CD34 Selected Allogeneic HCT w/ Myeloablative Conditioning Plus CD8+ Memory TCell Infusion in MDS, AL and CML

Study Overview
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Brief Summary
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This study will evaluate combining stem cells from the patient's matched sibling donor (a standard CD34-selected transplant) with a second infusion of white blood cells called CD8 memory T-cells from their sibling donor.

Detailed Description
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Primary Objective: To determine the rate of graft versus host disease (GvHD) free, relapse free survival (GRFS) at one year following CD34 selected allogeneic hematopoietic cell transplantation using myeloablative conditioning combined with an infusion of phenotypic CD8+ memory T cells from human leukocyte antigen (HLA) matched donors for patients with myelodysplastic syndrome (MDS), acute myeloid leukemia (AML), or acute lymphoblastic leukemia (ALL) and chronic myeloid leukemia (CML). Secondary Objective: To determine the rate of graft rejection, acute and chronic GvHD, non relapse mortality, relapse, overall survival, and disease free survival.

Official Title
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CD34 Selected Allogeneic Hematopoietic Cell Transplantation With Myeloablative Conditioning and CD8+ Memory T Cell Infusion For Patients With Myelodysplastic Syndrome, Acute Leukemia, and Chronic Myelogenous Leukemia

Conditions
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Acute Myeloid Leukemia, Acute Lymphoblastic Leukemia, Myelodysplastic Syndromes, Acute Leukemia, Chronic Myeloid Leukemia

Intervention / Treatment
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* Drug: CD8+ Memory T Cell Infusion
* Drug: Thiotepa
* Drug: Fludarabine
* Radiation: Hyperfractionated TBI
* Drug: Busulfan
* Drug: Cyclophosphamide


Participation Criteria
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Eligibility Criteria
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Recipient Inclusion Criteria: Acute leukemia, in morphologic complete remission, OR myelodysplasia with < 10% blasts in the marrow, and no circulating blasts that contain auer rods. Patients with chronic myelomonocytic leukemia (CMML) must have a WBC count ≤ 10,000 cells/μL and < 10% blasts in the marrow. Planned myeloablative conditioning regimen at Stanford University Medical Center. Karnofsky or Lansky Performance Score ≥ 70%. Must have an HLA related donor as follows: onor must be an 8/8 match for HLA A, B and C at intermediate (or higher) resolution, and DRB1 at high resolution using DNA based typing. The donors must be willing to receive G CSF followed by collection of cells by apheresis, and must meet the Program's criteria for donation. Cardiac function: Ejection fraction at rest ≥ 40%. Serum creatinine value of < 1.5 mg/dL, or an estimated creatinine clearance greater than 50 mL/minute (using the Stanford calculator for eGFR available in EPIC) Diffusing capacity of the lungs for carbon monoxide (DLCO) ≥ 50% (adjusted for Hgb) Forced vital capacity (FVC) ≥ 50%. Forced expiratory volume (FEV1) ≥ 50%. Total bilirubin < 2 times the upper limit of normal (ULN) (unless the elevated bilirubin is attributed to Gilbert's Syndrome) Alanine aminotransferase (ALT) < 2.5 x ULN Aspartate aminotransferase (AST) < 2.5 x ULN Total bilirubin < 2 times the upper limit of normal (unless elevated bilirubin is attributed to Gilbert's Syndrome) Signed informed consent Recipient Exclusion Criteria: Prior autologous or allogeneic hematopoietic stem cell transplant Prior malignancies, except resected non melanoma or treated cervical carcinoma in situ. Cancer treated with curative intent ≥ 5 years previously is allowed. Cancer treated with curative intent < 5 years previously will not be allowed unless approved by the Protocol Officer or one of the Protocol Chairs Active central nervous system (CNS) involvement by malignant cells Presence of fluid collection (ascites, pleural or pericardial effusion) that interferes with methotrexate clearance or makes methotrexate use contraindicated Requirement for supplemental oxygen Uncontrolled bacterial, viral or fungal infections (currently taking medication and with progression or no clinical improvement) at time of enrollment History of uncontrolled autoimmune disease or on active treatment (defined as > 5 mg prednisone daily) Seropositive for HIV 1 or 2 Seropositive for HTLV I or -II Active Hepatitis B or C viral replication by polymerase chain reaction (PCR) Documented allergy to iron dextran or murine proteins Pregnant (positive serum or urine βHCG) or breastfeeding) Females of childbearing potential (FCBP) or men who have sexual contact with FCBP unwilling to use an effective form of birth control or abstinence for one year after transplantation Unable to comply with the treatment protocol, including appropriate supportive care, follow up and research tests. Planned to receive post transplant maintenance therapy except for fms-like tyrosine kinase 3 (FLT3) inhibitors or BCR ABL tyrosine kinase inhibitors (TKIs). Donor Inclusion Criteria: HLA matched donor (matching at 8/8 antigens or alleles including HLA A, B, C, and -DRB1). ≥ 18 years to < 66.0 years State of general good health Completed a donor evaluation with history, medical examination and standard blood tests within 60 days of starting the hematopoietic cell collection procedure. In order to fairly represent the interests of the donor, the donor evaluation and consent will be performed by a study team member other than the recipient's attending physician. Hepatitis A, B and C, HIV 1 and 2, HTLV, VZV, EBV, HSV, West Nile virus, Syphilis Treponema, T cruzi (Chagas), CMV, and the MPX NAT IDT (HIV/HCV/HBV) will be tested as per national standard of care guidelines for transplant donors. Donors who are HIV positive will be excluded. Donors who are positive by serology for Hepatitis B or C are eligible as long as PCR for RNA/DNA is negative White blood cell count > 3.5 x 109/L Platelets > 150 x 109/L Hematocrit > 35% Capable of undergoing leukapheresis Able to understand and sign informed consent Donor Exclusion Criteria: Psychological traits or psychological or medical conditions which make them unlikely to tolerate the procedure Pregnant or lactating female

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 65 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: fTBI/Thiotepa/fludarabine<br>Participants will be infused on Day 0 with donor derived CD34+ selected cells combined with CD8+CD45RA- T cells {CD Memory T Cells} following a standard myeloablative conditioning regimen that might consist of fTBI, Thiotepa, and Fludarabine or Busulfan and Cyclophosamide. | Drug: CD8+ Memory T Cell Infusion<br>* Allogeneic phenotypic CD8+ memory T cells from HLA matched donors infused at the time of hematopoietic cell transplantation<br>* Other names: Enriched for CD8+CD45RA memory T cells.;Drug: Thiotepa<br>* 5 mg/kg/day: IV for 2 consecutive days (days -6 to -5)<br>* Other names: TESPA;Drug: Fludarabine<br>* 25 mg/m2/day: IV for 5 consecutive days (days -6 to -2)<br>* Other names: Beneflur;Radiation: Hyperfractionated TBI<br>* Administered in 11 fractions of 125 cGy over 4 days (Total dose of 1375 cGy)<br>Drug: Busulfan<br>* 6 mg/kg/dose Q24h IV. Infused over 3 hours. 1 dose per day x 4 consecutive days x 3.6 mg/kg/dose = 14.4 mg/kg<br>* Other names: Busulfanum;Drug: Cyclophosphamide<br>* 60 mg/kg/dose Q24h IV. Infused over 2 hours. 1 dose per day x 2 consecutive days x 60 mg/kg/dose = 120 mg/kg<br>* Other names: Neosar;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Graft versus Host Disease (GvHD) free and relapse free survival (GRFS) | The rate of participants who do not experience GvHD and also do not experience relapse are collectively considered to be GRFS. Relapse will be assessed according to the myelodysplastic syndrome or leukemia response criteria. The participants will be assessed for GRFS though 1 year post transplant. The outcome will be reported as the number of participants, a number without dispersion. | 1 year | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Graft Rejection | Graft rejection will be determined on the basis of reaction against the donor hematopoietic cells. The outcome will be reported as the number of participants who experience graft rejection though 1 year post transplant, a number without dispersion | 1 year | 
| Acute Graft versus Host Disease (GvHD) | The participants will be assessed for acute graft versus host disease (GvHD) though 1 year post transplant. The outcome will be reported as the number of participants who experience acute GvHD, a number without dispersion. | 1 year | 
| Chronic Graft versus Host Disease (GvHD) | The participants will be assessed for chronic, steroid requiring graft versus host disease (GvHD) though 1 year post transplant. The outcome will be reported as the number of participants who experience chronic GvHD, a number without dispersion. | 1 year | 
| Non relapse Mortality | : Non relapse mortality will be assessed as the number of participants who have died though 1 year post transplant, without a relapse or recurrence of their myelodysplastic syndrome or leukemia. Relapse will be assessed according to the myelodysplastic syndrome or leukemia response criteria. The outcome will be reported as the number of affected participants, a number without dispersion. | 1 year | 
| Relapse | Relapse will be assessed according to the myelodysplastic syndrome or leukemia response criteria. The outcome will be reported as the number of participants who experience relapse though 1 year post transplant, a number without dispersion. | 1 year | 
| Overall Survival (OS) | Overall Survival (OS) will be assessed as the number of participants who remain alive at 1 year post transplant. The outcome will be reported as a number without dispersion. | 1 year |