Recruiting
Phase 1

CLAG-M & FLAG-Ida

Sponsor:

Fred Hutchinson Cancer Center

Code:

NCT04375631

Conditions

Recurrent Acute Myeloid Leukemia

Recurrent Chronic Myelomonocytic Leukemia

Recurrent Myelodysplastic Syndrome

Refractory Acute Myeloid Leukemia

Refractory Chronic Myelomonocytic Leukemia

Eligibility Criteria

Sex: All

Age: 18+

Healthy Volunteers: Not accepted

Interventions

Cladribine

Cyclophosphamide

Cyclosporine

Cytarabine

Filgrastim

Study Details

Brief summary:

This phase I trial studies the best dose of total body irradiation when given with cladribine, cytarabine, filgrastim, and mitoxantrone (CLAG-M) or idarubicin, fludarabine, cytarabine and filgrastim (FLAG-Ida) chemotherapy reduced-intensity conditioning regimen before stem cell transplant in treating patients with acute myeloid leukemia, myelodysplastic syndrome, or chronic myelomonocytic leukemia that has come back (relapsed) or does not respond to treatment (refractory). Giving chemotherapy and total body irradiation before a donor peripheral blood stem cell transplant helps kill cancer cells in the body and helps make room in the patient's bone marrow for new blood-forming cells (stem cells) to grow. When the healthy stem cells from a donor are infused into a patient, they may help the patient's bone marrow make more healthy cells and platelets and may help destroy any remaining cancer cells. Sometimes the transplanted cells from a donor can attack the body's normal cells called graft versus host disease. Giving cyclophosphamide, cyclosporine, and mycophenolate mofetil after the transplant may stop this from happening.

Conditions

Recurrent Acute Myeloid Leukemia

Recurrent Chronic Myelomonocytic Leukemia

Recurrent Myelodysplastic Syndrome

Refractory Acute Myeloid Leukemia

Refractory Chronic Myelomonocytic Leukemia

Study ID

NCT04375631

Start date

Dec 3, 2020

Status verified date

Mar, 2026

Completion date

Mar 17, 2027

Anticipated

Primary completion date

Feb 28, 2027

Anticipated

Eligibility Criteria

Eligibility Criteria

Sex: All

Age: 18+

Healthy Volunteers: Not accepted

Inclusion Criteria:

  • Age >= 18 years with an Hematopoietic Cell Transplantation-Comorbidity Index (HCT-CI) =< 5 for patients over 60 years -(Enrollment of patients >= 75 years of age will require case presentation at the transplant Patient Care Conference (PCC) and approval by consensus)
  • Acute myeloid leukemia (AML) (2016 World Health Organization \[WHO\] criteria) that is either primary refractory (as defined by failure of 2 cycles of 7+3-like chemotherapy, 1 cycle of high-dose cytarabine-based chemotherapy, or at least 2 cycles of venetoclax in combination with other therapies), or is in untreated or unsuccessfully treated first or subsequent relapse. Patients in morphological remission (i.e. < 5% blasts in the bone marrow) but evidence of minimal residual disease (MRD) by multiparameter flow cytometry, cytogenetics/fluorescence in situ hybridization (FISH), or molecular means will be eligible for trial participation. Patients with relapsed or refractory acute leukemia of ambiguous lineage (acute undifferentiated leukemia, mixed phenotype acute leukemia) that is either primary refractory or is in untreated or unsuccessfully treated first or subsequent relapse are also eligible
  • Subjects with previously treated myelodysplastic syndrome (MDS) and chronic myelomonocytic leukemia (CMML), defined as prior treatment with at least one hypomethylating agent (HMA; azacitidine and/or decitabine) whose disease progressed, relapsed, or was refractory to HMA treatment as follows: 1) patients who have failed at least 4 cycles of monotherapy with azacitidine or decitabine, 2) patients who received at least 2 cycles of HMA in combination with another therapeutic agent. Subjects with MDS and CMML who failed at least 1 cycle of induction chemotherapy will be also eligible
  • The use of hydroxyurea prior to initiation of study treatment is allowed. Patients with symptoms/signs of hyperleukocytosis, WBC > 100,000/uL or with concern for other complications of high tumor burden (e.g. disseminated intravascular coagulation) can be treated with leukapheresis or may receive up to 2 doses of cytarabine (up to 500 mg/m\^2 per dose) prior to start of study treatment
  • Karnofsky score >= 70; Eastern Cooperative Oncology Group (ECOG) 0-1
  • Adequate cardiac function defined as absence of decompensated congestive heart failure and/or uncontrolled arrhythmia and left ventricular ejection fraction >= 45%
  • Bilirubin =< 2.5 x institutional upper limit of normal unless elevation is thought to be due to hepatic infiltration by AML, Gilbert's syndrome, or hemolysis
  • Adequate pulmonary function defined as absence of oxygen (O2) requirements and either carbon monoxide diffusing capability test (DLCO) correct >= 70% mmHg or DLCO corrected 60-69% mmHg and partial pressure of oxygen (pO2) >= 70 mmHg
  • Serum creatinine =< 1.5 mg/dL
  • Prior autologous HCT is permissible if relapse occurred > 3 months but =< 6 months after HCT
  • Prior TBI-containing allogeneic HCT up to 3 Gy is permissible if > 6 months after HCT
  • A human leukocyte antigen (HLA)-matched or near-matched related, unrelated or haploidentical donor for collection of stimulated peripheral blood stem cells or HLA-matched or near-matched cord blood unit must be identified and readily available
  • Women of childbearing potential and men must agree to use adequate contraception beginning at the signing of the consent until at least 12 months post-transplant
  • Patients may have previously received chemotherapy with a mitoxantrone, idarubicin- or cladribine/fludarabine-based regimen for MDS or AML. If the patient has received CLAG-M or FLAG-Ida before and has been sensitive to this regimen, eligibility will be determined on a case-by-case basis by the study principal investigator (PI)
  • Ability to understand and sign a written informed consent document (or legal representative)
  • DONOR: Patients must have an HLA-matched related donor or an HLA-matched unrelated donor, or haploidentical donor who meets standard FHCC and/or National Marrow Donor Program (NMDP) or other donor center criteria for peripheral blood stem cell (PBSC) donation as follows:

  • Related donor: related to the patient and genotypically or phenotypically identical for HLA-A, B, C, DRB1 and DQB1. Phenotypic identity must be confirmed by high-resolution typing
  • Unrelated donor:

  • Matched for HLA-A, B, C, DRB1 and DQB1 by high resolution typing; OR
  • Mismatched for a single allele without antigen mismatching at HLA-A, B, or C as defined by high resolution typing but otherwise matched for HLA-A, B, C, DRB1 and DQB1 by high resolution typing
  • Donors are excluded when preexisting immunoreactivity is identified that would jeopardize donor hematopoietic cell engraftment. The recommended procedure for patients with 10 of 10 HLA allele level (phenotypic) match is to obtain panel reactive antibody (PRA) screens to class I and class II antigens for all patients before HCT. If the PRA shows > 10% activity, then flow cytometric or B and T cell cytotoxic cross matches should be obtained. The donor should be excluded if any of the cytotoxic cross match assays are positive. For those patients with an HLA class I allele mismatch, flow cytometric or B and T cell cytotoxic cross matches should be obtained regardless of the PRA results. A positive anti-donor cytotoxic crossmatch is an absolute donor exclusion
  • Patient and donor pairs homozygous at a mismatched allele in the graft rejection vector are considered a two-allele mismatch, i.e., the patient is A\*0101 and the donor is A\*0102, and this type of mismatch is not allowed
  • Haploidentical donor:

  • Donors must be haploidentical relatives of the patients. Donor-recipient compatibility will be tested through HLA typing at high resolution for the HLA loci (-A, -B, -C, -DRB1, -DQB1). Donor and recipient should share at least 5/10 HLA loci.
  • Age ≥ 12 years
  • Weight ≥ 40 kg.
  • Ability of donors younger than 18 years of age to undergo apheresis without use of a vascular access device. Vein check must be performed and verified by an apheresis nurse prior to arrival.
  • Donor must meet the selection criteria as defined by the Foundation of the Accreditation of Cell Therapy (FACT) and will be screened per the American Association of Blood Banks (AABB) guidelines.
  • In case of more available haploidentical donors, selection criteria should include, in this order:

  • For cytomegalovirus (CMV) seronegative recipients, a CMV seronegative donor
  • Red Blood Cell compatibility

  • i. RBC cross match compatible
  • ii. Minor ABO incompatibility
  • iii. Major ABO incompatibility

Exclusion Criteria:

  • Patients >= 18 years being treated at Seattle Children's Hospital
  • Active central nervous system (CNS) disease
  • Concomitant illness associated with a likely survival of < 1 year
  • Active systemic fungal, bacterial, viral, or other infection, unless disease is under treatment with anti-microbials and/or controlled or stable. Patients with fever thought to be likely secondary to myeloid malignancy are eligible
  • Known hypersensitivity or contraindication to any study drug used in this trial
  • Pregnancy or lactation
  • Concurrent treatment with any other approved or investigational anti-leukemia agent
  • Haploidentical donor exclusion criteria:

  • Since detection of anti-donor-specific antibodies (anti-DSA) is associated with higher graft rejection rate, patients will be screened for anti-DSA pre-transplant. Patient with DSA mean fluorescent intensity (MFI) <5000 after desensitization treatment, will be considered eligible to participate in the study.

Study Design

Enrollment

120 participants

Anticipated

Allocation

Non randomized

Intervention Model

Parallel Assignment

Primary purpose

Treatment

Interventions and Outcome Measures

Arms

experimental: Arm I (CLAG-M, TBI, HCT, GVHD prophylaxis)

See detailed description.

experimental: Arm II (FLAG-Ida, TBI, HCT, GVHD prophylaxis)

See detailed description.

Interventions

Cladribine

Given IV

Cyclophosphamide

Given IV

Cyclosporine

Given IV then PO

Cytarabine

Given IV

Filgrastim

Given SC

Hematopoietic Cell Transplantation

Undergo HCT

Mitoxantrone

Given IV

Mycophenolate Mofetil

Given IV or PO

Mycophenolate Sodium

Given PO

Total-Body Irradiation

Undergo TBI

Idarubicin

Given IV

Fludarabine

Given IV

Cytarabine

Given IV

Multigated Acquisition Scan

Undergo MUGA

Echocardiography Test

Undergo ECHO

X-Ray Imaging

Undergo x-ray

Bone Marrow Biopsy

Undergo bone marrow biopsy and aspirate

Bone Marrow Aspiration

Undergo bone marrow biopsy and aspirate

Biospecimen Collection

Undergo blood sample collection

Primary outcome measure

  • Rate of hematopoietic cell transplantation (HCT) failure [ Time Frame: Within 200 days post-transplant ]
  • Rate of disease progression [ Time Frame: Within 200 days post-transplant ]

Central Contacts and Locations

Central contacts

Filippo Milano

206.667.5925fmilano@fredhutch.org

Locations

Fred Hutch/University of Washington Cancer Consortium

Recruiting

Seattle, Washington, United States, 98109

Contacts

Filippo Milano

206-667-5925fmilano@fredhutch.org

Principal Investigator:

Filippo Milano

More Information

Sponsor

Fred Hutchinson Cancer Center

Last update posted

Mar 5, 2026

Last verified

Mar, 2026

Trial information was received from ClinicalTrials.gov and was last updated on 2026-09-10. This information was provided to ClinicalTrials.gov by Fred Hutchinson Cancer Center on 2026-03-05.