Acute Leukaemia, Chronic Disease, Leukemia, Lymphoma, Myelodysplasia
Conditions
Keywords
cancer, Hematologic Malignancies, Hematopoietic Cell Transplantation
Brief summary
This is a phase II trial of reduced intensity conditioning with Bu/Flu/ATG in pediatric patients with hematologic malignancies at high risk for transplant related mortality with standard transplantation. Patients qualify based on organ system dysfunction, active but stable infection, history of previous transplant or late stage disease. We plan to enroll 45 patients through the Pediatric Blood and Marrow Transplant Consortium (PBMTC) and anticipate that the outcome of the trial will pave the way for phase II or III disease specific protocols addressing efficacy of the approach compared to standard transplant approaches in better risk patients.
Detailed description
Summary/Proposal: Reduced Intensity Hematopoietic Cell Transplantation for High-Risk Relapsed Pediatric Hematologic Malignancies and Patients Ineligible for Standard Transplantation We propose a phase II trial of reduced intensity conditioning with Bu/Flu/ATG in pediatric patients with hematologic malignancies at high risk for transplant related mortality with standard transplantation. Patients qualify based on organ system dysfunction, active but stable infection, history of previous transplant, or late stage disease. We plan to enroll 45 patients through the Pediatric Blood and Marrow transplant Consortium (PBMTC) and anticipate that the outcome of the trial will pave the way for phase II or III disease specific protocols addressing efficacy of the approach compared to standard transplant approaches in better risk patients. Hypothesis High risk pediatric hematologic malignancy patients ineligible for standard myeloablative HCT undergoing reduced intensity conditioning (RIC) HCT can achieve a sustained engraftment rate \> 90% with a 100day TRM \< 30% using either bone marrow or PBSC from related or unrelated donors. High risk pediatric patients undergoing RIC-HCT using related or unrelated cord blood can achieve a sustained engraftment rate \>80% and a 100d TRM \<30%. Rationale for Reduced Intensity Approaches in High Risk Patients There are a number patient-specific risk factors associated with increased transplant related mortality. They can be broadly placed into three categories: pretransplant organ system dysfunction, active infections at the time of transplant, and degree of pretransplant therapy (previous transplants, third or subsequent remission, etc.). The primary objective of this study is to determine the likelihood of achieving sustained donor engraftment using reduced intensity conditioning (fludarabine/busulfan/ATG) followed by hematopoietic cell transplantation (HCT) with either cord blood, bone marrow or peripheral blood stem cells (PBMTC) in pediatric patients with hematopoietic malignancies who are at high risk of transplant related mortality (TRM) with myeloablative HCT. Patients qualify based on organ system dysfunction, active but stable infection, history of previous transplant or late stage disease. We plan to enroll 45 patients through the Pediatric Blood and Marrow Transplant Consortium (PBMTC) and anticipate that the outcome of the trial will pave the way for phase II or III disease specific protocols addressing efficacy of the approach compared to standard transplant approaches in better risk patients. Study procedures Patients receive their conditioning regimen consisting of fludarabine, busulfan, and ATG and then receive their stem cell transplant. Patients receive immunosuppression consisting of cyclosporine and mycophenolate mofetil. Patients with persistent or progressive disease may receive donor lymphocyte infusion off protocol.
Interventions
DRUGBusulfan
This drug is a bifunctional alkylating agent. Busulfan is highly toxic to noncycling or slowly-cycling cells. Pharmacokinetic studies of the IV formulation in pediatrics have shown that using a dose of 0.8mg/kg IV q6 hours most patients will achieve AUC levels between 800 and 1300 uM/min, representing steady state levels between 600-900ug/ml. The manufacturer recommends higher doses, 1.1mg/kg for children less than 12kg. Because this is a reduced intensity study and infants on the study will be very heavily pretreated we will use the lower dose of 0.8mg/kg q6 hours for a total of 8 doses for all patients.
DRUGAnti-Thymocyte Globulin
Thymoglobulin will be administered at a dose of 2.5 mg/kg recipient body weight intravenously on each of 4 successive mornings (Days -4, -3,-2,-1) for patients receiving unrelated grafts and at a dose of 2.5mg/kg as a single dose on d-1 for patients receiving related marrow grafts. ATG is infused over a minimum of 4 hours, but is generally better tolerated over 6-8 hours. Suggested premedications are acetaminophen (10 mg/kg/dose), diphenhydramine (1 mg/kg/dose), and methylprednisolone. The methylprednisolone should be given at a dose of 1mg/kg 30 minutes prior to the ATG, with another 1mg /kg four hours into the infusion (total 2mg/kg/d). Patients are observed continuously for possible allergic reactions throughout the infusion.
DRUGFludarabine
Administration and Dosage: Fludarabine will be administered at a dose of 30 mg/m2 in 100 ml of D5W intravenously over one hour on each of six consecutive days -10 through -5 for unrelated grafts or d-7 through d-2 for related grafts. Fludarabine is a fluorinated nucleotide analog of the antiviral agent vidarabine, 9-beta-D-arabinofuranosyladenine. Fludarabine phosphate is rapidly dephosphorylated to 2-fluoro-ara-A and then phosphorylated intracellularly by deoxycytidine kinase to the active triphosphate, 2-fluoro-ara-ATP. The half-life of 2-fluoro-ara-A is approximately 10 hours. The mean total plasma clearance is 8.9 L/hr/m2 and the mean volume of distribution is 98 L/m2. Approximately 23% is excreted unchanged. This metabolite appears to act by inhibiting DNA polymerase alpha, ribonucleotide reductase and DNA primase, thus inhibiting DNA synthesis.
DRUGCyclosporine
Cyclosporine is a potent immunosuppressive agent that in animals prolongs survival of allogeneic transplants involving skin, kidney, liver, heart, pancreas, bone marrow, small intestine, and lung. The effectiveness of cyclosporine results from specific and reversible inhibition of immunocompetent lymphocytes in the G 0 - and G 1 -phase of the cell cycle. Administration and Dosage: Cyclosporin start on day -3 initially at a dose of 2.5mg/kg IV q12 hours or 3mg/kg/dose (neoral equivalent) PO q12 hours targeting suggested troughs of 250 to 350 ng/ml. Continuous infusion cyclosporin may be allowed per institutional preference. 3x daily dosing may be used for younger children to achieve therapeutic levels. PBMTC Protocol #ONC0313 19 Continuous infusion cyclosporin may be allowed per institutional preference.
DRUGMycophenolate mofetil
MMF is a potent, selective, uncompetitive, and reversible inhibitor of inosine monophosphate dehydrogenase (IMPDH), and therefore inhibits the de novo pathway of guanosine nucleotide synthesis without incorporation into DNA. Administration and Dosage: Initial dosage will be IV or PO with switch to PO when tolerated. Starting doses will be 15 mg/kg/day bid (total dose 30mg/kg/d, IV same as PO dose) beginning day 0 with the first dose given approximately 4-6 hours after the stem cell infusion. This dose will stop on day +30 for patients receiving matched sibling BM/PBSC and UCB grafts, but will continue until day +40 and then taper at approximately 11%/wk over 8 weeks until patients are off at day +96.
Sponsors
University of Utah
Study design
Allocation
NON_RANDOMIZED
Intervention model
SINGLE_GROUP
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
No minimum to 21 Years
Healthy volunteers
No
Inclusion criteria
1. Patients must be age 21 or younger and must have hematologic malignancies treatable with allogeneic hematopoietic transplantation (acute and chronic leukemias, myelodysplasia or lymphomas, see protocol for further details). Patients qualify for this approach in four ways: 1) presence of organ system dysfunction or severe systemic infections that significantly increase transplant related mortality with standard myeloablative transplant regimens, 2) history of previous myeloablative allogeneic or autologous transplantation, 3) currently in a third or higher CR receiving an unrelated stem cell transplant, or 4) a combination of toxicities that leads the investigator to feel that the child is at high risk (\>50%) of TRM. Patients eligible for inclusion based on consideration number 4 above cannot be enrolled unless discussed with the study chair. 2. Organ system dysfunction: at least one of the following organ system dysfunction criteria plus minimum organ function listed in
Exclusion criteria
qualify a patient for treatment on this protocol 1. Pulmonary: DLCO, FEV1 or TLC/FVC \<60% predicted. Patients too young for PFTs with suspected pulmonary toxicity should be assessed by a consulting pulmonologist. If the pulmonologist judges the child to have moderate-severe pulmonary disease they qualify for inclusion. 2. Renal: creatinine clearance \<60ml/m/1.73m2 3. Hepatic: transaminases \>4x normal or total bilirubin \>2.0 4. Cardiac: all patients with suspected cardiac toxicity should undergo a cardiac echo. If the shortening fraction (SF) is \<25% a measurement of ejection fraction must be obtained. Patients qualify for reduced intensity therapy if the SF is \<25% and the EF \<50%. 3. Infections: Patients with responsive but unresolved invasive infections. These infections may be fungal, bacterial or other opportunistic infections. Viral infections do not meet this eligibility criteria. 4. Other patient groups at high risk for transplant related mortality: Patients with a history of a prior allogeneic or autologous transplantation and patients who are in CR3 or greater and receiving an unrelated stem cell transplant are also eligible for this protocol. If the investigator feels that a patient has a combination of risk factors that could increase their risk of transplant related mortality to \>50% with standard transplantation they may be eligible for inclusion, but such patients must be reviewed with the protocol chairman prior to enrollment.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Number of High Risk Pediatric Patients With Successful Sustained Donor Engraftments | 24 months | Assessed donor engraftment in very high risk pediatric patients. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Two Year Overall Survival | 24 months | The probability that a given patient will be alive two years after transplantation. |
| Number of Participants Who Experienced Transplantation-related Mortality (TRM) | 24 months | Cumulative incidence transplantation-related mortality (TRM) |
Countries
United States
Participant flow
Participants by arm
| Arm | Count |
|---|---|
| All Study Participants This group contains data from all groups (Related Bone marrow Peripheral Blood Stem Cell (BM PBSC), Unrelated Peripheral Blood Stem Cell (PBSC), and Unrelated Cord blood. | 47 |
| Total | 47 |
Withdrawals & dropouts
| Period | Reason | FG000 |
|---|---|---|
| Overall Study | Death | 1 |
| Overall Study | Relapse | 2 |
Baseline characteristics
| Characteristic | All Study Participants |
|---|---|
| Age, Categorical <=18 years | 35 Participants |
| Age, Categorical >=65 years | 0 Participants |
| Age, Categorical Between 18 and 65 years | 12 Participants |
| Age Continuous | 13 years STANDARD_DEVIATION 9.899 |
| Region of Enrollment Australia | 4 participants |
| Region of Enrollment Canada | 8 participants |
| Region of Enrollment United States | 35 participants |
| Sex: Female, Male Female | 22 Participants |
| Sex: Female, Male Male | 25 Participants |
Adverse events
| Event type | EG000 affected / at risk |
|---|---|
| deaths Total, all-cause mortality | — / — |
| other Total, other adverse events | 0 / 47 |
| serious Total, serious adverse events | 0 / 47 |
Outcome results
Primary
Number of High Risk Pediatric Patients With Successful Sustained Donor Engraftments
Assessed donor engraftment in very high risk pediatric patients.
Time frame: 24 months
Population: All enrolled patients were analyzed except for the 3 patients who relapsed or died prior to engraftment.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Related BM PBSC | Number of High Risk Pediatric Patients With Successful Sustained Donor Engraftments | 16 participants |
| Unrelated BM PBSC | Number of High Risk Pediatric Patients With Successful Sustained Donor Engraftments | 18 participants |
| Unrelated Cord Blood | Number of High Risk Pediatric Patients With Successful Sustained Donor Engraftments | 10 participants |
Secondary
Number of Participants Who Experienced Transplantation-related Mortality (TRM)
Cumulative incidence transplantation-related mortality (TRM)
Time frame: 24 months
Population: All incidences of enrolled patients were analyzed.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Related BM PBSC | Number of Participants Who Experienced Transplantation-related Mortality (TRM) | 0 participants |
| Unrelated BM PBSC | Number of Participants Who Experienced Transplantation-related Mortality (TRM) | 5 participants |
| Unrelated Cord Blood | Number of Participants Who Experienced Transplantation-related Mortality (TRM) | 1 participants |
Secondary
Two Year Overall Survival
The probability that a given patient will be alive two years after transplantation.
Time frame: 24 months
Population: All enrolled participants were analyzed.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Related BM PBSC | Two Year Overall Survival | 0.501 probability | Standard Error 0.141 |
| Unrelated BM PBSC | Two Year Overall Survival | 0.395 probability | Standard Error 0.12 |
| Unrelated Cord Blood | Two Year Overall Survival | 0.438 probability | Standard Error 0.165 |