Cord Blood Expansion on Mesenchymal Stem Cells
Condition: Myelodysplastic Syndrome; Leukemia
MeSH terms: Leukemia; Preleukemia; Myelodysplastic Syndromes
Study type: Interventional
Phase: Phase 1

Summary: 
      The goal of this clinical research study is to learn if combining cord blood units will be
      safe and result in the cells "taking" faster in recipients. The cord blood units will have
      their cell number increased in the lab using cells from a family member or they will be
      collected from an unrelated healthy donor.
    

Detailed description: 
      Umbilical cord blood is a source of blood-forming cells that can be used for transplantation.
      The major problem with this type of transplant is the small number of blood-forming cells
      available in each cord unit, which may delay the "take" of the graft in the recipient. A
      strategy to overcome this problem is to give 2 cord blood units, increasing the number of
      cord blood cells in one of them in the laboratory before they are transplanted. This is done
      in order to increase their number. The expansion of 1, but not both, of the cord blood units
      will allow the research team to decide more effectively whether the laboratory expansion is
      responsible for the speed and content of the "take." At this time, no proof exists that this
      expansion technique will improve the performance of the cord blood specimens.

      In order to collect a larger expansion of the numbers of cord blood cells, recent research
      suggests that growing the cord blood cells on a layer of bone marrow stromal cells increases
      the number of expanded cells which can be collected. In the body, these stromal cells form a
      matrix or "spider web" in the bone marrow. Blood-forming bone marrow cells (looking like
      dewdrops) grow on this stromal cell matrix (spider web) and are nurtured by the stromal
      cells. In this research study, researchers will either collect marrow stromal cells from a
      family member through a bone marrow aspiration, or they will use "off-the-shelf" marrow
      stromal cells that have been collected from a healthy donor. These "off-the-shelf" marrow
      stromal cells were grown and frozen by Mesoblast Systems. These stromal cells from either
      your family member or "off-the-shelf" will hopefully improve the performance of the cord
      blood cells after they are given to you.

      Placement of central venous catheter for collection of "back-up" peripheral blood progenitor
      cells (PBPC):

      Before you have back-up PBPC collected or you receive chemotherapy, you will require
      placement of a hollow plastic tube (catheter) into a large vein inside your body. This
      catheter will be used to draw blood and to give medications and fluids. The catheter is
      inserted through the skin in the upper chest and extends to a point above the right side of
      your heart. Your doctor will explain this procedure to you in more detail, and you will be
      required to sign a separate consent form for this procedure.

      Collection of back-up stem cells:

      Because collecting additional cells from the donor of the cord blood is not possible if the
      transplant with cord blood fails, a back-up PBPC or bone marrow sample to ensure recovery of
      your marrow function will be collected from you and frozen before the high dose chemotherapy
      begins. This specimen will only be used if doctors think it is necessary.

      Peripheral blood progenitor cell collection (Leukapheresis):

      Before collection of the PBPC, you will be treated with a drug called granulocyte colony
      stimulating factor (G-CSF), which will cause the important stem cells in the marrow to move
      the peripheral blood where they will be collected. This medication is given as a shot under
      the skin once a day for 3-7 days, at which time your PBPC will be collected from your central
      catheter during a 3-4 hour outpatient procedure. This procedure is standard, and is called
      leukapheresis. You will be required to sign a separate consent form for this procedure.

      Bone Marrow Collection:

      If the leukapheresis cannot be performed successfully, you will receive general anesthesia in
      the operating room and will have multiple needle sticks of the hip bones in order to collect
      bone marrow. Less than 5 percent of your bone marrow will be taken. This procedure, if done,
      will also require you to sign a separate consent form.

      Selection of alternate back-up donor:

      If your own back-up bone marrow or back-up PBPC cannot be collected, a family member will be
      asked to serve as a back-up donor or an identified third cord blood unit may be used should
      both the cord blood units fail to function. A back-up donor or product will be required for
      you to participate in this research

      Selection of a stromal cell donor for cord cultures:

      In this study, researchers will identify a donor for the stromal cells. This will either be a
      family member or from an unrelated healthy donor whose marrow stromal cells were collected,
      grown, and frozen by Mesoblast Systems (off-the-shelf). If your family member is used, they
      will collect about 7 tablespoons of bone marrow from them.This family member's tissue type
      (HLA antigens) does not exactly match yours. That bone marrow will be taken to the laboratory
      where over 3-4 weeks, marrow stromal cells will be grown. These marrow stromal cells produce
      vitamin-like growth factors that may help your cord blood cells expand to greater numbers. If
      a family member is not appropriately HLA matched, does not meet eligibility, is not a
      candidate due to health reasons, or if the participant's disease is getting worse so that
      there is not enough time to grow the family member's marrow cells into marrow stromal cells,
      then "off-the-shelf" marrow stromal cells that have been collected from a healthy donor will
      be used for the procedure. These "off-the-shelf" marrow stromal cells were grown and frozen
      by Mesoblast Systems. These cells have been safely given to patients with peripheral vascular
      disease, but their use in this study is considered investigational.

      Your bone marrow transplant doctors will assign you to one of 3 chemotherapy treatments,
      which are discussed below.

      High-dose chemotherapy treatment (Myeloablative):

      If you are between 1 and 55 years of age and can receive high-dose chemotherapy, or you are
      between 55 and 65 years old and your doctor agrees, you will receive fludarabine,
      clofarabine, busulfan, antithymocyte globulin (ATG), and total body irradiation.

      You will receive a test dose of busulfan by vein over 60 minutes as an outpatient usually
      during the week before admission. If the test dose cannot be given as an outpatient, you will
      be admitted to the hospital on Day -9 for IV fluids and the busulfan test dose. This
      low-level "test" dose of busulfan is to check how the level of busulfan in your blood levels
      changes over time. This information will be used to decide the next dose needed to reach the
      target blood level that matches your body size.

      About 11 samples of blood will be drawn for pharmacokinetic (PK) testing of busulfan. PK
      testing measures the amount of study drug in the body at different time points. These blood
      samples will be drawn at various timepoints starting before the Busulfan infusion and
      continuing over approximately the next 11 hours. The blood samples will be repeated again
      with the first day of high-dose busulfan treatment. Each sample will be about 1 teaspoon of
      blood. A temporary heparin lock will be placed in your vein to lower the number of needle
      sticks needed for these draws. If it is not possible for the PK tests to be performed for
      technical or scheduling reasons, you will receive the standard fixed dose of busulfan.

      If you received the test dose as an outpatient, you will be admitted to the hospital on Day
      -8 and will receive fluids by vein. On Days -7 through -4, you will receive by vein
      fludarabine over 1 hour, clofarabine by vein over 1 hour, and busulfan by vein over 3 hours.
      You will receive ATG on Days -4 and -3. On Day -3, you will receive a single treatment of
      low-dose total body irradiation. You will "rest" (not receive chemotherapy drugs) on Days -2
      and -1. Day 0 is the day of transplantation, so the negative day numbers are used to label
      the treatment days before transplant.

      All chemotherapy drugs, fluids, and other medications that must be given by vein will be
      infused through the catheter. Once the back-up cells are collected, all participants will be
      admitted to the hospital as indicated by their assigned treatment plan schedule. Chemotherapy
      may be stopped if intolerable side effects occur.

      Lower-dose chemotherapy treatment (Non-myeloablative):

      If you are older than 55 and 80 years of age or less, or are of any age with a pre-existing
      medical condition that prevents you from receiving high dose chemotherapy, you will receive
      fludarabine- cyclophosphamide-ATG-total body irradiation. You will receive cyclophosphamide
      as a single dose on Day -6. Fludarabine will be given once a day for 4 days in a row (Days -6
      through -3). You will receive ATG on Days -4 and -3. You will also receive a single treatment
      of low-dose total body irradiation on Day -1. Day 0 is the day of transplantation. Rituximab
      may be given on Day -9 if appropriate for your disease.

      All chemotherapy drugs, fluids, and other medications that must be given by vein will be
      infused through the catheter. Once the back-up cells are collected, all participants will be
      admitted to the hospital as indicated by their assigned treatment plan schedule. Chemotherapy
      may be stopped if intolerable side effects occur.

      Reduced Intensity chemotherapy treatment:

      If you are between the ages of 1 and 80 years old (and the study doctors think this would
      keep you from receiving the full myeloablative therapy), if you cannot receive low-dose total
      body irradiation, and if your doctor agrees, you will receive fludarabine-melphalan-ATG.
      Starting on Day -5 you will receive fludarabine given once a day for 4 days in a row (Days -5
      through -2). You will receive Melphalan as a single dose on Day -2. You will receive ATG on
      Days -3 and -2. Day 0 is the day of transplantation.

      All chemotherapy drugs, fluids, and other medications that must be given by vein will be
      infused through the catheter. Once the back-up cells are collected, all participants will be
      admitted to the hospital as indicated by their assigned treatment plan schedule. Chemotherapy
      may be stopped if intolerable side effects occur.

      Expansion of cord blood:

      On Day -14, one of your two cord blood units will be thawed in the MD Anderson Stem Cell
      Laboratory and expanded over a layer of marrow stromal cells from your family member or from
      "off-the-shelf" marrow stromal cells. The expansion will continue for about 2 weeks and when
      complete, the cells will be given to you on Day 0 as described below. A small amount of cord
      blood cells (less than 3%) will be used for laboratory procedures that measure the quality of
      the product.

      The CliniMACS System is a medical device that is used to separate types of blood cells from
      blood that is removed from the body during leukapheresis. These separated cells are processed
      for use in treatments such as stem cell transplants.

      Transplantation of cord blood:

      Two (2) days after completion of high or lower-dose therapy (Day 0), both units of cord blood
      (the expanded and the unexpanded cord) will be infused into you (one at a time) through your
      catheter. The unexpanded cord will be thawed and infused first, followed by the infusion of
      the cells that were expanded in the lab. Each unit will take about 30 minutes to infuse. You
      will then be hospitalized until your marrow function is restored enough. This usually takes
      between 3-6 weeks. During this time, you will receive a variety of medications, transfusions,
      and other standard procedures aimed at decreasing the risks of this procedure, such as graft
      vs. host disease (GVHD).

      Graft versus host disease (GVHD) preventive therapy:

      GVHD results from a reaction of the transplanted cord blood cells against certain tissues in
      your body. In an attempt to prevent or decrease the severity of GVHD, you will receive 2
      drugs. Mycophenolate will be given through your catheter 2 times per day (morning and
      evening) on Days -3 through Day 100. Tacrolimus will be given as a 24-hour continuous
      infusion over 3-6 weeks. Around Day 30 or 40 (after engraftment), the tacrolimus will be
      changed to pills given once a day for 180 days (6 months). If GVHD is present, tacrolimus may
      then be continued longer. The number of tacrolimus pills may vary according to the blood
      levels of the drug, but usually are between 1-5 pills. Your dose of tacrolimus can be
      gradually lowered around Day 180 if no GVHD is present. This medicine is used for 6-9 months
      (longer if chronic GVHD occurs).

      You will remain on study as long as your disease does not return. If your disease returns,
      you will be taken off study and you may be offered participation in another study or other
      standard treatments.

      Follow-up after transplant:

      After you leave the hospital, you will be seen regularly in the Department of Blood and
      Marrow Transplantation at MD Anderson. The frequency of the visits may vary, but may be as
      often as daily. Routine blood (1-2 tablespoons) and urine tests will be performed. The
      frequency of blood tests may also vary, but may be performed daily. You will have bone marrow
      samples collected before transplant and then as needed during the first 100 days after
      transplant, every 3 months during the first year after transplant, and then once a year while
      you are on study. After that, bone marrow samples will be collected once a year,
      indefinitely. These samples are being collected to look for tumor (as a staging test) and to
      looFk for chimerism (the percent of tumor cells detectable that can predict graft failure
      and/or relapse). To collect a bone marrow sample, an area of the hip or chest bone is numbed
      with anesthetic and a small amount of bone marrow is withdrawn through a large needle.

      Participants with lymphomas and Hodgkin's disease will need a computed tomography (CT) scan
      of the chest, abdomen, and pelvis performed before transplant, then as needed during the
      first 100 days after transplant, and then every 3 months for the first year after transplant.
      After that, these scans will be done yearly. You will be on study for 1 year but then will be
      followed yearly as is standard of care.

      This is an investigational study. All treatment drugs given to you are FDA approved and
      commercially available. The CliniMACS device is not FDA approved. At this time, it is being
      used in research only. Up to 125 patients may take part in this study. All will be enrolled
      at MD Anderson.
    

Intervention name(s): Cord Blood Infusion; Busulfan; Fludarabine; Rituximab; ATG; Cyclophosphamide; Clofarabine; Total Body Irradiation (TBI); Melphalan; Tacrolimus; Mycophenolate Mofetil; G-CSF
Intervention type(s): Procedure; Drug; Drug; Drug; Other; Drug; Drug; Radiation; Drug; Drug; Drug; Drug
Intervention description(s): Cord blood transplantation performed on day 0.; 32 mg/m2 by vein as an outpatient before Day -14 or as an inpatient on Day -9, and AUC of 4,000 microMol.min-1 by vein on Days -7 to -4 for patients with ALL, AML, NHL, CLL, CML, HD, and MM who are >1 and < 55 years old. Patients >55 but < 65 years who have a Performance Status of 0 or 1 and no comorbidities may receive the myeloablative regimen 4 at the discretion of the investigator(s).; 10 mg/m2 by vein on Days -7 to -4 for patients with ALL, AML, NHL, CLL, CML, HD, and MM who are >1 and < 55 years old. Patients >55 but < 65 years who have a Performance Status of 0 or 1 and no comorbidities may receive the myeloablative regimen 4 at the discretion of the investigator(s).
40 mg/m2 by vein on Days -6 to -3 for patients with AML, ALL, NHL, CLL,CML, HD and MM who are > 55 and < 80 years old or of any age with co-morbid condition that in the opinion of the investigators would preclude myeloablative therapy.
40 mg/m2 by vein on Days -5 to -2 for patients with AML, ALL, NHL, CLL, CML, and HD who are >1 and < 80 years old that in the opinion of the investigator(s) would preclude myeloablative therapy and who cannot receive Total Body Irradiation (TBI) may receive the reduced intensity treatment regimen 3.; 375 mg/m2 by vein on Day -9 for patients with AML, ALL, NHL, CLL,CML, HD and MM who are > 55 and < 80 years old or of any age with co-morbid condition that in the opinion of the investigators would preclude myeloablative therapy.; 1.25 mg/Kg by vein on Day -4 and 1.75 mg/Kg by vein on Day -3 for patients with AML, ALL, NHL, CLL,CML, HD and MM who are > 55 and < 80 years old or of any age with co-morbid condition that in the opinion of the investigators would preclude myeloablative therapy.
1.25 mg/kg by vein on Day -3 and 1.75 mg/kg by vein on Day -2 for patients with AML, ALL, NHL, CLL, CML, and HD who are >1 and < 80 years old that in the opinion of the investigator(s) would preclude myeloablative therapy and who cannot receive Total Body Irradiation (TBI) may receive the reduced intensity treatment regimen 3.; 50 mg/kg by vein on Day -6 for patients with AML, ALL, NHL, CLL,CML, HD and MM who are > 55 and < 80 years old or of any age with co-morbid condition that in the opinion of the investigators would preclude myeloablative therapy.; 30 mg/m2 by vein on Days -7 to -4 for patients with ALL, AML, NHL, CLL, CML, HD, and MM who are >1 and < 55 years old. Patients >55 but < 65 years who have a Performance Status of 0 or 1 and no comorbidities may receive the myeloablative regimen 4 at the discretion of the investigator(s).; 200 cGy at 25 cGy/minute delivered on Day -3.; 140 mg/m2 by vein on Day -2 for patients with AML, ALL, NHL, CLL, CML, and HD who are >1 and < 80 years old that in the opinion of the investigator(s) would preclude myeloablative therapy and who cannot receive Total Body Irradiation (TBI) may receive the reduced intensity treatment regimen 3.; 0.03 mg/kg by vein daily starting on D-2, to be changed to oral dosing when tolerated. Tacrolimus is to be tapered around Day +180, if no GVHD is present.; 1 gram by vein twice a day Days -3 through Day 100.; 5 mcg/kg/day subcutaneously beginning on day 0, and continuing until the absolute neutrophil count (ANC) is > 2.5 x 109/L.
Other intervention name(s): Busulfex; Myleran; Fludarabine Phosphate; Fludara; Rituxan; Antithymocyte Globulin; Thymoglobulin; Cytoxan; Neosar; Clofarex; Clolar; TBI; XRT; Alkeran; Prograf; MMF; CellCept; Filgrastim; Neupogen
Intervention MeSH terms: Mycophenolic Acid; Cyclophosphamide; Melphalan; Busulfan; Rituximab; Fludarabine; Fludarabine phosphate; Clofarabine; Tacrolimus; Thymoglobulin; Antilymphocyte Serum
Intervention model: Single Group Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Myelodysplastic Syndrome; Leukemia; Cord Blood Expansion; Umbilical Cord Blood; Mesenchymal Stem Cells; Acute Myelogenous Leukemia; Acute Lymphoblastic Leukemia; ALL; AML; MDS