Administration of Anti-CD19-chimeric-antigen-receptor-transduced T Cells From the Original Transplant Donor to Patients With Recurrent or Persistent B-cell Malignancies After Allogeneic Stem Cell Transplantation

BACKGROUND:

Many patients with advanced B-cell malignancies that cannot be cured by chemotherapy and
monoclonal antibodies have prolonged relapse-free survival after allogeneic hematopoietic
stem cell transplantation (alloHSCT); however, a substantial fraction of patients with B-cell
malignancies relapse following alloHSCT.

The first therapeutic maneuver attempted when patients without graft-versus-host disease
(GVHD) relapse after alloHSCT is usually withdraw of immunosuppressive drugs. If a remission
does not occur after withdraw of immunosuppression, patients are often treated with donor
lymphocyte infusions (DLI). Withdraw of immunosuppression and DLI can lead to complete
remissions in patients with B-cell malignancies that relapse after alloHSCT. Unfortunately, a
substantial fraction of patients do not enter a complete remission after withdraw of
immunosuppression followed by DLI, and these therapies are often complicated by GVHD.

The outcomes of alloHSCT might be improved if T cells could be manipulated so that they
generate a more potent graft-versus-malignancy (GVM) effect than unmanipulated T cells.

We hypothesize that the GVM effect against B-cell malignancies can be augmented by
genetically engineering donor T cells to express receptors that specifically recognize
antigens expressed by malignant B cells.

Chimeric antigen receptors (CARs) consist of an antigen recognition moiety combined with
T-cell signaling domains. CARs are capable of activating T cells in an antigen-specific
manner.

Expression of the CD19 antigen is limited to B cells and perhaps follicular dendritic cells.
Most malignant B cells express CD19.

We have constructed a retroviral vector encoding an anti-CD19 CAR. Large numbers of T cells
that have been transduced with this retroviral vector can be generated in vitro for clinical
adoptive T cell therapy. These anti-CD19-CAR-transduced T cells specifically recognize a
variety of CD19+ target cells and kill primary chronic lymphocytic leukemia (CLL) cells in
vitro.

PRIMARY OBJECTIVE:

To assess the safety of administering allogeneic anti-CD19-CAR-transduced T cells to patients
with B-cell malignancies that are persistent or relapsed after alloHSCT. The allogeneic
anti-CD19-CAR-transduced T cells will be derived from the original allogeneic transplant
donor.

ELIGIBILITY:

Patients with any CD19-expressing malignancy that is persistent or recurrent following
successful T-cell engraftment after HLA-identical sibling, 1-antigen mismatched related, or
greater than or equal to 9/10-matched unrelated donor (URD) alloHSCT and sequential treatment
with withdraw of immunosuppression and DLI. Patients with acute lymphoblastic leukemia (ALL).
ALL -like high grade lymphomas, Burkitt lymphoma or diffuse large B-cell lyphoma will be
eligibile after alloHSCT and withdraw of immunosuppression whether or not they have received
a DLI.

The same donor that provided cells for the alloHSCT must be willing and able to undergo
leukapheresis so that cells can be obtained to prepare the anti-CD19-CAR-transduced T cells.

The recipient must have at most grade I acute GVHD (see Appendix 1) or at most mild global
score chronic GVHD (see Appendix 9). The recipient must not have received systemic
immunosuppressive drugs for at least 28 days at the time of study enrollment. Patients must
be on a dose of corticosteroids of an equivalent of 5 mg/day or less of prednisone.

DESIGN:

- The alloHSCT donor will undergo leukapheresis.

- Patients will undergo apheresis to obtain peripheral blood mononuclear cells. These
cells will be processed to produce anti-CD19 CAR stem memory T cells (anti-CD19 CAR
Tscm). This process involves sorting the cells and then culturing the cells in vitro for
9 days. During the 9-day culture period, the cells will be transduced with
gammaretroviruses encoding the FMC63-28Z.

- CAR recipients will be monitored for development of acute treatment-related toxicities
for at least 9 days after cell infusion as inpatients. Dose-limiting toxicities (DLTs)
will include severe acute GVHD and Grade 4 toxicities not associated with GVHD.

- A maximum of 126 evaluable patients (donors plus recipients) will be treated.

- Assessment of safety is a primary objective of this clinical trial. Safety will be
defined as a lack of severe acute post-infusional toxicities and an incidence of GVHD
that is not higher than historical rates of GVHD occurring after standard DCI.

- Anti-CD19-CAR-transduced T-cell persistence in the peripheral blood will be measured at
multiple time points from 1 week to 1 year after anti-CD19-CARtransduced T cell infusion
by flow cytometry.

- To assess for an anti-malignancy effect of the infused cells, patients will be staged
using standard staging systems.

- INCLUSION CRITERIA:

Inclusion Criteria: Recipient

1. Recipients (patients with B-cell malignancy) must have received an HLA-identical
sibling allogeneic hematopoietic stem cell transplant, a 1-antigen mismatched related
transplant, or a greater than or equal to 7/8-matched unrelated donor (URD) alloHSCT
for any CD19+ B-cell malignancy. Patients with any CD19+ B-cell malignancy that is
persistent or relapsed after all of the following interventions are eligible:

1. Donor T cell engraftment after alloHSCT (>50% donor chimerism of the T cell
compartment and a circulating T cell population for at least 12 weeks).

2. A trial of withdrawal of immunosuppressive therapy.

3. At least one donor cell infusion (DCI) with a minimum T cell dose of 5 times
10(6) CD3+ cells/kg.

Exception: Prior (DCI) DLI is not an eligibility requirement for patients with ALL,
Burkitt lyphoma, ALL like high-grade lymphomas, or diffuse large B-cell lymphoma.

At least 28 days weeks must have elapsed since the latest trial of withdraw of
immunosuppression or DLI until the patient can be deemed to have persistent disease.

2. CD19 expression must be detected on the majority of the malignant cells by
immunohistochemistry or by flow cytometry in the Laboratory of Pathology, CCR, NCI,
NIH. Definition of which cells are malignant must be determined for each patient by
the Laboratory of Pathology using techniques to demonstrate monoclonality such as
kappa/lambda restriction (other techniques can be used to determine monoclonality at
the discretion of the Laboratory of Pathology). The choice of whether to use flow
cytometry or immuohistochemistry will be determined by what is the most easily
available tissue sample in each patient. Immunohistochemistry will be used for lymph
node biopsies and bone marrow biopsies. Flow cytometry will be used for peripheral
blood, fine needle aspirate, and bone marrow aspirate samples.

3. Patients must be 18-75 years of age.

4. Performance status: ECOG less than or equal to 2 (Karnofsky performance status greater
than or equal to 60%)

5. Life expectancy greater than or equal to 3 months.

6. Either no evidence of GVHD or minimal clinical evidence of acute GVHD and chronic GVHD
while off of systemic immunosuppressive therapy for at least 28 days. Minimal clinical
evidence of acute GVHD is defined as grade 0 to I acute GVHD. Minimal evidence of
chronic GVHD is defined as mild global score chronic GVHD (as defined by the 2005 NIH
consensus project) or no chronic GVHD. Subjects with disease that is controlled to
stage I acute GVHD or to mild global score chronic GVHD with local therapy only, e.g.,
topical cutaneous steroids or oral budesonide, will be eligible for enrollment.

7. Provision for a Durable Power of Attorney.

8. Ability to give informed consent.

9. Prior Therapy: Therapy with monoclonal antibodies and/or chemotherapy must be stopped
at least 7 days prior to anti-CD19 CAR-transduced T cell infusion, and recovery of
treatment-associated toxicity to < grade 2 is required prior to infusion of cells. For
patients that have received prior DLI, the last dose must be at least 28 days prior to
anti-CD19 CAR-transduced T cell administration. Note that patients can be enrolled on
this study at any time after or during therapy, but at least 14 days must elapse from
the time of prior monoclonal antibody administration or chemotherapy until anti-CD19
CAR-transduced T cells are infused, and at least 28 days must elapse from the time of
withdraw of immunosuppression or DLI until anti-CD19 CAR-transduced T cells are
infused. Systemic immunosuppression must be stopped at least 28 days prior to protocol
entry. There is no time restriction in regard to prior intrathecal chemotherapy
provided there is complete recovery from any acute toxic effects of such.

10. Recipients of unrelated donor transplants from a National Marrow Donor Program (NMDP)
Center must sign a release of information form to authorize NMDP transfer of
information to the NIH.

11. Previous allogeneic donor must be willing and available to donate again.

12. Patients of childbearing or child-fathering potential must be willing use an effective
method of contraception while being treated on this study and for 4 months after the
last cell infusion.

13. Normal left ventricular function as evaluated by echocardiograph within 6 weeks of
anti- CD19-CAR-transduced T cell infusion

Inclusion Criteria: Donor

1. Donors greater than or equal to 18 years of age must be the same individual whose
cells were used as the source for the patient s original stem cell transplant.

2. Adequate venous access for peripheral leukapheresis, or consent to use a temporary
central venous catheter for leukapheresis.

3. Donors must be HIV negative, hepatitis B surface antigen negative, and hepatitis C
antibody negative.

4. Ability to give informed consent.

5. Donor selection will be in accordance with NIH/CC Department of Transfusion Medicine
(DTM) criteria and, in the case of an unrelated donor from a Transplant Center, the
National Marrow Donor Program (NMDP) standards. When a potentially eligible recipient
of an unrelated donor product from an NMDP Center is identified, the recipient will
complete an NMDP search transfer request to allow NIH NMDP staff to contact the NMDP
Coordinating Center, who will, in turn, contact the donor s prior Donor Center. The
NMDP Policy for Subsequent Donation Requests will be followed and the appropriate
forms (Subsequent Donation Request form) and Therapeutic T Cell Collection
Prescription will be submitted as required.

EXCLUSION CRITERIA:

Exclusion Criteria: Recipients

1. Active infection that is not responding to antimicrobial therapy.

2. Evidence of infection with HIV, Hepatitis B or Hepatitis C. Patients must be HIV
negative, Hepatitis B surface antigen, and Hepatitis C antibody negative. The high
degree of immune suppression that may be used in this study may lead to the activation
or progression of these viral illnesses.

3. Active psychiatric disorder which may compromise compliance with the treatment
protocol, or which does not allow for appropriate informed consent (as determined by
Principal Investigator and/or his designee).

4. Pregnant or lactating. The effects of the immunosuppressive medications that could be
required to treat GHVD are likely to be harmful to a fetus. The effects upon breast
milk are also unknown and may be harmful to an infant.

5. Serum total bilirubin > 2.5 mg/dl, serum ALT and AST values greater than or equal to
2.5 times the upper limit of normal based on age-specific normal values. If the
abnormal liver function is attributable to liver involvement by malignancy, patients
may be eligible with serum total bilirubin up to 5.0 mg/dl, and serum ALT and AST
values up to 5.0 times the upper limit of normal, provided the patient has no evidence
of impending hepatic failure (encephalopathy or prothrombin time >2 times the upper
limit of normal).

6. Serum creatinine greater than 1.6 mg/dL

7. Absolute neutrophil count of less than 1000 cells/microL unless low neutrophil count
is thought to be due to malignancy in the bone marrow and malignancy is documented in
the bone marrow.

8. Active cerebrospinal fluid involvement with malignancy or brain metastasis.

9. Platelet count less than 30,000/microL unless low platelet count is thought to be due
to malignancy in the bone marrow and malignancy is documented in the bone marrow.

10. Hemoglobin less than 8.0 g/dL.

11. Receiving corticosteroids above physiological dosing within 28 days prior to
anti-CD19-CAR-transduced T cell administration.

Exclusion Criteria: Donors

1. History of psychiatric disorder which may compromise compliance with this protocol or
which does not allow for appropriate informed consent.

2. History of hypertension that is not controlled by medication, stroke, or severe heart
disease (donors with symptomatic angina will be excluded). Donors with a history of
coronary artery bypass grafting or angioplasty who are symptom free will receive a
cardiology evaluation and be considered on a case-by-case basis.

3. Donors must not be pregnant.

4. Anemia (Hb < 11 gm/dl) or thrombocytopenia (platelets < 100,000 per microL). However,
potential donors with Hb levels < 11 gm/dl that is due to iron deficiency will be
eligible as long as the donor is initiated on iron replacement therapy. The NIH
Clinical Center, Department of Transfusion Medicine/NMDP physicians will determine the
appropriateness of individuals as donors.