Moxetumomab Pasudotox (CAT-8015, HA22) in Children With B-lineage Acute Lymphoblastic Leukemia and Minimal Residual Disease Prior to Allogeneic Hematopoietic Stem Cell Transplantation
Moxetumomab Pasudotox (CAT-8015, HA22) in Children With B-lineage Acute Lymphoblastic Leukemia and Minimal Residual Disease Prior to Allogeneic Hematopoietic Stem Cell Transplantation
This is a phase II, open-label, nonrandomized, prospective study to evaluate the activity,
 safety, and feasibility of administration of moxetumomab pasudotox in the pre-allogeneic
 hematopoietic cell transplantation (HCT) setting to patients with B-lineage Acute
 Lymphoblastic Leukemia (ALL) who are in a morphologic complete remission and have
 pre-transplant minimal residual disease (MRD) > 0.01% (detected by flow cytometry). The
 primary objective of this study is to determine if treatment with moxetumomab pasudotox in
 the MRD positive setting is able to lead to MRD negativity (< 0.01% by flow cytometry) or at
 least a 1-log10 reduction in MRD prior to allogeneic HCT.
This is a Phase 2 study designed to assess safety, feasibility and clinical activity of
 pre-HCT moxetumomab pasudotox for patients with ALL in morphologic CR but with MRD. It is
 hypothesized that subjects in a morphologic complete remission with proven minimal residual
 disease (MRD) after chemotherapy for ALL planned for allogeneic HCT who receive a course of
 moxetumomab pasudotox prior to the start of conditioning will show a marked reduction or
 elimination of detectable MRD after moxetumomab pasudotox treatment without adverse impact on
 the feasibility or safety of allogeneic HCT.

 The primary objective of this study is to determine if treatment with moxetumomab pasudotox
 in the MRD positive setting is able to lead to MRD negativity (< 0.01% by flow cytometry) or
 at least a 1-log10 reduction in MRD prior to allogeneic HCT.

 Secondary objectives to be studied include: toxicity profile (including safety and
 feasibility of administration in the pre-HCT setting and ability to proceed to transplant,
 incidence of capillary leak syndrome, hemolytic uremic syndrome and other post-HCT
 toxicities), comparison of quantitative MRD assessments, progression-free survival, overall
 survival, pharmacokinetic profiles, immunogenicity to moxetumomab pasudotox,
 transplant-related mortality, acute and chronic graft-versus-host disease (GVHD), and
 relapse.
Inclusion Criteria:

 1. ≥ 6 months and < 25 years of age

 2. Histologically confirmed diagnosis of B-lineage ALL. Verification of CD22 expression
 is not required

 3. Bone marrow in morphologic remission (any remission number) defined as < 5% blasts (M1
 classification) performed in local institution lab

 4. CNS 1 (< 5/μL WBCs in CSF and cytospin negative for blasts)

 5. Evidence of bone marrow MRD defined as ≥ 0.01% by flow cytometry performed in the
 study central lab

 6. Candidate committed to HCT independent of participation in this study, with the
 following requirements:

 -  Meets local transplant center eligibility requirements for HCT

 -  In the opinion of the HCT center will be ready to begin pre-transplant
 conditioning within 6 weeks of trial enrollment from a medical and psychosocial
 standpoint

 -  Has an available HCT donor or identified cord blood unit. Related and unrelated
 donors, and bone marrow, peripheral blood, or cord blood stem cell sources
 allowed

 7. Adequate organ function including the following:

 -  Hepatic function: Total bilirubin < 1.5 × upper limit of normal (ULN) (except in
 the case of subjects with known Gilbert's disease: < 5 × ULN) and transaminases
 (alanine aminotransferase (ALT) and aspartate aminotransferase (AST)) < 3 × ULN
 based on age- and institution specific laboratory-specific normal ranges

 -  Renal function: Age-adjusted normal serum creatinine is required. A 24-hour
 creatinine clearance value > 60 mL/min/1.73 m2 (updated Schwartz formula or
 nuclear GFR) must be obtained if serum creatinine is elevated.

 -  Hematologic function: Absolute neutrophil count (ANC) > 500/μL and platelet count
 > 25,000/μL without transfusion

 -  Oxygen saturation at rest or with exercise > 88% as measured by pulse oximeter or
 PaO2 > 55 mm Hg without need for supplemental oxygen at rest or with activity

 -  Serum albumin > 2 g/dL

 8. Performance status:

 -  Subjects ≥ 16 years of age: Karnofsky ≥ 60% (Appendix A)

 -  Subjects < 16 years of age: Lansky scale ≥ 60% (Appendix A)

 -  Subjects who are unable to walk because of paralysis, but who are upright in a
 wheel chair will be considered ambulatory for the purpose of calculating the
 performance score

 9. Patients > 18 years of age must have the ability to give informed consent according to
 applicable regulatory and local institutional requirements. Legal guardian permission
 must be obtained for patients < 18 years of age. Pediatric patients will be included
 in age appropriate discussion in order to obtain assent

 10. Sexually active female subjects of childbearing potential and male subjects and their
 sexual partners who are of childbearing potential must agree to use contraception

 Exclusion Criteria:

 1. Active extramedullary disease at any site. (Note: Definitive therapy of known previous
 sites of extramedullary disease is allowed)

 2. Females who are breast-feeding or pregnant

 3. Subjects with known 11q23 MLL rearrangement are excluded.

 4. Prior therapy:

 -  Prior treatment with CAT-3888 (BL22), moxetumomab pasudotox (CAT-8015, HA22), any
 pseudomonas-exotoxin-containing compound, or any anti-CD22 directed therapy at
 any time in the past

 -  Prior allogeneic or autologous HCT or adoptive cellular therapies, including
 T-cell chimeric antigen receptor (CAR) therapy

 -  Chemotherapy < 2 weeks prior to starting study drug with the following exception:
 There is no time restriction in regard to prior intrathecal chemotherapy provided
 there is complete recovery from any acute toxic effects of such

 -  Monoclonal antibody therapy < 30 days from study enrollment

 -  Other investigational agents currently or within 30 days prior to study
 enrollment

 5. Subjects with an absolute contraindication to corticosteroid administration

 6. HIV infection (due to increased risk of severe infection and unknown interaction of
 moxetumomab pasudotox with antiretroviral drugs)

 7. Active hepatitis B or C infection as defined by seropositivity for hepatitis B
 (hepatitis B surface antigen [HbsAg]) or hepatitis C (hepatitis C antibody) and
 elevated liver transaminases (defined as above the ULN per the institution normal
 ranges)

 8. Second malignancy other than non-basal cell carcinoma of the skin or in situ carcinoma
 of the cervix, unless the tumor was treated with curative intent at least two years
 previously and subject is in remission

 9. Subject with clinical or laboratory evidence of active DIC

 10. Subject with prior history of thrombotic microangiopathy or HUS within 3 months prior
 to enrollment

 11. History of known congenital hypercoagulable condition

 12. Previous life-threatening anaphylactic reactions to prior monoclonal antibody-based
 immunotherapy or any component of the moxetumomab pasudotox formulation

 13. Subjects who will be or are currently being treated with high dose estrogen (high dose
 is defined as >0.625mg daily as conjugated estrogens or equivalent) within 7 days
 prior to study enrollment