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The EndRAD Trial: Eliminating Total Body Irradiation (TBI) for NGS-MRD Negative Children, Adolescents, and Young Adults With B-ALL

NCT03509961

Description:

This study will evaluate the use of non- TBI (total body irradiation) conditioning for B-ALL patients with low risk of relapse as defined by absence of NGS-MRD (next generation sequencing minimal residual disease) before receiving a hematopoietic cell transplant (HCT). Patients diagnosed with B-ALL who are candidates for HCT will be screened by NGS-MRD on a test of bone marrow done before the HCT. Subjects who are pre-HCT NGS-MRD negative will be eligible to receive a non-TBI conditioning regimen as part of the treatment cohort of the study. Subjects who are pre-HCT NGS-MRD positive will be treated as per treating center standard and will be followed in an observational cohort (HCT center standard of care).

Related Conditions:
  • B-Cell Acute Lymphoblastic Leukemia
  • Mixed Phenotype Acute Leukemia
  • T-Cell Acute Lymphoblastic Leukemia
Recruiting Status:

Recruiting

Phase:

Phase 2

Trial Eligibility

Document

Title

  • Brief Title: The EndRAD Trial: Eliminating Total Body Irradiation (TBI) for NGS-MRD Negative Children, Adolescents, and Young Adults With B-ALL
  • Official Title: A Phase II Pilot Trial to Estimate Survival After a Non-total Body Irradiation (TBI) Based Conditioning Regimen in Patients Diagnosed With B-acute Lymphoblastic Leukemia (ALL) Who Are Pre-allogeneic Hematopoietic Cell Transplantation (HCT) Next-generation-sequence (NGS) Minimal Residual Disease (MRD) Negative

Clinical Trial IDs

  • ORG STUDY ID: PBMTC ONC1701
  • NCT ID: NCT03509961

Conditions

  • B-cell Acute Lymphoblastic Leukemia

Interventions

DrugSynonymsArms
Myeloablative allogeneic HCT with a non-TBI conditioning regimenTreatment Arm

Purpose

This study will evaluate the use of non- TBI (total body irradiation) conditioning for B-ALL patients with low risk of relapse as defined by absence of NGS-MRD (next generation sequencing minimal residual disease) before receiving a hematopoietic cell transplant (HCT). Patients diagnosed with B-ALL who are candidates for HCT will be screened by NGS-MRD on a test of bone marrow done before the HCT. Subjects who are pre-HCT NGS-MRD negative will be eligible to receive a non-TBI conditioning regimen as part of the treatment cohort of the study. Subjects who are pre-HCT NGS-MRD positive will be treated as per treating center standard and will be followed in an observational cohort (HCT center standard of care).

Detailed Description

      A Phase II pilot trial will estimate survival after a non-TBI based conditioning regimen in
      patients diagnosed with B-acute lymphoblastic leukemia (ALL) who are pre-allogeneic
      hematopoietic cell transplantation (HCT) next-generation-sequence (NGS) minimal residual
      disease (MRD) negative.

      The relationship of NGS-MRD status to survival in children, adolescents, and young adults
      with B-ALL undergoing any approach to allogeneic HCT will be explored in a larger cohort
      (treatment [phase II] and observational arms of the study).

      The primary objective is to estimate 2-year event free survival (EFS) in pre-HCT NGS-MRD
      negative patients with B-ALL undergoing a non-TBI based conditioning regimen through a
      multi-center prospective trial. The accrual period is 3 years.

      Patients that are NGS-MRD negative with B-ALL may be eligible for the Treatment Arm, which is
      myeloablative non-TBI conditioning with busulfan, fludarabine, and thiotepa followed -matched
      related, unrelated, and umbilical cord blood transplants. Patients that are NGS-MRD positive
      will be followed on the observational arm for outcome.

      Study sampling will include NGS-MRD bone marrow (BM) aspirate and peripheral blood (PB)
      samples collected [same day when possible] pre-HCT (within 4 weeks), and post-HCT on days 42
      ± 14, 100 ± 20, and 365 ± 60; PB samples only will also be collected day 180± 60 and 270± 60;
      day +30, day +100, and 1-year post-HCT. NGS-MRD peripheral blood sample only at 6 months and
      9 months post-HCT; (Blast specimen at time of diagnosis or relapse is required for NGS-MRD
      testing).
    

Trial Arms

NameTypeDescriptionInterventions
Observational ArmOtherPatients are enrolled to the observational arm to proceed with NGS-MRD testing pre-HCT. If NGS-MRD negative, eligible patients may be considered for the Treatment Arm to receive a myeloablative non-TBI conditioning regimen prior to HCT. If NGS-MRD positive, patients may continue in the observational arm and receive HCT under the direction of their transplant physician and followed on the study for outcome.
    Treatment ArmOtherPatients enrolled to the observational arm that are NGS-MRD pre-HCT are considered for the Treatment Arm. Patients will receive a myeloablative non-TBI conditioning regimen prior to the transplant consisting on busulfan, fludarabine and thiotepa. Patients will be followed for outcome for up to 5 years.
    • Myeloablative allogeneic HCT with a non-TBI conditioning regimen

    Eligibility Criteria

            Inclusion Criteria for the Observational Arm:
    
            Any patient with ALL who undergoes Myeloablative HCT including any of the following:
    
              -  Patients who are pre-HCT NGS-MRD positive.
    
              -  Patients <1 year old who are pre-HCT NGS-MRD negative.
    
              -  Patients who are pre-HCT NGS-MRD negative (CR1/CR2) who received inotuzumab ozogamicin
                 therapy before proceeding to HCT.
    
              -  Patients who are pre-HCT NGS-MRD negative and will be receiving haploidentical HCT.
    
              -  Patients who are pre-HCT NGS-MRD negative in CR2 with history of CNS relapse.
    
              -  Patients who have received blinatumomab, but are >CR2 prior to HCT.
    
              -  Patients who have received CART-T cellular therapy, but are >CR2 prior to HCT.
    
              -  Patients with pre-HCT NGS-MRD negative in ≥ CR3.
    
              -  Any T-ALL and MPAL patients undergoing first allogeneic HCT
    
              -  Any patient who is pre-HCT NGS-MRD negative and eligible for participation in the
                 treatment arm but family does not consent for treatment arm or treating physician
                 believe it is in the patient best interest not to enroll on the treatment arm
    
            Inclusion Criteria for the Treatment Arm:
    
              -  Pre-HCT NGS-MRD negative
    
              -  Age ≥ 1 year and ≤ 25 years
    
              -  Disease status: B-ALL in first (CR1) or second remission (CR2)
    
              -  No prior allogeneic hematopoietic stem cell transplant.
    
              -  Patients in CR1 or CR2 after blinatumomab treatment.
    
              -  Patients in CR1 or CR2 after CAR-T cellular therapy.
    
              -  Karnofsky Index or Lansky Play-Performance Scale ≥ 60 % on pre-transplant evaluation.
                 Karnofsky scores must be used for patients > 16 years of age and Lansky scores for
                 patients < 16 years of age.
    
              -  Able to give informed consent if > 18 years, or with a legal guardian capable of
                 giving informed consent if < 18 years.
    
              -  Adequate organ function (within 4 weeks of initiation of preparative regimen), defined
                 as:
    
              -  Pulmonary: FEV1, FVC, and corrected DLCO must all be ≥ 50% of predicted by pulmonary
                 function tests (PFTs). For children who are unable to perform for PFTs due to age, the
                 criteria are: no evidence of dyspnea at rest and no need for supplemental oxygen.
    
              -  Renal: Creatinine clearance or radioisotope GFR ≥ 60 mL/min/1.73 m2 or a serum
                 creatinine based on age/gender.
    
              -  Cardiac: Shortening fraction of ≥ 27% by echocardiogram or radionuclide scan (MUGA) or
                 ejection fraction of ≥ 50% by echocardiogram or radionuclide scan (MUGA), choice of
                 test according to local standard of care.
    
              -  Hepatic: SGOT (AST) or SGPT (ALT) < 5 x upper limit of normal (ULN) for age.
                 Conjugated bilirubin < 2.5 mg/dL, unless attributable to Gilbert's Syndrome.
    
            Exclusion Criteria:
    
              -  CR2: exclude patients with history of CNS relapse (i.e. in CR2 with history of CNS
                 isolated or combined relapse; CNS 2 will also be considered as CNS 3 for this purpose)
                 from the treatment arm of study (can be enrolled on the observational arm).
    
              -  Patients who have received inotuzumab treatment prior to allogeneic HCT are NOT
                 eligible for the study treatment arm. Inotuzumab treatment may increase the risk of
                 VOD/SOS for any allogeneic HCT recipient, but could potentiate the risk for with
                 busulfan-based myeloablation (study-directed non-TBI conditioning). All
                 inotuzumab-treated patients are eligible for the observational arm (HCT center
                 standard of care).
    
              -  Patients receiving non-myeloablative conditioning are not allowed on the observational
                 arm (reduced toxicity conditioning with Flu/Mel/Thio is allowed on the observational
                 arm).
    
              -  Pregnant or lactating females are ineligible as many of the medications used in this
                 protocol could be harmful to unborn children and infants.
    
              -  Patients with HIV or uncontrolled fungal, bacterial or viral infections are excluded.
                 Patients with history of fungal disease during induction therapy may proceed if they
                 have a significant response to antifungal therapy with no evidence or minimal evidence
                 of non-progressive disease remaining by CT evaluation.
    
              -  Patients with active CNS leukemia or any other active site of extramedullary disease
                 at the time of enrollment are not permitted.
    
              -  T-ALL and MPAL patients are only allowed on the observational arm.
    
              -  Patients with genetic disorders (generally marrow failure syndromes) prone to
                 secondary AML/ALL with known poor outcome are not eligible (Fanconi Anemia, Kostmann
                 Syndrome, Dyskeratosis Congenita, etc).
          
    Maximum Eligible Age:25 Years
    Minimum Eligible Age:1 Year
    Eligible Gender:All
    Healthy Volunteers:No

    Primary Outcome Measures

    Measure:Two Year Event-free Survival
    Time Frame:Two years
    Safety Issue:
    Description:The primary objective of this study is the two Year Event-free Survival for patients with high-risk or recurrent B-ALL who proceed to HCT and who are NGS-MRD negative when treated with a non-TBI preparative regimen.

    Details

    Phase:Phase 2
    Primary Purpose:Interventional
    Overall Status:Recruiting
    Lead Sponsor:Children's Hospital Los Angeles

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