PRIMARY OBJECTIVES:
I. To determine the safety and tolerability of natural killer (NK) cells that have been propagated ex vivo with genetically-modified feeder cells and administered intra-tumoral via an Ommaya reservoir in patients with recurrent or progressive supratentorial malignant brain tumors.
II. To determine the recommended phase 2 dose (RP2D) for natural killer (NK) cells that have been propagated ex vivo with genetically-modified feeder cells and administered intra-tumoral via an Ommaya reservoir in patients with recurrent or progressive supratentorial malignant brain tumors.
EXPLORATORY OBJECTIVES:
I. To determine the 6 months overall survival (OS), defined as the percentage of patients in the study who are alive at 6 months following start of treatment.
II. To determine the persistence, immuno-phenotype and function of adoptively-transferred expanded NK cells, and correlate the findings with the overall response.
III. To determine the immune signature-based profile of each patient's tumor. IV. To determine changes in the T-cell receptor (TCR) repertoire diversity before and after Transforming growth factor beta imprinted (TGFβi) NK cell treatment.
V. To evaluate the effect of systemic steroids on the persistence and efficacy of TGFβi NK cells.
VI. To assess Quality of Life (QOL) and cognitive measures in children and young adults with recurrent or progressive supratentorial malignant brain tumors.
OUTLINE: This is a dose-escalation study.
Participants undergo placement of an Ommaya reservoir and receive universal donor expanded TGF-beta-imprinted NK cells (TGFBi NK cells) intratumorally via Ommaya reservoir in 4-week cycles. Infusions via Ommaya will occur once weekly for three weeks followed by one week of rest. If patients have stable or improved disease, patients may continue to receive therapy for a total of 12 cycles. Participants will be followed for 5 years after completion of treatment, or until removal from study or death, whichever comes first.
Inclusion Criteria:
1. Participants must have a histologically-confirmed recurrent or progressive,
non-metastatic supratentorial World Health Organization (WHO) Grade III/IV malignant
brain tumor. Including, but not limited to: anaplastic ependymoma, embryonal tumor,
primitive neuroectodermal tumor, atypical teratoid rhabdoid tumor (ATRT) , anaplastic
astrocytoma, anaplastic oligoastrocytoma, anaplastic oligodendroglioma, anaplastic
pleomorphic xanthoastrocytoma, glioblastoma multiforme, gliosarcoma, or malignant
glioma (NOS), WHO Grade II ependymoma.
2. Participants should be candidates for resection/open biopsy of the recurrent tumor and
be deemed candidate for placement of an Ommaya reservoir placed
intra-cavitary/intra-tumoral; measurable residual tumor after surgery is not required
for study entry.
3. Given the lack of a standard of care treatment for children with recurrent or
progressive grade III/IV malignant brain tumors, participants must have completed
first-line treatment with radiation and/or chemotherapy prior to participating in this
trial.
4. All participants must be >= 1 year of age and < 39 years of age at the time of entry
into the study. The first 3 participants must be >= 8 years of age and < 39 years of
age at the time of entry into the study.
5. Performance Score: Karnofsky >= 50 for participants > 16 years of age and Lansky >= 50
for participants <=16 years of age. Participants who are unable to walk because of
paralysis, but who are up in a wheelchair, will be considered ambulatory for the
purpose of assessing the performance score.
6. Must have recovered from the acute toxic effects of prior therapy (i.e., NCI Common
Terminology Criteria for Adverse Events (CTCAE) version 5, grade 1 or less)
- An interval of at least 12 weeks must have elapsed since the completion of
radiation therapy.
- At least 6 weeks since the completion of any cytotoxic chemotherapy regimen.
- At least 12 weeks since the completion of any immunotherapies or cell therapies.
- For targeted agents only, patient should have recovered from any toxicity of the
agent and have a minimum of 2 weeks since the last dose.
- For patients who have received prior bevacizumab, at least 6 weeks is required.
7. Organ Function Requirements:
1. Adequate Bone Marrow Function Defined as:
- Peripheral absolute neutrophil count (ANC) >750/mm^3.
- Platelet count >75,000/mm^3 (transfusion independent, defined as not
receiving platelet transfusions for at least 7 days prior to enrollment).
2. Adequate Renal Function Defined as:
- A serum creatinine > 1.5 x upper limit normal (ULN) based on age/gender.
3. Adequate Liver Function Defined as:
- Total bilirubin < 1.5 x upper limit of normal (ULN) for age; in presence of
Gilbert's syndrome, total bilirubin < 3 x ULN or direct bilirubin < 1.5 x
ULN.
- Alanine aminotransferase (ALT) < 3 x ULN.
- Aspartate aminotransferase (AST) < 3 x ULN.
4. Adequate Neurologic Function Defined as:
- Participants with seizure disorder may be enrolled if seizures are
well-controlled. Patients on non-enzyme inducing anticonvulsants may be
excluded pending interaction(s) with study drug.
- Signs and symptoms of neurologic deficit must be stable for > 1 week prior
to enrollment.
8. The effects of Transforming growth factor beta resistant (TGFβi) natural killer (NK)
cells on the developing human fetus are unknown. For this reason and because TGFβi NK
cells as well as other therapeutic agents used in this trial are known to be
teratogenic, women of child-bearing potential and men must agree to use adequate
contraception (hormonal or barrier method of birth control; abstinence) prior to study
entry, for the duration of study participation and 6 months after completion of TGFβi
NK cells administration. Should a woman become pregnant or suspect she is pregnant
while she or her partner is participating in this study, she should inform her
treating physician immediately.
9. A legal parent/guardian or patient must be able to understand, and willing to sign, a
written informed consent and assent document, as appropriate.
Exclusion Criteria:
1. Participants with evidence of disseminated disease, including multi-focal disease,
diffuse leptomeningeal disease, Cerebral spinal fluid (CSF) dissemination or
extra-neural disease.
2. Tumor involvement that would require ventricular, brainstem or posterior fossa
injection or access through a ventricle or risk of ventricular penetration in order to
deliver the TGFβi NK cells.
3. Participants undergoing needle biopsies only (open biopsies are the minimum
requirement for enrollment).
4. Participants who are receiving any other investigational agents.
5. Women of childbearing potential must not be pregnant or breast-feeding.
6. Participants on chronic corticosteroid therapy (except for replacement therapy).
7. Evidence of active uncontrolled infection or unstable or severe intercurrent medical
conditions.
8. Any medical condition that precludes surgery.
9. Prothrombin time/international normalized ratio (PT/INR) or partial thromboplastin
time (PTT) > 1.5 x ULN.
10. Participants with a known disorder that affects their immune system, such as human
immunodeficiency virus (HIV), or an auto- immune disorder requiring systemic cytotoxic
or immunosuppressive therapy are not eligible.
11. Evidence of bleeding diathesis or use of anticoagulant medication or any medication
which may increase the risk of bleeding. If the medication can be discontinued >1 week
prior to NK cell infusion then the subject may be eligible following consultation with
the Study Chairs.
12. Participants with significant systemic or major illnesses including but not limited
to: congestive heart failure, ischemic heart disease, kidney disease or renal failure,
organ transplantation, or significant psychiatric disorder.
13. History or current diagnosis of any medical or psychological condition that in the
Investigator's opinion, might interfere with the participants ability to participate
or inability to obtain informed consent because of psychiatric or complicating medical
problems.
Important note: The eligibility criteria listed above are interpreted literally and cannot
be waived.