Gene Therapy for Fanconi Anemia

• Feasibility of mobilizing sufficient hematopoietic progenitor cells in patients with FANCA with filgrastim or combination of filgrastim and plerixafor [ Time Frame: 5 days prior to transduction therapy ] [ Designated as safety issue: No ]
  Total cell CD34+ cell count to be determined after completion of leukapheresis procedure. A successful mobilization for a given patient will be defined by our ability to collect at least 1 X 10^6 CD34+ cells/kg.
• Transduction efficiency [ Time Frame: Day 0 ] [ Designated as safety issue: No ]
  After completion of lentiviral transduction, the percent gene modified cells will be determined by molecular studies.
• Detectable levels of transduced cells in blood and marrow [ Time Frame: Up to 1 year ] [ Designated as safety issue: No ]
  Blood and bone marrow samples will be assayed by real-time quantitative polymerase chain reaction (PCR).
• Improved blood counts [ Time Frame: Up to 15 years ] [ Designated as safety issue: No ]
  Complete blood counts will be monitored, initially weekly, then monthly during the first year, then quarterly during the 2nd year after infusion.
• Demonstrable functional expression by growth of recipient cells in mitomycin C [ Time Frame: 3 months ] [ Designated as safety issue: No ]
  Blood and bone marrow cells will be assayed for viability of cultured cells and hematopoietic colonies in the presence of the chemotherapy drug and deoxyribonucleic acid (DNA) crosslinking agent, mitomycin C.

• Total Number of CD34+ Cells Mobilized per Kilogram Weight after G-CSF with Plerixafor (latter if age 18 or older) [ Time Frame: 5 days ] [ Designated as safety issue: No ]
  Total cell CD34+ cell count to be determined after completion of leukapheresis procedure.
• Transduction efficiency [ Time Frame: 6th day ] [ Designated as safety issue: No ]
  After completion of lentiviral transduction, the percent gene modified cells will be determined by molecular studies.
• Percent of transduced cells in blood and bone marrow [ Time Frame: 12 months ] [ Designated as safety issue: No ]
  Blood and bone marrow samples will be assayed by real time quantitative polymerase chain reaction at intervals from weekly to quarterly during the first year after infusion.
• Improved blood counts [ Time Frame: 2 years ] [ Designated as safety issue: No ]
  Complete blood counts will be monitored, initially weekly, then monthly during the first year, then quarterly during the 2nd year after infusion.
• Mitomycin C resistance in blood and bone marrow cells [ Time Frame: 3 months ] [ Designated as safety issue: No ]
  Blood and bone marrow cells will be assayed for viability of cultured cells and hematopoietic colonies in the presence of the chemotherapy drug and DNA crosslinking agent, mitomycin C.

This pilot trial will assess the toxicity and efficacy of infusion of gene modified cells, as well as the feasibility of mobilization of peripheral blood stem cells with filgrastim and plerixafor for patients with Fanconi anemia (FA). Infusion of autologous patient blood stem cells that have been corrected in the laboratory by introduction of the normal gene may improve blood counts in patients with FA

PRIMARY OBJECTIVES:

I. To determine the safety of lentiviral gene transfer for patients with Fanconi anemia complementation group A (FANCA).

SECONDARY OBJECTIVES:

I. To determine the feasibility of collection of the number of hematopoietic progenitor cells from Fanconi anemia complementation group A patients that would be expected to have potential for therapeutic benefit after transduction and infusion. The mobilization will be performed with G-CSF (filgrastim) or with a combination of G-CSF and plerixafor for patients aged 18 and older. Additional bone marrow may be collected if insufficient cells are collected after mobilization and apheresis.

II. To determine the transduction efficiency for human FA patient hematopoietic progenitor cells transduced with a clinical grade lentiviral vector encoding the gene for Fanconi anemia complementation group A.

III. To determine if the clinical grade transduction will result in phenotypic correction of gene modified cells by in vitro assays.

IV. To determine if infusion of FANCA gene-modified cells will result in engraftment and improvement in blood counts in FA patients.

OUTLINE:

STEM CELL MOBILIZATION: Patients receive filgrastim subcutaneously (SC) twice daily on days -5 to -1. Patients 18 years of age or older also receive plerixafor SC on days -2 and -1.

CELL COLLECTION: Patients undergo apheresis for collection of stem/progenitor cells on days -2 and -1. Patients with insufficient cell mobilization (< 1 x 10^6 CD34+ cells/kg) undergo bone marrow harvest.

REINFUSION: Patients undergo reinfusion of genetically modified hematopoietic progenitor cells on day 0.

After completion of study treatment, patients are followed up periodically for 15 years.

• Biological: filgrastim
  Given SC
  Other Names:

  • G-CSF
  • Neupogen
• Drug: plerixafor
  Given SC
  Other Names:

  • AMD 3100
  • Mozobil
• Procedure: leukapheresis
  Undergo apheresis
• Biological: genetically engineered lymphocyte therapy
  Undergo infusion of genetically modified hematopoietic progenitor cell therapy
• Other: laboratory biomarker analysis
  Correlative studies
• Genetic: polymerase chain reaction
  Correlative studies
  Other Name: PCR

Inclusion Criteria:

• FA demonstrated by a positive test for increased sensitivity to chromosomal breakage with mitomycin C or diepoxybutane performed by a Clinical Laboratory Improvement Amendments (CLIA) or College of American Pathologists (CAP) approved laboratory
• FA complementation group A as determined by somatic cell hybrids, molecular characterization, western blot analysis, or acquisition of mitomycin C resistance after in vitro lentiviral transduction with a vector bearing the cDNA for Fanconi complementation group A
• Bone marrow analysis demonstrating normal cytogenetics, and no more than 5% of cells with a single clonal abnormality by fluorescence in situ hybridization (FISH) for myelodysplastic syndrome (MDS) panel within 3 months of stem cell collection
• Signed informed consent by the patient or legally authorized representative
• Absolute neutrophil count >= 0.5 X 10^9/L
• Hemoglobin >= 8 g/dl
• Platelet count >= 20 X 10^9/L and able to achieve a platelet count of >= 50 X 10^9/L with transfusion support
• Adequate hepatic function with aspartate aminotransferase (AST) and alanine aminotransferase (ALT) < 5 X upper limit of normal (ULN)
• Adequate renal function with Creatinine =< 1.5; if greater, then glomerular filtration rate (GFR) > 60 ml/min/ 1.73 m^2 as calculated by the Modification of Diet in Renal Disease equation
• Adequate pulmonary function with corrected diffusion capacity of carbon monoxide (DLCO) > 50%
• For subjects < 17 years of age, Modified Lansky Play-Performance Score of >= 70%; for subjects 17 and older, Karnofsky score of >= 70%

Exclusion Criteria:

• Non-hematopoietic malignancy where the expected survival is less than 2 years
• Myelodysplastic syndrome as defined by World Health Organization (WHO) criteria
• Acute myeloid leukemia as defined by WHO criteria
• Pregnancy or lactation; females of childbearing potential and males who are admitted to the study will be advised that the study procedures and study drugs may be teratogenic, and they will be required to take adequate measures to prevent conception for the duration of the study
• Concurrent enrollment in any other study using an investigational drug
• Physical or emotional status that would prevent informed consent, protocol compliance, or adequate follow-up

• Patients for whom an HLA matched sibling donor bone marrow transplant is being actively pursued will not be eligible for study until it is determined that no sibling donor is available or that a stem cell transplant is not feasible during the time the patient might be on study

  • No patient will be included in this study as an alternative to a clinically indicated HLA matched sibling donor stem cell transplant
  • If an HLA matched sibling donor is identified, but stem cell or marrow collection is not feasible (e.g., donor is in utero, is a newborn from whom cord blood was not collected, or is unable to undergo a donation procedure because of ill health), a patient may be included in the study at the discretion of the investigators
• Significant associated diseases including documented human immunodeficiency virus (HIV) infection, uncontrolled hypertension (diastolic blood pressures > 95%ile for age), unstable angina, congestive heart failure (> New York Heart Association [NYHA] II), poorly controlled diabetes (Hgb A1c > 7%), coronary angioplasty within 6 months, myocardial infarction within the last 6 months, or uncontrolled atrial or ventricular cardiac arrhythmia, abnormal coagulation, persistent abnormal urinalysis reflecting intrinsic renal disease
• Active ongoing viral, bacterial, or fungal infection

• National Heart, Lung, and Blood Institute (NHLBI)
• National Cancer Institute (NCI)