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Chemotherapy and Cord Blood Transplant in Children and Young Adults with Hematologic Malignancies or Non-malignant Diseases

Trial Status: Active

This phase II trial studies the effect of chemotherapy and a cord blood transplant in children and young adults with hematologic malignancies or non-malignant diseases. Chemotherapy drugs, such as clofarabine, fludarabine, and busulfan, 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. Before receiving stem cells, the standard process, called cytoreduction, is to receive high doses of chemotherapy. This helps to make room in the bone marrow for new blood stem cells to grow, helps prevent the body from rejecting the transplanted cells, and helps kill any cancer cells that are in the body. This is called a conditioning regimen. However, high doses of chemotherapy can have serious side effects. This study may help researchers learn whether combining the chemotherapy drugs clofarabine, fludarabine, and busulfan is a safe and effective way to reduce the side effects from receiving a conditioning regimen in children and young adults receiving cord blood transplants.

Inclusion Criteria

  • Patients with age =< 21 years at time of consent with no available and suitably matched related or unrelated donor in the required time period
  • Acute myelogenous leukemia (AML): * Complete first remission (CR1) at high risk for relapse such as any of the following: ** Known prior diagnosis of myelodysplasia (MDS) or myeloproliferative disorder (MPS) ** Therapy-related AML (t-AML) ** White cell count at presentation > 100,000 ** Presence of extramedullary leukemia at diagnosis ** Any unfavorable subtype by French-American-British (FAB) or World Health Organization (WHO) classification ** High-risk cytogenetics (e.g. those associated with MDS, abnormalities of 5, 7, 8, complex karyotype) or high-risk molecular abnormalities ** Requirement for 2 or more inductions to achieve CR1 ** Presence of minimal residual disease (MRD+) by cytogenetics, flow cytometry or molecular methods after induction ** Any patient with newly diagnosed AML with intermediate risk cytogenetics who elects allograft with curative intent over consolidation chemotherapy ** Any patient unable to tolerate consolidation chemotherapy as would have been deemed appropriate by the treating physician ** Other high-risk features not defined above * Complete second remission (CR2) * Primary refractory or relapsed AML with less than 10% blasts by bone marrow morphology. Patients with cytogenetic, flow cytometric, or molecular abnormalities in =< 10% of cells are eligible
  • Acute lymphoblastic leukemia (ALL): * Complete first remission (CR1) at high risk for relapse such as any of the following: ** White cell count at presentation > 30,000 for B-cell lineage and > 100,000 for T-cell lineage ** Presence of any high-risk cytogenetic abnormalities such as t (9;22), t (1;19), t (4;11) or other mixed lineage leukemia (MLL) rearrangements (11q23) or other high-risk molecular abnormality ** Failure to achieve complete remission (CR) after four weeks of induction therapy ** Persistence or recurrence of MRD 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) * Primary refractory or relapsed ALL with MRD disease after antibody therapy (e.g., blinatumomab, inotuzumab, other) and/or chimeric antigen receptor T-cell (CAR-T) cell therapy
  • Other acute leukemias: * Leukemias of ambiguous lineage or of other types (e.g. blastic plasmacytoid dendritic cell neoplasm) with less than 5% blasts by bone marrow (BM) morphology. Patients with persistent/relapsed disease with cytogenetic, flow cytometric or molecular aberrations in =< 5% of cells are eligible
  • Myelodysplastic syndrome (MDS) / myeloproliferative disorders (MPD) other than myelofibrosis: * International prognostic scoring system (IPSS) risk score of intermediate-2 (INT-2) or high risk at the time of diagnosis * Any IPSS risk category if life-threatening cytopenia(s) exists * Any IPSS risk category with karyotype or genomic changes that indicate high risk for progression to acute myelogenous leukemia * MDS/ myeloproliferative disorder overlap syndromes without myelofibrosis * MDS/ MPD patients must have less than 10% bone marrow myeloblasts and ANC >= 0.2 (growth factor supported if necessary) at transplant work-up
  • Non-Hodgkin lymphoma (NHL) or Hodgkin lymphoma (HL) 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 * 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 stable disease/ CR/ partial remission (PR) with no single lesion equal to or more than 5 cm * Eligible patients with HL will be those without progression of disease (POD) after salvage chemotherapy with no single lesion >= 5 cm
  • Inherited metabolic disorders: * Hurler Syndrome * Hunter (MPS 2 – early disease) * Sly syndrome (MPSVIII) * Alpha-mannosidosis * X-linked adrenoleukodystrophy (X- ALD) * Osteopetrosis * Metachromatic leukodystrophy * Globoid (globoid cell leukodystrophy [GLD])
  • Non-malignant disorders (other): * Hemoglobinopathies * Bone marrow failure syndromes * Immunodeficiencies, including hemophagocytic lymphohistiocytosis (HLH)
  • Karnofsky or Lansky score >= 70%
  • Bilirubin =< 1.5 mg/dL (unless benign congenital hyperbilirubinemia)
  • Alanine aminotransferase (ALT) =< 3 x upper limit of normal
  • Pulmonary function (spirometry and corrected diffusion capacity of the lung for carbon monoxide [DLCO]) >= 50% predicted (corrected for hemoglobin)
  • Left ventricular ejection fraction >= 50%
  • Age-adjusted Hematopoietic Cell Transplantation-Comorbidity Index (aaHCT-CI) less than or equal to 7
  • Serum creatinine =< 1.5 x normal for age. If serum creatinine is outside the normal range, then creatinine clearance (CrCl) > 50 mL/min/1.73 m^2 (calculated or estimated) or GFR (mL/min/1.72 m^2) > 30% of predicted normal for age
  • For metabolic diseases: disease status to be evaluated according to European Society for Blood and Marrow Transplantation (EBMT) Handbook
  • GRAFT CRITERIA: CB units will be selected according to the current Memorial Sloan Kettering Cancer Center (MSKCC) unit selection algorithm. High resolution 8 allele HLA typing and recipient HLA antibody profile will be performed. Cord unit selection will occur based on HLA-match, total nucleated cell (TNC) and CD34+ cell dose adjusted per patient body weight. The cord bank of origin will also be considered. Donor specific HLA antibodies, if present, will also be taken into consideration and may influence the selection of the graft. CB graft will consist of one or two CB units (CBU) based on MSKCC selection algorithm * Each CB unit must be at least 3/8 HLA-matched to the patient considering high-resolution 8-allele HLA typing. * For malignant diseases follow MSKCC CBU selection algorithm * For non-malignant diseases, CBU will be required to have > 5 x 10^7 TNC/kg; high HLA allele level match is preferable * A minimum of one domestic CBU will be reserved as a backup graft

Exclusion Criteria

  • Inadequate performance status/ organ function
  • Advanced metabolic disease (EBMT handbook)
  • Active central nervous system (CNS) leukemic involvement
  • Indolent NHL or Hodgkin lymphoma with progression of disease after most recent salvage chemotherapy
  • Diagnosis of myelofibrosis or other malignancy with moderate-severe bone marrow fibrosis
  • Autologous stem cell transplant within the preceding 6 months
  • Any prior allogeneic stem cell transplant
  • Active and uncontrolled infection (bacterial/fungal/viral) at time of transplantation
  • Human immunodeficiency virus (HIV) infection
  • Seropositivity for human T-cell leukemia virus type 1 (HTLV-1)
  • 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

New York

New York
Memorial Sloan Kettering Cancer Center
Status: ACTIVE
Contact: Maria I. Cancio
Phone: 212-639-2446

PRIMARY OBJECTIVE:

I. To assess treatment related mortality (TRM) at 1 year after myeloablative cord transplant.

OUTLINE: Patients are assigned to 1 of 2 arms.

ARM I:

CONDITIONING: Patients with malignant disorders receive clofarabine IV over 2 hours, fludarabine phosphate (fludarabine) IV over 30 minutes, and busulfan IV over 3 hours on days -5 to -2. Beginning on day -3, patients receive cyclosporine IV or orally (PO) and mycophenolate mofetil IV over at least 2 hours in the absence of unacceptable toxicity. Patients may begin to taper cyclosporine at approximately 3 months post-transplant and mycophenolate mofetil at approximately 60 days post-transplant in the absence of ongoing graft versus host disease (GVHD) requiring systemic immune suppression.

TRANSPLANT: Patients undergo cord blood transplantation (CBT) on day 0.

POST-TRANSPLANT: Beginning on day 7, patients receive filgrastim subcutaneously (SC) or IV over 15-30 minutes until absolute neutrophil count (ANC) recovery.

ARM II:

CONDITIONING: Patients with non-malignant disorders receive rituximab IV on day -10 and lapine T-lymphocyte immune globulin IV over 12 hours on days -9 to -6. Patients then receive clofarabine IV over 2 hours, fludarabine IV over 30 minutes, and busulfan IV over 3 hours on days -5 to -2. Beginning on day -3, patients receive cyclosporine IV or PO and mycophenolate mofetil IV over at least 2 hours. Patients may begin to taper cyclosporine at approximately 6 months post-transplant and mycophenolate mofetil at approximately 60 days post-transplant in the absence of ongoing GVHD requiring systemic immune suppression.

TRANSPLANT: Patients undergo CBT on day 0.

POST-TRANSPLANT: Beginning on day 7, patients receive filgrastim SC or IV over 15-30 minutes until ANC recovery. Patients also receive rituximab IV on day 30.

After completion of CBT, patients are followed up at 21, 28, 42, 60, and 100 days, and then at 4, 6, 9, 12, 18, 24, and 36 months.

Trial Phase Phase II

Trial Type Treatment

Lead Organization
Memorial Sloan Kettering Cancer Center

Principal Investigator
Maria I. Cancio

  • Primary ID 20-480
  • Secondary IDs NCI-2020-11789
  • Clinicaltrials.gov ID NCT04644016