Clinical Trials /

Optimizing PTCy Dose and Timing

NCT03983850

Description:

Background: Stem cell or bone marrow transplants can cure or control blood cancers. Sometimes the donor cells see the recipient s body as foreign. This can cause complications. A high dose of the drug cyclophosphamide (PTCy) can help reduce these risks. Researchers want to see if a lower dose of PTCy can have the same benefits. Objective: To see if a lower dose of PTCy will help people with blood cancers have a more successful transplant and fewer side effects. Eligibility: People ages 12-65 with leukemia, lymphoma, or multiple myeloma that is not curable with standard therapy and is at high risk of returning without transplant, and their healthy adult relatives Design: Transplant participants will be screened with: Blood, urine, breathing, and heart tests Scans Chest x-ray Bone marrow samples: A needle inserted into the participant s pelvis will remove marrow and a bone fragment. Transplant recipients will stay at the hospital and be prepped with chemotherapy over 6 days for the transplant. They will get stem cells through a catheter in the chest or neck. They will get the cyclophosphamide chemotherapy. They will stay in the hospital about 4 more weeks. They will have blood transfusions. They will have frequent blood tests and 2 bone marrow samples within 1 year after the transplant. Donor participants will be screened with: Blood, urine, and heart tests Chest x-ray Scans Donor participants will have bone marrow taken from their pelvis or stem cells taken from their blood. For the blood donation, blood will be taken from a vein in one arm, move through a machine to remove white blood cells, and be returned through a vein in the other arm. Participation will last up to 5 years....

Related Conditions:
  • Acute Myeloid Leukemia
  • B-Cell Acute Lymphoblastic Leukemia
  • B-Cell Non-Hodgkin Lymphoma
  • Chronic Lymphocytic Leukemia
  • Chronic Myeloid Leukemia
  • Chronic Myelomonocytic Leukemia
  • Histiocytic and Dendritic Cell Neoplasm
  • Hodgkin Lymphoma
  • Mature T-Cell and NK-Cell Neoplasm
  • Multiple Myeloma
  • Myelodysplastic Syndromes
  • Primary Myelofibrosis
  • T-Cell Acute Lymphoblastic Leukemia
Recruiting Status:

Recruiting

Phase:

Phase 1/Phase 2

Trial Eligibility

Document

Title

  • Brief Title: Optimizing PTCy Dose and Timing
  • Official Title: Phase I/II Study De-intensifying Exposure of Post-transplantation Cyclophosphamide as GVHD Prophylaxis After HLA-haploidentical Hematopoietic Cell Transplantation for Hematologic Malignancies

Clinical Trial IDs

  • ORG STUDY ID: 190112
  • SECONDARY ID: 19-C-0112
  • NCT ID: NCT03983850

Conditions

  • Graft Versus Host Disease
  • Hematologic Neoplasms

Interventions

DrugSynonymsArms
BusulfanPhase I Dose De-escalation
FludarabinePhase I Dose De-escalation
CyclophosphamidePhase I Dose De-escalation
Mycophenolate MofetilPhase I Dose De-escalation
SirolimusPhase I Dose De-escalation

Purpose

Background: Stem cell or bone marrow transplants can cure or control blood cancers. Sometimes the donor cells see the recipient s body as foreign. This can cause complications. A high dose of the drug cyclophosphamide (PTCy) can help reduce these risks. Researchers want to see if a lower dose of PTCy can have the same benefits. Objective: To see if a lower dose of PTCy will help people with blood cancers have a more successful transplant and fewer side effects. Eligibility: People ages 12-65 with leukemia, lymphoma, or multiple myeloma that is not curable with standard therapy and is at high risk of returning without transplant, and their healthy adult relatives Design: Transplant participants will be screened with: Blood, urine, breathing, and heart tests Scans Chest x-ray Bone marrow samples: A needle inserted into the participant s pelvis will remove marrow and a bone fragment. Transplant recipients will stay at the hospital and be prepped with chemotherapy over 6 days for the transplant. They will get stem cells through a catheter in the chest or neck. They will get the cyclophosphamide chemotherapy. They will stay in the hospital about 4 more weeks. They will have blood transfusions. They will have frequent blood tests and 2 bone marrow samples within 1 year after the transplant. Donor participants will be screened with: Blood, urine, and heart tests Chest x-ray Scans Donor participants will have bone marrow taken from their pelvis or stem cells taken from their blood. For the blood donation, blood will be taken from a vein in one arm, move through a machine to remove white blood cells, and be returned through a vein in the other arm. Participation will last up to 5 years....

Detailed Description

      Background:

        -  Post-transplantation cyclophosphamide (PTCy) reduces rates of severe acute and chronic
           graft-versus-host disease (GVHD) after allogeneic hematopoietic cell transplantation
           (HCT) and safely facilitates human leukocyte antigen (HLA)-haploidentical HCT

        -  When clinically translated, the dose (50 mg/kg) and timing (days +3 and +4) of PTCy used
           were partly extrapolated from murine major histocompatibility complex (MHC)-matched skin
           allografting models and were partly empirical

        -  In both MHC-haploidentical and MHC-disparate murine HCT models, a dose of 25 mg/kg/day
           was superior to 50 mg/kg/day on days +3 and +4 in terms of GVHD severity and mortality

        -  In the MHC-haploidentical HCT model, a dose of 25 mg/kg on day +4 was equivalent to 25
           mg/kg/day on days +3 and +4

        -  In addition to better GVHD prevention, lower dosing of PTCy is associated with less
           broad reduction of T-cell numbers after PTCy

      Objective:

      -Determine whether a dose of PTCy 25 mg/kg on day +3 and +4 or on day +4 only can maintain
      adequate protection against grade III-IV acute GVHD.

      Eligibility:

        -  Histologically or cytologically confirmed hematologic malignancy with standard
           indication for allogeneic hematopoietic cell transplantation including one of the
           following:

             -  Acute myeloid leukemia (AML) of intermediate or adverse risk disease by the 2017
                European LeukemiaNet criteria in first morphologic complete remission

             -  AML of any risk in second or subsequent morphologic complete remission

             -  B-cell acute lymphoblastic leukemia in first or subsequent complete remission

             -  T-cell acute lymphoblastic leukemia with minimal residual disease detected after
                first line therapy and/or adverse genetics

             -  Myelodysplastic syndrome of intermediate or higher score by the Revised
                International Prognostic Scoring System (IPSS-R)

             -  Primary myelofibrosis of intermediate-2 or higher risk by the Dynamic International
                Prognostic Scoring System (DIPSS)

             -  Chronic myelomonocytic leukemia

             -  Chronic myelogenous leukemia resistant to or intolerant of greater than or equal to
                3 tyrosine kinase inhibitors or with prior history of accelerated phase or blast
                crisis

             -  B-cell lymphoma including Hodgkin lymphoma that has relapsed within 1 year of
                completion of primary treatment

             -  Chronic lymphocytic leukemia with 17p deletion and/or unmutated IgHV or refractory
                to or intolerant of both BTK and PI3K inhibitors

             -  Mature T or NK neoplasms as defined in the WHO guidelines of sufficient type and
                severity for allogeneic HCT based on the Prognostic Index for T- cell lymphoma
                (PIT) score of low-intermediate risk or higher or on recently published clinical
                practice guidelines

             -  Hematologic malignancy of dendritic cell or histiocytic cell type

             -  Multiple myeloma, stage III, relapsing after therapy with both a proteasome
                inhibitor and an immunomodulatory drug (IMiD)

        -  Age 15-65.

        -  At least one potentially suitable HLA-haploidentical donor.

        -  Karnofsky performance score greater than or equal to 60

        -  Adequate organ function

      Design:

        -  Open-label, single-center, non-randomized, phase I/II study

        -  All patients will receive myeloablative conditioning, HLA-haploidentical bone marrow
           HCT, and GVHD prophylaxis with PTCy, MMF, and sirolimus.

        -  A small pilot of 5 evaluable patients will receive the standard PTCy 50 mg/kg on days
           +3/+4 to obtain a limited amount of comparative pharmacokinetic and T-cell
           immunophenotyping and repertoire data

        -  Then the study will proceed to a small, two-level [1) 25 mg/kg/day on days +3 and +4, 2)
           25 mg/kg on day +4 only] phase I dose de-escalation study based on the standard 3+3
           approach

        -  Patients will be evaluated for development of grade III-IV acute GVHD (aGVHD) at day +60
           as the dose-limiting toxicity and then phase II will proceed with the shorter duration
           of the days of treatment (+3/+4 or +4) which is associated with 0-1 of 6 patients with
           grade III- IV aGVHD at day +60 and with the least amount of toxicity

        -  Simon optimal two-stage phase II trial design, to rule out excess grade III-IV acute
           GVHD with this decreased PTCy exposure, will be used in the phase II portion of the
           study which will enroll an additional 14 patients to see if this lower PTCy exposure is
           associated with a similar rate of grade III-IV acute GVHD as is expected with 50 mg/kg
           on days +3/+4
    

Trial Arms

NameTypeDescriptionInterventions
Donor ArmNo InterventionCollection of bone marrow and/or PBSC (Up to 40 donors)
    Phase I Dose De-escalationExperimentalPTCy at deescalating doses (25 mg /kg/day on days +3 and +4, and PTCy 25 mg/kg on day +4) to assess forsafety and determine Phase II dose (up to 12 evaluable patients)
    • Busulfan
    • Fludarabine
    • Cyclophosphamide
    • Mycophenolate Mofetil
    • Sirolimus
    Phase I Pilot for Comparative DataExperimentalStandard PTCy 50 mg/kg/day on days +3 and +4, in asmall pilot (up to 5 evaluable patients) for comparativedata
    • Busulfan
    • Fludarabine
    • Cyclophosphamide
    • Mycophenolate Mofetil
    • Sirolimus
    Phase II EfficacyExperimentalPTCy at shortest duration, safe dose (from Phase I) toassess efficacy at providing adequate protection from grade 3-4 acute GVHD (up to 14 additional patients)
    • Busulfan
    • Fludarabine
    • Cyclophosphamide
    • Mycophenolate Mofetil
    • Sirolimus

    Eligibility Criteria

            -  INCLUSION CRITERIA:
    
            Inclusion Criteria - Recipient
    
              -  Patients must have a histologically or cytologically confirmed hematologic malignancy
                 with standard indication for allogeneic hematopoietic cell transplantation limited to
                 one of the following:
    
                   -  Acute myeloid leukemia (AML) of intermediate or adverse risk disease by the 2017
                      European LeukemiaNet criteria in first morphologic complete remission (<5% blasts
                      in the bone marrow, no detectable abnormal peripheral blasts, and no
                      extramedullary disease)
    
                   -  AML of any risk in second or subsequent morphologic complete remission
    
                   -  B-cell acute lymphoblastic leukemia in first or subsequent complete remission
    
                   -  T-cell acute lymphoblastic leukemia with minimal residual disease detected after
                      first line therapy and/or adverse genetics (no NOTCH1/FBXW7 mutation or presence
                      of N/K-RAS mutation and/or PTEN gene alteration)
    
                   -  Myelodysplastic syndrome of intermediate or higher score by the Revised
                      International Prognostic Scoring System (IPSS-R)
    
                   -  Primary myelofibrosis of intermediate-2 or higher risk by the DIPSS
    
                   -  Chronic myelomonocytic leukemia
    
                   -  Chronic myelogenous leukemia resistant to or intolerant of greater than or equal
                      to 3 tyrosine kinase inhibitors or with history of accelerated phase or blast
                      crisis
    
                   -  B-cell lymphoma including Hodgkin lymphoma that has relapsed within 1 year of
                      completion of primary treatment
    
                   -  Chronic lymphocytic leukemia with 17p deletion and/or unmutated IgHV or
                      refractory to or intolerant of both BTK and PI3K inhibitors
    
                   -  Mature T or NK neoplasms as defined in the WHO guidelines of sufficient type and
                      severity for allogeneic HCT based on the Prognostic Index for T-cell lymphoma
                      (PIT) score of low-intermediate risk or higher or on recently published clinical
                      practice guidelines
    
                   -  Hematologic malignancy of dendritic cell or histiocytic cell type
    
                   -  Multiple myeloma, stage III, relapsing after therapy with both a proteasome
                      inhibitor and an immunomodulatory drug (IMiD)
    
              -  Age 15-65. Patients <18 years old must be at least 50 kg. Note: Because patients 15-17
                 years old and <50 kg are not able to be cared for on the adult oncology wards and by
                 the investigative team, they are excluded.
    
              -  At least one potentially suitable HLA-haploidentical donor.
    
              -  Karnofsky performance score greater than or equal to 60
    
              -  Adequate organ function defined as possessing all of the following:
    
                   -  Cardiac ejection fraction greater than or equal to 45% by 2D ECHO;
    
                   -  Forced expiratory volume-1 (FEV-1), forced vital capacity (FVC), and diffusing
                      capacity of the lung for carbon monoxide (DLCO) (corrected for hemoglobin) all of
                      greater than or equal to 50% predicted;
    
                   -  Estimated serum creatinine clearance of greater than or equal to 60
                      ml/minute/1.73m(2) calculated using eGRF in the clinical lab for adults and the
                      Schwartz formula for pediatric subjects;
    
                   -  Total bilirubin less than or equal to 2X the upper limit of normal;
    
                   -  Alanine aminostransferase and aspartate aminotransferase less than or equal to 3X
                      the upper limit of normal.
    
              -  Myeloablative conditioning is toxic to the developing human fetus and is teratogenic.
                 For this reason, the following measures apply:
    
                   -  Women of child-bearing potential (WOCBP) and men must agree to use adequate
                      contraception (hormonal or barrier method of birth control; abstinence) prior to
                      study entry and for at least one year post-transplant.
    
                   -  Should a woman become pregnant or suspect she is pregnant while she or her
                      partner is participating in this study, she should inform her treating physician
                      immediately.
    
                   -  WOCBP must have a negative serum or urine pregnancy test within 7 days prior to
                      enrollment.
    
              -  Ability of subject or Legally Authorized Representative to understand and the
                 willingness to sign a written informed consent document. Pediatric patients (<18 years
                 of age) will provide assent, and the parent(s) or legal guardian(s) will provide
                 informed consent.
    
              -  Subjects requiring standard therapies to prepare for HCT should be referred in
                 remission if possible. However, these diseases are often aggressive and require swift
                 evaluation for HCT while concurrently attempting to establish disease control through
                 the administration of standard therapies. If ongoing therapy for the underlying
                 disease outside of the NIH is not in the best interest of the subject according to the
                 clinical judgment of the PI, then the subject may receive up to 2 cycles of standard
                 treatment for his/her underlying hematologic malignancy as a bridge to HCT on this
                 protocol, prior to starting the research phase of the study. The subject must have a
                 Karnofsky performance status of greater than or equal to 60% at the start of the first
                 cycle to proceed. If it becomes apparent that the subject will not be able to proceed
                 to HCT, then he/she must come off study. Subjects receiving standard therapy will be
                 told about the therapy, associated risks, potential benefits, alternatives to the
                 proposed therapy, and the availability of receiving the same treatment elsewhere,
                 outside of a research protocol.
    
            Inclusion Criteria - Related Donor
    
              -  Related donor deemed suitable and eligible, and willing to donate, per clinical
                 evaluations, who are additionally willing to donate blood, bone marrow, saliva, oral
                 swab and stool for research. Related donors will be evaluated in accordance with
                 existing institutional Standard Policies and Procedures for determination of
                 eligibility and suitability for clinical donation
    
              -  Age greater than or equal to 12 years
    
            EXCLUSION CRITERIA:
    
            Exclusion Criteria - Recipient
    
              -  Patients who are receiving any other investigational agents. Prior experimental
                 therapies must have been completed at least 4 weeks prior to the date of beginning
                 conditioning.
    
              -  Uncontrolled intercurrent illness including, but not limited to, ongoing or active
                 infection excluding controlled fungal infection on appropriate treatment, symptomatic
                 congestive heart failure, unstable angina pectoris, cardiac arrhythmia, endocrinopathy
                 (significant uncontrolled or untreated hypothyroidism, hyperthyroidism, or adrenal
                 insufficiency), or active psychiatric illness/social situations that would limit
                 compliance with study requirements
    
              -  Prior myeloablative conditioning for autologous or allogeneic HCT.
    
              -  An HLA-matched-sibling donor who is available and willing to donate bone marrow. Note:
                 The patient must have access to HCT using this donor for this to be an exclusion
                 criterion.
    
              -  Pregnant women or women who intend to become pregnant during the study are excluded
                 because myeloablative conditioning is toxic to the developing fetus with the potential
                 for teratogenic or abortifacient effects.
    
              -  The potential for some of the study medications to be transmissible via breast milk of
                 nursing mothers is unknown. Because there is unknown but potential risk for adverse
                 events in nursing infants secondary to treatment of the mother, breastfeeding must be
                 discontinued.
    
              -  Active malignancy of non-hematopoietic type (excluding non-melanoma skin cancers)
                 which is: metastatic, or relapsed/refractory to treatment, or locally advanced and not
                 amenable to curative treatment, or limited disease treated with curative intent
                 treatment within the last 2 years. This excludes non-melanoma skin cancers.
    
              -  The severity of the hematologic malignancy does not warrant the potential toxicity of
                 myeloablative allogeneic HCT as judged by the PI.
    
            Exclusion Criteria - Related Donor
    
            -None
          
    Maximum Eligible Age:65 Years
    Minimum Eligible Age:12 Years
    Eligible Gender:All
    Healthy Volunteers:Accepts Healthy Volunteers

    Primary Outcome Measures

    Measure:aGVHD protection from PTCy 25 mg/kg
    Time Frame:60 days
    Safety Issue:
    Description:The fraction of evaluable patients who experience grade III-IV aGVHD at day +60 will be determined and reported along with 80% and 95% two-sided confidence intervals.

    Secondary Outcome Measures

    Measure:Determine, at the PTCy dose used in phase II, the cumulative incidences
    Time Frame:100 days
    Safety Issue:
    Description:Rate and timing of neutrophil and platelet engraftment also will be evaluated descriptively, including fractions who attain each condition at day 28 and 100, along with 95% confidence intervals. Ranges and medians will be calculated only in engrafting patients. Grade II-IV aGVHD also will be evaluated descriptively including fractions who attain each condition at day 100 and 200 days, and 95% confidence intervals. Grade III-IV aGVHD also will be evaluated descriptively including fractions who attain each condition at day 100 and 200 days, and 95% confidence intervals

    Details

    Phase:Phase 1/Phase 2
    Primary Purpose:Interventional
    Overall Status:Recruiting
    Lead Sponsor:National Cancer Institute (NCI)

    Trial Keywords

    • Human Leukocyte Antigen
    • Busulfan
    • Fludarabine
    • Mycophenolate Mofetil
    • Sirolimus

    Last Updated

    June 11, 2021