Engineered NK Cells Containing Deleted TGF-BetaR2 and NR3C1 for the Treatment of Recurrent Glioblastoma

This phase I trial is to find out the best dose, possible benefits and/or side effects of engineered natural killer (NK) cells containing deleted TGF-betaR2 and NR3C1 (cord blood \[CB\]-NK-TGF-betaR2-/NR3C1-) in treating patients with glioblastoma that has come back (recurrent). CB-NK-TGF-betaR2-/NR3C1- cells are genetically changed immune cells that may help to control the disease.

PRIMARY OBJECTIVES:

I. To determine the safety and tolerability of escalating doses of off-the-shelf CB-NK-TGF-betaR2-/NR3C1- in patients with recurrent glioblastoma (GBM), occurrence of dose limiting toxicities (DLTs) and determine the maximum tolerated dose (MTD). (Group 1) II. To evaluate the immunological phenotype and anti-tumor function of NK cells in resected tumor tissue after treatment with CB-NK-TGF-betaR2-/NR3C1- in the surgical expansion group. (Group 2)

SECONDARY OBJECTIVE:

I. To determine response as measured by Response Assessment in Neuro-Oncology (RANO), duration of clinical response, progression free survival (PFS), time to progression (TTP), and overall survival (OS).

EXPLORATORY OBJECTIVES:

I. Monitoring immune responses following CB-NK-TGF-betaR2-/NR3C1- dosing, in vivo persistence and expansion of CB-NK-TGF-betaR2-/NR3C1- during treatment, characterization of immune cell subpopulations in the peripheral blood, serum analysis of immune correlates, alloreactivity characterization, and anti-HLA antibody analysis, and CB-NK-TGF-betaR2-/NR3C1- trafficking in tumor microenvironments in the surgical expansion cohort.

II. Tumor tissue from surgical resection will be further analyzed for immune infiltrates, fibrosis, and tumor microenvironment.

OUTLINE: This is a dose-escalation study followed by a dose-expansion study. Patients are assigned to 1 of 2 groups.

GROUP 1: Ommaya catheter will be inserted prior to 1st injection of NK cells (at the time of screening biopsy). Participants will receive CB-NK-TGF-betaR2-/NR3C1- intratumorally over 10 minutes every 4 weeks for up to 8 doses in the absence of disease progression or unacceptable toxicity. Every NK cell Injection is 10 min followed by 1 ml of Normal Saline injected over additional 10 min via Ommaya catheter .

GROUP 2: Ommaya catheter will be inserted prior to the 1st injection of NK cells (at the time of screening biopsy). Two weeks prior to Surgical resection participants will receive the 1st dose of CB-NK-TGF-betaR2-/NR3C1- intratumorally over 10 minutes followed by 1 ml of Normal Saline injected over an additional 10 min via Ommaya catheter. Ommaya catheter It will be taken out at the time of standard of care surgical resection of the tumor on day 15 and then another one will be inserted at the end of surgery for future IT injections. Beginning 2 weeks after surgery, participants will receive CB-NK-TGF-betaR2-/ NR3C1- intratumorally over 10 minutes followed by 1 ml of Normal Saline injected over additional 10 min via Ommaya catheter every 4 weeks for up to 7 doses (total of 8 doses) in the absence of disease progression or unacceptable toxicity.

After completion of study treatment, participants are followed up at 30, and 90 days.

Eligibility Criteria:
Inclusion Criteria

1. Signed and dated informed consent.
2. Male or female subjects aged ≥ 18 years on the day of signing informed consent.
3. Has histologically confirmed supratentorial World Health Organization grade 4 recurrent astrocytoma to include recurrent glioblastoma (IDH-wildtype grade 4 astrocytoma) recurrent IDH-mutant grade 4 astrocytoma, and recurrent gliosarcoma with any prior number of recurrences, and who have received prior radiation and temozolomide therapy. Participants will be eligible if the original histology was lower-grade glioma grade 2 or 3 and a subsequent histological diagnosis of recurrent glioblastoma or IDH-mutant grade 4 astrocytoma is made.
4. Karnofsky Performance Score (KPS) of \>70 at trial entry.
5. Must be at least 12 weeks from receiving conformal radiation, unless RANO criteria for early progression are met.
6. A baseline brain MRI with Advance Brain Tumor Imaging (ABTI) must be obtained no more than 30 days prior to study registration
7. Patients having undergone recent surgery are eligible so long as they are at least 3 weeks from resection or at least 1 week from stereotactic biopsy and recovered from any operative or perioperative complications. Patients with non-measurable tumor after resection will NOT be excluded; if they do not experience tumor progression while on trial, response will be labeled as "stable disease" (and not as "complete response").
8. Adequate hematological function defined by white blood cell (WBC) count ≥ 3 × 109 /L with absolute neutrophil count (ANC) ≥ 1.5 × 109 /L, lymphocyte count ≥ 0.5 × 109 /L, platelet count ≥ 100 × 109 /L, and Hgb ≥ 9 g/ dL (in absence of blood transfusion).
9. Adequate hepatic function defined by a total bilirubin level ≤ 1.5 × ULN, an AST level ≤ 2.5 × ULN, and an ALT level ≤ 2.5 × ULN, and INR ≤ 1.5
10. Adequate renal function defined creatinine ≤1.5 X upper limit of normal (ULN) OR creatinine clearance ≥60 mL/min for subject with creatinine levels \> 1.5 X institutional ULN
11. Female subject of childbearing potential should have a negative serum pregnancy test within 14 days (+/-2 working days) of study registration.
12. Female subjects of childbearing potential should be willing to use 2 methods of birth control or be surgically sterile, or abstain from heterosexual activity for the course of the study and for 3 months after the last dose of study therapy. Subjects of childbearing potential are those who have not been surgically sterilized or have not been free from menses for \> 1 year.
13. Male subjects should agree to use 2 methods of highly effective contraception starting with the first dose of study therapy and for 3 months after the last dose of study therapy.
14. Have evaluable or measurable disease of at least 1cm2 of contrast-enhancing disease that is considered resectable by the neurosurgeon.
15. Have a tumor that is judged to be surgically resectable by the treating neurosurgeon.

Exclusion Criteria

The subject must be excluded from participating in the trial if the subject:

1. Has been treated previously with bevacizumab or Gliadel® wafers.
2. Has received prior interstitial brachytherapy, implanted chemotherapy, or therapeutics delivered by local injection or convection enhanced delivery.
3. Is currently participating in or has participated in a study of an investigational agent or using an investigational device 4 weeks since last dose of agent administration, or is planning to continue or start treatment with Optune® during participation in this trial.
4. Has known severe hypersensitivity reactions to monoclonal antibodies (Grade ≥ 3 NCI-CTCAE v5.0), any history of anaphylaxis, or recent, within 5 months, history of uncontrolled asthma.
5. Has a known history of Human Immunodeficiency Virus (HIV) (positive HIV 1/2 antibodies); HTLV1 and/or HTLV2; active Hepatitis B (e.g., HBsAg reactive) or Hepatitis C (e.g., HCV RNA \[qualitative\] is detected). Patients with prior HBV vaccination (anti-HBs positive, HBsAg negative, anti-HBc negative) will NOT be excluded.
6. Has a diagnosis of immunodeficiency or is receiving any immunosuppressive therapy within 7 days prior to study registration.
7. Has had prior chemotherapy or targeted small molecule therapy within 2 weeks prior to study Day 1 or who has not recovered (i.e., ≤ Grade 1 or at baseline) from adverse events due to a previously administered agent.

   1. Note: Subjects with ≤ Grade 2 neuropathy are an exception to this criterion and may qualify for the study.
   2. Note: If subject received major surgery (other than craniotomy), they must have recovered adequately from the toxicity and/or complications from the intervention prior to starting therapy.
8. Has had prior radiation therapy less than 12 weeks prior to enrollment; unless RANO criteria for early progression are met.
9. Has had prior therapy with any antibody/drug targeting T cell co-regulatory proteins (immune checkpoints) such as anti-PD-1, anti-PD-L1, or anti-CTLA-4 antibody
10. Has a known additional malignancy that is progressing or requires active treatment. Exceptions include superficial tumors considered adequately treated locally with curative intent, including but not limited to basal cell carcinoma of the skin, squamous cell carcinoma of the skin, or in situ cervical cancer that has undergone potentially curative therapy. Any exceptions must be discussed with the protocol PI.
11. Has known gliomatous meningitis or extracranial disease, or tumor localized primarily to the brainstem or spinal cord
12. Midline shift greater than 0.5 cm or pending herniation.
13. Tumors larger than 5 cm in its greatest diameter.
14. Has an active autoimmune disease requiring systemic treatment within the past 3 months or a documented history of clinically severe autoimmune disease, or a syndrome that requires systemic steroids or immunosuppressive agents. Subjects with vitiligo or resolved childhood asthma/atopy would be an exception to this rule. Subjects that require intermittent use of bronchodilators or local steroid injections would not be excluded from the study. Subjects with hypothyroidism stable on hormone replacement or Sjogren's syndrome will not be excluded from the study.
15. Has evidence of interstitial lung disease or active, non-infectious pneumonitis.
16. Has an active infection requiring systemic therapy or that in the opinion of the PI may interfere with the subject's participation, assessment of experimental treatment toxicity or increase the subject's risk of side effects.
17. Has a history or current evidence of any condition, therapy, or laboratory abnormality that might confound the results of the trial, interfere with the subject's participation for the full duration of the trial, or is not in the best interest of the subject to participate in the opinion of the treating investigator.
18. Has known psychiatric or substance abuse disorders that would interfere with cooperation with the requirements of the trial.
19. Is pregnant or breastfeeding, or expecting to conceive or father children within the projected duration of the trial, starting with the screening visit and through 3 months after last dose of the study treatment.
20. Has received a live vaccine within 30 days prior to the first dose of trial treatment.
21. Has a contraindication for undergoing MRIs.
22. Has evidence of bleeding diathesis or coagulopathy.
23. Is on full dose anticoagulation or antiplatelet therapy.
24. Has significant hemorrhage on baseline MRI ABTI defined as \>1 cm diameter of acute blood.
25. Has received any organ transplantation, including allogeneic stem-cell transplantation, but with the exception of transplants that do not require immunosuppression (e.g., corneal transplant, hair transplant).
26. Has multifocal disease. Subject has multifocal GBM, defined as discrete sites of contrast enhancing disease without contiguous T2/FLAIR abnormality that require distinct radiotherapy ports. Satellite lesions that are associated with a contiguous area of T2/FLAIR abnormality as the main lesion(s) and that are encompassed within the same radiotherapy port as the main lesion(s) are permitted.