Testing a New Immune Cell Therapy, GD2-Targeted Modified T-cells (GD2CART), in Children, Adolescents, and Young Adults With Relapsed/Refractory Osteosarcoma and Neuroblastoma, The GD2-CAR PERSIST Trial

This is an interventional treatment trial for Neuroblastoma Read More

Inclusion Criteria:

• Must have histologically confirmed neuroblastoma or osteosarcoma that is recurrent or refractory and for which standard curative measures do not exist or are no longer effective. Must have histologic verification of their disease at diagnosis or at relapse
• For the dose escalation cohort, must have evaluable or measurable disease at enrollment

• Patients with osteosarcoma must have at least one of the following:

  • Progressive, recurrent or refractory disease (local recurrence) or new disease after all curative measures, including first line chemotherapy
  • Evidence of persistent and progressive disease on imaging including fludeoxyglucose F-18 positron emission tomography (FDG-PET) avid bone metastasis that has failed to achieve complete remission to upfront conventional therapy (surgery, radiotherapy, chemotherapy) and standard salvage therapy, excluding lung metastases amenable to surgical resection

• Patients with neuroblastoma must have at least one of the following:

  • New disease site documented on:

    • Iodine (I)-123 metaiodobenzylguanidine scan (MIBG) or computed tomography (CT)/magnetic resonance imaging (MRI); OR
    • FDG-PET (in patients known to have MIBG non-avid tumor) and MRI findings consistent with tumor (i.e., bone lesions); OR
    • Biopsy of any lesion documenting tumor
  • Greater than 20% increase in a least one dimension of soft tissue mass documented by CT/MRI and a minimum absolute increase of 5 mm in longest dimension in existing lesion(s). Previously irradiated lesions may be included
  • Bone marrow biopsy meeting revised International Neuroblastoma Response Criteria (INRC) criteria for progressive disease (PD)
  • Stable persistent disease, such that response at the completion of upfront therapy or salvage therapy is less than partial response AND has a biopsy of at least one site showing viable solid tumor consistent with initial diagnosis
  • Responding persistent disease, defined as at least a partial response to frontline therapy (i.e., at least a partial response to frontline therapy but still has residual disease by MIBG scan, CT/MRI, or bone marrow aspirations/biopsies). Patients in this category are required to have histologic confirmation of viable neuroblastoma from at least one residual site (tumor seen on routine bone marrow morphology is sufficient)

• For the expansion cohorts:

  • Patients with osteosarcoma must have measurable disease by Response Evaluation Criteria in Solid Tumors (RECIST) version (v)1.1 at enrollment
  • Patients with neuroblastoma must have measurable disease by above criteria or MIBG-evaluable disease at enrollment. Evaluable disease for eligibility is defined as MIBG scan obtained within 3 weeks prior to study entry with positive uptake at a minimum of one site.

• There is no limit to the number of prior treatment regimens. The following washout periods apply to eligibility for leukapheresis (applies to patients undergoing leukapheresis on this study).

  • Myelosuppressive chemotherapy: Patients must not have received myelosuppressive chemotherapy within 3 weeks of leukapheresis (6 weeks if prior nitrosourea)
  • Hematopoietic growth factors: At least 7 days must have elapsed since the completion of therapy with a growth factor. At least 14 days must have elapsed after receiving pegfilgrastim
  • Biological agent, tyrosine kinase inhibitor, targeted agent, metronomic chemotherapy: At least 7 days must have elapsed since the completion of therapy with a biologic agent, tyrosine kinase inhibitor, targeted agent, or metronomic non-myelosuppressive regimen
  • 131I-MIBG: At least 12 weeks must have elapsed since prior therapy with 131I-MIBG
  • Monoclonal antibodies and checkpoint inhibitors: At least 3 weeks or 5 half-lives (whichever is shorter) must have elapsed since prior therapy that included a monoclonal antibody or checkpoint inhibitor
  • Radiotherapy (XRT): 3 weeks must have elapsed since XRT, but at least 6 weeks if central nervous system (CNS) or lung fields, with the exception that there is no time restriction for palliative radiation with minimal bone marrow involvement and the patient has measurable/evaluable disease outside the radiation port or the site of radiation has documented progression
  • Vaccine therapy, anti-GD2 monoclonal antibody (mAb) therapy, or therapy with any genetically engineered T cells: Patients may have received previous vaccine therapy, anti-GD2 mAb therapy, or therapy with any genetically engineered T cells except prior GD2 CAR T cell therapy. At least 3 weeks or 5 half-lives, whichever is shorter, must have elapsed since any prior vaccine or monoclonal antibody therapy. At least 42 days must have elapsed since prior modified T cell, natural killer (NK) cell, or dendritic cell therapy
  • Allogeneic stem cell transplant/infusion: At least 12 weeks must have elapsed since allogeneic stem cell transplant and without evidence of active graft versus host disease (GVHD). Patients who received an autologous stem cell infusion following myeloablative therapy should be at least 6 weeks from their infusion. Patients who received an autologous stem cell infusion following non-myeloablative therapy do not have a wash-out period; they are eligible once they meet all other eligibility requirements, including recovery from acute side effects. This criterion does not apply to patients with apheresis product or usable T cell product available for use
• Must meet parameters for apheresis per institutional guidelines. (This criterion does not apply to patients with apheresis product or usable T cell product available for use. Cryopreserved peripheral blood mononuclear cells (PBMCs) stored from participation in other institutional cell therapy or cell collection studies or standard of care may be used to generate the cellular product on this study if they meet the criteria established in this investigational new drug (IND)
• Patients > 16 years of age must have Karnofsky >= 50%. Patients =< 16 years of age must have Lansky scale >= 50%; or Eastern Cooperative Oncology Group (ECOG) performance status =< 2

• Leukocytes >= 750/mcL

  • Cytopenias deemed to be disease-related and not therapy-related are exempt from this exclusion. Patients must not be refractory to transfusions

• Platelets >= 75,000/mcL

  • Cytopenias deemed to be disease-related and not therapy-related are exempt from this exclusion. Patients must not be refractory to transfusions
• Aspartate aminotransferase (AST)(serum glutamic-oxaloacetic transaminase [SGOT])/alanine aminotransferase (ALT)(serum glutamate pyruvate transaminase [SGPT]) (For the purpose of this study, the upper limit of normal [ULN] for SGOT is 50 U/L and the ULN for SGPT is 45 U/L) =< 5 x ULN
• Total bilirubin =< 2 x institutional upper limit of normal (ULN) for age. Patients with Gilbert's syndrome are excluded from the requirement of a normal bilirubin and patients will not be excluded if bilirubin elevation is due to tumor involvement. (Gilbert's syndrome is found in 3-10% of the general population, and is characterized by mild, chronic unconjugated hyperbilirubinemia in the absence of liver disease or overt hemolysis). Note: Adult values will be used for calculating hepatic toxicity and determining eligibility

• Age, maximum serum creatinine (mg/dL):

  • 1 month to < 6 months: 0.2 (male), 0.4 (female)
  • 6 months to < 1 year: 0.5 (male), 0.5 (female)
  • 1 to < 2 years: 0.6 (male), 0.6 (female)
  • 2 to < 6 years: 0.8 (male), 0.8 (female)
  • 6 to < 10 years: 1 (male), 1 (female)
  • 10 to < 13 years: 1.2 (male), 1.2 (female)
  • 13 to < 16 years: 1.5 (male), 1.2 (female)
  • >= 16 years: 1.7 (male), 1.4 (female) OR Creatinine clearance or glomerular filtration rate (GFR) >= 60 mL/min/1.73 m^2 for patients with levels above institutional normal
• Cardiac ejection fraction >= 45% or shortening fraction >= 28%, no evidence of physiologically significant pericardial effusion as determined by an echocardiogram (ECHO). No clinically significant electrocardiogram (ECG) findings
• Pulmonary status: No clinically significant pleural effusion. Baseline oxygen saturation > 92% on room air at rest
• Neurologic status: Baseline neurotoxicity equal to grade 1 or less

• Females of childbearing potential must have a negative serum or urine pregnancy test. The effects of autologous GD2CART on the developing human fetus are unknown. For this reason and because the chemotherapy agents as well as other therapeutic agents used in this trial are known to be teratogenic, females of child-bearing potential and males of reproductive potential who are sexually active must agree to use adequate contraception (hormonal or barrier method of birth control; abstinence) prior to study entry, for the duration of study participation, and 4 months after completion of chemotherapy preparative administration or until chimeric antigen receptor (CAR) is no longer detectable, whichever is later. Should a female become pregnant or suspect she is pregnant while she or her partner is participating in this study, she should inform her treating physician immediately

  • Note: Females of childbearing potential are defined as those who are past the onset of menarche and are not surgically sterile (i.e., bilateral salpingectomy, bilateral oophorectomy, complete hysterectomy) or post menopausal
• All patients >= 18 years of age must be able to give informed consent or if unable to give consent have a legal authorized representative (LAR) who can give consent for the patient. For patients < 18 years old their LAR (i.e., parent or legal guardian) must give informed consent. Pediatric patients will be included in age appropriate discussion and verbal assent will be obtained for those > 7 years of age, when appropriate, according to local policy

Exclusion Criteria:

• Receiving any other current investigational agents
• History of anaphylactic reactions attributed to anti-GD2 antibodies or to compounds of similar chemical or biologic composition to GD2CART, cyclophosphamide, fludarabine, or other agents used in this study. History of hypersensitivity to dornase alfa, Chinese hamster ovary cell products, or any of the components of pulmozyme
• Patients who require systemic corticosteroid or other immunosuppressive therapy. (A one-week washout from systemic corticosteroid or other immunosuppressive therapy is permitted.) Use of physiologic doses of corticosteroids (up to 3 mg/m^2/day prednisone equivalent) are permitted. Use of topical, ocular, intra-articular, intra-nasal, or inhaled corticosteroids are permitted
• Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or psychiatric illness/social situations that would limit compliance with study requirements
• History of additional malignancy other than non-melanoma skin cancer or carcinoma in situ (e.g., cervix, bladder, breast) unless untreated and stable or disease free for at least 3 years
• Untreated central nervous system (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 permitted. Patients who are clinically stable as evidenced by no requirements for corticosteroids, no evolving neurologic deficits, and no progression of residual brain abnormalities without specific therapy, are permitted. Patients with asymptomatic subcentemeric CNS lesions are permitted if no immediate radiation or surgery is indicated
• CNS disorder such as cerebrovascular ischemia/hemorrhage, dementia, cerebellar disease, or autoimmune disease with CNS involvement that in the judgement of the investigator may impair the ability to evaluate neurotoxicity
• Presence of fungal, bacterial, viral, or other infection that is uncontrolled. Urinary tract infection (UTI), uncomplicated bacterial pharyngitis, cellulitis, or pneumonia is permitted if responding to active treatment
• Ongoing infection with human immunodeficiency virus (HIV), hepatitis B (hepatitis B surface antigen [HBsAg] positive), or hepatitis C virus (anti-HCV positive) as the immunosuppression contained in this study will pose unacceptable risk. A history of HIV, hepatitis B, or hepatitis C is permitted if the viral load is undetectable per quantitative polymerase chain reaction (PCR) and/or nucleic acid testing
• Primary immunodeficiency or history of systemic autoimmune disease (e.g., Crohns, rheumatoid arthritis, systemic lupus) requiring systemic immunosuppression/systemic disease modifying agents within the last 2 years
• Pregnant females are excluded from this study because the effects of autologous GD2CART on the developing human fetus are unknown and because the chemotherapy agents used in this trial (cyclophosphamide and fludarabine) are category D agents with the potential for teratogenic or abortifacient effects. Additionally, because there is an unknown but potential risk for adverse events (AEs) in nursing infants secondary to treatment of the mother with cyclophosphamide/fludarabine, breastfeeding should be discontinued if the mother is treated with cyclophosphamide/fludarabine. These potential risks may also apply to other agents used in this study
• Patients with known GD2 negative tumors by validated immunohistochemistry (IHC) will be excluded from enrollment given the change in risk profile
• In the investigator's judgment, unlikely to complete protocol-required study visits or procedures, including follow-up visits, or comply with the study requirements for participation