Tocilizumab for the Prevention of Graft Failure and GVHD in Haplo-Cord Transplantation

Sponsor

Weill Medical College of Cornell University (Other)

Overall Status

Recruiting

CT.gov ID

NCT04395222

Collaborator

(none)

Enrollment

Location

Arms

33.8

Anticipated Duration (Months)

2.1

Patients Per Site Per Month

Study Details

Study Description

Brief Summary

The purpose of this study is to evaluate the safety of reducing and ultimately eliminating anti-thymocyte globulin (ATG) from the haplo-cord transplant conditioning regimen and replacing it with tocilizumab, an IL-6 receptor monoclonal antibody, to improve immune reconstitution and reduce relapse while preserving low rates of graft failure and graft versus host disease (GVHD).

Condition or Disease	Intervention/Treatment	Phase
Hematologic Malignancy Bone Marrow Transplant	Drug: Tocilizumab Drug: Fludarabine Drug: Melphalan Drug: Anti-thymocyte globulin (rabbit) Radiation: Total Body Irradiation	Phase 2

Detailed Description

This study is a prospective phase II non-inferiority study investigating tocilizumab as a potential alternative to anti-thymocyte globulin (ATG) in haplo-cord transplantation. It is a single-center study based at Weill Cornell Medicine/NewYork Presbyterian Hospital.

The hypothesis is that tocilizumab is a safe and effective alternative to ATG in haplo-cord transplantation, facilitating transient engraftment of the haplo-identical stem cell graft without prolonged neutropenia or second nadir prior to durable cord engraftment while also preventing graft versus host disease (GVHD).

This study plans to enroll patients with hematologic malignancies in need of alternate donor transplant. All subjects will be conditioned with fludarabine, melphalan and total body irradiation (TBI), followed by a single dose of tocilizumab 8 mg/kg on Day -1. Patients will be enrolled into 4 successive cohorts, initially administering the current standard 3 doses of ATG 1.5 mg/kg (total 4.5 mg/kg). In the absence of safety signals, we will drop one dose of ATG in successive cohorts until the drug ultimately has been eliminated.

The primary endpoint of the study is successful haplo-derived neutrophil engraftment. Treatment will only be of interest if there is evidence that this rate is greater than 60%. If there are 4 or fewer successes, that dose group will be deemed unacceptable and the next higher ATG dose for which there were 5 or more success will be expanded.

Study Design

Study Type:

Interventional

Anticipated Enrollment :

70 participants

Allocation:

Non-Randomized

Intervention Model:

Sequential Assignment

Masking:

None (Open Label)

Primary Purpose:

Treatment

Official Title:

A Prospective Study of Tocilizumab for the Prevention of Graft Failure and Graft-versus-Host Disease in Haplo-Cord Transplantation

Actual Study Start Date :

Oct 7, 2020

Anticipated Primary Completion Date :

Aug 1, 2022

Anticipated Study Completion Date :

Aug 1, 2023

Arms and Interventions

Arm	Intervention/Treatment
Experimental: ATG Group I Anti-thymocyte Globulin (ATG) 1.5 mg/kg administered on Day -5, Day -3 and Day -1 of the transplant conditioning regimen. Fludarabine 30mg/m2 administered on Day -7 through Day -3 of transplant conditioning regimen (if under 60 years old), or on Day -5 through Day -3 of transplant conditioning regimen (if over 60 years old) Melphalan 140 mg/m2 administered on Day -2 of transplant conditioning regimen. Total Body Irradiation 2 Gray administered on Day -4, Day -3 of transplant conditioning regimen. Tocilizumab 8 mg/kg administered on Day -1 of transplant conditioning regimen.	Drug: Tocilizumab Tocilizumab 8 mg/kg intravenously administered as a single dose on Day -1 of transplant conditioning regimen Other Names: Actemra Drug: Fludarabine Fludarabine 30 mg/m2 intravenously administered on Day -7, Day -6, Day -5, Day -4, Day -3 of transplant conditioning regimen if under the age of 60. If over the age of 60, Fludarabine 30 mg/m2 intravenously administered on Day -5, Day -4 and Day -3 of transplant conditioning regimen. Other Names: Fludara Drug: Melphalan Melphalan 140 mg/m2 intravenously administered on Day -2 of transplant conditioning regimen. Other Names: Alkeran Drug: Anti-thymocyte globulin (rabbit) Anti-thymocyte globulin (ATG) 1.5 mg/kg Other Names: Thymoglobulin Radiation: Total Body Irradiation Total Body Irradiation (TBI) 2 Gray, administered on Day -4 and Day -3 of transplant conditioning regimen
Experimental: ATG Group II Anti-thymocyte Globulin (ATG) 1.5 mg/kg administered on Day -5, and Day -3 of the transplant conditioning regimen. Fludarabine 30mg/m2 administered on Day -7 through Day -3 of transplant conditioning regimen (if under 60 years old), or on Day -5 through Day -3 of transplant conditioning regimen (if over 60 years old) Melphalan 140 mg/m2 administered on Day -2 of transplant conditioning regimen. Total Body Irradiation 2 Gray administered on Day -4, Day -3 of transplant conditioning regimen. Tocilizumab 8 mg/kg administered on Day -1 of transplant conditioning regimen.	Drug: Tocilizumab Tocilizumab 8 mg/kg intravenously administered as a single dose on Day -1 of transplant conditioning regimen Other Names: Actemra Drug: Fludarabine Fludarabine 30 mg/m2 intravenously administered on Day -7, Day -6, Day -5, Day -4, Day -3 of transplant conditioning regimen if under the age of 60. If over the age of 60, Fludarabine 30 mg/m2 intravenously administered on Day -5, Day -4 and Day -3 of transplant conditioning regimen. Other Names: Fludara Drug: Melphalan Melphalan 140 mg/m2 intravenously administered on Day -2 of transplant conditioning regimen. Other Names: Alkeran Drug: Anti-thymocyte globulin (rabbit) Anti-thymocyte globulin (ATG) 1.5 mg/kg Other Names: Thymoglobulin Radiation: Total Body Irradiation Total Body Irradiation (TBI) 2 Gray, administered on Day -4 and Day -3 of transplant conditioning regimen
Experimental: ATG Group III Anti-thymocyte Globulin (ATG) 1.5 mg/kg administered on Day -5 of the transplant conditioning regimen. Fludarabine 30mg/m2 administered on Day -7 through Day -3 of transplant conditioning regimen (if under 60 years old), or on Day -5 through Day -3 of transplant conditioning regimen (if over 60 years old) Melphalan 140 mg/m2 administered on Day -2 of transplant conditioning regimen. Total Body Irradiation 2 Gray administered on Day -4, Day -3 of transplant conditioning regimen. Tocilizumab 8 mg/kg administered on Day -1 of transplant conditioning regimen.	Drug: Tocilizumab Tocilizumab 8 mg/kg intravenously administered as a single dose on Day -1 of transplant conditioning regimen Other Names: Actemra Drug: Fludarabine Fludarabine 30 mg/m2 intravenously administered on Day -7, Day -6, Day -5, Day -4, Day -3 of transplant conditioning regimen if under the age of 60. If over the age of 60, Fludarabine 30 mg/m2 intravenously administered on Day -5, Day -4 and Day -3 of transplant conditioning regimen. Other Names: Fludara Drug: Melphalan Melphalan 140 mg/m2 intravenously administered on Day -2 of transplant conditioning regimen. Other Names: Alkeran Drug: Anti-thymocyte globulin (rabbit) Anti-thymocyte globulin (ATG) 1.5 mg/kg Other Names: Thymoglobulin Radiation: Total Body Irradiation Total Body Irradiation (TBI) 2 Gray, administered on Day -4 and Day -3 of transplant conditioning regimen
Experimental: ATG Group IV Fludarabine 30mg/m2 administered on Day -7 through Day -3 of transplant conditioning regimen (if under 60 years old), or on Day -5 through Day -3 of transplant conditioning regimen (if over 60 years old) Melphalan 140 mg/m2 administered on Day -2 of transplant conditioning regimen. Total Body Irradiation 2 Gray administered on Day -4, Day -3 of transplant conditioning regimen. Tocilizumab 8 mg/kg administered on Day -1 of transplant conditioning regimen.	Drug: Tocilizumab Tocilizumab 8 mg/kg intravenously administered as a single dose on Day -1 of transplant conditioning regimen Other Names: Actemra Drug: Fludarabine Fludarabine 30 mg/m2 intravenously administered on Day -7, Day -6, Day -5, Day -4, Day -3 of transplant conditioning regimen if under the age of 60. If over the age of 60, Fludarabine 30 mg/m2 intravenously administered on Day -5, Day -4 and Day -3 of transplant conditioning regimen. Other Names: Fludara Drug: Melphalan Melphalan 140 mg/m2 intravenously administered on Day -2 of transplant conditioning regimen. Other Names: Alkeran Radiation: Total Body Irradiation Total Body Irradiation (TBI) 2 Gray, administered on Day -4 and Day -3 of transplant conditioning regimen

Outcome Measures

Primary Outcome Measures

Percentage of subjects with successful haplo-derived neutrophil engraftment [21 days post-transplant]
This is defined as: Achieve an absolute neutrophil count (ANC) of 500 cells/microL for three consecutive days with the first on or prior to Day +21 post-transplant, AND Absence of a second nadir - a drop in the ANC to <300 cells/microL for five consecutive days - after initial neutrophil recovery.

Secondary Outcome Measures

Progression-Free Survival [5 years post-transplant]
Time elapsed between Day 0 and progression of the underlying malignancy for which the transplant was performed, assessed up to 5 years post-transplant.
Overall Survival [5 years post-transplant]
Time elapsed between Day 0 and death from any cause, assessed up to 5 years post-transplant.
Transplant-Related Mortality [5 years post-transplant]
Proportion of deaths which cannot be explained by persistence, relapse or progression of the underlying malignancy once the preparative regimen starts, assessed up to 5 years post-transplant.
Proportion of Platelet Engraftment Success [6 months post-transplant]
Proportion of patients who successfully achieve platelet engraftment, defined as a platelet count of >20k/microL for three consecutive days without transfusion support for seven consecutive days.
Proportion of Failure of the Haplo-Graft [21 days post-transplant]
Proportion of patients with a failed haplo-graft, defined as the absence of neutrophil engraftment by Day +21 or a drop in the absolute neutrophil count to <0.3 cells/microL for five consecutive days occurring after initial neutrophil engraftment within the first 3 weeks post-transplantation (second nadir)
Proportion of Acute Graft-versus-Host Disease [1 year post-transplant]
Proportion of patients who develop acute graft-versus-host disease
Proportion of Chronic Graft-versus-Host Disease [5 years post-transplant]
Proportion of patients who develop chronic graft-versus-host disease

Eligibility Criteria

Criteria

Ages Eligible for Study:

18 Years and Older

Sexes Eligible for Study:

All

Accepts Healthy Volunteers:

Inclusion Criteria:

Subject must have a confirmed diagnosis of one of the following:
Relapsed or refractory acute leukemia (myeloid or lymphoid)
Acute leukemia in first remission at high-risk for recurrence
Chronic myelogenous leukemia in chronic, accelerated phase or blast-crisis
Myelodysplastic syndromes
Chronic myeloproliferative disease
Recurrent, refractory or high-risk malignant lymphoma
Chronic lymphocytic leukemia, relapsed or with poor prognostic features
Multiple myeloma
Other hematological disorder in need of allogeneic transplant (e.g. blastoid dendritic cell neoplasm)
Age ≥ 18 years.
Likely to benefit from allogeneic transplant in the opinion of the transplant physician.
An HLA-identical related or unrelated donor cannot be identified within an appropriate time frame.
Karnofsky Performance Status (KPS) of ≥ 70%.
Acceptable organ function as defined below:
Serum bilirubin: <2.0 mg/dL
ALT (SGPT) <3x upper limit of normal (ULN)
Creatinine Clearance: >50 mL/min/1.73m2 (eGFR as estimated by the modified MDRD equation)
Left ventricular ejection fraction >40%
Pulmonary diffusion capacity >40% predicted
Ability to understand and the willingness to sign a written informed consent document.

Exclusion Criteria:

Life expectancy is severely limited by concomitant illness or uncontrolled infection.
Evidence of chronic active hepatitis or cirrhosis
Uncontrolled HIV disease.
Pregnancy or lactation.
History of complicated diverticulitis, including fistulae, abscess formation or gastrointestinal perforation
History of allergic reactions attributed to compounds of similar chemical or biological composition as tocilizumab, including known allergies to Chinese hamster ovary cell products or other recombinant human or humanized antibodies.