Tris-CAR-T Cell Therapy for Recurrent Glioblastoma

Study Overview
=================
Brief Summary
-----------------
This is a Phase 1 study of recurrent glioblastoma locoregional adoptive therapy with autologous peripheral blood T cells lentivirally transduced to express a dual-target, truncated IL7Ra modified chimeric antigen receptor (CAR), delivered by Ommaya reservoir, a pre-indwelled catheter in the tumor resection cavity. Patients with recurrent glioblastoma will have surgical treatment and pathological test for target expression at their home institution or at Beijing Tiantan Hospital. If the tumor is target positive and the patient meets all other eligibility criteria, and meets none of the exclusion criteria, will have Ommaya reservoir implantation, and a subsequent Peripheral Blood Mononuclear Cells (PBMCs) collection. T cells will then be isolated from the PBMC sample and then be bioengineered in to a 4th generation CAR-T cell, Tris-CAR-T cells. Recipients with Ommaya reservoir implanted will be assigned to three courses. The first 2 patients will be assigned to low dose group, and will have one dose of autologous Tris-CAR-T cells delivery via Ommaya reservoir. The second 2 patients will be assigned to high dose group, and will have one dose of autologous Tris-CAR-T cells delivery via Ommaya reservoir. The last 4 patients will be assigned to multidose group, and will receive a weekly dose of autologous Tris-CAR-T cells for maximum 8 weeks. All patients will undergo studies including MRI to evaluate the effect of the CAR-T cells, physical examination and cerebrospinal fluid cytokine assays to evaluate side effects. All patients will undergo a long-term follow-up. The hypothesis is that an adequate amount of Tris-CAR-T cells can be manufactured to complete all the three courses. The other hypothesis is that Tris-CAR-T cells can safely and effectively be administered through Ommaya reservoir to allow the CAR-T cells to directly interact with the tumor cells for each patient enrolled on the study. The primary aim of the study will be to evaluate the safety of Tris-CAR-T administering. Secondary aims of the study will include to evaluate CAR-T cell distribution within cerebrospinal fluid and peripheral blood, tumor progress post CAR-T cell infusion, and, if tissues samples from multiple time points are available, also evaluate the degree of target expression, biological characteristics of samples at diagnosis versus at recurrence or progression.

Detailed Description
-----------------
The autologous Tris-CAR-T cell, targeting both CD44 and CD133, the two inverse correlated targets, introduced truncated IL7Ra to the intracellular domain of CAR molecule, has shown ideal survival and tumor suppression in our previous studies. The cells will be tested for safety and kinetics in this clinical trial. All patients are required to have an Ommaya reservoir in tumor resection cavity prior to CAR-T cell infusion. Ommaya reservoir placement is done by a surgery. Autologous Tris-CAR-T cell will be manufactured via CliniMACS Instrument (Miltenyi Biotec). Cells will be frozen and stored to infuse to the patients. Each infusion will take between 5 and 10 minutes. We will then monitor the patient in the hospital for at least 3 days post the first dose of infusion. If the first infusion is tolerated well and the patient is assigned to multidose group, a second infusion may be given 7 days after the initial infusion and patient will be monitored in the hospital for no longer than 1 day. And the subsequent infusion will be done in the same manner. The treatment will be given by the Department of neurosurgery, Beijing Tiantan hospital. If patient is receiving a single dose of the cells, the patient will be monitored at least 3 days after the infusion. Patients assigned to multidose group will be needed to stay in Beijing for up to 8 weeks from the first infusion so we can monitor for side effects and will be readmitted to the hospital if patient develops a fever. If patient develops severe fevers after discharge from the hospital, patient will be readmitted to the hospital for close monitoring for at least one night during safety observation Patients receive single dose infusion will have follow-up visits at weeks 2, 3, 4, then at months 3, 6,9 post infusion. Patients receive multiple dose infusion will have follow-up visits at week 2, then at months 1, 3post infusion. All patients receive long-term twice a year for a total of 15 years. Medical tests before treatment-- Before being treated, the patient will receive a series of standard medical tests: Physical exam Blood routine, serum biochemical test, kidney and liver function Measurements of the tumor by routine MRI Medical tests during and after treatment-- The patient will receive standard medical tests when they are getting the infusions and afterwards: Physical exams Blood routine, serum biochemical test, kidney and liver function, serum and (or) cerebrospinal fluid analysis Measurements of the tumor by MRI. Cerebrospinal fluid may be drawn from the patient's existing Ommaya reservoir preferentially, or via lumbar puncture before each infusion and at each time of follow-up. This procedure can be done at the bedside under local anesthesia and about 1ml of cerebrospinal fluid will be removed. Additional cerebrospinal fluid may be removed when intracranial hypertension occurs or other clinical needs. To learn more about pharmacokinetics of autologous Tris-CAR-T cell, peripheral blood will be obtained simultaneously with cerebrospinal fluid collection. The amount of blood taken will be based on clinical need, for approximately 5 mL each time. If the tumor samples of the patients are obtained, we will request a sample to be used for research purposes. The patient will receive supportive care for any acute or chronic cytotoxicity, including blood components, cytokine antagonist, glucocorticoid, antibiotics, and other intervention as appropriate.

Official Title
-----------------
Phase 1 Study of Autologous Tris-CAR-T Cell Locoregional Immunotherapy for Recurrent Glioblastoma

Conditions
-----------------
Recurrent Glioblastoma

Intervention / Treatment
-----------------
* Genetic: Inverse correlated dual-target, truncated IL7Ra modified CAR -expressing autologous T-lymphocytes.


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: Age: 18 years to 70 years (including cut-off values). Patients with history of glioblastoma are diagnosed with recurrent glioblastoma and residual tumor after intracranial tumor resection/biopsy performed in Beijing Tiantan Hospital. Patients who finished radiotherapy or temozolomide/bevacizumab or other drugs for at least 4 weeks. All toxicities of prior treatment should be defined as less than or equal to grade 1 (except for toxicities such as hair loss or leukoplakia) according to the Common Terminology Standard for Adverse Events (CTCAE 5.0). Patients who is suitable for craniotocerebrospinal fluid shunt and attachment (Ommaya device) implantation confirmed by a competent physician. Patients and/or legal representative is able to sign written informed consent. Kanovsky Performance Status (KPS) ≥ 70. According to the researchers' judgment, the life expectancy ≥ 8 weeks. White blood cells (WBC) > 3.50×10^9/L (performed within 14 days prior to PBMC collection unless otherwise noted). Platelet ≥ 200×10^9/L (performed within 14 days prior to PBMC collection unless otherwise noted). Hemoglobin ≥ 120 g/L (performed within 14 days prior to PBMC collection unless otherwise noted). Total bilirubin ≤ 20 μmol/L (performed within 14 days prior to PBMC collection unless otherwise noted). Aspartic acid aminotransferase (AST) ≤ 2.5×42 U/L (performed within 14 days prior to PBMC collection unless otherwise noted). Alanine aminotransferase (ALT) ≤ 2.5×41 U/L (performed within 14 days prior to PBMC collection unless otherwise noted). Serum creatinine ≤ 90 μmol/L (performed within 14 days prior to PBMC collection unless otherwise noted). Blood oxygen saturation ≥ 95% (performed within 14 days prior to PBMC collection unless otherwise noted). Seronegative of the combination of human immunodeficiency virus (HIV) antibody (Ab) (performed within 14 days prior to PBMC collection unless otherwise noted). Fertile women: a negative serum pregnancy test (performed within 14 days prior to PBMC collection unless otherwise noted). The patient agrees that contraception should be used in patients of childbearing age for at least 3 months from screening to the last infusion of Tris-CAR-T cells. The period of childbearing age is defined as unsurgically neutered (men and women) or without menopause for more than 1 year (women only). Exclusion Criteria: Kanovsky Performance Status (KPS) ≤ 70. Highly allergic constitution or severe allergies history. Those who have psychiatric or psychological diseases and cannot cooperate with treatment and efficacy assessment. Receive other drug trials within 60 days before enrollment, or receive other routine treatment in non-experimental designs for glioblastoma, such as stereotactic radiation therapy or placement of carmustine wafers. Combined with infection, active infection, fever of unknown cause. Combined with serious or unstable heart, lung, liver, kidney and hematopoietic system diseases, including active hepatitis. Combined with inflammation and immune system diseases (such as rheumatoid arthritis), or known immunosuppressive diseases. Combined with neurological diseases, such as diffuse leptomeningeal disease, or neurodegenerative diseases. Known allergies to immunotherapy and related cellular products. Patients who have received any gene therapy before. Long-term use of immunosuppressants is required for any reason. Patients with a history of organ transplantation or who are waiting for organ transplantation. Special cases: pregnancy or lactation. Other circumstances in which the investigators believe the patient is unsuitable for this trial.

Ages Eligible for Study
-----------------
Minimum Age: 18 Years
Maximum Age: 70 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
No

Study Plan
=================
How is the study designed?
-----------------

Design Details

Primary Purpose: Treatment
Intervention Model: Single Group Assignment
Interventional Model Description: Recipients with Ommaya reservoir implanted will be assigned to three courses. Arm A: Two patients, 1×10^7 autologous Tris-CAR-T, 1 dose. Arm B: Two patients 1×10^8 autologous Tris-CAR-T, 1 dose. Arm C: Two patients 5×10^7 autologous Tris-CAR-T, maximum 8 doses.
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Autologous Tris-CAR-T cell<br>Patients with supratentorial tumors for which CAR T cells will be delivered into the tumor resection cavity. | Genetic: Inverse correlated dual-target, truncated IL7Ra modified CAR -expressing autologous T-lymphocytes.<br>* Intratumorally administrate via Ommaya reservoir. Dose level 0: 1×10^7 autologous Tris-CAR-T cells, one dose, 2 patients. Dose level 1: 1×10^8/ 5×10^6autologous Tris-CAR-T cells, one dose, 2 patients. The dose of Dose level 1 will refer to the adverse effect of Dose level 0. When 1 of the 2 patients in the Dose level 0 had dose-related toxic side effects, 2 patients in the Dose level 1 could be enrolled. When dose-related side effects occurred in 2 patients in the Dose level 0, the dose should be reduced to 5×10^6cells to continue enrollment. Dose level2: 5×10^7 autologous Tris-CAR-T cells, weekly administered, maximum 8 weeks, 4 patients. If the results of Dose level 0 and 1 suggested that dose-related toxic side effects could be occurred in the 1×10^7cells dose, the researcher would re-determine the dosage of the multidose clinical exploration study.<br>* Other names: Autologous Tris-CAR-T cell.;|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Safety: any adverse events associated with one or multiple autologous Tris-CAR-T cell infusions will be assessed by CTCAE v5.0. | Assesing the type, frequency, severity, and duration of adverse events as a result of autologous Tris-CAR-T cell infusion via physical, laboratory and imaging examination. | 6 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| CAR-T pharmacokinetics: the distribution, persistence of autologous Tris-CAR-T cell in the cerebrospinal fluid (CSF) and peripheral blood will be measured by qPCR. | The trafficking of autologous Tris-CAR-T cell in the CSF and peripheral blood will be assessed by quantifying the mRNA of CAR gene at the time of each infusion as well as at each time of follow-up via CSF extraction/ lumbar puncture and blood collection. CSF and peripheral blood will be collected prior to the initial infusion and will be set as baseline. | 6 months | 
| CAR-T pharmacodynamics: chemokines and cytokines produced by autologous Tris-CAR-T cell in the cerebrospinal fluid (CSF) and peripheral blood will be measured by Olink Proteomics. | The effect and its persistence of autologous Tris-CAR-T cell in the CSF and peripheral blood will be assessed via investigating the concentration of chemokines and cytokines. CSF and peripheral blood samples will be harvested at the time of each infusion as well as at each time of follow-up via CSF extraction/ lumbar puncture and blood collection. IL-6, TNF-α, IFN-γ, CCL2, CXCL10, G-CSF, GM-CSF, IL-10, IL-15, IL-7 and IL-1α will be investigated. CSF and peripheral blood will be collected prior to the initial infusion and will be set as baseline. | 6 months | 
| CAR-T therapeutic effect evaluation: the therapeutic effect of autologous Tris-CAR-T cell will be assessed by iRANO. | The total lesions will be mesured by MRI. Total lesions will be collected and calcultated prior to the initial infusion and will be set as baseline. | 12 months | 

 Terms related to the study
=================
Keywords Provided by Centre Hospitalier Valida
-----------------
Recurrent Glioblastoma, Immunotherapy, Adverse Events