CAR-T Cell Immunotherapy for Advanced Lung Cancer
Condition: Advanced Lung Cancer
MeSH terms: Lung Neoplasms
Intervention: CAR-T cells to treat advanced lung cancer
Intervention description: Drug: fludarabine. On days -4 through -2, fludarabine (25mg/m2) will be infused for 3 consecutive days; Drug: cyclophosphamide. On days -4 through -2, cyclophosphamide (250mg/m2) will be infused for 3 consecutive days.
Patients will receive the above chemotherapy for lymphocyte-depletion followed by PD-L1 CAR-T cells.
Phase: Phase 1
Study type: Interventional
Primary purpose: Treatment
Intervention model: Single Group Assignment
Masking: None (Open Label)
Enrollment: 1.0
Sex: All
Minimum age: 18 Years
Maximum age: 65 Years
Healthy volunteers: No
Keywords: CAR-T; advanced lung cancer; single-arm; phase I clinical study

Summary:

      The NSCLC patients who failed the standard treatments, with positive Programmed Death-Ligand
      1 (PD-L1) expression, were enrolled into this trial. About 22 advanced NSCLC patients will be
      screened according to the criteria. The qualified patients will be recruited and sign the
      informed consent.Participants will be hospitalized and undergo clinical examinations.

      Appropriate volume of peripheral blood will be draw (from 66 ml to 360 ml, depend on the body
      weight and blood routine test), using Ficoll method to centrifuge peripheral blood cell and
      collected T cells. PD-L1 CAR gene is cloned in a lenti-viral vector that was composed of T
      cell activation molecules (Cluster of Differentiation 137 (CD137/CD28) and Cluster of
      Differentiation 3(CD3) zeta intracellular domains) and PD-L1 single-chain variable
      fragment(scFv) derived from the variable regions of a PD-L1 monoclonal antibody.Then,
      investigators packaged pseudo-lentiviral particles in human embryonic kidney (293T) cells
      that will be used to transduce autologous T cells isolated from the patients. CAR positive T
      lymphocytes will be determined by FACS with florescence labeled goat anti-human F(ab')2. The
      plasmids, pseudo-lentiviral particles and transduced T cells will be subject to the
      stipulated tests by a third party.

      Patients will receive leukodepletion chemotherapy (cyclophosphamide: 250mg/m^2 × 3 days;
      fludarabine: 25mg/m^2× 3 days). One day later, the chemotherapeutic effects would be
      assessed. PD-L1 CAR-T cells will be infused on day 0 with 10%, day 3 with 30% and day 7 with
      60% (total number is (1-2)×10^6/kg). The patients will be observed closely for any adverse
      reactions and if happened, given supportive treatments.

      The patients will be discharged on day 14 and will be followed up for two years according to
      the study scheme, i.e. once a month for the first three months; once every two months in the
      first year; since then, once a quarter in the second year. The persistence of PD-L1 CAR-T
      cells in the circulation will be monitored by fluorescent activated cell sorting (FACS) and
      polymerase chain reaction (PCR). If the patients undergo core needle biopsy, the infiltration
      of CAR positive cells in the tumor tissue will be evaluated by immunohistochemistry (IHC).
      The safety profile and anti-tumor efficacy of the CAR-T cells immunotherapy will be assessed
      during the whole process based on CTCAE v4.1 and RECIST v1.1.
    

Eligibility criteria:

        Inclusion Criteria:

          1. Subjects were diagnosed with NSCLC by pathology and at clinical stages ⅢB/Ⅳ based on
             the 8th Union for International Cancer Control/American Joint Committee on Cancer
             (UICC/AJCC) Staging System or the disease has recurred or progressed after multi-mode
             therapy (radiotherapy, surgical excision or radical radiotherapy/chemotherapy to treat
             local advanced lesions ).

          2. Subjects whose recurrent or advanced NSCLC has progressed after standard treatments
             (operation, radiotherapy and targeting therapy, not including PD-1/PD-L1 checkpoint
             inhibition therapy) or who are reluctant to receive chemotherapy.

          3. Subjects should undertake core needle biopsy again to collect at least one fresh
             biopsy specimen and at least 10 non-stained sections before recruitment.

          4. TKI or chemotherapeutic should be discontinued at least 21 days before Day 0 of the
             clinical trial while radiotherapy of lung cancer at least 6 months before Day 0 of the
             clinical trial . Subjects should receive baseline imaging scan after the previous
             treatments are suspended.

          5. Lesions must be detected by CT or MRI according to RECIST 1.1 Criteria. Tumor imaging
             should be performed at least within 28 days before the beginning of the clinical
             study.

          6. Age>=18 years old and weight >=40kg.

          7. PD-L1 is positive by IHC in tissue biopsies of progressive lung cancer after standard
             treatments(>10%).Ventana PD-L1 (SP142) approved by FDA is used to detect PD-L1
             expression level on participated patients' lung cancer sections.

          8. Life expectancy>=12 weeks

          9. Eastern Cooperative Oncology Group (ECOG) score≤ 2

         10. Blood pregnancy tests should be negative within 14 days before the woman of
             childbearing age starts treatment and agrees to take contraceptive methods with a
             failure rate of no more than 1% per year until the final follow-up.Contraceptive
             methods with a failure rate of no more than 1% per year include tubal ligation,
             vasectomy, hormonal contraceptives, intrauterine hormone release system and copper
             intrauterine device (IUDs).

         11. Hematology and liver and kidney functions should meet the following laboratory values.
             These laboratory tests should be completed in 7 days before the first therapeutic cell
             infusion.

             Tests and Laboratory Values:

             Hematology:

               1. White Blood Cell (WBC): >=3.5*10^9/L;

               2. Absolute Neutrophil Count (ANC): >=1.5*10^9/L;

               3. Hemoglobin (HGB): >=90g/L;

               4. Platelet (PLT): >=80*10^9/L;

             Blood Coagulation Function:

             PT、APTT、FIB、TT: within normal limits;

             Liver Function:

               1. Aspartic Transaminase (AST): <2.5*upper normal limits(ULN)(hepatic metastasis
                  subjects with 0-1 ECOG score < 5*ULN);

               2. Alanine Aminotransferase (ALT): <2.5*ULN(hepatic metastasis subjects with 0-1
                  ECOG scorer < 5*ULN);

               3. Total Bilirubin (TIBC): <1.5*ULN;

             Kidney Function:

             Serum Creatinine (CR): <1.0*ULN.

         12. Subjects are willing to participate in this study and agree to sign the Informed
             Consent.

        Exclusion Criteria:

          1. Subjects who are receiving systematic steroid treatments 3 days before the first cell
             treatment.

             Notice:

               1. Corticosteroids can be used to treat adverse event (AE) and serious adverse event
                  (SAE) after the experimental cell treatment.

               2. Subjects who receive steroid replacement therapy everyday can be included in the
                  clinical study. Prednisone therapy in a dose of 5-7.5mg/day is replacement
                  therapy.

               3. Subjects who receive equivalent dose of hydrocortisone treatment as replacement
                  therapy are also allowed into the clinical trial.

          2. Subjects who have received systematic cytotoxic chemotherapy, biological therapy or
             major operations in 3 weeks before the first dose of experimental cell therapy or
             subjects who have received lung radiation more than 30 gray (Gy) in 6 months before
             the first dose of experimental cell therapy.

          3. Subjects who have received previous cell treatments such as CAR-T and cytokine-induced
             killer (CIK) cells or anti-PD-1 or anti- PD-L1 antibody treatment.

          4. Subjects with confirmed Central Nervous System (CNS) metastasis and/or carcinomatous
             meningitis.

             Notice:

             Subjects who have received brain metastasis treatments are allowed in this study, in
             the case that subjects' conditions are stable (no CNS symptoms) and no radiographic
             evidence of new or extensive brain metastasis is found at least 4 weeks after the
             treatments (such as operation or RT). Subjects should suspend hormone treatment at
             least 3 days before the first dose of experimental cell treatment.

          5. Subjects with active autoimmune diseases who need systematic treatments (such as
             disease improving drugs, corticosteroids and immunosuppressive drugs) in the last 2
             years.

             Notice:

             Replacement therapy (thyroxine, insulin or physiological corticosteroid replacement
             therapy to treat adrenal dysfunction or pituitary dysfunction) is not considered as
             systematic therapy. Subjects who need inhalation corticosteroid therapy can be
             included in this trial. Subjects with vitiligo or in long-term remission of pediatric
             asthma or allergic diseases can be included in this trial.

          6. Subjects with interstitial pneumonia or a history of pneumonia with oral or
             intravenous steroid treatments.

          7. Subjects whose lymphocytes are difficult to transduce (<20%) or can not proliferate
             over 5 times.

          8. Subjects who have received allotransplantation or solid organ transplantation.

          9. Subjects who have received or will receive live vaccines in 30 days before the first
             experimental cell treatment. Inactivated seasonal flu vaccination is allowed.

         10. Subjects with active infections who need intravenous systematic treatments.

         11. Subjects with a history of human immunodeficiency virus (HIV)（HIV 1/2 antibody
             positive）infection.

         12. Subjects with known active hepatitis B or hepatitis C. Subjects with HBsAg positive
             will be excluded. The definition of active hepatitis C is that hepatitis C antibody is
             positive while quantitative hepatitis C virus (HCV) RNA results exceed the lower
             detection limit.

         13. Subjects with a history of mental disorders or drug abuse that may influence treatment
             compliance.

         14. Women in pregnancy or lactation or are expected to be pregnant during the study (from
             the screening and to 60 days after the final experimental cell treatment) or men whose
             wives are in pregnancy.