Leukemia
Conditions
Keywords
juvenile myelomonocytic leukemia
Brief summary
RATIONALE: Giving chemotherapy drugs, such as cytarabine and mitoxantrone, before a donor stem cell transplant helps stop the growth of cancer cells and helps stop the patient's immune system from rejecting the donor's stem cells. When certain stem cells from a donor are infused into the patient they may help the patient's bone marrow make stem cells, red blood cells, white blood cells, and platelets. Sometimes the transplanted cells from a donor can make an immune response against the body's normal cells. Giving cyclosporine, methotrexate, and methylprednisolone before or after transplant may stop this from happening. PURPOSE: This phase I/II trial is studying the side effects and best way to give high-dose cytarabine together with mitoxantrone in treating patients with juvenile myelomonocytic leukemia undergoing a second donor stem cell transplant.
Detailed description
OBJECTIVES: Primary * To determine the incidence of 1-year disease-free survival in patients with juvenile myelomonocytic leukemia and who is undergoing a repeat stem cell transplantation. Secondary * To evaluate the incidence of regimen-related toxicity. * To evaluate the incidence of acute and chronic graft-versus-host-disease. * To evaluate the incidence of relapse. OUTLINE: * Preparative cytoreductive therapy: Patients receive high-dose cytarabine IV over 2 hours on days -9 to -4 and mitoxantrone hydrochloride IV over 30 minutes on days -9 to -7. * Allogeneic hematopoietic stem cell transplantation (HSCT): Patients undergo HSCT on day 0. Patients undergoing umbilical cord blood transplantation receive methylprednisolone (as graft failure prophylaxis) IV twice daily on days 5 to 19 followed by a taper every other day thereafter until day 25. * Graft-versus-host-disease (GVHD) prophylaxis: Patients receive cyclosporine IV over 2 hours every 8-12 hours or orally twice daily beginning on day -3 and continuing until day 50, followed by a taper to day 90, in the absence of GVHD. Patients undergoing nongenotypically identical bone marrow transplantation also receive methotrexate IV on day 1 beginning 24 hours after completion of stem cell infusion and on days 3, 6, and 11. * Post-transplantation isotretinoin therapy: Patients receive oral isotretinoin once daily beginning on day 60 and continuing until 1 year after HSCT. Patients undergo bone marrow sample collection on day 21, day 60, day 100, at 6 months, and at 1 year for chimerism studies. Patients also undergo blood sample collection periodically to monitor peripheral blood counts for immune reconstitution. After completion of study treatment, patients are followed on day 21, day 100, at 6 months, and at 1 year.
Interventions
DRUGcyclosporine
Patients will receive CSA therapy beginning on day -3, with a taper commencing on day +60 (unless GVHD) and ending on day +90. For patients \>40 kg with normal renal function (creatinine \<1.3 mg/dL), the initial dose will be 2.5 mg/kg intravenously (IV) over 2 hours every 12 hours. For children \<40 kg, the initial dose will be 2.5 mg/kg IV over 2 hours every 8 hours.
DRUGcytarabine
3000 mg/m\^2 intravenously (IV) over 2 hours x 2 (i.e. total 6000 mg/m\^2/day) on days -9 through -4.
DRUGfilgrastim
Patients with absolute neutrophil count (ANC) \<0.2 x 10\^8/L on day 21 may receive G-CSF at 5 mcg/kg/day. G-CSF will be continued until ANC ≥2.5 x 10\^8/L for two consecutive days. As the malignant cell population of JMML is known to be hypersensitive to GM-CSF, this cytokine will not be given to these patients.
DRUGmethotrexate
MTX will be administered to recipients of non-genotypically identical BMT. MTX will be administered at a dose of 15 mg/m\^2 (based on adjusted ideal body weight) intravenously (IV) on day +1 and at a dose of 10 mg/m\^2 IV on days +3, +6, and +11.
DRUGmethylprednisolone
Recipients of UCB will receive methylprednisolone 2 mg/kg/day from day +5 to +19 at a dose of 1 mg/kg twice a day (bid) with a 10% taper every week thereafter.
DRUGmitoxantrone hydrochloride
10 mg/m\^2 over 30 minutes intravenously (IV) on days -9 through -7.
PROCEDUREallogeneic bone marrow transplantation
Donor marrow will be collected in the usual sterile manner with a collection goal of 2.0 \>10\^8/kg recipient weight. Infused on Day 0.
PROCEDUREumbilical cord blood transplantation
Umbilical cord blood (UCB) will be cryopreserved prior to transplantation. Cord blood units will be selected for transplantation according to current University of Minnesota Department of Blood and Marrow Transplantation Guidelines.
Post-Transplant Cis-Retinoic Acid (CRA) Therapy - CRA will be given at a dosage of 100 mg/m\^2/day by mouth in a single daily dose starting on day +60 and continuing until 1 year after transplant.
Sponsors
Masonic Cancer Center, University of Minnesota
Study design
Allocation
NON_RANDOMIZED
Intervention model
SINGLE_GROUP
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
No minimum to 18 Years
Healthy volunteers
No
Inclusion criteria
* Patients age 0-18 with juvenile myelomonocytic leukemia (JMML) who have relapsed or have residual disease after allogeneic HCT. Residual disease is defined as failure to eradicate original disease without prior documentation of remission. Relapse is defined as reappearance of i) leukocytosis with absolute monocytosis \>1 x 10\^8/L, ii) presence of immature myeloid cells in the peripheral circulation in two consecutive bone marrow specimens taken at least one month apart, or iii) presence of clonal cytogenetic abnormality. The diagnosis of relapse will be supported by the return of an abnormal cytogenetic marker (if present at diagnosis) or the presence of host cells by RFLP or other method. * Patients should be at least 6 months from first hematopoietic cell transplant (HCT) if clinically stable. (If JMML is rapidly progressive, second HCT may be performed earlier). * Adequate major organ function including: * Cardiac: ejection fraction ≥45% * Pulmonary: FEV \>50%, DLCO \>50% * Renal: creatinine clearance ≥40 mL/min * Hepatic: no clinical evidence of hepatic failure (e.g. coagulopathy, ascites) * Karnofsky performance status ≥70% or Lansky score ≥50% * Written informed consent.
Exclusion criteria
* Active uncontrolled infection within one week of HCT.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Disease-free Survival | 1 year | Number of patients who were free of disease and alive at 1 year. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Patients With Regimen-Related Toxicity | Up to 30 Days Post Study Treatment | Number of patients with adverse events related to treatment. |
| Patients With Graft-Versus-Host-Disease | Up to 30 Days Post Study Treatment | Number of patients who exhibited acute and/or chronic graft-versus-host disease. |
| Patients Who Relapsed | 1 Year | Number of patients whose disease relapsed. |
Countries
United States
Participant flow
Recruitment details
Only 1 patient was enrolled (yr 1999) and later died (yr 2000). Study was terminated due to low accrual.
Participants by arm
| Arm | Count |
|---|---|
| Cytarabine + Mitoxantrone Patients receive administration of high dose cytosine arabinoside and mitoxantrone followed by hematopoietic cell transplant. | 1 |
| Total | 1 |
Baseline characteristics
| Characteristic | Cytarabine + Mitoxantrone |
|---|---|
| Age, Categorical <=18 years | 1 Participants |
| Age, Categorical >=65 years | 0 Participants |
| Age, Categorical Between 18 and 65 years | 0 Participants |
| Region of Enrollment United States | 1 participants |
| Sex: Female, Male Female | 1 Participants |
| Sex: Female, Male Male | 0 Participants |
Adverse events
| Event type | EG000 affected / at risk |
|---|---|
| deaths Total, all-cause mortality | — / — |
| other Total, other adverse events | 0 / 1 |
| serious Total, serious adverse events | 1 / 1 |
Outcome results
Primary
Disease-free Survival
Number of patients who were free of disease and alive at 1 year.
Time frame: 1 year
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Cytarabine + Mitoxantrone | Disease-free Survival | 0 Participants |
Secondary
Patients Who Relapsed
Number of patients whose disease relapsed.
Time frame: 1 Year
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Cytarabine + Mitoxantrone | Patients Who Relapsed | 1 participants |
Secondary
Patients With Graft-Versus-Host-Disease
Number of patients who exhibited acute and/or chronic graft-versus-host disease.
Time frame: Up to 30 Days Post Study Treatment
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Cytarabine + Mitoxantrone | Patients With Graft-Versus-Host-Disease | 1 participants |
Secondary
Patients With Regimen-Related Toxicity
Number of patients with adverse events related to treatment.
Time frame: Up to 30 Days Post Study Treatment
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Cytarabine + Mitoxantrone | Patients With Regimen-Related Toxicity | 0 participants |