Pilot Study of Memory-like Natural Killer (ML NK) Cells After TCRαβ T Cell Depleted Haploidentical Transplant in AML

Study Overview
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Brief Summary
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This phase I/II pilot study aims to enhance the effectiveness of stem cell transplant for children and young adults with high-risk acute myeloid leukemia (AML). Patients will undergo a stem cell transplant from a half-matched family donor. One week later, patients will receive an additional infusion of immune cells and a drug called interleukin-2. To mitigate the potential complications associated with graft-versus-host-disease, the donated stem cell product undergoes a process that removes a specific type of immune cell. After transplant, recipients are administered additional immune cells known as memory-like natural killer (ML NK) cells. These cells are derived by converting conventional natural killer cells obtained from the donor. The infusion of a modified stem cell product, along with administration of ML NK cells may help prevent the development of GvHD while simultaneously improving the efficacy of the treatment.

Official Title
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A Phase I/II Pilot Study of Memory-like NK Cells to Consolidate TCRαβ T Cell Depleted Haploidentical Transplant in High-risk AML

Conditions
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Acute Myeloid Leukemia, AML, Childhood, Aml, Acute Myeloid Leukemia, Pediatric

Intervention / Treatment
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* Drug: Rabbit Anti thymocyte globulin
* Drug: Busulfan
* Drug: Fludarabine
* Drug: Thiotepa
* Drug: Melphalan
* Biological: TCR alpha beta / CD19+ depleted haploidentical hematopoietic progenitor cell graft
* Biological: memory-like natural killer cells
* Biological: IL-2
* Drug: Plerixafor
* Biological: Granulocyte Colony-Stimulating Factor
* Device: CliniMACS


Participation Criteria
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Eligibility Criteria
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Patient Inclusion Criteria: High risk acute myeloid leukemia (AML) in either: Complete remission (CR) as defined by < 5% marrow blasts by morphology in the context of hematological recovery (ANC ≥ 0.5× 10^9/L, platelet count ≥ 50 × 10^9/L). Morphological leukemia free state (MLFS), defined by the lack of hematological recovery, < 5% marrow blasts by morphology with at least 200 nucleated cells present in the bone marrow aspirate. Patients must further meet one of the below for inclusion into the study: De novo AML in CR1 with any of the following high-risk features: MRD ≥ 1% after first induction course MRD ≥ 0.1% after second induction course RPN1-MECOM RUNX1-MECOM NPM1-MLF1 DEK-NUP214 KAT6A-CREBBP (if ≥ 90 days at diagnosis) FUS-ERG KMT2A-AFF1 KMT2A-AFDN KMT2A-ABI1 KMT2A-MLLT1 11p15 rearrangement (NUP98 - any partner gene) 12p13.2 rearrangement (ETV6 - any partner gene) Deletion 12p to include 12p13.2 (loss of ETV6) Monosomy 5/Del(5q) to include 5q31 (loss of EGR1) Monosomy 7 10p12.3 rearrangement (MLLT10b - any partner gene) FLT3/ITD with allelic ratio > 0.1%, without bZIP CEBPA or NPM1 RAM phenotype as evidenced by flow cytometry Other high-risk features not explicitly stated here, after discussion/approval with protocol PI. De novo AML in ≥ CR2 Therapy-related AML in CR1 AML evolving from myelodysplastic syndrome (MDS) Prior hematopoietic cell transplant is allowed, provided remission criteria as defined above are met. No more than 30 years of age. Lansky (<16 years) or Karnofsky (≥16 years) performance status of >60%. Adequate organ function as defined below: Total bilirubin ≤ 3 x IULN for age AST(SGOT)/ALT(SGPT) ≤ 5 x IULN for age GFR ≥ 60 mL/min/1.73m2 as estimated by (1) updated Schwartz formula for ages 1-17 years or Cockcroft-Gault formula for ages ≥ 18 years, (2) 24-hour creatinine clearance, or (3) renal scintigraphy. If GFR is abnormal for age based on updated Schwartz or Cockcroft-Gault formula, accurate measurement should be obtained by either 24-hour creatinine clearance or renal scintigraphy. Renal function may also be estimated by serum creatinine based on age/gender. A serum creatinine < 2 x IULN for age/gender is required for inclusion on this protocol. Adequate cardiac function, defined by left ventricular ejection fraction (LVEF) at rest ≥50% or shortening fraction (SF) ≥27% (via echocardiogram or MUGA). Adequate pulmonary function, defined by: FEV1, FVC, and DLCO ≥50% of predicted. O2 saturation ≥ 92% on room air by pulse oximetry and no supplemental O2 at rest for children < 8 years of age or those unable to perform pulmonary function testing (PFT). For children unable to perform PFT, a high-resolution CT chest should be obtained. The effects of these treatments on the developing human fetus are unknown. For this reason, women of childbearing potential and men must agree to use adequate contraception (hormonal or barrier method of birth control, abstinence) prior to study entry, for the duration of study participation, and for 24 months following transplant. Should a woman become pregnant or suspect she is pregnant while participating in this study, she must inform her treating physician immediately. Ability to understand and willingness to sign an IRB approved written informed consent document, or patient has a guardian who has the ability to understand and willingness to sign an IRB approved written informed consent document. Available familial haploidentical donor. The HCT donor must be available and willing to undergo 2 leukapheresis procedures: (I) one mobilized collection for the HPC graft and (II) one non-mobilized leukapheresis collection for the manufacturing of ML NK cells. Donor and recipient must be identical at a minimum of one allele of each of the following genetic loci: HLA-A, HLA-B, HLA-Cw, HLA-DRB1, and HLA- DQB1. A minimum of 5/10 match is required and will be considered sufficient evidence that the donor and recipient share one HLA haplotype. Patient Exclusion Criteria: Active GvHD. If patient had prior GvHD, patient must be off immunosuppression for at least 3 months prior to starting study treatment. Active non-hematologic malignancy. History of other malignancy is acceptable as long as therapy has been completed and there is no current evidence of disease. Currently receiving any other investigational agents. Active CNS or extramedullary disease. History of CNS or extramedullary disease currently in remission is acceptable. A history of allergic reactions attributed to compounds of similar chemical or biologic composition to agents used in the study. Inability to discontinue medications that are likely to interfere with ML NK cell activity, i.e., glucocorticoids and other immunosuppressants. Presence of significant anti-donor HLA antibodies per institutional standards. Anti-donor HLA - Antibody Testing is defined as a positive crossmatch test of any titer (by complement dependent cytotoxicity or flow cytometric testing) or the mean fluorescence intensity (MFI) of any anti-donor HLA antibody by solid phase immunoassay > 3000. Presence of a second major disorder deemed a contraindication for HCT. Patients with Fanconi Anemia or Down Syndrome. Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection (bacterial, viral with clinical instability, or fungal), symptomatic congestive heart failure, or unstable cardiac arrhythmia. Pregnant and/or breastfeeding. Women of childbearing potential must have a negative pregnancy test within 14 days of the start of conditioning. Donor Eligibility Criteria Donor must be at least 18 years of age. Donor must be HLA haploidentical (≥ 5/10 and ≤ 9/10 allele match at the -A, -B, -C, DRB1 and DQ loci) by high resolution typing and related to the patient. Donor must meet the selection criteria as defined by the Foundation for the Accreditation of Hematopoietic Cell Therapy (FACT). Donor must be available and willing to undergo one mobilized and one non-mobilized leukapheresis procedure. Donor may not be pregnant and/or breastfeeding. Women of childbearing potential must have a negative pregnancy test within 30 days prior to apheresis. Donor must be able to understand and willing to sign an IRB-approved written informed consent document.
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
Interventional Model Description: The study will enroll both transplant recipients and their haploidentical donors.
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Recipient, Myeloablative Conditioning (MAC)<br>Patients will undergo Myeloablative Conditioning (MAC) consisting of rabbit antithymocyte globulin (rATG), Busulfan, Fludarabine, and Thiotepa. All agents are administered intravenously. rATG is administered from days -9 to -7, followed by Busulfan and Fludarabine from days -6 to -3, and Thiotepa on day -2. On Day 0, patients will undergo infusion of the ex vivo TCRαβ/CD19+ depleted haploidentical HPC graft. On Day +7, patients will undergo infusion of the memory-like NK (ML NK) cells, followed by IL-2 subcutaneously 4 hours after the ML NK infusion. IL-2 will continue every other day through Day +19 for a maximum of 7 doses. | Drug: Rabbit Anti thymocyte globulin<br>* rATG is administered intravenously over 6-18 hours for a total of 2 to 3 doses. The daily dose is based on body weight and lymphocyte count.<br>* Other names: rATG;Drug: Busulfan<br>* Busulfan is administered intravenously either Q6H or Q24H, with a recommended target Busulfan AUC of 70-90 mg*h/L.<br>Drug: Fludarabine<br>* Fludarabine is administered intravenously at a dose of 40 mg/m^2/dose once daily for 4 days.<br>Drug: Thiotepa<br>* Thiotepa is administered intravenously at a dose of 5 mg/kg/dose Q12H for 2 doses.<br>Biological: TCR alpha beta / CD19+ depleted haploidentical hematopoietic progenitor cell graft<br>* The HPC product obtained from a haploidentical donor will undergo ex vivo TCR alpha beta and CD19+ depletion, and will be infused fresh on Day 0. There is no maximum limit for CD34+ dose. A maximum dose of 1 x 10^5/kg recipient weight of TCRαβ cells should not be exceeded in the final HPC product.<br>* Other names: TCRab/CD19+ depleted haploidentical HPC graft;Biological: memory-like natural killer cells<br>* The ML NK cells (dose: max capped at 20 x 10^6/kg recipient weight, minimum dose allowed is 0.5 x 10^6/kg recipient weight) will be infused on Day +7.<br>* Other names: ML NK cells;Biological: IL-2<br>* IL-2 is administered subcutaneously at a dose of 1 million units/m^2 on Days +7, +9, +11, +13, +15, +17, and +19 (7 doses total).<br>Device: CliniMACS<br>* After stem cells are collected by leukapheresis, in order to create the HPC product, the stem cells will be washed to remove platelets and the cell concentration will be adjusted per laboratory and CliniMACS technology recommendations. The cells are then labeled using the CliniMACS TCRαβ Biotin Kit and CD19+ immunomagnetic microbeads. After labeling, the cells are washed to remove unbound microbeads. The partially processed product is loaded on the CliniMACS device where labeled cells are depleted and the negative fraction is eluted off the device. The negative fraction is centrifuged and volume reconstituted to obtain the final product.<br>|
| Experimental: Recipient, Reduced Intensity Conditioning (RIC)<br>Patients will undergo Reduced Intensity Conditioning (RIC) consisting of rabbit antithymocyte globulin (rATG), Fludarabine, Melphalan, and Thiotepa. All agents are administered intravenously. rATG is administered from days -9 to -7. Fludarabine is administered from day -8 to day -5, followed by Thiotepa on day -4 and Melphalan on days -3 and -2. On Day 0, patients will undergo infusion of the ex vivo TCRαβ/CD19+ depleted haploidentical HPC graft. On Day +7, patients will undergo infusion of the memory-like NK (ML NK) cells, followed by IL-2 subcutaneously starting 4 hours after the ML NK infusion. IL-2 will continue every other day through Day +19 for a maximum of 7 doses. | Drug: Rabbit Anti thymocyte globulin<br>* rATG is administered intravenously over 6-18 hours for a total of 2 to 3 doses. The daily dose is based on body weight and lymphocyte count.<br>* Other names: rATG;Drug: Fludarabine<br>* Fludarabine is administered intravenously at a dose of 40 mg/m^2/dose once daily for 4 days.<br>Drug: Thiotepa<br>* Thiotepa is administered intravenously at a dose of 5 mg/kg/dose Q12H for 2 doses.<br>Drug: Melphalan<br>* Melphalan is administered intravenously at a dose of 70 mg/m^2/dose once daily for 2 days.<br>* Other names: Alkeran;Biological: TCR alpha beta / CD19+ depleted haploidentical hematopoietic progenitor cell graft<br>* The HPC product obtained from a haploidentical donor will undergo ex vivo TCR alpha beta and CD19+ depletion, and will be infused fresh on Day 0. There is no maximum limit for CD34+ dose. A maximum dose of 1 x 10^5/kg recipient weight of TCRαβ cells should not be exceeded in the final HPC product.<br>* Other names: TCRab/CD19+ depleted haploidentical HPC graft;Biological: memory-like natural killer cells<br>* The ML NK cells (dose: max capped at 20 x 10^6/kg recipient weight, minimum dose allowed is 0.5 x 10^6/kg recipient weight) will be infused on Day +7.<br>* Other names: ML NK cells;Biological: IL-2<br>* IL-2 is administered subcutaneously at a dose of 1 million units/m^2 on Days +7, +9, +11, +13, +15, +17, and +19 (7 doses total).<br>Device: CliniMACS<br>* After stem cells are collected by leukapheresis, in order to create the HPC product, the stem cells will be washed to remove platelets and the cell concentration will be adjusted per laboratory and CliniMACS technology recommendations. The cells are then labeled using the CliniMACS TCRαβ Biotin Kit and CD19+ immunomagnetic microbeads. After labeling, the cells are washed to remove unbound microbeads. The partially processed product is loaded on the CliniMACS device where labeled cells are depleted and the negative fraction is eluted off the device. The negative fraction is centrifuged and volume reconstituted to obtain the final product.<br>|
| Other: Donor<br>Donors will undergo 2 leukapheresis collections. First, patients will be mobilized using G-CSF for 5 days followed by leukapheresis on the day prior to planned stem cell transplant. The second collection will occur on Day +6 after stem cell transplant and will be non-mobilized. | Drug: Plerixafor<br>* If suboptimal collection of stem cells is predicted, plerixafor may be administered at a dose of 0.24 mg/kg subcutaneous injection once (maximum 40mg/dose). For patients with renal impairment, plerixafor will be administered at a dose of 0.16 mg/kg subcutaneous injection (maximum 27 mg/day).<br>Biological: Granulocyte Colony-Stimulating Factor<br>* G-CSF will be administered at a dose of 10 mcg/kg/day for 5 days, or 6 days if two days of collection are needed.<br>* Other names: G-CSF;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Safety of patients being administered donor-derived ML NK cells following TCR alpha beta depleted haploidentical cell transplant | Safety will be determined by events occurring following transplant. Non-relapse mortality, engraftment failure, and development of severe GvHD will be considered events. | From transplant through Day +100 | 
| Feasibility of manufacturing and administering donor-derived ML NK cells following TCR alpha beta depleted haploidentical cell transplant | Feasibility is defined by product manufacture failure, i.e., the inability to infuse ML NK cells due to product contamination or insufficient cell dose (<0.5x10^6 / kg recipient weight). | Through time of ML NK cell infusion (around Day +7) | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Relapse Free Survival (RFS) | Defined as the time between the date of transplant and date of last follow up, relapse, or death due to any cause. | From transplant through Month 12 | 
| Overall Survival (OS) | Defined as death from any cause following transplant. | From transplant through Month 12 | 
| Development of acute graft versus host disease (aGvHD) | Incidence of grade II, III, or IV acute GvHD as graded according to the NIH consensus criteria. Severe aGvHD (Grades III-IV) is considered an event. | From transplant through Day +100 | 
| Development of chronic graft versus host disease (cGvHD) | Incidence of chronic GvHD as graded according to the NIH consensus criteria. Severe cGvHD is considered an event. | From transplant through Day +180 | 
| Development of chronic graft versus host disease (cGvHD) | Incidence and severity of chronic GvHD as graded according to the NIH consensus criteria. Severe cGvHD is considered an event. | From transplant through Day +365 | 
| Development of infections | Significant infections include, but are not limited to, bacterial or fungal sepsis, viral reactivation with or without clinical disease, other viral infections, and community acquired infections. | From transplant through Day +180 | 
| Analysis of immune reconstitution | Immune reconstitution is defined as regain of function of donor-derived immunogenic cells and is measured by recovery of individual cellular compartments. | From transplant through Month 24 | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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high-risk AML, haploidentical transplant, high-risk acute myeloid leukemia, AML from MDS, memory-like natural killer cells, ML NK cells