Phase I Study of Escalating Doses of 225Ac-DOTA-Anti-CD38 Daratumumab Monoclonal Antibody Added to the Conditioning Regimen of Fludarabine, Melphalan and Organ Sparing Total Marrow and Lymphoid Irradiation (TMLI) as Conditioning for Allogeneic Hematopoietic Cell Transplantation in Patients With High-Risk Acute Myeloid Leukemia, Acute Lymphoblastic Leukemia and Myelodysplastic Syndrome
Summary
This phase I trial tests the safety, side effects, best dose, and effectiveness of 225Ac-DOTA-Anti-CD38 daratumumab monoclonal antibody in combination with fludarabine, melphalan and total marrow and lymphoid irradiation (TMLI) as conditioning treatment for donor stem cell transplant in patients with high-risk acute myeloid leukemia (AML), acute lymphoblastic leukemia (ALL) and myelodysplastic syndrome (MDS). Daratumumab is in a class of medications called monoclonal antibodies. It binds to a protein called CD38, which is found on some types of immune cells and cancer cells. Daratumumab may block CD38 and help the immune system kill cancer cells. Radioimmunotherapy is treatment with a radioactive substance that is linked to a monoclonal antibody, such as daratumumab, that will find and attach to cancer cells. Radiation given off by the radioisotope my help kill the cancer cells. Chemotherapy drugs, such as fludarabine and melphalan, work in different ways to stop the growth of cancer cells, either by killing the cells, by stopping them from dividing, or by stopping them from spreading. Radiation therapy uses high energy x-rays, particles, or radioactive seeds to kill cancer cells and shrink tumors. TMLI is a targeted form of body radiation that targets marrow, lymph node chains, and the spleen. It is designed to reduce radiation-associated side effects and maximize therapy effect. Actinium Ac 225-DOTA-daratumumab combined with fludarabine, melphalan and TMLI may be safe, tolerable, and/or effective as conditioning treatment for donor stem cell transplant in patients with high-risk AML, ALL, and MDS.
Detailed description
PRIMARY OBJECTIVES: I. Describe toxicities attributable to actinium Ac 225-DOTA-daratumumab (225Ac-DOTA-anti-CD38 daratumumab) radioimmunotherapy by dose level in patients treated under this regimen. II. Determine the maximum tolerated dose/recommended phase II dose (MTD/RP2D) of 225Ac-DOTA-anti-CD38 daratumumab radioimmunotherapy with fixed doses of organ sparing TMLI (12 Gy), fludarabine and melphalan (FM100) as conditioning regimen for allogeneic hematopoietic cell transplantation (HCT) for treatment of high-risk acute myeloid leukemias, acute lymphoblastic leukemia or myelodysplastic syndrome (MDS), in patients who are not eligible for standard myeloablative regimens. SECONDARY OBJECTIVES: I. Evaluate the safety of the regimen, at each dose level, by assessing the following: Ia. Type, frequency, severity, attribution, time course and duration of adverse events, including acute/chronic graft-versus-host disease (GVHD), infection and delayed engraftment. II. Estimate overall survival (OS), event-free survival (EFS), GVHD relapse free survival (GRFS), cumulative incidence (CI) of relapse/progression, and non-relapse mortality (NRM) at 100 days, 1 year and 2 years. III. Describe biodistribution, pharmacokinetics and organ dosimetry of 225Ac-DOTA-daratumumab. OUTLINE: This is a dose escalation of actinium Ac 225-DOTA-Daratumumab in combination with fludarabine, melphalan and TMLI. Patients receive daratumumab intravenously (IV) over 45 minutes followed by indium In 111-DOTA-daratumumab IV over 15 minutes and actinium Ac 225-DOTA-daratumumab IV over \~20-40 minutes on day -15. Patients receive TMLI twice daily (BID) on days -8 to -5, fludarabine IV on days -4 to -2 and melphalan IV on day -2, followed by HCT on day 0. Patients receive GVHD prophylaxis with sirolimus and tacrolimus starting on day -1. Patients also undergo computed tomography (CT) during screening, nuclear scan and single photon emission computed tomography (SPECT) scans on study, bone marrow biopsy and aspiration, echocardiography, or multigated acquisition scan (MUGA), and blood sample collection during screening and throughout study. After completion of study treatment, patients are followed up twice weekly for the first 100 days post-transplant, then twice monthly up to 6 months post-transplant followed by monthly until discontinuation of immunosuppressive therapy without evidence of GVHD with at least yearly follow-up for 2 years.
Arms & interventions
- BiologicalActinium Ac 225-DOTA-Daratumumab
Given IV
- ProcedureBiospecimen Collection
Undergo blood sample collection
- ProcedureBone Marrow Aspiration
Undergo bone marrow biopsy and aspiration
- ProcedureBone Marrow Biopsy
Undergo bone marrow biopsy and aspiration
- ProcedureComputed Tomography
Undergo CT
- BiologicalDaratumumab
Given IV
- ProcedureEchocardiography
Undergo echocardiography
- DrugFludarabine
Given IV
- ProcedureHematopoietic Cell Transplantation
Undergo SCT
- BiologicalIndium In 111-DOTA-Daratumumab
Given IV
- DrugMelphalan
Given IV
- ProcedureMultigated Acquisition Scan
Undergo MUGA
- ProcedureRadionuclide Imaging
Undergo nuclear scan
- ProcedureSingle Photon Emission Computed Tomography
Undergo SPECT scan
- DrugSirolimus
Given sirolimus
- DrugTacrolimus
Given tacrolimus
- RadiationTotal Marrow and Lymphoid Irradiation
Undergo TMLI
Outcome measures
Primary
Incidence of adverse events (CTCAE)
Toxicity will be scored on the National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE) version (v) 5 scale. Toxicity will be recorded in each patient and will include the type, severity, and probable association with the study regimen.
Time frame: Up to 2 years post-transplant
Incidence of adverse events (Bearman)
Toxicity will be scored on the Bearman Scale. Toxicity will be recorded in each patient and will include the type, severity, and probable association with the study regimen.
Time frame: Up to 2 years post-transplant
Dose limiting toxicity (DLT)
DLT will be graded using the NCI CTCAE v5 scale.
Time frame: Up to 30 days post-stem cell infusion
Maximum tolerated dose/recommended phase II dose (MTD/RP2D)
MTD/RP2D will be defined as the highest dose where 6 patients have been treated and at most on patient experiences a DLT.
Time frame: Up to 30 days post stem cell infusion
Secondary
Overall survival (OS)
Time frame: At start of protocol therapy to death or last follow-up up to 2 years post transplant
Event-free survival (EFS)
Time frame: At start of protocol therapy to death, relapse/progression or last follow-up up to 2 years post-transplant
Cumulative incidence of relapse/progression (CIR)
Time frame: At start of therapy up to 2 years post transplant
Graft versus host disease and relapse free survival (GRFS)
Time frame: At start of therapy up to 2 years post-transplant
Complete remission (CR) proportion
Time frame: At start of therapy up to day 30
Non-relapse mortality (NRM)
Time frame: At start of therapy until non-disease related death or last follow-up up to 2 years post-transplant
Incidence of infection
Time frame: At day 0 up to 100 days post-transplant
Neutrophil recovery rate
Time frame: At stem cell infusion up to the first to three consecutive days with neutrophil count greater than 0.5 x 10^9/L up to 2 years post-transplant
Incidence of grade 2-4 and 3-4 acute graft-versus-host disease (GVHD)
Time frame: At date of stem cell infusion to document/biopsy proven acute GVHS onset (within first 100 days post-transplant)
Incidence of chronic GVHD (cGVHD)
Time frame: At 80-100 days post-transplant to documented/biopsy proven cGVHD onset date up to 2 years post-transplant
Eligibility criteria
Study locations (1)
City of Hope Medical Center
Duarte, California, 91010