Pilot Study of Reduced-Intensity Hematopoietic Stem Cell Transplant of DOCK8 Deficiency

• INCLUSION CRITERIA:

Recipient:

1. Patient age of 10-60 years.

2. DOCK8 deficiency (documentation of DOCK 8 mutation acceptable from an outside Laboratory) with the two criteria listed below:

   1. Clinical history of two or more episodes of life-threatening or severely disfiguring infection with opportunistic organisms, including severe recurrent cutaneous and sinopulmonary infections with bacterial or fungal infection, or viral infections with herpes simplex, herpes zoster, Molluscum contagiosum, or human papilloma virus.
   2. Homozygous or compound heterozygous mutations in the DOCK8 gene.
3. Available 10/10 HLA-matched related donor, 10/10 or 9/10 matched unrelated donor, or a haploidentical donor.
4. 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.
5. Pulmonary Function Tests: Adult patients: Corrected DLCO diffusion capacity and FEV1 greater than or equal to 20% 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.

6. Creatinine: Adult patients: less than or equal to 2.0 mg/dl and creatinine clearance greater than or equal to 30 ml/min/1.73 m(2).

   Pediatric patients (less than 18 years old): Creatinine less than or equal to 1.5 and a creatinine clearance greater than or equal to 30 mL/min/1.73 m(2).

7. Serum total bilirubin < 2.5 mg/dl; serum ALT and AST less than or equal to 5 times upper limit of normal.
8. Adequate central venous access potential.
9. Written informed consent/assent obtained from patient/parent or legal guardian.
10. 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.

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. Ability to give informed consent; for donors less than 18 years of age, he/she must be the oldest eligible donor, their legal guardian must give informed consent, the donor must give verbal assent, and he/she must be cleared by social work and mental health specialist to participate.
3. Age 4-60 years, and weight of greater than or equal to 15 kilograms.
4. At least one normal DOCK8 allele by DNA sequencing by GeneDx.
5. Adequate venous access for peripheral apheresis, or consent to use a temporary central venous catheter for apheresis.
6. Donors must be HIV negative, hepatitis B surface antigen negative, and hepatitis C antibody negative.
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.

Matched Unrelated Donor

1. Unrelated donor matched at 10/10 or 9/10 HLA-A, B, C, DR, and DQ loci by 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

1. 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, CMV, etc. to select the donor

2. Age 15-60 years
3. No history of life-threatening opportunistic infection
4. Adequate venous access for peripheral apheresis, or consent to use a temporary central venous catheter for apheresis.
5. 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.
6. 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.
7. 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.
8. Subjects will undergo follow-up history and physical examination within 1 week of donation.

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 posititve CSF cytology or parenchymal lesions visible by CT or MRI).
6. Pregnant or lactating. 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.
7. Sexually active individuals capable of becoming pregnant who are unable or unwilling to use effective form(s) of contraception during the time enrolled on the 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, partner's vasectomy, barrier methods, (condom, diaphragm, or cervical cap), or abstinence. Males on the protocol must use an effective form of contraception at study entry, and for one year posttransplant. 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 system.
9. No available 10/10 HLA-matched related donor, 10/10 or 9/10 matched unrellated donor.

Matched Related Donor

1. History of severe cutaneous viral infections with herpes simplex, herpes zoster, or molluscumm contagiosum.
2. Hyper IgE > 3 times the upper limit of normal.
3. HIV infection.
4. Chronic active hepatitis B. Donor may be hepatitis core antibody postitive.
5. 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.

6. 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.

7. Other medical contraindications to stem cell donation
8. History of prior malignancy.
9. Donors must not be pregnant.
10. Thrombocytopenia (platelets less than 150,000 per microl) at baseline evaluation.
11. Donors receiving experimental therapy or investigational agents.
12. Sensitivity to filgrastim or to E. coli-derived recombinant protein products.
13. History of autoimmune disorders, including rheumatic diseases and thyroid disorders.
14. History of documented deep vein thrombosis or pulmonary embolism.

Matched Unrelated Donor

Failure to qualify as an NMDP donor

Exclusion Criteria

Haploidentical donor

1. Age less than 15 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 for appropriate 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) (Anderlini, Korbling et al. 1997).
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 ?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
14. Mutation on both alleles of the DOCK8 gene