Combination of an Anti-PD1 Antibody With Tisagenlecleucel Reinfusion in Children, Adolescents and Young Adults With Acute Lymphoblastic Leukemia After Loss of Persistence (CAPTiRALL)

Assistance Publique - Hôpitaux de Paris

Status and phase

Enrolling

Phase 2

Phase 1

Conditions

B Acute Lymphoblastic Leukemia

Acute Lymphoblastic Leukemia, in Relapse

Treatments

Drug: Nivolumab starting at day -1

Drug: Decreasing starting times for beginning nivolumab (Time to Event Continual Reassessment Method (TITE-CRM) )

Study type

Interventional

Funder types

Other

Identifiers

NCT05310591

APHP200132

Details and patient eligibility

About

Tisagenlecleucel (CTL019) is an anti-CD19 autologous Chimeric Antigen Receptor (CAR) T-cell therapy, which has shown dramatic early results in advanced ALLs. Early loss of B-cell aplasia (recovery of B-cells in marrow/ peripheral blood within 6 months after infusion), a marker of the loss or non-functionality of the CAR T-cells, is associated to a very high risk of relapse. A reinfusion of CTL019, even after Fludarabine-Cyclophosphamide reconditioning, frequently fails to induce further expansion as observed in UPENN studies and in the Robert Debré Hospital experience.

Non-persistence of CAR T-cells may be due to immune- mediated rejection or environment-mediated suppression of their growth. Evidence for increased PD-1 expression in CAR T-cells between infusion and peak expansion has been demonstrated in clinical samples.

Preclinical data and few clinical data support a role of PD- 1-PD-L1 blockade in improving the effectiveness of CAR T-cell therapy.

The objectives of this phase I/II study is to determine the safety, efficacy and feasibility of Nivolumab (Opdivo®)- an anti-PD1 treatment- combined to tisagenlecleucel in a cohort of relapsed or refractory B-ALL patients, aged 1-25 years old, previously treated by tisagenlecleucel (Kymriah®), with a demonstrated early loss of B-cell aplasia (within 6 months), a surrogate marker of the loss of CAR T-cells or their non- functionality.

More specifically, the main objectives are:

• In cohort 1 that includes patients with a MRD negative disease status combined to an early loss (within 6 months) of B-cell aplasia :

To determine the optimal starting time of Nivolumab (Opdivo®) in terms of safety and efficacy among 4 candidate time points (day 14, day 11, day 5, and day - 1).

• In cohort 2 that includes relapsed patients with an early loss (within 6 months) of B-cell aplasia :

To estimate the feasibility in terms of safety and efficacy of a very early start of nivolumab (day-1), prior to the reinfusion of tisagenlecleucel

Enrollment

26 estimated patients

Sex

All

Ages

1 to 25 years old

Volunteers

No Healthy Volunteers

Inclusion criteria

Patients aged from 1 to 25 years (pediatric and young adults) with a history of CD19+ relapsed or refractory B-ALL (any relapse after HSCT, 2nd relapse or later, refractory ALL).
Patient must have a second tisagenlecleucel (Kymriah ®) product available
Cohort 1: previously treated by tisagenlecleucel (Kymriah ®), and who present an early loss of B-cell aplasia defined by blood B lymphocytes < 10 /mm3 and/ or < 3% of total lymphocytes (< 6 months after infusion) while still being in CR with undetectable MRD
Cohort 2: previously treated by tisagenlecleucel (Kymriah ®), who present a loss of B-cell aplasia defined by blood B lymphocytes < 10 /mm3 and/ or < 3% of total lymphocytes and a CD19+ ALL detectable disease in the marrow and/or Blood
Life expectancy > 12 weeks.
Karnofsky (age > 16) Lansky (age < 16) > 70 at screening.
No organ dysfunction
Who have signed an informed consent
Affiliation to social security or any health insurance (as a beneficiary or assignee)

Exclusion criteria

Patient has received intervening therapy for leukemia after first tisagenlecleucel infusion (chemotherapy, anti leukemic immunotherapy, ITK, allogeneic HSCT).
Patient has an active autoimmune disease requiring systemic treatment within the past 2 years.
Patient has known history of, or any evidence of active, non-infectious pneumonitis.
Patient has a history of non-infectious pneumonitis that required steroid or has current pneumonitis.
Had receive prior therapy with an anti-PD1, Anti- PDL1 or anti-PDL2 agent.
Patient has hypersensivity to pembrolizumab/ nivolumab or one of its excipients
Patient has received a live vaccine injection within 45 days of planned start of study therapy.
Patients with concomitant genetic syndromes associated with bone marrow failure states: such as patients with Fanconi anemia, Kostmann syndrome, Shwachman syndrome or any other known bone marrow failure syndrome. Patients with Down syndrome will not be excluded.
Patients with Burkitt's lymphoma/leukemia
Prior malignancy, except carcinoma in situ of the skin or cervix treated with curative intent and with no evidence of active disease.
Prior treatment with any gene therapy product except first tisagenlecleucel (Kymriah ®) injection.
Prior treatment with any anti-CD19/anti-CD3 therapy, or any other anti-CD19 therapy, except for patients pre-treated with blinatumomab and/or tisagenlecleucel (Kymriah®)
Prior anti-cancer monoclonal antibody within 4 weeks before starting the study.
Prior chemotherapy, targeted small molecule therapy, or radiation therapy within 2 weeks prior to study Day 1 or who has not recovered (i.e., ≤ Grade1 or at baseline) from adverse events due to a previously administered agent.
Active or latent hepatitis B or active hepatitis C (test within 8 weeks of Screening), or any uncontrolled infection at Screening.
Human immunodeficiency virus (HIV) positive test within 8 weeks of Screening.
Presence of grade 2 to 4 acute or extensive chronic GVHD.
Active CNS involvement by malignancy, defined as CNS-3 per NCCN guidelines. Note: Patients with history of CNS disease that has been effectively treated will be eligible.
Uncontrolled acute life threatening bacterial, viral or fungal infection at Screening.
Previous or concurrent malignancy with the following exceptions:
- Adequately treated basal cell or squamous cell carcinoma
- in situ carcinoma of the cervix or breast, treated curatively and without evidence of recurrence for at least 3 years prior to the study.
- A primary malignancy completely resected and in CR for ≥ 5 years
Pregnant or lactating women (female study participants of reproductive potential must have a negative serum or urine pregnancy test performed within 48 hours before infusion)
Patient with hypersensivity to Fludarabine and/or cyclophosphamide and/or tisagenlecleucel and/or nivolumab or one of their excipients.