITERIA FOR TNBC: Patients must be off chemotherapy for a minimum of 3 weeks prior to planned leukapheresis
  -  INCLUSION CRITERIA FOR TNBC: Negative pregnancy test for women of childbearing potential; subjects of childbearing potential are those who have not been surgically sterilized or have not been free from menses for > 1 year
  -  INCLUSION CRITERIA FOR TNBC: Fertile male and female patients must be willing to use a contraceptive method before, during and for at least two months after the T cell infusion
  -  INCLUSION CRITERIA FOR TNBC: Ability to understand and provide informed consent
  Exclusion Criteria:
  EXCLUSION CRITERIA FOR PATIENTS WITH CLL, MCL, OR ALL (COHORT A)
  -  Treatment with other investigational agent(s) within 30 days of planned lymphodepletion
  -  Patients requiring ongoing daily corticosteroid therapy at a dose of > 15 mg of prednisone per day (or equivalent); pulsed corticosteroid use for disease control is acceptable
  -  Active autoimmune disease requiring immunosuppressive therapy
  -  Serum creatinine > 2.5 mg/dL
  -  Serum glutamic oxaloacetic transaminase (SGOT) > 5 x upper limit of normal
  -  Bilirubin > 3.0 mg/dL
  -  Patients with clinically significant pulmonary dysfunction, as determined by medical history and physical exam should undergo pulmonary function testing; those with a forced expiratory volume in 1 second (FEV1) of < 2.0 L or diffusion capacity of the lung for carbon monoxide (DLCO) (corrected) < 40% will be excluded
  -  Significant cardiovascular abnormalities as defined by any one of the following: congestive heart failure, clinically significant hypotension, symptomatic coronary artery disease, or a documented ejection fraction of < 45%; any patient with an ejection fraction (EF) of 45-49% must receive clearance by a cardiologist to be eligible for the trial
  -  Patients who are human immunodeficiency virus (HIV) seropositive
  -  Uncontrolled active infection (bacterial, viral, fungal, mycobacterial) not responding to treatment with intravenous antibiotics, antiviral or antifungal agents, or long-term treatment with oral agents
  -  Anticipated survival of < 3 months
  -  Women who are breast-feeding
  -  Patients who have contraindication to cyclophosphamide chemotherapy
  -  Known additional malignancy that is progressing or requires active treatment; exceptions include basal cell carcinoma of the skin, squamous cell carcinoma of the skin, or in situ cervical cancer that has undergone potentially curative therapy
  -  Active central nervous system (CNS) metastases and/or carcinomatous meningitis; subjects with previously treated brain metastases may participate provided they are stable (without evidence of progression by imaging for at least four weeks prior to enrollment and any neurologic symptoms have returned to baseline), have no evidence of new or enlarging brain metastases
  EXCLUSION CRITERIA FOR PATIENTS WITH NSCLC OR TNBC (COHORT B)
  -  EXCLUSION CRITERIA FOR PATIENTS WITH NSCLC OR TNBC (COHORT B): Absolute neutrophil count (ANC) < 1000/mm^3
  -  EXCLUSION CRITERIA FOR PATIENTS WITH NSCLC OR TNBC (COHORT B): Hemoglobin (Hgb) < 9 mg/dl (transfusion permitted to achieve this)
  -  EXCLUSION CRITERIA FOR PATIENTS WITH NSCLC OR TNBC (COHORT B): Platelet count < 75,000/mm^3
  -  EXCLUSION CRITERIA FOR PATIENTS WITH NSCLC OR TNBC (COHORT B): Treatment with other investigational agent(s) within 30 days of planned lymphodepletion
  -  EXCLUSION CRITERIA FOR PATIENTS WITH NSCLC OR TNBC (COHORT B): Patients requiring ongoing daily corticosteroid therapy at a dose of > 15 mg of prednisone per day (or equivalent); pulsed corticosteroid use for disease control is acceptable
  -  EXCLUSION CRITERIA FOR PATIENTS WITH NSCLC OR TNBC (COHORT B): Active autoimmune disease requiring immunosuppressive therapy
  -  EXCLUSION CRITERIA FOR PATIENTS WITH NSCLC OR TNBC (COHORT B): Serum creatinine > 2.5 mg/dL
  -  EXCLUSION CRITERIA FOR PATIENTS WITH NSCLC OR TNBC (COHORT B): SGOT > 5 x upper limit of normal
  -  EXCLUSION CRITERIA FOR PATIENTS WITH NSCLC OR TNBC (COHORT B): bilirubin > 3.0 mg/dL
  -  EXCLUSION CRITERIA FOR PATIENTS WITH NSCLC OR TNBC (COHORT B): Patients with clinically significant pulmonary dysfunction, as determined by medical history and physical exam should undergo pulmonary function testing; those with an FEV1 of < 2.0 L or DLCO (corrected) < 40% will be excluded
  -  EXCLUSION CRITERIA FOR PATIENTS WITH NSCLC OR TNBC (COHORT B): Significant cardiovascular abnormalities as defined by any one of the following: congestive heart failure, clinically significant hypotension, symptomatic coronary artery disease, or a documented ejection fraction of < 45%; any patient with an EF of 45-49% must receive clearance by a cardiologist to be eligible for the trial
  -  EXCLUSION CRITERIA FOR PATIENTS WITH NSCLC OR TNBC (COHORT B): Patients who are HIV seropositive
  -  EXCLUSION CRITERIA FOR PATIENTS WITH NSCLC OR TNBC (COHORT B): Uncontrolled active infection (bacterial, viral, fungal, mycobacterial) not responding to treatment with intravenous antibiotics, antiviral or antifungal agents, or long-term treatment with oral agents
  -  EXCLUSION CRITERIA FOR PATIENTS WITH NSCLC OR TNBC (COHORT B): Women who are breastfeeding
  -  EXCLUSION CRITERIA FOR PATIENTS WITH NSCLC OR TNBC (COHORT B): Anticipated survival of < 3 months
  -  EXCLUSION CRITERIA FOR PATIENTS WITH NSCLC OR TNBC (COHORT B): Patients who have contraindication to cyclophosphamide chemotherapy
  -  EXCLUSION CRITERIA FOR PATIENTS WITH NSCLC OR TNBC (COHORT B): Known additional malignancy that is progressing or requires active treatment; exceptions include basal cell carcinoma of the skin, squamous cell carcinoma of the skin, or in situ cervical cancer that has undergone potentially curative therapy
  -  EXCLUSION CRITERIA FOR PATIENTS WITH NSCLC OR TNBC (COHORT B): Active central nervous system (CNS) metastases and/or carcinomatous meningitis; subjects with previously treated brain metastases may participate provided they are stable (without evidence of progression by imaging for at least four weeks prior to enrollment and any neurologic symptoms have returned to baseline), have no evidence of new or enlarging brain metastases
  EXCLUSION CRITERIA FOR TNBC
  -  EXCLUSION CRITERIA FOR TNBC: ANC < 1000/mm^3
  -  Hgb < 9 mg/dl (transfusion permitted to achieve this)
  -  EXCLUSION CRITERIA FOR TNBC: Platelet count < 75,000/mm^3
  -  EXCLUSION CRITERIA FOR TNBC: Treatment with other investigational agent(s) within 30 days of planned lymphodepletion
  -  EXCLUSION CRITERIA FOR TNBC: Patients requiring ongoing daily corticosteroid therapy at a dose of > 15 mg of prednisone per day (or equivalent); pulsed corticosteroid use for disease control is acceptable
  -  EXCLUSION CRITERIA FOR TNBC: Active autoimmune disease requiring immunosuppressive therapy
  -  EXCLUSION CRITERIA FOR TNBC: Serum creatinine > 2.5 mg/dL
  -  EXCLUSION CRITERIA FOR TNBC: SGOT > 5 x upper limit of normal
  -  EXCLUSION CRITERIA FOR TNBC: Bilirubin > 3.0 mg/dL
  -  EXCLUSION CRITERIA FOR TNBC: Patients with clinically significant pulmonary dysfunction, as determined by medical history and physical exam should undergo pulmonary function testing; those with an FEV1 of < 2.0 L or DLCO (corrected) < 40% will be excluded
  -  EXCLUSION CRITERIA FOR TNBC: Significant cardiovascular abnormalities as defined by any one of the following: congestive heart failure, clinically significant hypotension, symptomatic coronary artery disease or a documented ejection fraction of < 45%; any patient with an EF of 45-49% must receive clearance by a cardiologist to be eligible for the trial
  -  EXCLUSION CRITERIA FOR TNBC: Patients who are HIV seropositive
  -  EXCLUSION CRITERIA FOR TNBC: Uncontrolled active infection (bacterial, viral, fungal, mycobacterial) not responding to treatment with intravenous antibiotics, antiviral or antifungal agents, or long-term treatment with oral agents
  -  EXCLUSION CRITERIA FOR TNBC: Anticipated survival of < 3 months
  -  EXCLUSION CRITERIA FOR TNBC: Breast-feeding women
  -  EXCLUSION CRITERIA FOR TNBC: patients who have contraindication to cyclophosphamide chemotherapy
  -  EXCLUSION CRITERIA FOR TNBC: Has a known additional malignancy that is progressing or requires active treatment; exceptions include basal cell carcinoma of the skin, squamous cell carcinoma of the skin, or in situ cervical cancer that has undergone potentially curative therapy
  -  EXCLUSION CRITERIA FOR TNBC: Has known active central nervous system (CNS) metastases and/or carcinomatous meningitis; subjects with previously treated brain metastases may participate provided they are stable (without evidence of progression by imaging for at least four weeks prior to enrollment and any neurologic symptoms have returned to baseline) and have no evidence of new or enlarging brain metastases

Relevance to patient case: not relevant