Reduced Intensity Conditioning for Non-Malignant Disorders Undergoing UCBT, BMT or PBSCT

Official title

A Phase II Study of Reduced Intensity Conditioning in Pediatric Patients and Young Adults ≤55 Years of Age With Non-Malignant Disorders Undergoing Umbilical Cord Blood, Bone Marrow, or Peripheral Blood Stem Cell Transplantation

Overview

The objective of this study is to evaluate the efficacy of using a reduced-intensity condition (RIC) regimen with umbilical cord blood transplant (UCBT), double cord UCBT, matched unrelated donor (MUD) bone marrow transplant (BMT) or peripheral blood stem cell transplant (PBSCT) in patients with non-malignant disorders that are amenable to treatment with hematopoietic stem cell transplant (HSCT). After transplant, subjects will be followed for late effects and for ongoing graft success.

Detailed description

For some non-malignant diseases (NMD; i.e., thalassemia, sickle cell disease, most immune deficiencies) a hematopoietic stem cell transplant may be curative by healthy donor stem cell engraftment alone. HSCT in patients with NMD differs from that in malignant disorders for two important reasons: 1) these patients are typically naïve to chemotherapy and immunosuppression. This may potentially lead to difficulties with engraftment. And 2) RIC with subsequent bone marrow chimerism may be beneficial even in mixed chimerism and result in decreased transplant-related mortality (TRM). Nevertheless, any previous organ damage, as a result of the underlying disease, may remain present after the HSCT.

For other diseases (metabolic disorders, some immunodeficiencies, etc.), a transplant is not curative. For these diseases, the main intent of the transplant is to slow down, or stop, the progress of the disease. In select few cases/diseases, the presence of healthy bone marrow derived cells may even prevent progression and prevent neurological decline.

Research funds are not available to assist with enrollment on this trial.

In this research study, instead of using the standard myeloablative conditioning, the study doctor is using RIC, in which significantly lower doses of chemotherapy will be used. The lower doses may not eradicate every stem cell in the patient's bone marrow, however, in the presented combination, the intention is to eliminate already formed immune cells and provide maximum growth advantage to healthy donor stem cells. This paves the way to successful engraftment of donor stem cells. Engrafting donor stem cells can outcompete, and donor lymphocytes could suppress, the patients' surviving stem cells. With RIC, the side effects on the brain, heart, lung, liver, and other organ functions are less severe and late toxic effects should also be reduced.

The purpose of this study is to collect data from the patients undergoing reduced-intensity conditioning before HSCT, and compare it to the standard myeloablative conditioning. It is expected there will be therapeutic benefits, paired with better survival rate, less organ toxicity and improved quality of life, following the RIC compared to the myeloablative regimen.

Interventions

• Drug Hydroxyurea
  Oral administration
• Drug Alemtuzumab
  Intravenous (IV) administration.
• Drug Fludarabine
  IV administration
• Drug Melphalan
  IV administration
• Drug Thiotepa
  IV administration

Primary outcome measures

• Post-transplant treatment-related mortality (TRM) [Time frame: 1 year post-transplant]
• Neurodevelopmental milestones [Time frame: 1 year post-transplant]
• Immune Reconstitution [Time frame: 1 year post-transplant]
• Severe opportunistic infections [Time frame: 1 year post-transplant]
• GVHD occurrence [Time frame: 1 year post-transplant]

Secondary outcome measures (6)

• Donor cell engraftment [Time frame: 6 months post-transplant]
• Normal enzyme level [Time frame: 1 year post-transplant]
• Neutrophil recovery [Time frame: 1 year post-transplant]
• Platelet recovery [Time frame: 1 year post-transplant]
• Grade 3-4 organ toxicity [Time frame: 1 year post-transplant]
• Late graft failure [Time frame: 1 year post-transplant]

Eligibility criteria

Inclusion:

• A 4/6, 5/6 or 6/6 HLA matched related or unrelated UCB unit available that will deliver a pre-cryopreservation total nucleated cell dose of ≥ 3 x 10e7 cells/kg, or double unit grafts, each cord blood unit delivering at least 2 x 10e7 cells/kg OR an 8 of 8 or 7 of 8 HLA allele level matched unrelated donor bone marrow or peripheral blood progenitor graft.
• Adequate organ function as measured by:

• Creatinine ≤ 2.0 mg/dL and creatinine clearance ≥ 50 mL/min/1.73 m2.
• Hepatic transaminases (ALT/AST) ≤ 4 x upper limit of normal (ULN).
• Adequate cardiac function by echocardiogram or radionuclide scan (shortening fraction > 26% or ejection fraction > 40% or > 80% of normal value for age).
• Pulmonary evaluation testing demonstrating CVC or FEV1/FVC of ≥ 50% of predicted for age and/or resting pulse oximeter ≥ 92% on room air or clearance by the pediatric or adult pulmonologist. For adult patients DLCO (corrected for hemoglobin) should be ≥ 50% of predicted if the DLCO can be obtained.
• Written informed consent and/or assent according to FDA guidelines.
• Negative pregnancy test if pubertal and/or menstruating.
• HIV negative.
• A non-malignant disorder amenable to treatment by stem cell transplantation, including but not limited to:

• Primary Immunodeficiency syndromes including but not limited to:

• Severe Combined Immune Deficiency (SCID) with NK cell activity
• Omenn Syndrome
• Bare Lymphocyte Syndrome (BLS)
• Combined Immune Deficiency (CID) syndromes
• Combined Variable Immune Deficiency (CVID) syndrome
• Wiskott-Aldrich Syndrome
• Leukocyte adhesion deficiency
• Chronic granulomatous disease (CGD)
• X-linked Hyper IgM (XHIM) syndrome
• IPEX syndrome
• Chediak - Higashi Syndrome
• Autoimmune Lymphoproliferative Syndrome (ALPS)
• Hemophagocytic Lymphohistiocytosis (HLH) syndromes
• Lymphocyte Signaling defects
• Other primary immune defects where hematopoietic stem cell transplantation may be beneficial
• Congenital bone marrow failure syndromes including but not limited to:

• Dyskeratosis Congenita (DC)
• Congenital Amegakaryocytic Thrombocytopenia (CAMT)
• Osteopetrosis
• Inherited Metabolic Disorders (IMD) including but not limited to:

• Mucopolysaccharidoses

• Hurler syndrome (MPS I)
• Hunter syndrome (MPS II)
• Leukodystrophies

• Krabbe Disease, also known as globoid cell leukodystrophy
• Metachromatic leukodystrophy (MLD)
• X-linked adrenoleukodystrophy (ALD)
• Hereditary diffuse leukoencephalopathy with spheroids (HDLS)
• Other inherited metabolic disorders

• alpha mannosidosis
• Gaucher Disease
• Other inheritable metabolic diseases where hematopoietic stem cell transplantation may be beneficial.
• Hereditary anemias

• Thalassemia major
• Sickle cell disease (SCD) - patients with sickle disease must have one or more of the following:

• Overt or silent stroke
• Pain crises ≥ 2 episodes per year for past year
• One or more episodes of acute chest syndrome
• Osteonecrosis involving ≥ 1 joints
• Priapism
• Diamond Blackfan Anemia (DBA)
• Other congenital transfusion dependent anemias
• Inflammatory Conditions

• Crohn's Disease/Inflammatory Bowel Disease

Exclusion:

• Allogeneic hematopoietic stem cell transplant within the previous 6 months.
• Any active malignancy or MDS.
• Severe acquired aplastic anemia.
• Uncontrolled bacterial, viral or fungal infection (currently taking medication and with progression of clinical symptoms).
• Pregnancy or nursing mother.
• Poorly controlled pulmonary hypertension.
• Any condition that precludes serial follow-up.

Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.

Healthy volunteers: No

Study design

Allocation

Non-randomized

Model

Parallel assignment

Masking

Open label

Primary purpose

Treatment

Study locations

United States · 1 center

• UPMC Children's Hospital of Pittsburgh — Pittsburgh

Publications

• Vander Lugt MT, Chen X, Escolar ML, et al. Reduced-intensity single-unit unrelated cord blood transplant with optional immune boost for nonmalignant disorders. Blood Adv. 2020;4(13):3041-3052. Blood Adv. 2020 Aug 11;4(15):3508. doi: 10.1182/bloodadvances.2020002967. No abstract available. PMID 32750127
• Vander Lugt MT, Chen X, Escolar ML, Carella BA, Barnum JL, Windreich RM, Hill MJ, Poe M, Marsh RA, Stanczak H, Stenger EO, Szabolcs P. Reduced-intensity single-unit unrelated cord blood transplant with optional immune boost for nonmalignant disorders. Blood Adv. 2020 Jul 14;4(13):3041-3052. doi: 10.1182/bloodadvances.2020001940. PMID 32634238

Identifiers

NCT: NCT01962415 · STUDY19060337

Primary sources (government registries)

• ClinicalTrials.gov (US NIH)

View this study on ClinicalTrials.gov ↗