Stem Cell Transplant With Th2/Tc2 Cells to Treat Advanced Breast Cancer

Background:

- In CC# 00-C-0119 we were able to demonstrate that allogeneic T cells could mediate a
clinically relevant graft-versus-tumor (GVT) effect against MBC after a
reduced-intensity, T cell depleted allogeneic hematopoietic stem cell transplant
(alloHSCT).

- Responses were observed after establishment of complete lymphoid chimerism, which was
frequently delayed and required the use of planned donor lymphocyte infusions (DLI). DLI
were associated with a significant incidence of graft-versus-host disease (GVHD).

- In murine models, in vitro generated T cells of Th2/Tc2 phenotype can facilitate
engraftment of HLA disparate allografts with significantly reduced GVHD as compared to T
cell replete allografts that have not been manipulated. In addition, Th2/Tc2 cells
provide an anti-tumor effect through the perforin/granzyme pathway.

- Allogeneic Th2/Tc2 cells may facilitate rapid allo-engraftment post-transplant with
reduced GVHD. In addition, the perforin-mediated anti-tumor activity of Th2/Tc2 cells
should provide earlier benefit compared with T-cell depleted allografts.

Objectives:

-To determine the safety, as defined by the incidence of acute graft-versus-host disease, and
feasibility of administering in vitro generated donor T cells of Th2/Tc2 phenotype to augment
a T cell depleted allograft (T cell exchange) after reduced-intensity conditioning.

Eligibility:

- Patients with measurable, metastatic breast cancer and an HLA matched sibling donor

- Patients must have received treatment with a taxane, an anthracycline, a hormonal agent
and/or Herceptin, if the tumor expresses the respective receptors, and at least one
treatment for metastatic disease that has not resulted in a complete response.

Design:

- Donors will initially have lymphocytes collected to generate the Th2/Tc2 product and
then have blood stem cells collected following mobilization with filgrastim. The stem
cell product will be T-cell depleted, and the T-cell dose will be adjusted to 1 x 10(5)
CD3+ cells/kg.

- Patients will receive induction (immune depleting) chemotherapy with the goal of
reducing circulating CD4+ cell less than 50/microliter prior to proceeding to alloHSCT.

- Patients will receive a reduced-intensity conditioning regimen consisting of fludarabine
and cyclophosphamide. This will be followed by infusion of the T cell depleted
allograft, which will be supplemented with Th2/Tc2 cells (i.e. T cell exchange).

- Cyclosporine will be discontinued after 40 days to permit a full GVT effect. Patients
may receive donor lymphocyte infusions at days +42, +70, +98 post-transplant to further
potentiate a GVT effect.

- Patients will be enrolled in three cohorts, with escalating Th2/Tc2 cell doses (0.5 -
12.5 x 10(7) cells/kg) given in a phase-I manner.

- INCLUSION CRITERIA:

Inclusion Criteria - Recipient:

1. Patients with measurable stage IV breast cancer. Patients with central nervous system
CNS metastases are eligible if the CNS metastases have been treated and remained
stable a minimum of four weeks after the completion of therapy.

2. Patients must have received at least one prior chemotherapy regimen for treatment of
distant metastases and achieved less than a complete response to this therapy.

1. Patients must have received prior therapy with a taxane (e.g. paclitaxel) and an
anthracycline (e.g. doxorubicin) as part of either adjuvant therapy or treatment
of metastatic disease.

2. Patients whose tumor expresses estrogen and/or progesterone receptors must have
received at least one hormonal therapy (e.g. Tamoxifen) as part of either
adjuvant therapy or treatment of metastatic disease.

3. Patients whose tumor expresses Her2-neu must have received trastuzumab (Herceptin
) as part of either adjuvant therapy or treatment of metastatic disease.

4. Patients who have undergone prior autologous stem cell transplantation are
eligible for this protocol.

3. Patients 18 - 75 years of age. The upper age limit was chosen in order not to be
discriminatory, provided that patients meet all other eligibility criteria.

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

5. Life expectancy greater than 6 months.

6. Left ventricular ejection fraction has to be greater than or equal to 45% by either
MUGA or 2-D echo. This test will repeated immediately after induction and prior to
transplantation. Patients who do not have the minimally required function will be
removed from trial.

7. DLCO greater than or equal to 50% of the expected value when corrected for Hb. This
test will repeated immediately after induction and prior to transplantation. Patients
who do not have the minimally required function will be removed from trial.

8. Creatinine less than or equal to 1.5 mg/dl and a creatinine clearance greater than or
equal to 50 ml/min/1.73 m(2). This test will repeated immediately after induction and
prior to transplantation. Patients who do not have the minimally required function
will be removed from trial.

9. Direct bilirubin less than or equal to 2.5 mg/dl, SGOT less than 4x high normal value.
Values above these levels may be accepted, at the discretion of the PI or study
chairperson, if such elevations are thought to be due to liver involvement by
malignancy. This test will repeated immediately after induction and prior to
transplantation. Patients who do not have the minimally required function will be
removed from trial.

10. Patients must be HIV-, HbsAg-, and Hepatitis C antibody negative. The high degree of
immune suppression that will be used in this study may lead to the activation or
progression of these viral illnesses.

11. Not pregnant or lactating. Patients of childbearing potential must use an effective
method of contraception. The effects of the chemotherapy, the subsequent transplant
and the medications used after the transplant are highly likely to be harmful to a
fetus. The effects upon breast milk are unknown and may be harmful to the infant.

12. Consenting sibling matched at 6/6 HLA antigens.

13. Provision for a Durable Power of Attorney.

14. Ability to give informed consent.

Inclusion Criteria - Donor:

1. Age 18 - 75 years. As the potential for cerebrovascular and cardiac complications may
potentially increase with age, 75 years has been chosen arbitrarily as the upper age
limit. However, if it is determined after initial accrual of patients in this upper
age range that this procedure is relatively safe, the age range may be extended.

2. No physical contraindications to stem cell donation (i.e. severe atherosclerosis,
auto-immune disease, cerebrovascular accident, prior malignancy. Patients with severe
atherosclerosis by history will receive a cardiology consult and be judged eligible on
a case by case basis. The exclusion of patients with a prior malignancy will be
evaluated on a case by case basis. If it is felt by the investigators that the risk of
potential transfer of malignant cells is far outweighed by the potential benefit of
the procedure the patient may be eligible to serve as a donor. Persons with a history
of non-hematologic malignancy must have undergone potentially curative therapy for
that malignancy and 1) have had no evidence of that disease for 5 years, and/or 2) be
deemed at low risk for recurrence (less than or equal to 20% at 5 years). Such persons
will be considered eligible for stem cell donation at the discretion of the principal
investigator, who will evaluate the possible benefit to the potential transplant
recipient and the risk of disease transmission in consultation with Department of
Transfusion Medicine staff. Prospective donors with a history of non-hematologic
malignancy who have received potentially curative therapy and are in remission, but
whose estimated risk of recurrence is greater than 20% at 5 years, will be considered
on an individual basis in consultation with the NCI IRB. Any prospective transplant
recipient whose donor has a history of malignancy will be counseled about the
theoretical risk of transmission of cancer from the donor to the recipient.

3. Donors must be HIV-negative, HbsAg, and Hepatitis C antibody negative. As donors are
providing an allogeneic blood product there is the potential risk of transmitting
these viral illnesses to the recipient.

4. Donor must not be pregnant or breastfeeding an infant. A donor who is lactating must
substitute formula feeding for her infant during the period of cytokine
administration. Filgrastim may be secreted in human milk, although its bioavailability
from this source is not known. Limited clinical data suggest that short-term
administration of filgrastim or sargramostim to neonates is not associated with
adverse outcomes. Donors of childbearing potential must use an effective method of
contraception during the time they are receiving cytokines. The effects of cytokine
administration on a fetus are unknown and may be potentially harmful. The effects upon
breast milk are also unknown and may potentially be harmful to the infant.

5. Ability to give informed consent.

EXCLUSION CRITERIA:

Exclusion Criteria - Patient

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

2. History of psychiatric disorder which may compromise compliance with transplant
protocol, or which does not allow for appropriate informed consent (as determined by
principal investigator).

Exclusion Criteria - Donor

1. History of psychiatric disorder which may compromise compliance with transplant
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. Individuals with symptomatic angina will be considered to have severe heart
disease and will not be eligible to be a donor.

3. Anemia (Hb less than 11 gm/dl) or thrombocytopenia (platelets less than 100,000 per
ml).