swog-9239 reduction of immunosuppression plus interferon alfa and combination chemotherapy in treating patients with malignant tumors that develop after organ transplant

Conditions: Lymphoma; Multiple Myeloma and Plasma Cell Neoplasm

Summary: rationale: reducing the amount of drugs used to prevent transplant rejection may help a person's body kill tumor cells. giving biological therapy, such as interferon alfa, which may interfere with the growth of cancer cells, or combination chemotherapy, which uses different ways to stop tumor cells from dividing so they stop growing or die, may kill more tumor cells. purpose: phase ii trial to study the effectiveness of reducing immunosuppression, and giving interferon alfa and combination chemotherapy, in treating patients who have malignant tumors that develop after organ transplant.

objectives: i. evaluate the complete remission rate and survival of patients with lymphoproliferation following organ transplantation treated with a defined sequential approach: modification of immunosuppression, with surgery or limited radiotherapy for an isolated site of disease; interferon alfa; and chemotherapy (promace-cytabom; cyclophosphamide, doxorubicin, etoposide, prednisone, cytarabine, bleomycin, vincristine, methotrexate). outline: all patients receive modification of immunocompetence, unless rejection is present at outset. these patients proceed directly to interferon treatment. group 1 (see disease characteristics): patients receive reduced doses of their current immunosuppressive therapy for 10 days. group 2: patients receive reduced doses of some of their current immunosuppressive therapy and discontinue some of the other therapy for 14 days. immunosuppressive therapy then resumes on day 15. immunosuppressive therapy continues throughout other therapy, unless otherwise noted. some patients may then undergo surgery or radiotherapy. interferon therapy: patients receive interferon alfa (ifna) subcutaneously or intramuscularly on days 1-28 for a maximum of 3 courses. patients then receive maintenance therapy with ifna 3 days a week for 4 weeks for up to 6 courses. chemotherapy (promace-cytabom): immunosuppressive therapy is stopped on days 1-20. patients receive cyclophosphamide iv, doxorubicin iv, and etoposide iv over 60 minutes on day 1, oral prednisone on days 1-14, and cytarabine iv, bleomycin iv, vincristine iv, and methotrexate iv on day 8. treatment is repeated every 21 days for up to 6 courses. patients with positive csf cytology receive intrathecal methotrexate or cytarabine on days 1, 3, 5, 7, and 14. some patients may continue this therapy on day 21 , then every 3 weeks for 5 doses, or may receive cranial irradiation. patients are followed monthly for 1 year, every 2 months for 1 year, every 4 months for 1 year, then every 6 months thereafter. projected accrual: a total of 50 patients will be accrued for this study within 4-5 years.

Eligibility criteria:
disease characteristics: histologically proven lymphoproliferation following organ (kidney, liver, or heart) allograft bidimensionally measurable disease if all disease removed at biopsy, eligible only if recurrence is bidimensionally measurable group 1 (clinically urgent disease): histologically proven involvement of the allograft or histologically proven bone marrow involvement or liver involvement with hepatic insufficiency bilirubin greater than upper limit of normal (uln) or sgot or sgpt at least 2 times uln or clinical hepatic encephalopathy or ldh at least 3 times uln or systemic sepsis or locally urgent lesions tonsillar enlargement that threatens airway superior vena cava syndrome bilateral hydronephrosis postobstructive pneumonia or small noncleaved lymphocytic lymphoma (i.e., adult burkitt's lymphoma) group 2: all other patients no cns disease only patient characteristics: age: 15 and over performance status: not specified hematopoietic: not specified hepatic: see disease characteristics renal: not specified cardiovascular: see disease characteristics pulmonary: see disease characteristics other: no known aids, hiv-associated complex, or positive hiv antibody no other malignancy within past 5 years, except: adequately treated basal or squamous cell skin cancer adequately treated stage i or ii cancer or other noninvasive cancers carcinoma in situ of the cervix not pregnant or nursing fertile patients must use effective contraception prior concurrent therapy: biologic therapy: no prior interferon for lymphoma no prior bone marrow transplantation chemotherapy: no prior chemotherapy for lymphoma endocrine therapy: not specified radiotherapy: not specified surgery: see disease characteristics other: intra-aortic balloon pump allowed only for heart failure caused by acute rejection or lymphomatous involvement

Keywords: isolated plasmacytoma of bone extramedullary plasmacytoma refractory multiple myeloma waldenstrom macroglobulinemia stage i multiple myeloma stage ii multiple myeloma stage iii multiple myeloma stage i small lymphocytic lymphoma stage i grade 1 follicular lymphoma stage i grade 2 follicular lymphoma stage i grade 3 follicular lymphoma stage i adult diffuse small cleaved cell lymphoma stage i adult diffuse mixed cell lymphoma stage i adult diffuse large cell lymphoma stage i adult immunoblastic large cell lymphoma stage i adult burkitt lymphoma stage ii small lymphocytic lymphoma stage ii grade 1 follicular lymphoma stage ii grade 2 follicular lymphoma stage ii grade 3 follicular lymphoma stage ii adult diffuse small cleaved cell lymphoma stage ii adult diffuse mixed cell lymphoma stage ii adult diffuse large cell lymphoma stage ii adult immunoblastic large cell lymphoma stage ii adult burkitt lymphoma stage iii small lymphocytic lymphoma stage iii grade 1 follicular lymphoma stage iii grade 2 follicular lymphoma stage iii grade 3 follicular lymphoma stage iii adult diffuse small cleaved cell lymphoma stage iii adult diffuse mixed cell lymphoma stage iii adult diffuse large cell lymphoma stage iii adult immunoblastic large cell lymphoma stage iii adult burkitt lymphoma stage iv small lymphocytic lymphoma stage iv grade 1 follicular lymphoma stage iv grade 2 follicular lymphoma stage iv grade 3 follicular lymphoma stage iv adult diffuse small cleaved cell lymphoma stage iv adult diffuse mixed cell lymphoma stage iv adult diffuse large cell lymphoma stage iv adult immunoblastic large cell lymphoma stage iv adult burkitt lymphoma recurrent small lymphocytic lymphoma recurrent grade 1 follicular lymphoma recurrent grade 2 follicular lymphoma recurrent grade 3 follicular lymphoma recurrent adult diffuse small cleaved cell lymphoma recurrent adult diffuse mixed cell lymphoma recurrent adult diffuse large cell lymphoma recurrent adult immunoblastic large cell lymphoma recurrent adult burkitt lymphoma contiguous stage ii grade 1 follicular lymphoma contiguous stage ii grade 2 follicular lymphoma contiguous stage ii grade 3 follicular lymphoma contiguous stage ii adult diffuse small cleaved cell lymphoma contiguous stage ii adult diffuse mixed cell lymphoma contiguous stage ii adult immunoblastic large cell lymphoma contiguous stage ii adult diffuse large cell lymphoma contiguous stage ii adult burkitt lymphoma noncontiguous stage ii grade 1 follicular lymphoma noncontiguous stage ii grade 2 follicular lymphoma noncontiguous stage ii grade 3 follicular lymphoma noncontiguous stage ii adult diffuse small cleaved cell lymphoma noncontiguous stage ii adult diffuse mixed cell lymphoma noncontiguous stage ii adult immunoblastic large cell lymphoma noncontiguous stage ii adult diffuse large cell lymphoma noncontiguous stage ii adult burkitt lymphoma noncontiguous stage ii small lymphocytic lymphoma noncontiguous stage ii marginal zone lymphoma recurrent marginal zone lymphoma stage i marginal zone lymphoma stage iii marginal zone lymphoma stage iv marginal zone lymphoma contiguous stage ii marginal zone lymphoma contiguous stage ii small lymphocytic lymphoma extranodal marginal zone b-cell lymphoma of mucosa-associated lymphoid tissue nodal marginal zone b-cell lymphoma splenic marginal zone lymphoma