RAFA: HSCT for Patients With Fanconi Anemia Using Risk-Adjusted Chemotherapy

Sponsor
Children's Hospital Medical Center, Cincinnati (Other)
Overall Status
Recruiting
CT.gov ID
NCT02143830
Collaborator
Memorial Sloan Kettering Cancer Center (Other), Fred Hutchinson Cancer Center (Other)
70
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3
147
23.3
0.2

Study Details

Study Description

Brief Summary

The purpose of this study is to determine whether the use of lower doses of busulfan and the elimination of cyclosporine will further reduce transplant-related side effects for patients with Fanconi Anemia (FA). Patients will undergo a transplant utilizing mis-matched related or matched unrelated donors following a preparative regimen of busulfan, fludarabine, anti-thymocyte globulin and cyclophosphamide.

Condition or Disease Intervention/Treatment Phase
Phase 2

Detailed Description

The trial proposed is a three arm phase II treatment protocol designed to investigate the safety and efficacy of risk-adjusted chemotherapy-based cytoreductive regimen plus a CD34+ selected T-cell depleted peripheral blood stem cell (PBSC) stem cell transplant for the treatment of patients with Fanconi anemia and severe hematologic disease. Candidates for this trial will include patients with Fanconi anemia presenting with severe marrow failure (transfusion dependent) or myelodysplastic syndrome, or acute myelogenous leukemia for whom an allogeneic stem cell transplant is indicated.

Study Design

Study Type:
Interventional
Anticipated Enrollment :
70 participants
Allocation:
Non-Randomized
Intervention Model:
Parallel Assignment
Masking:
None (Open Label)
Primary Purpose:
Treatment
Official Title:
A Phase II Trial of HSCT for the Treatment of Patients With Fanconi Anemia Lacking a Genotypically Identical Donor, Using a Risk-Adjusted Chemotherapy Only Cytoreduction With Busulfan, Cyclophosphamide and Fludarabine
Study Start Date :
Apr 1, 2014
Anticipated Primary Completion Date :
Jul 1, 2024
Anticipated Study Completion Date :
Jul 1, 2026

Arms and Interventions

Arm Intervention/Treatment
Experimental: Arm A: Good Risk Patients

Patients 18 years old or younger with marrow aplasia or single lineage cytopenias will be receive intravenous busulfan (4 doses x 2 days), cyclophosphamide (4 doses x 4 days) and fludarabine (4 doses x 4 days), as used in our most current study that led to > 90% survival rates . Busulfan pharmacokinetics will not be used. All patients will receive rabbit ATG (4 doses x 4 days) prior to and granulocyte-colony stimulating factor (G-CSF) after transplant to promote engraftment. Cyclosporine will not be used for GVHD prophylaxis. The source of the stem cells for all patients will be peripheral blood stem cells mobilized by treatment of the donor with G-CSF. T-cell depletion will be performed by positive CD34 selection with the use of the Miltenyi system (CliniMACS device). Enrollment on this arm will include up to 50 patients.

Drug: Busulfan
A standard dose of busulfan, associated with excellent outcomes in our previous trial will be used for young patients with marrow aplasia (arm A). A higher dose of busulfan will be used in younger patients with MDS and AML (arm B) to maximize disease control. A lower dose of busulfan will be used in older patients (arm C) to minimize toxicity.
Other Names:
  • Myleran
  • Busulfex IV
  • Drug: Cyclophosphamide
    Arms A, B and C - Cytoxan will be given as a 1-2 hour infusion for 4 days. The dose will be adjusted according to patients ideal body weight for obese patients.
    Other Names:
  • Cytoxan
  • Drug: Fludarabine
    Arms A, B and C - Fludarabine will be given IV over 30 minutes daily for 4 days. The dose will be adjusted according to renal function according to Institutional guidelines.
    Other Names:
  • Fludara
  • Drug: rabbit ATG
    Arms A, B and C - 4 doses will be given prior to transplant to promote engraftment.
    Other Names:
  • thymoglobulin
  • Drug: G-CSF
    All patients will also receive G-CSF post-transplant to foster engraftment.
    Other Names:
  • Granulocyte colony-stimulating factor
  • filgrastim
  • neupogen
  • Biological: Peripheral blood stem cell
    The source of stem cells for all patients will be peripheral blood stem cells (PBSC) induced and mobilized by treatment of the donor with G-CSF for 4-6 days. T-cell depletion will be uniformly performed by positive CD34 selection with the use of the Miltenyi system (CliniMACS device).

    Experimental: Arm B: Intermediate Risk Patients

    Patients 18 years old or younger with MDS or AML will receive intravenous busulfan (4 doses x 2 days), cyclophosphamide (4 doses x 4 days) and fludarabine (4 doses x 4 days). Busulfan pharmacokinetics will be used in this arm, as the dose of busulfan is higher. All patients will receive rabbit ATG (thymoglobulin) (4 doses x 4 days) prior to and G-CSF post transplant to promote engraftment. Cyclosporine will not be used for prophylaxis against GVHD. The source of the stem cells for all patients will be peripheral blood stem cells induced and mobilized by treatment of the donor. T-cell will be performed by positive CD34 selection with the use of the Miltenyi system (CliniMACS device). The maximum number of patients enrolled in this arm will be 10.

    Drug: Busulfan
    A standard dose of busulfan, associated with excellent outcomes in our previous trial will be used for young patients with marrow aplasia (arm A). A higher dose of busulfan will be used in younger patients with MDS and AML (arm B) to maximize disease control. A lower dose of busulfan will be used in older patients (arm C) to minimize toxicity.
    Other Names:
  • Myleran
  • Busulfex IV
  • Drug: Cyclophosphamide
    Arms A, B and C - Cytoxan will be given as a 1-2 hour infusion for 4 days. The dose will be adjusted according to patients ideal body weight for obese patients.
    Other Names:
  • Cytoxan
  • Drug: Fludarabine
    Arms A, B and C - Fludarabine will be given IV over 30 minutes daily for 4 days. The dose will be adjusted according to renal function according to Institutional guidelines.
    Other Names:
  • Fludara
  • Drug: rabbit ATG
    Arms A, B and C - 4 doses will be given prior to transplant to promote engraftment.
    Other Names:
  • thymoglobulin
  • Drug: G-CSF
    All patients will also receive G-CSF post-transplant to foster engraftment.
    Other Names:
  • Granulocyte colony-stimulating factor
  • filgrastim
  • neupogen
  • Biological: Peripheral blood stem cell
    The source of stem cells for all patients will be peripheral blood stem cells (PBSC) induced and mobilized by treatment of the donor with G-CSF for 4-6 days. T-cell depletion will be uniformly performed by positive CD34 selection with the use of the Miltenyi system (CliniMACS device).

    Experimental: Arm C: High Risk Patients

    Patients 19 years old or older with marrow aplasia or MDS or AML will receive intravenous busulfan (4 doses x 2 days), cyclophosphamide (4 doses x 4 days) and fludarabine (4 doses x 4 days). In this study, we will test whether outcomes can be improved, yet engraftment maintained, with a slightly reduced dose of busulfan. Patients will receive rabbit ATG (4 doses x 4 days) prior to and G-CSF post transplant to promote engraftment. Cyclosporine will not be used for GVHD prophylaxis. The source of the stem cells will be peripheral blood stem cells collected from donors treated with G-CSF. T-cell depletion will be performed by positive CD34 selection with the use of the Miltenyi system (CliniMACS device). The maximum number of patients enrolled will be 10.

    Drug: Busulfan
    A standard dose of busulfan, associated with excellent outcomes in our previous trial will be used for young patients with marrow aplasia (arm A). A higher dose of busulfan will be used in younger patients with MDS and AML (arm B) to maximize disease control. A lower dose of busulfan will be used in older patients (arm C) to minimize toxicity.
    Other Names:
  • Myleran
  • Busulfex IV
  • Drug: Cyclophosphamide
    Arms A, B and C - Cytoxan will be given as a 1-2 hour infusion for 4 days. The dose will be adjusted according to patients ideal body weight for obese patients.
    Other Names:
  • Cytoxan
  • Drug: Fludarabine
    Arms A, B and C - Fludarabine will be given IV over 30 minutes daily for 4 days. The dose will be adjusted according to renal function according to Institutional guidelines.
    Other Names:
  • Fludara
  • Drug: rabbit ATG
    Arms A, B and C - 4 doses will be given prior to transplant to promote engraftment.
    Other Names:
  • thymoglobulin
  • Drug: G-CSF
    All patients will also receive G-CSF post-transplant to foster engraftment.
    Other Names:
  • Granulocyte colony-stimulating factor
  • filgrastim
  • neupogen
  • Biological: Peripheral blood stem cell
    The source of stem cells for all patients will be peripheral blood stem cells (PBSC) induced and mobilized by treatment of the donor with G-CSF for 4-6 days. T-cell depletion will be uniformly performed by positive CD34 selection with the use of the Miltenyi system (CliniMACS device).

    Outcome Measures

    Primary Outcome Measures

    1. Graft Failure or Rejection [5 years]

      Primary non-engraftment is diagnosed when the patient fails to achieve an ANC >=500/mm3 at any time in the first 28 days post-transplant. If (1) after achievement of an absolute neutrophil count (ANC) >=500/mm3, the ANC declines to <500/mm3 for more than 3 consecutive days in the absence of relapse, or, (2) there is absence of donor cells in the marrow and/or blood as demonstrated by chimerism assay in the absence of relapse, a diagnosis of secondary graft failure is made. The patient is not evaluable for graft failure or rejection if recurrence of host MDS is detected concurrently.

    Secondary Outcome Measures

    1. Post-transplant severe morbidity and mortality [2 years post-transplant]

      The occurrence of severe post-transplant regimen-related severe morbidity (grade IV toxicity) and/or mortality will be the second endpoint of this study. In the context of the agents or agent-combination used for cytoreduction used, particular attention will be given to toxicity involving (1) the liver, (2) the lungs, (3) the oral mucosa and gastrointestinal tract, and (4) the central nervous system.

    Other Outcome Measures

    1. Graft Versus Host Disease [One year]

      Patients will be observed for acute and/or chronic graft versus host disease (GvHD). Standard clinical criteria for the grading of acute and chronic GvHD will be done according to IBMTR guidelines.

    2. Leukemic Relapse [5 years]

      For patients with MDS or AML, relapse will be analyzed as to type and genetic origin of the MDS/leukemic cells.

    3. Secondary malignancies [5 years]

      Patients will be followed for 5 years through annual contact with their treatment center in order to track the risk of developing a secondary malignancy.

    Eligibility Criteria

    Criteria

    Ages Eligible for Study:
    3 Months and Older
    Sexes Eligible for Study:
    All
    Accepts Healthy Volunteers:
    No
    Inclusion Criteria:
    • Patients must have a diagnosis of Fanconi anemia

    • Patients must have one of the following hematologic diagnoses:

    1. Severe Aplastic Anemia (SAA), with bone marrow cellularity of <25% OR Severe
    Isolated Single Lineage Cytopenia and at least one of the following features:
    1. Platelet count <20 x 109/L or platelet transfusion dependence*

    2. ANC <1000 x 109/L

    3. Hgb <8 gm/dl or red cell transfusion dependence*

    4. Myelodysplastic Syndrome (MDS) (based on WHO or IPSS Classification

    5. Acute Myelogenous Leukemia (untreated, in remission or with refractory or relapsed disease)

    • Donors will be either human leukocyte antigen (HLA) compatible unrelated or HLA-genotypically matched related donors (no fully matched sibling donor).

    • Patients and donors may be of either gender or any ethnic background.

    • Patients must have a Karnofsky adult, or Lansky pediatric performance scale status > 70%.

    • Patients must have adequate physical function measured by:

    1. Cardiac: asymptomatic or if symptomatic then 1) left ventricular ejection fraction (LVEF) at rest must be > 50% and must improve with exercise or 2) Shortening Fraction > 29%

    2. Hepatic: < 5 x upper limit of normal (ULN) alanine transaminase (ALT) and < 2.0 mg/dl total serum bilirubin.

    3. Renal: serum creatinine <1.5 mg/dl or if serum creatinine is outside the normal range, then CrCl > 50 ml/min/1.73 m2

    4. Pulmonary: asymptomatic or if symptomatic, DLCO > 50% of predicted

    • Each patient must be willing to participate as a research subject and must sign an informed consent form.

    • Female patients and donors must not be pregnant or breastfeeding at the time of signing consent. Women must be willing to undergo a pregnancy test prior to transplant and avoid becoming pregnant while on study.

    Exclusion Criteria:
    • Active CNS leukemia

    • Female patients who are pregnant (positive serum or urine HCG) or breast-feeding.

    • Active uncontrolled viral, bacterial or fungal infection

    • Patient seropositive for HIV-I/II; HTLV -I/II

    Contacts and Locations

    Locations

    Site City State Country Postal Code
    1 Memorial Sloan Kettering Cancer Center New York New York United States 10174
    2 Cincinnati Children's Hospital Medical Center Cincinnati Ohio United States 45229
    3 Fred Hutchinson Cancer Research Center Seattle Washington United States 98109

    Sponsors and Collaborators

    • Children's Hospital Medical Center, Cincinnati
    • Memorial Sloan Kettering Cancer Center
    • Fred Hutchinson Cancer Center

    Investigators

    • Principal Investigator: Parinda Mehta, MD, CCHMC

    Study Documents (Full-Text)

    None provided.

    More Information

    Publications

    None provided.
    Responsible Party:
    Children's Hospital Medical Center, Cincinnati
    ClinicalTrials.gov Identifier:
    NCT02143830
    Other Study ID Numbers:
    • 2013-7501
    First Posted:
    May 21, 2014
    Last Update Posted:
    Apr 8, 2022
    Last Verified:
    Apr 1, 2022

    Study Results

    No Results Posted as of Apr 8, 2022