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

Overview

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

Interventions

• Drug Decreasing starting times for beginning nivolumab (Time to Event Continual Reassessment Method (TITE-CRM) )
  Patients included first receive a lympho-depleting chemotherapy by Fludarabine / Cyclophosphamide. tisagenlecleucel infusion should then be administered 2 to 14 days after completion of chemotherapy. Nivolumab (Opdivo®) will be given intravenously at 3mg/kg every 2 weeks. It will include patients with MRD negative disease status. 1. Four decreasing starting times for beginning nivolumab (day 14, day 11, day 5 and day -1) will be available for testing 2. Patients will be enrolled sequentially b
• Drug Nivolumab starting at day -1
  It will include relapsed patients. Patients included first receive a lympho-depleting chemotherapy by Fludarabine / Cyclophosphamide. tisagenlecleucel infusion should then be administered 2 to 14 days after completion of chemotherapy. Nivolumab (Opdivo®) will be given intravenously at 3mg/kg every 2 weeks. -nivolumab starting at day -1. Nivolumab will be given until 12 months after tisagenlecleucel infusion in case of response.

Primary outcome measures

• Proportion of patients with limiting-toxicities [Time frame: at day 28]
• Efficacy assessed by Minimal residual disease (MRD) negative Complete remission (CR) and B cell aplasia. [Time frame: at 3 months]

Secondary outcome measures (12)

• Incidence of B cell aplasia [Time frame: at 6 months]
• Increase of B cell aplasia duration compared to the previous one observed [Time frame: up to 24 months]
• Proportion of patients with Disease best response [Time frame: up to three months]
• Proportion of patients with Complete remission [Time frame: at 1 month]
• Proportion of patients with Complete remission [Time frame: at 3 months]
• Proportion of patients with Complete remission [Time frame: at 6 months]
• Proportion of patients with Complete remission [Time frame: at 12 months]
• Proportion of patients with Minimal residual disease [Time frame: at 1 month]
• Proportion of patients with Minimal residual disease [Time frame: at 3 months]
• Proportion of patients with Minimal residual disease [Time frame: at 6 months]
• Proportion of patients with Minimal residual disease [Time frame: at 12 months]
• Overall survival [Time frame: at one year]

Eligibility criteria

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.

Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.

Healthy volunteers: No

Study design

Allocation

Non-randomized

Model

Single group

Masking

Open label

Primary purpose

Treatment

Study locations

France · 13 centers

• CHRU Bordeaux — Bordeaux
• CHRU Lille — Lille
• HCL - Lyon Sud — Lyon
• HCL — Lyon
• HCL — Lyon
• Hôpital pour enfants - La Timone — Marseille
• CHU Montpellier - Hopital Arnaud de Villeneuve — Montpellier
• CHU Nancy — Nancy
• … and 5 more centers

Publications

• Davis KL, Yao CC, Zimmerman JAO, Rau RE. Immunotherapy in B-Cell Acute Lymphoblastic Leukemia. J Natl Compr Canc Netw. 2025 Dec;23(12):e257067. doi: 10.6004/jnccn.2025.7067. PMID 41671463

Identifiers

NCT: NCT05310591 · APHP200132

Primary sources (government registries)

• ClinicalTrials.gov (US NIH)

View this study on ClinicalTrials.gov ↗