Pilot and Feasibility Study of Reduced-Intensity Hematopoietic Stem Cell Transplant for MonoMAC

BACKGROUND:

Mutations in GATA binding protein 2 (GATA2) lead to an immunodeficiency disease that
transforms into myelodysplastic syndrome (MDS) and acute myelogenous leukemia (AML). This
syndrome, previously known as MonoMAC, has 4 clinical features: 1) infections with
Mycobacterium Avium Complex (MAC) and other opportunistic infections as a teenager or young
adult, 2) a peripheral blood leukocyte flow cytometry profile with T-lymphocytes, but a
severe deficiency of monocytes, B-lymphocytes, and Natural Killer (NK) cells, 3) the
propensity to progress to MDS/AML, and 4) mutations in the gene GATA2. In this pilot study we
propose to evaluate the efficacy and safety of a reduced intensity allogeneic hematopoietic
stem cell transplantation (HSCT) regimen for patients with mutations in GATA2. We are
particularly interested in determining whether allogeneic HSCT using this regimen
reconstitutes normal hematopoiesis in patients with mutations in GATA2.

OBJECTIVES:

Primary Objective:

- To determine efficacy, namely whether reduced-intensity allogeneic HSCT results in
engraftment and restores normal hematopoiesis by day +100 in patients with mutations in
GATA2.

- To determine the safety of this HSCT regimen in patients with mutations in GATA2,
including transplant related toxicity, the incidence of acute and chronic graft-versus
host disease, immune reconstitution, overall survival, and disease-free survival

ELIGIBILITY:

Eligibility includes patients 12-60 years old with mutations in GATA2 who have a life
expectancy of > 3 months but < 24 months, and who have a 10/10 matched related donor, a 10/10
or 9/10 matched unrelated donor (HLA -A, -B, -C, DRB1, DQB1 by high resolution typing
identified through the National Marrow Donor Program), a 4/6 (or greater human leukocyte
antigens (HLA -A), -B, DRB1) matched unrelated umbilical cord donor, or a haploidentical
donor. Patients with GATA2 mutations who are 12-17 years of age are required to have MDS with
chromosomal abnormalities to be eligible for this protocol.

DESIGN:

- Patients with mutations in GATA2 with a 10/10 matched related or 10/10 matched unrelated
donor, will receive a reduced-intensity pre-transplant conditioning regimen consisting
of fludarabine 30 mg/m(2)/day on days -4, -3, and -2, 200 centigray (cGy) total body
irradiation (TBI) on day -1, and HSCT on day 0. Patients with mutations in GATA2 and a
9/10 matched unrelated donor will receive a reduced-intensity pre-transplant
conditioning regimen consisting of fludarabine 30 mg/m(2)/day on days -4, -3, and -2,
300cGy total body irradiation (TBI) on day -1, and HSCT on day 0. Patients with
mutations in GATA2 with umbilical cord blood units will receive a reduced-intensity
conditioning regimen with cyclophosphamide 50 mg/kg on day -6, fludarabine 40 mg/m(2) on
days -6 to -2, equine anti-thymocyte globulin (ATG) 30 mg/kg intravenous (IV) on days
-6, -5 and -4, 200 cGy TBI on day -1, and HSCT on day 0. Patients with a haploidentical
donor will receive a reduced intensity-conditioning regimen with cyclophosphamide 14.5
mg/kg on days -6 and -5, fludarabine 30 mg/m(2) on 4days -6 to -2, and 200 cGy TBI on
day -1. Donor bone marrow cells will be infused on day 0.

- Post-transplant immunosuppression for graft-versus-host-disease prophylaxis will consist
of sirolimus (Rapamycin) and tacrolimus until day +180, provided that there is no
evidence of graft-versus-host disease. Post-transplant immunosuppression for graft
versus-host-disease prophylaxis for recipients of haploidentical donors will consist of
cyclophosphamide 50 mg/kg on days +3 and +4, along with sirolimus from day +5 to day
180, and tacrolimus from day +5 to day 180, providing that there is no graft-versus-host
disease (GVHD).

- INCLUSION CRITERIA RECIPIENT:

1. Patient age of 12-60 years

2. GATA2 Mutation Syndrome

1. Clinical history of at least two episodes of life-threatening infection with
opportunistic organisms, one of which is a MAC infection.

2. Mutation in the GATA2 gene performed by the CLIA certified laboratory of Dr.
Steven Holland of the NIAID Institute of the NIH.

3. Available 10/10 HLA-matched related or 8/8 matched unrelated donor, or 4/6 (or
greater) matched UCB unit(s) with a total dose of greater than or equal to 3.5
times 10(7) TNC/kg.

4. Patients may have evidence of MDS with one or more peripheral blood cytopenias
and greater than 5% blasts but less than 10% blasts in the bone marrow in the
absence of GCSF.

Patients previously treated for acute myelogenous leukemia are eligible if they
have less than or equal to 10% blasts in the bone marrow in the absence of G-CSF.

Subjects 12-17 years of age are required to have MDS with chromosomal
abnormalities in addition to mutation in the GATA2 gene for enrollment on this
protocol.

5. Left ventricular ejection fraction > 50%, preferably by 2-D echo, or by MUGA, or
shortening fraction > 28% by ECHO, obtained within 28 days of enrollment.

6. Pulmonary Function Tests: Adult patients: DLCO diffusion capacity and FEV1
greater than 10% of expected value obtained within 28 days of enrollment.
Pediatric patients: DLCO corrected for hemoglobin and alveolar volume greater
than or equal to 20% of predicted.

7. Creatinine: Adult patients: less than or equal to 2.0 mg/dl and creatinine
clearance greater than or equal to 30 ml/min; Pediatric patients: age-adjusted
normal serum creatinine OR a creatinine clearance > 60 mL/min/1.73m(2).

8. Serum total bilirubin less than 2.5 mg/dl; ALT and AST less than or equal to 5
times upper limit of normal .

9. Adequate central venous access potential.

10. Written informed consent/assent obtained from patient/parent or legal guardian.

11. Life expectancy of at least 3 months but less than 24 months.

12. Disease status: Patients are to be referred in remission for evaluation. Should a
patient have progressive disease or a donor not be available after enrollment,
the patient will be referred back to their primary hematologist-oncologist for
treatment. If this course of action is not in the best interest of the patient
according to the clinical judgment of the PI/LAI, then the patient may receive
standard treatment for the malignant disease under the current study. If under
either of these settings, it becomes apparent that the patient will not be able
to proceed to transplant, then he/she must come off study. Recipient-Subjects
receiving a standard therapy will be told about the therapy, associated risks,
benefits alternatives of the proposed therapy, and availability of receiving the
same treatment elsewhere, outside of a research protocol.

EXCLUSION CRITERIA- RECIPIENT:

1. HIV infection.

2. Chronic active hepatitis B. Patient may be hepatitis B core antibody positive. For
patients with a concomitant positive hepatitis B surface antigen, patients will
require a hepatology consultation. The risk-benefit profile of transplant and
hepatitis B will be discussed with the patient, and eligibility determined by the PI
and the protocol chairperson.

3. History of psychiatric disorder which may compromise compliance with transplant
protocol, or which does not allow for appropriate informed consent.

4. Active infection that is not responding to antimicrobial therapy.

5. Active CNS involvement by malignancy (patients with known positive CSF cytology or
parenchymal lesions visible by CT or MRI.

6. Pregnant or lactating.

7. Sexually active individuals capable of becoming pregnant who are unable or unwilling
to use effective form(s) of contraception during time enrolled on study and for 1 year
post-transplant. Effective forms of contraception include one or more of the
following: intrauterine device (IUD), hormonal (birth control pills, injections, or
implants), tubal ligation/hysterectomy, partners vasectomy, barrier methods, (condom,
diaphragm, or cervical cap), or abstinence. The effects on breast-milk are also
unknown and may be harmful to the infant; therefore, women should not breast feed
during the interval from study entry to one year post-transplant. Males on the
protocol must use an effective form of contraception at study entry, and for one year
post-transplant. The effects of transplant, the radiation, and the medications used
after transplant may be harmful to a fetus.

8. Presence of active malignancy in another organ system other than the hematopoietic

9. No available 10/10 HLA-matched related or 8/8 matched unrelated donor, or 4/6 (or
greater) matched UCB unit(s) with a total dose of greater than or equal to 3.5 times
10(7) TNC/kg.

10. Lack of mutation in GATA2 as demonstrated by the CLIA certified laboratory of Dr.
Steven Holland in the NIAID.

INCLUSION CRITERIA- MATCHED RELATED DONOR:

1. Related donor matched at HLA-A, B, C, DR, and DQ loci by high resolution typing (10/10
antigen/allele match) are acceptable donors.

2. Matched related donors for pediatric recipients must be 18 years of age or older. If
more than one matched related donor is available, we will select the oldest donor to
further decrease the risk of potential disease transmission.

3. Ability to give informed consent.

4. Age 18-60 years.

5. No history of life-threatening opportunistic infection.

6. Adequate venous access for peripheral apheresis, or consent to use a temporary central
venous catheter for apheresis.

7. Donors must be HIV negative, hepatitis B surface antigen negative, and hepatitis C
antibody negative. This is to prevent the possible transmission of these infections to
the recipient.

8. A donor who is lactating must be willing and able to interrupt breast-feeding or
substitute formula feeding for her infant during the period of filgrastim
administration and for two days following the final dose. Filgrastim may be secreted
in human milk, although its bioavailability from this source is not known. Limited
clinical data suggest that short-term administration of filgrastim or sargramostim to
neonates is not associated with adverse outcomes.

INCLUSION CRITERIA- MATCHED UNRELATED DONOR:

1. Unrelated donor matched at 10/10 or 9/10 HLA-A, B, C, DRB1, and DQB1 loci by high
resolution typing.

2. Matched unrelated donors for pediatric recipients must be 18 years of age or older.

3. The evaluation of donors shall be in accordance with existing NMDP Standard Policies
and Procedures. General donor inclusion criteria specified in the NMDP Standard.

EXCLUSION CRITERIA- MATCHED RELATED DONOR:

1. Age less than 18 years.

2. HIV infection.

3. Chronic active hepatitis B. Donor may be hepatitis core antibody positive.

4. History of psychiatric disorder which in the opinion of the PI may compromise
compliance with transplant protocol, or which does not allow to be appropriately
informed.

5. History of hypertension that is not controlled by medication, stroke, or severe heart
disease. Individuals with symptomatic angina will be considered to have severe heart
disease and will not be eligible to be a donor.

6. Other medical contraindications to stem cell donation (i.e. severe atherosclerosis,
autoimmune disease, iritis or episcleritis, deep venous thrombosis, cerebrovascular
accident).

7. History of prior malignancy. However, cancer survivors who have undergone potentially
curative therapy may be considered for stem cell donation on a case-by-case basis. The
risk/benefit of the transplant and the possibility of transmitting viable tumor cells
at the time of transplantation will be discussed with the patient.

8. Donors must not be pregnant. Pregnancy is an absolute contraindication under this
protocol. The effects of cytokine administration on a fetus are unknown. Donors of
childbearing potential must use an effective method of contraception. Effective forms
of contraception include one or more of the following: intrauterine device (IUD),
hormonal (birth control pills, injections, or implants), tubal ligation/hysterectomy,
partner s vasectomy, barrier methods, (condom, diaphragm, or cervical cap), or
abstinence.

9. Thrombocytopenia (platelets less than 150,000 per micro l) at baseline evaluation.

10. Donors receiving experimental therapy or investigational agents.

11. Sensitivity to filgrastim or to E. coli-derived recombinant protein products.

12. History of autoimmune disorders, with the exception of thyroid disorders.

13. History of documented deep vein thrombosis or pulmonary embolism.

EXCLUSION CRITERIA- MATCHED UNRELATED DONOR:

Failure to qualify as an NMDP donor

INCLUSION CRITERIA- UMBILICAL CORD BLOOD UNIT-HLA TYPING AND DOSE

1. At least an HLA UCB 4/6 match (Class I-A, B by low resolution, and Class II-DR by high
resolution) to recipient. The following algorithm will be applied to determine if
patient will receive single or double umbilical cord graft:

2. For Single UCB SCT:

- If 6/6 match the unit must have > 3 x 10(7) nucleated cells /kg of recipient body
weight.

- If 5/6 match the unit must have > 4 x 10(7) nucleated cells /kg of recipient body
weight.

- If 4/6 match the unit must have > 5 x 10(7) nucleated cells/kg of recipient body
weight. Recipient body weight will be determined as per standard guidelines.

3. If no single UCB with the above characteristics is available, a double UCB will be
considered. Units will be selected with the following criteria:

- Both units will be at least 4/6 match (Class I-A, B by low resolution, Class
II-DR by high resolution) to recipient, and should be at least a 4/6 match (Class
I-A, B by low resolution, Class II-DR by high resolution) to each other.

- At least one UCB will have a minimum cell dose of 2.0 X 10(7) TNC/kg of recipient
body weight.

- The minimum combined dose of both units must be at least 3.5 x 10(7) TNC/kg of
recipient body weight.

- The smaller of the two units (UCB2) will have a minimum of 1.5 X 10(7) TNC/kg of
recipient body weight.

- The TNC of non-RBC reduced units will be dose corrected by -25% to allow for cell
loss while washing the unit.

INCLUSION CRITERIA- HAPLOIDENTICAL RELATED DONOR:

- A haploidentical donor that shares one haplotype in common with the recipient such
that HLA compatibility will be a minimum of 5 out of 10 HLA loci matched. The HLA loci
to be tested will be HLA A, B, Cw, DRB1, and DQB1. A minimum number of mismatches is
desirable; however if several options are available the selection of a donor will be
based on the loci where the mismatch occurs and the relative importance of its
potential immunological function. Donor-recipient pairs will initially be typed
molecularly to provide a low resolution typing (antigen-level) to aid in the selection
of the potential donor. Upon review of the familial inheritance pattern, a qualified
HLA staff member will review haplotype inheritance. High resolution (allele-level)
typing will be performed. Final selection of a donor will be in consultation with NCI
physicians and qualified HLA personnel. Haploidentical related donors for pediatric
recipients must be 15 years of age or older. If more than one haploidentical related
donor is available, we will evaluate each donor individually according to overall
health, ABO matching, cytomegalovirus (CMV), etc. to select the donor

- Age 15-60 years

- No history of life-threatening opportunistic infection

- Adequate venous access for peripheral apheresis, or consent to use a temporary central
venous catheter for apheresis.

- Donors must be HIV negative, hepatitis B surface antigen negative, and hepatitis C
antibody negative. This is to prevent the possible transmission of these infections to
the recipient.

- Haploidentical donors will undergo marrow harvest with general anesthesia. Subjects
will undergo anesthesia consultation, and meet criteria for eligibility/enrollment.
CD34+ fraction will be determined.

- Subjects will also undergo the Donor Health History Screen to determine donor
eligibility using standard DTM criteria in the Dowling Apheresis Clinic by skilled
staff in the Blood Services Section for adult patients and age-appropriate questioning
when indicated for pediatric subjects.

- Subjects will undergo follow-up history and physical examination within 1 week of
donation.

EXCLUSION CRITERIA- HAPLOIDENTICAL DONOR:

- Age less than 15 years.

- HIV infection

- Chronic active hepatitis B. Donor may be hepatitis core antibody positive.

- History of psychiatric disorder which in the opinion of the PI may compromise
compliance with transplant protocol, or which does not allow for appropriate informed

- History of hypertension that is not controlled by medication, stroke, or severe heart
disease. Individuals with symptomatic angina will be considered to have severe heart
disease and will not be eligible to be a donor.

- Other medical contraindications to stem cell donation (i.e. severe atherosclerosis,
autoimmune disease, iritis or episcleritis, deep venous thrombosis, cerebrovascular
accident)

- History of prior malignancy. However, cancer survivors who have undergone potentially
curative therapy may be considered for stem cell donation on a case-by-case basis. The
risk/benefit of the transplant and the possibility of transmitting viable tumor cells
at the time of transplantation will be discussed with the patient.

- Donors must not be pregnant. Pregnancy is an absolute contraindication under this
protocol. The effects of cytokine administration on a fetus are unknown. Donors of
childbearing potential must use an effective method of contraception. Effective forms
of contraception include one or more of the following: intrauterine device (IUD),
hormonal (birth control pills, injections, or implants), tubal ligation/hysterectomy,
partners vasectomy, barrier methods, (condom, diaphragm, or cervical cap), or
abstinence.

- Thrombocytopenia (platelets less than 150,000 per microliter) at baseline evaluation.

- Donors receiving experimental therapy or investigational agents.

- Sensitivity to filgrastim or to E. coli-derived recombinant protein products.

- History of autoimmune disorders, with the exception of thyroid disorders

- History of documented deep vein thrombosis or pulmonary embolism

- Mutation in GATA2