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The Role of Minimal Residual Disease Testing Before and After Hematopoietic Cell Transplantation for Pediatric Acute Myeloid Leukemia

21 Years
Open (Enrolling)
Acute Myeloid Leukemia

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Trial Information

The Role of Minimal Residual Disease Testing Before and After Hematopoietic Cell Transplantation for Pediatric Acute Myeloid Leukemia

This is a prospective, non-therapeutic study, assessing the significance of minimal residual
disease (MRD) at three different time points in relation to allogeneic HCT for pediatric
AML. The study is a collaboration between the Pediatric Blood and Marrow Transplant
Consortium (PBMTC) and the Resource for Clinical Investigations in Blood and Marrow
Transplantation (RCI-BMT) of the Center for International Blood and Marrow Transplant
Research (CIBMTR). The study will enroll pediatric AML patients who undergo myeloablative
HCT at PBMTC sites. The eligibility criteria for this non-therapeutic study mirror widely
accepted criteria for allogeneic HCT in pediatric AML.

The study tests the hypothesis that assessment of pre-transplant and post-transplant MRD
predicts 2-year outcomes following transplant. Two MRD methodologies are being studied: flow
cytometry and WT1 PCR. The secondary hypothesis is that combining these 2 methodologies will
improve the accuracy in predicting 2-year outcomes following transplant.

It is well established that the level of minimal residual disease (MRD) during chemotherapy
is a strong predictor of relapse in children with acute lymphoblastic leukemia (ALL) [33,
34]. Within this population, MRD levels have the potential to predict those patients who
will respond well to standard therapy, thus allowing clinicians to tailor therapy and
minimize toxicity while ensuring maximal cure rates [10]. MRD levels before allogeneic
hematopoietic stem cell transplantation (HCT) also predict the risk of relapse post-HCT
[25], leading to the clinical practice of reducing MRD levels as much as possible before
transplant. By contrast, in children with acute myeloid leukemia (AML), the prognostic value
of MRD levels prior to HCT remains unclear.

Our long-term objective is to improve the cure rate for children with AML. The investigators
hypothesize that MRD levels before HCT will provide a powerful tool to select the best
candidates for transplant, guide decision making in stem cell source and preparative
therapy, and optimize the timing of the transplant. Measurements of MRD post-HCT will allow
informed decisions about withdrawal of immunosuppressive therapy, administration of donor
lymphocyte infusions, or alternative targeted therapies.

Inclusion Criteria:

1. Subject or legal guardian to understand and voluntarily sign an informed consent.

2. Age 0-21 at time of transplant.

3. Karnofsky score ≥ 70% (age ≥ 16 years old), or Lansky score ≥ 70% (age<16 years old).

4. Patients with adequate physical function as measured by:

- Cardiac: Left ventricular ejection fraction at rest must be > 40%, or
shortening fraction > 26%

- Hepatic: Bilirubin ≤ 2.5 mg/dL; and ALT, AST and Alkaline Phosphatase≤ 5 x ULN

- Renal: Serum creatinine within normal range for age, or if serum creatinine
outside normal range for age, then renal function (creatinine clearance or GFR)
> 70 mL/min/1.73 m2.

- Pulmonary: DLCO, FEV1, FVC (diffusion capacity) > 50% of predicted (corrected
for hemoglobin); if unable to perform pulmonary function tests, then O2
saturation > 92% in room air.

5. Acute myelogenous leukemia (AML) at the following stages:

- High risk first complete remission (CR1), defined as:

- Having preceding myelodysplasia (MDS) -or-

- Diagnostic high risk karyotypes: del (5q) -5, -7, abn (3q), t (6;9),
abnormalities of 12, t (9:22), complex karyotype (≥3 abnormalities), the
presence of a high FLT3 ITD-AR (> 0.4) -or-

- Having >15% bone marrow blasts after 1st cycle and/or >5% after 2nd cycle
before achieving CR -and-

- <5% blasts in the bone marrow, with peripheral ANC>500

- Intermediate risk first complete remission (CR1), defined as:

- Diagnostic karyotypes that are neither high-risk (as defined above) nor low
risk (inv(16)/t(16:16); t(8;21); t(15;17)). Included are cases where
cytogenetics could not be performed. -and-

- <5% blasts in the bone marrow, with peripheral ANC>500

- High risk based upon COG AAML 1031 criteria:

- High allelic ratio FLT3/ITD+, monosomy 7, del(5q) with any MRD status or
standard risk cytogenetics with positive MRD at end of Induction I.

- <5% blasts in the bone marrow, with peripheral ANC>500

- Second or greater CR

- <5% blasts in the bone marrow, with peripheral ANC>500

- Therapy-related AML at any stage

- Prior malignancy in remission for >12 months.

- <5% blasts in the bone marrow, with peripheral ANC>500

6. Myeloablative preparative regimen, defined as a regimen including one of the
following as a backbone agent*:

- Busulfan ≥ 12.8mg/kg total dose (IV or PO). PK-based dosing allowed, if intent
is total overall dose ≥ 12.8mg/kg OR

- Total Body Irradiation≥1200cGy fractionated OR

- Treosulfan ≥ 42g/m2 total dose IV *Regimens may include secondary agents such
as, but not limited to Ara-C, Fludarabine, VP-16. Regimens that combine Busulfan
and TBI or treosulfan and TBI are allowed as long as the Busulfan or treosulfan
meets or exceeds the dose listed and the TBI is below the dose listed.

7. Graft source:

- HLA-identical sibling PBSC, BM, or cord blood

- Adult related or unrelated donor PBSC or BM matched at the allelic level for
HLA-A, HLA-B, HLA-C, and HLA-DRB1 with no greater than a single antigen

- One or two unrelated cord blood units:

- HLA≥4:6 at the low resolution level for HLA-A, HLA-B, at high resolution
level at HLA-DRB1 for one or both units.

- If one unit, must have TNC≥2.5x107/kg; if two units, combination of the two
must have TNC≥2.5x107/kg

Exclusion Criteria:

1. Women who are pregnant (positive HCG) or breastfeeding.

2. Evidence of HIV infection or HIV positive serology.

3. Positive viral load (PCR) for Hepatitis B or C.

4. Current uncontrolled bacterial, viral or fungal infection (currently taking
medication and progression of clinical symptoms).

5. Autologous transplant < 12 months prior to enrollment.

6. Prior allogeneic hematopoietic stem cell transplant.

Type of Study:


Study Design:

Observational Model: Cohort, Time Perspective: Prospective

Principal Investigator

David A. Jacobsohn, MD, ScM

Investigator Role:

Principal Investigator

Investigator Affiliation:

Children's Research Institute


United States: Institutional Review Board

Study ID:




Start Date:

October 2011

Completion Date:

September 2015

Related Keywords:

  • Acute Myeloid Leukemia
  • Pediatric (ages 0-21 years)
  • myeloablative HCT
  • PBMTC sites
  • Leukemia
  • Leukemia, Myeloid, Acute
  • Leukemia, Myeloid
  • Neoplasm, Residual



University of Michigan Ann Arbor, Michigan  48109-0624
Roswell Park Cancer Institute Buffalo, New York  14263
University of Mississippi Medical Center Jackson, Mississippi  39216-4505
Medical University of South Carolina Charleston, South Carolina  29425-0721
Children's Hospital of Michigan Detroit, Michigan  48201
Mount Sinai School of Medicine New York, New York  10029
New York Medical College Valhalla, New York  10595
University Hospitals of Cleveland Cleveland, Ohio  44106
Hackensack University Medical Center Hackensack, New Jersey  07601
Children's National Medical Center Washington, District of Columbia  20010-2970
Miami Children's Hospital Miami, Florida  33155-4069
All Children's Hospital St. Petersburg, Florida  33701
Phoenix Children's Hospital Phoenix, Arizona  85016-7710
Duke University Medical Center Durham, North Carolina  27710
University of California San Francisco San Francisco, California  941104206
Dana Farber Cancer Institute Boston, Massachusetts  02115
University of Louisville Louisville, Kentucky  40202
Children's Memorial Hospital Chicago, Illinois  60614
Virginia Commonwealth University Richmond, Virginia  
Children's Healthcare of Atlanta Atlanta, Georgia  30342
Loma Linda University Loma Linda, California  92354
Johns Hopkins Baltimore, Maryland  21231
University of North Carolina at Chapel Hill Chapel Hill, North Carolina  27599
Penn State Milton S. Hershey Medical Center Hershey, Pennsylvania  17033
The Children's Hospital of Alabama, University of Alabama at Birmingham Birmingham, Alabama  35233
The Children's Hospital Colorado Aurora, Colorado  80045
Riley Hospital for Children/Indiana University Indianapolis, Indiana  46202
Washington University, St. Louis Children's Hospital St. Louis, Missouri  63110
Columbia University - The Morgan Stanley Children's Hospital of New York New York, New York  10032
Oregon Health & Sciences University - Doerbecher Children's Portland, Oregon  97239
Methodist Children's Hospital of South Texas/Texas Institute of Medicine and Surgery San Antonio, Texas  78229
University of Utah - Primary Children's Medical Center Salt Lake City, Utah  84108