HLA-Nonidentical Stem Cell and Natural Killer Cell Transplantation for Children Less the Two Years of Age With Hematologic Malignancies

St. Jude Children's Research Hospital40 enrolled

Overview

Recent studies of conventional chemotherapy for infants with high-risk hematologic malignancies show that the long-term disease-free survival is low. Although blood and marrow stem cell transplantation using an HLA identical sibling has improved the outcome for these children, less than 25% have this donor source available. Another option is haploidentical transplantation using a partially matched family member donor (i.e. parental donor). Although haploidentical transplantation has proven curative for some patients, this procedure has been hindered by significant complications, primarily regimen-related toxicity including infection and graft versus host disease (GVHD). Building on prior institutional trials, this study will provide patients a haploidentical graft depleted of T lymphocytes using the investigational device, CliniMACS selection system. One week after the transplant procedure, patients will also receive an infusion of additional donor derived white blood cells called Natural Killer (NK) cells in an effort to decrease risks for rejection of the graft, disease relapse, and regimen related toxicity. The primary objective of the study is to evaluate 1 year survival in infants with high risk hematologic malignancies who receive this study treatment.

Secondary objectives for this study include the following: * To estimate the incidence of three transplant-related adverse outcomes (i.e., regimen-related mortality, engraftment failure, and fatal acute GVHD) in the first 100 days after transplantation. * To estimate the incidence of chronic graft-versus-host disease. * To evaluate those factors that affect one-year survival. * To assess the kinetics of lymphohematopoietic reconstitution. * To assess the frequency and clinical relevance of minimal residual disease (MRD) before and after transplantation. * To evaluate the incidence of and risk factors for long-term neurocognitive deficit and organ dysfunction.

Study Type

INTERVENTIONAL

Allocation

Purpose

TREATMENT

Masking

NONE

Interventions

Chemotherapy and antibodiesDRUG

Study participants will receive a non-TBI based preparative regimen consisting of Cyclophosphamide, fludarabine, thiotepa, melphalan, and muromonab-CD3 (OKT3) followed by an infusion of a T-lymphocyte depleted haploidentical hematopoietic stem cell graft. Seven days posttransplant, participants will receive an infusion of additional donor derived cells called NK cells.

Miltenyi Biotec CliniMACSDEVICE

Stem cell selection device

Allogeneic stem cell transplantationPROCEDURE

Allogeneic natural killer (NK)cell infusion

Eligibility

Sex: ALLMax age: 24 Months

Medical Language ↔ Plain English

Inclusion Criteria: Must have one of the following diagnosis: * AML in remission or relapse (e.g., FAB M7 or biphenotypic leukemia) * High-risk ALL in first remission (e.g., poor responder to prednisone, Ph+ ALL) * ALL beyond first remission * Secondary leukemia * Primary myelodysplasia (including RAEB, RAEB-T, CMML, JCML, and JMML) * Chronic myeloid leukemia * Histiocytoses (including multi-system Langerhans' cell histiocytosis and hemophagocytic lymphohistiocytosis Inclusion criteria Donor research participants * HIV negative (date). * Hepatitis B surface antigen negative (date). * Hepatitis C antibody negative (date). * Syphilis negative (date). * Donor is equal to or greater than 3 on 6 HLA match (date). * Not pregnant (negative pregnancy test). * Not lactating. * At least 18 years of age. Exclusion Criteria * Patients greater than 24 months of age at the time of transplant. * HLA-identical sibling donor is available. * Cardiac function: shortening fraction \<25%. * Pulse oximetry oxygen saturation \<92% on room air. * Glomerular filtration rate less than 40 ml/min/1.73 m2 (may use Technetium-99 result for GFR). * Direct bilirubin \> 3 mg/dl. * SGPT \> 500 U/L. * Patients with previous allergy to mouse proteins. * Patients with previous allergy to rabbit serum products. * Patients with Down's syndrome

Outcomes

Primary Outcomes

One-year Survival

The one-year survival of infants with high-risk hematologic malignancies who receive a haploidentical transplant procedure using a total body irradiation (TBI)-excluding conditioning regimen followed by an HLA-nonidentical family donor hematopoietic stem cell (HSC) graft depleted of T cells ex vivo using the CliniMACS CD34+ selection system, with a subsequent infusion of donor NK cells purified ex vivo using the CliniMACS CD3+ depletion and CD56+ enrichment system. The Kaplan-Meier estimate for one-year survival is reported.

Time frame: One year after transplant

Secondary Outcomes

Number of Transplant-Related Adverse Outcomes: Regimen-Related Mortality

The cumulative incidences of regimen-related mortality will be estimated using method of Kalbfleisch and Prentice.

Time frame: 100 days post-transplantation

Number of Transplant-Related Adverse Outcomes: Engraftment Failure

Engraftment failure is defined as \<10% donor cell chimerism at any time point between 28 and 100 days after transplant with no evidence of disease relapse or requiring stem cell boost.

Time frame: 100 days post-transplantation

Number of Transplant-Related Adverse Outcomes: Fatal Acute Graft-Versus Host Disease (GVHD)

The cumulative incidence estimate for occurrence of fatal acute GVHD by the end of the first 100 days post-transplant was calculated using method of Kalbfleisch and Prentice.

Time frame: 100 days post-transplantation

Number of Incidences of Chronic GVHD.

Chronic GVHD was graded according to Seattle Criteria: limited or extensive. Limited is defined as localized skin and/or hepatic dysfunction. Extensive is defined as one or more of the following: * generalized skin involvement * liver histology showing chronic aggressive hepatitis, bridging necrosis or cirrhosis * eye dryness with Schirmer's test \<5 mm wetting * oral: involvement of salivary glands or oral mucosa * other: another target organ involvement

Time frame: Up to 5 years after transplant

Factors Affecting One-year Survival: Median Age of Donor at HSCT

Due to small sample size (n=14) and total number of events (n=7), the analysis to check the various factors that affect the one-year survival was not performed (using logistic and cox model).