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Clinical Trial 19203

Cancer Type:
Interventions:Cellcept (Mycophenolate Mofetil); Hydroxyurea (Droxia); MESNA; Mycophenolate Mofetil; Radiotherapy; Rapamune (Sirolimus); Rapamycin (Sirolimus); Sirolimus; Thiotepa (Thioplex); Thymoglobulin; cyclophosphamide; cytoxan (cyclophosphamide); fludarabine (Fludarabine phosphate)

Study Type: Treatment
Phase of Study: Phase II
Investigators:

  • Michael Nieder

Call 813-745-6100
or 1-800-679-0775
Overview

Study Title

Reduced Intensity Conditioning for Haploidentical Bone Marrow Transplantation in Patients with Symptomatic Sickle Cell Disease

Summary

The purpose of this study is to learn if a haploidentical transplant is safe and effective to treat Sickle Cell Disease (SCD). A haploidentical transplant uses a half or partially-matched donor. ("Haplo" means half.) This study will use a parent or other family member who is a half tissue match. This site will not enroll children.

Objective

The primary objective is to estimate event-free survival (EFS) at 2 years after a reduced intensity conditioning regimen and human leukocyte antigen (HLA)-haploidentical bone marrow transplantation (haploBMT) in children with SCD and adults with severe SCD. Secondary Objectives: Within each stratum: 1. Estimate overall survival at one year and two years after enrollment and after haploBMT. 2. Estimate EFS at one year after haploBMT. 3. Estimate incidence of primary and secondary graft rejection at one and two years after haploBMT. 4. Estimate incidence and severity of acute GVHD until Day 100 then chronic GVHD at six months, one year, 18 months, and two years post-transplant. 5. Characterize donor hematopoietic chimerism in peripheral blood at days 28, 100, and 180 and at 1 and 2 years after haploBMT. 6. Characterize hematologic and non-hematologic toxicities of haploBMT, including the incidence and severity of acute and chronic graft-versus-host disease; time to and probability of red blood cell, neutrophil, and platelet recovery; hepatic veno-occlusive disease (VOD); idiopathic pneumonia syndrome (IPS); central nervous system (CNS) toxicity (reversible posterior leukoencephalopathy syndrome [RPLS], hemorrhage, and seizures); cytomegalovirus (CMV) infection; adenovirus infection; Epstein Barr virus post-transplant lymphoproliferative disease (EBV PTLD); invasive fungal infection. 7. Evaluate if sickle vasculopathy is halted by successful transplantation as determined by comparing brain MRI pre- and 2 years post-haploBMT. Cerebral MRI/MRA is required for all pediatric patients to assess progression of CNS disease. For adults with where the indication for the transplant is a stroke, cerebral MRI/MRA is required after transplant to assess progression of CNS disease. 8. Evaluate sickle-related events and end organ function in all recipients after haploBMT to determine if severe and debilitating vaso-occlusive pain and cerebral infarction are stabilized after transplantation. 9. Evaluate patient-reported quality of life (pain and fatigue domains) pre- and 1 and 2 years post-haploBMT in the adult stratum. 10. Lung function pre- and 2 years post-haploBMT. 11. TRJV pre- and 1 and 2 years post-haploBMT. 12. 6 min walk distance pre- and 1 and 2 years post-haploBMT. 13. Pain intensity assessed by an electronic pain diary at baseline, 1 and 2 years post-haploBMT for patient >/= 13.00 years of age at time of enrollment. 14. Hematological outcomes at 2 years (hgb, retic, %HbS, LDH, bili, last date of red blood cell transfusion). 15. Viral mold infections/bacterial or fungal sepsis at anytime up to 2 years post transplant. 16. Proportion on immunosuppression at 2 years post-haploBMT.

Inclusion Criteria

Adequate physical function as measured by all of the following:

  • A Karnofsky/Lansky performance score of ≥ 60.
  • Cardiac function: Left ventricular ejection fraction (LVEF) > 40%; or LV shortening fraction > 26% by cardiac echocardiogram or by Multi Gated Acquisition Scan (MUGA) scan.
  • Pulmonary function: Pulse oximetry with a baseline O2 saturation of ≥ 85% and Diffusing capacity of the lung for carbon monoxide (DLCO) > 40% (corrected for hemoglobin).
  • Renal function: Serum creatinine ≤ 1.5 x upper limit of normal for age and estimated or measured creatinine clearance ≥ 70 mL/min/1.73 m2.
  • Hepatic function: Serum conjugated (direct) bilirubin > Liver MRI using a validated methodology per institutional preference (T2* or R2* or by ferriscan [R2 MRI]) for estimation of hepatic iron content is required for participants who are currently receiving ≥8 packed red blood cell transfusions per year for ≥1 year or have received ≥20 packed red blood cell transfusions (lifetime cumulative). Participants who have hepatic iron content ≥ 10 mg Fe/g liver dry weight by liver MRI must have a Gastroenterology/hepatology consultation with liver biopsy and histological examination including documentation of the absence of cirrhosis, bridging fibrosis, and active hepatitis.
  • Participants must be HLA typed at high resolution using DNA based typing at HLA-A, -B, -C, DRB1, and have available: a. An HLA haploidentical first degree relative donor (parents, siblings or half siblings, or children) with 2, 3, or 4 (out of 8) HLA-mismatches who is willing and able to donate bone marrow. A unidirectional mismatch in either the graft versus host or host versus graft direction is considered a mismatch. The donor and recipient must be HLA identical for at least one antigen (using high resolution DNA based typing) at the following genetic loci: HLA-A, HLA-B, HLA-C, and HLA-DRB1. Fulfillment of this criterion shall be considered sufficient evidence that the donor and recipient share one HLA haplotype, and typing of additional family members is not required. Confirmatory donor HLA typing must be completed > Umbilical cord blood or peripheral blood stem cell donors will not be accepted. Inclusion Criteria for Stratum 2: Adults Ages 18 to 45 at segment A enrollment. Participants with sickle cell anemia (Hb SS or Sß° Thalassemia) who have one or more of the following:
  • A neurological event resulting in focal neurologic deficits that lasted ≥ 24 hours (classical clinical definition of stroke, not requiring imaging studies of the brain) OR a focal neurological event resulting in abnormalities on T2-weighted or FLAIR images using a MRI scan, indicative of an acute infarct, with no other reasonable medical explanation, OR both.
  • History of two or more episodes of acute chest syndrome (ACS) in the 2-year period preceding enrollment despite the institution of supportive care measures.
  • History of three or more severe vaso-occlusive pain crises per year in the 2-year period preceding enrollment despite the institution of supportive care measures; painful episodes related to priapism, osteonecrosis or any sickle-related complication are acceptable;
  • Administration of regular RBC transfusion therapy, defined as receiving ≥8 packed red blood cell transfusions per year for ≥1 year in the 12 months before enrollment to prevent vaso-occlusive clinical complications.
  • An echocardiographic finding of tricuspid valve regurgitant jet velocity (TRJV) ≥ 2.7 m/sec.

  • Exclusion Criteria

  • Participants who have an HLA-matched sibling who is able and willing to donate bone marrow. Patients with a HLA-matched unrelated donor are not excluded.
  • Uncontrolled bacterial, viral or fungal infection in the 6 weeks before enrollment (currently taking medication with evidence of progression of clinical symptoms or radiologic findings).
  • Evidence of HIV infection or known HIV positive serology.
  • Participants who have received a previous hematopoetic cell transplant (HCT).
  • Participants who have received a prior solid organ transplant.
  • Participants who have participated in another clinical trial in which the patient received an investigational or off-label use of a drug or device within 3 months of enrollment.
  • Females who are pregnant or breastfeeding.
  • Participants with clinically significant, uncontrolled autoimmune disease, requiring active medical management (immunosuppressive therapy or chemotherapy), which, in the judgment of the local Principal Investigator, indicates that the patient could not tolerate transplantation.
  • Females of child bearing potential (to include all female participants > 10 years of age, unless postmenopausal for a minimum of 1 year before the time of consent or surgically sterilized), who do not agree to practice two (2) effective methods of contraception at the same time, or do not agree to practice true abstinence when this is in line with the preferred and usual lifestyle of the subject, from the time of signing of informed consent through 12 months post-transplant.
  • Males (even if surgical sterilized) who do not agree to practice effective barrier contraception, or who do not agree to practice true abstinence from the time of signing informed consent through 12 months post-transplant.
  • Presence of anti-donor specific HLA antibodies. HLA antibody presence and specificity will be determined by solid phase immunoassays. An anti-donor specific HLA antibody will be considered positive when the mean fluorescence intensity (MFI) is higher than the cut-off defined by each institution. Recommended cut-off values are MFI >1000 for donor specific antibody to HLA-A, -B, and DRB1 and MFI >2000 for HLA-C, DQB1 and DPB1. This must be measured before the final donor selection, and 1000 for donor specific antibody to HLA-A, -B, DRB1 and/or MFI >2000 for HLA-C, DQB1 and DPB1, documentation must be submitted to the coordinator for review and approval prior to enrollment.