Acute Biphenotypic Leukemia, Acute Erythroid Leukemia in Remission, Acute Leukemia in Remission, Acute Lymphoblastic Leukemia in Remission, Acute Myeloid Leukaemia With Prior Myelodysplastic Syndrome, Acute Myeloid Leukemia in Remission, Acute Myeloid Leukemia With FLT3/ITD Mutation, Acute Myeloid Leukemia With Inv(3)(Q21Q26.2); RPN1-EVI1, Acute Myeloid Leukemia With Multilineage Dysplasia, Acute Myeloid Leukemia With t(6;9), Acute Undifferentiated Leukemia, Adult Acute Lymphoblastic Leukemia in Complete Remission, B Acute Lymphoblastic Leukemia With T(1;19)(Q23;P13.3); E2A-PBX1 (TCF3-PBX1), Blasts Under 5 Percent of Bone Marrow Nucleated Cells, Burkitt Lymphoma, Childhood Acute Lymphoblastic Leukemia in Complete Remission, DS Stage III Plasma Cell Myeloma, DS Stage II Plasma Cell Myeloma, Hematopoietic Cell Transplant Recipient, Myelodysplastic Syndrome, Ph+ ALL, Recurrent Anaplastic Large Cell Lymphoma, Recurrent Follicular Lymphoma, Recurrent Hodgkin Lymphoma, Recurrent Mantle Cell Lymphoma, Recurrent Marginal Zone Lymphoma, Recurrent Plasma Cell Myeloma, Refractory Plasma Cell Myeloma, Secondary Acute Myeloid Leukemia, T Lymphoblastic Lymphoma
Conditions
Brief summary
This phase II trial studies how well donor peripheral blood stem cell (PBSC) transplant works in treating patients with hematologic malignancies. Cyclophosphamide when added to tacrolimus and mycophenolate mofetil is safe and effective in preventing severe graft-versus-host disease (GVHD) in most patients with hematologic malignancies undergoing transplantation of bone marrow from half-matched (haploidentical) donors. This approach has extended the transplant option to patients who do not have matched related or unrelated donors, especially for patients from ethnic minority groups. The graft contains cells of the donor's immune system which potentially can recognize and destroy the patient's cancer cells (graft-versus-tumor effect). Rejection of the donor's cells by the patient's own immune system is prevented by giving low doses of chemotherapy (fludarabine phosphate and cyclophosphamide) and total-body irradiation before transplant. Patients can experience low blood cell counts after transplant. Using stem cells and immune cells collected from the donor's circulating blood may result in quicker recovery of blood counts and may be more effective in treating the patient's disease than using bone marrow.
Detailed description
PRIMARY OBJECTIVES: I. To demonstrate that use of PBSC in place of marrow as the source of lymphocytes and stem cells for nonmyeloablative transplants from related, haploidentical donors will not result in unacceptable rates of high-grade acute or chronic GVHD, non-relapse mortality or relapse compared to historical data on nonmyeloablative transplants from unrelated donors. SECONDARY OBJECTIVES: I. Estimates of the rates of neutrophil and platelet recovery, number of red blood cell (RBC) and platelet transfusions, incidences of graft failure, transplant-related toxicities, disease-free survival and overall survival. OUTLINE: Patients receive fludarabine intravenously (IV) over 30-60 minutes daily on days -6 through -2 and cyclophosphamide IV over 1-2 hours on days -6, -5, and 3-4. Patients undergo total-body irradiation on day -1. Patients undergo donor peripheral blood stem cell transplant on day 0. Patients then receive tacrolimus IV once daily or orally (PO) twice daily (BID) on days 5-180 (may be continued if active GVHD is present), mycophenolate mofetil IV or PO thrice daily (TID) on days 5-35 (may be continued if GVHD present), and filgrastim IV beginning on day 5 until the absolute neutrophil count (ANC) is \>= 1,000/mm\^3 for three consecutive days. Treatment continues in the absence of disease progression or unacceptable toxicity.
Interventions
Given IV
Given SQ
Given IV
Given PO
Undergo PBSC
Undergo PBSC
Given IV or PO
Undergo total-body irradiation (TBI)
Sponsors
Study design
Eligibility
Inclusion criteria
* Molecular based human leukocyte antigen (HLA) typing will be performed for the HLA-A, -B, -Cw, -DRB1 and -DQB1 loci to the resolution adequate to establish haplo-identity; a minimum match of 5/10 is required; an unrelated donor search is not required for a patient to be eligible for this protocol if the clinical situation dictates an urgent transplant; clinical urgency is defined as 6-8 weeks from referral or low-likelihood of finding a matched, unrelated donor * Acute leukemias (includes T lymphoblastic lymphoma); remission is defined as \< 5% blasts with no morphological characteristics of acute leukemia (e.g., Auer rods) in a bone marrow with \> 20% cellularity, peripheral blood counts showing ANC \> 1000/ul, including patients in complete remission with incomplete platelet recovery (CRp); if the marrow has \< 20% cellularity due to treatment related cytotoxicity, but still has \< 5% blasts, an exception may be made to include this patient up to principal investigator (PI) discretion * Acute lymphoblastic leukemia in high risk first complete remission (CR1) as defined by at least one of the following: * Adverse cytogenetics including but not limited to t(9;22), t(1;19), t(4;11), mixed lineage leukemia (MLL) rearrangements * White blood cell counts \> 30,000/mcL * Patients over 30 years of age * Time to complete remission \> 4 weeks * Presence of extramedullary disease * Minimal residual disease * Other risk factors determined by the patient's attending physician to be high risk features requiring transplantation * Acute myelogenous leukemia in high risk CR1 as defined by at least one of the following: * Greater than 1 cycle of induction therapy required to achieve remission * Preceding myelodysplastic syndrome (MDS) * Presence of fms-like tyrosine kinase receptor-3 (Flt3) abnormalities * French-American-British (FAB) M6 or M7 leukemia, or * Adverse cytogenetics for overall survival such as: * Those associated with MDS * Complex karyotype (\>= 3 abnormalities); or * Any of the following: inv(3) or t(3;3), t(6;9), t(6;11), + 8 \[alone or with other abnormalities except for t(8;21), t(9;11), inv(16) or t(16;16)\], t(11;19)(q23;p13.1)\] * Other risk factors determined by the patient's attending physician to be high risk features requiring transplantation * Acute leukemias in second (2nd) or subsequent remission * Biphenotypic/undifferentiated leukemias in first (1st) or subsequent complete remission (CR) * High-risk MDS status-post cytotoxic chemotherapy * Burkitt's lymphoma: second or subsequent CR * Chemotherapy-sensitive (at least stable disease) large cell, mantle cell or Hodgkin's lymphomas that have failed at least 1 prior regimen of multi-agent chemotherapy and are ineligible for an autologous transplant * Marginal zone B-cell lymphoma or follicular lymphoma that has progressed after at least two prior therapies (excluding single agent Rituxan) * Multiple myeloma (MM) stage II or III patients who have progressed after an initial response to chemotherapy or autologous hematopoietic stem cell transplantation (HSCT) or MM patients with refractory disease who may benefit from tandem autologous-nonmyeloablative allogeneic transplant * Left ventricular ejection fraction at rest must be \>= 35% * Bilirubin =\< 2.5 mg/dL * Alanine aminotransferase (ALT) \< 5 x upper limit of normal (ULN) * Aspartate aminotransferase (AST) \< 5 x ULN * Alkaline phosphatase \< 5 x ULN * Serum creatinine within normal range for age, or if serum creatinine outside normal range for age, then renal function (creatinine clearance or glomerular filtration rate \[GFR\]) \> 40 mL/min/1.73m\^2 * Forced expiratory volume in one second (FEV1), forced vital capacity (FVC), diffusion capacity of carbon monoxide (DLCO) (diffusion capacity) \>= 40% predicted (corrected for hemoglobin); if unable to perform pulmonary function tests, then oxygen (O2) saturation \> 92% on room air * Karnofsky/Lansky score \>= 60% * Patients who have received a prior allogeneic HSCT and who have either rejected their grafts or who have become tolerant of their grafts with no active GVHD requiring immunosuppressive therapy * Patients will undergo standard pre-transplant work-up as dictated by standard practice guidelines the results of which may be used for screening for this study * DONOR: Donors must be HLA-haploidentical first-degree relatives of the patient; eligible donors include biological parents, siblings, or children, or half-siblings * DONOR: Age \>= 12 years * DONOR: Weight \>= 40 kg * DONOR: Ability of donors \< 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 at the Seattle Cancer Care Alliance (SCCA) * DONOR: Donors must meet the selection criteria as defined by the Foundation for the Accreditation of Cell Therapy (FACT) and will be screened per the American Association of Blood Banks (AABB) guidelines
Exclusion criteria
* HLA-matched or single allele-mismatched donor able to donate * Pregnancy or breast-feeding * Current uncontrolled bacterial, viral or fungal infection (currently taking medication with evidence of progression of clinical symptoms or radiologic findings) * Patients with primary idiopathic myelofibrosis * DONOR: Positive anti-donor HLA antibody
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Non-relapse Mortality at 1 Year | Up to 1 year | Cumulative incidence of death without evidence of disease progression at 1 year |
| Percentage of Participants With Chronic Graft Versus Host Disease | Up to 2 years post-transplant | Scored according to the National Cancer Institute criteria. Mild-to-severe chronic GVHD at 2 years. |
| Incidence of Grades III/IV Acute Graft Versus Host Disease | At day 84 | Grading determined by organ system stages. Grade III/IV acute graft versus host disease is defined as skin: stage IV, liver: stages II-IV, and/or gastrointestinal tract: stages II-IV. |
| Relapse of Malignancy After Transplantation | Up to 7 years | Defined by either morphological or cytogenetic evidence of acute leukemia consistent with pre-transplant features, or radiologic evidence of lymphoma progression. When in doubt, the diagnosis of recurrent or progressive lymphoma should be documented by tissue biopsy. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Toxicity of Treatment Regimen Determined by Number of Adverse Events Per Organ System | Up to day 90 | Assessed by Common Terminology Criteria for Adverse Events version 3.0. The incidence of all adverse events greater or equal to grade 3 was determined. |
| Number of Red Blood Cell Transfusions | Day 0-100 | Number of units of RBCs given to the patient between day 0 and day 100 post transplant |
| Time to Neutrophil Recovery | Up to day 84 post-transplant | Achievement of an absolute neutrophil count greater or equal to 500/mm\^3 for three consecutive measurements on different days. The first of the three days will be designated the day of neutrophil recovery. |
| Point Estimate of Overall Survival at 3 Years | 3 years | Kaplan Meier estimate of the percentage of participants with overall survival at 3 years |
| Number of Platelet Transfusions | Day 0-100 | Number platelet transfusions given to the patient between day 0 and day 100 post transplant |
| Time to Platelet Recovery | Up to day 84 post-transplant | The first day of a sustained platelet count \> 20,000/mm\^3 with no platelet transfusions in the preceding seven days. |
| Incidence of Primary Graft Failure | At day 84 | Defined as \< 5% donor CD3 chimerism. Chimerism will be measured by short tandem repeat-polymerase chain reaction on peripheral blood sorted into CD3 and CD33 cell fractions. |
| Disease-free Survival | 3 years from the date of transplant | Defined as being alive and in remission by \< 5% blasts by bone marrow morphology for patients with myeloid malignancies and CT or PET imaging for patients with lymphoid malignancies at the time of the assessment |
Countries
United States
Participant flow
Participants by arm
| Arm | Count |
|---|---|
| Treatment (Nonmyeloablative HCT, TBI) Patients receive fludarabine IV over 30-60 minutes daily on days -6 through -2 and cyclophosphamide IV over 1-2 hours on days -6, -5, and 3-4. Patients undergo total-body irradiation on day -1. Patients undergo donor peripheral blood stem cell transplant on day 0. Patients then receive tacrolimus IV once daily or PO BID on days 5-180 (may be continued if active GvHD is present), mycophenolate mofetil IV or PO TID on days 5-35 (may be continued if GvHD present), and filgrastim IV beginning on day 5 until the ANC is \>= 1,000/mm\^3 for three consecutive days. | 45 |
| Total | 45 |
Withdrawals & dropouts
| Period | Reason | FG000 |
|---|---|---|
| Overall Study | Physician Decision | 1 |
Baseline characteristics
| Characteristic | Treatment (Nonmyeloablative HCT, TBI) |
|---|---|
| Age, Continuous | 52 years |
| Ethnicity (NIH/OMB) Hispanic or Latino | 4 Participants |
| Ethnicity (NIH/OMB) Not Hispanic or Latino | 29 Participants |
| Ethnicity (NIH/OMB) Unknown or Not Reported | 12 Participants |
| Race (NIH/OMB) American Indian or Alaska Native | 1 Participants |
| Race (NIH/OMB) Asian | 7 Participants |
| Race (NIH/OMB) Black or African American | 4 Participants |
| Race (NIH/OMB) More than one race | 0 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 1 Participants |
| Race (NIH/OMB) White | 32 Participants |
| Sex: Female, Male Female | 19 Participants |
| Sex: Female, Male Male | 26 Participants |
Adverse events
| Event type | EG000 affected / at risk |
|---|---|
| deaths Total, all-cause mortality | 21 / 45 |
| other Total, other adverse events | 44 / 45 |
| serious Total, serious adverse events | 4 / 45 |
Outcome results
Incidence of Grades III/IV Acute Graft Versus Host Disease
Grading determined by organ system stages. Grade III/IV acute graft versus host disease is defined as skin: stage IV, liver: stages II-IV, and/or gastrointestinal tract: stages II-IV.
Time frame: At day 84
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Treatment (Nonmyeloablative HCT, TBI) | Incidence of Grades III/IV Acute Graft Versus Host Disease | 82 percent |
Non-relapse Mortality at 1 Year
Cumulative incidence of death without evidence of disease progression at 1 year
Time frame: Up to 1 year
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Treatment (Nonmyeloablative HCT, TBI) | Non-relapse Mortality at 1 Year | 22 percent of participants |
Percentage of Participants With Chronic Graft Versus Host Disease
Scored according to the National Cancer Institute criteria. Mild-to-severe chronic GVHD at 2 years.
Time frame: Up to 2 years post-transplant
Population: Patients who were alive greater than day 100 were included
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Treatment (Nonmyeloablative HCT, TBI) | Percentage of Participants With Chronic Graft Versus Host Disease | 26 percentage of participants |
Relapse of Malignancy After Transplantation
Defined by either morphological or cytogenetic evidence of acute leukemia consistent with pre-transplant features, or radiologic evidence of lymphoma progression. When in doubt, the diagnosis of recurrent or progressive lymphoma should be documented by tissue biopsy.
Time frame: Up to 7 years
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Treatment (Nonmyeloablative HCT, TBI) | Relapse of Malignancy After Transplantation | 29 percent |
Disease-free Survival
Defined as being alive and in remission by \< 5% blasts by bone marrow morphology for patients with myeloid malignancies and CT or PET imaging for patients with lymphoid malignancies at the time of the assessment
Time frame: 3 years from the date of transplant
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Treatment (Nonmyeloablative HCT, TBI) | Disease-free Survival | 40 percent of participants |
Incidence of Primary Graft Failure
Defined as \< 5% donor CD3 chimerism. Chimerism will be measured by short tandem repeat-polymerase chain reaction on peripheral blood sorted into CD3 and CD33 cell fractions.
Time frame: At day 84
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Treatment (Nonmyeloablative HCT, TBI) | Incidence of Primary Graft Failure | 0 Participants |
Number of Platelet Transfusions
Number platelet transfusions given to the patient between day 0 and day 100 post transplant
Time frame: Day 0-100
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Treatment (Nonmyeloablative HCT, TBI) | Number of Platelet Transfusions | 6 transfusions |
Number of Red Blood Cell Transfusions
Number of units of RBCs given to the patient between day 0 and day 100 post transplant
Time frame: Day 0-100
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Treatment (Nonmyeloablative HCT, TBI) | Number of Red Blood Cell Transfusions | 8 transfusions |
Point Estimate of Overall Survival at 3 Years
Kaplan Meier estimate of the percentage of participants with overall survival at 3 years
Time frame: 3 years
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Treatment (Nonmyeloablative HCT, TBI) | Point Estimate of Overall Survival at 3 Years | 45.3 percent |
Time to Neutrophil Recovery
Achievement of an absolute neutrophil count greater or equal to 500/mm\^3 for three consecutive measurements on different days. The first of the three days will be designated the day of neutrophil recovery.
Time frame: Up to day 84 post-transplant
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Treatment (Nonmyeloablative HCT, TBI) | Time to Neutrophil Recovery | 16 days |
Time to Platelet Recovery
The first day of a sustained platelet count \> 20,000/mm\^3 with no platelet transfusions in the preceding seven days.
Time frame: Up to day 84 post-transplant
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Treatment (Nonmyeloablative HCT, TBI) | Time to Platelet Recovery | 23 days |
Toxicity of Treatment Regimen Determined by Number of Adverse Events Per Organ System
Assessed by Common Terminology Criteria for Adverse Events version 3.0. The incidence of all adverse events greater or equal to grade 3 was determined.
Time frame: Up to day 90
| Arm | Measure | Group | Value (NUMBER) |
|---|---|---|---|
| Treatment (Nonmyeloablative HCT, TBI) | Toxicity of Treatment Regimen Determined by Number of Adverse Events Per Organ System | CMV Reactivation | 26 events |
| Treatment (Nonmyeloablative HCT, TBI) | Toxicity of Treatment Regimen Determined by Number of Adverse Events Per Organ System | Febrile Neutropenia | 25 events |
| Treatment (Nonmyeloablative HCT, TBI) | Toxicity of Treatment Regimen Determined by Number of Adverse Events Per Organ System | Cardiac | 13 events |
| Treatment (Nonmyeloablative HCT, TBI) | Toxicity of Treatment Regimen Determined by Number of Adverse Events Per Organ System | Fever | 9 events |
| Treatment (Nonmyeloablative HCT, TBI) | Toxicity of Treatment Regimen Determined by Number of Adverse Events Per Organ System | Rash | 4 events |
| Treatment (Nonmyeloablative HCT, TBI) | Toxicity of Treatment Regimen Determined by Number of Adverse Events Per Organ System | Gastrointestinal | 17 events |
| Treatment (Nonmyeloablative HCT, TBI) | Toxicity of Treatment Regimen Determined by Number of Adverse Events Per Organ System | Infections | 55 events |
| Treatment (Nonmyeloablative HCT, TBI) | Toxicity of Treatment Regimen Determined by Number of Adverse Events Per Organ System | Metabolic/laboratory | 24 events |
| Treatment (Nonmyeloablative HCT, TBI) | Toxicity of Treatment Regimen Determined by Number of Adverse Events Per Organ System | Musculoskeletal | 3 events |
| Treatment (Nonmyeloablative HCT, TBI) | Toxicity of Treatment Regimen Determined by Number of Adverse Events Per Organ System | Neurologic | 5 events |
| Treatment (Nonmyeloablative HCT, TBI) | Toxicity of Treatment Regimen Determined by Number of Adverse Events Per Organ System | Pain | 6 events |
| Treatment (Nonmyeloablative HCT, TBI) | Toxicity of Treatment Regimen Determined by Number of Adverse Events Per Organ System | Pulmonary | 10 events |
| Treatment (Nonmyeloablative HCT, TBI) | Toxicity of Treatment Regimen Determined by Number of Adverse Events Per Organ System | Renal/Genitourinary | 10 events |