Ph2 NK Cell Enriched DCIs w/wo RLR9 Agonist, DUK-CPG-001 From Donors Following Allogeneic SCT

This is a randomized, parallel phase II study to evaluate the rates of progression-free survival and unacceptable toxicity in patients receiving NK cell-enriched donor lymphocyte infusions (DLIs) when administered alone or administered with the TLR9 agonist, DUK-CPG-001, from a 7-8/8 HLA-matched related or unrelated donor (Cohort A) or 4-6/8 HLA-matched related donor (Cohort B) following reduced intensity or non-ablative allogeneic stem cell transplantation. Randomization will be stratified for disease types (myeloid versus lymphoid malignancies). Primary endpoints are analyzed separately in Cohort A and B.

Cohort A: 7-8/8 HLA-matched related or unrelated donor ("NK cell enriched-DLI only" arm or "NK cell enriched-DLI + DUK-CPG-001" arm)

Cohort B: 4-6/8 HLA-matched related donor ("NK cell enriched-DLI only" arm or "NK cell enriched-DLI + DUK-CPG-001" arm)

This is a randomized, parallel phase II study to evaluate the rates of progression-free survival and unacceptable toxicity in patients receiving NK cell-enriched donor lymphocyte infusions (DLIs) when administered alone or administered with the TLR9 agonist, DUK-CPG-001, from a 7-8/8 HLA-matched related or unrelated donor (Cohort A) or 4-6/8 HLA-matched related donor (Cohort B) following reduced intensity or non-ablative allogeneic stem cell transplantation. Randomization will be stratified for disease types (myeloid versus lymphoid malignancies).

Patient prior to starting therapy Within 21 days prior to initiating therapy, patients will have an updated history and physical examination performed, lab tests, stool collection, and pregnancy test if the patient is a female of childbearing potential. Patients will have blood or marrow stored for analysis of immune function and chimerism. Tests documenting the patient's disease state are required at study entry as well (bone marrow aspirate/biopsy, blood studies, and/or radiographic tests such as CTs, MRI, PET scans as determined by treating physician,and as required for standardized response evaluations).

Donor apheresis and cell processing Donors will return to the center for a fresh collection of NK cells and they will not need growth factor mobilization. One collection will be used for each NK cell infusion. Cells will be transfused immediately after collection and processing or the next day. Cell processing will be performed in our cryopreservation lab according to SOP for collection, labeling and handling. The cells will be NK selected using a CD56 antibody (CliniMACS CD56 Reagent), CliniMACSplus instrument and CliniMACS tubing set provided by Miltenyi Biotec using the company protocol (Miltenyi Biotec Inc, Auburn, California). Pre and post processing cell count, viability, Hematopoietic Progenitor Cell Assay (HPCA) and flow analysis per SOP will be done.

Patient Evaluation Assessment of disease will use standardized criteria and shall include a careful examination of the studies needed to detect the disease (PET, radiographs, immuno phenotype, marrow, molecular studies etc). Restaging may be altered at the discretion of the transplant physician following the patient (who are all subinvestigators in this study) if the patient is felt to be progressing before these time points but the recommended restaging is q3 months for 1 year after the last NK-enriched DLI, q6 months for the next 2 years, then as indicated clinically. Immune reconstitution studies prior to and 1 and 7 days after each NK cell-enriched DLI, and 3, 6, and 12 months after the last NK-enriched DLI. Determination of chimerism (by short tandem repeat analysis in use in our DUKE HLA laboratory with a 2% sensitivity) just prior to each NK cell-enriched DLI, and 3, 6, 12 months after the last NK-enriched DLI.

Toxicity will be formally evaluated post infusion and a week later (more as determined by treatment team) and at a minimum of every other week through 6 weeks post infusion, then q3 months starting at 3 months post-second DLI for the first year. Assessments include history (specific to GI toxicity as well as overall new problems), physical exam, CBC, liver function tests (AST, ALT, bilirubin at a minimum), and Chemistry CS to include creatinine and BUN for toxicity assessment following the NCI common toxicity criteria (version 4) and standard GVHD criteria (appendix I). Further follow up will be required as needed if the patient has a toxicity due the transplant or infusion procedures. Patients with a grade 3 or greater toxicity due to the study will be seen every other week at a minimum until the toxicity is \< grade 3, and then will be seen as clinically appropriate.

Stool Collection and Microbiome Analysis:

We will collect stool samples from patients at the following time points throughout the study: pre-DLI, day +7, pre-second DLI, day +7, then every 3 months post DLI for one year. Stool samples from patients may be stored at 4°C for up to 24 h before freezing at -80°C for batch analysis.

Patient NK cell infusion and CpG administration plan The target cell dose for NK cell-enriched DLI will be as many cells as can be collected with less than 0.5 x 106 CD3+ CD56- cells/kg patient weight in the 4-6/8 HLA-matched related setting and 1 x 106 CD3+ CD56- cells/kg patient weight in the 7-8/8 HLA-matched related or unrelated setting. The first NK cell-enriched DLI will be administered one to six months post transplant. The second NK cell-enriched DLI will be administered one to three months post the first infusion, in patients who have \< grade II aGVHD at the time of infusion and have not had unacceptable toxicities that are at least possibly related to the previous DLI and resolved to grade 1 or less. The second DLI will NOT be administered in patient with ≥grade III aGVHD at the time of infusion or unacceptable toxicities at least possibly related to the first infusion. If patients have GVHD and were on immunosuppressive therapy at study entry, patients will continue on their stable dose of immunosuppressive agents started for therapy of acute GVHD before the NK cell-enriched DLI, and will not taper until at least 6 weeks following the each NK cell-enriched DLI (unless disease progression or patient toxicity from the agents requires earlier taper). The donor NK cells will be infused over 30 minutes. Diphenhydramine 25 mg iv or po, and Acetaminophen 650 mg po will be used prior to each reinfusion, unless there is a history of allergy or contraindication in the patient, in which case hydrocortisone 50mg IV will be used.

These cells are infused into the patient via a peripheral intravenous line or central line. If signs of GVHD occur after NK cell-enriched DLI, immunosuppressive agents (prednisone, cyclosporine, tacrolimus and/ or mycophenolate preferred first choices) may be started.

Eligibility Criteria:
Inclusion Criteria:

1. Patients with hematologic diseases who have undergone T-cell depleted reduced intensity or non-ablative allogeneic transplantation, using a 7-8/8 HLA-matched related or unrelated donor or 4-6/8 HLA-matched related donor. This may include patients with a mixed chimeric state or disease persistence or at high risk of relapse.
2. Performance status must be ECOG PS 0, 1, or 2.
3. Donor cellular engraftment of at least 2.5% from the non-myeloablative procedure.
4. \< Grade 2 acute GVHD at time of the first NK cell-enriched DLI. Patients with treated acute GVHD must be on a stable dose of therapy (no increase in immunosuppressive therapy for the 2 weeks before planned NK cell-enriched DLIs). The dosage/level of immunosuppressive therapy at the time of NK-DLIs should be no greater than 20 mg of prednisone daily or mycophenolate 500 mg bid daily or cyclosporine with a target level of 200 ng/mL or tacrolimus with a target level of 10 ng/mL.
5. Estimated survival of at least 8 weeks.
6. Age of \>= 18 years.
7. Females of childbearing potential should have a negative serum beta-HCG test within 48 hours of beginning DLI and/or DUK-CPG-01 unless contraception is used after initial testing. A female of childbearing potential (FCBP) is a sexually mature female who: 1) has not undergone a hysterectomy or bilateral oophorectomy; or 2) has not been naturally postmenopausal for at least 24 consecutive months (i.e., has had menses at any time in the preceding 24 consecutive months).
8. Males must agree to use a medically acceptable form of birth control in order to be in this study and for 3 months after infusion

Exclusion Criteria:

1. Pregnant or lactating women.
2. Patients with other major medical or psychiatric illnesses, which the treating physician feels, could seriously compromise tolerance to this protocol.
3. Patients likely to have a significantly better durable response to allogeneic transplant alone (better than 60% progression free longer than 2 years) includes: those with myeloproliferative diseases or hemoglobinopathies with over 50% T cell subset engraftment (assessed around 100 days post transplant); It is not anticipated that any such patients would be transplanted within our program, however but those in first remission AML patients with good risk standard genetics or normal genetics with either NPM1 or CEBPA mutations, first chronic phase CML without kinase gene mutations, follicular lymphoma patients in first remission who only required 1 regimen to attain remission all would be excluded from this protocol.

HLA 4-6/8 matched related donor inclusion/exclusion criteria (criterion below are recommended but may evolve to follow current program standards) to be completed within 30 days of apheresis per standard guidelines

1. Adult donors must be an HLA 4-8/8 match with the patient and must be capable of providing informed consent.
2. Potential donors under the age of 18 must have a 'single patient exemption' approved by the IRB. The donor must provide assent and the donor's parent or guardian must provide permission for minor participation. Donors under the age of 18 who cannot assent based on their developmental stage will not be included.
3. Donor must not have any medical condition which would make apheresis more than a minimal risk, and should have the following:

   1. Family members will be considered for donation if they do not have a history of known cardiac problem and do not have abnormal cardiac findings by physical examination. Those with a history of cardiac problems or abnormal cardiac findings by physical examination should undergo a stress evaluation or be evaluated by a cardiologist and deemed eligible to donate.
   2. Documented bilirubin and hepatic transaminases of \< 2.5 x ULN,
   3. Documented adequate hematologic parameters including a hematocrit \> 35% for males and 33% for females, white blood cell count of \>=3,000, and platelets \>=80,000.
   4. FACT labs and final test results available prior to infusion into the patient. In the second donation from the donor, the FACT labs must be redrawn within 30 days of initiation of apheresis. Positive serologies are not repeated as they remain positive for lifetime.
4. Females of childbearing potential should have a negative serum beta-HCG test within 1 week of beginning apheresis. A female of childbearing potential (FCBP) is a sexually mature female who: 1) has not undergone a hysterectomy or bilateral oophorectomy; or 2) has not been naturally postmenopausal for at least 24 consecutive months (i.e., has had menses at any time in the preceding 24 consecutive months). A tubal ligation is adequate documentation that a patient is not of child bearing potential.

7-8/8 HLA matched unrelated donors will be matched at least as HLA -A, -B, C and -DRB1. Criterion for donation will be those allowing donation following the NMDP accepted donor criterion and program SOPs for the typical matched unrelated donors.