Reduced-Intensity Hematopoietic Stem Cell Transplant for High Risk Lysosomal and Peroxisomal Disorders

This study is currently recruiting participants.
Verified May 2013 by Masonic Cancer Center, University of Minnesota
Sponsor:
Information provided by (Responsible Party):
Masonic Cancer Center, University of Minnesota
ClinicalTrials.gov Identifier:
NCT01626092
First received: June 20, 2012
Last updated: May 8, 2013
Last verified: May 2013
  Purpose

This study is designed to test the ability to achieve donor hematopoietic engraftment while maintaining low rates of transplant-related mortality (TRM) in patients with high-risk lysosomal and peroxisomal disorders using a novel conditioning regimen for hematopoietic cell transplantation (HCT). After a reduced-intensity conditioning regimen using volumetric-modulated arc therapy (VMAT)-delivered low-dose total body irradiation (TBI) with highly conformal marrow boosting, patients will be transplanted using either a related or unrelated allograft. The cell source may be marrow, peripheral blood or cord blood based on donor availability.


Condition Intervention
Lysosomal Storage Disease
Peroxisomal Disorder
Drug: Campath-1H
Drug: Clofarabine
Drug: Melphalan
Radiation: Total Body Irradiation with Marrow Boosting
Biological: Hematopoietic stem cell transplantation
Drug: Cyclosporine A
Drug: Mycophenolate mofetil

Study Type: Interventional
Study Design: Endpoint Classification: Safety/Efficacy Study
Intervention Model: Single Group Assignment
Masking: Open Label
Primary Purpose: Treatment
Official Title: Treatment of High Risk, Inherited Lysosomal and Peroxisomal Disorders by Reduced-Intensity Hematopoietic Cell Transplantation and Low-Dose Total Body Irradiation With Marrow Boosting by Volumetric-Modulated Arc Therapy (VMAT)

Resource links provided by NLM:


Further study details as provided by Masonic Cancer Center, University of Minnesota:

Primary Outcome Measures:
  • Donor (Allogeneic) Hematopoietic Engraftment [ Time Frame: Day 100 Following Hematopoietic Cell Transplant (HCT) ] [ Designated as safety issue: No ]
    Number of patients who achieve hematopoietic engraftment - assessment of nucleated peripheral blood cells for donor (allogeneic) chimerism following this reduced-intensity HCT.


Secondary Outcome Measures:
  • Transplant-Related Mortality [ Time Frame: Day 100 following HCT ] [ Designated as safety issue: Yes ]
    Incidence of death due to complications of HCT following this reduced-intensity conditioning regimen.

  • Neurologic Outcomes [ Time Frame: Changes from Baseline, Days 30, 60, 100, Year 1, Year 2, Year 3 Following HCT ] [ Designated as safety issue: No ]
    Depending upon underlying primary disease, a combination of evaluative tools (e.g. brain magnetic resonance imaging (MRI), clinical neurologic exam, neuropsychologic testing, electromyography) will be applied for assessment of neurologic function and how it may be affected by this reduced-intensity HCT regimen.


Estimated Enrollment: 37
Study Start Date: July 2012
Estimated Study Completion Date: June 2020
Estimated Primary Completion Date: June 2020 (Final data collection date for primary outcome measure)
Arms Assigned Interventions
Experimental: Intent-To-Treat Patients
Patients with high-risk lysosomal and peroxisomal disorders treated with preparative regimen (Campath-1H 0.3 mg/kg intravenous (IV) on days -12 through -8, clofarabine 40 mg/m^2 IV on days -9 through -5, melphalan 140 mg/m^2 IV on day -4 and Total Body Irradiation with Marrow Boosting [ first dose of 200 cGy single dose; 5 doses of 160cGy for marrow boosting - 1000cGy cumulative exposure] by Volumetric-Modulated Arc Therapy [VMAT] on days -3 through -1). Hematopoietic stem cell transplantation will be infused on Day 0. Post-transplant immunosuppression to follow: Mycophenolate mofetil (MMF) begin day -3 and continue to day +30 or 7 days after engraftment, whichever is later; Cyclosporine A (CsA) begin day -3 and then taper at day +100 if related donor, day +180 for unrelated donor.
Drug: Campath-1H
A daily dose of 0.3 mg/kg IV over 2 hours will be administered on days - 12, -11, -10, -9, and -8.
Other Name: alemtuzumab
Drug: Clofarabine

A daily dose of 40 mg/m2 will be administered IV over 2 hours on days -9,

-8, -7, -6, and -5.

Drug: Melphalan
A single dose of 140 mg/m2 will be given IV on day -4 over 15 minutes.
Radiation: Total Body Irradiation with Marrow Boosting
  1. Dose to total body 200 cGy in single dose
  2. Dose to bone marrow of the following bones 800 cGy in 5 divided daily fractions (160 cGy x 5 doses ). Treated with up to 3 abutting VMAT photon arcs from top of head to maximum inferior border.
Other Name: Volumetric-Modulated Arc Therapy (VMAT)
Biological: Hematopoietic stem cell transplantation
Patients will be transplanted using either a related or unrelated allograft. The cell source may be marrow, peripheral blood or cord blood based on donor availability.
Drug: Cyclosporine A
Patients will receive CsA therapy beginning on day -3. Dosing of CsA will be 2.5 mg/kg/dose IV; if the recipient body weight is <40 kg, dosing will be 3 times daily, and if > 40 kg, twice daily. An attempt will be made to maintain a trough cyclosporine level of 200 mg/L to 400 mg/L.
Other Name: CsA
Drug: Mycophenolate mofetil
Patients will receive mycophenolate mofetil (MMF) therapy beginning on day -3. Dosing of MMF will be 1 gram three times daily (total daily dose 3 grams/day) if the recipient is >50 kg, or 15 mg/kg/dose three times daily if the recipient is ≤50 kg. The same dosage is used orally or intravenously.
Other Name: MMF

Detailed Description:

The conditioning regimen consists of alemtuzumab (Campath-1H), clofarabine, melphalan, and VMAT-delivered low-dose TBI with boosted marrow irradiation. Additional graft-versus-host disease prophylaxis consists of mycophenolate mofetil and cyclosporine.

  Eligibility

Ages Eligible for Study:   up to 55 Years
Genders Eligible for Study:   Both
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  • Adrenoleukodystrophy (ALD): Patients from 0-55 years of age diagnosed with ALD as determined by very long chain fatty acid testing will be eligible for this protocol if they have evidence of cerebral or cerebellar disease based on MRI testing, AND they are determined high risk for any of the following reasons:

    • Age >18 years
    • Magnetic resonance imaging (MRI )radiographic severity (Loes) score >10
    • Evidence of aggressive disease that in the judgment of the Inherited Metabolic and Storage Disease group is sufficiently concerning to consider transplantation with a reduced intensity regimen instead of a standard full preparative regimen.
  • Metachromatic Leukodystrophy (MLD): Patients from 0-55 years of age diagnosed with MLD as determined by arylsulfatase A activity. Testing will be eligible for this protocol IF they are determined high risk for any of the following reasons:

    • Age >18 years
    • Symptomatic disease, as based on neurologic examination or evidence of deterioration based on subsequent neuropsychologic evaluations.
    • Evidence of aggressive disease (such as rapidly changing MRI determinations) that in the judgment of the Inherited Metabolic and Storage Disease group is sufficiently concerning to consider transplantation with a reduced intensity regimen instead of a standard full preparative regimen.
  • Globoid Cell Leukodystrophy (GLD): Patients from 0-55 years of age diagnosed with GLD as determined by galactocerebrosidase activity will be eligible for this protocol IF they are determined high risk for any of the following reasons:

    • Age >18 years
    • Symptomatic disease, as based on neurologic examination or evidence of deterioration based on subsequent neuropsychologic evaluations.
    • Evidence of aggressive disease (such as rapidly changing MRI determinations) that in the judgment of the Inherited Metabolic and Storage Disease group is sufficiently concerning to consider transplantation with a reduced intensity regimen instead of a standard full preparative regimen.
  • Wolman's disease, GM1 gangliosidosis, Tay Sachs disease, Sanfilippo syndrome, Sandhoff disease or other inherited metabolic diseases including but not limited to I-cell disease (mucolipidosis II): Patients who are determined to be sufficiently advanced or high risk based on the following reasons:

    • Symptomatic disease, as based on neurologic examination or evidence of deterioration based on subsequent neuropsychologic evaluations.
    • Evidence of an expected poor outcome based on genetic testing or a prior family history of aggressive disease.
    • Other metabolic disorders, including but not limited to I-cell disease, that are deemed to be high-risk for a poor outcome with a standard transplant regimen due to anticipated toxicity based on experience gained at the University of Minnesota or other centers.

Donor Availability

  • Patients considered for transplantation must have a sufficient graft as based on current criteria of the University of Minnesota Blood and Marrow Transplantation Program

    • Transplantation using sufficiently matched related donors (such as matched siblings) or unrelated donors will be considered. Both granulocyte-colony stimulating factor (G-CSF) stimulated peripheral blood grafts and bone marrow grafts will be considered, although bone marrow will be the priority.
    • Cord blood grafts, both related and unrelated, are also eligible. As this protocol will use a reduced intensity regimen, this protocol will use the current recommendations of the University of Minnesota for choosing cord blood grafts. If a single cord blood unit cell dose is insufficient, double cord transplantation should be considered if sufficiently matched cord blood units are available. The priority of choosing cord blood donors is based on the current institutional recommendations.
    • Exclusion of Metabolic Disorder Carrier Status from related donor and unrelated cord blood grafts as appropriate for primary disease.
  • Adequate Organ Function - Measured within 30 days of study enrollment and defined as:

    • Cardiac: left ventricular ejection fraction ≥ 25%
    • Renal: serum creatinine ≤ 3 x normal for age and/or glomerular filtration rate (GFR) ≥ 20 mL/min
    • Hepatic: total bilirubin and Alanine transaminase (ALT) ≤ 5 x upper limit of normal (ULN)
    • Pulmonary: does not require continuous oxygen supplementation
  • Signed consent

Exclusion Criteria:

  • Inability to receive total body irradiation (TBI) with marrow boosting per protocol guidelines as determined by the Radiation Oncologist - any patient who has had prior radiation therapy or TBI will be evaluated by the Radiation Oncologist for approval for study participation.
  • Pregnant - Menstruating females must have a negative serum pregnancy test within 14 days of treatment start.
  • Advanced Disease Exclusion: Following evaluation, if a consensus of the members of the Inherited Metabolic and Storage Disease Program is that a patient is too advanced to benefit in a measurable and meaningful way from transplant, this will be communicated to the family, and transplant will not be offered. Measures to assist in those determinations may include neuro-radiographic imaging, neuropsychometric testing, and general neurologic assessment.
  Contacts and Locations
Please refer to this study by its ClinicalTrials.gov identifier: NCT01626092

Contacts
Contact: Weston Miller, MD 612-626-2778 mill4991@umn.edu
Contact: Patricia Kleinke, RN 612-273-0857 pkleink1@fairview.org

Locations
United States, Minnesota
Masonic Cancer Center, University of Minnesota Recruiting
Minneapolis, Minnesota, United States, 55455
Contact: Weston Miller, MD    612-626-2778    mill4991@umn.edu   
Principal Investigator: Weston Miller, MD         
Sponsors and Collaborators
Masonic Cancer Center, University of Minnesota
Investigators
Principal Investigator: Weston Miller, MD Masonic Cancer Center, University of Minnesota
  More Information

No publications provided

Responsible Party: Masonic Cancer Center, University of Minnesota
ClinicalTrials.gov Identifier: NCT01626092     History of Changes
Other Study ID Numbers: 2011LS147, MT2011-24
Study First Received: June 20, 2012
Last Updated: May 8, 2013
Health Authority: United States: Institutional Review Board

Keywords provided by Masonic Cancer Center, University of Minnesota:
Wolman's disease
Tay Sachs disease
Sandhoff disease
I-cell disease
bone marrow transplantation
reduced intensity conditioning
Adrenoleukodystrophy
Metachromatic Leukodystrophy
Globoid Cell Leukodystrophy
GM1 gangliosidosis
Sanfilippo syndrome
inherited metabolic
mucolipidosis II

Additional relevant MeSH terms:
Lysosomal Storage Diseases
Metabolic Diseases
Peroxisomal Disorders
Genetic Diseases, Inborn
Brain Diseases, Metabolic, Inborn
Brain Diseases, Metabolic
Brain Diseases
Central Nervous System Diseases
Nervous System Diseases
Metabolism, Inborn Errors
Cyclosporins
Cyclosporine
Mycophenolic Acid
Melphalan
Mycophenolate mofetil
Campath 1G
Clofarabine
Alemtuzumab
Enzyme Inhibitors
Molecular Mechanisms of Pharmacological Action
Pharmacologic Actions
Immunosuppressive Agents
Immunologic Factors
Physiological Effects of Drugs
Antifungal Agents
Anti-Infective Agents
Therapeutic Uses
Dermatologic Agents
Antirheumatic Agents
Myeloablative Agonists

ClinicalTrials.gov processed this record on April 15, 2014