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ATG/PTCy in Haplo-PBSCT Randomized Controlled,Multi-center (ATG/PTCy)

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ClinicalTrials.gov Identifier: NCT03608059
Recruitment Status : Recruiting
First Posted : July 31, 2018
Last Update Posted : August 3, 2018
Sponsor:
Information provided by (Responsible Party):
Xianmin Song, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine

Brief Summary:
A novel regimen, which is composed of a low dose of ATG (5 mg/kg) and low-dose PTCy (one dose of PTCy, 50mg/kg) for GvHD prophylaxis in Haplo-PBSCT for patients with hematologic malignancies, was designed to decrease the risk of aGvHD and lower the incidence of virus reactivation.

Condition or disease Intervention/treatment Phase
Myeloid Tumor Drug: ATG/PTCy Drug: standard ATG Drug: standard PTCy Phase 4

Detailed Description:

Acute graft-versus-host disease (aGvHD) is the most important obstacle of haploidentical hematopoietic stem cell transplantation (Haplo-HSCT) for treatment of patients with hematologic malignancies. In the last two decades, the results of Haplo-HSCT have been conspicuously improved due to effective prophylaxis strategies for aGvHD, such as in vivo T cell depletion (TCD) with anti-thymocyte globulin (ATG) or post-transplant cyclophosphamide (PTCy).

The regimens for prophylaxis of GvHD based on rabbit anti-human thymocyte immunoglobin (ATG 10mg/kg, Thymoglobin®, Genzyme Polyclonals S.A.S) effectively prevented the occurrence of grade II-IV aGvHD with an incidence of 33.4%-46%, grade III-IV aGvHD 12%-14.9%, but the reactivation incidences of cytomegalovirus (CMV) and EB virus (EBV) were higher due to a slower immune reconstitution(2-4). The 100-day CIs of CMV and EBV viremia were 61%-64%and over 50%, respectively. Although ATG-based regimens have achieved excellent results, the incidences of aGvHD and the post-transplant virus reactivation are still higher, affecting the long-term survival of the patients.

The regimen of PTCy for prevention of GvHD was developed in 1999 by St. Johns Hopkin's group in Baltimore (1) and had outstanding results with the CIs of 34% grades II-IV and of 6% grades III-IV aGvHD by day 200 in haplo-bone marrow transplantation (Haplo-BMT) (7), respectively. The incidences of viral and fungal infection in Haplo-HSCT with PTCy for GvHD prophylaxis were much lower than ATG based regimens. Ruggeri A(8)et al retrospectively analyzed the effects of different stem cell source (BM vs PBSC) on the transplant results in Haplo-HSCT with PTCy. The results showed that BM was associated with a lower incidence of grades II-IV and grades III-IV acute GVHD (21% vs 38%, P ≤ .01; and 4% vs 14%, P < .01, respectively), which was further confirmed by Bashey A et al' study(9). These data indicated that PTCy regimen don't have the same effects for GvHD prophylaxis with PBSC graft as compared with BM graft in Haplo-HSCT.

A novel regimen, which is composed of a low dose of ATG (5 mg/kg) and low-dose PTCy (one dose of PTCy, 50mg/kg) for GvHD prophylaxis in Haplo-PBSCT for patients with hematologic malignancies, was designed to decrease the risk of aGvHD and lower the incidence of virus reactivation. A prospective, phase II clinical trial (Clinicaltrials.org NCT03395860) was performed to evaluate the efficacy with low dose ATG followed by low dose PTCy as GvHD prophylaxis.Thirty-two patients diagnosed with hematological malignancies were enrolled in this trial. All patients received myeloablative conditioning regimens except for three patients. The cumulative incidences (CIs) of grades II-IV and III-IV acute GvHD were 19.4% (95% CI, 5.5-33.3%) and 6.9% (95% CI 0-16.3%) by day 100, respectively. The one-year probability of relapse was 25.1% (95% CI, 7.3-42.9%). The one-year probabilities of disease free-survival (DFS) and overall survival (OS) was 59% (95% CI, 33.3%-84.7%) and 78.4% (95% CI, 63%-93.8%), respectively. The CIs of CMV reactivation and EBV reactivation by day 180 were 37.5% (95% CI, 19.8-55.2%) and 40.6% (95% CI, 22.6-58.6%), respectively. The results suggested that low dose ATG with low dose PTCy as GvHD prophylaxis in Haplo-PBSCT had promising activity. A prospective randomized trial is required to compare the efficacies of this regimen with ATG-based or PTCy-based regiments in Haplo-PBSCT.


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Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 324 participants
Allocation: Randomized
Intervention Model: Single Group Assignment
Intervention Model Description: ATG+PTCy
Masking: Single (Participant)
Primary Purpose: Treatment
Official Title: Shanghai General Hospital Affiliated to Shanghai Jiao Tong University
Actual Study Start Date : July 28, 2018
Estimated Primary Completion Date : July 28, 2022
Estimated Study Completion Date : July 28, 2023

Arm Intervention/treatment
Experimental: ATG/PTCy
The GvHD prophylaxis consisted of ATG 2.5mg/kg administered on day -2 to -1 and cyclophosphamide (Cy) 50 mg/kg on day +3, cyclosporine A (CsA) and mycophenolate mofetil (MMF) initiating on day +4. CsA was prescribed at 2 mg/kg as a continuous infusion. The CsA doses were modified to obtain nadir serum levels between 200 and 300 ng/ml. MMF was administered at 15 mg/kg oral 3 times per day (maximum dose 3g per day) until day +34 and was then stopped if no aGvHD. Mycophenolate Sodium Enteric-coated Tablets (MPA) can be used instead of MMF, one tablet MPA corresponds to one tablet MMF. CsA was tapered from day +90 to day +180.
Drug: ATG/PTCy
low dose Antithymocyte Globulin plus low dose post-transplant cyclophosphamide as graft-versus-host disease prophylaxis in haploidentical peripheral blood stem cell transplantation

Active Comparator: standard ATG
The GvHD prophylaxis consisted of ATG 2.5mg/kg administered on day -4 to -1 , cyclosporine A (CsA) initiating on day -5 and mycophenolate mofetil (MMF) initiating on day +1 . CsA was prescribed at 2 mg/kg as a continuous infusion. The CsA doses were modified to obtain nadir serum levels between 200 and 300 ng/ml. MMF was administered at 15 mg/kg oral 2 times per day (maximum dose 2g per day) until day +30 and was then stopped if no aGvHD. Mycophenolate Sodium Enteric-coated Tablets (MPA) can be used instead of MMF, one tablet MPA corresponds to one tablet MMF. CsA was tapered from day +90 to day +180.
Drug: standard ATG
in vivo T cell depletion (TCD) with anti-thymocyte globulin (ATG) as graft-versus-host disease prophylaxis in haploidentical peripheral blood stem cell transplantation
Other Name: ATG

Active Comparator: standard PTCy
The GvHD prophylaxis consisted of cyclophosphamide (Cy) 50 mg/kg on day +3, +4,cyclosporine A (CsA) and mycophenolate mofetil (MMF) initiating on day +5. CsA was prescribed at 2 mg/kg as a continuous infusion. The CsA doses were modified to obtain nadir serum levels between 200 and 300 ng/ml. MMF was administered at 15 mg/kg oral 3 times per day (maximum dose 3g per day) until day +35 and was then stopped if no aGvHD. Mycophenolate Sodium Enteric-coated Tablets (MPA) can be used instead of MMF, one tablet MPA corresponds to one tablet MMF. CsA was tapered from day +90 to day +180.
Drug: standard PTCy
post-transplant cyclophosphamide (PTCy) as graft-versus-host disease prophylaxis in haploidentical peripheral blood stem cell
Other Name: PTCy




Primary Outcome Measures :
  1. The cumulative incidences of acute GVHD [ Time Frame: 100 days after transplantation ]
    The cumulative incidences of aGvHD was defined as the number and the ratio of the participants with aGVHD


Secondary Outcome Measures :
  1. Leukocyte engraftment [ Time Frame: 1 month ]
    Leukocyte engraftment:(was defined as the first of three consecutive days of peripheral white blood count >1000/ul.

  2. Platelet engraftment [ Time Frame: 1 month ]
    Platelet engraftment:(was defined as the first of seven consecutive days of platelet counts of >20000/ul.

  3. Donor chimerism [ Time Frame: 2 years ]
    Quantitative chimerism analyzes were performed using short-tandem-repeat-based polymerase chain reaction technique sat regular intervals for every 4 weeks after allografting in bone marrow.

  4. Relapse incidence (RI) [ Time Frame: 2 YEARS] ]
    RI was defined as the number and ratio of the participants with relapse after transplantation

  5. chronic GVHD [ Time Frame: 2 years ]
    cGvHD was diagnosed and graded according to the 2014 National Institutes of Health (NIH) consensus criteria: mild, moderate or severe respectively.The number and ratio of participants with cGVHD after transplatation

  6. infection [ Time Frame: 2 years ]
    CMV and EB infections(The number and ration of participants with infection after transplantaton)

  7. OS [ Time Frame: 2 years ]
    overall survival

  8. DFS [ Time Frame: 2 years ]
    disease free survival



Information from the National Library of Medicine

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Ages Eligible for Study:   14 Years to 70 Years   (Child, Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  1. Clinical diagnosis of hematologic malignancies (AML CR/blast cell≤20% high-risk MDS) were enrolled in this study. Diagnosis was according to the criteria of 2008 World Health Organization (WHO) classification of myeloid tumors.
  2. Family members selected as donors were typed at the HLA-A, -B, -DQB1, -C and -DRB1 locus at high-resolution level. Haplotype was defined as recipient-donor number of HLA mismatches > 3.

3.14 to 70 years old. 4.Performance status scores no more than 2 (ECOG criteria). 5.Adequate organ function as defined by the following criteria: alanine transaminase (ALT), aspartate transaminase(AST) and total serum bilirubin <2×ULN (upper limit of normal). Serum creatinine and blood urea nitrogen (BUN) <1.25×ULN.

6.Adequate cardiac function without acute myocardial infarction, arrhythmia or atrioventricular block, heart failure, active rheumatic heart disease and cardiac dilatation(the patients has been improved after treatment of the disease and are not expected to affect transplant can include in the study).

7.Absence of any other contraindications of stem cell transplantation. Willingness and ability to perform HSCT.

8.Signed and dated informed consent document indicating that the patient (or legally acceptable representative) has been informed of all pertinent aspects of the trial prior to enrollment. Willingness and ability to comply with scheduled visits, treatment plans, laboratory tests, and other study procedures.

Exclusion Criteria:

  1. DSA strong positive (titer >10000MFI)
  2. Life expectancy < 3 months because of other severe diseases.
  3. Presence of any fatal disease, including respiratory failure, heart failure, liver or kidney function failure.
  4. Uncontrolled infection.
  5. Pregnancy or breastfeeding.
  6. Has enrolled in another clinical trials.
  7. Other severe acute or chronic medical or psychiatric condition or laboratory abnormality that may increase the risk associated with study participation or study drug administration, or may interfere with the interpretation of study results, and in the judgment of the investigator would make the patient inappropriate for entry into this study.

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): NCT03608059


Contacts
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Contact: jun yang, M.D 021-63240090 yangjuan74@hotmail.com
Contact: xianming song 021-63240090 shongxm@sjtu.edu.cn

Locations
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China, Shandong
General Hospital of Jinan Military Command. Recruiting
Qinan, Shandong, China
Contact: fang zhou    021-63240090    shongxm@139.com   
China, Shanghai
Shanghai Ruijin Hospital, affiliated with the Medical School of Shanghai Jiaotong University, Recruiting
Shanghai, Shanghai, China, 200002
Contact: jiong hu, M.D    13764313546    hujiong@medmail.com.cn   
Contact: xianming song, M.D    021-63240090*3171    shongxm@139.com   
Changhai Hospital Recruiting
Shanghai, Shanghai, China, 200080
Contact: xiaxiao hu, Doctor    86-21-63240090-3932    shongxm@sjtu.edu.cn   
Xianmin Song Recruiting
Shanghai, Shanghai, China, 200080
Contact: Xianmin Song, Doctor    86-21-63240090-3932    shongxm@sjtu.edu.cn   
Shanghai Xinghua Hospital, affiliated with the Medical School of Shanghai Jiaotong University, Recruiting
Shanghai, Shanghai, China
Contact: siguo hao, M.D    15301655537    shongxm@139.com   
Sponsors and Collaborators
Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine
Investigators
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Study Chair: xinpeng wang Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine

Publications:

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Responsible Party: Xianmin Song, Principal Investigator, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine
ClinicalTrials.gov Identifier: NCT03608059     History of Changes
Other Study ID Numbers: SHSYXY-ATG/PTCy multi-center
First Posted: July 31, 2018    Key Record Dates
Last Update Posted: August 3, 2018
Last Verified: July 2018
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: No

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Studies a U.S. FDA-regulated Drug Product: No
Studies a U.S. FDA-regulated Device Product: No
Product Manufactured in and Exported from the U.S.: No
Keywords provided by Xianmin Song, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine:
ATG
PTCy
haplo-PBSCT
GVHD
Additional relevant MeSH terms:
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Cyclophosphamide
Immunosuppressive Agents
Immunologic Factors
Physiological Effects of Drugs
Antirheumatic Agents
Antineoplastic Agents, Alkylating
Alkylating Agents
Molecular Mechanisms of Pharmacological Action
Antineoplastic Agents
Myeloablative Agonists