T Cells Expressing a Fully-Human Anti-CD30 Chimeric Antigen Receptor for Treating CD30-Expressing Lymphomas

Background:

- Improved treatments for a variety of treatment-resistant, CD30-expressing malignancies
including Hodgkin lymphoma, anaplastic large cell lymphoma, and other CD30- expressing
lymphomas are needed.

- T cells can be genetically modified to express chimeric antigen receptors (CARs) that
specifically target malignancy-associated antigens.

- Autologous T cells genetically modified to express CARs targeting the B-cell antigen
CD19 have caused complete remissions in a small number of patients with lymphoma. These
results demonstrate that CAR-expressing T cells can have anti-lymphoma activity in
humans.

- CD30 expression can be easily detected by immunohistochemistry on lymphoma cells, which
allows selection of CD30-expressing malignancies for treatment.

- CD30 is not known to be expressed by normal cells except for a small number of activated
lymphocytes.

- We have constructed a novel fully-human anti-CD30 CAR that can specifically recognize
CD30-expressing target cells in vitro and eradicate CD30-expressing tumors in mice.

- This particular CAR has not been tested before in humans.

- Possible toxicities include cytokine-associated toxicities such as fever, hypotension,
and neurological toxicities. Elimination of a small number of normal activated
lymphocytes is possible, and unknown toxicities are also possible.

Objectives:

Primary

-Determine the safety and feasibility of administering T-cells expressing a novel fullyhuman
anti-CD30 CAR to patients with advanced CD30-expresssing lymphomas.

Eligibility:

- Patients must have Hodgkin lymphoma, anaplastic large cell lymphoma, peripheral T-cell
lymphoma not otherwise specified, diffuse large B-cell lymphoma not otherwise specified,
primary mediastinal B-cell lymphoma, grey zone lymphoma, enteropathyassociated T-cell
lymphoma, or extranodal NK/T-cell lymphoma, nasal type

- Patients must have malignancy that is both measurable on a CT scan with a largest
diameter of at least 1.5 cm and possessing increased metabolic activity detectable by
PET scan. Alternatively patients with lymphoma detected by flow cytometry of bone marrow

are eligible.

- Patients must have a creatinine of 1.4 mg/dL or less and a normal cardiac ejection
fraction.

- An ECOG performance status of 0-1 is required.

- No active infections are allowed including any history of HIV, hepatitis B, or hepatitis
C. At the time of protocol enrollment patients must be seronegative for CMV by antibody
testing or must have a negative blood CMV PCR.

- Absolute neutrophil count greater than or equal to 1000/micro L, platelet count greater
than or equal to 45,000/micro L, hemoglobin greater than or equal to 8g/dL

- Serum ALT and AST less or equal to 3 times the upper limit of the institutional normal
unless liver involvement by malignancy is demonstrated.

- At least 14 days must elapse between the time of any prior systemic treatment (including
corticosteroids) and initiation of protocol enrollment.

- Clear CD30 expression must be detected on 75% or more of malignant cells from either
bone marrow or lymphoma mass by flow cytometry or immunohistochemistry. The patient s
malignancy will need to be assessed for CD30 expression by flow cytometry or
immunohistochemistry performed at the NIH. If unstained, paraffin-embedded bone marrow
or lymphoma sections are available from prior biopsies, these can be used to determine
CD30 expression by immunohistochemistry; otherwise, patients will need to come to the
NIH for a biopsy to determine CD30 expression. The sample for CD30 expression can come
from a biopsy obtained at any time before enrollment, unless the patient has received a
prior anti-CD30 monoclonal antibody, in which case the sample must come from a biopsy
following completion of the most recent anti-CD30 monoclonal antibody treatment.

- Eligible patients with Hodgkin lymphoma must fulfill one of the following criteria: 1)
have received two prior therapies, one of which must be an autologous stem cell
transplant, or 2) have received three prior lines of therapy. Eligible patients with any
of the listed peripheral T cell lymphomas or non-Hodgkin lymphomas must have received
two lines of prior therapy, at least one of which must contain cytotoxic

chemotherapyPatients with diffuse large B-cell lymphoma or primary mediastinal B-cell
lymphoma must have received 2 prior treatment regimens at least 1 of which included an
anthracycline and an anti-CD20 monoclonal antibody.

- Patients who have never had an allogeneic hematopoietic stem cell transplant as well as
patients who have had an HLA-matched sibling or a 8/8 HLA-matched unrelated donor or
8/8-matched related (not HLA-identical) hematopoietic stem cell transplant are
potentially eligible.

- Women who are pregnant or plan to become pregnant will be excluded.

Design:

- This is a phase I dose-escalation trial.

- Patients will undergo leukapheresis.

- T cells obtained by leukapheresis will be genetically modified to express an anti-CD30
CAR.

- Patients will receive a lymphocyte-depleting chemotherapy conditioning regimen with the
intent of enhancing the activity of the infused anti-CD30 CAR-expressing T cells.

- A chemotherapy conditioning regimen of cyclophosphamide and fludarabine will be
administered prior to all CAR T-Cell infusions. Fludarabine will be given on the same
days as the cyclophosphamide.

- Two days after the chemotherapy ends, patients will receive an infusion of
anti-CD30-CAR-expressing T cells.

- The initial dose level of this dose-escalation trial will be 0.3x10(6) CAR+ T cells/kg
of recipient bodyweight for Cohort 1. The initial dose level will be 1 x 10 (6) CAR+T
cells/kg for Cohort 2.

- The cell dose administered will be escalated until a maximum tolerated dose is
determined.

- Following the T-cell infusion, there is a mandatory 9-day inpatient hospitalization to
monitor for toxicity.

- Outpatient follow-up is planned for 2 weeks and 1, 2, 3, 4, 6, 9, and 12 months after
the CAR T-cell infusion. Long-term gene-therapy follow-up consisting of yearly visits to
a doctor near the patient s home for 4 more years and then yearly telephone contact for
10 additional years will be required.

- As of Amendment E, repeat treatments consisting of the conditioning chemotherapy
followed by a CAR T-cell infusion at the MTD for the patient s cohort are allowed for
eligible patients with any best responses except continuing complete remission or
progressive malignancy.

- Re-enrollment will be allowed for a small number of subjects.

- INCLUSION CRITERIA:

Malignancy Criteria:

- Patients must have Hodgkin lymphoma, anaplastic large cell lymphoma, peripheral T-cell
lymphoma not otherwise specified, diffuse large B-cell lymphoma not otherwise
specified, primary mediastinal B-cell lymphoma, grey zone lymphoma,
enteropathy-associated T-cell lymphoma, or extranodal NK/T-cell lymphoma, nasal type

- Clear CD30 expression must be detected on 75% or more of malignant cells from either
bone marrow or lymphoma mass by flow cytometry or immunohistochemistry. The patient s
malignancy will need to be assessed for CD30 expression by flow cytometry or
immunohistochemistry performed at the NIH. If unstained, paraffin-embedded bone marrow
or lymphoma sections are available from prior biopsies, these can be used to determine
CD30 expression by immunohistochemistry; otherwise, patients will need to come to the
NIH for a biopsy to determine CD30 expression. The sample for CD30 expression can come
from a biopsy obtained at any time before enrollment, unless the patient has received
a prior anti-CD30 monoclonal antibody, in which case the sample must come from a
biopsy following completion of the most recent anti-CD30 monoclonal antibody
treatment.

- Eligible patients with Hodgkin lymphoma must fulfill one of the following criteria: 1)
have received two prior therapies, one of which must be an autologous stem cell
transplant, or 2) have received three prior lines of therapy. Eligible patients with
any of the listed peripheral T- cell lymphomas or non-Hodgkin lymphomas must have
received two lines of prior therapy, at least one of which must contain cytotoxic
chemotherapy. Patients with diffuse large B-cell lymphoma or primary mediastinal
B-cell lymphoma must have received 2 prior treatment regimens at least 1 of which
included an anthracycline and an anti-CD20 monoclonal antibody.

- Patients must have measurable malignancy as defined by at least one of the criteria
below.

- Lymphoma mass that is measurable (minimum 1.5 cm in largest diameter) by CT scan is
required unless bone marrow lymphoma is detectable.

- For a lymphoma mass to count as measurable malignancy, it must have abnormally
increased metabolic activity when assessed by positron emission tomography (PET) scan.

- For lymphoma with only bone marrow involvement, no mass is necessary, but if a mass is
not present, bone marrow malignancy must be detectable by flow cytometry.

Other Inclusion Criteria:

- Greater than or equal to 18 years of age and less than or equal to age 73.

- Able to understand and sign the Informed Consent Document.

- Clinical performance status of ECOG 0-1

- Room air oxygen saturation of 92% or greater

- Male patients and must be willing to practice birth control from the time of
enrollment on this study and for four months following the final CAR T-cell infusion.
Pre-menopausal patients (female patients who have had a menstrual period within the
last year) must be willing to practice birth control from the time of enrollment and
for one year following the final CAR T cell infusion.

- Seronegative for 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 are less responsive to the experimental
treatment and more susceptible to its toxicities.)

- Patients with a known history of hepatitis B or hepatitis C are not eligible due to
the risk of re-activation of hepatitis after possible immunosuppression due to
anti-CD30 CAR T-cells and chemotherapy administered on this protocol.

- Seronegative for HTLV-1.

- Negative for hepatitis B surface antigen. Positive hepatitis B tests can be further
evaluated by confirmatory tests; and if confirmatory tests are negative, the patient
can be enrolled. Patients with a known history of hepatitis B are not eligible.

- Seronegative for hepatitis C antibody unless antigen negative. If hepatitis C antibody
test is positive, then patients must be tested for the presence of RNA by RT-PCR and
be HCV RNA negative. Patients with a known history of hepatitis C are not eligible.

- At time of protocol enrollment, the patient should be negative for CMV by antibody
testing or by PCR. In case of disagreement between these 2 CMV tests, the tests will
be repeated and Dept. of Laboratory Medicine consulted.

- Absolute neutrophil count greater than or equal to 1000/mm3 without the support of
filgrastim or other growth factors.

- Platelet count greater than or equal to 55,000/mm3 without transfusion support

- Hemoglobin greater than 8.0 g/dl.

- Less than 5% malignant cells in the peripheral blood leukocytes

- Serum ALT and AST less or equal to 3 times the upper limit of the institutional normal
unless liver involvement by malignancy is demonstrated.

- Serum creatinine less than or equal to 1.4 mg/dL.

- Total bilirubin less than or equal to 2.0 mg/dl.

- At least 14 days must have elapsed since any prior systemic therapy prior to apheresis
and prior to the initiation of chemotherapy (including systemic corticosteroids at any
dose). Because this protocol requires collection of autologous blood cells by
leukapheresis in order to prepare CAR T cells, systemic anti-malignancy therapy
including systemic corticosteroid therapy of any dose is not allowed within 14 days
prior to the required leukapheresis. NOTE: Because of the long half-life and potential
to affect CAR T-cells, 30 days must elapse from the time of administration of
anti-PD-1 or anti-PD-L1 antibodies or other agents that in the opinion of the PI can
stimulate immune activity and infusion of CAR T-cells.

- Normal cardiac ejection fraction (greater than or equal to 50% by echocardiography)
and no evidence of hemodynamically significant pericardial effusion as determined by
an echocardiogram within 4 weeks of the start of the treatment protocol.

- Patients must not take corticosteroids including prednisone, dexamethasone or any
other corticosteroid for 14 days before apheresis and CAR T-cell infusion. Patients
must also not take corticosteroids at doses higher than 5 mg/day of prednisone or
equivalent at any

time after the CAR T cell infusion.

- Patients must be willing to undergo endotracheal intubation, mechanical ventilation,
dialysis, CPR, and electrical defibrillation. Patients must be willing to receive
vasopressor drugs and all other standard intensive care unit interventions. Any living
will must be amended to allow these interventions or the patient will not eligible.

- Patients who have been treated on other protocols of genetically-modified T-cells at
the NIH only are potentially eligible under these conditions:

- At least 6 months have elapsed since the last genetically-modified T-cell therapy
that the patient received and there is no evidence of replication-competent
retroviruses (evidence must be provided from prior NIH gene-therapy protocol
Principal Investigator) and persisting genetically-modified T cells are not
detectable in the patient s blood (evidence must be provided by prior NIH
gene-therapy protocol Principal Investigator).

Additional Inclusion Criteria Pertinent Only for Patients with Prior Allogeneic
Transplantation:

- Recipients must have received an HLA-identical sibling allogeneic hematopoietic stem
cell transplant, or an 8/8-matched (HLA-A, B, C, DR) other-than-sibling related
donors, or a 8/8-matched (HLA-A, B, C, DR) unrelated donor (URD) allo-HSCT for an
eligible CD30+ lymphoma

- Donor T cell engraftment after allo-HSCT (>90% donor chimerism of the T-cell
compartment).

- Patients must be at least 90 days post-transplant.

- Patients must be off all systemic immunosuppressive drugs including corticosteroids at
any dose for at least 28 days prior to protocol enrollment and must remain off
immunosuppressive drugs while enrolled on the protocol. Patients must not be taking
any systemic steroids at all for 14 days prior to apheresis and initiation of
chemotherapy. Topical corticosteroid preparations applied to the skin such as
solutions, creams, and ointments are allowed. Inhaled corticosteroids are allowed, and
corticosteroid eye drops are allowed.

- Prior DLIs are not necessary.

- 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 defined as grade 0 to I acute GVHD 109 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 .107 Subjects with disease that is controlled to
stage I acute GVHD or to mild global score chronic GVHD with local topical cutaneous
steroids will be eligible for enrollment.

EXCLUSION CRITERIA:

- Patients that require urgent therapy due to tumor mass effects or spinal cord
compression.

- Patients with lymphoma masses 10.0 cm or larger in longest diameter will not be
eligible.

- Patients that have active hemolytic anemia.

- Patients who are currently taking any medications for systemic anticoagulation other
than aspirin will not be eligible.

- Patients with second malignancies in addition to their lymphoma are not eligible if
the second malignancy has required treatment (including maintenance therapy) within
the past 4 years or is not in complete remission. There are two exceptions to this
criterion:

successfully treated non-metastatic basal cell or squamous cell skin carcinoma.

- 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.
Women of child-bearing potential are defined as all women except women who are
postmenopausal or who have had a hysterectomy. Postmenopausal will be defined as women
over the age of 55 who have not had a menstrual period in at least 1 year.

- Active uncontrolled systemic infections (defined as infections causing fevers and
infections requiring intravenous antibiotics when the intravenous antibiotics have
been administered for less than 72 hours); active coagulation disorders or other major
uncontrolled medical illnesses of the cardiovascular, respiratory, endocrine, renal,
gastrointestinal, genitourinary or immune system; history of myocardial infarction;
history of ventricular tachycardia or ventricular fibrillation; active cardiac
arrhythmias (Active atrial fibrillation is not allowed, but resolved atrial
fibrillation is allowed.); active obstructive or restrictive pulmonary disease; or
active autoimmune diseases such as rheumatoid arthritis.

- Patients will not be seen for screening appointments or enrolled on the protocol if
they have been hospitalized within the 7 days prior to the screening appointment or
the date of protocol enrollment.

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

- Systemic corticosteroid therapy of any dose is not allowed within 14 days prior to the
required leukapheresis, or the initiation of the conditioning chemotherapy regimen.
Corticosteroid creams, ointments, and eye drops are allowed.

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

- Patients with current CNS involvement by malignancy (either by imaging or
cerebrospinal fluid involvement or biopsy-proven).

- Patients currently taking anticoagulants.