Summary

This phase II trial studies how well naive T-cell depletion works in preventing chronic graft-versus-host disease in children and young adults with blood cancers undergoing donor stem cell transplant. Sometimes the transplanted white blood cells from a donor attack the body’s normal tissues (called graft versus host disease). Removing a particular type of T cell (naive T cells) from the donor cells before the transplant may stop this from happening.

Objectives

PRIMARY OBJECTIVES:
I. To confirm that selective depletion of naive T cell (TN) from peripheral blood stem cell (PBSC) grafts is feasible in a multi-institutional setting. (Feasibility phase)
II. To confirm that engraftment with neutrophils is achieved by day +28. (Feasibility phase)
III. To compare the ‘current-graft-versus-host disease (GVHD)-free, relapse-free survival’ at one year post-hematopoietic cell transplantation (HCT) between subjects who receive allogeneic HCT using TN-depleted PBSC and those who receive unmanipulated T cell-replete bone marrow (BM). (Randomized Controlled Trial [RCT])

SECONDARY OBJECTIVES:
I. To compare the probabilities/proportions of the following outcomes between subjects who receive allogeneic HCT using TN-depleted PBSC and those who receive unmanipulated T cell-replete BM:
* Chronic GVHD (cGVHD) (National Institutes of Health [NIH] criteria) requiring prednisone (or equivalent systemic corticosteroid).
* Proportion of subjects alive and off prednisone (or equivalent systemic corticosteroid) for treatment of GVHD at 3, 6, 9, 12, 15, 18, 21, 24 months post-HCT.
* Time-to-neutrophil engraftment.
* Time-to-platelet engraftment.
* Acute GVHD (aGVHD) grade III-IV.
* AGVHD grade II-IV.
* Overall survival (OS).
* Disease-free survival (DFS).
* Non-relapse mortality (NRM).
* Relapse.
* Days alive out of hospital in the first year post-HCT.
* Infection and viral reactivation.
* Peripheral blood (PB) chimerism (CD3+ and CD33+).
* Lymphocyte recovery.
* Immune dysregulation phenomenon (including: type 1 diabetes mellitus, Grave’s disease, immune-mediated cytopenias, other newly diagnosed immune dysregulation [other than GVHD]).
* Thrombotic microangiopathy (TMA).

OUTLINE: Patients are randomized to 1 of 2 arms. All patients receive 1 of 3 conditioning regimens.

CONDITIONING REGIMEN A: Patients undergo total body irradiation (TBI) twice daily (BID) on days -10 to -7, then receive thiotepa intravenously (IV) over 3 hours once daily (QD) on days -6 and -5, and fludarabine IV over 30 minutes once daily on days -6 to -2.

CONDITIONING REGIMEN B: Patients undergo TBI BID on days -8 to -5, then receive fludarabine IV over 30 minutes QD on days -4 to -2, and cyclophosphamide IV over 1 hour QD on days -3 and -2.

CONDITIONING REGIMEN C: Patients receive fludarabine IV over 30 minutes QD on days -6 to -2, busulfan IV over 180 minutes QD on days -5 to -2, and undergo total body irradiation BID on day -1.

ARM I: Patients receive naive T-cell depleted PBSCs on day 0.

ARM II: Patients receive unmanipulated T cell-replete BM on day 0.

GVHD PROPHYLAXIS: All patients receive tacrolimus IV on days -1 to +50 followed by a taper in the absence of grade II-IV aGVHD. Patients also receive methotrexate IV on days +1, +3, +6, and +11.

After completion of study treatment, patients are followed up periodically.

Eligibility

1. The patient must have one of the following diagnoses and be considered to be an appropriate candidate for allogeneic HCT by the study site principal investigator (PI): * Acute lymphoblastic leukemia (ALL) with < 5% marrow blasts. * Acute myeloid leukemia (AML) with < 25% marrow blasts. * Other acute leukemia (OAL) including but not limited to acute biphenotypic leukemia (ABL), ambiguous lineage (ALAL), mixed phenotype acute leukemia (MPAL), blastic plasmacytoid dendritic cell neoplasm (BPDCN), and acute undifferentiated leukemia (AUL) with < 5% marrow blasts. * Myelodysplastic syndrome (MDS) with excess blasts (EB-1 and EB-2) and has received cytotoxic induction chemotherapy.
2. Age 6 months to 22 years at the time informed consent.
3. Matched related donor (MRD) or matched unrelated donor (MUD) (defined as 8/8 match for human leukocyte antigen [HLA]-A, -B, -C, -DRB1).
4. Planned product type for infusion is PBSC or BM (i.e. not cord blood): * For feasibility phase, planned product type for infusion must be PBSC. * For RCT, planned product type must be PBSC or BM.
5. Karnofsky or Lansky score >= 60%.
6. Left ventricular ejection fraction (LVEF) at rest >= 40%.
7. Diffusing capacity of the lungs for carbon monoxide (DLCO) (corrected for hemoglobin) >= 60% predicted by pulmonary function tests (PFTs) * Patients who are unable to perform PFTs (age < 6 years or considered developmentally incapable of PFTs): oxygen saturation (by oximetry) must be >= 92% on room air.
8. Total bilirubin =< 2 x upper limit of normal (ULN) (unless value[s] > 2 x ULN are disease- or medication-related). * If value(s) are > 2 x ULN and not disease- or medication related, patient must be evaluated by a gastrointestinal (GI) physician. If GI physician considers protocol treatment to be contraindicated for the patient, the patient will not be eligible for the study.
9. Alanine aminotransferase (ALT), aspartate aminotransferase (AST) =< 2 x ULN (unless value[s] > 2 x ULN are disease- or medication-related). * If value(s) are > 2 x ULN and not disease- or medication related, patient must be evaluated by a gastrointestinal GI physician. If GI physician considers protocol treatment to be contraindicated for the patient, the patient will not be eligible for the study.
10. Serum creatinine (SCr) within normal range for age. If SCr is outside normal range for age, creatinine clearance (CrCl) > 40 mL/min/1.73m^2 must be obtained (measured by 24-hour [hr] urine specimen or nuclear glomerular filtration rate [GFR]). * Age (Years): Maximum SCr (mg/dL) * =< 5: 0.8 * 6-10: 1 * 11-15: 1.2 * > 15: 1.5
11. Recipient informed consent/assent/legal guardian permission documentation must be obtained.
12. DONOR: May be related (MRD) or unrelated (MUD) to the subject.
13. DONOR: Must be matched to the subject at 8/8 HLA alleles (HLA-A, -B, -C, and –DRB1)
14. DONOR: Be >=14 years of age.
15. DONOR: Must be available to donate in the United States of America (USA) (i.e. excludes international donors).
16. DONOR: Must agree to donate BM or PBSC (i.e. agree to donate whichever product type is requested) (applicable only to the RCT phase of this study).
17. DONOR: MUDs: * Must give informed consent according to applicable National Marrow Donor Program (NMDP) donor regulatory requirements * Must meet eligibility criteria as defined by the NMDP or be ineligible with statement of urgent medical need (exception 21 CFR 1271.65(b)(iii)) ** Tests must be performed using Food and Drug Administration (FDA) licensed, cleared, and approved test kits in a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory
18. DONOR: MRDs: * Must be negative for human immunodeficiency virus (HIV)-1, HIV-2, human T-lymphotropic virus (HTLV)-1, HTLV-2, hepatitis B, hepatitis C (serological and/or nucleic acid testing [NAT] and/or other approved testing) * Must meet institutional donor eligibility criteria, or be ineligible with statement that the donor is a first or second degree relative (exception 21 CRF 1271.65(b)(i)). ** Tests must be performed using FDA licensed, cleared, and approved test kits in a CLIA-certified laboratory.

Treatment Sites in Georgia