A Study of ALT-801 in Combination With Cisplatin and Gemcitabine in Muscle Invasive or Metastatic Urothelial Cancer

Study Overview
=================
Brief Summary
-----------------
This is a Phase Ib/II, open-label, multi-center, competitive enrollment and dose-escalation study of ALT-801 in a biochemotherapy regimen either containing cisplatin and gemcitabine or containing gemcitabine alone in patients who have muscle invasive or metastatic urothelial cancer of bladder, renal pelvis, ureters and urethra. The purpose of this study is to evaluate the safety, determine the maximum tolerated dose (MTD) and the recommended dose (RD), and assess the anti-tumor response of ALT-801 in combination with cisplatin and gemcitabine or ALT-801 in combination with gemcitabine alone. The pharmacokinetic profile of ALT-801 in combination with cisplatin and gemcitabine will also be assessed. The study includes a dose escalation phase (Phase Ib) and a dose expansion phase (Phase II). Phase II has two treatment groups, Expansion Group 1 and Expansion Group 2. Expansion Group 2 is for platinum-refractory patients, consisting of two treatment arms based on the patient's renal function. Patients will enroll to Expansion Group 2 after stage 1 of the Group 1 expansion is complete.

Detailed Description
-----------------
Bladder cancer is the fourth most common malignancy in men and the ninth most common in women in the US, with an estimated 68,810 new cases and 14,070 deaths for the year 2008. Approximately 90% to 95% of newly diagnosed patients are with transitional cell carcinomas (TCC). Approximately 20% to 25% contain advanced (muscle invasive or metastatic) disease. Muscle invasive bladder cancer is life threatening. Clinical trials have demonstrated that TCC is a chemotherapy-sensitive malignancy. Most current cancer treatment strategies involve the use of chemotherapeutic or biological drugs that have a low therapeutic ratio. The limitations are a consequence of effects of the therapeutic drug on normal tissues. One approach to control systemic exposure effects is to target the drug itself into the site of the tumor. For example, antibodies have been developed for use as tumor targeting agents and have had success in the clinic. However, despite the promise of antibody-based immunotherapy, there are limitations with these class of reagents. Even so, immunotherapy remains a promising approach to treat cancer. One strategy that has received attention is treatment with cytokines such as IL-2 to enhance anti-tumor immunity. IL-2 has stimulatory effects on a number of immune cell types including T and B cells, monocytes, macrophages, lymphokine-activated killer cells (LAK) and natural killer (NK) cells. Based on the ability of IL-2 to provide durable curative anti-tumor responses, systemic administration of IL-2 has been approved to treat patients with metastatic melanoma or renal carcinoma. Unfortunately, the considerable toxicity associated with this treatment makes it difficult to achieve an effective dose at the site of the tumor and limits the population that can be treated. Thus, there is critical need for innovative strategies that enhance the effects of IL-2, to reduce its toxicity without compromising the clinical benefit, and to treat other diagnoses. The study drug, ALT-801, is a biologic compound of interleukin-2 (IL-2) genetically fused to a humanized soluble T-cell receptor directed against the p53-derived peptides expressed on tumor cells. The p53 protein is one of the most important factors that protects from developing cancer and is also one of the most frequently mutated genes in many cancers, which include muscle-invasive bladder cancer. For any given cancer type, p53 dysfunction generally correlates with poor prognosis versus other the same site-of-origin. In some tumors, p53 mutation and over-expression also is associated with resistance to chemotherapy. This study is to further evaluate whether directing IL-2 activity using ALT-801 to the patient's tumor sites that over-express p53 results in clinical benefits

Official Title
-----------------
A Phase Ib/II Trial of ALT-801 in Combination With Cisplatin and Gemcitabine in Muscle Invasive or Metastatic Urothelial Cancer

Conditions
-----------------
Transitional Cell Carcinoma of Bladder, Urethra Cancer, Ureter Cancer, Malignant Tumor of Renal Pelvis

Intervention / Treatment
-----------------
* Drug: Cisplatin
* Drug: Gemcitabine
* Biological: ALT-801


Participation Criteria
=================
Eligibility Criteria
-----------------
ENTRY CRITERIA: DISEASE CHARATERISTICS: Muscle invasive or metastatic urothelial cancer of bladder, ureters, renal pelvis, and urethra Histologically or cytologically confirmed with a clinical plan that would potentially include cisplatin* plus gemcitabine systemic therapy or with disease refractory to a first-line platinum-based therapy (as defined in the protocol). * Does not apply to patients screened for Phase II expansion Surgically incurable PRIOR/CONCURRENT THERAPY: No concurrent radiotherapy, other chemotherapy, or other immunotherapy Must have recovered from side effects of prior treatments If prior Proleukin® treatment, must have had a clinical benefit No use of other investigational agents within 30 days of start or concurrently PATIENT CHARACTERISTICS: Age ≥ 18 years Performance Status ECOG 0 or 1 Bone Marrow Reserve Absolute neutrophil count (AGC/ANC) ≥ 1,500/uL Platelets ≥ 100,000/uL Hemoglobin ≥ 10g/dL Renal Function Glomerular Filtration Rate (GFR): ≥ 50mL/min/1.73m^2 for cisplatin-containing regimen ≥ 40mL/min/1.73m^2 for non-cisplatin-containing regimen Hepatic Function Total bilirubin ≤ 1.5 X ULN AST, ALT, ALP ≤ 2.5 X ULN, or ≤ 5.0 X ULN (if liver metastases exists) PT INR ≤ 1.5 X ULN Cardiovascular No congestive heart failure < 6 months No unstable angina pectoris < 6 months No myocardial infarction < 6 months No history of ventricular arrhythmias No NYHA Class > II CHF Normal cardiac stress test required for subjects who are ≥ 50 years old, or have a history of EKG abnormalities, or have symptoms of cardiac ischemia or arrhythmia No uncontrolled hypertension Pulmonary Not receiving chronic medication for asthma Normal clinical assessment of pulmonary function Hematologic No evidence of bleeding diathesis or coagulopathy Other Negative serum pregnancy test if female and of childbearing potential No women who are pregnant or nursing Subjects, both females and males, with reproductive potential must agree to use effective contraceptive measures for the duration of the study No known autoimmune disease other than corrected hypothyroidism No known prior organ allograft or allogeneic transplantation Not HIV positive No active systemic infection requiring parenteral antibiotic therapy No ongoing systemic steroid therapy required No history or evidence of CNS disease (Controlled brain metastases treated with radiation therapy or surgery where the disease has been clinically stable for a period of a least 3 months before screening is allowed) No psychiatric illness/social situation No other illness that in the opinion of the investigator would exclude the subject from participating in the study Must provide informed consent and HIPAA authorization and agree to comply with all protocol-specified procedures and follow-up evaluations

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

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

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

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

Design Details

Primary Purpose: Treatment
Allocation: Non-Randomized
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: ALT-801 with Cisplatin and Gemcitabine (Phase Ib and Phase II)<br> | Drug: Cisplatin<br>* Intravenous infusion; 3 initial treatment courses and an additional 3 maintenance courses for responders (maintenance revised for Phase II): on day 1 of each course (if given)<br>Drug: Gemcitabine<br>* Intravenous infusion; 3 initial treatment courses and an additional 3 maintenance courses for responders (maintenance revised for Phase II); on day 1 and 8 of each course<br>Biological: ALT-801<br>* Intravenous infusion; 3 initial treatment courses and an additional 3 maintenance courses for responders (maintenance revised for Phase II): on day 3, 5, 8, and 12 of each course<br>* Other names: c264scTCR-IL2;|
| Experimental: ALT-801 and Gemcitabine (Phase II only)<br> | Drug: Gemcitabine<br>* Intravenous infusion; 3 initial treatment courses and an additional 3 maintenance courses for responders (maintenance revised for Phase II); on day 1 and 8 of each course<br>Biological: ALT-801<br>* Intravenous infusion; 3 initial treatment courses and an additional 3 maintenance courses for responders (maintenance revised for Phase II): on day 3, 5, 8, and 12 of each course<br>* Other names: c264scTCR-IL2;|

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

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Maximum Tolerated Dose (MTD) and/or the recommended dose (RD) for dose expansion of ALT-801 in combination with cisplatin and gemcitabine or ALT-801 in combination with gemcitabine alone |  | 8 weeks | 
| Safety Profile | Number and severity of treatment related AEs that occur or worsen after the first dose of study treatment | 8 weeks | 
| Clinical Benefit | Number of participants with an objective response, which includes, a complete response,a partial response or a stable disease | 12 weeks | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Progression Free Survival | Number of participants with, 6-month, 9-month, 12-month, 18-month, 24-month, 30-month, or 36-month progression-free survival. | 36 months | 
| Overall survival | Number of participants with 6-month, 9-month, 12-month, 18-month, 24-month, 30-month or 36-month overall survival | 36 months | 
| Pharmacokinetics and immunogenicity | Area under the plasma concentration-time curve from time zero to infinity (AUC) and the half-life of ALT-801 for patients enrolled up to the stage 1 expansion. Measures of anti-ALT-801 and IL-2 neutralizing antibodies | 9 weeks | 
| Tumor Typing | Assess the relationship between the tumor presentation of HLA-A*0201/p53 aa 264-272 complexes and the safety and clinical benefits of study treatment | 1 month | 

 Terms related to the study
=================
Keywords Provided by Centre Hospitalier Valida
-----------------
cancer, immunotherapy, immunochemotherapy, combinational therapy, targeted, metastatic, muscle invasive, interleukin-2, cisplatin, gemcitabine, antitumor, TCR, T-cell receptor, p53, p53 gene, p53 tumor supressor protein, urothelial cancer, bladder cancer, renal pelvis cancer, ureters cancer, urethra cancer, HLA-A2 positive, HLA-A*0201/p53 aa264-272, HLA complex, Muscle Invasive or Metastatic