This phase I trial tests the safety, side effects, best dose, and effectiveness of 225Ac-DOTA-Anti-CD38 daratumumab monoclonal antibody in combination with fludarabine, melphalan and total marrow and lymphoid irradiation (TMLI) as conditioning treatment for donor stem cell transplant in patients with high-risk acute myeloid leukemia (AML), acute lymphoblastic leukemia (ALL) and myelodysplastic syndrome (MDS). Daratumumab is in a class of medications called monoclonal antibodies. It binds to a protein called CD38, which is found on some types of immune cells and cancer cells. Daratumumab may block CD38 and help the immune system kill cancer cells. Radioimmunotherapy is treatment with a radioactive substance that is linked to a monoclonal antibody, such as daratumumab, that will find and attach to cancer cells. Radiation given off by the radioisotope my help kill the cancer cells. Chemotherapy drugs, such as fludarabine and melphalan, work in different ways to stop the growth of cancer cells, either by killing the cells, by stopping them from dividing, or by stopping them from spreading. Radiation therapy uses high energy x-rays, particles, or radioactive seeds to kill cancer cells and shrink tumors. TMLI is a targeted form of body radiation that targets marrow, lymph node chains, and the spleen. It is designed to reduce radiation-associated side effects and maximize therapy effect. Actinium Ac 225-DOTA-daratumumab combined with fludarabine, melphalan and TMLI may be safe, tolerable, and/or effective as conditioning treatment for donor stem cell transplant in patients with high-risk AML, ALL, and MDS.
PRIMARY OBJECTIVES: I. Describe toxicities attributable to actinium Ac 225-DOTA-daratumumab (225Ac-DOTA-anti-CD38 daratumumab) radioimmunotherapy by dose level in patients treated under this regimen. II. Determine the maximum tolerated dose/recommended phase II dose (MTD/RP2D) of 225Ac-DOTA-anti-CD38 daratumumab radioimmunotherapy with fixed doses of organ sparing TMLI (12 Gy), fludarabine and melphalan (FM100) as conditioning regimen for allogeneic hematopoietic cell transplantation (HCT) for treatment of high-risk acute myeloid leukemias, acute lymphoblastic leukemia or myelodysplastic syndrome (MDS), in patients who are not eligible for standard myeloablative regimens. SECONDARY OBJECTIVES: I. Evaluate the safety of the regimen, at each dose level, by assessing the following: Ia. Type, frequency, severity, attribution, time course and duration of adverse events, including acute/chronic graft-versus-host disease (GVHD), infection and delayed engraftment. II. Estimate overall survival (OS), event-free survival (EFS), GVHD relapse free survival (GRFS), cumulative incidence (CI) of relapse/progression, and non-relapse mortality (NRM) at 100 days, 1 year and 2 years. III. Describe biodistribution, pharmacokinetics and organ dosimetry of 225Ac-DOTA-daratumumab. OUTLINE: This is a dose escalation of actinium Ac 225-DOTA-Daratumumab in combination with fludarabine, melphalan and TMLI. Patients receive daratumumab intravenously (IV) over 45 minutes followed by indium In 111-DOTA-daratumumab IV over 15 minutes and actinium Ac 225-DOTA-daratumumab IV over \~20-40 minutes on day -15. Patients receive TMLI twice daily (BID) on days -8 to -5, fludarabine IV on days -4 to -2 and melphalan IV on day -2, followed by HCT on day 0. Patients receive GVHD prophylaxis with sirolimus and tacrolimus starting on day -1. Patients also undergo computed tomography (CT) during screening, nuclear scan and single photon emission computed tomography (SPECT) scans on study, bone marrow biopsy and aspiration, echocardiography, or multigated acquisition scan (MUGA), and blood sample collection during screening and throughout study. After completion of study treatment, patients are followed up twice weekly for the first 100 days post-transplant, then twice monthly up to 6 months post-transplant followed by monthly until discontinuation of immunosuppressive therapy without evidence of GVHD with at least yearly follow-up for 2 years.
Study Type
INTERVENTIONAL
Allocation
NA
Purpose
TREATMENT
Masking
NONE
Enrollment
15
Given IV
Undergo blood sample collection
Undergo bone marrow biopsy and aspiration
Undergo bone marrow biopsy and aspiration
Undergo CT
Given IV
Undergo echocardiography
Given IV
Undergo SCT
Given IV
Given IV
Undergo MUGA
Undergo nuclear scan
Undergo SPECT scan
Given sirolimus
Given tacrolimus
Undergo TMLI
City of Hope Medical Center
Duarte, California, United States
RECRUITINGIncidence of adverse events (CTCAE)
Toxicity will be scored on the National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE) version (v) 5 scale. Toxicity will be recorded in each patient and will include the type, severity, and probable association with the study regimen.
Time frame: Up to 2 years post-transplant
Incidence of adverse events (Bearman)
Toxicity will be scored on the Bearman Scale. Toxicity will be recorded in each patient and will include the type, severity, and probable association with the study regimen.
Time frame: Up to 2 years post-transplant
Dose limiting toxicity (DLT)
DLT will be graded using the NCI CTCAE v5 scale.
Time frame: Up to 30 days post-stem cell infusion
Maximum tolerated dose/recommended phase II dose (MTD/RP2D)
MTD/RP2D will be defined as the highest dose where 6 patients have been treated and at most on patient experiences a DLT.
Time frame: Up to 30 days post stem cell infusion
Overall survival (OS)
OS will be defined as the time from start of protocol therapy to death or last follow-up whichever comes first. OS will be calculated using the Kaplan-Meier method.
Time frame: At start of protocol therapy to death or last follow-up up to 2 years post transplant
Event-free survival (EFS)
EFS will be defined as the time from start of protocol therapy to death, relapse/progression or last follow-up, whichever comes first. EFS will be calculated using the Kaplan-Meier method.
Time frame: At start of protocol therapy to death, relapse/progression or last follow-up up to 2 years post-transplant
Cumulative incidence of relapse/progression (CIR)
CIR will be measured from start of therapy. Death without relapse/progression is considered a competing risk.
Time frame: At start of therapy up to 2 years post transplant
Graft versus host disease and relapse free survival (GRFS)
GRFS will be measured from the start of therapy. GRFS will be calculated using the Kaplan-Meier method.
Time frame: At start of therapy up to 2 years post-transplant
Complete remission (CR) proportion
CR will be defined as the time from start of therapy to the time of biopsy proven CR.
Time frame: At start of therapy up to day 30
Non-relapse mortality (NRM)
NRM will be defined as the time from start of therapy until non-disease related death, or last follow-up, whichever comes first. NRM will be calculated as competing risks.
Time frame: At start of therapy until non-disease related death or last follow-up up to 2 years post-transplant
Incidence of infection
Microbiologically documented infections will be reported by site of disease, date of onset, severity and resolution, if any.
Time frame: At day 0 up to 100 days post-transplant
Neutrophil recovery rate
Neutrophil recovery rate will be measured from stem cell infusion to the first to three consecutive days with neutrophil count greater than 0.5 x 10\^9/L.
Time frame: At stem cell infusion up to the first to three consecutive days with neutrophil count greater than 0.5 x 10^9/L up to 2 years post-transplant
Incidence of grade 2-4 and 3-4 acute graft-versus-host disease (GVHD)
Documented/biopsy proven acute GVHD will be graded according to the Consensus Grading. Acute GVHD will be measured from date of stem cell infusion to document/biopsy proven acute GVHD onset date (within the first 100 days post-transplant) and will be used to estimate the cumulative incidence. GVHD will be calculated as competing risks.
Time frame: At date of stem cell infusion to document/biopsy proven acute GVHS onset (within first 100 days post-transplant)
Incidence of chronic GVHD (cGVHD)
Documented/biopsy proven cGVHD is scored according to National Institutes of Health Consensus Staging. CGVHD is measured from approximately 80-100 days post-transplant to the documented/biopsy proven cGVHD onset date and will be used to estimate the cumulative incidence. The incidence of cGVHD will be calculated as competing risks.
Time frame: At 80-100 days post-transplant to documented/biopsy proven cGVHD onset date up to 2 years post-transplant
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