Trial Information

Anti-Tumor Immunotherapy Targeted Against Cytomegalovirus in Patients With Newly-Diagnosed Glioblastoma Multiforme During Recovery From Therapeutic Temozolomide-induced Lymphopenia

OBJECTIVES:

Primary

- To evaluate the feasibility and safety of vaccination with cytomegalovirus (CMV)
pp65-lysosomal-associated membrane protein (LAMP) mRNA-loaded dendritic cells (DCs)
during recovery from therapeutic temozolomide-induced lymphopenia with or without
autologous lymphocyte transfer (ALT) in patients with newly diagnosed glioblastoma
multiforme and who are seropositive or seronegative for CMV.

Secondary

- To assess humoral and cellular immune responses in these patients to CMV pp65-LAMP
mRNA-loaded dendritic cell (CMV-DC) vaccine and to compare the impact of ALT and CMV
seropositivity on these parameters.

- To determine if vaccination with or without ALT extends total time to progression or
overall survival of these patients when compared to a recent historical cohort.

- To assess the differential ability of indium In^111-labeled DCs to track to the
inguinal lymph nodes under different skin preparative conditions.

- To assess the differential ability of ^111In-labeled DCs to track to lymph nodes on the
tumor-bearing and non-tumor-bearing side of the cervical lymph nodes.

- To characterize immunologic cell infiltrate in recurrent tumors and seek evidence of
antigen escape in recurrent or progressive tumors.

OUTLINE: This is a multicenter study.

Patients undergo leukapheresis no more than 4 weeks after surgical resection to obtain
peripheral blood lymphocytes (PBLs) for human cytomegalovirus (CMV)-autologous lymphocyte
transfer (ALT) and CMV-dendritic cell (DC) generation.

Beginning 2-6 weeks after resection, patients undergo external beam radiotherapy (RT) once
daily, 5 days a week, for up to 7 weeks. Beginning on day 1 of RT, patients receive oral
temozolomide (TMZ) once daily for up to 49 days. Patients with progressive disease during
RT, dependence on steroids above physiologic levels, intolerance to TMZ, or failure to meet
cell release criteria for DCs or PBLs are removed from study.

Beginning within 2-4 weeks after completion of concurrent RT and TMZ, patients resume oral
TMZ once daily on days 1-5. Treatment repeats every 4-6 weeks for up to 6 courses* in the
absence of disease progression or unacceptable toxicity. Beginning on day 19-23 of course 1,
patients also receive an intradermal immunization. Patients are stratified by CMV serology
status (positive vs negative) and are randomized to 1 of 2 vaccine treatment arms.

NOTE: *Patients may receive additional TMZ treatment at the discretion of the patient and
their treating neuro-oncologist.

- Arm I (DC vaccination plus ALT): Patients receive CMV-ALT IV over 45-90 minutes (course
1 only) and 2 x 10^7 CMV pp65-LAMP mRNA-loaded DC (CMV-DC) vaccine intradermally and
administered in equal portions to each inguinal region. Vaccination repeats every 1-3
weeks for up to 3 doses in the absence of unacceptable toxicity.

- Arm II (DC vaccination alone): Patients receive CMV-DC vaccine as in arm I. At
approximately 2-6 weeks after the third vaccination, all patients undergo a second
leukapheresis to obtain peripheral blood mononuclear cells for immunologic monitoring
and additional DCs for continued vaccinations. Patients may undergo an additional
leukapheresis if they achieve a positive immunological response to therapy or if they
require additional DCs to be generated due to a prolonged progression-free survival.
Leukapheresis may be performed monthly, but will likely be performed every 4 months
throughout the study to generate enough DCs to continue monthly vaccinations.

- Additional cohort (GM-CSF): Patients receive CMV-DC vaccine as in arm II, except that
they will also receive GM-CSF in each vaccine. Vaccines continue for a total of 10
unless tumor progression occurs. Patients in this cohort may be enrolled at any point
prior to completion of adjuvant TMZ provided they meet all other eligibility criteria.

Prior to the fourth vaccination, patients in both arms and patients with disease progression
determined prior to the first scheduled vaccination are stratified according to side of
inguinal injection (left vs right) and vaccination skin site preparation (unpulsed DCs vs
tetanus toxoid). Patients are then randomized to 1 of 2 treatment arms.

- Arm I (unpulsed DCs): Within 6 to 24 hours prior to vaccination, patients undergo skin
site preparation with 1 x 10^6 unpulsed DCs at the vaccination site in one inguinal
region. Patients then receive indium In^111-labeled CMV-DC.

- Arm II (tetanus toxoid): Within 6 to 24 hours prior to vaccination, patients undergo
vaccination skin site preparation in the opposite inguinal region with tetanus toxoid.
Patients then receive indium In^111-labeled CMV-DC as in arm I.

At the time of progression, patients receive a final intradermal vaccination comprising
^111In-labeled CMV-DCs at the base of the jaw bilaterally and to the inguinal region, as a
control. Gamma camera images are then taken at 24 and 48 hours after the vaccination to
compare DC migration in the groin to each side of the neck injection sites and to observe
migration from the neck injection sites to the deep and superficial cervical lymph nodes.

After completion of TMZ therapy, patients continue receiving DC vaccinations in the absence
of disease progression (except GM-CSF cohort - total of 10 vaccinations).

Patients undergo blood sample collection periodically for immunologic studies. Samples are
examined for functional CD4 and CD8 immune response of patients by cytokine fluorescent
cytometry; enumeration of pp65 antigen-specific CD8+ T cells by tetramer analysis;
antigen-induced T-cell proliferation; cytokine secretion and quantitative anti-pp65 antibody
concentration in the serum by ELISA; and CMV pp65 quantitation in genomic DNA by reverse
transcriptase-polymerase chain reaction. Patients may also undergo stereotactic biopsy or
tumor resection to confirm tumor progression histologically and to assess immunologic cell
infiltration and pp65 antigen escape at the tumor site by immunohistochemistry and
polymerase chain reaction.

Quality of life is assessed by the self-reported Functional Assessment of Cancer
Therapy-Brain questionnaire at initial leukapheresis, at the first vaccination, after the
third vaccination at the time of post-vaccine leukapheresis, and then with every
even-numbered vaccination thereafter. A neuropsychological assessment is also conducted
prior to the first vaccine and then with every second vaccination thereafter in order to
monitor for any changes in neurocognitive or affective changes.

After completion of study therapy, patients are followed periodically.