Allogeneic Hematopoietic Stem Cell Transplant for GATA2 Mutations

Background:

Genetic and sporadic mutations on one allele of the GATA2 gene lead to a syndrome termed
MonoMAC. MonoMAC is characterized by: 1) infections with Mycobacterium avium complex (MAC)
and other opportunistic infections, 2) deficiency of monocytes, B-lymphocytes, and Natural
Killer (NK) cells in the peripheral blood, and 3) progression to myelodysplastic syndrome
(MDS), chronic myelomonocytic leukemia (CMML), and acute myelogenous leukemia (AML), and 4)
mutations on one allele of GATA2 in most patients. We propose to evaluate the efficacy and
safety of allogeneic hematopoietic stem cell transplantation (HSCT) using different
conditioning regimens from different donor sources and post-transplant immunosuppressive
regimens in reconstituting normal hematopoiesis and reversing the disease phenotype in
patients with mutations in GATA2, or the clinical syndrome of MonoMAC.

Objectives: Primary:

-To determine whether allogeneic hematopoietic stem cell transplant (HSCT) approach
reconstitutes normal hematopoiesis and reverses the disease phenotype by one year post-
transplant in patients with mutations in GATA2 or the clinical syndrome of MonoMAC.

Eligibility:

- Recipients ages 8-70 years old with mutations in GATA2 or the clinical syndrome of
MonoMAC. Clinical history of at least one life-threatening infection.

- Have a 10/10 or a 9/10 HLA-matched related or unrelated donor (HLA -A, -B, -C, DRB1,
DQB1 by high resolution typing identified through the National Marrow Donor Program), or
a haploidentical related donor.

Design:

- Patients with mutations in GATA2, or the clinical syndrome of MonoMAC, with a 10/10 (or
9/10 matched if the mismatch is at DQ) HLA-matched related or unrelated donor will
receive a pre-transplant conditioning regimen consisting of fludarabine 40 mg/m2 IV once
daily for 4 days on day s -6, -5, -4, and -3, busulfan based on pharmacokinetic levels
from test dose (3.2 mg/kg IV will be the default dose) once daily on days -6, -5, -4,
and -3, and HSCT on day 0. If the patient has very good, good, or intermediate
cytogenetics, post-transplant GVHD prophylaxis will consist of cyclophosphamide 50 mg/kg
IV once daily for 2 days on days +3 and +4, along with mycophenolate mofetil from day +5
to approximately day +35 and tacrolimus from day +5 to approximately day +180. If there
is no evidence of GVHD, tacrolimus will be stopped or tapered at approximately day +180.
If the patient has poor or very poor risk cytogenetic abnormalities prior to transplant,
then the post-transplant GVHD prophylaxis will consist of methotrexate 5 mg/m2 IV on
days +1, +3, +6, and +11 and tacrolimus daily from day -3 until there is no evidence of
graft-versus-host disease, tacrolimus will be stopped or tapered at approximately day
+180.

- Patients with mutations in GATA2, or the clinical syndrome of MonoMAC, with a 9/10
HLA-matched related or unrelated donor - except if the mismatch is at DQ, will receive a
pre-transplant conditioning regimen consisting of cyclophosphamide 14.5 mg/kg IV once
daily for 2 days on days -6 and -5, busulfan based on pharmacokinetic levels from test
dose ( 3.2 mg/kg IV will be the default dose) once daily on days -4, -3, (if poor or
very poor risk clonal cytogenetic abnormalities are present, then three days of busulfan
IV once daily on days -4, -3, and -2 will be given), fludarabine 30 mg/m2 IV once daily
for 5 days on days -6 to -2, 200 cGy TBI on day -1, and HSCT on day 0. Post-transplant
immunosuppression for GVHD prophylaxis for recipients of 9/10 donors will consist of
cyclophosphamide 50 mg/kg IV once daily for 2 days on day s +3 and +4, along with
mycophenolate mofetil from day +5 to approximately day +35 and tacrolimus from day +5 to
approximately day +180. If there is no evidence of graft-versus- host disease,
tacrolimus will be stopped or tapered at approximately day +180.

- Patients with mutations in GATA2, or the clinical syndrome of MonoMAC, with a
haploidentical related donor will receive pre-transplant conditioning with
cyclophosphamide

14.5 mg/kg IV once daily for 2 days on days -6 and -5, busulfan based on pharmacokinetic
levels from test dose ( 3.2 mg/kg IV will be the default dose) once daily on days -4, -3, (if
poor or very poor risk clonal cytogenetic abnormalities are present, then three days of
busulfan IV once daily on days -4, -3, and -2) will be given, fludarabine 30 mg/m2 IV once
daily for 5 days on day s -6 to -2, and 200 cGy TBI on day -1, and HSCT on day 0. Post-
transplant immunosuppression for GVHD prophylaxis for recipients of haploidentical donors
will consist of cyclophosphamide 50 mg/kg IV once daily for 2 days on day s +3 and +4, along
with mycophenolate mofetil from day +5 approximately day +35 and tacrolimus from day +5 to
approximately day +180. If there is no evidence of graft-versus-host disease, tacrolimus will
be stopped or tapered at approximately day +180.

- ELIGIBILITY CRITERIA:

INCLUSION CRITERIA- Recipient

1. Patient age of 8-70 years.

2. Mutation in the GATA2 gene, or evidence of loss of expression of one allele of GATA2,
by cDNA analysis performed by a CLIA certified laboratory, or the clinical syndrome of
MonoMAC

3. Clinical history of at least one life-threatening infection and/or MDS with
International Prognostic Scoring System (IPSS) category of Intermediate-1,
Intermediate-2 or High.

4. 10/10 or 9/10 HLA-matched related or unrelated donor, or a haploidentical related
donor.

5. 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
filgrastim - The majority of patients with MDS will have less than 5% blasts.

6. Left ventricular ejection fraction > 40%, preferably by 2-D echocardiogram obtained
within 60 days of enrollment

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 ( <18 years old) creatinine
<1.5 mg/dL and a creatinine clearance > 30 mL/min/1.73m(2).

Serum conjugated bilirubin < 2.5 mg/dl; serum ALT and AST less than or equal to 5
times upper limit of normal

8. Ability of subject or Legally Authorized Representative (LAR) (if the patient is
deemed by the treating physician to be cognitively impaired or questionably impaired
in such a way that the ability of the patient to give informed consent is
questionable) to understand and the willingness to sign a written informed consent
document indicating that they are aware of the investigational nature of this study or
written informed consent obtained from parent or legal guardian if subject is a minor.

9. Disease status: Patients are to be referred in remission for evaluation. Should a
patient have progressive disease, or a donor becomes not 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 or hematological disorder 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 and alternatives of the proposed therapy, and availability
of receiving the same treatment elsewhere, outside of a research protocol.

EXCLUSION CRITERIA- Recipient

- HIV infection.

- 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
or Lead Associate Investigator.

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

- Active infection refractory to antimicrobial therapy.

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

- Pregnant or lactating.

- 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
posttransplant. 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. 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.

- Presence of active malignancy in another organ system other than the hematopoietic,
except when driven by viruses in which case the immune reconstitution after transplant
may control the malignancy.

- No available 10/10 or 9/10 HLA-matched related or unrelated donor, or haploidentical
related donor.

INCLUSION CRITERIA- Matched Related Donor

1. Related donor matched at 9/10 or 10/10 HLA-A, B, C, DR, and DQ loci 9/10 matched
related donors will undergo by high resolution typing.

2. Ability to give informed consent

3. Age 6-70 years

4. No history of life-threatening opportunistic infection

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

6. 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.

7. 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.

8. No mutation in GATA2, or in the case where the mutation in GATA2 has not been
identified, but the recipient has the clinical syndrome of MonoMAC, the donor is
required to have no clinical evidence of MonoMAC .

INCLUSIN CRITERIA- Matched Unrelated Donor

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

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

INCLUSION CRITERIA- Haploidentical Related Donor

- A haploidentical donor is a related 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 (allelelevel) typing will be performed. additionally, HLA Class I and
Class II Antibody tests will also be performed on the selected haploididentical donor.

- Haploidentical related donors for pediatric recipients must be 6 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, CMV, etc. to select
the donor

- Age 6-70 years

- No history of life-threatening opportunistic infection

- 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.

- A donor who will undergo marrow harvest with general anesthesia will have a
pre-anesthesia consultation prior to the collection.

- A donor, who will donate peripheral stem cells by apheresis, 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 ailability from this source is not known.

f) No mutation in GATA2, or in the case where the mutation in GATA2 has not been
identified, but the recipient has the clinical syndrome of MonoMAC, the donor is
required to have no clinical evidence of MonoMAC

EXCLUSION CRITERIA- Matched Related Donor

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

- History of other medical conditions that in the opinion of PI constitute a
contraindication to donation.

- 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.
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,
partner s vasectomy, barrier methods, (condom, diaphragm, or cervical cap), or
abstinence.

- Mutation in GATA2, or evidence of loss of expression of one allele of GATA2 by cDNA
analysis performed by a CLIA certified laboratory, or in the case where the mutation
in GATA2 has not been identified, but the recipient has the clinical syndrome of
MonoMAC, the donor is excluded if he or she has the clinical syndrome of MonoMAC.

EXCLUSION CRITERIA- Matched Unrelated Donor

a) Failure to qualify as an NMDP donor.

EXCLUSION CRITERIA- Haploidentical Related Donor

- 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
consent

- History of other medical conditions that in the opinion of PI constitute a
contraindication to donation.

- 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,
partner s vasectomy, barrier methods, (condom, diaphragm, or cervical cap), or
abstinence.

- Mutation in GATA2, or evidence of loss of expression of one allele of GATA2 by Cdna
analysis performed by a CLIA certified laboratory, or in the case where the mutation
in GATA2 has not been identified, but the recipient has the clinical syndrome of
MonoMAC, the donor is required to have no clinical history of MonoMAC