Combination Chemotherapy, Total Body Irradiation, and Donor Blood Stem Cell Transplant in Treating Patients With Secondary Myelofibrosis

Secondary Myelofibrosis Clinical Trial

Official title:

A Pilot Study of Reduced Intensity HLA-Haploidentical Hematopoietic Cell Transplantation With Post-Transplant Cyclophosphamide in Patients With Advanced Myelofibrosis

Clinical Trial Details — Status: Recruiting

Administrative data

• NCT number: NCT03118492
• Other study ID #: 16420
• Secondary ID: NCI-2017-0061316
• Status: Recruiting
• Phase: Phase 1
• Start date: May 24, 2017
• Est. completion date: March 24, 2025

Study information

• Verified date: June 2024
• Source: City of Hope Medical Center
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

This pilot phase I trial studies the side effects of combination chemotherapy, total body irradiation, and donor blood stem cell transplant in treating patients with secondary myelofibrosis. Drugs used in chemotherapy work in different ways to stop the growth of cancer cells, either by killing the cells, by stopping them from dividing, or by stopping them from spreading. Radiation therapy uses high energy x-rays to kill cancer cells and shrink tumors. Giving combination chemotherapy and total body irradiation before a donor blood stem cell transplant helps to stop the growth of cells in the bone marrow, including normal blood-forming cells (stem cells) and cancer cells. When the healthy stem cells from a donor are infused into the patient they may help the patient's bone marrow make stem cells, red blood cells, white blood cells, and platelets.

Description:

PRIMARY OBJECTIVE:

I. To evaluate the safety and tolerability of reduced-intensity (fludarabine/melphalan) haploidentical hematopoietic cell transplantation (Haplo-HCT) followed by post-transplant cyclophosphamide (PTCy) in patients with advanced myelofibrosis (MF), as assessed by the evaluation of toxicities, including type, frequency, severity, attribution, time course and duration.

SECONDARY OBJECTIVES:

I. To summarize and evaluate hematologic (neutrophil and platelet) recovery. II. To evaluate and describe cytokine release syndrome (CRS) post haploidentical HCT in the setting of advanced myelofibrosis, as assessed by grade, frequency, severity, duration and reversibility (outcome).

III. To estimate graft failure-free survival (GFS) at 100-days post-transplant. IV. To estimate overall survival (OS), progression-free survival (PFS) and cumulative incidence (CI) of relapse/progression, and non-relapse mortality (NRM) at 100-days, 1-year, and 2-year post transplant.

V. To estimate the cumulative incidence of acute graft-versus-host disease (GvHD), grade II-IV, at 100-days post-transplant (per Keystone Consensus modification of the Glucksberg criteria).

VI. To estimate the cumulative incidence of chronic GvHD at 1-year and 2-year post transplant (per National Institutes of Health [NIH] Consensus Criteria).

VII. To characterize the severity and extent of acute and chronic GvHD.

EXPLORATORY OBJECTIVE:

I. To conduct correlative studies and describe inflammatory cytokine levels and GVHD biomarker levels in plasma and T cell differentiation/functions in patients enrolled onto the trial.

OUTLINE:

Patients receive melphalan intravenously (IV) over 30 minutes on day -5, fludarabine IV over 30-60 minutes on days -5 to -2. Patients undergo total body irradiation (TBI) on day -1 and hematopoietic cell transplantation (HCT) on day 0. Patients receive cyclophosphamide IV over 1-2 hours on days 3 and 4. Starting on day 5, patients receive tacrolimus IV then orally (PO) for 6 months followed by a taper, mycophenolate mofetil PO thrice daily (TID) until day 35, and glycosylated recombinant human G-CSF AVI-014 (G-CSF) IV daily until absolute neutrophil count > 1,500/mm^3 for 3 consecutive days. Treatment continues in the absence of disease progression or unexpected toxicity.

After completion of study treatment, patients are followed for up to 2 years.

Recruitment information / eligibility

• Status: Recruiting
• Enrollment: 16
• Est. completion date: March 24, 2025
• Est. primary completion date: March 24, 2025
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years to 65 Years

Eligibility

Inclusion Criteria:

• Diagnosis of primary of secondary myelofibrosis with transplant indication by Dynamic International Prognostic Scoring System (DIPSS)-plus (> intermediate-1)

• Patients >= age 50 must have a comorbidity score (hematopoietic cell transplant-comorbidity index [HCT-CI]) < 4 (Sorror)

• Patients can be in chronic phase (CP) with bone marrow (BM) blast count =< 15% as long as no evidence of disease acceleration per principal investigator (PI) and treating physician's opinion or after progression to acute myeloid leukemia (AML) and achieved =< 5% BM blasts (morphologic complete remission [CR] prior to transplant)

• Lack of an human leukocyte antigen (HLA) matched donor or need to proceed fast to transplantation when a patient does not have an immediately available matched unrelated donor (typed by high-resolution in the registry)

• Performance status >= 70% (Karnofsky); patients > 50 years should have adequate cognitive function; any concerns regarding cognitive function should be addressed by a geriatrician/neurologist

• Alanine aminotransferase (ALT)/aspartate aminotransferase (AST)/bilirubin =< 5 X upper limit of normal (ULN)

• Measured creatinine clearance > 60 mls/min

• Left ventricular ejection fraction (LVEF) >= 50%

• Corrected carbon monoxide diffusing capability (DLCOc) >= 50%

• No active infections

• Prior treatment with JAK2 inhibitor therapy is not excluded; a JAK2 inhibitor will need to be stopped 1-2 days prior to starting conditioning regimen

• DONOR: Documented informed consent per local, state and federal guidelines

• DONOR: Genotypically haploidentical as determined by HLA typing

• Preferably a non-maternal HLA haploidentical relative due to data of high incidence of graft failure with use of maternal HLA haploidentical cells

• Eligible donors include biological parents, siblings or half-siblings, children, or cousins in rare instances

• DONOR: Absence of pre-existing donor-specific anti-HLA antibodies (DSA) in the recipient; Patients with pre-existing DSA could undergo desensitization per City of Hope (COH) standard operating procedures [SOP] and should have DSA < MFI of 2000 prior to conditioning at discretion of PI

• DONOR: Infectious disease screening performed within 30 days prior to stem cell mobilization per federal guidelines and is:

• Seronegative for HIV 1+2 antibody (Ab) and/or HIV polymerase chain reaction (PCR), human T-cell leukemia virus (HTLV) I/II Ab, hepatitis B virus surface antigen (HBsAg), hepatitis B virus surface antibody (HBcAb), hepatitis C virus (HCV) Ab

• Negative rapid plasma reagin (RPR) for syphilis

• DONOR: Women of childbearing potential (WOCBP): Urine pregnancy testing performed within 7 days prior to stem cell mobilization

• DONOR: Is approved and completed evaluation prior to recipient initiation of the preparative regimen per institutional guidelines

Exclusion Criteria:

• Evidence of severe portal hypertension with evidence of decompensation either with bleeding varices, large volume ascites, or hepatic encephalopathy

• In a bone marrow biopsy 4 weeks prior to start of conditioning on study:

• > 15% bone marrow blasts at transplant if no history of AML and per PI and treating physician's opinion of disease acceleration

• > 5% if had previous progression to AML

• Human immunodeficiency virus (HIV) positive; active hepatitis B or C

• Patients with active infections; the PI is the final arbiter of the eligibility

• Patients with evidence of severe pulmonary hypertension by echocardiogram and confirmed by a subsequent right side cardiac catheterization pre-enrollment

• Liver cirrhosis

• Prior central nervous system (CNS) involvement by tumor cells

• History of another primary malignancy that has not been in remission for at least 3 years (the following are exempt from the 3-year limit: non-melanoma skin cancer, fully excised melanoma in situ [stage 0], curatively treated localized prostate cancer, and cervical or breast carcinoma in situ on biopsy or a squamous intraepithelial lesion on papanicolaou [PAP] smear)

• Positive beta human chorionic gonadotropin (HCG) test in a woman with child bearing potential defined as not post-menopausal for 12 months or no previous surgical sterilization

• Noncompliance - inability or unwillingness to comply with medical recommendations regarding therapy or follow-up, including smoking tobacco

• DONOR: Has undergone solid organ, stem cell, bone marrow or blood transplantation

• DONOR: Receiving any investigational agents, or concurrent biological, chemotherapy, immunosuppression or radiation therapy

• DONOR: Active infection

• DONOR: Thrombocytopenia < 150,000 cells /mm^3 at baseline evaluation

• DONOR: Sero-positive for HIV-1 & 2 antibody, HTLV-I & II antibody, hepatitis B virus (HBV) and HCV

• DONOR: Medical or physical reason which makes the donor unlikely to tolerate or cooperate with growth factor therapy and leukapheresis

• DONOR: Factors which place the donor at increased risk for complications from leukapheresis or G-CSF therapy

• DONOR: WOCBP: Pregnant or =< 6 months breastfeeding

Related Conditions & MeSH terms

• Neoplasm Metastasis
• Primary Myelofibrosis
• Secondary Myelofibrosis

Intervention

Procedure:
• Allogeneic Hematopoietic Stem Cell Transplantation
Undergo HCT

Drug:
• Cyclophosphamide
Given IV
• Fludarabine
Given IV

Biological:
• Glycosylated Recombinant Human G-CSF AVI-014
Given IV

Other:
• Laboratory Biomarker Analysis
Correlative studies

Drug:
• Melphalan
Given IV
• Mycophenolate Mofetil
Given PO
• Tacrolimus
Given IV or PO

Radiation:
• Total-Body Irradiation
Undergo TBI

Locations

Country	Name	City	State
United States	City of Hope Medical Center	Duarte	California

Sponsors (2)

Lead Sponsor	Collaborator
City of Hope Medical Center	National Cancer Institute (NCI)

Country where clinical trial is conducted

United States, 

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Incidence of adverse events	Assessed by Bearman Toxicity Scale and National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events version (CTCAE) 4.03. Observed toxicities will be summarized in terms of type (organ affected or laboratory determination), severity, time of onset, duration, probable association with the study regimen and reversibility or outcome.	Up to 100 days post-hematopoietic cell transplantation (HCT)
Primary	Incidence of unacceptable toxicity	Assessed by Bearman Toxicity Scale and NCI CTCAE version 4.03. Observed toxicities will be summarized in terms of type (organ affected or laboratory determination), severity, time of onset, duration, probable association with the study regimen and reversibility or outcome.	Up to 2 years
Secondary	Neutrophil recovery	Defined as the first of 3 measurements on different days when the patient has an absolute neutrophil count of >= 500/uL after conditioning.	Up to 2 years
Secondary	Platelet recovery	Defined as the first day of a minimum of 3 measurements on different days that the patient has achieved a platelet count >= 20,000/uL and did not receive a platelet transfusion in the previous 7 days.	Up to 2 years
Secondary	Incidence of cytokine release syndrome (CRS)	Defined and graded per American Society for Transplantation and Cellular Therapy (ASTCT) criteria.	After haploidentical HCT, assessed up to 2 years
Secondary	Graft failure-free survival	Will be calculated using Kaplan-Meier product-limit method, 95% confidence intervals will be calculated.	Time from start of protocol treatment/infusion of stem cell product to graft-failure, death (from any cause), or last contact, whichever occurs first, assessed up to 2 years
Secondary	Overall survival	Will be calculated using Kaplan-Meier product-limit method, 95% confidence intervals will be calculated.	Time from start of protocol treatment/infusion of stem cell product to death (from any cause), or last contact, whichever occurs first, assessed up to 36 months
Secondary	Progression-free survival	Will be calculated using Kaplan-Meier product-limit method, 95% confidence intervals will be calculated.	Time from start of protocol treatment/infusion of stem cell product to, relapse, progression, death (from any cause), or last contact, whichever occurs first, assessed up to 2 years
Secondary	Cumulative incidence of relapse/progression	The cumulative incidence of relapse/progression will be estimated using the method described by Gooley et al. (1999).	Up to 2 years
Secondary	Non-relapse mortality (NRM)	The cumulative incidence of NRM will be estimated using the method described by Gooley et al. (1999).	Up to 2 years
Secondary	Cumulative incidence of acute graft versus host disease (GvHD)	Assessed by Keystone Consensus criteria. Time to the first day of acute GvHD onset (of any grade) will be used to estimate the cumulative incidence.	Up to day 100 post-HCT
Secondary	Cumulative incidence of chronic graft versus host disease GvHD	Assessed by National Institutes of Health Consensus Criteria. Time to the first day of chronic GvHD onset (of any grade) will be used to estimate the cumulative incidence.	Up to 2 years post-HCT