Using cord blood transplant and chemotherapy to treat high-risk blood cancers

Optimized Cord Blood Transplantation for the Treatment of High-Risk Hematologic Malignancies in Adults and Pediatrics

This study is testing if combining umbilical cord blood transplants with certain chemotherapy treatments can help people with high-risk blood cancers do better and have fewer side effects.

Quick facts

• Phase: Phase 2
• Study type: Interventional
• Enrollment: 54 (estimated)
• Ages: 6 Months to 65 Years
• Sex: All
• Sponsor: Fred Hutchinson Cancer Center (Academic / other)
• Drugs / interventions: chemotherapy, radiation, fludarabine, cyclophosphamide
• Locations: 1 site (Seattle, Washington)
• Trial ID: NCT06013423 on ClinicalTrials.gov

What this trial studies

This phase II trial investigates the effectiveness of umbilical cord blood transplants combined with chemotherapy agents cyclophosphamide and fludarabine, along with total-body irradiation, in treating patients with high-risk hematologic diseases. The study involves two arms, one for younger patients receiving myeloablative conditioning and another for older patients receiving middle-intensity conditioning. Patients will undergo various assessments, including blood sample collection and imaging, to monitor their response to treatment and manage potential complications. The goal is to improve the success rate of transplants and reduce the risk of graft-versus-host disease.

Who should consider this trial

Good fit: Ideal candidates include patients aged 6 months to 65 years with specific types of acute leukemia in remission but at high risk for relapse.

Not a fit: Patients with hematologic diseases not meeting the eligibility criteria or those with advanced disease stages may not benefit from this study.

Why it matters

Potential benefit: If successful, this approach could significantly improve treatment outcomes for patients with high-risk hematologic diseases.

How similar studies have performed: Other studies have shown promise with similar approaches, indicating potential for success in this novel treatment strategy.

Eligibility criteria

Inclusion Criteria:

* Patients aged 6 months to =\< 65 years at time of consent.
* Acute myelogenous leukemia (AML):

  * Complete first remission (CR1), complete second remission (CR2) or greater (CR2+), must have \< 5% marrow blasts at the time of transplant.
  * Patients in morphologic remission with persistent cytogenetic, flow cytometric, or molecular aberrations are eligible.
* Acute lymphoblastic leukemia (ALL):

  * Complete first remission (CR1) at high risk for relapse such as any of the following:

    * Presence of any high-risk cytogenetic abnormalities such as t(9;22), t(1;19), t(4;11) or other MLL rearrangements (11q23) or other high-risk molecular abnormality.
    * Failure to achieve MRD- complete remission after induction therapy.
    * Persistence or recurrence of minimal residual disease on therapy.
    * Any patient unable to tolerate consolidation and/or maintenance chemotherapy as would have been deemed appropriate by the treating physician.
    * Other high-risk features not defined above.
  * Complete second remission (CR2) or greater (CR2+).

    * Note: ALL with less than 5% blasts at time of transplant but persistent cytogenetic, flow cytometric or molecular aberrations are eligible.
* Other acute leukemias: Acute leukemias of ambiguous lineage or mixed phenotype with less than 5% blasts. Leukemias in morphologic remission with persistent cytogenetic, flow cytometric or molecular aberrations are eligible.
* Chronic Myeloid Leukemia (CML): Excluding refractory blast crisis. To be eligible in first chronic phase (CP1) patient must have failed or be intolerant to tyrosine kinase inhibitor therapy.
* Myelodysplastic syndromes (MDS) and myeloproliferative disorders (MPD) other than myelofibrosis:

  * MDS/MPD overlap syndromes without myelofibrosis.
  * MDS/ MPD patients must have less than 10% bone marrow myeloblasts and absolute neutrophil count (ANC) \> 0.2 (growth factor supported if necessary) at transplant work-up.
* Non-Hodgkin lymphoma (NHL) at high-risk of relapse or progression if not in remission:

  * Eligible patients with aggressive histology (such as, but not limited to, diffuse large B-cell NHL, mantle cell NHL, and T-cell histology) in CR by PET/CT imaging.
  * Eligible patients with indolent B-cell NHL (such as, but not limited to, follicular, small cell or marginal zone NHL) will have 2nd or subsequent progression with PR or CR by PET/CT imaging.
* Blastic plasmacytoid dendritic cell neoplasm (BPDCN) in morphologic remission.
* Only for adult patients, to prevent graft rejection, patients who received only non-lymphodepleting agents for their malignancy (hypomethylating agents, venetoclax, hydroxyurea, TKIs etc.), or patients who received lymphodepleting chemotherapy \> 3 months prior to scheduled admission, may receive fludarabine 25 mg/m\^2 daily x 3 days for lymphodepletion 14-42 days (aiming for 2-4 weeks) at the discretion of the principal investigator (PI).
* For patients \> 18 years old, Karnofsky score ≥ 70%. For patients =\< 18 years old, Lansky score ≥ 50%.
* Calculated creatinine clearance \> 70 ml/min.
* Bilirubin \< 1.5 mg/dL (unless benign congenital hyperbilirubinemia or hemolysis).
* Alanine transaminase (ALT) \< 3 x upper limit of normal (ULN).
* For patients \> 18 years old, pulmonary function (spirometry and corrected diffusing capacity for carbon monoxide \[DLCO\]) \> 60% predicted. For patients =\< 18 years old, or any patient unable to perform pulmonary function tests, O2 saturation \> 92% on room air.
* Left ventricular ejection fraction \> 50%.
* Albumin \> 3.0 g/dL.
* For patients \> 18 years old, Hematopoietic Cell Transplantation Comorbidity index (HCT-CI) =\< 5.
* UCB units will be selected according to current umbilical cord blood graft selection algorithm. One or two UCB units may be used to achieve the required cell dose.
* The UCB graft is matched at 4-6 HLA-A, B, DRB1 antigens with the recipient. This may include 0-2 antigen mismatches at the A or B or DRB1 loci. Unit selection based on cryopreserved nucleated cell dose and HLA-A, B, DRB1 using intermediate resolution A, B antigen and DRB1 allele typing.

Exclusion Criteria:

* Diagnosis of myelofibrosis or other malignancy with moderate-severe bone marrow fibrosis.
* Patients persistent with central nervous system (CNS) involvement in cerebrospinal fluid (CSF) or CNS imaging at time of screening0
* Prior checkpoint inhibitors/ blockade in the last 12 months.
* Two prior stem cell transplants of any kind.
* One prior autologous stem cell transplant within the preceding 12 months.
* Prior allogeneic transplantation.
* Prior involved field radiation therapy that would preclude safe delivery of 400cGy total body irradiation (TBI) in the opinion of radiation oncology.
* Active and uncontrolled infection at time of transplantation.
* HIV infection.
* Inadequate performance status/ organ function.
* Pregnancy or breast feeding.
* Patient or guardian unable to give informed consent or unable to comply with the treatment protocol including appropriate supportive care, long-term follow-up, and research tests.

Where this trial is running

Seattle, Washington

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

Study contacts

• Principal investigator: Ann Dahlberg — Fred Hutch/University of Washington Cancer Consortium
• Study coordinator: Ann Dahlberg

Conditions Acute Leukemia of Ambiguous Lineage; Acute Lymphoblastic Leukemia; Acute Myeloid Leukemia; Blastic Plasmacytoid Dendritic Cell Neoplasm; Hematopoietic and Lymphatic System Neoplasm; Mixed Phenotype Acute Leukemia; Myelodysplastic Syndrome; Myeloproliferative Neoplasm