| Study summary: |
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SOURCE MATERIAL: Up to 240 ml (in 2 collections) of peripheral blood will be obtained from
the transplant donor according to the procurement consent. In some cases depending on the
size of donor and recipient, a leukopheresis will be performed to isolate sufficient T
cells. 10-30cc blood will be obtained from the recipient to generate the Epstein Barr virus
(EBV)-transformed lymphoblastoid cell line used as stimulator cells. In case of the
recipient extensive disease status and/or especially low B cells number, the LCL may be
generated using appropriate 1st degree relative peripheral blood mononuclear cells.
TRANSPLANT RECEIPIENTS: Patients will be scheduled to receive a haploidentical stem cell
transplant on our institutional protocols for haploidentical transplant which use
CD34-selected mobilized peripheral blood as the source of stem cells for recipients of HLA
haploidentical related donor stem cell grafts. At the time of transplant evaluation, this
ancillary study of allodepleted T cells will be discussed with the recipient and donor. If
they agree to participate, the recipient will sign a procurement consent for collection of
10-30cc (2-6 teaspoons) of blood to generate the lymphoblastoid cell line to be used as
stimulator cells in the production process. In case of the recipient extensive disease
status and/or especially low B cells number, the LCL may be generated using appropriate 1st
degree relative peripheral blood mononuclear cells.
DONOR SELECTION: These protocols are open to patients who lack a 5/6 or 6/6 HLA antigen
matched donor. For this protocol, the "best" donor will be defined as a first-degree
haploidentical family member who matches at the most MHC loci. Matching will be determined
by class I and class II DNA typing. The donor should be sufficiently healthy not to be at
increased risk from the mobilization procedure. Should more than one "equally" MHC
incompatible donor be identified, other selection criteria will include age and size of
donor, CMV status and sex. The physician treating the patient will make the final decision.
DONOR COLLECTIONS: Up to 240 ml (about 48 teaspoons total in 2 collections) of peripheral
blood will be obtained from the transplant donor according to the procurement consent. In
some cases depending on the size of donor and recipient, a leukopheresis will be performed
to isolate sufficient T cells either prior to stem cell mobilization or seven days after the
last dose of G-CSF. An extra 10 ml (2 teaspoons) of blood will also be collected to test for
infectious viruses such as hepatitis and HIV. Any leftover samples will be stored for future
testing related to this study
Due to space constraints, see Full Protocol Section 6.4 for TIMELINE FOR GENERATION OF
PRODUCT.
ADMINISTRATION OF ALLODEPLETED T CELLS: Recipients who meet eligibility criteria will be
eligible to receive allodepleted cells between thirty and ninety days following
transplantation (day +30 to day +90) if the product has completed final release testing and
a certificate of analysis has been issued by Quality Assurance in the GMP facility. The
cryopreserved T cells will be thawed and infused through a catheter line with normal saline
as per our institutional SOP. The patient will be premedicated as per SOP. For children,
premedications are dosed by weight as detailed per institutional SOPs for transplantation of
hemopoietic and T cell products. Outpatients may be treated in the clinic and monitoring
will be undertaken according to institutional standards with the exception that post
infusion monitoring will continue for 4 hours. All treatment will be given at CAGT in The
Methodist Hospital or Texas Children's Hospital. This study will begin with a dose of T
cells that did not cause GvHD in haploidentical recipients in our previous study and
escalate in half log increments. A continual reassessment method based on a logistic
dose-response curve with cohorts of size 2 will be employed to determine the MTD. Cohorts of
size 2 will be accrued beginning at dose level 1 and the dose-response curve is estimated
after toxicity outcome is observed to determine the recommended dose level for the next
patient cohort. Patients will be staggered so that another patient will not be treated at
any dose level until the previous patient is at least 42 days post T cell infusion.
Dose Level 1: 1 x 10exp6 T cells/Kg Dose Level 2: 3 x 10exp6 T cells/Kg Dose Level 3: 1 x
10exp7 T cells/Kg
Patients may be enrolled on the next dose level of T cells when all patients on the previous
dose level have reached Day 40 following the T cell infusion without unacceptable toxicity.
Other investigational agents may not be administered within 30 days of the allodepleted T
cell infusion.
ADMINISTRATION OF AP1903 DIMERIZER DRUG: Patients who develop GvHD after infusion of
allodepleted T cells will have a tissue biopsy where feasible to confirm the diagnosis and
will then receive 0.4 mg/kg of AP1903 as a 2 h infusion - based on published Pk data which
show plasma concentrations of 10-1275ng/mL over the 0.01mg/kg to 1.0mg/kg dose range with
plasma levels falling to 18% and 7% of maximum at 0.5 and 2hrs post dose.22 Patients with
Grade I GVHD will not receive other therapy initially but if they show progression of GvHD
they will be placed on conventional GvHD therapy as per institutional SOPs. Patients who
develop grades 2-4 GVHD should receive standard systemic immunosuppressive therapy per
institutional SOPs in addition to the AP1903 dimerizer drug, with the exception that other
investigational agents may not be administered within 30 days of the AP1903 infusion.
EVALUATIONS DURING STUDY:
General evaluations will be conducted as per standard of care for patients after receiving a
haploidentical PBSCT. - Donor Engraftment will be evaluated via standard studies on
peripheral blood (FISH/DNA studies for chimerism). - CMV antigenemia monitoring; EBV PCR as
per SOP. - Viral, protozoal, bacterial and fungal infections will be monitored according to
our SOPs.
Study Specific Evaluations: - Physical examination with each visit. - Toxicity and GVHD
grading with each visit. - The detailed schedule for laboratory monitoring of immune
recovery is (also attached in Section S):
Week 0: Pre-study Week 1: Treatment Week 2 through 15 years: Follow Up
Please see Study Calendar attached in Section S.
Week 0 ONLY: - Pulse Ox - Pregnancy Test (only required for at risk individuals defined as
female patients of childbearing potential who have received a reduced intensity conditioning
regimen)
WEEK 0, then each month from M1through M12 and then annually for 15 years total: - Hx - PE -
Weight - VS - Performance Status - CBC d/p - Lytes/BUN/Cr - AST/Billi/Alb - Function,
Persistence Studies
Week 1 and Week 2: -Infusion T Cells occurs on Week 1 only. - Function, Persistence Studies
Immunoglobulins will be taken at Week 0, M6 and M12 (then annually for 15 years).
RCR PCR and archive samples will be taken on Week 0, M3, M6 and M12 (then annually for 15
years).
Quantitative PCR will be taken at Week 0 (prestudy and between 2-6 hours after infusion),
Week 1, Week2, Week 3, M1, M3, M6, M9, and M12 (then annually for 15 years).
A serum sample of 3ml to test for HAMA will be taken prior to the infusion and a serum
sample of 3ml to test for HAMA/HARA will be taken a month after the infusion of allodepleted
T cells. This will be taken at Week 0 and M1.
Immune Reconstitution: Depending on availability of patient cells and reagents, immune
reconstitution studies (Immunophenotyping, T and B cell function) will be obtained at serial
intervals after transplant. We will analyze several parameters measuring immune
reconstitution resulting from iCaspase transduced allodepleted T cells. These include
repeated measurements of total lymphocyte counts, T and CD19 B cell numbers, and FACS
analysis of T cell subsets (CD3, CD4, CD8, CD16, CD19, CD27, CD28, CD44, CD62L, CCR7, CD56,
CD45RA, CD45RO, alpha/beta and gamma/delta T cell receptors). In case of sufficient amount
of T cells for analysis we will evaluate also T regulatory cell markers such as
CD4/CD25/FoxP3. Approximately 10-60 ml of patient blood will be taken, if feasible, 4 hours
after infusion, weekly for 1 month, monthly x 9 months, and then at 1 and 2 years. The
amount of blood taken will be dependent on the size of the recipient and will not exceed
10cc/kg in total (allowing for blood taken for clinical care and study evaluation) at any
one blood draw.
Persistence and safety of transduced allodepleted T cells: The following analysis will also
be performed on the above peripheral blood samples to monitor function, persistence and
safety of transduced T-cells at time-points indicated in the study calendar.
- Phenotype to detect the presence of transgenic cells - Quantitative real-time PCR to
detect retroviral integrants.
RCR testing by PCR. RCR testing by PCR will be performed pre study, 3, 6, and 12 months then
yearly for a total of 15 years. Aliquot of cells and serums will also be archived for use in
future studies for RCR as required by the FDA or RAC.
Quantitative PCR to detect retroviral integrant clonality and integrant locus if transgenes
detected at >0.5%. This will be collected at pre study, between 2 and 6 hours after
infusion, Week 1, Week 2, Week 3, Week 4, and at 3, 6, 9, and 12 months, then yearly for a
total of 15 years.
If there is insufficient blood for all the tests listed above at any time point, RCR testing
and Quantitative real-time PCR will be the first priorities.
Studies will be conducted depending on the availability of the patient and the ability to
safely draw the amount of blood needed for the studies. The time points given are
approximate as patients may not always be able to keep appointments. However, every effort
will be made, to obtain studies on the above-mentioned schedule.
Left over samples will be stored for any future study related assays.
Patients receiving AP1903: In patients who develop GVHD and receive AP1903 additional blood
samples of 10-30cc will be obtained to monitor the effects of AP1903 on transgene
persistence as follows:
Day 0: AP1903 dose; History; PE; CBC d/p; Lytes/BUN/Cr; AST/Bili/Alb; Function and
Persistence Studies; Phenotyping
Day 2: CBC d/p; Lytes/BUN/Cr; AST/Bili/Alb; Function and Persistence Studies; Phenotyping
Day 4: CBC d/p; Lytes/BUN/Cr; AST/Bili/Alb; Function and Persistence Studies; Phenotyping
Day 7: History; PE; CBC d/p; Lytes/BUN/Cr; AST/Bili/Alb; Function and Persistence Studies;
Phenotyping
Day 14: History; PE; CBC d/p; Lytes/BUN/Cr; AST/Bili/Alb; Function and Persistence Studies;
Phenotyping
In addition if recipients have biopsies of GVHD sites as part of diagnosis of clinical care
samples will be obtained for analysis of transgene persistence by PCR.
Left over samples will be stored for any future study related assays.
TIMELINE FOR GENERATION OF PRODUCT: Pre transplant: - Identify BMT donor - Prepare
recipient's LCLs.
When LCL line is available: - Obtain 240 ml of blood or unstimulated leukopheresis from
donor. - Prepare T cells and culture with recipient or appropriate 1st degree relative LCLs.
- Prepare donor LCLs for later immune reconstitution studies.
At 72 hours: - Treat T cells with RFT5-dgA
3 days later: - Transduce
4 days later: - CD19 selection - Check samples for sterility/endotoxin and allodepletion;
freeze remainder
From 30 to 90 days post transplant when COA available for cell product: - Thaw and infuse T
cells 30 to 90 days post stem cell infusion |