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  • C07K16/28—Immunoglobulins [IG], e.g. monoclonal or polyclonal antibodies against material from animals or humans against receptors, cell surface antigens or cell surface determinants
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  • C12N2501/50—Cell markers; Cell surface determinants
  • C12N2501/515—CD3, T-cell receptor complex

Definitions

• This invention relates to the field of genetically engineered, redirected immune cells and to the field of cellular immunotherapy of B-cell malignancies, B-cell lymphoproliferative syndromes and B-cell mediated autoimmune diseases.
• the publications and other materials used herein to illuminate the background ofthe invention or provide additional details respecting the practice are incorporated by reference.
• HSC hematopoietic stem cell transplantation
• the inability of maximally intensive preparative regimens combined with immunologic graft-versus-tumor reactivity to eradicate minimal residual disease is the mechanism of treatment failure in allogeneic transplantation while, in the autologous setting, tumor contamination ofthe stem cell graft can also contribute to post-transplant relapse [11].
• Targeting minimal residual disease early after transplantation is one strategy to consolidate the tumor cytoreduction achieved with myeloablative preparative regimens and purge, in vivo, malignant cells transferred with autologous stem cell grafts.
• the utility of therapeutic modalities for targeting minimal residual disease shortly following stem cell rescue is dependent on both a limited spectrum of toxicity and the susceptibility of residual tumor cells to the modality's antitumor effector mechanism(s).
• the successful elimination of persistent minimal residual disease should not only have a major impact on the outcome of transplantation for hematologic malignancy utilizing current myeloablative preparative regimens but may also provide opportunities to decrease the intensity of these regimens and their attendant toxicities
• ALL Leukemia treated with chemotherapy is poor and allogeneic transplantation has offered a curative option for many patients when an appropriate donor was available.
• BMT Bone Marrow Transplantation
• Post- transplant Polymerase Chain Reaction (PCR) screening of blood and marrow for bcr-abl transcript is under evaluation as a molecular screening tool for identifying early those transplant recipients at high risk for later development of overt relapse [13,14].
• Patients for whom detectable pi 90 transcript was detected following BMT had a 6J higher incidence of overt relapse than PCR negative patients.
• the median time from the development of a positive signal to morphologic relapse was 80-90 days in these patients.
• the identification of patients in the earliest phases of post-transplant relapse affords the opportunity for making therapeutic interventions when tumor burden is low and potentially most amenable to salvage therapy.
• mHA's minor histocompatibility antigens
• ⁇ on-transformed B-cells and malignant B-cells express an array of cell- surface molecules that define their lineage commitment and stage of maturation. These were identified initially by murine monoclonal antibodies and more recently by molecular genetic techniques. Expression of several of these cell-surface molecules is highly restricted to B-cells and their malignant counterparts.
• CD20 is a clinically useful cell- surface target for B-cell lymphoma immunotherapy with anti-CD20 monoclonal antibodies.
• This 33-kDa protein has structural features consistent with its ability to function as a calcium ion channel and is expressed on normal pre-B and mature B cells, but not hematopoietic stem cells nor plasma cells [31-33].
• CD20 does not modulate nor does it shed from the cell surface [34].
• In vitro studies have demonstrated that CD20 crosslinking by anti-CD20 monoclonal antibodies can trigger apoptosis of lymphoma cells [35,36].
• Clinical trials evaluating the antitumor activity of chimeric anti-CD20 antibody IDEC-C2B8 (Rituximab) in patients with relapsed follicular lymphoma have documented tumor responses in nearly half the patients treated, although the clinical effect is usually transient [37-40].
• Rituximab chimeric anti-CD20 antibody IDEC-C2B8
• Radioimmunotherapy with 131 I-conjugated and 90 Y-conjugated anti- CD20 antibodies also has shown promising clinical activity in patients with relapsed/refractory high-grade ⁇ on-Hodgkins Lymphoma but hematopoietic toxicities from radiation have been significant, often requiring stem cell support [42].
• CD 19 is expressed on all human B-cells beginning from the initial commitment of stem cells to the B lineage and persisting until terminal differentiation into plasma cells [43].
• CD 19 is a type I transmembrane protein that associates with the complement 2 (CD21), TAPA-1, and Leul3 antigens forming a B-cell signal transduction complex.
• CD 19 does not shed from the cell surface, it does internalize [45]. Accordingly, targeting CD 19 with monoclonal antibodies conjugated with toxin molecules is currently being investigated as a strategy to specifically deliver cytotoxic agents to the intracellular compartment of malignant B-cells [46-48].
• Anti-CD 19 antibody conjugated to blocked ricin and poke- weed antiviral protein (PAP) dramatically increase specificity and potency of leukemia cell killing both in ex vivo bone marrow purging procedures and when administered to NOD-SCID animals inoculated with CD19 + leukemia cells [49].
• CMN-specific CTL clones Fourteen patients were treated with four weekly escalating doses of these CMN-specific CTL clones to a maximum cell dose of 10 9 cells/m 2 without any attendant toxicity [65]. Peripheral blood samples obtained from recipients of adoptively transferred T cell clones were evaluated for in vivo persistence of transferred cells. The recoverable CMN-specific CTL activity increased after each successive infusion of CTL clones, and persisted at least 12 weeks after the last infusion. However, long term persistence of CD8 + clones without a concurrent CD4 + helper response was not observed. o patients developed CMN viremia or disease. These results demonstrate that ex-vivo expanded CMN-specific CTL clones can be safely transferred to BMT recipients and can persist in vivo as functional effector cells that may provide protection from the development of CMN disease.
• This rapidly progressive proliferation of EBN-transformed B-cells mimics immunoblastic lymphoma and is a consequence of deficient EBN-specific T cell immunity in individuals harboring latent virus or immunologically na ⁇ ve individuals receiving a virus inoculum with their marrow graft.
• Clinical trials by Rooney et al. have demonstrated that adoptively transferred ex-vivo expanded donor-derived EBN-specific T cell lines can protect patients at high risk for development of this complication as well as mediate the eradication of clinically evident EBN-transformed B cells [54]. No significant toxicities were observed in the forty-one children treated with cell doses in the range of 4x10 7 to 1.2xl0 8 cells/m 2 .
• Retroviral vectors have been used most extensively for this purpose due to their relatively high transduction efficiency and low in vitro toxicity to T cells [67]. These vectors, however, are time consuming and expensive to prepare as clinical grade material and must be meticulously screened for the absence of replication competent viral mutants [68].
• Rooney et al. transduced EBV-reactive T cell lines with the NeoR gene to facilitate assessment of cell persistence in vivo by PCR specific for this marker gene [69]. Riddell et al.
• HIN-specific CD8 + CTL clones have conducted a Phase I trial to augment HIN-specific immunity in HIN seropositive individuals by adoptive transfer using HIN-specific CD8 + CTL clones [70]. These clones were transduced with the retroviral vector tgLS + HyTK which directs the synthesis of a bifunctional fusion protein incorporating hygromycin phosphotransferase and herpes virus thymidine kinase (HSN-TK) permitting in vitro selection with hygromycin and potential in vivo ablation of transferred cells with gancyclovir.
• HSN-TK herpes virus thymidine kinase
• Six HIV infected patients were treated with a series of four escalating cell dose infusions without toxicities, with a maximum cell dose of 5x10 9 cells/m 2 [70].
• ⁇ abel et al. used plasmid
• D ⁇ A encoding an expression cassette for an anti-HIN gene in a Phase I clinical trial.
• Plasmid D ⁇ A was introduced into T cells by particle bombardment with a gene gun [71].
• Genetically modified T cells were expanded and infused back into HIV-infected study subjects.
• this study demonstrated the feasibility of using a non- iral genetic modification strategy for primary human T cells, one limitation of this approach is the episomal propagation ofthe plasmid vector in T cells. Unlike chromosomally integrated transferred D ⁇ A, episomal propagation of plasmid D ⁇ A carries the risk of loss of transferred genetic material with cell replication and of repetitive random chromosomal integration events.
• Chimeric antigen receptors engineered to consist of an extracellular single chain antibody (scFvFc) fused to the intracellular signaling domain ofthe T cell antigen receptor complex zeta chain ( ) have the ability, when expressed in T cells, to redirect antigen recognition based on the monoclonal antibody's specificity [72].
• the design of scFvFc: ⁇ receptors with target specificities for tumor cell-surface epitopes is a conceptually attractive strategy to generate antitumor immune effector cells for adoptive therapy as it does not rely on pre-existing anti-tumor immunity.
• receptors are "universal" in that they bind antigen in a MHC independent fashion, thus, one receptor construct can be used to treat a population of patients with antigen positive tumors.
• Several constructs for targeting human tumors have been described in the literature including receptors with specificities for Her2/Neu, CEA, ERRB-2, CD44v6, and epitopes selectively expressed on renal cell carcinoma [73-77]. These epitopes all share the common characteristic of being cell-surface moieties accessible to scFv binding by the chimeric T cell receptor. In vitro studies have demonstrated that both CD4 + and CD8 + T cell effector functions can be triggered via these receptors.
• the present invention provides genetically engineered T cells which express and bear on the cell surface membrane a CD19-specific chimeric T cell receptor (referred to herein as "CD19R") having an intracellular signaling domain, a transmembrane domain (TM) and a CD19-specific extracellular domain (also referred to herein as "CD19-specific T cells”).
• CD19R CD19-specific chimeric T cell receptor
• TM transmembrane domain
• CD19-specific extracellular domain also referred to herein as "CD19-specific T cells”
• the present invention also provides the CD 19- specific chimeric T cell receptors, DNA constructs encoding the receptors, and plasmid expression vectors containing the constructs in proper orientation for expression.
• the present invention provides a method of treating a
• CD19 + malignancy in a mammal which comprises administering CD19-specific T cells to the mammal in a therapeutically effective amount.
• CD8 + CD 19- specific T cells are administered, preferably with CD4 + CD19-specific T cells.
• CD4 + CD19-specific T cells are administered to a mammal, preferably with CD8 + cytotoxic lymphocytes which do not express the CD19-specific chimeric receptor ofthe invention, optionally in combination with CD8 + CD19-specific redirected T cells.
• the present invention provides a method of abrogating any untoward B cell function in a mammal which comprises administering to the mammal CD19-specific redirected T cells in a therapeutically effective amount.
• untoward B cell functions can include B-cell mediated autoimmune disease (e.g., lupus or rheumatoid arthritis) as well as any unwanted specific immune response to a given antigen.
• the present invention provides a method of making and expanding the CD19-specific redirected T cells which comprises transfecting T cells with an expression vector containing a DNA construct encoding the CD19-specific chimeric receptor, then stimulating the cells with CD19 + cells, recombinant CD 19, or an antibody to the receptor to cause the cells to proliferate.
• the redirected T cells are prepared by electroporation.
• the redirected T cells are prepared by using viral vectors.
• the present invention provides a method of targeting
• NK cells Natural Killer (NK) cells which express and bear on the cell surface membrane a CD 19- specific chimeric immune receptor having an intracellular signaling domain, a transmembrane domain (TM) and a CD19-specific extracellular domain.
• TM transmembrane domain
• the present invention provides a method of targeting macrophage cells which express and bear on the cell surface membrane a CD19-specific chimeric immune receptor having an intracellular signaling domain, a transmembrane domain (TM) and a CD19-specific extracellular domain.
• a CD19-specific chimeric immune receptor having an intracellular signaling domain, a transmembrane domain (TM) and a CD19-specific extracellular domain.
• the present invention provides a method of targeting neutrophils cells which express and bear on the cell surface membrane a CD19-specific chimeric immune receptor having an intracellular signaling domain, a transmembrane domain (TM) and a CD19-specific extracellular domain.
• a CD19-specific chimeric immune receptor having an intracellular signaling domain, a transmembrane domain (TM) and a CD19-specific extracellular domain.
• the present invention provides a method of targeting stem cells which express and bear on the cell surface membrane a CD19-specif ⁇ c chimeric immune receptor having an intracellular signaling domain, a transmembrane domain
• the invention provides a CD-19-specific chimeric T-cell receptor comprising an intracellular signalling domain, a transmembrane domain and a
• the CD19-specific chimeric T cell receptor ofthe invention comprises scFvFc: ⁇ , where scFvFc represents the extracellular domain, scFv designates the V H and V L chains of a single chain monoclonal antibody to CD 19, Fc represents at least part of a constant region of an IgG l5 and ⁇ represents the intracellular signaling domain of the zeta chain of human CD3.
• the CD19-specific chimeric T cell receptor ofthe invention comprises the scFvFc extracellular domain and the ⁇ intracellular domain are linked by the transmembrane domain of human CD4.
• the CD19-specific chimeric T cell receptor ofthe invention comprises amino acids 23-634 of SEQ ID NO:2.
• the invention provides a plasmid expression vector containing a DNA construct encoding a chimeric T-cell receptor ofthe invention in proper orientation for expression.
• Figures 1 A-1C show the double-stranded DNA sequence and amino acid sequence for the CD19:zeta chimeric immunoreceptor ofthe present invention, SEQ ID NO: 1
• Figure 2 is a schematic representation ofthe plasmid pMG-CD19R/HyTK.
• Figure 3 shows Western blot analyses which demonstrate the expression of the CD19R/scFvFc: ⁇ chimeric receptor.
• Figure 4 is a graphical representation showing the antigen-specific cytolytic activity of T-cells expressing the CD19R/scFvFc: ⁇ chimeric receptor.
• Figure 5 is a graphical representation ofthe production of interferon- ⁇ by T cells expressing the CD19R/scFvFc: ⁇ chimeric receptor that are incubated in the presence of various cell lines expressing CD-I 9.
• Figure 6 A-E are graphical representations showing the antigen-specific cytolytic activity of CD19R/scFvFc:( chimeric receptor redirected T-cell clones. DETAILED DESCRIPTION OF THE INVENTION
• the present invention is directed to genetically engineered, redirected T cells and to their use for cellular immunotherapy of B-cell malignancies, Epstein Barr Virus-related lymphoproliferative disorders, and B-cell mediated autoimmune diseases.
• the present invention provides genetically engineered T cells which express and bear on the cell surface membrane a CD19-specific chimeric T cell receptor having an intracellular signaling domain, a transmembrane domain and a CD 19- specif ⁇ c extracellular domain (referred to herein as CD19-specific T cells).
• the extracellular domain comprises a CD19-specific receptor.
• Individual T cells ofthe invention may be CD4 CD8 " , CD47CD8 + , CD47CD8 " or CD47CD8 + .
• the T cells may be a mixed population of CD47CD8 " and CD47CD8 + cells or a population of a single clone.
• CD4 + T cells ofthe invention produce IL-2 when co-cultured in vitro with CD19 + lymphoma cells.
• CD8 + T cells ofthe invention lyse CD19 + human lymphoma target cells when co-cultured in vitro with the target cells.
• the invention further provides the CD 19- specific chimeric T cell receptors, DNA constructs encoding the receptors, and plasmid expression vectors containing the constructs in proper orientation for expression.
• CD19-specific redirected T cells express CD 19- specific chimeric receptor scFvFc: ⁇ , where scFv designates the V H and V L chains of a single chain monoclonal antibody to CD 19, Fc represents at least part of a constant region of a human IgG l5 and ⁇ represents the intracellular signaling domain ofthe zeta chain of human CD3.
• the extracellular domain scFvFc and the intracellular domain ⁇ are linked by a transmembrane domain such as the transmembrane domain of CD4.
• the human Fc constant region may be provided by other species of antibody such as IgG 4 for example.
• a full length scFvFc: ⁇ cDNA comprises the human GM-CSF receptor alpha chain leader peptide, FMC63 V H , Gly-Ser linker, FMC63 V L , human IgG 4 Fc, human CD4 TM, and human cytoplasmic zeta chain.
• "Chimeric TCR” means a receptor which is expressed by T cells and which comprises intracellular signaling, transmembrane and extracellular domains, where the extracellular domain is capable of specifically binding in an HLA unrestricted manner an antigen which is not normally bound by a T cell receptor in that manner. Stimulation ofthe T cells by the antigen under proper conditions results in proliferation (expansion) ofthe cells and/or production of cytokines (e.g., IL-2) and/or cytolysis.
• cytokines e.g., IL-2
• the present invention provides a method of treating a
• CD19 + malignancy, lymphoproliferative disease or autoimmune disease mediated in part by B-cells in a mammal which comprises administering CDl 9-specific redirected T cells to the mammal in a therapeutically effective amount.
• a therapeutically effective amount of CD8 + CDl 9-specific redirected T cells are administered to the mammal.
• the CD8 + T cells are preferably administered with CD4 + CDl 9-specific redirected T cells.
• a therapeutically effective amount of CD4 + CDl 9-specific redirected T cells are administered to the mammal.
• the CD4 + CDl 9-specific redirected T cells are preferably administered with CD8 + cytotoxic lymphocytes which express the CDl 9-specific chimeric receptor ofthe invention.
• the invention provides genetically engineered stem cells which express on their surface membrane a CDl 9-specific chimeric T cell receptor having an intracellular signaling domain, a transmembrane domain and a CDl 9-specific extracellular domain.
• the invention provides genetically engineered natural killer(NK) cells which express on their surface membrane a CDl 9-specific chimeric T cell receptor having an intracellular signaling domain, a transmembrane domain and a CDl 9-specific extracellular domain.
• the invention provides genetically engineered macrophage which express on their surface membrane a CDl 9-specific chimeric T cell receptor having an intracellular signaling domain, a transmembrane domain and a CDl 9- specific extracellular domain.
• the present invention provides a method of abrogating any untoward B cell function in a mammal which comprises administering to the mammal CDl 9-specific redirected T cells in a therapeutically effective amount.
• Untoward B-cell functions can include B-cell mediated autoimmune disease (e.g., lupus or rheumatoid arthritis) as well as any unwanted specific immune response to a given antigen.
• CDl 9-specific redirected T cells can be administered in a method of immunosuppression prior to administering a foreign substance such as a monoclonal antibody or DNA or virus or cell in the situation where any immune response would decrease the effectiveness ofthe foreign substance.
• the present invention provides a method of making and expanding the CDl 9-specific redirected T cells which comprises transfecting T cells with an expression vector containing a DNA construct encoding the CDl 9-specific chimeric receptor, then stimulating the cells with CD19 + cells, recombinant CD 19, or an antibody to the receptor to cause the cells to proliferate.
• the method preferably stably transfects and re-directs T cells using electroporation of naked DNA.
• viral vectors carrying the heterologous genes are used to introduce the genes into T cells. By using naked DNA, the time required to produce redirected T cells can be significantly reduced.
• naked DNA means DNA encoding a chimeric T cell receptor (TCR) contained in a plasmid expression vector in proper orientation for expression.
• the electroporation method of this invention produces stable transfectants which express and carry on their surfaces the chimeric TCR (cTCR).
• the T cells are primary human T cells, such as human peripheral blood mononuclear cells (PBMC), which have previously been considered resistant to stable transfection by electroporation of plasmid vectors.
• Preferred conditions include the use of DNA depleted of endotoxin and electroporation within about 3 days following mitogenic stimulation of T cells.
• the transfectants are cloned and a clone demonstrating presence of a single integrated unrearranged plasmid and expression ofthe chimeric receptor is expanded ex vivo.
• the clone selected for expansion preferably is CD8 + and demonstrates the capacity to specifically recognize and lyse lymphoma target cells which express the target antigen.
• the clone is expanded by stimulation with IL-2 and preferably another stimulant which is specific for the cTCR.
• the T cells are expressed in immortalized/transformed cells such as the T-cell tumor line TALLIOI, for example.
• TALLIOI T-cell tumor line
• the scFv portion can be replaced by any number of different CD 19 binding domains, ranging from a minimal peptide binding domain, to a structured CD 19 binding domain from a phage library, to antibody like domains using different methods to hold the heavy and light chain together.
• the arrangement could be multimeric such as a diabody.
• the secreted form ofthe antibody forms multimers. It is possible that the T cell receptor variant is also a multimer. The multimers are most likely caused by cross pairing ofthe variable portion ofthe light and heavy chains into what has been referred to by Winters as a diabody.
• the hinge portion ofthe construct can have multiple alternatives from being totally deleted, to having the first cysteine maintained, to a proline rather than a serine substitution, to being truncated up to the first cysteine.
• the Fc portion can be deleted, although there is data to suggest that the receptor preferably extends from the membrane. Any protein which is stable and dimerizes can serve this purpose. One could use just one ofthe Fc domains, e.g, either the C H 2 or C H 3 domain.
• Alternatives to the CD4 transmembrane domain include the transmembrane
• CD3 zeta domain or a cysteine mutated CD 3 zeta domain, or other transmembrane domains from other transmembrane signaling proteins such as CD 16 and CD8.
• the CD3 zeta intracellular domain was taken for activation.
• the intracellular signaling domain of the chimeric receptor ofthe invention is responsible for activation of at least one ofthe normal effector functions ofthe immune cell in which the chimeric receptor has been placed.
• effector function refers to a specialized function of a differentiated cell. Effector function of a T cell, for example, may be cytolytic activity or helper activity including the secretion of cytokines.
• intracellular signaling domain refers to the portion of a protein which transduces the effector function signal and directs the cell to perform a specialized function. While usually the entire intracellular signaling domain will be employed, in many cases it will not be necessary to use the entire chain. To the extent that a truncated portion ofthe intracellular signaling domain may find use, such truncated portion may be used in place ofthe intact chain as long as it still transduces the effector function signal.
• intracellular signaling domain is thus meant to include any truncated portion ofthe intracellular signaling domain sufficient to transduce the effector function signal.
• Examples include the zeta chain ofthe T cell receptor or any of its homologs (e.g., eta, delta, gamma or epsilon), MB1 chain, B29, Fc RIII and Fc RI and the like.
• Intracellular signaling portions of other members ofthe families of activating proteins can be used, such as Fc ⁇ RIII and FceRI. See Gross et al. [84], Stancovski et al. [73], Moritz et al. [75], Hwu et al. [85], Weijtens et al. [79], and Hekele et al. [76], for disclosures of cTCR's using these alternative transmembrane and intracellular domains.
• EBV-specific donor-derived T cells have the capacity to protect patients at high risk for this complication as well as eradicate clinically evident disease which mimics immunoblastic B cell lymphoma [87].
• TIL tumor-infiltrating lymphocytes
• TIL infusions were sporadic due in part to the heterogeneous population of cells expanded with unpredictable antitumor specificities. Patients with melanoma and renal cell carcinoma however occasionally manifested striking tumor regressions following TIL infusions and tumor-specific MHC-restricted T cell clones have been isolated from these patients. Recently, expression cloning technologies have been developed to identify the genes encoding tumor antigens thereby facilitating the development of recombinant DNA-based vaccine strategies to initiate or augment host antitumor immunity, as well as in vitro culture systems for generating tumor-specific T cells from cancer patients [91]. Clinical trials utilizing autologous tyrosinase-specific CTL for the treatment of melanoma are currently underway.
• hematogenous malignancies as targets for T cell therapy is warranted based on the observed graft versus leukemia (GVL) effect observed in the setting of allogeneic BMT and the capacity of donor buffy coat infusions to have anti- leukemic activity [92].
• VTL graft versus leukemia
• mHA's host minor histocompatibility antigens
• T cells with a desired antigen specificity based on genetic modification with engineered receptor constructs is an attractive strategy since it bypasses the requirement for retrieving antigen-specific T cells from cancer patients and, depending on the type of antigen recognition moiety, allows for targeting tumor cell-surface epitopes not available to endogenous T cell receptors.
• Studies to define the signaling function of individual components ofthe TCR-CD3 complex revealed that chimeric molecules with intracellular domains ofthe CD3 complex's zeta chain coupled to extracellular domains which could be crosslinked by antibodies were capable of triggering biochemical as well as functional activation events in T cell hybridomas [98].
• idiotype-specific scFv chimeric TCR which recognizes the idiotype- expressing lymphoma cell's surface immunoglobulin as its ligand [101]. Although this approach swaps a low affinity MHC-restricted TCR complex for a high affinity MHC- unrestricted moleculer linked to an isolated member ofthe CD3 complex, these receptors do activate T cell effector functions in primary human T cells without apparent induction of subsequent anergy or apoptosis [79].
• Murine model systems utilizing scFv: ⁇ transfected CTL demonstrate that tumor elimination only occurs in vivo if both cells and IL-2 are administered, suggesting that in addition to activation of effector function, signaling through the chimeric receptor is sufficient for T cell recycling [76].
• chimeric receptor re-directed T cell effector function has been documented in the literature for over a decade, the clinical application of this technology for cancer therapy is only now beginning to be applied.
• Ex vivo expansion of genetically modified T cells to numbers sufficient for re-infusion represents a major impediment for conducting clinical trials. Not only have sufficient cell numbers been difficult to achieve, the retention of effector function following ex vivo expansion has not been routinely documented in the literature.
• This invention represents the targeting of a B cell malignancy cell-surface epitope with CDl 9-specific redirected T cells.
• Malignant B cells are an excellent target for redirected T cells, as B cells can serve as immunostimulatory antigen-presenting cells for T cells [102].
• Cytokine production by the CDl 9-specific scFvFc: ⁇ expressing Jurkat clones when co-cultured with CD19 + B-cell malignancy does not require the addition of professional antigen presenting cells to culture or pharmacologic delivery of a co- stimulatory signal by the phorbal ester PMA.
• the function ofthe CD19R:zeta chimeric immunoreceptor in T cells was first assessed by expressing this scFvFc: ⁇ construct in primary human T cell clones. Clones secrete cytokines (IFN- ⁇ , TNF- ⁇ , and gm-CSF) specifically upon co-culture with human CD19 + leukemia and lymphoma cells. Cytokine production by CDl 9-specific clones can be blocked in part by the addition to culture of the anti-CD19 specific antibody HIB19. Anti-CD20 antibody Leu-16 does not block cytokine production thereby demonstrating the specificity ofthe CD19R:zeta chimeric immunoreceptor for CD 19 on the tumor cell surface.
• cytokines IFN- ⁇ , TNF- ⁇ , and gm-CSF
• CD19R:zeta + CD8 + CTL clones display high levels of cytolytic activity in standard 4-hr chromium release assays against human CD19 + leukemia and lymphoma cell lines cell lines and do not kill other tumor lines that are devoid ofthe CD 19 epitope.
• These preclinical studies support the antitumor activity of adoptive therapy with donor-derived CD19R:zeta-expressing T cell clones in patients that relapse following HLA-matched allogeneic bone marrow transplantation.
• CD 19 is not tumor-specific and adoptive transfer of cells with this specificity is expected to kill the subset of non-transformed B cells which express CD 19.
• CD 19 is not expressed by hematopoietic stem cells or mature plasma cells, this cross-reactivity may exacerbate the humoral immunodeficiency of patients receiving chemotherapy and/or radiotherapy.
• Equipping T cells with a suicide gene such as the herpes virus thymidine kinase gene allows for in vivo ablation of transferred cells following adoptive transfer with pharmacologic doses of gancyclovir and is a strategy for limiting the duration or in vivo persistence of transferred cells [27].
• CDl 9-specific chimeric receptor-expressing T cells of this invention can be used to treat patients with CD19 + B-cell malignancies and B-cell mediated autoimmunie diseases, including for example, acute lymphoblastic leukemia. High relapse rates observed following autologous transplantation for leukemia can be reduced with post- transplant in vivo treatment with adoptively transferred CDl 9-specific redirected T cells to purge CD19 + leukemic stem cells. CDl 9-specific redirected T cells can be used to treat lymphoma patients with refractory or recurrent disease.
• the CD19 + redirected T cells can be administered following myeloablative chemotherapy and stem cell rescue, when tumor burden and normal CD19 + cell burden are at a nadir and when the potential of an immunologic response directed against the scFvFc: ⁇ protein is minimized.
• Patients can be treated by infusing therapeutically effective doses of CD8 +
• CDl 9-specific redirected T cells in the range of about 10 6 to 10 12 or more cells per square meter of body surface (cells/m 2 ).
• the infusion will be repeated as often and as many times as the patient can tolerate until the desired response is achieved.
• the appropriate infusion dose and schedule will vary from patient to patient, but can be determined by the treating physician for a particular patient.
• initial doses of approximately 10 9 cells/m 2 will be infused, escalating to 10 10 or more cells/m 2 .
• IL-2 can be co-administered to expand infused cells post-infusion.
• the amount of IL-2 can about 10 3 to 10 6 units per kilogram body weight.
• an scFvFc: ⁇ -expressing CD4 + T H1 clone can be co-transferred to optimize the survival and in vivo expansion of transferred scFvFc: ⁇ -expressing CD8 + T cells.
• the dosing schedule may be based on Dr. Rosenberg's published work [88-
• CDl 9-specific redirected T cells can be administered as a strategy to support CD8 + cells as well as initiate/augment a Delayed Type Hypersensitivity response against CD19 + target cells.
• chimeric immune receptors are capable of activating target- specific lysis by phagocytes, such as neutrophils and NK cells, for example (103).
• phagocytes such as neutrophils and NK cells
• the present invention also contemplates the use of chimeric T-cell receptor DNA to transfect into non-specific immune cells including neutrophils, macrophages and NK cells.
• the present invention contemplates the use of chimeric T-cell receptor DNA to transfect stem cells prior to stem cell transplantation procedures.
• EXAMPLE 1 Construction of a scFvFc: ⁇ cDNA Incorporating the FMC63 V H and V L Sequences [00065] Based on the V H and V L sequences ofthe CD19-specific murine IgGl monoclonal antibody published by Nicholson et al, a scFv sequence was constructed de novo utilizing PCR [83].
• a full length scFvFc: ⁇ cDNA designated CD19R:zeta was constructed by PCR splice overlap extension and consists ofthe human GM-CSF receptor alpha chain leader peptide, FMC63 V H , Gly-Ser linker, FMC63 V L , human IgG x Fc, human CD4 TM, and human cytoplasmic zeta chain.
• the nucleotide sequence ofthe construct and the resulting amino acid sequence are set forth in together in Figure 1 A-C or separately as SEQ ID Nos:l and 2, respectively.
• CD19-specif ⁇ c scFvFc ⁇ receptor protein is expressed in Primary
• T cells Human T cells.
• T cells were transfected with the plasmid of Example 1 containing the CD19R. Linearized plasmid was electroporated under optimized conditions and stable transfectants selected by addition of hygromycin to cultures.
• Figure 3 there are shown the results of Western blot analyses of T-cells transfected with the CD19R receptor in an expression vector ofthe present invention.
• the function ofthe CD19R:zeta chimeric immunoreceptor in T cells was first assessed by expressing this scFvFc: ⁇ construct in primary human T cell clones.
• Clones secrete cytokines (IFN- ⁇ , TNF- ⁇ , and gm-CSF) specifically upon co-culture with human CD19 + leukemia and lymphoma cells.
• cytokines IFN- ⁇ , TNF- ⁇ , and gm-CSF
• Figure 4 shows the results of incubation of various T-cell clones expressing the recombinant CD19:zeta chimeric immunoreceptor with CD- 19 leukemmia cell lines.
• 1873-CRL is a human CD19+/CD20- ALL cell line purchased from ATCC.
• DHL-4 is a human CD19+/CD20+ lymphoma cell line.
• Iona lonomycin purchased from Sigma. This chemical is a calcium ionaphore.
• PMA Phorbal-12-myristate-13 acetate (Sigma). Iono + PMA when added to T cells maximally activates them for cytokine production. Supernatant of T cells incubated with these chemicals serves as a positive control for maximal cytokine production.
• the cytokine assays are performed by adding 10 6 responsder T cells with the indicated stimulator (if the stimulator is a tumor cell it is added at 2x10 5 per 24- well and is irradiated 8K rads).
• the wells are supplemented with culture media to a final volume of 2 mis and incubated for 72 hrs at which time cell-free supernatants are harvested and assayed by specific ELISA using R+D Systems Kits per the manufactuer's instructions.
• Cytokine production by CD 19-specific clones can be blocked in part by the addition to culture ofthe anti-CD19 specific antibody HIB19.
• Anti-CD20 antibody Leu- 16 does not block cytokine production thereby demonstrating the specificity ofthe CD19R:zeta chimeric immunoreceptor for CD 19 on the tumor cell surface.
• the graph represents the results of ELISA with antibody specific for IFN- ⁇ .
• T cells administered are TCR / ⁇ + CD4 CD8 + scFvFc: ⁇ + T cell clones containing unrearranged chromosomally integrated plasmid DNA.
• T cells are isolated from the peripheral blood ofthe transplant recipient's HLA-matched marrow donor. Materials and methods employed to isolate, genetically modify, and expand CD8 + T cell clones from healthy marrow donors are detailed in Examples 4-8.
• T cell clones genetically modified to express the CD19R:zeta scFvFc: ⁇ chimeric immunoreceptor and HyTK are selected for: a.
• e. Dependence on exogenous IL-2 for in vitro growth.
• IL-2 (Proleukin) is supplied in vials containing 0.67 mg of lyophilized IL-2 and having a specific activity of 1.5 x 10 6 IU/mg protein.
• the lyophilized recombinant IL-2 is reconstituted with sterile water for infusion and diluted to a concentration of 5 x 10 4 units/ml.
• IL-2 is aliquoted into sterile vials and stored at -20°C in CRB-3008.
• rhIL-2 for direct patient administration is dispensed per standard practice. 4. Plasmid DNA
• the plasmid CD19R/HyTK-pMG containing the CD19-specific scFvFc: ⁇ cDNA and HyTK cDNA constructs is manufactured under GLP conditions. Ampules containing lOO ⁇ g of sterile plasmid DNA in 40 ⁇ l of pharmaceutical water. Vector DNA is stored in a -70°C freezer in CRB-3008.
• the mammalian antibiotic hygromycin is used to select genetically modified T cells expressing the HyTK gene.
• Commercially available hygromycin (Invivogen, San Diego, CA.) is prepared as a sterile solution of 100 mg/ml active drug and is stored at 4°C in CRB-3008.
• Lymphoblastoid cell lines are necessary feeder cells for T cell expansion and have been used for this purpose in FDA-approved clinical adoptive therapy trials.
• An EBV-induced B cell line designated TM-LCL was established from a healthy donor by co-culture of PBMC with supernatants ofthe B95-8 cell line (American Type Culture Collections) in the presence of cyclosporin A. This cell line is currently being used as an irradiated feeder cell by investigators at the Fred Hutcliinson Cancer Research Center (FHCRC) and City of Hope National Medical Center. This cell line has tested negative for adventitious microorganisms as well as EBV production by cord blood transformation assay.
• FHCRC Fred Hutcliinson Cancer Research Center
• TM-LCL feeder cells are irradiated to 8,000 cGy prior to co-culture with T cells.
• PBMC Peripheral blood mononuclear cells isolated from the study subject's marrow harvested by leukapheresis and transferred to CRB 3008 in a collection bag is used as autologous feeder cells.
• Peripheral Blood Lymphocytes Collection and Separation
• PBMC Peripheral blood mononuclear cells
• T cells present in patient PBMC are polyclonally activated by addition to culture of Orthoclone OKT3 (30ng/ml). Cell cultures are then incubated in vented T75 tissue culture flasks in the study subject's designated incubator. Twenty-four hours after initiation of culture rhIL-2 is added at 25 U/ml.
• PBMC Three days after the initiation of culture PBMC are harvested, centrifuged, and resuspended in hypotonic electroporation buffer (Eppendorf) at 20x10 6 cells/ml. 25 ⁇ g of plasmid DNA together with 400 ⁇ l of cell suspension are added to a sterile 0.2 cm electroporation cuvette. Each cuvette is subjected to a single electrical pulse of 250V/40 ⁇ s delivered by the Multiporator (Eppendorf) then incubated for ten minutes at room temperature. Following the RT incubation, cells are harvested from cuvettes, pooled, and resuspended in phenol red-free culture media containing 25 U/ml rhIL-2.
• Eppendorf hypotonic electroporation buffer
• Flasks are placed in the patient's designated tissue culture incubator. Three days following electroporation hygromycin is added to cells at a final concentration of 0.2 mg/ml. Electroporated PBMC are cultured for a total of 14 days with media and IL-2 supplementation every 48-hours.
• OKT3 -activated patient PBMC is initiated on day 14 of culture.
• Cells expressing FvFc product are positively selected for using antibodies to Fab and Fc and/or Protein A-FITC label using techniques well known in the art.
• cells expressing the FvFc are isolated by immunogenetic beads or colummns or fluorescent activated cell sorting procedures.
• Viable patient PBMC are added to a mixture of lOOxlO 6 cyropreserved irradiated feeder PBMC and 20x10 6 irradiated TM-LCL in a volume of 200ml of culture media containing 30 ng/ml OKT3 and 50 U/ml rhIL-2.
• This mastermix is plated into ten 96-well cloning plates with each well receiving 0.2 ml. Plates are wrapped in aluminum foil to decrease evaporative loss and placed in the patient's designated tissue culture incubator. On day 19 of culture each well receives hygromycin for a final concentration of 0.2 mg/ml. Wells are inspected for cellular outgrowth by visualization on an inverted microscope at Day 30 and positive wells are marked for restimulation.
• CTL selected for expansion for use in therapy are analyzed by immunofluorescence on a FACSCalibur housed in CRB-3006 using FITC-conjugated monoclonal antibodies WT/31 ( ⁇ TCR), Leu 2a (CD8), and OKT4 (CD4) to confirm the requisite phenotype of clones ( ⁇ TCR + , CD4 " , and CD8 + ). Criteria for selection of clones for clinical use include uniform TCR ⁇ + , CD4 " , CD8 + as compared to isotype control FITC-conjugated antibody.
• DNA from genetically modified T cell clones is screened with a DNA probe specific for the plasmid vector.
• the Hygro-specific DNA probe is the 420 basepair MscllNael restriction fragment isolated from CD19RR HyTK-pMG.
• Probe DNA is 32 P labeled using a random primer labeling kit (Boehringer Mannheim, Indianapolis, IN).
• T cell genomic DNA is isolated per standard technique. Ten micrograms of genomic DNA from T cell clones is digested overnight at 37° C with 40 units of Xbal and Hindlll and then electrophoretically separated on a 0.85% agarose gel. DNA is then transferred to nylon filters (BioRad, Hercules, CA) using an alkaline capillary transfer method.
• Expression ofthe CD19R scFvFc: ⁇ receptor is determined by Western blot procedure in which chimeric receptor protein is detected with an anti-zeta antibody.
• Whole cell lysates of transfected T cell clones are generated by lysis of 2 x 10 7 washed cells in 1 ml of RIP A buffer (PBS, 1% NP40, 0.5% sodium deoxycholate, 0.1% SDS) containing 1 tablet/10ml Complete Protease Inhibitor Cocktail (Boehringer Mannheim).
• Membranes are washed in T-TBS (.05% Tween 20 in Tris buffered saline pH 8.0) then incubated with primary mouse anti- human CD3 ⁇ monoclonal antibody 8D3 (Pharmingen, San Diego, CA) at a concentration of 1 ⁇ g/ml for 2 hours. Following an additional four washes in T-TBS, membranes are incubated with a 1:500 dilution of goat anti-mouse IgG alkaline phosphatase-conjugated secondary antibody for 1 hour. Prior to developing, membranes are rinsed in T-TBS then developed with 30 ml of "AKP" solution (Promega, Madison, WI) per the manufacturer's instructions. Criteria for clone selection is the presence of a 66 kDa chimeric zeta band.
• CD8 + cytotoxic T cell clones expressing the CD19R scFvFc: ⁇ receptor recognize and lyse human CD19 + leukemia target cells following interaction ofthe chimeric receptor with the cell surface target epitope in a HLA unrestricted fashion.
• the requirements for target cell CD 19 expression and class I MHC independent recognition were confirmed by assaying several ⁇ TCR + , CD8 + , CD4 " , CD19R + CTL clones against a panel of MHC-mismatched human leukemia cell lines (SupB15, JM-1, and 1873 CRL ) as well as the CD 19 " line K562 (a CD19-negative, NK-sensitive target) and recipient fibroblasts.
• T cell effectors are assayed 12-14 days following stimulation with OKT3. Effectors are harvested, washed, and resuspended in assay media; 2.5x10 5 , 1.25xl0 5 , 0.25xl0 5 , and 0.05xl0 5 effectors are plated in triplicate at 37° C for 4 hours with 5xl0 3 target cells in V-bottom microtiter plates (Costar, Cambridge, MA). After centrifugation and incubation, 100 ⁇ L aliquots of cell-free supernatant is harvested and counted. Per cent specific cytolysis is calculated as follows:
• Control wells contain target cells incubated in assay media.
• 51 Cr release is determined by measuring the 5I Cr content of target cells lysed with 2%
• Criteria for clone selection is >50% specific lysis of both neuroblastoma targets at an effecto ⁇ target ratio of 25:1 and less than 10% specific lysis of K562 and fibroblasts at an E:T ratio of 5:1.
• EXAMPLE 8 Quantitative PCR For T Cell Persistence In Vivo The duration of in vivo persistence of scFvFc: ⁇ + CD8 + CTL clones in the circulation is determined by quantitative PCR (Q-PCR) utilizing the recently developed TaqMan fluorogenic 5' nuclease reaction. Q-PCR analysis is performed by the Cellular and Molecular Correlative Core on genomic DNA extracted from study subject PBMC obtained prior to and on days +1 and +7 following each T cell infusion. Following the third infusion PBMC are also sampled on day +14, +21, +51 (Day +100 following stem cell rescue).
• the primers used to detect the scFvFc: ⁇ gene are 5'HcFc (5'-TCTTCCTCTACACAGCAAG CTCACCGTGG-3'; SEQ ID NO:3) and 3'HuZeta (5'-GAGGGTTCTTCCTTCTCG GCTTTC-3'; SEQ ID NO:4) and amplify a 360 basepair fragment spanning the Fc-CD4-TM-zeta sequence fusion site.
• the TaqMan hybridization probe is FAM-5'TTCACTCTGAA GAAGATGCCTAGCC 3'-TAMRA (SEQ ID NO: 5).
• a standard curve is generated from genomic DNA isolated from a T cell clone with a single copy of integrated plasmid spiked into unmodified T cells at frequencies of 10 "2 , 10 "3 , 10 "4 , 10 "5 , and 10 "6 .
• a control primer/probe set specific for the human beta-globin gene is used to generate a standard curve for cell number and permits the calculation ofthe frequency of genetically modified clone in a PBMC sample.
• the beta-globin amplimers are as follows: Pco3 (5'-ACACAACTGTGTTCACTAGC-3'; SEQ ID NO:6), Gil (5'-GTCTCCTT AAACCTGTCTTG-3'; SEQ ID NO:7) and the Taqman probe is HEX-5'ACCTGACTCCTGAGG AGAAGTCT3'-TAMRA (SEQ ID NO:8). All patients will have persistence data and immune response data to the scFvFc: ⁇ and HyTK genes compared to determine if limited persistence can be attributed to the development of an immune response to gene-modified T cells.
• Cardiac Asymptomatic or, if symptomatic, then left ventricular ejection fraction at rest must be ⁇ 50% or within normal range for COH.
• Hepatic within 5x normal range and total bilirubin ⁇ 5x normal range.
• Renal Serum creatinine within 1.5x normal range or creatinine clearance 60ml/min.
• Prior autologous or allogeneic bone marrow or PBSC transplant (Cohort 2). Patients who cannot complete total body irradiation dose requirements due to prior radiation treatment (Cohort 2). Female patients who are pregnant or breast feeding. Positive serology for HIV. Active infection requiring intravenous treatment with anti-fungal, anti-bacterial or antiviral agents within two weeks prior to conditioning with the exception of coagulase negative staphylococcal line infection (Cohort2). Failure to understand the basic elements ofthe protocol and/or the risks/benefits of participating in this phase I study (Children ⁇ 7-yrs as well as parent/legal guardian as determined by performance on a questionnaire administered prior to consent signing). Donor Selection
• the pilot Phase I study is an open-label, nonrandomized study.
• patients either who suffer a relapse of their CD19 + ALL following BMT (Cohort 1) or who experience a molecular post-transplant relapse of their Ph + CD19 + ALL receive donor-derived CD19R + HyTK + CD8 + CTL clones.
• T cell clones are generated from a leukapheresis product obtained from the patient's HLA-matched related marrow donor.
• clones are cryopreserved until such time that the research participant is diagnosed with a molecular relapse based on a positive and confirmatory PCR result for bcr-abl.
• Each research participant in each cohort receives a series of three escalating cell dose T cell infusions at two-week intervals beginning as soon as clones are available (typically by the 14th day following the diagnosis of molecular relapse in cohort 2, and as soon as clones are ready in cohort 1).
• Those research subjects on immunosuppressive medications for GVHD prophylaxis/treatment are first tapered off corticosteroids and have no more than grade 2 AGVHD prior to commencing with T cell administrations.
• the first cell dose is lxl 0 9 cells/m 2 , the second 5x10 9 cells/m 2 , and the third 5x10 9 cells/m 2 with IL-2.
• Patients without significant toxicity attributed to the T cell infusions and who have ⁇ grade 2 GVHD receive low-dose s.c. rhIL-2 for 14 days with the third T cell dose. Patients are evaluated prior to and weekly after the first infusion for a period of two months after which time, patients are evaluated monthly for an additional six months. Peripheral blood is drawn at specific times during the study to assay for the in vivo persistence ofthe transferred CTL clones and the induction of anti-scFvFc: ⁇ and HyTK immune responses.
• Anti-tumor responses are assessed by changes in the molecular tumor burden by serial Q-PCR for their leukemia-specific marker or bcr-abl, and, by standard morphologic, flow cytometric, and chimerism studies for ALL.
• the patient's primary Hematologist or pediatric oncologist manages the non-study specific aspects of their patient's medical management throughout the duration ofthe study and indefinitely thereafter.
• Treatment Plan a Schedule of Administration of CD19R:zeta + , CD8 + T Cell Clones
• the phase I pilot study determines the safety and toxicity of intravenously infused donor-derived CD8 + CTL clones genetically modified to express the CD19R scFvFc: ⁇ chimeric immunoreceptor and the selection/suicide gene HyTK.
• a series of three escalating cell dose infusions (Table 2) are administered at two-week intervals to research participants who demonstrate a post-transplant molecular relapse.
• T cell infusions commence at the earliest time of their availability (Cohort 1), or after documentation of a molecular leukemic relapse (Cohort 2) provided that research participants have tapered off steroids and have no more than grade 2 acute graft- versus- host disease.
• Low-dose subcutaneously administered IL-2 is given after the third T cell infusion to support the in vivo persistence of transferred CTL.
• IL-2 administration begins 24-hrs following adoptive transfer of T cell clones and continue for 14 days provided that no grade 3-4 toxicity (see below) is observed with the administration ofthe first two T cell doses and that AGVHD is ⁇ grade 2.
• Each infusion consists of a composite of up to five T cell clones to achieve the cell dose under study.
• T cell clones expanded in CRB-3008 are aseptically processed per standard technique on a CS-3000 blood separation device for cell washing and concentrating. Processed cells are resuspended in 100 ml of 0.9% NaCl with 2% human serum albumin in a bag for suitable for clinical re-infusion.
• T cells are infused intravenously over 30 minutes through a central line if available, if not an age appropriate sized I.V. catheter is inserted into a peripheral vein.
• the I.V. tubing does not have a filter to avoid trapping of cells.
• the infusion bag is gently mixed every 5 minutes during the infusion.
• Subjects' oxygen saturation is measured by continuous pulse-oximetry beginning pre-infusion and continuing for at least 2hrs or until readings return to their pre- infusion baseline.
• T cell infusions Subjects experiencing transplant-related toxicities have their infusion schedule delayed until these toxicities have resolved.
• the specific toxicities warranting delay of T cell infusions include:
• Pulmonary Requirement for supplemental oxygen to keep saturation greater than 95% or presence of radiographic abnormalities on chest x-ray that are progressive;
• Cardiac New cardiac arrhythmia not controlled with medical management. Hypotension requiring pressor support;
• Active Infection Positive blood cultures for bacteria, fungus, or virus within 48-hours of day 0;
• Hepatic Serum total bilirubin, or transaminases more than 5X normal limit;
• Renal Serum creatinine >2.0 or if patient requires dialysis;
• Neurologic Seizure activity within one week preceding day 0 or clinically detectable encephalopathy or new focal neurologic deficits;
• Hematologic Clinically evident bleeding diathesis or hemolysis.
• Patients having anti-tumor responses based on bcr-abl Q-PCR but persistent residual disease following the third T cell dose may have additional cell doses (5x10 9 cells/m 2 /dose at 14 day intervals) with IL-2 (5x10 5 U/m 2 q 12-hrs) provided no grade 3 or higher toxicity is encountered.
• IL-2 Interleukin-2 Administration
• Recombinant human IL-2 rHuIL-2, Proleukin, Chiron, Emeryville, CA.
• GVHD is not more than grade 2 off immunosuppressive medications.
• Ceftriaxone 50 mg/kg I.V. (max dose 2 gms) is administered to non-allergic patients who in the opinion ofthe physician in attendance appear septic; alternate antibiotic choices are used as clinically indicated.
• Headache is managed with acetaminophen.
• Nausea and vomiting are treated with diphenhydramine 1 mg/kg I.V. (max 50mg).
• Transient hypotension is initially managed by intravenous fluid administration, however, patients with persistent hypotension require transfer to the intensive care unit for definitive medical treatment.
• Hypoxemia is managed with supplemental oxygen.
• ganciclovir Patients receive ganciclovir if grade 3 or 4 treatment-related toxicity is observed.
• Parentally administered ganciclovir is dosed at 10 mg/kg/day divided every 12 hours. A 14-day course is prescribed but may be extended should symptomatic resolution not be achieved in that time interval. All patients not hospitalized at the time of presenting symptoms are hospitalized for the first 72 hours of ganciclovir therapy for monitoring purposes. If symptoms do not respond to ganciclovir within 72 hours additional immunosuppressive agents including but riot limited to corticosteroids and cyclosporin are added at the discretion ofthe principle investigator.
• Concomitant Therapy [000106] All standard supportive care measures for patients undergoing experimental therapies are used at the discretion ofthe patient's City of Hope pediatric oncologist.
• Active infections occurring after study enrollment are treated according to the standard of care.
• the following agents are not allowed while on study: systemic cortico- steroids (except as outlined for management of T cell therapy toxicity), immunotherapy (for example- interferons, vaccines, other cellular products), pentoxifylline, or other investigational agents), ganciclovir or any ganciclovir derivatives for non-life threatening herpes virus infections.
• CTC version 2.0 for toxicity and Adverse Event Reporting.
• a copy of the CTC version 2.0 is downloadable from the CTEP home page
• a grade 1 toxicity is an elevation from their pre-T cell infusion base line up to 2.5X that baseline level.
• Grade 2 hepatic is a >2.5-5X rise from their pre-T cell infusion baseline, a grade 3 toxicity >5-20X rise, and grade 4 >20x baseline.
• toxicity reported by research participants while receiving treatment or in follow-up for which there is no specific CTC designation is graded on the following scale: Grade 0- no toxicity, Grade 1- mild toxicity, usually transient, requiring no special treatment and generally not interfering with usual daily activities, Grade 2- moderate toxicity that may be ameliorated by simple therapeutic maneuvers, and impairs usual activities, Grade 3- severe toxicity which requires therapeutic intervention and interrupts usual activities. Hospitalization may be required or may not be required. Grade 4- life- threatening toxicity that requires hospitalization.
• Criteria for Dose Modification [000108] If a patient develops grade 2 toxicity with dose level I, the second cell dose for that patient remains at T cell dose level I.
• the third and final cell dose be administered. If the first grade 2 toxicity occurs with the second cell dose, the third cell dose is not be accompanied with s.c. IL-2. c. Criteria for Removal of Patient from Treatment Regimen [000109] If any patient develops grade 3 or higher toxicity or grade 3 or higher GVHD, IL-2 if being administered is stopped. Ganciclovir treatment as outlined above is initiated at the time a grade 3 or higher toxicity is encountered in those patients not receiving IL-2. For those patients receiving IL-2, ganciclovir treatment commences within 48-hours of stopping IL-2 if the encountered toxicity has not decreased to ⁇ grade 2 in that time interval.
• a grade 3 IL-2 injection site toxicity is an indication to discontinue IL-2 but not ablate T cells.
• Immunosuppression for GVHD is instituted in addition to ganciclovir administration in those patients with grade 3 or higher GVHD. Any patient requiring ganciclovir for T cell ablation does not receive further cell doses but continues being monitored per protocol. At the discretion ofthe principle investigator, corticosteroids and/or other immunosuppressive drugs are added to ganciclovir should a more rapid tempo of resolution of severe toxicities be indicated. d. Research Participant Premature Discontinuation
• FHCRC Dr. Radich
• Oxygen saturation will be monitored for 2 hours following T cell infusions. Values will be recorded prior to initiating the infusion, immediately post- infusion, and 2 hours post- infusion. In addition, values will be recorded every 15 minutes if they fall below 90% until the patient recovers to his/her pre-infusion room-air baseline saturation.
• Serious adverse events occurring during or after completion of therapy are defined as any one ofthe following: (a) patient death, regardless of cause, occurring within 30 days of study agent administration; (b) life threatening event; (c) prolonged hospitalization or requirement for additional hospitalizations during treatment and monitoring period due to toxicities attributed to study; (d) congenital anomaly in offspring conceived after initiation of study; (e) requirement for significant medical treatment due to toxicities encountered while on study; and (f) overdose of cells infused.
• a life-threatening event is defined as having placed the patient, in the view ofthe Investigator, at immediate risk of death from the adverse event as it occurred. It does not include an adverse event that, had it occurred in a more serious form, might have caused death. All adverse events that do not meet at least one ofthe above criteria are defined as non-serious. Assessment ofthe cause ofthe event has no bearing on the assessment ofthe event's severity. [000119] Unexpected adverse events are those which: (a) are not previously reported with adoptive T cell therapy and (b) are symptomatically andpathophysiologically related to a known toxicity but differ because of greater severity or specificity.

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• 2001
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