Cytokine-Induced Memory-Like Natural Killer Cells and Interleukin-2 with Venetoclax as Consolidation Therapy for the Treatment of Acute Myeloid Leukemia

Inclusion Criteria

• TRIAL ENROLLMENT (SCREENING VISIT #1): Diagnosis of acute myeloid leukemia (AML)
• TRIAL ENROLLMENT (SCREENING VISIT #1): Age ≥ 18 years old
• TRIAL ENROLLMENT (SCREENING VISIT #1): At time of screening patient is being treated with hypomethylating agent (HMA) (azacitidine or decitabine) + venetoclax therapy and has received ≥ 1 cycle of HMA (azacitidine or decitabine) + venetoclax. Patients can have received other lines of therapy prior to HMA + venetoclax therapy including prior chemotherapy and any prior stem cell transplant, provided that the stem cell transplant is > 6 months prior with no ongoing need for immunosuppressive therapy for active graft-versus-host disease
• TRIAL ENROLLMENT (SCREENING VISIT #1): Presence of molecular risk factors for relapse with continued HMA + venetoclax therapy as defined by any of the following present at the time of diagnosis or start of HMA + venetoclax therapy (these do not need to be present at the time the screening bone marrow [BM] biopsy): * 2022 European Leukemia Network (ELN) adverse risk karyotype: t(6;9)(p23.3;q34.1)/DEK::NUP214; t(v;11q23.3)/KMT2A-rearranged; t(9;22 (q34.1;q11.2)/BCR::ABL1; t(8;16)(p11.2;p13.3)/KAT6A::CREBBP; inv(3)(q21.3q26.2) or t(3;3)(q21.3;q26.2)/ GATA2, MECOM(EVI1), t(3q26.2;v)/MECOM(EVI1)-rearranged; −5 or del(5q); −7; Complex karyotype, monosomal karyotype * 2022 ELN adverse risk mutations: Any one of the following mutations: Mutated TP53, ASXL1, BCOR, EZH2, RUNX1, SF3B1, SRSF2, STAG2, U2AF1, and/or ZRSR2 * Additional mutations associated with acquired resistance to venetoclax: Mutated NRAS, KRAS, FLT3 ITD/TKD
• TRIAL ENROLLMENT (SCREENING VISIT #1): Eastern Cooperative oncology Group (ECOG) performance status ≤ 2
• TRIAL ENROLLMENT (SCREENING VISIT #1): Direct bilirubin: ≤1.5 x institutional upper limit of normal (ULN) (except Gilbert’s or disease-related hemolysis, then < 3 x ULN)
• TRIAL ENROLLMENT (SCREENING VISIT #1): Aspartate aminotransferase (AST)(serum glutamic oxaloacetic transaminase [SGOT])/ Alanine aminotransferase (ALT) (serum glutamic pyruvic transaminase [SGPT]): ≤ 3 x institutional ULN
• TRIAL ENROLLMENT (SCREENING VISIT #1): Creatinine clearance ≥ 45 mL/min; calculated by the Cockcroft Gault formula
• TRIAL ENROLLMENT (SCREENING VISIT #1): Oxygen saturation ≥ 90% on room air
• TRIAL ENROLLMENT (SCREENING VISIT #1): Left ventricular ejection fraction ≥ 40%
• TRIAL ENROLLMENT (SCREENING VISIT #1): Negative pregnancy test for women of childbearing potential only
• TRIAL ENROLLMENT (SCREENING VISIT #1): The effects of CIML NK cells and IL-2 on the developing human fetus are unknown. For this reason, 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 and for the duration of study participation. 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. Men treated or enrolled on this protocol must also agree to use adequate contraception prior to the study and until 4 months after the last IL-2 dose administration
• TRIAL ENROLLMENT (SCREENING VISIT #1): Participants with current symptoms of cardiac disease, should have a clinical risk assessment of cardiac function using the New York Heart Association Functional Classification. To be eligible for this trial, participants should be class 2B or better
• TRIAL ENROLLMENT (SCREENING VISIT #1): Participants with a prior or concurrent malignancy whose natural history or treatment does not have the potential to interfere with the safety or efficacy assessment of the investigational regimen are eligible for this trial
• TRIAL ENROLLMENT (SCREENING VISIT #1): Ability to understand and the willingness to sign a written informed consent document. (Providing consents in as many languages as possible is encouraged)
• TRIAL ENROLLMENT (SCREENING VISIT #1): Subjects must be able to swallow pills
• TRIAL ENROLLMENT (SCREENING VISIT #1): No laboratory evidence of ongoing hemolysis in opinion of investigator (demonstration of hemolysis should include a haptoglobin level that is below assay)
• START INVESTIGATIONAL TREATMENT PLAN (SCREENING VISIT #2): Patient was eligible for protocol
• START INVESTIGATIONAL TREATMENT PLAN (SCREENING VISIT #2): Repeat bone marrow biopsy at this time shows a complete remission (CR) or complete remission with incomplete count recovery (CRi) or morphologic leukemia free state (MLFS) (< 5% blasts) but with presence of measurable residual disease (MRD+). MRD can be determined by either flow cytometry, next generation sequencing or polymerase chain reaction (PCR). Patients with only persistent DNMTA, TET2 or ASXL1 mutations will not qualify as MRD+ as these DTA mutations without other comutations are associated with clonal hematopoiesis OR repeat bone marrow biopsy at this time shows 5-19% residual myeloblasts in the bone marrow by either bone marrow aspirate or core biopsy.
• START INVESTIGATIONAL TREATMENT PLAN (SCREENING VISIT #2): Confirmed haploidentical or fully HLA-matched related donor that is willing and eligible for non-mobilized collection
• START INVESTIGATIONAL TREATMENT PLAN (SCREENING VISIT #2): ECOG performance status ≤ 2
• START INVESTIGATIONAL TREATMENT PLAN (SCREENING VISIT #2): Direct bilirubin: ≤1.5 x institutional upper limit of normal (ULN) (except Gilbert’s or disease-related hemolysis, then < 3 x ULN)
• START INVESTIGATIONAL TREATMENT PLAN (SCREENING VISIT #2): AST(SGOT)/ALT(SGPT): ≤ 3 x institutional ULN
• START INVESTIGATIONAL TREATMENT PLAN (SCREENING VISIT #2): Creatinine clearance ≥ 45 mL/min; calculated by the Cockcroft Gault formula
• START INVESTIGATIONAL TREATMENT PLAN (SCREENING VISIT #2): Oxygen saturation ≥ 90% on room air
• START INVESTIGATIONAL TREATMENT PLAN (SCREENING VISIT #2): Left ventricular ejection fraction (LVEF) ≥ 40%
• START INVESTIGATIONAL TREATMENT PLAN (SCREENING VISIT #2): No significant change in clinical status that would, in the opinion of the investigator, increase the risk of adverse events associated with CIML NK infusion, (e.g., symptomatic congestive heart failure, unstable angina, cardiac arrhythmia)
• START INVESTIGATIONAL TREATMENT PLAN (SCREENING VISIT #2): Negative pregnancy test for women of childbearing potential only
• START INVESTIGATIONAL TREATMENT PLAN (SCREENING VISIT #2): Subjects must be able to swallow pills
• RECEIVE LYMPHODEPLETION ON DAY -5: Direct bilirubin: ≤ 1.5 x institutional upper limit of normal (ULN) (except Gilbert’s or disease-related hemolysis, then < 3 x ULN) within 24 hours of lymphodepletion
• RECEIVE LYMPHODEPLETION ON DAY -5: AST(SGOT)/ALT(SGPT): ≤ 3 x institutional ULN within 24 hours of lymphodepletion
• RECEIVE LYMPHODEPLETION ON DAY -5: No significant change in clinical status that would, in the opinion of the investigator, increase the risk of adverse events associated with lymphodepletion, (e.g., significant hypoxemia, symptomatic congestive heart failure, unstable angina, cardiac arrhythmia)
• RECEIVE LYMPHODEPLETION ON DAY -5: No evidence of active, uncontrolled infection. Patients receiving antibiotics for an infection may be treated if they have clinically responded to antibiotics. These cases should be reviewed with the study principal investigator (PI) before proceeding
• RECEIVE LYMPHODEPLETION ON DAY -5: No live vaccines within the last 6 months
• RECEIVE CIML NK INFUSION ON DAY 0: Direct bilirubin: ≤ 1.5 x institutional upper limit of normal (ULN) (except Gilbert’s or disease-related hemolysis, then < 3 x ULN) (within 24 hours of NK cell infusion)
• RECEIVE CIML NK INFUSION ON DAY 0: AST(SGOT)/ALT(SGPT): ≤ 3 x institutional ULN (except Gilbert’s or disease-related hemolysis, then < 3 x ULN) (within 24 hours of NK cell infusion)
• RECEIVE CIML NK INFUSION ON DAY 0: Creatinine clearance ≥ 45 mL/min; calculated by the Cockcroft Gault formula (within 24 hours of NK cell infusion)
• RECEIVE CIML NK INFUSION ON DAY 0: No grade ≥ 3 non-hematologic toxicities of cyclophosphamide and fludarabine conditioning (except for grade 3 nausea, vomiting, diarrhea, or constipation)
• RECEIVE CIML NK INFUSION ON DAY 0: No significant change in clinical status that would, in the opinion of the investigator, increase the risk of adverse events associated with CIML NK infusion, (e.g., significant hypoxemia, symptomatic congestive heart failure, unstable angina, cardiac arrhythmia)
• RECEIVE CIML NK INFUSION ON DAY 0: No evidence of active, uncontrolled infection. Patients receiving antibiotics for an infection may be treated if they have clinically responded to antibiotics. These cases should be reviewed with the study PI before proceeding
• RECEIVE CIML NK INFUSION ON DAY 0: No systemic steroid therapy (oral or IV) of > 10mg prednisone or equivalent dose of other steroid agent on the day of NK cell infusion
• RECEIVE VENETOCLAX ON DAY 7: Direct bilirubin: ≤ 1.5 x institutional upper limit of normal (ULN) (except Gilbert’s or disease-related hemolysis, then < 3 x ULN)
• RECEIVE VENETOCLAX ON DAY 7: AST(SGOT)/ALT(SGPT): ≤ 3 x institutional ULN within 24 hours of venetoclax initiation
• RECEIVE VENETOCLAX ON DAY 7: No grade ≥3 non-hematologic toxicities of cyclophosphamide and fludarabine conditioning (except for grade 3 nausea, vomiting, diarrhea, or constipation) within 24 hours of venetoclax initiation
• RECEIVE VENETOCLAX ON DAY 7: No significant change in clinical status that would, in the opinion of the investigator, increase the risk of adverse events associated with venetoclax administration, (e.g., significant hypoxemia, symptomatic congestive heart failure, unstable angina, cardiac arrhythmia, severe ongoing tumor lysis syndrome)
• RECEIVE VENETOCLAX ON DAY 7: No evidence of active, uncontrolled infection. Patients receiving antibiotics for an infection may be treated if they have clinically responded to antibiotics. These cases should be reviewed with the study PI before proceeding

Exclusion Criteria

• TRIAL ENROLLMENT (SCREENING VISIT #1): Prior allogeneic stem cell transplant, organ transplant or donor lymphocyte infusion (DLI), chimeric antigen receptor (CAR)-T cell or natural killer (NK) cell therapy
• TRIAL ENROLLMENT (SCREENING VISIT #1): Persisting grade > 1 non hematologic toxicity related to prior therapy; however, alopecia, sensory neuropathy grade ≤ 2, or other grade ≤ 2 not constituting a safety risk based on investigator’s judgment are acceptable
• TRIAL ENROLLMENT (SCREENING VISIT #1): Autoimmune disease: Patients with a history of inflammatory bowel disease, including ulcerative colitis and Crohn’s Disease, are excluded from this study, as are patients with a history of symptomatic disease requiring any steroids > the equivalent dose of 10 mg of prednisone or other immunosuppressive therapies at the time of this screening visit (e.g., rheumatoid arthritis, systemic progressive sclerosis [scleroderma], systemic lupus erythematosus, autoimmune vasculitis [e.g., Wegener’s Granulomatosis]) and motor neuropathy considered of autoimmune origin (e.g. Guillain-Barre Syndrome and Myasthenia Gravis). Patients with Hashimoto’s thyroiditis are eligible to go on study
• TRIAL ENROLLMENT (SCREENING VISIT #1): Pregnant women are excluded from this study because of the unknown teratogenic risk of CIML NK cells and IL-2 and with the potential for teratogenic or abortifacient effects by fludarabine (Flu)/cytarabine (Cy) chemotherapy regimen. Because there is an unknown but potential risk for adverse events in nursing infants secondary to treatment of the mother with CIML NK cells and IL-2, breastfeeding should be discontinued if the mother is treated on this study
• TRIAL ENROLLMENT (SCREENING VISIT #1): HIV-positive participants are ineligible because of the potential for pharmacokinetic interactions with anti-retroviral agents used in this study. In addition, these participants are at increased risk of lethal infections when treated with marrow suppressive therapy
• TRIAL ENROLLMENT (SCREENING VISIT #1): Individuals with active uncontrolled hepatitis B or C are ineligible as they are at high risk of lethal treatment-related hepatotoxicity after conditioning therapy
• TRIAL ENROLLMENT (SCREENING VISIT #1): Individuals with a history of a different malignancy are ineligible except for the following circumstances: * History of other malignancy and have had complete remission of disease for at least 2 years * Diagnosed and treated within the past 2 years for: ** Nonmetastatic melanoma ** Surgically resected (not needing systemic chemotherapy) squamous cell carcinoma of skin ** Nonmetastatic prostate cancer not needing systemic chemotherapy
• TRIAL ENROLLMENT (SCREENING VISIT #1): History of severe allergic reactions attributed to compounds of similar chemical or biologic composition to IL-2 or other agents used in study
• TRIAL ENROLLMENT (SCREENING VISIT #1): Participants who are receiving any other investigational agents for this condition
• TRIAL ENROLLMENT (SCREENING VISIT #1): Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, symptomatic congestive heart failure, unstable angina pectoris or cardiac arrhythmia, or psychiatric illness/social situations that would limit compliance with study requirements
• TRIAL ENROLLMENT (SCREENING VISIT #1): Prior history of grade 2 or higher hemolytic anemia (≥ 2g decrease in hemoglobin plus laboratory evidence of hemolysis) from any cause
• START INVESTIGATIONAL TREATMENT PLAN (SCREENING VISIT #2): No live vaccines within the last 6 months
• START INVESTIGATIONAL TREATMENT PLAN (SCREENING VISIT #2): No ongoing or active infections
• START INVESTIGATIONAL TREATMENT PLAN (SCREENING VISIT #2): Moderate/strong inhibitors of CYP3A except of antifungal medications (such as posaconazole, voriconazole) which the patient is on and the dose of venetoclax has already been adjusted. These are excluded as moderate/strong inhibitors of CYP3A induce higher drug levels of venetoclax which in turns carry the risk of CIML NK cell elimination
• START INVESTIGATIONAL TREATMENT PLAN (SCREENING VISIT #2): The presence of donor-specific antibodies (DSAs) with mean fluorescence intensity (MFI) > 1000 using a standard assay in subjects who do not receive a desensitization protocol prior to and during stem cell transplant