CIML NK Cells With Venetoclax for AML

The purpose of this research study is to test the safety and to explore the effectiveness of infusing cytokine- induced memory-like (CIML) natural killer (NK) cells in combination with Interleukin-2 (IL-2) and standard-of-care venetoclax as a treatment for Acute Myeloid Leukemia (AML).

Names of the study therapies involved in this study are:

* Lymphodepleting therapy with Fludarabine and Cyclophosphamide prior to CIML NK cell infusion
* CIML NK (a cellular therapy)
* IL-2 (a recombinant, human glycoprotein)
* Venetoclax (a selective inhibitor of BCL-2 protein)

This is an open-label, single center phase I trial combining Cytokine-induced memory-like natural killer (CIML NK) cell therapy with low-dose IL-2 and with venetoclax as consolidation therapy in acute myeloid leukemia (AML).

This is the first time that CIML NK cells in combination with venetoclax will be given to humans.

The U.S. Food and Drug Administration (FDA) has not approved CIML NK cells as a treatment for AML.

The U.S. FDA has not approved IL-2 for AML but it has been approved for other uses.

The U.S. FDA has approved venetoclax as a treatment option for AML.

The research study procedures include screening for eligibility, study treatment visits, electrocardiograms (ECGs), bone marrow biopsies, blood tests, and echocardiograms.

Participants will be followed for up to 1 year after the start of therapy.

It is expected that about 10 people will take part in this research study.

This research is funded by the Leukemia and Lymphoma Society.

Eligibility Criteria:
Inclusion Criteria for Trial Enrollment (Screening Visit #1):

* Acute myeloid leukemia (AML)
* Age ≥ 18 years old
* At time of screening patient is being treated with HMA(azacitidine or decitabine) + venetoclax therapy and has received at least 1 cycle of HMA (azacitidine or decitabine) + venetoclax. Patients can have received other lines of therapy prior to HMA + venetoclax therapy including prior chemotherapy but cannot have received a prior allogeneic stem cell transplant.
* Last bone marrow biopsy within 2 months (60 days) prior to the screening date showed a complete remission (CR) or complete remission with incomplete count recovery (CRi) or morphologic leukemia free state (MLFS) (\< 5% blasts). Bone marrow biopsy does NOT need to be repeated at screening visit #1 and a historic bone marrow biopsy report can be used if it was obtained within 2 months (60 days) of screening visit #1. A bone marrow biopsy will be repeated at screening visit #2.
* Last bone marrow biopsy within 2 months (60 days) prior to the screening date showed measurable residual disease (MRD+) by either flow cytometry, next generation sequencing or PCR. Patients with persistent DNMTA, TET2 or ASXL1 mutations will not qualify as MRD+ as these DTA mutations are associated with clonal hematopoiesis. Bone marrow biopsy does NOT need to be repeated at screening visit #1 and a historic bone marrow biopsy report can be used if it was obtained within 2 months (60 days) of screening visit #1. A bone marrow biopsy will be repeated at screening visit #2.
* Presence of molecular risk factors for relapse with continued HMA + venetoclax therapy as defined by any of the following present at the time of diagnosis or start of HMA + venetoclax therapy (these do not need to be present at the time the screening BM biopsy):

  * 2022 ELN adverse risk karyotype: t(6;9)(p23.3;q34.1)/DEK::NUP214; t(v;11q23.3)/KMT2A-rearranged; t(9;22)(q34.1;q11.2)/BCR::ABL1; t(8;16)(p11.2;p13.3)/KAT6A::CREBBP; inv(3)(q21.3q26.2) or t(3;3)(q21.3;q26.2)/ GATA2, MECOM(EVI1), t(3q26.2;v)/MECOM(EVI1)-rearranged; -5 or del(5q); -7; Complex karyotype, monosomal karyotype
  * 2022 ELN adverse risk mutations: Any one of the following mutations: Mutated TP53, ASXL1, BCOR, EZH2, RUNX1, SF3B1, SRSF2, STAG2, U2AF1, and/or ZRSR2
  * Additional mutations associated with acquired resistance to venetoclax: Mutated NRAS, KRAS, FLT3 ITD/TKD
* At the time of screening, the patient is considered not a good enough candidate to undergo allogeneic hematopoietic stem cell transplantation (HSCT) in the opinion of the treating physician. This could be either due to advanced age, significant comorbidities or high risk of disease relapse after HSCT without additional therapy prior to HSCT. The patient could potentially become eligible for a HSCT in the future if the situation changes in the future (e.g., performance status improves with therapy, MRD is eradicated with therapy).
* ECOG performance status ≤2 (see Appendix A)
* Available haploidentical or fully HLA-matched related donor that is willing and eligible for non-mobilized collection.
* Participants must meet the following organ function as defined below:

  * Total bilirubin: ≤1.5 x institutional upper limit of normal (ULN) (except Gilbert's or disease-related hemolysis, then \< 3 x ULN)
  * AST(SGOT)/ALT(SGPT): ≤3 x institutional ULN
  * creatinine clearance ≥ 45 mL/min; calculated by the Cockcroft Gault formula
  * oxygen saturation ≥ 90% on room air
  * left ventricular ejection fraction \> 40%
* Negative pregnancy test for women of childbearing potential only.
* The effects of CIML NK cells and IL-2 on the developing human fetus are unknown. For this reason, women of child-bearing potential and men must agree to use adequate contraception (hormonal or barrier method of birth control; abstinence) prior to study entry and for the duration of study participation. Should a woman become pregnant or suspect she is pregnant while she or her partner is participating in this study, she should inform her treating physician immediately. Men treated or enrolled on this protocol must also agree to use adequate contraception prior to the study and until 4 months after the last IL-2 dose administration.
* Participants with known history or current symptoms of cardiac disease, or history of treatment with cardiotoxic agents, should have a clinical risk assessment of cardiac function using the New York Heart Association Functional Classification. To be eligible for this trial, participants should be class 2B or better.
* Participants with a prior or concurrent malignancy whose natural history or treatment does not have the potential to interfere with the safety or efficacy assessment of the investigational regimen are eligible for this trial.
* Ability to understand and the willingness to sign a written informed consent document. (Providing consents in as many languages as possible is encouraged)
* Subjects must be able to swallow pills.
* No laboratory evidence of ongoing hemolysis in opinion of investigator

Exclusion Criteria for Trial Enrollment (Screening visit #1)

* Prior allogeneic stem cell transplant, organ transplant or donor lymphocyte infusion (DLI), CAR-T cell or NK cell therapy
* Persisting Grade \> 1 non hematologic toxicity related to prior therapy; however, alopecia, sensory neuropathy Grade ≤ 2, or other Grade ≤ 2 not constituting a safety risk based on investigator's judgment are acceptable.
* Autoimmune disease: Patients with a history of inflammatory bowel disease, including ulcerative colitis and Crohn's Disease, are excluded from this study, as are patients with a history of symptomatic disease (e.g., rheumatoid arthritis, systemic progressive sclerosis \[scleroderma\], systemic lupus erythematosus, autoimmune vasculitis \[e.g., Wegener's Granulomatosis\]) and motor neuropathy considered of autoimmune origin (e.g. Guillain-Barre Syndrome and Myasthenia Gravis). Patients with Hashimoto's thyroiditis are eligible to go on study.
* Systemic corticosteroid therapy (\> 10 mg of prednisone or equivalent dose of systemic steroids for non-autoimmune indications for at least 4 weeks prior to CIML NK cell infusion)
* Pregnant women are excluded from this study because of the unknown teratogenic risk of CIML NK cells and IL-2 and with the potential for teratogenic or abortifacient effects by Flu/Cy chemotherapy regimen. Because there is an unknown but potential risk for adverse events in nursing infants secondary to treatment of the mother with CIML NK cells and IL-2, breastfeeding should be discontinued if the mother is treated on this study.
* HIV-positive participants are ineligible because of the potential for pharmacokinetic interactions with anti-retroviral agents used in this study. In addition, these participants are at increased risk of lethal infections when treated with marrow suppressive therapy.
* Individuals with active uncontrolled hepatitis B or C are ineligible as they are at high risk of lethal treatment-related hepatotoxicity after conditioning therapy.
* Individuals with a history of a different malignancy are ineligible except for the following circumstances: 1. History of other malignancy and have had complete remission of disease for at least 2 years; 2. Diagnosed and treated within the past 2 years for: nonmetastatic melanoma, surgically resected (not needing systemic chemotherapy) squamous cell carcinoma of skin and nonmetastatic prostate cancer not needing systemic chemotherapy.
* History of severe allergic reactions attributed to compounds of similar chemical or biologic composition to IL-2 or other agents used in study.
* Participants who are receiving any other investigational agents for this condition
* Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, symptomatic congestive heart failure, unstable angina pectoris or cardiac arrhythmia, or psychiatric illness/social situations that would limit compliance with study requirements.
* Prior history of Grade 2 or higher hemolytic anemia (\>/= 2g decrease in hemoglobin plus laboratory evidence of hemolysis) from any cause

Inclusion Criteria to Start Investigational Treatment Plan (Screening visit #2)

* Patient was eligible for protocol per section 3.1.
* Bone marrow biopsy at screening visit #2 shows \< 5% in the bone marrow aspirate (if cellularity \> 20% and not aspicular). If aspirate is hypocellular and/or aspicular, bone marrow core biopsy is required to show \< 5% blasts based on immunohistochemistry.
* ECOG performance status ≤2 (see Appendix A)
* Participants must meet the following laboratory and organ function as defined below:

  * Absolute neutrophil count \> 500/microL
  * Platelets \> 50,000/microL
  * Total bilirubin: ≤1.5 x institutional upper limit of normal (ULN) (except Gilbert's or disease-related hemolysis, then \< 3 x ULN)
  * AST(SGOT)/ALT(SGPT): ≤3 x institutional ULN
  * creatinine clearance ≥ 45 mL/min; calculated by the Cockcroft Gault formula
  * oxygen saturation ≥ 90% on room air
  * left ventricular ejection fraction (LVEF) \> 40%
* No significant change in clinical status that would, in the opinion of the investigator, increase the risk of adverse events associated with CIML NK infusion, (e.g., symptomatic congestive heart failure, unstable angina, cardiac arrhythmia)
* Negative pregnancy test for women of childbearing potential only.
* Subjects must be able to swallow pills.
* No evidence of ongoing hemolysis in opinion of investigator
* No venetoclax or HMA for ≥ 7 days prior to screening visit #2

Exclusion Criteria to Start Investigational Treatment Plan (Screening visit #2)

* No live vaccines within the last 6 months.
* No ongoing or active infections.
* Moderate/strong inhibitors of CYP3A except of antifungal medications (such as posaconazole, voriconazole) which the patient is on and the dose of venetoclax has already been adjusted. These are excluded as moderate/strong inhibitors of CYP3A induce higher drug levels of venetoclax which in turns carry the risk of CIML NK cell elimination.

Criteria to Receive CIML NK Infusion

* Adequate organ function within 24 hours of NK cell infusion as defined below:

  * Total bilirubin: ≤1.5 x institutional upper limit of normal (ULN) (except Gilbert's or disease-related hemolysis, then \< 3 x ULN)
  * AST(SGOT)/ALT(SGPT): ≤3 x institutional ULN
  * No Grade ≥3 non-hematologic toxicities of cyclophosphamide and fludarabine conditioning (except for Grade 3 nausea, vomiting, diarrhea, or constipation).
* No significant change in clinical status that would, in the opinion of the investigator, increase the risk of adverse events associated with CIML NK infusion, (e.g., significant hypoxemia, symptomatic congestive heart failure, unstable angina, cardiac arrhythmia)
* No evidence of active, uncontrolled infection. Patients receiving antibiotics for an infection may be treated if they have clinically responded to antibiotics. These cases should be reviewed with the study PI before proceeding.
* No live vaccines within the last 6 months
* Systemic steroid therapy (oral or IV) of \> 10mg prednisone or equivalent dose of other steroid agent on the day of NK cell infusion

If any of the above criteria are noted at these time points, please discuss with PI the benefits/risks of proceeding with the CIML infusion and document rationale for course of action taken in study regulatory binder. However, patient may still receive CIML NK infusion if relevant parameters are reviewed and both PI and IND holder agree with proceeding.

If inclusion/exclusion criteria are not met on planned day of CIML NK cell infusion, the NK cell infusion may be delayed for up to 24 hours to enable inclusion criteria to be met.

Criteria to Receive Venetoclax

* Adequate organ function within 24 hours of venetoclax initiation as defined below:

  * Total bilirubin: ≤1.5 x institutional upper limit of normal (ULN) (except Gilbert's or disease-related hemolysis, then \< 3 x ULN)
  * AST(SGOT)/ALT(SGPT): ≤3 x institutional ULN
  * No Grade ≥3 non-hematologic toxicities of cyclophosphamide and fludarabine conditioning (except for Grade 3 nausea, vomiting, diarrhea, or constipation).
* No significant change in clinical status that would, in the opinion of the investigator, increase the risk of adverse events associated with venetoclax administration, (e.g., significant hypoxemia, symptomatic congestive heart failure, unstable angina, cardiac arrhythmia, severe ongoing tumor lysis syndrome)
* No evidence of active, uncontrolled infection. Patients receiving antibiotics for an infection may be treated if they have clinically responded to antibiotics. These cases should be reviewed with the study PI before proceeding.
* No live vaccines within the last 6 months