Pilot Trial of Clofarabine Added to Standard Busulfan and Fludarabine for Conditioning Prior to Allogeneic Hematopoietic Cell Transplantation

Study Overview
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Brief Summary
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The purpose of this study is to find out what effects, good and/or bad, the addition of clofarabine, a new chemotherapy agent, to a standard busulfan and fludarabine conditioning treatment has. The study will also look at what causes some people to have high drug levels of these medications in their body compared to other people that may have low drug levels even if they all receive the same dose of medication.

Official Title
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A Pilot Trial of Clofarabine Added to Standard Busulfan and Fludarabine for Conditioning Prior to Allogeneic Hematopoietic Cell Transplantation

Conditions
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Myeloid Malignancy, Bone Marrow Failure Syndrome, Transfusion-dependent Red Blood Cell (RBC) Defect, Congenital Immunodeficiency, Metabolic Disease, Severe Immune Dysregulation

Intervention / Treatment
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* Drug: Alemtuzumab
* Drug: Busulfan
* Drug: Fludarabine
* Drug: Clofarabine


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patients must be ≥ 3 months and ≤30 years of age. Stratum A: Non-Malignant Diseases, including: Bone Marrow Failure Syndromes Hemoglobinopathies or transfusion-dependent red blood cell (RBC) defects Congenital Immunodeficiencies Metabolic Diseases known to be treatable with Hematopoietic cell transplantation (HCT) (e.g. Hurler's) Other Bone Marrow Stem Cell Defects (e.g. Osteopetrosis) Severe Immune Dysregulation / Autoimmune Syndromes with at least transient prior response to immunosuppressive therapy Stratum B: Myeloid Malignancies, including: acute myeloid leukemia (AML), in greater than first clinical remission, or in CR1 but with detectable disease (≥0.1% Blasts by minimal residual disease (MRD) or Flow, or Positive Cytogenetics), or in CR1 but with a matched sibling Umbilical cord blood (UCB) donor. Myelodysplastic syndromes (MDS) Juvenile myelomonocytic leukemia (JMML) Chronic myeloid leukemia (CML), with detectable disease by polymerase chain reaction (PCR) Patients must have a suitable donor based on the University of California, San Francisco (UCSF) Pediatric Bone Marrow Transplant (BMT) standard operating procedures (SOP). 10/10 (HLA-A, -B, -C, -DR, -DQ) matching will be done for related and adult unrelated donors; 8/8 (HLA-A, -B, -C, -DR) for umbilical cord blood donors. Patients with non-malignant diseases will generally be eligible only if they have a mismatched donor, or an accepted clinical reason to be considered high-risk for rejection. Liver transaminases (aspartate aminotransferase (AST)/alanine aminotransferase (ALT)) and Direct Bilirubin less than twice the upper limit of normal within 2 weeks of admission. Cardiac Shortening Fraction ≥27% within 4 weeks of admission. Creatinine clearance by Schwartz formula, glomerular filtration rate (GFR) or 24 hr urine collection ≥50 cc/min/1.73 m2, within 4 weeks of admission. Pulmonary diffusion capacity ≥50% of predicted corrected for anemia/lung volume within 4 weeks of admission. If unable to do Pulmonary function testing(PFTs), then no active lung disease by chest x-ray (CXR) and/or oxygen (O2) Saturation ≥90% on room air. Exclusion Criteria: Fanconi Anemia Dyskeratosis Congenita A known syndrome with increased sensitivity to radiation or alkylating agents Severe Combined Immunodeficiency Disease eligible for a non-myeloablative HCT Trial A mismatched donor for whom ex vivo T-cell depletion of the donor stem cells is planned

Ages Eligible for Study
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Minimum Age: 3 Months
Maximum Age: 30 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: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Patients with Myeloid Malignancies<br> | Drug: Busulfan<br>* 0.8 mg/kg/dose q6hrs or 1.1 mg/kg/dose q6hrs, IV, Day -9 to Day -6 pre-HCT<br>* Other names: Busulfex;Drug: Fludarabine<br>* 40 mg/m2 or 1.33 mg/kg, IV, Day -5 to Day -2 pre-HCT<br>* Other names: Fludara;Drug: Clofarabine<br>* 10 mg/m2 or 0.33 mg/kg, IV, Day -5 to Day -2 pre-HCT<br>* Other names: Clolar;|
| Experimental: Patients with Non-Malignancies<br> | Drug: Alemtuzumab<br>* 0.5 mg/kg (max 15 mg or max 6 mg), IV, Day -12 to Day -10 pre-HCT<br>* Other names: Campath;Drug: Busulfan<br>* 0.8 mg/kg/dose q6hrs or 1.1 mg/kg/dose q6hrs, IV, Day -9 to Day -6 pre-HCT<br>* Other names: Busulfex;Drug: Fludarabine<br>* 40 mg/m2 or 1.33 mg/kg, IV, Day -5 to Day -2 pre-HCT<br>* Other names: Fludara;Drug: Clofarabine<br>* 10 mg/m2 or 0.33 mg/kg, IV, Day -5 to Day -2 pre-HCT<br>* Other names: Clolar;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of Participants With Treatment-Related Adverse Events as a Measure of Safety and Tolerability | Severe Toxicity will be defined as death or Grade IV by NCI Common Terminology Criteria for Adverse Events (CTCAE) version 4.0 pulmonary or hepatic failure (including moderate veno-occlusive disease(VOD) related to the transplant conditioning regimen within 100 days post-HCT. VOD will be defined by standard criteria. Patients must have Bilirubin >2.0 plus Hepatomegaly and/or Right upper quadrant (RUQ) pain plus Weight gain >5%. | Up to 5 years on average | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Engraftment Rate of Patients With Non-malignant Diseases (Stratum A) | Engraftment will be defined as the development of an Absolute Neutrophil Count (ANC) >500 for 3 consecutive days plus donor CD14/15 cells >70%. The engraftment rate in the population used for historical control is 40%. If 3 patients in Stratum A experience graft rejection, this stratum will close early for failing to achieve superior engraftment compared to standard-of-care. | Participants will have engraftment blood studies starting approximately Day 30 post hematopoietic stem cell transplant and then monthly until stable. Average study participation is approximately 5 years. | 
| Mixed-donor Chimerism Rate of Patients With High-risk Myeloid Malignancies (Stratum B) | Full-donor chimerism will be defined by as ≥99% donor cells by Short Tandem Repeat (STR) analysis in all cell lines (CD3, CD14/15, and CD19) in peripheral blood. The historic control for Stratum B was determined using the 20 patients who were transplanted from 2005 - 2010 with Busulfan (BU)-based regimens and who retrospectively would have been eligible for the current trial. Of these 20 patients, at 100 days post-HCT, only 8 (40%) patients had full-donor chimerism. If 5 patients in Stratum B experienced mixed-donor chimerism at Day 100, we will close this stratum early for failing to achieve superior donor cell engraftment compared to standard-of-care. | Participants will have peripheral blood chimerism assessed at Day 100 post hematopoietic stem cell transplant and then monthly until stable. | 
| Serum Concentrations and Potential for Drug-drug Interaction of Fludarabine and Clofarabine | Fludarabine and clofarabine drug levels and potential covariates influencing drug exposure such as renal function and genetic variants involved in drug metabolism, distribution, and activation will be analyzed using standard population pharmacokinetic methods using non-linear mixed effects modeling (NONMEM) software | Pharmacokinetics (PK) blood sampling Days -5 to -2 pre-hematopoietic stem cell transplant. | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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cell, conditioning, allogeneic, hematopoietic, transplantation, HCT