CELL INTELLIGENCE · 肿瘤细胞治疗研究

Procurement Inclusion Criteria:

* Diagnosis of a HER2-positive sarcoma. Immunohistochemistry (IHC) will be used to determine HER2 expression. Standard HER2 positive breast cancer density gradient tissue microarrays will be used as positive controls. HER2 expression will be graded for percent positive tumor cells (Grade 0: no staining; Grade 1: 1-25%; Grade 2: 26-50% and Grade 3: 51-100%) and intensity of staining (Negative; 1+; 2+; and 3+). For the patient to meet eligibility, tumors are required to have at least ≥ grade 1 and ≥ 1+ intensity score for HER2 staining.
* Age between 1 to 25 years
* Karnofsky or Lansky performance score of ≥ 60
* Informed consent explained to, understood by, and signed by patient/guardian. Patient or guardian given copy of informed consent.

Treatment Inclusion Criteria:

* Diagnosis of a HER2 positive sarcoma with active disease progression or recurrence after at least one prior systemic therapy
* At least 4 weeks from and having recovered from acute toxic effects of all prior cytotoxic chemotherapy. Those receiving targeted (non-cytotoxic) drugs must be at least 7 days or 3 drug half-lives, whichever is greater, from last receipt of said drug and must have recovered from all acute toxic effects of that drug.
* Normal cardiac left ventricular end diastolic function (LVEF) as measured by echocardiogram (normal per institutional limits)
* Karnofsky or Lansky performance score of ≥60
* Total bilirubin ≤1.5x upper limit of normal (ULN) for age AND direct bilirubin ≤ULN for age
* AST/ALT ≤ 2.5x ULN
* Serum creatinine ≤1.5x ULN for age
* Hgb ≥ 7.0 g/dL (transfusion allowed)
* WBC \> 2,000/µl
* ANC \>1,000/ul
* Platelets \>75,000/ul (not transfused)
* Pulse oximetry of ≥ 90% on room air
* Sexually active males and females of childbearing potential must agree to use a form of contraception considered effective and medically acceptable by the investigator. Non-childbearing potential is defined as pre-menarche, greater than 1-year post-menopausal, or surgically sterilized.
* Available autologous transduced cytotoxic T lymphocytes with ≥ 15% expression of HER2 CAR and killing of HER2-positive targets ≥ 20% in cytotoxicity assay
* Informed consent explained to, understood by, and signed by patient or guardian. Patient or guardian given copy of informed consent.

Procurement Exclusion Criteria:

* Known HIV positivity
* Severe previous toxicity from cyclophosphamide including, but not limited to, decreased heart function, abnormal heart rhythms, severe allergic reaction, or grade 4 hemorrhagic cystitis
* Severe previous toxicity from fludarabine including, but not limited to, neurotoxicity, coma, renal injury requiring dialysis, development of hemolytic anemia, or development of a secondary malignancy
* Severe hypersensitivity (≥Grade 3) to pembrolizumab or nivolumab or any of their excipients
* History of allergic reactions attributed to murine protein containing products, DMSO or dextran 40
* Known, active cardiac disorder defined as left ventricular ejection fraction below the institution normal as determined by echocardiogram or New York Heart Association (NYHA) functional class III or IV or clinically significant cardiac arrhythmia.

Note: A new echocardiogram or EKG is not required to make this determination.

* Active autoimmune disease that has required systemic treatment in the past 2 years (i.e. with use of disease-modifying agents, corticosteroids, or immunosuppressive drugs). Replacement therapy (e.g. thyroxine, insulin, or physiologic corticosteroid replacement therapy for adrenal or pituitary insufficiency, etc.) is not considered a form of systemic treatment
* History of non-infectious pneumonitis that required steroids or current pneumonitis
* Known history of active tuberculosis
* Has undergone solid organ transplantation at any time
* Has a diagnosis of immunodeficiency or is receiving any other form of immunosuppressive therapy aside from cytotoxic chemotherapy
* Presence of bulky tumor at the primary or metastatic site
* Has a history or current evidence of any condition, therapy, or laboratory or radiologic abnormality that is not in the best interest of the subject to participate, as determined by the treating investigator

Treatment Exclusion Criteria:

* Known HIV positivity
* Intercurrent infection
* Pregnant or lactating
* History of hypersensitivity to murine protein-containing products, DMSO or dextran 40
* Severe previous toxicity from cyclophosphamide including, but not limited to, decreased heart function, abnormal heart rhythms, severe allergic reaction, or grade 4 hemorrhagic cystitis
* Severe previous toxicity from fludarabine including, but not limited to, neurotoxicity, coma, renal injury requiring dialysis, development of hemolytic anemia, or development of a secondary malignancy
* Severe hypersensitivity (≥Grade 3) to pembrolizumab or nivolumab or any of their excipients
* Cardiac disorder defined as left ventricular ejection fraction below the institution normal as determined by echocardiogram or New York Heart Association (NYHA) functional class III or IV or clinically significant cardiac arrhythmia
* Active autoimmune disease that has required systemic treatment in the past 2 years (i.e. with use of disease-modifying agents, corticosteroids, or immunosuppressive drugs). Replacement therapy (e.g. thyroxine, insulin, or physiologic corticosteroid replacement therapy for adrenal or pituitary insufficiency, etc.) is not considered a form of systemic treatment.
* History of non-infectious pneumonitis that required steroids or current pneumonitis
* Known history of active tuberculosis
* Has received a live virus vaccine within previous 30 days
* Has undergone solid organ transplantation at any time
* Has a diagnosis of immunodeficiency or is receiving any other form of immunosuppressive therapy
* Presence of bulky tumor at the primary or metastatic site
* Has received radiotherapy within 14 days of start of trial treatment with the exception that those who have received palliative radiation (≤ 10 days of radiotherapy) to non-central nervous system disease within 7 days are permitted. Subjects must have recovered from all radiation-related toxicities, not require corticosteroids, and not have had radiation pneumonitis.
* Has a history or current evidence of any condition, therapy, or laboratory or radiologic abnormality that is not in the best interest of the subject to participate, as determined by the treating investigator

主要终点：ARM A: Dose-limiting toxicity (DLT) rate by CTCAE v5.0. Neurotoxicity and cytokine release syndrome (CRS) will be graded according to ASTCT Consensus Grading System. · Any grade 5 event, Grade 3 and 4 cytokine release syndrome (CRS) or neurological toxicities that fail to return to grade 2 within 5 days of T cell infusion , and all other grade 3 or 4 toxicities (including allergic reactions to T cell infusions) that fail to return to grade 2 within 72 hours. In the event that the combination treatment potentiates expected, severe toxicities attributable to PD-1 antibody, investigators will employ an additional stopping rule which will be applied to each arm separately. If (1) two within the initial six patients treated or (2) greater than 33% of all patients thereafter develop greater than or equal to grade 3 non-hematologic, non-dermatologic toxicity attributable to PD-1 antibody but not attributable to HER2 CAR T cells during the DLT window, investigators will pause enrollment to that study arm. Toxicity will be evaluated according to the CTCAE v5.0 except for CRS and neurotoxicity. · By day 42 or 14 days after second dose of Pembrolizumab (whichever is longer)；ARM B: Dose-limiting toxicity (DLT) rate by CTCAE v5.0. Neurotoxicity and cytokine release syndrome (CRS) will be graded according to ASTCT Consensus Grading System. · Any grade 5 event, Grade 3 and 4 cytokine release syndrome (CRS) or neurological toxicities that fail to return to grade 2 within 5 days of T cell infusion , and all other grade 3 or 4 toxicities (including allergic reactions to T cell infusions) that fail to return to grade 2 within 72 hours. In the event that the combination treatment potentiates expected, severe toxicities attributable to PD-1 antibody, investigators will employ an additional stopping rule which will be applied to each arm separately. If (1) two within the initial six patients treated or (2) greater than 33% of all patients thereafter develop greater than or equal to grade 3 non-hematologic, non-dermatologic toxicity attributable to PD-1 antibody but not attributable to HER2 CAR T cells during the DLT window, investigators will pause enrollment to that study arm. Toxicity will be evaluated according to the CTCAE v5.0 except for CRS and neurotoxicity. · By day 42 or 7 days after third dose of Nivolumab (whichever is longer)
次要终点：Overall Response rate according to RECIST 1.1 Criteria SD, PR and CR are considered responders.

• Arm A · EXPERIMENTAL · autologous HER2 CAR T cells infused in combination with lymphodepletion chemotherapy and the PD-1 antibody pembrolizumab
• Arm 2 · EXPERIMENTAL · autologous HER2 CAR T cells infused in combination with lymphodepletion chemotherapy and the PD-1 antibody nivolumab

The purpose of this study is to learn whether it is safe to give HER2-CAR T cells in combination with an immune checkpoint inhibitor drug (pembrolizumab or nivolumab), to learn what the side effects are, and to see whether this therapy might help patients with sarcoma. Another goal of this study is to study the bacteria found in the stool of patients with sarcoma who are being treated with HER2 CAR T cells and immune checkpoint inhibitor drugs to see if the types of bacteria influence how well the treatment works. The investigators have found from previous research that they can put a new gene into T cells that will make them recognize cancer cells and kill them. They now want to see if they can put a new gene in these cells that will let the T cells recognize and kill sarcoma cells. The new gene that the investigators will put in makes an antibody specific for HER2 (Human Epidermal Growth Factor Receptor 2) that binds to sarcoma cells. In addition, it contains CD28, which stimulated T cells and make them last longer. After this new gene is put into the T cell, the T cell becomes known as a chimeric antigen receptor T cell or CAR T cell. In another clinical study using these CAR T cells targeting HER2 as well as other studies using CAR T cells, investigators found that giving chemotherapy before the T cell infusion can improve the effect the T cells can have. Giving chemotherapy before a T cell infusion is called lymphodepletion since the chemotherapy is specifically chosen to decrease the number of lymphocytes in the body. Decreasing the number of the patient's lymphocytes first should allow the infused T cells to expand in the body, and potentially kill cancer cells more effectively. The chemotherapy used for lymphodepletion is a combination of cyclophosphamide and fludarabine. After the patient receives the lymphodepletion chemotherapy and CAR T cells during treatment on the study, they will receive an antibody drug called an immune checkpoint inhibitor, pembrolizumab or nivolumab. Immune checkpoint inhibitors are drugs that remove the brakes on the immune system to allow it to act against cancer.