Donor stem cell transplant with chemotherapy and radiation for blood cancers

Hematopoietic Stem Cell Transplantation From Haploidentical Donors in Patients With Hematological Malignancies Using a Treosulfan-Based Preparative Regimen

This study is testing if a donor stem cell transplant combined with different doses of chemotherapy and radiation can help people with blood cancers recover better.

Quick facts

• Phase: Phase 2
• Study type: Interventional
• Enrollment: 60 (estimated)
• Ages: 6 Months and up
• Sex: All
• Sponsor: Fred Hutchinson Cancer Center (Academic / other)
• Drugs / interventions: chemotherapy, radiation, cyclophosphamide, fludarabine
• Locations: 1 site (Seattle, Washington)
• Trial ID: NCT04195633 on ClinicalTrials.gov

What this trial studies

This phase II trial investigates the effectiveness of a donor stem cell transplant combined with treosulfan, fludarabine, and total-body irradiation in treating patients with various hematological malignancies. The study involves two arms: one receiving high-dose treosulfan and the other receiving low-dose treosulfan, both followed by total-body irradiation and stem cell transplantation. The goal is to eliminate cancer cells and support the patient's bone marrow recovery by infusing healthy donor stem cells. Patients will undergo various assessments, including bone marrow biopsies and imaging studies, to monitor their response to treatment.

Who should consider this trial

Good fit: Ideal candidates include patients with acute leukemia, chronic myelogenous leukemia, myelodysplastic syndromes, or high-grade lymphomas in complete or partial remission.

Not a fit: Patients with refractory blast crisis chronic myelogenous leukemia or those not in remission may not benefit from this study.

Why it matters

Potential benefit: If successful, this approach could improve treatment outcomes for patients with aggressive blood cancers.

How similar studies have performed: Other studies have shown promise with similar approaches, but this specific combination is being evaluated for its unique effectiveness.

Eligibility criteria

Inclusion Criteria:

* Acute leukemia (AL) that includes acute myeloid leukemia (AML) / acute lymphoblastic leukemia (ALL) / mixed phenotype leukemia (MPAL) in complete morphological remission (CR) with or without detectable minimal residual disease (MRD); complete morphological remission is defined by the presence of less than 5% of detectable blasts in bone marrow specimen, evaluated per standard of care. Patients with documented CR but without hematologic recovery since last chemotherapy are considered eligible to the study
* Chronic myelogenous leukemia (CML), except refractory blast crisis. To be eligible in first chronic phase, patients must have failed or be intolerant to at least one tyrosine-kinase inhibitor
* Chronic myelomonocytic leukemia (CMML)
* Myelodysplastic syndromes (MDS)
* Lymphoblastic, Burkitt's and other high-grade lymphoma in any complete (CR) or partial (PR) response

  * CR and PR are defined according to Lugano classification: Recommendations for Initial Evaluation, Staging, and Response Assessment of Hodgkin and Non-Hodgkin Lymphoma: The Lugano Classification
* Low grade lymphoma (chronic lymphocytic leukemia \[CLL\]/small lymphocytic lymphoma \[SLL\], marginal zone lymphoma, follicular lymphoma) progressed after two treatment regimens, in CR/PR

  * For CLL/SLL, CR and PR are defined according to: International Workshop on CLL (iwCLL) guidelines for diagnosis, indications for treatment, response assessment, and supportive management of CLL
  * CR and PR are defined according to Lugano classification: Recommendations for Initial Evaluation, Staging, and Response Assessment of Hodgkin and Non-Hodgkin Lymphoma: The Lugano Classification
* Large cell lymphoma in \> second CR (CR2)/ \>= PR2

  * CR and PR are defined according to Lugano classification: Recommendations for Initial Evaluation, Staging, and Response Assessment of Hodgkin and Non-Hodgkin Lymphoma: The Lugano Classification
* Mantle cell lymphoma, lymphoplasmacytic lymphoma and prolymphocytic leukemia may be eligible after initial therapy if in CR/PR

  * CR and PR are defined according to Lugano classification: Recommendations for Initial Evaluation, Staging, and Response Assessment of Hodgkin and Non-Hodgkin Lymphoma: The Lugano Classification
  * For prolymphocytic leukemia (PLL), CR is defined as a normalization of lymphadenopathies (long-axis diameter \< 1 cm) and splenomegaly (\< 13 cm), absence of constitutional symptoms, PLL cells \< 5% in bone marrow and circulating lymphocytes count \< 4 x 10\^9/L. Patients without hematopoietic recovery are considered eligible to the study. PR is defined as a decrease of \>= 30% of the sum of lymphadenopathies' long-axis diameters, a decrease of \>= 50% in spleen vertical length beyond normal from baseline, peripheral blood (PB) lymphocytes =\< 30 x 10\^9/L (and a decrease of \>= 50% from baseline)
* Hodgkin Lymphoma in \> CR2/PR2

  * CR and PR are defined according to Lugano classification: Recommendations for Initial Evaluation, Staging, and Response Assessment of Hodgkin and Non-Hodgkin Lymphoma: The Lugano Classification
* Subjects must be \>= 6 months old
* Karnofsky \>= 70 or Eastern Cooperative Oncology Group (ECOG) 0-1 (for adults)
* Lansky score \>= 50 (for children)
* Adequate cardiac function defined as absence of decompensated congestive heart failure or uncontrolled arrhythmia AND left ventricular ejection fraction \>= 40% or shortening fraction \> 22%
* Adequate pulmonary function defined as absence of oxygen (O2) requirements and one of the following:

  * Diffusion capacity of the lung for carbon monoxide (DLCO) corrected \>= 70% mm Hg
  * DLCO corrected between 60% - 69% mm Hg and partial pressure of oxygen (pO2) \>= 70 mm Hg
  * DLCO corrected between 50% - 59% mm Hg and pO2 \>= 80 mm Hg Pediatric patients unable to perform pulmonary function tests must have O2 saturation \>= 92% on room air. May not be on supplemental oxygen
* Total bilirubin \< 2 x upper limit of normal (ULN) unless felt to be related to Gilbert's disease or hemolysis
* Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) =\< 2.5 x ULN
* Alkaline phosphatase =\< 5 x ULN
* Creatinine \< 2.0 mg/dl (adults) or estimated creatinine clearance \> 40 ml/min (pediatrics)

  * All adults with a creatinine \> 1.2 or a history of renal dysfunction must have estimated creatinine clearance \> 40 ml/min
* If recent mold infection, e.g., aspergillus, must be cleared by infectious disease to proceed
* Patients who have undergone prior allogeneic hematopoietic cell transplant are eligible, but the prior transplant must have been performed at least 3 months prior to enrollment, unless in case of graft failure from the prior transplant
* Written and signed informed consent
* DONOR: Donors must be haploidentical relatives of the patients. Donor-recipient compatibility will be tested through HLA typing at high resolution for the HLA loci (-A, -B, -C, -DRB1, -DQB1). Donor and recipient should share at least 5/10 HLA loci
* DONOR: Age \>= 12 years
* DONOR: Weight \>= 40 Kg
* DONOR: Ability of donors younger than 18 years of age to undergo apheresis without use of a vascular access device. Vein check must be performed and verified by an apheresis nurse prior to arrival.
* DONOR: Donor must meet selection criteria as defined by the Foundation of the Accreditation of Cell Therapy (FACT) and will be screened per the American Association of Blood Banks (AABB) guidelines
* DONOR: In case of more available haploidentical donors, selection criteria should include, in this order:

  * For cytomegalovirus (CMV) seronegative recipients, a CMV seronegative donor
  * Red blood cell compatibility

    * Red blood cell (RBC) cross match compatible
    * Minor ABO incompatibility
    * Major ABO incompatibility

Exclusion Criteria:

* Active, uncontrolled, life-threatening viral, bacterial or fungal infection requiring treatment at time of conditioning regiment administration and transplantation
* Presence of a malignancy other than the one for which the transplant is being performed, with an expected survival less than 75% at 5 years
* Pregnant or breastfeeding
* Known hypersensitivity to treosulfan, fludarabine or cyclophosphamide
* Dosing with another investigational agent within 30 days prior to entry in the study
* Central nervous system (CNS) leukemic involvement not clearing with intrathecal chemotherapy and/or cranial radiation prior to initiation of conditioning (day -6)
* DONOR: Since detection of anti-donor-specific-antigen antibodies (anti-DSA) is associated with higher graft rejection rate, patients will be screened for anti-DSA pre-transplant. Patients with DSA mean fluorescent intensity (MFI) \< 5000 after desensitization treatment, will be considered eligible to participate in the study. The first 10 subjects enrolled in the trial will be DSA-negative.

Where this trial is running

Seattle, Washington

• Fred Hutch/University of Washington Cancer Consortium — Seattle, Washington, United States (Recruiting)

Study contacts

• Principal investigator: Filippo Milano — Fred Hutch/University of Washington Cancer Consortium
• Study coordinator: Filippo Milano

Conditions Acute Leukemia; Acute Lymphoblastic Leukemia; Acute Myeloid Leukemia; Adult Diffuse Large Cell Lymphoma; Anaplastic Large Cell Lymphoma; Burkitt Lymphoma; Chronic Myeloid Leukemia, BCR-ABL1 Positive; Chronic Myelomonocytic Leukemia