NK Cell Based Non-Myeloablative Transplantation in Acute Myeloid Diseases

• Disease Free Survival [ Time Frame: At 6 Months ] [ Designated as safety issue: No ]
• Treatment Related Mortality (TRM) [ Time Frame: At 6 Months ] [ Designated as safety issue: Yes ]
  Cumulative incidence will be used to estimate TRM.
• Incidence of Relapse [ Time Frame: 2 Years ] [ Designated as safety issue: No ]
  Cumulative incidence will be used to estimate relapse.
• Rate of Early In Vivo Expansion of Natural Killer (NK) Cells [ Time Frame: Day 0 ] [ Designated as safety issue: No ]
  Successful in vivo donor NK cell expansion will be defined by measuring an absolute circulating donor-derived NK cell count of >100 cells/μl in patient's peripheral blood 12 days after infusion.

• Disease Free Survival [ Time Frame: At 6 Months ] [ Designated as safety issue: No ]
• Treatment Related Mortality (TRM) [ Time Frame: At 6 Months ] [ Designated as safety issue: Yes ]
  Cumulative incidence will be used to estimate TRM.
• Incidence of Relapse [ Time Frame: 2 Years ] [ Designated as safety issue: No ]
  Cumulative incidence will be used to estimate relapse.

This is a phase II multi-institutional therapeutic study of NK-cell based nonmyeloablative haploidentical transplantation for the treatment of high-risk acute myeloid diseases. Enrollment will use a two-stage design. Stage 1 will enroll 15 patients unless an early stopping rule is met. If 9 or more of these first 15 patients achieve leukemia free neutrophil engraftment at day +28 accrual will move to stage 2. In stage 2, an additional 28 patients will be enrolled for a total of 43 patients. Patients will be followed for disease response for 2 years.

A reduced intensity conditioning will start on day -18, followed by infusion of adult donor NK (natural killer) cells on day-12, 6 doses of interleukin-2 (IL-2) to promote NK expansion (day -12 to day -2), and infusion of a CD34+ selected haploidentical graft followed by ATG on day 0, +1 and +2.

• Acute Myeloid Leukemia
• Myelodysplastic Syndrome

• Drug: Preparative Regimen

  Preparative Regimen:

  1) fludarabine 35 mg/m^2 x 5 doses on Days 18 through 14 pretransplant, 2) cyclophosphamide 50 mg/kg x 2 doses on Days 16 and 15 pretransplant, 3) total body irradiation 200 cGy twice a day (BID) (at least 6 hours apart) on Day 13 pretransplant,

  Other Names:

  • Fludara
  • Cytoxan
  • CSA
  • radiation
• Biological: NK Cell Product
  CD3^- CD19^- selected, interleukin-2 (IL-2) activated, haploidentical donor natural killer (NK) cells infused on Day 12 pretransplant.
  Other Name: Natural Killer cells
• Drug: Interleukin-2
  Interleukin-2 6 million units (MU) subcutaneously (SQ) every other day for 6 doses beginning evening of NK cell infusion
  Other Name: IL-2
• Biological: Donor CD34+ Cells
  Single donor CD34+ selected filgrastim-mobilized peripheral blood stem cells (PBSC) graft (minimum cell dose of 5 x 10^6/kg) on day 0
  Other Name: stem cell transplant
• Biological: Anti-thymocyte globulin
  rabbit antithymocyte globulin - 3 mg/kg/day will be administered on day 0 per institutional guidelines.
  Other Names:

  • ATG
  • Thymoglobulin

Inclusion Criteria:

• Acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS)

RAEB-1 or RAEB-2 fitting within one of the following disease groups:

• Primary induction failure (PIF): Patients who have not achieved a complete remission (CR) after two induction cycles of cytotoxic therapy (i.e. 7+ 3, MEC, FLAG, etc.) and having <30% blasts by morphology and < 2500 absolute circulating blasts. (Measured at least 21 days from prior therapy.) Demethylating agents do not count as induction therapy; however early re-induction therapy based on residual disease on a day 14 BM will count as a 2nd cycle
• Relapsed Disease with low disease burden (AML or MDS with <30% blasts by morphology and < 2500 absolute circulating blasts):

No re-induction attempts are required, but a maximum of 2 reinduction attempts are allowed to be eligible.

• CR3 or greater: This will include CRp defined as CR without platelet recovery to 100,000/mcL.
• CR1 or CR2 with high risk features: Includes therapy induced, prior MDS or MPD, high risk cytogenetic or molecular phenotype with no available donor (sibling or unrelated adult)

Patients with known prior central nervous system (CNS) involvement are eligible provided that it has been treated and CSF is clear for at least 2 weeks prior to enrollment. CNS therapy (chemotherapy or radiation) should continue as medically indicated during the study treatment.

• Available related HLA-haploidentical adult donor by at least Class I serologic typing at the A&B locus
• Karnofsky score > 50%

• Adequate organ function within 28 days of study registration defined as:

  • Hepatic: AST ≤ 3 x upper limit of institutional normal, total bilirubin ≤ 2.0 mg/dl
  • Renal: estimated glomerular filtration rate (GFR) ≥ 50 mL/min/1.73m^2
  • Pulmonary: Oxygen saturation ≥ 90% on room air and DLCOcor ≥ 40%
  • Cardiac: Ejection Fraction ≥ 35% and no uncontrolled angina, severe uncontrolled ventricular or arterial arrhythmias, or any evidence of acute ischemia or active conduction system abnormalities (rate controlled atrial fibrillation is not an exclusion)
• Able to be off prednisone or other immunosuppressive medications for at least 3 days prior to NK cell infusion (except for those prescribed as part of the study)
• Women of child bearing potential must have a negative pregnancy test within 14 days prior to study registration and agree to use adequate birth control during study treatment
• Voluntary written consent

Exclusion Criteria:

• Biphenotypic leukemia
• Prior allogeneic transplant for AML within previous 6 months
• New or progressive pulmonary infiltrates on screening chest x-ray or chest CT scan that has not been evaluated with bronchoscopy, if feasible. Infiltrates attributed to infection must be stable/improving (with associated clinical improvement) after 1 week of appropriate therapy (4 weeks for presumed or documented fungal infections).
• Uncontrolled bacterial, fungal or viral infections including HIV - chronic asymptomatic viral hepatitis is allowed
• Known hypersensitivity to any of the study agents
• Received any investigational drugs within the 14 days before 1st dose of fludarabine
• Requires hydrea or other agents to control blast count

Donor Selection:

• Related donor (sibling, parent, offspring, parent or offspring of an HLA identical sibling) 12-75 years of age. (It is recognized individual institutions may have differing donor age guidelines. This is acceptable as long as no donor is younger than 12 years or older than 75 years).
• At least 40 kilograms
• In general good health as determined by the medical provider
• HLA-haploidentical donor/recipient match by at least Class I serologic typing at the A&B locus
• Able and willing to have up to 4 separate apheresis collections
• Not pregnant
• Voluntary written consent