Alemtuzumab Plus Fludarabine and Melphalan With or Without Cyclosporine, Mycophenolate Mofetil, and Low-Dose Total-Body Irradiation Therapy Followed by Donor Peripheral Stem Cell Transplant in Treating Patients With Hematologic Cancer
Study Details
Study Description
Brief Summary
RATIONALE: Giving low doses of chemotherapy, monoclonal antibodies, and radiation therapy before a donor peripheral blood stem cell transplant helps stop the growth of cancer cells. It also stops the patient's immune system from rejecting the donor's stem cells when they do not exactly match the patient's blood. The donated stem cells may replace the patient's immune system and help destroy any remaining cancer cells (graft-versus-tumor effect). Sometimes the transplanted cells from a donor can also make an immune response against the body's normal cells. Giving cyclosporine and mycophenolate mofetil before transplant may stop this from happening.
PURPOSE: This phase I/II trial is studying the side effects of alemtuzumab, fludarabine, and melphalan with or without cyclosporine, mycophenolate mofetil, and total-body irradiation before donor peripheral blood stem cell transplant and to see how well they work in treating patients with relapsed or refractory hematologic cancer.
Condition or Disease | Intervention/Treatment | Phase |
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Phase 1/Phase 2 |
Detailed Description
OBJECTIVES:
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Determine the ability of a reduced-intensity conditioning regimen comprising alemtuzumab, fludarabine, and melphalan with or without cyclosporine, mycophenolate mofetil, and low-dose total body radiotherapy followed by haplotype-mismatched, KIR class I epitope-mismatched CD34-positive allogeneic peripheral blood stem cell transplantation to facilitate engraftment by day 35 post-transplantation in at least 85% of patients with relapsed, refractory, or poor-risk hematological malignancies.
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Determine the risk of graft-versus-host-disease in patients treated with these regimens.
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Determine, preliminarily, the efficacy of these regimens, in terms of progression-free survival, in these patients.
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Correlate outcomes, engraftment, and progression-free survival with the number of detectable alloreactive natural killer cell clones before transplantation and after engraftment in patients treated with these regimens.
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Determine immune reconstitution in patients treated with these regimens.
OUTLINE: This is a multicenter, pilot study. Patients are initially treated with conditioning regimen A. If adequate donor engraftment is not achieved, subsequent patients are treated with conditioning regimen B.
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Conditioning regimen A: Patients receive alemtuzumab IV over 2 hours on days -14 to -12; fludarabine IV over 30 minutes on days -7 to -3; and melphalan IV over 20-30 minutes on day -2.
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Conditioning regimen B: Patients receive oral or IV cyclosporine twice daily and oral or IV mycophenolate mofetil twice daily on days -15 to 0. Patients also receive alemtuzumab, fludarabine, and melphalan as in conditioning regimen A. Patients undergo low-dose total body irradiation twice daily on days -2 and -1.
All patients undergo allogeneic, T-cell-depleted, CD34-positive peripheral blood stem cell transplantation on day 0. Patients receive sargramostim (GM-CSF) subcutaneously beginning on day 1 and continuing until blood counts recover.
Patients are followed every 3 months for 1 year and then every 6 months for 5 years.
PROJECTED ACCRUAL: A total of 14-56 patients (14-28 per regimen) will be accrued for this study.
Study Design
Arms and Interventions
Arm | Intervention/Treatment |
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Experimental: Regimen A + B Conditioning regimen A: Patients receive alemtuzumab IV over 2 hours on days -14 to -12; fludarabine IV over 30 minutes on days -7 to -3; and melphalan IV over 20-30 minutes on day -2. Conditioning regimen B: Patients receive oral or IV cyclosporine twice daily and oral or IV mycophenolate mofetil twice daily on days -15 to 0. Patients also receive alemtuzumab, fludarabine, and melphalan as in conditioning regimen A. Patients undergo low-dose total body irradiation twice daily on days -2 and -1. All patients undergo allogeneic, T-cell-depleted, CD34-positive peripheral blood stem cell transplantation on day 0. Patients receive sargramostim (GM-CSF) subcutaneously beginning on day 1 and continuing until blood counts recover. Patients are followed every 3 months for 1 year and then every 6 months for 5 years. |
Biological: alemtuzumab
Drug: cyclosporine
Drug: fludarabine phosphate
Drug: melphalan
Drug: mycophenolate mofetil
Procedure: peripheral blood stem cell transplantation
Radiation: radiation therapy
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Outcome Measures
Primary Outcome Measures
- Engraftment rate [Up to 6 years]
- Risk of graft-vs-host disease [Up to 6 years]
- Progression-free survival (PFS) [Up to 6 years]
Eligibility Criteria
Criteria
DISEASE CHARACTERISTICS:
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Histologically confirmed hematological malignancy of 1 of the following types:
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Acute myeloid leukemia meeting at least 1 of the following criteria:
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Poor-risk cytogenetics, including -5, 5q-, -7, 7q-, 11q23, and Philadelphia (Ph) chromosome-positive in first or subsequent complete remission (CR)
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Relapsed or primary refractory disease with ≤ 10% blasts in the peripheral blood and ≤ 20% blasts in the bone marrow
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Standard-risk cytogenetics in second CR AND autologous transplantation is not feasible
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Standard-risk cytogenetics in third or subsequent CR
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Acute lymphoblastic leukemia meeting 1 of the following criteria:
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Second or subsequent CR
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High-risk cytogenetics, including Ph chromosome-positive and t(4:11) in first CR
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Relapsed or primarily refractory disease with ≤ 10% blasts in the peripheral blood and ≤ 20% blasts in the bone marrow
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High-risk myelodysplasia
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International Prognostic Scoring System Score ≥ 2.5
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Chronic myeloid leukemia (CML)* with an inadequate response to imatinib meeting 1 of the following criteria:
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Second or subsequent chronic phase
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Accelerated phase NOTE: *Patients with CML in blast crisis (> 30% promyelocytes and myeloblasts in the bone marrow) are not eligible
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Non-Hodgkin's lymphoma meeting 1 of the following criteria:
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Primarily refractory disease or in refractory relapse
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Relapsed disease after autologous stem cell transplantation
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Chemosensitive relapsed disease without CR to standard salvage therapy AND no option for autologous stem cell transplantation due to blood or marrow involvement or failure to harvest sufficient autologous stem cells
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Chronic lymphocytic leukemia meeting both of the following criteria:
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Stage III or IV disease
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Refractory to fludarabine
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Multiple myeloma meeting 1 of the following criteria:
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Primarily refractory disease or in refractory relapse
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Relapsed disease after autologous stem cell transplantation
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No relapsed disease < 6 months after autologous stem cell transplantation
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No available eligible HLA-matched (i.e., 5 of 6 or 6 of 6 antigen match for HLA-A, -B, and -DR loci) family donor by serological or molecular typing
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Available suitable family donor meeting the following criteria:
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Parent, sibling, or child of the recipient
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≥ 16 years of age
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Identical for only one HLA haplotype (i.e., haploidentical) AND incompatible at the HLA-A, -B, -C, and -DR loci of the unshared haplotype by serological or molecular typing
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Mismatched with respect to KIR class I epitopes graft-vs-host directional activity
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Mismatching that predicts both graft-vs-host and host-vs-graft bi-directional activity eligible
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No mismatching that predicts only host-vs-graft directional activity
PATIENT CHARACTERISTICS:
Age
- 18 to 60
Performance status
- ECOG 0-1
Hepatic
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Bilirubin < 2 times upper limit of normal (ULN)
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AST and ALT < 2 times ULN
Renal
- Creatinine ≤ 2 mg/dL
Cardiovascular
- LVEF > 40% (corrected)
Pulmonary
- DLCO > 50% of predicted
Other
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No active infection requiring oral or IV antibiotics
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HIV negative
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Not pregnant or nursing
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Negative pregnancy test
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Fertile patients must use effective contraception
PRIOR CONCURRENT THERAPY:
Biologic therapy
- See Disease Characteristics
Chemotherapy
- See Disease Characteristics
Endocrine therapy
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Concurrent corticosteroids allowed for adrenal failure, treatment of graft-vs-host disease, or as premedication during study
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No concurrent corticosteroids for antiemesis
Contacts and Locations
Locations
Site | City | State | Country | Postal Code | |
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1 | Moores UCSD Cancer Center | La Jolla | California | United States | 92093-0658 |
2 | Samuel Oschin Comprehensive Cancer Institute at Cedars-Sinai Medical Center | Los Angeles | California | United States | 90048 |
3 | UCSF Comprehensive Cancer Center | San Francisco | California | United States | 94115 |
4 | CCOP - Christiana Care Health Services | Newark | Delaware | United States | 19713 |
5 | Lombardi Comprehensive Cancer Center at Georgetown University Medical Center | Washington | District of Columbia | United States | 20007 |
6 | University of Chicago Cancer Research Center | Chicago | Illinois | United States | 60637-1470 |
7 | Holden Comprehensive Cancer Center at University of Iowa | Iowa City | Iowa | United States | 52242-1009 |
8 | Massachusetts General Hospital Cancer Center | Boston | Massachusetts | United States | 02114 |
9 | Dana-Farber/Harvard Cancer Center at Dana Farber Cancer Institute | Boston | Massachusetts | United States | 02115 |
10 | University of Minnesota Cancer Center | Minneapolis | Minnesota | United States | 55455 |
11 | Siteman Cancer Center at Barnes-Jewish Hospital | Saint Louis | Missouri | United States | 63110 |
12 | UNMC Eppley Cancer Center at the University of Nebraska Medical Center | Omaha | Nebraska | United States | 68198-7680 |
13 | St. Joseph's Hospital and Medical Center | Paterson | New Jersey | United States | 07503 |
14 | Roswell Park Cancer Institute | Buffalo | New York | United States | 14263-0001 |
15 | Don Monti Comprehensive Cancer Center at North Shore University Hospital | Manhasset | New York | United States | 11030 |
16 | Memorial Sloan-Kettering Cancer Center | New York | New York | United States | 10021 |
17 | Mount Sinai Medical Center | New York | New York | United States | 10029 |
18 | Lineberger Comprehensive Cancer Center at University of North Carolina - Chapel Hill | Chapel Hill | North Carolina | United States | 27599-7295 |
19 | Duke Comprehensive Cancer Center | Durham | North Carolina | United States | 27710 |
20 | Wake Forest University Comprehensive Cancer Center | Winston-Salem | North Carolina | United States | 27157-1082 |
21 | Arthur G. James Cancer Hospital and Solove Research Institute at Ohio State University | Columbus | Ohio | United States | 43210-1240 |
22 | Western Pennsylvania Cancer Institute at Western Pennsylvania Hospital | Pittsburgh | Pennsylvania | United States | 15224 |
23 | Hollings Cancer Center at Medical University of South Carolina | Charleston | South Carolina | United States | 29425 |
24 | Virginia Commonwealth University Massey Cancer Center | Richmond | Virginia | United States | 23298-0037 |
Sponsors and Collaborators
- Alliance for Clinical Trials in Oncology
- National Cancer Institute (NCI)
Investigators
- Study Chair: Sherif S. Farag, MD, PhD, Indiana University Melvin and Bren Simon Cancer Center
Study Documents (Full-Text)
None provided.More Information
Publications
None provided.- CALGB-100102
- CALGB-100102
- CDR0000370797