NMA Haplo or MUD BMT for Newly Diagnosed Severe Aplastic Anemia

Study Overview
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Brief Summary
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Our primary objective is to determine if it is feasible for previously untreated severe aplastic anemia (SAA) patients to be transplanted using non-myeloablative conditioning and post transplantation cyclophosphamide.

Detailed Description
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This is a clinical trial of upfront bone marrow transplantation for patients with SAA who do not have a fully human leukocyte antigen (HLA) matched donor. The trial uses a conditioning regimen which has been successful in the refractory and relapsed setting to maximize engraftment and post transplant therapy to minimize graft versus host disease (GVHD). This would be used here in patients who have not yet undergone immunosuppressive therapy for their SAA or are thought to be unlikely to respond to immunosuppressive therapy for SAA.

Official Title
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A Phase II Trial of Non-Myeloablative (NMA) Conditioning and Transplantation of Partially HLA-Mismatched/Haploidentical Related or Matched Unrelated Donor (MUD) Bone Marrow for Newly Diagnosed Patients With Severe Aplastic Anemia

Conditions
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Severe Aplastic Anemia, Aplastic Anemia, Bone Marrow Failure, Immunosuppression

Intervention / Treatment
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* Drug: Thymoglobulin
* Drug: Fludarabine
* Drug: Cyclophosphamide
* Radiation: Total body irradiation
* Drug: Tacrolimus
* Drug: Mycophenolate mofetil


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Confirmed diagnosis of inherited or acquired severe aplastic anemia (SAA) One of the following available donors: HLA-haploidentical relative If recipient is >= 40 years old, may use HLA-matched related donor For recipients with inherited bone marrow failure syndromes (IBMFS) with clear evidence of same disorder in potential related donors, may use 10/10 matched unrelated donor Recipient and/or legal guardian must sign protocol informed consent Donor must be willing to donate bone marrow Left ventricular ejection fraction (LVEF) >= 40%. For recipients < 13 years old, shortening fraction >= 26% may be used instead. Bilirubin < 3 x upper limit of normal (ULN) for age, unless patient has Gilbert's disease aspartate aminotransferase (AST) and alanine aminotransferase (ALT) < 5 x ULN for age For patients >= 13 years old: estimated creatinine clearance > 50 mL/min using Cockcroft-Gault formula and actual body weight For patients >= 1 but < 13 years old: glomerular filtration rate (GFR) estimated by updated Schwartz formula >= 90 mL/min/1.73 m^2. If estimated GFR is < 90 mL/min/1.73 m^2, 24-hour measured creatinine clearance must be > 50 mL/min/1.73 m^2. For patients >= 8 years old, diffusing capacity of the lung for carbon monoxide (DLCO) (corrected for hemoglobin) > 40%; forced expiratory volume at one second (FEV1) > 50%; forced vital capacity (FVC) > 50% For patients < 8 years old or unable to undergo pulmonary function testing: no evidence of dyspnea at rest; no need for supplemental oxygen; oxygen saturation > 92% on room air Karnofsky/Lansky status (depending on age) >= 70% Females and males of childbearing potential must agree to practice 2 effective methods of contraception at the same time. If unwilling, they must agree to complete abstinence. Exclusion Criteria: Previous administration of immunosuppressive therapy for SAA. Fanconi anemia. At minimum, this diagnosis must be excluded by diepoxybutane (DEB) or equivalent testing on peripheral blood or marrow in patients < 30 years old. Clonal cytogenetic abnormalities consistent with pre-myelodysplastic syndrome (pre-MDS) or MDS on bone marrow examination Presence of anti-donor antibodies Prior allogeneic stem cell transplant Prior solid organ transplant Uncontrolled bacterial, viral, or fungal infection HIV seropositivity Active hepatitis B or C infection determined by serology and/or nucleic acid testing (NAT) Pregnancy or active breastfeeding Prior malignancies except: resected basal carcinoma or treated cervical carcinoma in situ; cancer treated with curative intent > 5 years previously. Other prior cancers will not be allowed unless approved by the PI.
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
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Bone marrow transplant<br>Non-myeloablative bone marrow transplant with a Thymoglobulin (ATG), fludarabine (Flu), cyclophosphamide (Cy), total body irradiation (TBI) preparative regimen and post-transplant Cy, mycophenolate mofetil (MMF), and tacrolimus as GVHD prophylaxis. | Drug: Thymoglobulin<br>* Day -9: 0.5 mg/kg Days -8 and -7: 2 mg/kg daily<br>* Other names: ATG;Drug: Fludarabine<br>* Days -6 through -2: 30 mg/m^2 IV daily<br>* Other names: Fludara;Drug: Cyclophosphamide<br>* Days -6 and -5: 14.5 mg/kg IV daily Days 3 and 4: 50 mg/kg IV daily<br>* Other names: CTX;Radiation: Total body irradiation<br>* Day -1: 200 centigray (cGy) in a single fraction<br>* Other names: TBI;Drug: Tacrolimus<br>* Start on Day 5 through Day 365<br>* Other names: Prograf;Drug: Mycophenolate mofetil<br>* Days 5 through 35: 15 mg/kg PO three times daily (max 3 g/day)<br>* Other names: CellCept;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Overall Survival and Engraftment at One Year | Number of enrolled participants who receive BMT, achieve engraftment, and are alive at one year post bone marrow transplant (BMT). | 1 year | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Overall Survival at One Year | Number of participants alive at one year after BMT. | 1 year | 
| Probability of Neutrophil Recovery as Assessed by the Number of Participants Who Have Recovered Neutrophil Counts | Probability of neutrophil recovery will be assessed by the number of participants who have recovered neutrophil counts at 1 year (>500 ANC). | 1 year | 
| Probability of Platelet Recovery as Assessed by Number of Participants Who Have Recovered Platelet Counts | Probability of platelet recovery will be assessed by the number of participants who have recovered platelet counts at 1 year. | 1 year | 
| Number of Participants Who Experience Primary Graft Failure | Number of participants who experience primary graft failure by one year after BMT. | 1 year | 
| Number of Participants Who Experience Secondary Graft Failure | Number of participants who experience secondary graft failure by one year after BMT. | 1 year | 
| Number of Participants Who Experience Grades II-IV Acute GVHD | Number of participants who experience grade II, III, or IV acute GVHD by Day 100. | Day 100 | 
| Number of Participants Who Experience Grades III-IV Acute GVHD | Number of participants who experience grade III or IV acute GVHD by Day 100. | Day 100 | 
| Number of Participants Who Experience Chronic GVHD | Number of participants who experience chronic GVHD by two years after BMT. | 2 years | 
| Number of Participants With Full Donor Chimerism | Number of participants with full donor chimerism at Day 60. | Day 60 | 
| GVHD-free Relapse-free Survival (GRFS) | Number of participants alive, without relapse, and without GVHD at 1 year. | 1 year | 
| Transplant-related Mortality | Number of participants deceased for reasons related to BMT at 1 year. | 1 year | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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ATG, bone marrow, immunosuppression, nonmyeloablative, non-myeloablative, allogeneic, tacrolimus, bone marrow transplant, cyclophosphamide, thymoglobulin, fludarabine