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JAK Inhibitor Before Donor Stem Cell Transplant in Treating Patients With Primary or Secondary Myelofibrosis

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ClinicalTrials.gov Identifier: NCT02251821
Recruitment Status : Recruiting
First Posted : September 29, 2014
Last Update Posted : March 20, 2018
Sponsor:
Collaborators:
National Cancer Institute (NCI)
National Heart, Lung, and Blood Institute (NHLBI)
Information provided by (Responsible Party):
Fred Hutchinson Cancer Research Center

Brief Summary:
This phase II trial studies how well giving a JAK inhibitor before a donor stem cell transplant works in treating patients with myelofibrosis that developed without another condition (primary) or evolved from other bone marrow disorders (secondary). JAK inhibitors are a class of drugs that may stop the growth of abnormal cells by blocking an enzyme needed for cell growth. Giving a JAK inhibitor before a donor stem cell transplant may help reduce symptoms of myelofibrosis such as inflammation and enlargement of the spleen, improve the patient's general physical condition, and prevent complications from occurring after the transplant. Infusing healthy stem cells from a donor into the patient may help the patient's bone marrow work normally and make stem cells, red blood cells, white blood cells, and platelets. Giving a JAK inhibitor before a donor stem cell transplant may help improve transplant outcomes in patients with myelofibrosis.

Condition or disease Intervention/treatment Phase
Primary Myelofibrosis Secondary Myelofibrosis Procedure: Allogeneic Hematopoietic Stem Cell Transplantation Drug: Busulfan Drug: Cyclophosphamide Drug: Fludarabine Phosphate Other: Laboratory Biomarker Analysis Drug: Melphalan Drug: Methotrexate Drug: Momelotinib Drug: Mycophenolate Mofetil Drug: Pacritinib Drug: Ruxolitinib Drug: Tacrolimus Radiation: Total-Body Irradiation Procedure: Umbilical Cord Blood Transplantation Phase 2

Detailed Description:

PRIMARY OBJECTIVES:

I. To optimize the role of allogeneic transplantation for primary and secondary myelofibrosis (MF) in the JAK inhibitor era.

OUTLINE:

PART 1: Patients receive a JAK inhibitor (ruxolitinib, momelotinib, or pacritinib) orally (PO) twice daily (BID) from at least 8 weeks prior to the start of conditioning until best response through day -4 before transplantation, with a taper schedule reducing the dose every 2-3 days beginning after day -4.

PART 2: Patients are assigned to 1 of 2 conditioning regimens at the discretion of the clinical provider and Clinical Coordinators Office (CCO).

MYELOABLATIVE CONDITIONING: Patients receive fludarabine phosphate intravenously (IV) over 1 hour on days -8 to -6 (umbilical cord blood transplant recipients only), cyclophosphamide IV on days -7 and -6, and busulfan IV over 3 hours on days -5 to -2.

REDUCED-INTENSITY CONDITIONING: Patients receive fludarabine phosphate IV over 1 hour on days -6 to -2 and melphalan IV over 15-30 minutes on days -3 and -2. Patients also undergo total-body irradiation (TBI) on day -1 (umbilical cord blood transplant recipients only).

TRANSPLANT: Patients undergo allogeneic hematopoietic stem cell transplant or umbilical cord blood transplant on day 0.

GRAFT-VERSUS-HOST DISEASE (GVHD) PROPHYLAXIS: Patients receive tacrolimus IV continuously (inpatients) or over 1-2 hours twice daily (BID) (outpatients) or orally (PO) BID on days -1 to +180 (patients receiving related or unrelated stem cells) or days -3 to +180 (patients receiving umbilical cord blood) with taper beginning on day +56 (related donor recipients) or +100 (unrelated donor or umbilical cord blood recipients) in the absence of GVHD. Patients also receive methotrexate IV on days +1, +3, +6, and +11 (related and unrelated donor recipients only) or mycophenolate mofetil IV or PO every 8 hours on days 0 to +40 with taper to day +96 (umbilical cord blood transplant recipients only).

After completion of study treatment, patients are followed up at 6 months, 1 year, and then yearly for 4 years.


Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 33 participants
Intervention Model: Single Group Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
Official Title: JAK Inhibitor Prior to Allogeneic Stem Cell Transplant for Patients With Primary and Secondary Myelofibrosis: A Prospective Study
Actual Study Start Date : October 20, 2014
Estimated Primary Completion Date : March 1, 2019


Arm Intervention/treatment
Experimental: Treatment (JAK inhibitor, transplant)
Patients receive a JAK inhibitor (ruxolitinib, momelotinib, or pacritinib) and undergo myeloablative or reduced-intensity conditioning followed by transplant and GVHD prophylaxis; see detailed description.
Procedure: Allogeneic Hematopoietic Stem Cell Transplantation
Undergo allogeneic hematopoietic stem cell transplant
Other Names:
  • Allogeneic Hematopoietic Cell Transplantation
  • allogeneic stem cell transplantation
  • HSC
  • HSCT
Drug: Busulfan
Given IV
Other Names:
  • 1, 4-Bis[methanesulfonoxy]butane
  • BUS
  • Bussulfam
  • Busulfanum
  • Busulfex
  • Busulphan
  • CB 2041
  • CB-2041
  • Glyzophrol
  • GT 41
  • GT-41
  • Joacamine
  • Methanesulfonic Acid Tetramethylene Ester
  • Methanesulfonic acid, tetramethylene ester
  • Mielucin
  • Misulban
  • Misulfan
  • Mitosan
  • Myeleukon
  • Myeloleukon
  • Myelosan
  • Mylecytan
  • Myleran
  • Sulfabutin
  • Tetramethylene Bis(methanesulfonate)
  • Tetramethylene bis[methanesulfonate]
  • WR-19508
Drug: Cyclophosphamide
Given IV
Other Names:
  • (-)-Cyclophosphamide
  • 2H-1,3,2-Oxazaphosphorine, 2-[bis(2-chloroethyl)amino]tetrahydro-, 2-oxide, monohydrate
  • Carloxan
  • Ciclofosfamida
  • Ciclofosfamide
  • Cicloxal
  • Clafen
  • Claphene
  • CP monohydrate
  • CTX
  • CYCLO-cell
  • Cycloblastin
  • Cycloblastine
  • Cyclophospham
  • Cyclophosphamid monohydrate
  • Cyclophosphamidum
  • Cyclophosphan
  • Cyclophosphane
  • Cyclophosphanum
  • Cyclostin
  • Cyclostine
  • Cytophosphan
  • Cytophosphane
  • Cytoxan
  • Fosfaseron
  • Genoxal
  • Genuxal
  • Ledoxina
  • Mitoxan
  • Neosar
  • Revimmune
  • Syklofosfamid
  • WR- 138719
Drug: Fludarabine Phosphate
Given IV
Other Names:
  • 2-F-ara-AMP
  • 9H-Purin-6-amine, 2-fluoro-9-(5-O-phosphono-.beta.-D-arabinofuranosyl)-
  • Beneflur
  • Fludara
  • SH T 586
Other: Laboratory Biomarker Analysis
Correlative studies
Drug: Melphalan
Given IV
Other Names:
  • Alanine Nitrogen Mustard
  • CB-3025
  • L-PAM
  • L-Phenylalanine mustard
  • L-Sarcolysin
  • L-Sarcolysin Phenylalanine mustard
  • L-Sarcolysine
  • Melphalanum
  • Phenylalanine Mustard
  • Phenylalanine Nitrogen Mustard
  • Sarcoclorin
  • Sarkolysin
  • WR-19813
Drug: Methotrexate
Given IV
Other Names:
  • Abitrexate
  • Alpha-Methopterin
  • Amethopterin
  • Brimexate
  • CL 14377
  • CL-14377
  • Emtexate
  • Emthexat
  • Emthexate
  • Farmitrexat
  • Fauldexato
  • Folex
  • Folex PFS
  • Lantarel
  • Ledertrexate
  • Lumexon
  • Maxtrex
  • Medsatrexate
  • Metex
  • Methoblastin
  • Methotrexate LPF
  • Methotrexate Methylaminopterin
  • Methotrexatum
  • Metotrexato
  • Metrotex
  • Mexate
  • Mexate-AQ
  • MTX
  • Novatrex
  • Rheumatrex
  • Texate
  • Tremetex
  • Trexeron
  • Trixilem
  • WR-19039
Drug: Momelotinib
Given PO
Other Names:
  • CYT387
  • GS-0387
Drug: Mycophenolate Mofetil
Given IV or PO
Other Names:
  • Cellcept
  • MMF
Drug: Pacritinib
Given PO
Other Names:
  • Oral JAK2 Inhibitor SB1518
  • SB1518
Drug: Ruxolitinib
Given PO
Other Names:
  • INCB-18424
  • INCB18424
  • Oral JAK Inhibitor INCB18424
Drug: Tacrolimus
Given IV or PO
Other Names:
  • FK 506
  • Fujimycin
  • Hecoria
  • Prograf
  • Protopic
Radiation: Total-Body Irradiation
Undergo TBI
Other Names:
  • TOTAL BODY IRRADIATION
  • Whole-Body Irradiation
Procedure: Umbilical Cord Blood Transplantation
Undergo umbilical cord blood transplant
Other Names:
  • Cord Blood Transplantation
  • UCB transplantation



Primary Outcome Measures :
  1. Probability of 2-year survival in patients with myelofibrosis (MF) who receive treatment with a JAK inhibitor followed by an allogeneic transplant [ Time Frame: At 2 years ]
    The exact benchmark that will be used for comparison will be determined from the mix of Dynamic International Prognostic Scoring System (DIPSS) categories among those enrolled and treated with JAK on the current trial. From this mix, an expected two-year survival will be created as a weighted average of the data cited above. This weighted average will be used as the benchmark to which the data from the current trial will be compared.


Secondary Outcome Measures :
  1. Biology of post transplant disease progression [ Time Frame: Up to 5 years ]
  2. Incidence and severity of acute GVHD [ Time Frame: Up to 70 days post-transplant ]
  3. Incidence and severity of chronic GVHD [ Time Frame: Up to 2 years ]
  4. Incidence of relapse [ Time Frame: 1 year ]
  5. Kinetics of donor chimerism [ Time Frame: Up to 5 years ]
  6. Mechanism of responses to JAK inhibitors [ Time Frame: Up to 5 years ]
  7. Neutrophil engraftment, defined as the first of 3 days absolute neutrophil count (ANC) >= 500 [ Time Frame: Up to 5 years ]
  8. Non-relapse mortality (NRM) [ Time Frame: Day 100 ]
  9. Non-relapse mortality (NRM) [ Time Frame: 1 year ]
  10. Overall incidence of primary graft failure/rejection [ Time Frame: Up to 5 years ]
  11. Overall incidence of secondary graft failure/rejection [ Time Frame: Up to 5 years ]
  12. Overall survival [ Time Frame: Up to 5 years ]
  13. Platelet engraftment defined as first day of 20,000 and 50,000 with no transfusions x 7 days [ Time Frame: Up to 5 years ]


Information from the National Library of Medicine

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Ages Eligible for Study:   18 Years and older   (Adult, Senior)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

PART 1:

  • PART 1: Disease criteria

    • Diagnosis of primary MF (PMF) as defined by the 2008 World Health Organization classification system or diagnosis of secondary MF as defined by the International Working Group (IWG) for Myeloproliferative Neoplasms Research and Treatment criteria
    • Patients meeting the criteria for intermediate-1, intermediate-2 or high-risk disease by the Dynamic International Prognostic Scoring System (DIPSS) or DIPSS-plus scoring system
  • PART 1: Ability to understand and the willingness to sign a written informed consent document

PART 2:

  • PART 2: Meeting criteria for 1st phase as above, at time of initiation of JAK inhibitor, including ability to understand and willingness to sign a written informed consent; patients arriving to our institution for transplant and not enrolled in Part 1 may still be enrolled in Part 2 if Part 1 criteria met; these patients will have Part 1 endpoints transcribed from medical records
  • PART 2: Received JAK inhibitor for at least 8 weeks immediately prior to conditioning and be able to continue until Day -4 pre-transplant
  • PART 2: Performance status score

    • Karnofsky >= 70
  • PART 2: Calculated creatinine clearance using the Cockcroft-Gault formula or 24 hr urine creatinine clearance must be > 60 ml/min
  • PART 2: Total serum bilirubin must be < 3 mg/dL unless the elevation is thought to be due to Gilbert's disease or hemolysis
  • PART 2: Transaminases must be < 3 x the upper limit of normal
  • PART 2: Patients with clinical or laboratory evidence of liver disease will be evaluated for the cause of liver disease, its clinical severity in terms of liver function, and the degree of portal hypertension; patients with fulminant liver failure, cirrhosis with evidence of portal hypertension or bridging fibrosis, alcoholic hepatitis, hepatic encephalopathy, or correctable hepatic synthetic dysfunction evidenced by prolongation of the prothrombin time, ascites related to portal hypertension, bacterial or fungal abscess, biliary obstruction, chronic viral hepatitis with total serum bilirubin > 3 mg/dL, and symptomatic biliary disease will be excluded
  • PART 2: Diffusing capacity of the lung for carbon monoxide (DLCO) corrected > 60% normal

    • May not be on supplemental oxygen
  • PART 2: Left ventricular ejection fraction > 40% OR
  • PART 2: Shortening fraction > 26%
  • PART 2: Comorbidity Index < 5 at the time of pre-transplant evaluation

DONOR:

  • DONOR: Human leukocyte antigen (HLA)-matched or 1 antigen mismatched sibling donor
  • DONOR: 10 of 10 HLA-matched or 1 allele mismatched (9 of 10) unrelated donor
  • DONOR: Peripheral blood is preferred over bone marrow for non-umbilical cord blood recipients
  • DONOR: Umbilical cord blood units will be selected according to the following umbilical cord blood graft selection criteria; one or 2 cord blood (CB) units may be used to achieve the required cell dose
  • DONOR: The CB graft(s) must be matched at 4-6 HLA-A, B, DR Beta 1 (DRB1) loci with the recipient and therefore may include 0-2 mismatches at the A or B or DRB1 loci; unit selection will be based on cryopreserved nucleated cell dose and intermediate resolution A, B antigen and DRB1 allele typing for determination of HLA-match; while HLA-C antigen/allele level typing is not considered in the matching criteria, if available, it may be used to optimize unit selection
  • DONOR: Selection of two CB units is allowed to provide sufficient cell dose (see below for algorithm to determine single versus double unit transplant); when multiple units are selected, the following rules apply:

    • The CB unit with the least HLA disparity (with the patient) will be selected first (i.e., selection priority is 6/6 match > 5/6 match > 4/6 match); additional CB units then may be selected to achieve the required cell dose, as outlined below; if a second unit is required, this unit will be the unit that most closely HLA matches the patient and meets minimum size criteria outlined below of at least 1.5 x 10^7 total nucleated cells (TNC)/kg (i.e. a smaller, more closely matched unit will be selected over a larger, less well matched unit as long as minimum criteria are met)
    • If two CB units are used:

      • The total cell dose of the combined units must be at least 3.0 x 10^7 TNC per kilogram recipient weight
      • Each CB unit MUST contain at least 1.5 x 10^7 TNC per kilogram recipient weight
    • Algorithm for determining single versus double unit cord blood transplant:

      • Match grade 6/6: TNC dose >= 2.5 x 10^7/kg
      • Match grade 5/6, 4/6: TNC dose >= 4.0 (+/- 0.5) x 10^7/kg
  • DONOR: General comments:

    • Units will be selected first based on the TNC dose and HLA matching
    • Cluster of differentiation (CD)34+ cell dose will not be used for unit selection unless 2 units of equal HLA-match grade and similar TNC dose (+/- 0.5 x 10^7 TNC/kg) are available; in this case, the unit with the larger CD34+ cell dose (if data available) should be selected
    • A CB unit that is 5/6 mismatched but homozygous at the locus of mismatch should be chosen over a 5/6 unit with bidirectional mismatch even if the latter unit is larger (has more cells); this also applies to 4/6 units; this is only applicable to choosing units within a given match grade
    • Other factors to be considered:

      • Within the same HLA match grade, matching at DR takes preference
      • Cord blood banks located in the United States are preferred
    • Up to 5% of the cord blood product(s), when ready for infusion, may be withheld for research purposes as long as thresholds for infused TNC dose are met; these products will be used to conduct studies involving the kinetics of engraftment and immunobiology of double cord transplantation

Exclusion Criteria:

PART 1:

  • PART 1: Evidence of human immunodeficiency virus (HIV) infection or known HIV positive serology
  • PART 1: Uncontrolled viral, bacterial, or fungal infections at the time of study enrollment
  • PART 1: History of prior allogeneic transplant
  • PART 1: Pregnant or breastfeeding

PART 2:

  • PART 2: Uncontrolled viral or bacterial infection at the time of study enrollment
  • PART 2: Active or recent (prior 6 month) invasive fungal infection without infectious disease (ID) consult and approval
  • PART 2: History of HIV infection
  • PART 2: Pregnant or breastfeeding
  • PART 2: Patients without an HLA-identical or 1-allele-mismatched related donor or unrelated donor or umbilical cord blood units that meet transplant criteria

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT02251821


Locations
United States, Washington
Fred Hutch/University of Washington Cancer Consortium Recruiting
Seattle, Washington, United States, 98109
Contact: Rachel B. Salit    206-667-1317    rsalit@fredhutch.org   
Principal Investigator: Rachel B. Salit         
Sponsors and Collaborators
Fred Hutchinson Cancer Research Center
National Cancer Institute (NCI)
National Heart, Lung, and Blood Institute (NHLBI)
Investigators
Principal Investigator: Rachel Salit Fred Hutch/University of Washington Cancer Consortium

Responsible Party: Fred Hutchinson Cancer Research Center
ClinicalTrials.gov Identifier: NCT02251821     History of Changes
Other Study ID Numbers: 9033
NCI-2014-01882 ( Registry Identifier: CTRP (Clinical Trial Reporting Program) )
9033 ( Other Identifier: Fred Hutch/University of Washington Cancer Consortium )
P30CA015704 ( U.S. NIH Grant/Contract )
First Posted: September 29, 2014    Key Record Dates
Last Update Posted: March 20, 2018
Last Verified: March 2018

Studies a U.S. FDA-regulated Drug Product: Yes
Studies a U.S. FDA-regulated Device Product: No

Additional relevant MeSH terms:
Neoplasm Metastasis
Primary Myelofibrosis
Neoplastic Processes
Neoplasms
Pathologic Processes
Myeloproliferative Disorders
Bone Marrow Diseases
Hematologic Diseases
Cyclophosphamide
Methotrexate
Tacrolimus
Melphalan
Busulfan
Fludarabine phosphate
Mechlorethamine
Nitrogen Mustard Compounds
Fludarabine
Mycophenolic Acid
Immunosuppressive Agents
Immunologic Factors
Physiological Effects of Drugs
Antirheumatic Agents
Antineoplastic Agents, Alkylating
Alkylating Agents
Molecular Mechanisms of Pharmacological Action
Antineoplastic Agents
Myeloablative Agonists
Abortifacient Agents, Nonsteroidal
Abortifacient Agents
Reproductive Control Agents