Patient case: 13-year-old male with acute myeloid leukemia; genetic feature: FLT3

Clinical trial: Treosulfan, Fludarabine Phosphate, and Total-Body Irradiation Before Donor Stem Cell Transplant in Treating Patients With High-Risk Acute Myeloid Leukemia, Myelodysplastic Syndrome, Acute Lymphoblastic Leukemia

Summary: This phase II trial is studying how well giving treosulfan together with fludarabine phosphate and total-body irradiation followed by donor stem cell transplant works in treating patients with high-risk acute myeloid leukemia, myelodysplastic syndrome, acute lymphoblastic leukemia. Giving chemotherapy, such as treosulfan and fludarabine phosphate, and total-body irradiation before a donor bone marrow or peripheral blood stem cell transplant helps stop the growth of cancer cells. It may also stop the patient's immune system from rejecting the donor's stem cells. The donated stem cells may replace the patient's immune cells 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 tacrolimus and methotrexate before and after transplant may stop this from happening

Detailed description: PRIMARY OBJECTIVES:
  I. Decrease the incidence of relapse to < 15% at 6 month post transplant in patients with high risk acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS) transplanted from related or unrelated donors, without unacceptably increasing toxicity (10% non-relapse mortality [NRM] at 6 months).
  SECONDARY OBJECTIVES:
  I. Evaluate the incidence of NRM at 180 days and 1 year after hematopoietic cell transplantation (HCT).
  II. Evaluate overall survival (OS) and relapse-free survival (RFS). III. Incidence of grades II-IV acute graft-versus-host disease (GVHD). IV. Incidence of chronic GVHD. V. Donor chimerism on days +28 and +100.
  OUTLINE:
  CONDITIONING REGIMEN: Patients receive fludarabine phosphate intravenously (IV) over 30 minutes on days -6 to day -2 and treosulfan IV over 2 hours on days -6 to day -4. Patients also undergo total-body irradiation on day 0.
  TRANSPLANTATION: Patients undergo allogeneic peripheral blood stem cell transplantation or bone marrow transplantation on day 0.
  GVHD PROPHYLAXIS: Patients receive tacrolimus IV continuously or orally (PO) twice daily (BID) on days -1 to 56, followed by a taper until day 180 in the absence of GVHD. Patients also receive methotrexate IV on days 1, 3, 6, and 11.
  After completion of study treatment, patients are followed up periodically.

Eligibility: Inclusion Criteria:
  -  Acute myeloid leukemia (AML):
  -  All AML patients beyond 1st remission;
  -  Intermediate or high risk AML patients (based on South West Oncology Group [SWOG] cytogenetic criteria) in 1st complete remission
  -  Myelodysplastic syndrome (MDS)
  -  Other myeloid malignancies as chronic myelogenous leukemia (CML), CML accelerated phase, CML blast crisis, chronic myelomonocytic leukemia (CMML) (to be approved by patient care conference [PCC])
  -  With Karnofsky Index or Lansky Play-Performance Scale > 70% on pre-transplant evaluation
  -  Able to give informed consent (if > 18 years), or with a legal guardian capable of giving informed consent (if < 18 years)
  -  Previous autologous or allogeneic HCT is allowed
  -  Donors must be:
  -  Human leukocyte antigen (HLA)-identical related donors or
  -  Unrelated donors matched for HLA-A, B, C, DRB1, and DQB1 defined by high resolution deoxyribonucleic acid (DNA) typing or mismatched for one HLA allele, except for HLA-C where no mismatch is allowed
  -  Able to undergo peripheral blood stem cell collection or bone marrow harvest
  -  In good general health, with a Karnofsky or Lansky Play Performance score > 90%
  -  Able to give informed consent (if > 18 years), or with a legal guardian capable of giving informed consent (if < 18 years)
  -  Acute lymphoblastic leukemia (ALL): all ALL patients not eligible for other protocols
  Exclusion Criteria:
  -  Receiving umbilical cord blood
  -  With impaired cardiac function as evidenced by ejection fraction < 35% or cardiac insufficiency requiring treatment or symptomatic coronary artery disease
  -  With impaired pulmonary function as evidenced by partial pressure of oxygen (pO2) < 70 mm Hg and diffusing capacity of the lung for carbon monoxide (DLCO) < 70% of predicted or pO2 < 80 mm Hg and DLCO < 60% of predicted; or receiving supplementary continuous oxygen
  -  With impaired renal function as evidenced by creatinine-clearance < 50% for age, weight, height or serum creatinine > 2x upper normal limit or dialysis-dependent
  -  With hepatic dysfunction as evidenced by total bilirubin or aspartate aminotransferase (AST) or alanine aminotransferase (ALT) > 2.0 x upper normal limit or evidence of synthetic dysfunction or severe cirrhosis
  -  With active infectious disease requiring deferral of conditioning, as recommended by an Infectious Disease specialist
  -  With human immunodeficiency virus (HIV)-positivity or active infectious hepatitis because of possible risk of lethal infection when treated with immunosuppressive therapy
  -  With central nervous system (CNS) leukemic involvement not clearing with intrathecal chemotherapy and/or cranial radiation prior to initiating conditioning (day -6)
  -  With life expectancy severely limited by diseases other than malignancy
  -  Women who are pregnant or lactating because of possible risk to the fetus or infant
  -  With known hypersensitivity to treosulfan and/or fludarabine
  -  Receiving another experimental drug within 4 weeks before initiation of conditioning (day -6)
  -  Unable to give informed consent (if > 18 years) or with a legal guardian (if < 18 years) unable to give informed consent
  -  Ineligible donors will be those:
  -  Deemed unable to undergo marrow harvesting or PBSC mobilization and leukapheresis
  -  Who are HIV-positive
  -  With active infectious hepatitis
  -  Females with a positive pregnancy test
  -  Unable to give informed consent (if > 18 years) or with a legal guardian (if < 18 years) unable to give informed consent

Relevance to patient case: not relevant