Biparental HLA Haplotype Disparate T-cell Depleted Transplants for Patients Lacking an HLACompatible Donor

Study Overview
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Brief Summary
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Approximately 30% of patients who are candidates for bone marrow transplants do not have an HLA-matched, or close to matched, donor available. For this reason, doctors have been testing ways to make transplants from HLA-partially matched donors as safe and effective as transplants from HLA-matched donors. This study is being done to test the safety and the treatment results of a specific kind of transplant. In this transplant, blood from two donors will be used. Each donor will share one half of your HLA type. Blood from both donors will be transplanted at the same time.

Official Title
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Biparental HLA Haplotype Disparate T-cell Depleted Transplants for Patients Lacking an HLACompatible Donor

Conditions
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Acute Leukemia, Chronic Leukemia, Myelodysplastic Syndrome, Non-Hodgkins Lymphoma

Intervention / Treatment
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* Radiation: total-body irradiation (TBI)
* Drug: thiotepa
* Drug: fludarabine phosphate
* Drug: melphalan
* Biological: anti-thymocyte globulin
* Procedure: allogeneic hematopoietic stem cell transplantation
* Biological: peripheral blood stem cell transplantation
* Other: laboratory biomarker analysis


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Malignant conditions for which CD34+ selected, T-cell depleted allogeneic hematopoietic stem cell transplantation is indicated such as: AML in 1st remission - for patients whose AML does not have 'good risk' cytogenetic features (i.e. t 8;21, t15;17, inv 16). Secondary AML in 1st remission AML in 1st relapse or > 2nd remission ALL/LL in 1st remission clinical or molecular features indicating a high risk for relapse; or ALL > 2nd remission CML failing to respond to or not tolerating Imatinib, dasatinib, or nilotinib in first chronic phase of disease; or CML in accelerated phase or second chronic phase. Non-Hodgkins lymphoma with chemoresponsive disease in any of the following categories: a) intermediate or high grade lymphomas who have failed to achieve a first CR or have relapsed following a 1st remission who are not candidates for autologous transplants. any NHL in remission which is considered not curable with chemotherapy alone and not eligible/appropriate for autologous transplant. Myelodysplastic syndrome (MDS): RA/RCMD with high risk cytogenetic features or transfusion dependence, RAEB-1 and RAEB-2 and Acute myelogenous leukemia (AML) evolved from MDS, who are not eligible for transplantation under protocol IRB 08-008. Chronic myelomonocytic leukemia: CMML-1 and CMML-2. Other rare lethal disorders of Hematopoiesis and Lymphopoiesis for which a T-cell depleted transplant is indicated (e.g. hemophagocytic lymphohistiocytosis; refractory aplastic anemia or conjugated cytopenias; non-SCID lethal genetic immunodeficiencies such as Wiskott Aldrich Syndrome, CD40 ligand deficiency, ALPS). Patients may be of either gender and of any racial or ethnic background. Patients must have a Karnofsky (adult) or Lansky (pediatric) Performance Status > 70%. Patients must have adequate organ function measured by: Cardiac: asymptomatic or if symptomatic then LVEF at rest must be > 50% and must improve with exercise. Hepatic: < 3x ULN ALT and < 2.0x ULN total serum bilirubin, unless there is congenital benign hyperbilirubinemia. Renal: serum creatinine <1.2 mg/dl or if serum creatinine is outside the normal range, then CrCl > 40 ml/min (measured or calculated/estimated) Pulmonary: asymptomatic or if symptomatic, DLCO > 50% of predicted (corrected for hemoglobin) Each patient must be willing to participate as a research subject and must sign an informed consent form. Exclusion Criteria: Female patients who are pregnant or breast-feeding Uncontrolled viral, bacterial or fungal infection Patient seropositive for HIV-I/II; HTLV -I/II Presence of leukemia in the CNS. Donor Inclusion Criteria: Each donor must meet criteria outlined by institutional policies Donor must have adequate peripheral venous catheter access for leukapheresis or must agree to placement of a central catheter. Donor Exclusion Criteria: Evidence of active infection (including urinary tract infection, or upper respiratory tract infection), viral hepatitis exposure (on screening), unless only HBS Ab+ and HBV DNA negative, or serologic evidence of exposure or infection with HIV-I/II or HTLV-I/II If donors do not meet institutional guidelines, exclusion will be considered.

Ages Eligible for Study
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Maximum Age: 19 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Non-Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: REGIMEN 1<br>REGIMEN 1: Patients undergo hyperfractionated TBI TID for a total of 11-12 doses on days -10 to -7 and receive thiotepa IV over 4 hours QD on days -6 and -5, fludarabine phosphate IV over 30 minutes QD on days -6 to -2, and anti-thymocyte globulin IV on days -4 to -2. TRANSPLANTATION: Patients undergo CD34-selected allogeneic PBSCT on day 0. | Radiation: total-body irradiation (TBI)<br> <br> Drug: thiotepa<br> <br> Drug: fludarabine phosphate<br> <br> Biological: anti-thymocyte globulin<br> <br> Procedure: allogeneic hematopoietic stem cell transplantation<br> <br> Biological: peripheral blood stem cell transplantation<br> <br> Other: laboratory biomarker analysis<br> <br> |
| Experimental: Regimen 2<br>To be given to patients non-malignant, life-threatening diseases and patients with hematologic malignancies, with extensive prior therapy and comorbidities who are unable to receive TBI, consists of Melphalan 70mg/m2 IV x 2 days, thiotepa 5mg/kg IV x 2 days (or 10mg/kg x 1 day), and fludarabine 25 mg/m2 IV x 5 days. TRANSPLANTATION: Patients undergo CD34-selected allogeneic PBSCT on day 0. | Drug: thiotepa<br> <br> Drug: fludarabine phosphate<br> <br> Drug: melphalan<br> <br> Biological: anti-thymocyte globulin<br> <br> Procedure: allogeneic hematopoietic stem cell transplantation<br> <br> Biological: peripheral blood stem cell transplantation<br> <br> Other: laboratory biomarker analysis<br> <br> |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Efficacy of HLA-haploidentical Biparental T-cell Depleted CD34+ Peripheral Blood Stem Cell Transplants | Efficacy is measured by: incidence of transplant-related mortality, overall survival and disease-free survival at 1 year post transplant. incidence, tempo and complications of engraftment and hematopoietic reconstitutions and conversely, the risk of graft failure incidence and severity of acute and/or chronic GVHD incidence and severity of opportunistic infections developing following engraftment | 1 year | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Evaluation of Recipients Post Transplant | The levels of engraftment and persistence of hematopoietic cells and their myeloid and lymphoid progressing from each donor post transplant. The tolerance or reactivity of engrafted T cells from each donor detected in the blood at 3, 6, and thereafter every 3-6 months until normal, post transplant against host cells and cells derived from the other parent as measured by standard mixed lymphocyte culture and cell mediated cytolysis assays. | 1 year | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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ANTITHYMOCYTE GLOBULIN:ATG, FLUDARABINE, THI0TEPA, CliniMACS-CD34 Reagent System, 12-053