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To assess in a multi-center setting whether the disease-free survival (DFS) at one-year post-HCT for children with high-risk ALL, AML and MDS can be improved following favorably KIR-mismatched haplo-HCT using a graft ex vivo depleted of T cell receptor (TCR) αβ+CD3+/CD19+ cells from CliniMacs TCR alpha-beta-Biotin system

Graft ex vivo depleted of T cell receptor (TCR) αβ+CD3+/CD19+ cells

CliniMacs TCR alpha-beta-Biotin system

Michael Pulsipher, MD

This is a phase II, open-label, non-randomized, prospective study of haploidentical transplantation using KIR-favorable donors for children with acute lymphoblastic leukemia (ALL), acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS) undergoing allogeneic hematopoietic cell transplantation (HCT). The relationship of KIR2DL1 polymorphisms to survival in children with these diseases undergoing any approach to allogeneic HCT during the study time frame will also be determined.

Allogeneic hematopoietic stem cell transplantation (HCT) using matched related and unrelated donors is well-accepted therapy for children with subtypes of high-risk acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML). For the 40-50% of children who do not have matched donors available, HCT approaches have varied by center and regional preferences. HCT physicians in France and North America tend to use human leukocyte antigen (HLA)-mismatched umbilical cord blood (UCB), while those in many large centers in Germany, parts of Asia, and selected US centers favor HLA-haploidentical donors. Both approaches have improved significantly through the years for a variety of reasons, including better supportive care, cell processing techniques that now deliver more consistently high-quality products, understanding of the importance of cell dose, and key modifications of preparative and immunosuppressive regimens.

Both stem cell sources offer distinct advantages and disadvantages. T-cell-depleted haploidentical approaches with killer-cell immunoglobulin-like receptor (KIR) mismatches have been shown to lead to less relapse in patients with AML13 and, in some studies, children with ALL as well. Disadvantages to this approach have been vulnerability to viral infection and the requirement for an ex vivo T-cell depletion procedure that is currently under IND. Cord blood is readily available and is permissive of some degree of HLA mismatch, but current studies show no advantage in survival compared with matched unrelated donors. Recently, a randomized study of one vs. two UCB units based on a hypothesis of decreased relapse incidence with two units resulted in equivalent outcomes in both arms. Neutrophil engraftment and immune recovery after UCB transplantation is relatively slow, leading to a higher risk of transplant-related mortality; in addition, larger patients require two cord units, dramatically increasing the cost of stem cell procurement. No direct comparisons of these two stem cell sources (haploidentical vs. UCB) have been performed in pediatric patients.

Recently, investigators at St. Jude Children's Research Hospital published excellent outcomes using haploidentical donors with grafts depleted for CD3+ cells by an ex vivo Miltenyi CliniMACS system. Their recent cohort of AML and ALL patients treated without total body irradiation (TBI) had a 5-year survival of 88±15% in 19 consecutive patients, with 17 surviving long-term and disease-free and only 2 patients died of progressive leukemia. These results compared favorably with the 5-year survival of 70±38% for transplantations using matched siblings and 61±17% for matched unrelated donors treated with identical leukemia protocols with indications for transplantation defined a priori. These preliminary results suggest that a strategy of using favorable KIR-mismatched haploidentical transplantation may lead to a better outcome than other alternative donor approaches without the side effects of TBI. This protocol is a phase II trial seeking to establish the feasibility and preliminary outcomes with this approach in a multi-institutional setting.

In addition to KIR-HLA matching, KIR allele polymorphism may also affect transplant outcomes.Recent data from St. Jude showed that in 312 pediatric HCTs, the patients who received a donor graft containing the functionally stronger KIR2DL1 allele with arginine at amino acid position 245 (KIR2DL1-R245) had better survival (p=0.0028) and a lower relapse rate (p=0.022) than those who received a donor graft that contained only the functionally weaker KIR2DL1 allele with cysteine at the same position (KIR2DL1-C245). Patients who received a KIR2DL1-R245-positive graft with an HLA-C receptor-ligand mismatch had the best survival (p=0.00004) and lowest risk of leukemia relapse (p=0.005). Thus, both KIR-HLA matching and KIR allele polymorphism have prognostic value. We will attempt to prospectively confirm these results in this multicenter trial.

KIR Favorable Mismatched Haplo Transplant and KIR Polymorphism in ALL/AML/MDS Allo-HCT Children

The Role of KIR-favorably Mismatched Haploidentical Transplantation and KIR-polymorphisms in Determining Outcomes of Children With ALL/AML/MDS Undergoing Allogeneic Hematopoietic Cell Transplantation

University of California, San Francisco

Children's Hospital of Philadelphia

Medical College of Wisconsin

Ann & Robert H Lurie Children's Hospital of Chicago

New York Medical College

UCSF Benioff Children's Hospital Oakland

Vanderbilt University

Rady Children's Hospital, San Diego

Head of Section of Blood and Marrow Transplantation

Heart and Blood Diseases

Multiple Myeloma

Neoplasms, Plasma Cell

Hematologic Neoplasms

Hemostatic Disorders

Blood Coagulation Disorders

Vascular Diseases

Paraproteinemias

Blood Protein Disorders

Hemorrhagic Disorders

Antineoplastic Agents

Fludarabine

Fludarabine phosphate

Melphalan

Immunosuppressive Agents

Immunologic Factors

Antineoplastic Agents, Alkylating

Alkylating Agents

For patients who are \< 60 years.

* Melphalan: 140 mg/m2/day IV on Day: -6
* Fludarabine: 40 mg/ m2/day IV Days: -5 -4, -3, -2 (Adults: creatinine clearance (CrCl) may be estimated by the Cockcroft Formula: CrCl = \[(140-age) x weight (kg) x 0.85 (for women only)\]/ \[72 x creat (mg/dl)\].)
* TBI: 200 cGy Day: -1.

For patients who are ≥60 years and/or Hematopoietic Cell Transplant-Co-morbidity Index (HCT-CI) score of \>3 (at the discretion of treating physician will have an option to receive):

* Melphalan: 70 mg/m2/day IV on Day -6.
* Fludarabine: 40 mg/m2/day IV Days -5, -4, -3, -2.
* TBI: 200 cGy; Days -1.

140 mg/m\^2/day IV on Day -6 for patients who are \< 60 years of age. 70 mg/m\^2/day IV on Day -6 For patients who are ≥60 years or have a HCT-CI score of \>3

Evomela

40 mg/ m\^2/day intravenous on Days: -5 -4, -3, -2

Total Body Irradiation

Medical College of Wisconsin Cancer Center Clinical Trials Office

Mehdi Hamadani, MD

Mehdi H Hamadani, MD

Mehdi Hamadani

This is an open-label, single-arm, phase II study to determine the safety of propylene glycol-free melphalan HCl (EVOMELA®), in combination with fludarabine and total-body irradiation-based reduced-intensity conditioning for haploidentical transplantation. In addition, the study evaluates the one-year progression-free survival of patients undergoing this treatment.

OVERVIEW:

Elderly and infirm patients with hematological malignancies often cannot undergo allogeneic hematopoietic cell transplantation (HCT) because of high-toxicity rates and nonrelapse mortality (NRM) associated with higher-intensity conditioning allografts.

Reduced-intensity conditioning (RIC) transplantation has emerged as an attractive alternative for these populations.

FLUDARABINE/MELPHALAN. In RIC, fludarabine is often used as the lymphocyte-depleting component to facilitate donor-cell engraftment. This drug can be given once daily because of its plasma half-life. M.D. Anderson pioneered the use of fludarabine melphalan (FLU/MEL) conditioning, which has since gained wide usage. (1) Melphalan is convenient, has broad antitumor activity in hematologic malignancies and has immunosuppressive effects. The Flu/Mel conditioning regimen can provide long-term disease control, especially in the subset of patients with chemo sensitive disease. (1) TOTAL-BODY IRRADIATION. In a recent study, total-body irradiation (200 cGy) was used with flu/mel for advanced lymphoma treated with HCT. With a median follow-up time close to two years, the survival of these mostly advanced, relapsed/refractory patients was very encouraging with overall survival of 54% and progression-free survival of 54% for the entire group. (2) Treatment-related mortality was low at day 100 (9.1%) and two years (19%) after transplantation, with stable engraftment achieved in the great majority of patients.

PROPYLENE GLYCOL-FREE MELPHALAN HCL (EVOMELA®). In theory, intensifying the dose of melphalan in flu/mel conditioning could provide better disease control post HCT, allowing more time for curative graft-versus-leukemia effects to emerge. The use of the commercial formulation of melphalan (Alkeran®) proved somewhat problematic, however, because it must be reconstituted with propylene glycol, a substance that has been associated with toxic side effects. The substitution of Captisol® in propylene glycol-free melphalan HCl (EVOMELA®) for Injection (Spectrum Pharmaceuticals, Inc.) for the excipients found in Alkeran®, directly overcomes the formulation limitations noted with Alkeran®.

STUDY RATIONALE. The preliminary data suggest that the substitution of Captisol® in EVOMELA® for the excipients found in Alkeran® directly overcomes the formulation limitations and provides a potentially safer melphalan formulation for administration at higher doses used in HCT conditioning regimens.

Based on these observations, we now propose a phase II study of a RIC regimen consisting of EVOMELA® in combination with fludarabine and total-body irradiation for patients undergoing haplo-HCT. The study will investigate the safety and tolerability of this conditioning approach. While the FDA indication for EVOMELA® is for myeloablative conditioning prior to autologous HCT in patients with multiple myeloma, we anticipate our study will provide critical preliminary data to explore this formulation in allogeneic HCT conditioning.

Study subjects will receive different doses of Melphalan during the trial. This is done for safety per FDA recommendations. Subjects younger than 60 years or have will receive doses at 140 mg/m\^2/day while subject 60 years or old or have a Hematopoietic Cell Transplant-Co-morbidity Index (HCT-CI) score of \>3 will receive 70 mg/m\^2/day. The populations will be combined for analysis and reporting.

Propylene Glycol-Free Melphalan HCl (EVOMELA®) in Combination With Fludarabine and Total Body Irradiation Based Reduced Intensity Conditioning for Haploidentical Transplantation

Progression-free survival (PFS) is defined as the length of time during and after the treatment that a participant lives with the disease but it does not get worse.

This is the number of participants expiring unrelated to relapse of disease.

The number of participants still alive at one year and 2 years.

The number of participants who relapse following reduced-intensity conditioning haploidentical transplantation at Day 100 and 1 Year.

The average of the number of days that it takes for neutrophil recovery from reduced-intensity conditioning haploidentical transplantation. Neutrophil recovery means absolute neutrophil count of 0.5x10\^3 cells/uL.

The average of the number of days that it takes for platelet recovery from reduced-intensity conditioning haploidentical transplantation. Platelet recovery means absolute neutrophil count of 50x10\^3 cells/uL.

The number of participants with graft-versus-host disease using the Center for International Bone Marrow Transplant Research criteria.

The number of participants with chronic GVHD at one-year post transplantation using the Center for International Bone Marrow Transplant Research criteria.

Number of subjects whose grafts failed to implant.

Professor, Department of Medicine, Division of Hematology/Oncology

Graft vs Host Disease

Homologous Wasting Disease

Childhood Acute Lymphoblastic Leukemia

Use the CliniMACS TCRα/β and CD45 Systems to deplete TCRα/β+ and CD45RA+ cells from the mobilized peripheral blood stem cells of a haploidentical donor in patients with leukemia.

In Vitro T cells depletion using CliniMCAS system

luo chengjuan

Jing Chen

This is a multi-center clinical study in China using CliniMACS TCRα/β+ and CD45RA+ T cell depleted stem cell grafts from haploidentical donors for hematopoietic stem cell transplantation in children.

This clinical study will the CliniMACS TCRα/β and CD45RA Systems to deplete TCRα/β+ and CD45RA+ cells from the mobilized peripheral blood stem cells of a haploidentical donors to treat pediatric patients who were suffuring form relapsed or refactory leukemia.

Aming to evaluate the safety/tolerability and feasibility of haploidentical PBSC grafts depleted of TCRα/β+ and CD45RA+ cells using the CliniMACS TCRαβ/CD45RA System in pediatric patients with hematological malignancies diseases. And the incidence of grade II-IV acute graft-versus-host disease (GVHD) until Day 100 post-transplantation of this new In Vitro T cell depletion technology in China.

The investigators will monitor the incidence of grade I acute GVHD until Day 100 post-transplantation, incidence and severity of chronic GVHD after 1 year and 2 years, incidence of NRM at all visits throughout the study, and graft failure from Day 0 to Day 28 at the same time.

TCDαβ/CD45RA Haploidentical Transplantation in Children With Leukemia

A Multi-center Prospective Clinical Study in China Using CliniMACS TCRα/β+ and CD45RA+ T Cell Depleted Stem Cell Grafts From Haploidentical Donors for Hematopoietic Stem Cell Transplantation in Children With Leukemia

Log number of In Vitro T cells depletion using CliniMACS TCRab/CD45RA system.

Incidence of grade II-IV acute graft-versus-host disease (GVHD) until Day 100 post-transplantation.

Incidence of grade I acute GVHD until Day 100 post-transplantation

Incidence and severity of chronic GVHD in 1 year and 2 years

Incidence of NRM at all visits throughout the study

incidence of Graft failure from Day 0 to Day 28

Nanfang Hospital, Southern Medical University

Children's Hospital of Soochow University

Chinese University of Hong Kong

Miltenyi Biomedicine GmbH

Shanghai Children's Medical Center

The third party UCB will be infused the day after infusion of PBSCs from HID.

The BMSCs from the same HID will be infused the day after infusion of PBSCs.

PBSCs harvest is performed from day 5 of G-CSF to obtain at least 7.0×10\^8 total nucleated cells/kg recipient ideal body weight.

PBSCs

The criteria for cord selection included the following: (1) ≥3 of 6 HLA loci , (2) blood type matches, (3) contained a minimum cell count of 0.3×10\^8 nucleated cells/kg and 0.15×10\^6 CD34-positive cells/kg before freezing. The third party UCB will be infused the day after infusion of PBSCs.

Cord

BMSCs of donor will be collected and infused at least 0.5×10\^8 total nucleated cells/kg recipient ideal body weight the day after PBSCs infusion.

BMSCs

Xiangzong Zeng

Qifa Liu

The objective of this study was to explore whether the combination with umbilical cord blood (UCB) is associated with superior disease-free survival (DFS) in the setting of haploidentical donors (HID) transplantation.

The main causes of allogeneic hematopoietic stem cell transplantation (allo-HSCT) failure are primary disease relapse and transplant-related complications, especially relapse. In recent years, with the development of transplantation technology, alternative donors such as HID and UCB have been widely used. But, these alternative donors are associated with high incidences of transplant-related complications and mortalities when compared with human leukocyte antigen (HLA)-matched donors. Some studies suggeted that mixed grafts might overcome the disadvantages of a single alternative graft. UCB transplant (UCBT) supported by third-party HID or HID transplants supported by third-party UCB has been reported to have rapid engraftment and low incidences of graft-versus-host-disease (GVHD), making survival improvement. However, most of these results came from single-arm studies. The comparative studies between haplo-PBSC+Cord and haplo-PBSC+BM are scarce in the setting of HID transplantation. In a retrospective study, the investigators found haplo-PBSC+Cord transplantation has superior DFS than haplo-PBSC+BM in hematological malignancies. To further confirmed this conclusion, the investigators plan to conduct a prospective, multicenter, phase 3 randomized controlled trial.

Haplo-PBSC+Cord vs Haplo-PBSC+BM for Hematological Malignancies Undergoing Allo-HSCT

A Comparative Study of Haploidentical Transplantation Supported by Third-party Cord Blood and Haploidentical Transplantation in Hematological Malignancies

Hematopoietic engraftment includes the time of neutrophil and platelet engraftment. Neutrophil engraftment was defined as the first of two consecutive days with an absolute neutrophil count in the peripheral blood exceeding 0.5 × 10\^9/L and the platelet engraftment was defined as the first of 3 days with an absolute platelet count exceeding 20 × 10\^9 /L without transfusion support.

Acutue GVHD was defined according to the 1994 consensus conference on acute GVHD grading and graded from I to IV.

Chronic GVHD was graded as mild, moderate and severe according to the national institutes of health consensus development project on criteria for clinical trials in chronic GVHD: the 2014 diagnosis and staging working group report.

Anhui Provincial People's Hospital Affiliated to University of Science and Technology of China

The Seventh Affiliated Hospital of Sun Yat-sen University

The First People's Hospital of Guangzhou

The First People's Hospital of Chenzhou

Professor

Infections

Communicable Diseases

Disease Attributes

Antirheumatic Agents

Cyclophosphamide

The planned number of mDLI is 3.

1. Day +50 (+/- 7 days) from allogenic transplant, 1st mDLI 5x105CD3+/kg of recipient.
2. 4-6 weeks after 1st DLI, 2nd mDLI 1x106CD3+/kg of recipient.
3. 4-6 weeks after 2nd DLI, 3rd mDLI 5x106CD3+/kg of recipient.

modified donor lymphocytes infusion (mDLI)

Interventional non-randomized trial. The duration of study will be 47 months.

After haploidentical transplantation, patients without complications, mainly a GVHD ≥ grade 2, will receive mDLI. mDLI consists of donor lymphocytes infusion, harvested by apheresis the day before the day planned for infusion (or up to -7 days) as outpatient basis in the Day Hospital using a cell separator.

The mDLIs preparation will be performed using a CliniMACS® (Miltenyi). A CD45RA-depletion Product LineTM from Miltenyi, including disposable reagents and devices, will be used.

The planned number of mDLI is 3.

1. Day +50 (+/- 7 days) from allogenic transplant, 1st mDLI 5x105CD3+/kg of recipient.
2. 4-6 weeks after 1st DLI, 2nd mDLI 1x106CD3+/kg of recipient.
3. 4-6 weeks after 2nd DLI, 3rd mDLI 5x106CD3+/kg of recipient. Day +50 was chosen as the starting time-point because at that time over two thirds of all acute GvHD episodes have already occurred in the absence of DLI (internal data, median +49 after bone marrow, +27 after peripheral stem cells); acute GvHD will thus be less likely a confounding factor. The choice of a maximum number of 3 mDLIs is based on the relatively narrow time interval where outcome improvement is expected, that is mainly in the first 6 months after haplo-HSCT. The planned doses are those mainly used in conventional DLIs during haplo-HSCT setting.

Stopping infusion rules:

If GvHD ≥ Grade 2 or relapse occurs, mDLIs will not be administered at any time and patient will be permanently discontinued from treatment.

If any severe adverse event (SAE) occurs after the first mDLI, the administration of mDLI will be interrupted for a maximum of 6 weeks until event resolution. If the SAE does not resolve after 6 weeks from last mDLI infusion, patient will be permanently discontinued. At any time, the experimental treatment may be stopped according to clinical judgement or patient's willing.

Feasibility and Efficacy of Modified Donor Lymphocytes Infusion (CD45RA Negative Selected) After Haploidentical Transplantation With Post-transplantation Cyclophosphamide in Patients With Hematological Malignancies (ONC-2016-002).

The primary endpoint is the rate of viral infections at day +100 after haplo-BMT.

100-day cumulative incidence of other type of infections

Study title	NCT ID	Conditions	Interventions	Eligibility	Organization
KIR Favorable Mismatched Haplo Transplant and KIR Polymorphism in ALL/AML/MDS Allo-HCT Children	NCT02646839	Acute Lymphobla... Acute Myeloid L... Myelodysplastic...	CliniMacs TCR a...	- 21 Years	Children's Hospital Los Angeles
Propylene Glycol-Free Melphalan HCl (EVOMELA®) in Combination With Fludarabine and Total Body Irradiation Based Reduced Intensity Conditioning for Haploidentical Transplantation	NCT03159702	Hematological M... Multiple Myelom...	Evomela Fludarabine Total Body Irra...	18 Years -	Medical College of Wisconsin
TCDαβ/CD45RA Haploidentical Transplantation in Children With Leukemia	NCT04033627	Relapsed Pediat... Acute Graft-Ver... Relapsed Pediat...	In Vitro T cell...	2 Months - 18 Years	Shanghai Children's Medical Center
Haplo-PBSC+Cord vs Haplo-PBSC+BM for Hematological Malignancies Undergoing Allo-HSCT	NCT05290545	Hematological M... Hematopoietic S...	PBSCs Cord BMSCs	18 Years - 65 Years	Nanfang Hospital, Southern Medical University
KIR Favorable Mismatched Haplo Transplant and KIR Polymorphism in ALL/AML/MDS Allo-HCT Children	NCT02646839	Acute Lymphobla... Acute Myeloid L... Myelodysplastic...	CliniMacs TCR a...	- 21 Years	Children's Hospital Los Angeles
Feasibility and Efficacy of Modified Donor Lymphocytes Infusion (CD45RA Negative Selected) After Haploidentical Transplantation With Post-transplantation Cyclophosphamide in Patients With Hematological Malignancies (ONC-2016-002).	NCT04687982	Bone Marrow Tra... Bone Marrow Tra... Graft Vs Host D... Infection Hematological M...	modified donor ...	18 Years -	Istituto Clinico Humanitas

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