Anti-GD2 CAR T Cells in Pediatric Patients Affected by High Risk And/or Relapsed/refractory Neuroblastoma or Other GD2-positive Solid Tumors

The purpose of this study is to test the safety and efficacy of GD2-CART01, a CAR T cell treatment targeting GD2 in paediatric or young adult patients with High Risk and/or relapsed/refractory Neuroblastoma.

A small exploratory cohort of patients with GD2-positive tumors other than Neuroblastoma has also been included.

The study will consist of 2 phases, a Phase I or dose escalation phase and a Phase II or expansion phase. Paediatric or young adult patients with relapsed High Risk and/or relapsed/refractory Neuroblastoma will be enrolled in the study.

After completion of the phase I portion of the study, a small cohort of patients with GD2-positive tumors other than Neuroblastoma has also been included.

Eligible patients will undergo leukapheresis in order to harvest T cells, which will be manufactured to obtain the autologous CAR T product GD2-CART01, a GD2-targeting CAR T product. Briefly, the patients will be treated with a lymphodepleting regimen containing conventional chemotherapic agents and subsequently will receive a single infusion of GD2-CART01. Moreover, the product contains a suicide gene safety switch (namely inducible Caspase 9): in case of relevant toxicities, the patient will receive the dimerizing agent in order to activate the apoptotic pathway in the infused T cells.

After infusion of CAR T cells, the patients will enter a 5-year active follow-up period.

Eligibility Criteria:
Inclusion Criteria:

Phase I The patient must meet the following eligibility inclusion criteria to be enrolled to receive treatment in the Phase I study.

1. Diagnosis of NBL that have been treated with frontline therapy and is judged to be incurable, based upon the following criteria:

   1. Relapse after first-line treatment, proved by a positive 123-I-mMIBG-scan
   2. Persistence/progression of disease after the initiation of the upfront treatment
2. Patients must have measurable or evaluable disease at the time of treatment enrollment, as shown by bone marrow biopsy/aspirate, US or CT/MRI scan or by 123-I-mMIBG scan.
3. Recover from the toxic effect of previous chemotherapies: grade 4 and or 3 non-hematologic toxicities must have resolved to grade ≤2; if some effects of the therapies have become chronic (i.e. treatment associated thrombocytopenia), the patient must be clinically stable, according to the opinion of the treating physicians, and meet all other eligibility criteria.
4. Age: 12 months -18 years.
5. Voluntary informed consent is given. For subjects \< 18 years old their legal guardian must give informed consent. Pediatric subjects will be included in age appropriate discussion and verbal assent will be obtained for those greater than or equal to 12 years of age, when appropriate.
6. Clinical performance status: Patients \> 16 years of age: Karnofsky greater than or equal to 60%; Patients less than or equal to 16 years of age: Lansky scale greater than or equal to 60%.
7. Patients of child-bearing or child-fathering potential must be willing to practice birth control from the time of enrollment on this study and for four months after receiving the preparative regimen.
8. Females of child-bearing potential must have a negative pregnancy test because of the potentially dangerous effects on the fetus.

Phase II

The patient must meet the following eligibility inclusion criteria to be enrolled to receive treatment in the Phase II study.

1. Diagnosis of NBL that have been treated with frontline therapy and is judged to be incurable, based upon the following criteria:

   1. Relapse after first-line treatment, proved by a positive MIBG-scan
   2. Persistence/progression of disease after the initiation of the upfront treatment

   OR
2. Diagnosis of extremely High Risk NBL at high risk of relapse, defined by stage III/IV and Myc-N amplification, at the end of the first-line treatment according to the Standard of Care, even if NED.

   OR
3. Diagnosis of GD2+ tumors other than Neuroblastoma, considered incurable with conventional treatments by the treating physician.
4. Patients with relapsed/refractory disease must have measurable or evaluable disease at the time of treatment enrollment, as shown by bone marrow biopsy/aspirate, US or CT/MRI scan or by MIBG-scan.
5. Recover from the toxic effect of previous chemotherapies: grade 4 and or 3 non-hematologic toxicities must have resolved to grade ≤2; if some effects of the therapies have become chronic (i.e. treatment associated thrombocytopenia), the patient must be clinically stable, according to the opinion of the treating physicians, and meet all other eligibility criteria.
6. Age: 12 months - 18 years.
7. Voluntary informed consent is given. For subjects \< 18 years old their legal guardian must give informed consent. Pediatric subjects will be included in age appropriate discussion and verbal assent will be obtained for those greater than or equal to 12 years of age, when appropriate.
8. Clinical performance status: Patients \> 16 years of age: Karnofsky greater than or equal to 60%; Patients less than or equal to 16 years of age: Lansky scale greater than or equal to 60%.
9. Patients of child-bearing or child-fathering potential must be willing to practice birth control from the time of enrollment on this study and for four months after receiving the preparative regimen.
10. Females of child-bearing potential must have a negative pregnancy test because of the potentially dangerous effects on the fetus

Exclusion Criteria:

1. Pregnant or lactating women
2. Severe, uncontrolled active intercurrent infections
3. Active hepatitis B or hepatitis C infection
4. HIV infection
5. Rapidly progressive disease with life-expectancy \< 6 weeks
6. History of grade 3 or 4 hypersensitivity to murine protein-containing products
7. Hepatic function: Inadequate liver function defined as total bilirubin \> 4x upper limit of normal (ULN) or transaminase (ALT and AST) \> 6 x ULN based on age and laboratory specific normal ranges
8. Renal function: serum creatinine \> 3x ULN for age.
9. Blood oxygen saturation \< 90%.
10. Cardiac function: Left ventricular ejection fraction lower than 45% by ECHO.
11. Marrow function: ANC lower than 500/mm3 and/or platelets lower than 20.000 (not reached by transfusion).
12. Congestive heart failure, cardiac arrhythmia, psychiatric illness, or social situations that would limit compliance with study requirements or in the opinion of the PI would pose an unacceptable risk to the subject.
13. Untreated CNS metastasis; patients with previous CNS tumor involvement that has been treated and is stable for at least 6 weeks following completion of therapy are eligible.
14. Concurrent or recent prior therapies, before infusion:

    1. Systemic steroids (at a dose equivalent to or greater 2 mg/kg prednisone) in the 2 weeks before infusion. Recent or current use of inhaled/topical/non-absorbable steroids is not exclusionary.
    2. Systemic chemotherapy in the 2 weeks preceding infusion.
    3. Immunosuppressive agents less than or equal to 30 days.
    4. Radiation therapy must have been completed at least 3 weeks prior to enrollment.
    5. I131-MIBG therapy must have been completes at least 6 weeks prior to enrollment
    6. Anti-GD2 murine monoclonal antibody (ch14.18 antibody) in the 2 weeks preceding infusion
    7. Other anti-neoplastic investigational agents currently or within 30 days prior to start of protocol therapy;
    8. Exceptions:
    9. Subjects receiving steroid therapy at physiologic replacement doses only are allowed provided there has been no increase in dose for at least 2 weeks prior to starting apheresis
15. Patient-derived GD2-CART01 production failure.