Sequential, Related Donor Partial Liver Transplantation Followed by Bone Marrow Transplantation for Hepatocellular Carcinoma (HCC)

Johns Hopkins Medicine

Status and phase

Withdrawn

Phase 2

Conditions

Fibrolamellar Hepatocellular Carcinoma

Hepatocellular Carcinoma

Hepatocellular Carcinoma (Fibrolamellar Variant)

Treatments

Procedure: living related donor partial liver transplantation

Radiation: Total body irradiation

Drug: fludarabine

Drug: Filgrastim

Drug: mycophenolate mofetil

Drug: Tacrolimus

Drug: Prednisone

Procedure: Bone marrow transplant from same donor

Drug: Mesna

Drug: Cyclophosphamide

Drug: Antithymocyte globulin

Study type

Interventional

Funder types

Other

Identifiers

NCT02702960

J15171

IRB00080373 (Other Identifier)

Details and patient eligibility

About

This trial is a phase II, single arm, open-label, single center study to assess a reduced-intensity conditioning regimen, bone marrow transplantation and high dose PTCy in recipients of a partial liver allograft from a Human Leukocyte Antigen (HLA)-matched or -haploidentical living related donor in patients with HCC.

The primary objective of this trial is to characterize recurrence-free survival at 1 year following bone marrow transplantation among recipients of prior partial liver transplantation from the same donor.

Full description

The purpose of this study is to characterize the safety and anti-tumor efficacy of sequential partial liver transplantation followed by bone marrow transplantation from the same living related donor. This treatment applies to patients whose cancer remains confined to the liver but is too widespread to be removed by surgery or treated by a liver transplant from a deceased donor. The purpose of this combined treatment is to reduce the risk of the cancer coming back after the liver transplant The bone marrow transplant may reduce the risk of cancer relapse in two ways. First, patients who have combined bone marrow and solid organ transplants may be able to get off all anti-rejection drugs, which inhibit the immune system from destroying cancer cells. Second, the donor's bone marrow contains cells of the immune system, which can attack any cancer cells that remain after the liver transplant.

This trial is a phase II, single arm, open-label, single center pilot study to assess a reduced-intensity conditioning regimen, bone marrow transplantation and high dose post-transplantation cyclophosphamide (PTCy) in recipients of a partial liver allograft from a Human Leukocyte Antigen (HLA)-matched or -haploidentical living related donor in patients with HCC. The trial includes analyses of tumor characteristics and the number and phenotype of tumor infiltrating lymphocytes in the explanted tumor. The trial also includes periodic monitoring of circulating hepatocytes to correlate with tumor response.

The study is expected to take two years to complete accrual of six patients, and the primary objective of this trial is to characterize recurrence-free survival at 1 year following bone marrow transplantation among recipients of prior partial liver transplantation from the same donor. Secondary objectives include documenting percentage of patients who become tolerant of the transplanted liver, i.e. off immunosuppression for >6 months without biochemical evidence of liver rejection, and characterizing the relationship between donor chimerism and transplantation tolerance.

Sex

All

Ages

16 to 65 years old

Volunteers

No Healthy Volunteers

Inclusion criteria

RECIPIENT

Histologic diagnosis of liver-confined fibrolamellar or non-fibrolamellar HCC. Ineligible for curative resection or deceased donor liver transplantation by virtue of NOT meeting the Milan criteria or down-staging criteria:
1. Single viable tumor ≤5 cm in size or ≤3 tumors each ≤3 cm in size based on CT or Magnetic resonance (MR) imaging
2. Pretransplant alpha fetoprotein (AFP) level of ≤400.
Available human leukocyte antigen (HLA)-matched or -haploidentical, living related donor who is willing to donate bone marrow and part of liver. The donor and recipient must be HLA identical for at least one allele (using high resolution DNA based typing) at the following genetic loci: HLA-A, HLA-B, HLA-C and HLA-DRB1. Fulfilment of this criterion shall be considered sufficient evidence that the donor and recipient share one HLA haplotype.
Age 16 to 65 years.
Normal estimated left ventricular ejection fraction ( >30% ) and no history of ischemic heart disease requiring revascularization, unless cleared by a cardiologist (as per normal liver and bone marrow (BM) transplant eligibility requirements). Those with an ejection fraction between 30-40%, will require a cardiology consultation and clearance for transplantation.
Forced expiratory volume (FEV1) and forced vital capacity (FVC) > 40% of predicted at the screening visit.
Serum creatinine <2.0 mg/dl
For women of childbearing potential, a negative serum or urine pregnancy test with sensitivity less than 50 milli-International unit (mIU)/m within 72 hours before the start of study medication.
Use of two forms of contraception with less than a 5% failure rate or abstinence by all transplanted participants for 12 months after the first dose of study therapy. For the first 60 days post-transplant, recipients should be encouraged to use non-hormonal contraceptives due to the potential adverse effect of hormones on bone marrow engraftment.
Ability to receive oral medication.
Ability to understand and provide informed consent.
Must meet all other criteria for listing for liver transplantation

DONOR:

HLA-matched or -haploidentical, parent, child, sibling, or half-sibling of the recipient
Meets all requirements for live liver donation based on established criteria
Ability to understand and provide informed consent for all study procedures including partial liver transplant and bone marrow harvest.
Age < 60 years
Body Mass Index (BMI) <35

Exclusion criteria

RECIPIENT

Extrahepatic disease at the time of enrollment.
Macrovascular invasion by tumor as seen on imaging
Anti-donor HLA antibody with a level that produces a positive test on flow cytometric crossmatch. [Note: patients with a positive flow cytometric crossmatch may undergo desensitization and may become eligible, at the discretion of the protocol investigators, if desensitization decreases the antibody concentration to a level that produces a negative flow cytometric crossmatch.]
Ineligible for liver transplantation per institutional criteria (see Appendix 1)
Women who are breastfeeding.
History of positive HIV-1 or HIV-2 serologies or nucleic acid test.
Active hepatitis B infection as documented by positive Hepatitis B assay
Any active, severe local or systemic infection at the screening visit.
Use of investigational drug, other than the study medications specified by the protocol, within 30 days of transplantation.
Receipt of a live vaccine within 30 days of receipt of study therapy.
The presence of any medical condition that the Investigator deems incompatible with participation in the trial.

DONOR

Age: less than age 18 or older than age 60
BMI >35
History of blood product donation to the recipient
Significant cardiovascular disease (per cardiology consultation)
Significant pulmonary disease (per pulmonology consultation)
Significant renal disease
History of diabetes mellitus
Ongoing malignancies
Severe local or systemic infection
Severe neurologic deficits
Active substance abuse
Untreatable/unstable psychiatric illness
History of positive HIV-1 or HIV-2 serology or nucleic acid test.
Evidence of prior hepatitis B infection as evaluated by hepatitis B surface antigen (HBsAg), total hepatitis B core antibody, and hepatitis B surface antibody (anti-HBsAb).
Positive HBV PCR
Positive anti-hepatitis C (HCV) antibodies and a positive serum HCV RNA PCR. All positive HCV antibody results must be assessed by an electroimmunoassay enzyme-linked immunosorbent assay (EIA) assay and confirmed by a quantitative serum HCV RNA assay. Participants with positive HCV antibodies but undetectable serum HCV RNA may be considered for eligibility. Participants with negative anti-HCV antibodies but unexplained liver enzyme abnormalities must undergo a quantitative serum RNA assay to rule out false negative HCV serologies.
Autoimmune disease requiring immunosuppressive drugs for maintenance.
The presence of any medical condition that the Investigator deems incompatible with participation in the trial.

Trial design

Primary purpose

Treatment

Allocation

N/A

Interventional model

Single Group Assignment

Masking

None (Open label)

0 participants in 1 patient group

part. liver transplant and BMT

Experimental group

Description:

Patients receive living related donor partial liver transplantation performed according to standard practices. Patients will be maintained on tacrolimus, MMF, and prednisone after liver transplantation. Upon recovery, patient must undergo eligibility screening for bone marrow transplantation (BMT). If eligible, patients will begin: Antithymocyte globulin (ATG): Day -16 to Day -14; fludarabine: Days -6 to Day -2 low-dose cyclophosphamide: Day -6 and -5. Tacrolimus, mycophenolate mofetil (MMF), and prednisone: day -7 and day -6. Total body irradiation on Day -1 Bone marrow infusion on Day 0. High dose cyclophosphamide plus MESNA: Day 3 and 4th Filgrastim, tacrolimus,MMF, and prednisone: Day 5 until neutrophil counts recover. Patients followed up through post transplant day 60, then weekly following discharge.

Treatment: