Trivalent CAR-T Cell in Acute B-Lineage Leukemia (TRICAR-ALL) (TRICAR-ALL)

(H-49235) Trivalent Autologous T-Lymphocytes Co-Expressing Three Chimeric Antigen Receptors Targeting CD19, CD20 AND CD22 in Acute B-lineage Leukemia (TRICAR-ALL)

This is a gene transfer study for patients with a type of blood cancer called Acute Lymphoblastic Leukemia (ALL) that has come back or has not gone away after treatment. The body has different ways of fighting infection and disease. No single way seems perfect for fighting cancers. This research study combines two different ways of fighting cancer: antibodies and T cells. Antibodies are types of proteins that protect the body from infectious diseases and possibly cancer. T cells, also called T lymphocytes, are special infection-fighting blood cells that can kill other cells, including cells infected with viruses and tumor cells. Both antibodies and T cells have been used to treat patients with cancers. They have shown promise but have not been strong enough to cure most patients. For example, T lymphocytes can kill cancer cells but there normally are not enough of them to kill all the cancer cells. Some researchers have taken T cells from a person's blood, grown more of them in the laboratory and then given them back to the person. The antibody used in this study targets CD19, CD20 and CD22. This antibody sticks to ALL cells because of a substance on the outside of these cells called CD19, CD20 and/or CD22. For this study, the antibody to CD19, CD20 and CD22 has been changed so that instead of floating free in the blood, it is now joined to the T cells. When T-cells contain an antibody that is joined to them, they are called chimeric antigen receptor- T cells or CAR-T cells. In the laboratory, we have also found that T cells work better if we also add proteins that stimulate them. One such protein is called 4-1BB. Adding the 4-1BB molecule makes the cells grow better and last longer in the body, giving them a better chance of killing the leukemia cells. In this study we are going to attach the CD19/CD20/CD22 chimeric receptor that has 4-1BB added to the patient's T cells. We will then test how long the cells last. These T cells, called "TRICAR-ALL" T cells are investigational products not approved by the Food and Drug Administration (FDA).

The TRICAR-ALL T-cells were made in the laboratory by stimulating the patient's blood with growth factors to make the T cells grow. To get the CD19/CD20/CD22 antibody and 4-1BB to attach to the surface of the T cell, we inserted the antibody gene into the T cell. This is done using a virus called a retrovirus that has been made for this study and will carry the antibody gene into the T cell. Enrolled patients will be assigned a dose of TRICAR-ALL T-cells. Prior to receiving the TRICAR-ALL T-cells patients will receive two chemotherapy medications, cyclophosphamide (for 2 days) and fludarabine (4 days). An injection of TRICAR-ALL T-cells will be given into a vein through an IV at the assigned dose. The injection will take from 1 to 20 minutes. Before receiving the infusion of TRICAR-ALL T-cells patients may be pre-medicated with Benadryl and Tylenol. Patients will be monitored for up to 3 hours after the injection, and will have to remain locally for at least 4 weeks. If after a 4-week evaluation period, the patient has a complete response, they may proceed to bone marrow transplant, and will be removed from the treatment portion of the study. Before treatment, patients will undergo a series of tests: Physical exam and History Blood tests to measure blood cells, kidney and liver function Pregnancy test for female patients who are of childbearing potential Measurements of your leukemia tumor cells by bone marrow studies Echocardiogram Imaging such as PET scans, CT scans or MRIs will be obtained if needed During and after treatment, patients will receive these standard medical tests: History and physical examination: pre-infusion of T cells (pre-day 0, day 0) and at day 1, 4, 7, 10, 14, 28 and 63 post infusion of T- cells. Subsequently, history will be taken at 3-, 6-, and 12-months post infusion of T-cells, and then yearly for a total of 15 years. Blood tests to measure blood cells, kidney and liver function (On Days 4, 7, 10, 14, 28 and 63; then at month 3, 6, and 12; then yearly to year 15) Measurements of your leukemia tumor cells by bone marrow studies 3-6 weeks after the infusion, possibly 9-12 weeks after the infusion and then per standard of care. Imaging such as PET scans, CT scans or MRIs will be obtained, if needed, 4-6 weeks following the infusion Blood Draws: Blood will be taken before the chemotherapy drugs, 2-4 hours after the T cell infusion, at around day 7, day 10, day 14, day 28 and day 63 after the infusion, at 3 months, 6 months, 9 months, at 1 year, every 6 months for 4 years, then yearly for a total of 15 years. Additional doses of TRICAR-ALL T-cells (re-treatment): Up to three additional infusions of TRICAR-ALL -T cells may be given if eligible. In the event of your death, we will request permission from your next of kin to perform an autopsy to learn more about the effect of this experimental treatment on your cancer.

Three dose levels will be evaluated. The TRICAR-ALL T-cells will be administered after lymphodepletion chemotherapy with Cyclophosphamide and fludarabine.

Three dose levels will be evaluated with the opportunity to dose de-escalate (dose level -1) for toxicity. DL-1: 3x10^6 cells/m2 DL1: 1×10^7 cells/m2 DL2: 3×10^7 cells/m2 DL3: 1×10^8 cells/m2 Lymphodepletion chemotherapy consisting of Fludarabine 30 mg/m2 IV once daily x 4 doses; and Cyclophosphamide 500mg/m2 IV once daily x 2 doses (starting with the first dose of fludarabine)must be completed greater than or equal to 48 hours prior to infusion of CAR-T cells. The protocol will allow for up to three additional infusions of the CAR-T product for subjects who meet criteria for retreatment.

Defined as the proportion of patients, within the assigned dose level, with DLT evaluated as any grade 3 or 4 toxicity as determined by CTCAE (v5.0) which is unmanageable, unexpected and unrelated to lymphodepletion, and that is probably or definitely attributable to the study protocol occurring within 28 days of the TRICAR-ALL T cell infusion

Inclusion Criteria for Procurement: Diagnosis of refractory or recurrent B cell Acute Lymphoblastic Leukemia (B-ALL) with expression of CD19, CD20 and/or CD22 Projected age ≥ 12 months and ≤ 21 years at the time of TRICAR-ALL T cell infusion. To obtain the necessary safety data, the projected age of the first three patients enrolled on dose level 1 of the study will be 16 years and older. Life expectancy of greater than or equal to 8 weeks Weight greater than or equal to 10 kg Subjects greater than or equal to 18 years of age must have the ability to give informed consent according to applicable regulatory and local institutional requirements. Legal guardian's consent must be obtained for subjects < 18 years of age. Assent will be obtained from pediatric subjects and according to applicable regulatory and local institutional requirements. Adults with cognitive impairment who are unable to consent and those with Down's syndrome are also eligible for this protocol with consent/assent according to applicable regulatory and local institutional requirements. Unless a subject has a previously obtained apheresis/phlebotomy product that is acceptable and available for manufacturing of CAR-T cells, the subject must discontinue all anti-cancer agents and, in the opinion of the investigator, have recovered from significant acute toxic effects of: Chemotherapy and biologic agents: All chemotherapy and biologic therapy not specifically mentioned below must be discontinued greater than or equal to 7 days prior to collection, with the exception of intrathecal chemotherapy and maintenance chemotherapy but greater than or equal to 72 hours prior to collection (for the subset of subjects who relapse during maintenance); both of which may be administered at any point pre-study or upon enrollment Steroid use: All systemic corticosteroid therapy (unless physiologic replacement dosing of less than or equal to 12mg/m2/day hydrocortisone or equivalent) must be discontinued greater than or equal to 7 days prior to collection Tyrosine Kinase Inhibitor (TKI) use: All TKIs must be discontinued greater than or equal to 3 days prior to collection Hydroxyurea: must be discontinued greater than or equal to 1 day prior to collection Prior CAR-T cell therapy: must be at least 30 days from most recent CAR-T cell infusion prior to collection Immunotherapy directed at leukemia: No antibodies within three (3) half-lives prior to collection (or within 4 weeks) whichever is shorter. This includes Antithymocyte globulin (ATG) formulations. Anti T-cell Antibodies, Alemtuzumab: must be discontinued greater than or equal to 8 weeks prior to collection Absolute Lymphocyte count (ALC) greater than or equal to 100 cells/μL Subject willing to participate in long-term follow-up for up to 15 years if enrolled in the study Inclusion Criteria for T-cell Therapy Age ≥ 12 months and ≤ 22 years. To obtain the necessary safety data, the first three patients enrolled on dose level 1 of the study will be patients 16 years and older. Weight greater than or equal 10.0 Kg Life expectancy of greater than or equal 6 weeks B-ALL with no prior history of allo-HCT with one of the following: Second or subsequent marrow relapse with or without extramedullary disease First marrow relapse at the end of re-induction with marrow having greater than or equal 0.01% blasts by morphology &/or flow cytometry with or without extramedullary disease Primary refractory disease defined by having greater than or equal 5% blasts in the marrow by morphology and/or minimal residual (MRD) testing after 2 or more separate induction regimens Subject has an indication for allo-HCT but deemed ineligible (including subjects who have persistent MRD prior to allo-HCT) CD19(+) or CD19(-) relapse or refractory ALL after infusion of CD19-targeted immunotherapy including CAR-T cells or blinatumomab (CD20 or CD22 expression is required for CD19- B-ALL). Or B-ALL recurrent after allo-HCT defined as having greater than or equal 0.01% marrow disease Available transduced T-cells with greater than or equal 15% expression of CD19, CD20 or CD22 CAR by flow cytometry. Prohibited medications: Cranial radiation therapy (inclusive of TBI) greater than or equal to 4 weeks Cytotoxic chemotherapy greater than or equal to 2 days Tyrosine Kinase Inhibitors greater than or equal to 7 days Total Bilirubin: less than or equal to 3X upper limit of normal (ULN) for age OR conjugated bilirubin less than or equal to 2mg/dl, except in subjects with Gilbert's syndrome where a total bilirubin level of up to 5.3 mg/dL will be acceptable ALT less than or equal to 5 times upper limit of normal Adequate renal function defined as serum creatinine that is less than or equal to maximum based on age/gender (as per table below) or Creatinine clearance or GFR (as measured or estimated by Cockcroft Gaultor Schwartz) greater than or equal 50 mL/min/1.73m2 Pulse oximetry of greater than or equal 90% on room air Left ventricular fractional shortening (LVFS) greater than or equal 28% confirmed by echocardiogram or left ventricular ejection fraction (LVEF) greater than or equal 45% confirmed by echocardiogram (MUGA or MRI heart may replace echocardiogram). Lansky score of greater than or equal 50% (age greater than or equal 1 and < 16 years) or Karnofsky score of greater than or equal 50% (age greater than or equal 16 years) Donor lymphocyte infusions (DLI) completed > 6 weeks prior to CAR-T cell infusion Subjects of childbearing/fathering potential must agree to use highly effective contraception from the time of initial T cell infusion through 12 months following the last T cell infusion Subjects > 18 years of age must have the ability to give informed consent according to applicable regulatory and local institutional requirements. Legal guardian's consent must be obtained for subjects < 18 years of age. Assent will be obtained from pediatric subjects and according to applicable regulatory and local institutional requirements. Adults with cognitive impairment who are unable to consent and those with Down's Syndrome are also eligible for this protocol with consent/assent according to applicable regulatory and local institutional requirements. Exclusion Criteria for Procurement: Active malignancy other than disease under study CNS 3 involvement with leukemia that, in the opinion of the investigator, cannot be controlled (to CNS 2 or 1) during the interval between enrollment and CAR-T cell infusion If history of allogeneic hematopoietic cell transplant (allo-HCT): active GVHD, or receiving immunosuppressive therapy for treatment or prevention of GVHD within 4 weeks prior to enrollment Presence of active severe infection, defined as: positive blood culture within 48 hours of collection, OR fever above 38.2° C, AND clinical signs of infection within 48 hours of collection (unless fever is attributed to leukemia) active viral infections including infection with HIV, hepatitis B, hepatitis C or HTLV Primary immunodeficiency syndrome Pregnant or breastfeeding Presence of any condition that, in the opinion of the investigator, would prohibit the subject from undergoing treatment under this protocol History of symptomatic CNS pathology or ongoing symptomatic CNS pathology requiring medical intervention, including paresis, aphasia, cerebrovascular ischemia/hemorrhage, severe brain injury, dementia, cerebellar disease, organic brain syndrome, psychosis, coordination or movement disorder (subjects with non-febrile seizure disorder controlled on anti-epileptic medication and without seizure activity within 3 months are eligible) Exclusion Criteria for T-cell Therapy Pregnant or lactating Presence of any condition that, in the opinion of the PI or designee, would prevent the patient from undergoing protocol-based therapy. Active CNS involvement by ALL, defined as CNS-3 or symptomatic CNS 2 (Refer to appendix III for definitions of CNS status). Note: Asymptomatic CNS2 or patients with history of CNS disease that has been effectively treated will be eligible. Patients that have a significant neurologic deterioration will not be eligible for T cell infusion until alternate therapies result in neurological stabilization.