Adoptive Cell Therapy for B-Cell Cancers in Patients After Stem Cell Transplantation
Condition: Chronic Lymphocytic Leukemia
MeSH terms: Leukemia, Lymphoid; Leukemia, Lymphocytic, Chronic, B-Cell
Study type: Interventional
Phase: Phase 1

Summary: 
      Background:

        -  After allogeneic (donor) stem cell transplantation, a new immune system grows in the
           patient from the transplanted donor stem cells and lymphocytes (type of immune cell).
           Donor lymphocytes, unlike the patient s own lymphocytes, often can recognize the patient
           s tumor cells as being foreign and destroy them.

        -  It is thought that tumor shrinkage after stem cell transplantation is the result of
           donor T lymphocytes, or T cells. Some studies show that patients with tumors that have T
           cells are better able to keep tumor growth in check.

        -  Patients who have had donor stem cell transplantation may have donor T cells in their
           tumors that can recognize and fight their cancer. Compared with donor T cells taken
           directly from the donor and infused into the patient, donor T cells found in patients
           tumors may be specific for the cancer cells and thus better able to attack tumor. Also,
           because the T cells found their way to the tumor, they may be less likely to recognize
           and attack non-tumor tissues than the T cells given in donor lymphocyte infusions.

        -  The T cells may be especially effective at controlling tumor if they are given an
           additional stimulus to become active. Costimulation is the name of the body s natural
           process for providing an extra stimulus, and can be performed on cells in the
           laboratory. Costimulation can produce large numbers of activated cells that may be able
           to attack cancer cells and shrink tumors.

      Objectives:

      -To evaluate the ability of lymphocytes found in tumors from patients who have received donor
      stem cell transplants to control their tumor growth.

      Eligibility:

      -Patients between 18 and 75 years of age with a B-cell cancer that has continued to grow or
      recurred after remission following allogeneic stem cell transplantation. This includes
      patients who have received transplants from unrelated donors and cord blood.

      Design:

        -  Immune cells are collected from patients blood and blood from their stem cell donor.

        -  Patients undergo surgery to remove their tumor and a small piece of skin. In the
           laboratory, donor T cells are isolated from the tumor and costimulated to expand the
           number of cells and activate them.

        -  The expanded, activated T cells as infused into the patient.

        -  Patients have a needle biopsy and possibly surgery to remove a sample of remaining tumor
           for research studies.

        -  Patients are followed at the NIH clinic 48 hours after the cell infusion, and again at
           1, 2, 4, 8 and 12 weeks after the infusion. Tumor size is monitored every month with CT
           scans, and possibly also with a PET or bone marrow aspiration and biopsy, for the first
           3 months after the cells are infused. Thereafter, visits are less frequent (every 3
           months, then every 6 months, and then yearly) during a minimum 5-year follow-up.
    

Detailed description: 
      Background:

        -  The prognosis for patients with B-cell lymphoid malignancies (BCL) with relapse or
           refractory disease after allogeneic hematopoietic stem cell transplantation (AlloHSCT)
           is poor. Effective therapy for patients who fail withdrawal of immune suppression and
           administration of donor lymphocyte infusions (DLI) has not been identified.

        -  In the setting of recurrent or refractory BCL, the immunologic graft-versus-tumor (GVT)
           effect generated by unmanipulated donor lymphocytes is often not durable and can be
           accompanied by graft-versus-host disease (GVHD).

        -  We have hypothesized that lymphocytes found in tumor after alloHSCT are of donor origin,
           and because they are tumor-derived, they may be tumor-specific in their homing and
           antigen specificity characteristics. Similarly, inpatients with bone marrow involvement
           with tumor, the marrow may be enriched with similarly tumor-specific T cells. Further,
           activation and expansion of these cells through CD3/CD28 costimulation may yield a more
           effective form of cell therapy than DLI after alloHSCT, with enhanced GVT effects and
           less GVHD.

      Objectives:

        -  To evaluate the feasibility of isolating and expanding clinically relevant numbers of
           TDL from patients after alloHSCT.

        -  To determine the safety, vis-a-vis infusion toxicities and/or GVHD, of administering
           TDL.

      Eligibility:

        -  Adults with B cell malignancies with tumor that has not responded to successful T cell
           engraftment after alloHSCT, withdrawal of immune suppression and administration of donor
           lymphocyte infusion will be eligible for this trial.

        -  Subjects must have a minimum of 1.5 cm of accessible tumor which is amenable to
           resection with minimal surgical morbidity and/or bone marrow tumor involvement.

      Design:

        -  Subjects will have accessible lesion surgically resected and/or harvested via bone
           marrow aspiration.

        -  Lymphocytes will be liberated and expanded using a co-stimulatory approach with
           anti-CD3/CD28 magnetic beads to generate TDL and/or marrow-TDL.

        -  1.0 x 10(6) - 1.0 x 10(8) TDL will be administered.

        -  Subjects will be monitored for the development of infusion reactions (in-hospital for 24
           hours after infusion), GVHD (weekly for four weeks then monthly) and tumor responses
           (monthly).

        -  Two cohorts will be enrolled, with an arm evaluating TDL from resected tumor and an arm
           to evaluate marrow-TDL from tumor-involved bone marrow. For the TDL arm, 15 to 18
           patients and up to 18 donors will be enrolled; for the marrow-TDL arem, 15 patients and
           up to 15 donors will be enrolled. Both arms will test the primary endpoints of
           feasibility (with at least 11 of 15 tumors yielding 1.0 x 10(6) TDL/kg meeting defined
           release criteria) and safety (primarily defined as having a no greater risk of
           developing grade II-IV acute GVHD by day 28 as standard therapy with unmanipulated DLI).
    

Intervention name(s): Allogeneic Cell Therapy w/ Tumor-derived Lypho
Intervention type(s): Drug
Primary purpose: Treatment
Keywords: Adoptive Immunotherapy; Tumor Infiltrating Lymphocytes; Refractory Tumor; Resection; B-Cell Malignancies; Chronic Lymphocytic Leukemia; BCL; B-Cell Lymphoid Malignancy