MAGE-A3/12 Metastatic Cancer Treatment With Anti-MAGE-A3/12 TCR-Gene Engineered Lymphocytes

Background

We have constructed a single retroviral vector that contains both alpha and beta chains of a
T cell receptor (TCR) that recognizes the MAGE-A3/12 tumor antigen, which can be used to
mediate genetic transfer of this TCR with high efficiency (> 30%) without the need to
perform any selection.

In co-cultures with human leukocyte antigen serotype within HLA-A serotype group (HLA-A2)
and MAGE-A3/12 double positive tumors, anti-MAGE-A3/12 TCR transduced T cells secreted
significant amounts of Interferon (IFN)-gamma with high specificity.

Objectives:

Primary objectives:

- Determine if the administration of anti-MAGE-A3/12 engineered peripheral blood
lymphocytes and aldesleukin to patients following a nonmyeloablative but lymphoid
depleting preparative regimen will result in clinical tumor regression in patients with
metastatic cancer that expresses the MAGE-A3/12 antigen.

- Determine the toxicity profile of this treatment regimen

Secondary objectives:

-Determine the in vivo survival of TCR gene-engineered cells.

Eligibility:

Patients who are human leukocyte antigen (HLA)-A*0201 positive and 18 years of age or older
must have:

- metastatic cancer whose tumors express the MAGE-A3/12 antigen;

- previously received and have been a non-responder to or recurred following standard
care for metastatic disease;

Patients may not have:

-contraindications for high dose aldesleukin administration.

Design:

PBMC obtained by leukapheresis (approximately 10^10) cells) will be cultured in the presence
of anti-CD3 (OKT3) and aldesleukin in order to stimulate T-cell growth.

Transduction is initiated by exposure of approximately 10^7 to 5 X 10^8 cells to retroviral
vector supernatant containing the anti-MAGE-A3/12 TCR genes.

The study will begin by evaluating the safety of two ranges of cells, 5 x 10^9 - 3 x 10^10,
and greater than 3 x 10^10- 1 x 10^11 in a standard phase I dose escalation fashion using a
3+3 design. Once this safety has been confirmed, patients will be enrolled into the phase 2
portion of the trial using up to 1 x 10^11 cells. In the phase 2 portion, patients will be
entered into two cohorts based on histology: cohort 1 will include patients with metastatic
melanoma or renal cell cancer; cohort 2 will include patients with other types of metastatic
cancer.

Patients will receive a nonmyeloablative but lymphocyte depleting preparative regimen
consisting of cyclophosphamide and fludarabine followed by intravenous infusion of ex vivo
tumor reactive, TCR gene-transduced peripheral blood mononuclear cells (PBMC) plus
intravenous (IV) aldesleukin (720,000 IU/kg every (q)8h for a maximum of 15 doses).

Patients will undergo complete evaluation of tumor with physical examination, computed
tomography (CT) of the chest, abdomen and pelvis and clinical laboratory evaluation four to
six weeks after treatment. If the patient has stable disease (SD) or tumor shrinkage, repeat
complete evaluations will be performed every 1-3 months. After the first year, patients
continuing to respond will continue to be followed with this evaluation every 3-4 months
until off study criteria are met.

For each of the 2 strata evaluated in the phase 2 portion, the study will be conducted using
a phase II optimal design where initially 21 evaluable patients will be enrolled. For each
of these two arms of the trial, if 0 or 1 of the 21 patients experiences a clinical
response, then no further patients will be enrolled but if 2 or more of the first 21
evaluable patients enrolled have a clinical response, then accrual will continue until a
total of 41 evaluable patients have been enrolled in that stratum.

For both strata, the objective will be to determine if the combination of high dose
aldesleukin, lymphocyte depleting chemotherapy, and anti-MAGE-A3/12 TCR-gene engineered
lymphocytes is able to be associated with a clinical response rate that can rule out 5%
(p0=0.05) in favor of a modest 20% partial response (PR) + complete response (CR) rate
(p1=0.20).

- INCLUSION CRITERIA:

Metastatic cancer that expresses MAGE-A3/12 as assessed by one of the following methods:
reverse transcription polymerase chain reaction (RT-PCR) on tumor tissue defined as 30,000
copies of MAGE-A3/12 per 106 GAPDH copies, or by immunohistochemistry of resected tissue
defined as 10% or greater of cells being 2-3+, or serum antibody reactive with MAGE-A3/12.
Metastatic cancer diagnosis will be confirmed by the Laboratory of Pathology at the
National Cancer Institute (NCI).

Patients with melanoma or renal cell cancer must have previously received high dose
aldesleukin and have been either non-responders (progressive disease) or have recurred.
Patients with other histologies, must have previously received at least one systemic
standard care (or effective salvage chemotherapy regimens) for metastatic disease, if
known to be effective for that disease, and have been either non-responders (progressive
disease) or have recurred.

Greater than or equal to 18 years of age.

Willing to sign a durable power of attorney

Able to understand and sign the Informed Consent Document

Clinical performance status of Eastern Cooperative Oncology Group (ECOG) 0 or 1.

Life expectancy of greater than three months.

Patients of both genders must be willing to practice birth control for four months after
receiving the preparative regimen.

Patients must be human leukocyte antigen (HLA)-A*0201 positive

Serology:

- Seronegative for human immunodeficiency virus (HIV) antibody. (The experimental
treatment being evaluated in this protocol depends on an intact immune system.
Patients who are HIV seropositive can have decreased immune -competence and thus be
less responsive to the experimental treatment and more susceptible to its
toxicities.)

- Seronegative for hepatitis B antigen and hepatitis C antibody unless antigen
negative.

Hematology:

- Absolute neutrophil count greater than 1000/mm^3 without the support of filgrastim.

- White blood cell (WBC) (> 3000/mm^3).

- Platelet count greater than 100,000/mm^3.

- Hemoglobin greater than 8.0 g/dl.

Chemistry:

- Serum alanine aminotransferase (ALT)/aspartate aminotransferase (AST) less or equal
to 2.5 times the upper limit of normal.

- Serum creatinine less than or equal to 1.6 mg/dl.

- Total bilirubin less than or equal to 1.5 mg/dl, except in patients with Gilbert's
Syndrome who must have a total bilirubin less than 3.0 mg/dl.

More than four weeks must have elapsed since any prior systemic therapy at the time the
patient receives the preparative regimen, and patients' toxicities must have recovered to
a grade 1 or less (except for toxicities such as alopecia or vitiligo).

EXCLUSION CRITERIA:

Women of child-bearing potential who are pregnant or breastfeeding because of the
potentially dangerous effects of the preparative chemotherapy on the fetus or infant.

Active systemic infections, coagulation disorders or other major medical illnesses of the
cardiovascular, respiratory or immune system, myocardial infarction, cardiac arrhythmias,
obstructive or restrictive pulmonary disease.

Any form of primary immunodeficiency (such as Severe Combined Immunodeficiency Disease).

Concurrent opportunistic infections (The experimental treatment being evaluated in this
protocol depends on an intact immune system. Patients who have decreased immune competence
may be less responsive to the experimental treatment and more susceptible to its
toxicities).

Concurrent Systemic steroid therapy

History of severe immediate hypersensitivity reaction to any of the agents used in this
study.

History of coronary revascularization or ischemic symptoms

Any patient known to have an left ventricular ejection fraction (LVEF) less than or equal
to 45%.

Documented LVEF of less than or equal to 45% tested in patients with:

- History of ischemic heart disease, chest pain, or clinically significant atrial
and/or ventricular arrhythmias including but not limited to: atrial fibrillation,
ventricular tachycardia, second or third degree heart block

- Age greater than or equal to 60 years old

Documented forced expiratory volume 1 (FEV1) less than or equal to 60% predicted tested in
patients with:

- A prolonged history of cigarette smoking (20 pk/year of smoking within the past 2
years).

- Symptoms of respiratory dysfunction