A Phase1 Clinical Trial Evaluating Locoregional Delivery Of Engineered NK Cells Containing IL13Ra And EGFvIII Chimeric Antigen Receptor (CAR), IL-21 Secretion And Deleted TGF-BetaR2 And NR3C1 In Recurrent Glioblastoma

Primary Objectives

• To undertake a window of opportunity (WOO) clinical trial to compare the biological endpoints of Dual CAR Dual KO NK cells persistence, immunological phenotype and anti-tumor function after administration of Dual CAR Dual KO NK cells via 3 different routes: intra-tumoral, intra-ventricular or intra-arterial injection. By quantitatively assessing post-treatment specimens, the trial will determine the optimal route of administration of this agent.
• To assess the safety of Dual CAR Dual KO NK cells after administration via 3 different routes: intra-tumoral, intra-ventricular or intra-arterial injection.

Secondary Objectives

• To determine response as measured by Response Assessment in Neuro-Oncology (RANO), progression free survival (PFS), time to progression (TTP), and overall survival (OS).
• To assess for systemic changes in immune cell subpopulations in the peripheral blood, serum analysis of immune correlates, CSF NK cell persistence/immune correlates, alloreactivity characterization, anti-HLA antibody analysis.

Eligibility Criteria

• Male or female subjects aged ≥ 18 years.
• Histologically confirmed supratentorial 2021 World Health Organization recurrent glioblastoma (IDH-wildtype GBM), gliosarcoma, or recurrent IDH-mutant WHO grade 4 astrocytoma, with any prior number of recurrences.
• Have received prior radiation and temozolomide therapy.
• Single tumor no larger than 5 cm in its greatest diameter.
• Karnofsky Performance Status (KPS) score of >70.
• Has a baseline brain MRI obtained no more than 30 days prior to NK cell infusion
• Adequate hematological function defined by white blood cell (WBC) count ≥ 3 x 10/L with absolute neutrophil count (ANC) ≥1.5 x109/L, lymphocyte count ≥ 0.5 x 109/L, platelet count ≥ 100 x 109/L, and Hgb ≥ 9 g/ dL (in absence of blood transfusion).
• Adequate hepatic function defined by a total bilirubin level . 1.5 ~ ULN, an AST level ≤ 2.5 x ULN, and an ALT level ≤ 2.5 x ULN, and INR ≤ 1.5.
• Adequate renal function defined by creatinine ≤ 1.5 X upper limit of normal (ULN) OR creatinine clearance ≥ 60 mL/min for subject with creatinine levels > 1.5 X institutional ULN.
• Female subject of childbearing potential should have a negative serum pregnancy test. Subjects and their partners must be willing to use effective birth control during the study and for up to 3 months following last administration of NK cells. .
• Prior Avastin use is allowed after at least a 12-week washout period.
• Agree to sign consent to the long-term follow-up protocol PA17-0483 to fulfill the institutional responsibilities to various regulatory agencies.

Exclusion criteria

• Has received prior interstitial brachytherapy, implanted chemotherapy, or therapeutics delivered by local injection or convection enhanced delivery.
• Is currently participating in or has participated in a study of an investigational agent or using an investigational device within 4 weeks since last dose of agent administration.
• Has known severe hypersensitivity reactions to monoclonal antibodies (Grade ≥ 3 NCI-CTCAE v5.0), any history of anaphylaxis, within 5 months.
• Has a known history of Human Immunodeficiency Virus (HIV) (positive HIV 1/2 antibodies); HTLV1 and/or HTLV2; active Hepatitis B (e.g., HBsAg reactive) or Hepatitis C (e.g., HCV RNA [qualitative] is detected). Participants with prior HBV vaccination (anti-HBs positive, HBsAg negative, anti-HBc negative) will NOT be excluded.
• Has a diagnosis of immunodeficiency or is receiving any immunosuppressive therapy (such as tacrolimus, cyclosporine, infliximab) within 7 days prior to study registration.
• Has had prior chemotherapy or targeted small molecule therapy within 2 weeks prior to study Day 0 or who has not recovered (i.e., ≤ Grade 1 or at baseline) from adverse events due to a previously administered agent such as thrombocytopenia or platelets toxicity. Note: Subjects with ≤ Grade 2 neuropathy are an exception to this criterion and may qualify for the study at the discretion of the treating investigator.
• Has a known additional malignancy that is progressing or requires active treatment. Exceptions include superficial tumors considered adequately treated locally with curative intent, including but not limited to basal cell carcinoma of the skin, squamous cell carcinoma of the skin, or in situ cervical cancer that has undergone potentially curative therapy. Any exceptions must be discussed with the protocol PI.
• Has known Gliomatous meningitis or extracranial disease, or tumor localized primarily to the brainstem or spinal cord
• Midline shift greater than 0.5 cm or pending herniation
• Has an active autoimmune disease requiring systemic treatment within the past 3 months or a documented history of clinically severe autoimmune disease, or a syndrome that requires systemic steroids or immunosuppressive agents. Subjects with vitiligo or resolved childhood asthma/atopy would be an exception to this rule. Subjects that require intermittent use of bronchodilators or local steroid injections would not be excluded from the study. Participants receiving epidural steroid injections for pain will be excluded. Subjects with hypothyroidism stable on hormone replacement or Sjogren's syndrome will not be excluded from the study.
• Has evidence of interstitial lung disease or active, non-infectious pneumonitis
• Has an active infection requiring systemic therapy or that in the opinion of the PI may interfere with the subject's participation, assessment of experimental treatment toxicity or increase the subject's risk of side effects
• Has a history or current evidence of any condition, therapy, or laboratory abnormality that might confound the results of the trial, interfere with the subject's participation for the full duration of the trial, or is not in the best interest of the subject to participate in the opinion of the treating investigator.
• Has known psychiatric or substance abuse disorders that would interfere with cooperation with the requirements of the trial
• Is pregnant or breastfeeding, or expecting to conceive or father children within the projected duration of the trial, starting with the screening visit and through 3 months after last dose of the study treatment
• Has received a live vaccine within 30 days prior to the first dose of trial treatment
• Has a contraindication for undergoing MRIs
• Has evidence of bleeding diathesis or coagulopathy
• Is on full dose anticoagulants or antiplatelet therapy that cannot be held (full dose depends on the actual anticoagulant)
• Has significant hemorrhage on baseline scan defined as >1 cm diameter of acute blood
• Has received any organ transplantation, including allogeneic stem-cell transplantation, but with the exception of transplants that do not require immunosuppression (e.g., corneal transplant, hair transplant)
• Has multifocal disease. Subject has multifocal GBM, defined as discrete sites of contrast enhancing disease without contiguous T2/FLAIR abnormality that require distinct radiotherapy ports. Satellite lesions that are associated with a contiguous area of T2/FLAIR abnormality as the main lesion(s) and that are encompassed within the same radiotherapy port as the main lesion(s) are permitted.