HLA-Mismatched Unrelated Donor Bone Marrow Transplantation With Post-Transplantation Cyclophosphamide

Center for International Blood and Marrow Transplant Research (CIBMTR)

Status and phase: Completed; Phase 2

Conditions: Acute Lymphoblastic Leukemia (ALL)/T Lymphoblastic Lymphoma; Myelodysplastic Syndrome (MDS); Acute Myelogenous Leukemia (AML); Acute Undifferentiated Leukemia (AUL); Acute Biphenotypic Leukemia (ABL); Chronic Lymphocytic Leukemia (CLL); Chemotherapy-sensitive Lymphoma

Treatments: Drug: Mycophenolate mofetil; Drug: Pre-HCT Mesna on Days -5 and -4; Drug: Post-HCT Mesna; Drug: Pre-HCT Mesna on Days -6 and -5; Procedure: Infusion of non-T-cell depleted bone marrow on Day 0; Drug: Cyclophosphamide 50mg/kg/day IV on Days -5,-4; Drug: Busulfan; Radiation: Total Body Irradiation (TBI) 200cGy on Day -1; Drug: Cyclophosphamide 50mg/kg/day IV on Days -2,-1; Drug: Pre-HCT Mesna on Days -2 and -1; Radiation: Total Body Irradiation (TBI) 200cGy twice a day on Days -3, -2, -1; Drug: Fludarabine; Drug: Post-HCT Cyclophosphamide 50mg/kg IV on Day+3, +4; Drug: G-CSF; Drug: Sirolimus; Drug: Cyclophosphamide 14.5 mg/kg/day IV on Days -6, -5

Study type: Interventional

Funder types: Other; NETWORK

Identifiers

NCT02793544

15-MMUD

Details and patient eligibility

About

This is a multi-center, single arm Phase II study of hematopoietic cell transplantation (HCT) using human leukocyte antigen (HLA)-mismatched unrelated bone marrow transplantation donors and post-transplantation cyclophosphamide (PTCy), sirolimus and mycophenolate mofetil (MMF) for graft versus host disease (GVHD) prophylaxis in patients with hematologic malignancies.

Enrollment: 80 patients

Sex: All

Ages: 15 to 70 years old

Volunteers: No Healthy Volunteers

Inclusion criteria

1. Age ≥ 15 years and < 71 years at the time of signing the informed consent form

2. Partially HLA-mismatched unrelated donor: HLA typing will be performed at high resolution (allele level) for the HLA-A, -B, -C, and -DRB1 loci; a minimum match of 4/8 at HLA-A, -B, -C, and -DRB1 is required

3. Product planned for infusion is bone marrow

4. Disease and disease status:

   1. Acute Leukemias or T lymphoblastic lymphoma in 1st or subsequent complete remission (CR): Acute lymphoblastic leukemia (ALL)/T lymphoblastic lymphoma; acute myelogenous leukemia (AML); acute biphenotypic leukemia (ABL); acute undifferentiated leukemia (AUL)
   2. Myelodysplastic Syndrome (MDS), fulfilling the following criteria: Subjects with de novo MDS who have or have previously had Intermediate-2 or High risk disease as determined by the International Prognostic Scoring System (IPSS). Current Intermediate-2 or High risk disease is not a requirement; Subjects must have < 20% bone marrow blasts, assessed within 60 days of informed consent; Subjects may have received prior therapy for the treatment of MDS prior to enrollment
   3. Chronic Lymphocytic Leukemia (CLL) in CR if RIC is to be used; in CR or partial response (PR) if FIC is to be used
   4. Chronic myeloid leukemia (CML) in 1st or subsequent chronic phase characterized by <10% blasts in the blood or bone marrow.
   5. Chemotherapy-sensitive lymphoma in status other than 1st CR

5. Performance status: Karnofsky or Lansky score ≥ 60% (Appendix A)

6. Adequate organ function defined as:

   1. Cardiac: left ventricular ejection fraction (LVEF) at rest ≥ 35% (RIC cohort) or LVEF at rest ≥ 40% (FIC cohort), or left ventricular shortening fraction (LVFS) ≥ 25%
   2. Pulmonary: diffusing capacity of the lungs for carbon monoxide (DLCO), forced expiratory volume (FEV1), forced vital capacity (FVC) ≥ 50% predicted by pulmonary function tests (PFTs)
   3. Hepatic: total bilirubin ≤ 2.5 mg/dL, and alanine aminotransferase (ALT), aspartate aminotransferase (AST), and alkaline phosphatase (ALP) < 5 x upper limit of (ULN) (unless disease related)
   4. Renal: serum creatinine (SCr) within normal range for age (see table 2.3). If SCr is outside normal range for age, creatinine clearance (CrCl) > 40 mL/min/1.73m2 must be obtained (measured by 24-hour (hr) urine specimen or nuclear glomerular filtration rate (GFR), or calculated GFR (by Cockcroft-Gault formula for those aged ≥ 18 years; by Original Schwartz estimate for those < 18 years))

7. Subjects ≥ 18 years of age must have the ability to give informed consent according to applicable regulatory and local institutional requirements. Legal guardian permission must be obtained for subjects < 18 years of age. Pediatric subjects will be included in age appropriate discussion in order to obtain assent.

8. Subjects with documentation of confirmed HIV-1 infection (i.e. HIV-positive), and a hematologic malignancy who meets all other eligibility requirements must:

   1. Receive only RIC regimen (i.e. Regimen A)
   2. Be willing to comply with effective antiretroviral therapy (ARV)
   3. Have achieved a sustained virologic response for 12 weeks after cessation of hepatitis C antiviral treatment (in HIV-positive subjects with hepatitis C)

Exclusion criteria

1. HLA-matched related or 8/8 allele matched (HLA-A, -B, -C, -DRB1) unrelated donor available. This exclusion does not apply to HIV-positive subjects who have a CCR5delta32 homozygous donor.

2. Autologous HCT < 3 months prior to the time of signing the informed consent form

3. Females who are breast-feeding or pregnant

4. HIV-positive subjects:

   1. Acquired immunodeficiency syndrome (AIDS) related syndromes or symptoms that may pose an excessive risk for transplantation-related morbidity as determined by the Treatment Review Committee (see Appendix D).
   2. Untreatable HIV infection due to multidrug ARV resistance. Subjects with a detectable or standard viral load > 750 copies/mL should be evaluated with an HIV drug resistance test (HIV-1 genotype). The results should be included as part of the ARV review (described in Appendix D).
   3. May not be currently prescribed ritonavir, cobacistat and/or zidovudine

5. Current uncontrolled bacterial, viral or fungal infection (currently taking medication with evidence of progression of clinical symptoms or radiologic findings)

6. Prior allogeneic HCT

7. History of primary idiopathic myelofibrosis

8. MDS subjects may not receive RIC and must be < 50 years of age at the time of signing the informed consent form

Trial design

Primary purpose: Treatment

Allocation: Non-Randomized

Interventional model: Single Group Assignment

Masking: None (Open label)

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80 participants in 4 patient groups

Regimen A (RIC: Flu/Cy/TBI)

Active Comparator group

Description:

1. Fludarabine 30 mg/m2/day IV on Days -6, -5, -4, -3, -2 2. Cyclophosphamide 14.5 mg/kg/day IV on Days -6, -5 3. Total Body Irradiation (TBI) 200cGy on Day -1 4. Infusion of non-T-cell depleted bone marrow on Day 0 Although a schedule is proposed above, the regimen can be given according to institutional standards as long as the prescribed doses are the same as in the recommended regimen above.

Treatment:

Drug: Cyclophosphamide 14.5 mg/kg/day IV on Days -6, -5

Drug: Sirolimus

Drug: G-CSF

Drug: Post-HCT Cyclophosphamide 50mg/kg IV on Day+3, +4

Drug: Fludarabine

Radiation: Total Body Irradiation (TBI) 200cGy on Day -1

Procedure: Infusion of non-T-cell depleted bone marrow on Day 0

Drug: Pre-HCT Mesna on Days -6 and -5

Drug: Post-HCT Mesna

Drug: Mycophenolate mofetil

Regimen B 2a (FIC: Bu/Cy)

Active Comparator group

Description:

1. Busulfan ≥ 9mg/kg total dose on Days -6, -5, -4, -3 (IV or PO) 2. Cyclophosphamide 50mg/kg/day IV on Days -2,-1 3. Infusion of non-T-cell depleted bone marrow on Day 0 Although a schedule is proposed above, the regimen can be given according to institutional standards as long as the prescribed doses are the same as in the recommended regimen above.

Treatment:

Drug: Sirolimus

Drug: G-CSF

Drug: Post-HCT Cyclophosphamide 50mg/kg IV on Day+3, +4

Drug: Pre-HCT Mesna on Days -2 and -1

Drug: Cyclophosphamide 50mg/kg/day IV on Days -2,-1

Drug: Busulfan

Procedure: Infusion of non-T-cell depleted bone marrow on Day 0

Drug: Post-HCT Mesna

Drug: Mycophenolate mofetil

Regimen B 2b (FIC: Bu/Flu)

Active Comparator group

Description:

1. Busulfan ≥ 9mg/kg total dose on Days -6, -5, -4, -3 (IV or PO) 2. Fludarabine 30 mg/m2/day IV on Days -6, -5, -4, -3, -2 3. Infusion of non-T-cell depleted bone marrow on Day 0 Although a schedule is proposed above, the regimen can be given according to institutional standards as long as the prescribed doses are the same as in the recommended regimen above.

Treatment:

Drug: Sirolimus

Drug: G-CSF

Drug: Post-HCT Cyclophosphamide 50mg/kg IV on Day+3, +4

Drug: Fludarabine

Drug: Busulfan

Procedure: Infusion of non-T-cell depleted bone marrow on Day 0

Drug: Post-HCT Mesna

Drug: Mycophenolate mofetil

Regimen C (FIC: Cy/TBI)

Active Comparator group

Description:

1. Cyclophosphamide 50mg/kg/day IV on Days -5,-4 2. Total Body Irradiation (TBI) 200cGy twice a day on Days -3, -2, -1 3. Infusion of non-T-cell depleted bone marrow on Day 0 Although a schedule is proposed above, the regimen can be given according to institutional standards as long as the prescribed doses are the same as in the recommended regimen above.

Treatment:

Drug: Sirolimus

Drug: G-CSF

Drug: Post-HCT Cyclophosphamide 50mg/kg IV on Day+3, +4

Radiation: Total Body Irradiation (TBI) 200cGy twice a day on Days -3, -2, -1

Drug: Cyclophosphamide 50mg/kg/day IV on Days -5,-4

Procedure: Infusion of non-T-cell depleted bone marrow on Day 0

Drug: Post-HCT Mesna

Drug: Pre-HCT Mesna on Days -5 and -4

Drug: Mycophenolate mofetil