Patient case: 4-year-old female with leukemia; genetic feature: ABL1

Clinical trial: Donor Atorvastatin Treatment in Preventing Severe Acute GVHD After Nonmyeloablative Peripheral Blood Stem Cell Transplant in Patients With Hematological Malignancies

Summary: This phase II trial studies how well donor atorvastatin treatment works in preventing severe graft-versus-host disease (GVHD) after nonmyeloablative peripheral blood stem cell (PBSC) transplant in patients with hematological malignancies. Giving low doses of chemotherapy, such as fludarabine phosphate, before a donor PBSC transplantation slows the growth of cancer cells and may also prevent 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 cause an immune response against the body's normal cells (GVHD). Giving atorvastatin to the donor before transplant may prevent severe GVHD.

Detailed description: PRIMARY OBJECTIVES:
  I. To assess whether 2 weeks of donor statin treatment reduces the risk of severe acute GVHD.
  SECONDARY OBJECTIVES:
  I. To assess whether 2 weeks of statin treatment of normal PBSC donors is feasible, tolerable and safe.
  OUTLINE:
  DONOR: Donors receive atorvastatin orally (PO) once daily (QD) beginning on day -14 and continuing until the last day of stem cell collection.
  NONMYELOABLATIVE PREPARATIVE REGIMEN: If the patient is enrolled on an investigational nonmyeloablative hematopoietic cell transplant (HCT) protocol or a treatment plan that uses a nonmyeloablative preparative regimen with postgrafting cyclosporine (CSP) that does not use acute GVHD as its primary endpoint, the preparative regimen and immunosuppression after transplant will be according to respective protocol or treatment plan (Protocol 2546 serves as adjunct protocol).
  If the patient is not enrolled on an investigational nonmyeloablative HCT protocol or a treatment plan that uses a nonmyeloablative preparative regimen, Protocol 2546 serves as an independent primary treatment protocol. The preparative regimen and immunosuppression after transplant is as follows:
  Patients receive fludarabine phosphate intravenously (IV) on days -4 to -2 (except for patients who had prior autologous HCT or equivalent high-dose therapy without HCT) and undergo low-dose total body irradiation (TBI) on day 0.
  TRANSPLANT: Patients undergo donor PBSC transplant on day 0.
  POST-GRAFTING IMMUNOSUPPRESSION: Patients receive CSP PO twice daily (BID) on days -3 to +56 with taper to day +180. Patients also receive mycophenolate mofetil (MMF) PO BID or IV every 12 hours on days 0-27.
  After completion of study treatment, patients are followed up at 1 year and then annually thereafter.

Eligibility: Inclusion Criteria:
  -  IF PROTOCOL 2546 SERVES AS AN ADJUNCT PROTOCOL, THE PATIENTS ONLY NEEDS TO MEET INCLUSION CRITERIA 1 THROUGH 5A
  -  Availability of human leukocyte antigen (HLA)-identical sibling donor
  -  Transplantation with PBSC
  -  CSP-based postgrafting immunosuppression
  -  Willingness to give informed consent
  -  Patient is enrolled on an investigational nonmyeloablative HCT protocol or a nonmyeloablative treatment plan with postgrafting CSP that does not use acute GVHD as its primary endpoint (protocol 2546 serves as adjunct protocol); OR
  -  Patient is not enrolled on an investigational nonmyeloablative HCT protocol, in which case protocol 2546 serves as an independent primary treatment protocol and the patient must meet the following inclusion and exclusion criteria:
  -  Patients must have a hematologic malignancy treatable by nonmyeloablative HCT; the following diseases will be permitted although other diagnoses can be considered if approved by Patient Care Conference (PCC) and the principal investigator:
  -  Aggressive non-Hodgkin lymphomas (NHL) and other histologies such as diffuse large B-cell NHL - not eligible for autologous HCT, not eligible for high-dose allogeneic HCT, or after failed autologous HCT
  -  Mantle-cell NHL - may be treated in first complete remission (CR); (diagnostic lumbar puncture [LP] required pre-transplant)
  -  Low grade NHL - with < 6 month duration of CR between courses of conventional therapy
  -  Chronic lymphocytic leukemia (CLL) - must have either:
  -  Failed to meet National Cancer Institute (NCI) Working Group criteria for complete or partial response after therapy with a regimen containing fludarabine phosphate (FLU) (or another nucleoside analog) or experience disease relapse within 12 months after completing therapy with a regimen containing FLU (or another nucleoside analog)
  -  Failed FLU-cyclophosphamide (CY)-Rituximab (FCR) combination chemotherapy at any time point; or
  -  Have "17p deletion" cytogenetic abnormality; patients should have received induction chemotherapy but could be transplanted in 1st CR
  -  Patients with a diagnosis of CLL (or small lymphocytic lymphoma) that progresses to prolymphocytic leukemia (PLL); or
  -  Patients with T-cell CLL or PLL
  -  Hodgkin lymphoma - must have received and failed frontline therapy
  -  Multiple myeloma - must have received prior chemotherapy; consolidation of chemotherapy by autografting prior to nonmyeloablative HCT is permitted
  -  Acute myeloid leukemia (AML) - must have < 5% marrow blasts at the time of transplant
  -  Acute lymphocytic leukemia (ALL) - must have < 5% marrow blasts at the time of transplant
  -  Chronic myeloid leukemia (CML) - Patients will be accepted if they have shown intolerance to tyrosine kinase inhibitors or are beyond first chronic phase (CP1) and if they have received previous myelosuppressive chemotherapy or HCT, and have < 5% marrow blasts at time of transplant
  -  Myelodysplasia (MDS)/myeloproliferative syndrome (MPS) - Patients must have < 5% marrow blasts at time of transplant
  -  Waldenstrom's macroglobulinemia - must have failed 2 courses of therapy
  -  Patients < 12 years of age must be approved by the principal investigator and by a relevant patient review committee, such as the Fred Hutchinson Cancer Research Center (FHCRC) Patient Care Conference (PCC)
  -  Patients must have either relapsed after previous high-dose chemotherapy and autologous or allogeneic HCT, or else be ineligible for such an approach due to age, failure to mobilize sufficient hematopoietic stem cells, medical comorbidities, or patient refusal
  -  Patients who refuse to be treated on a conventional autologous or allogeneic HCT protocol
  -  DONOR GROUP A: Age >= 18 years
  -  DONOR GROUP A: HLA genotypically identical sibling
  -  DONOR GROUP A: Willingness to give informed consent
  -  DONOR GROUP B: Age >= 18 years
  -  DONOR GROUP B: HLA genotypically identical sibling
  -  DONOR GROUP B: Willingness to give informed consent
  Exclusion Criteria:
  -  IF PROTOCOL 2546 SERVES AS AN ADJUNCT PROTOCOL, THE PATIENT ONLY NEEDS TO MEET EXCLUSION CRITERIA 1 THROUGH 3
  -  Myeloablative preparative regimen
  -  Participation in an investigational study that has acute GVHD as the primary endpoint
  -  The allogeneic PBSC donor has a contraindication to statin treatment
  -  Patients eligible for and willing to receive potentially curative high-dose chemotherapy and autologous HCT
  -  Cardiac ejection fraction < 30% on multi gated acquisition scan (MUGA) scan or cardiac echocardiogram (echo) or active symptomatic coronary artery disease; patients with cardiac disease should be evaluated with appropriate cardiac studies and/or cardiology consultation as clinically indicated
  -  Corrected diffusion capacity of the lung for carbon monoxide (DLCO) < 40% of predicted, total lung capacity (TLC) < 30% of predicted, forced expiratory volume in one second (FEV1) < 30% of predicted, or receiving continuous supplementary oxygen
  -  Patients with clinical or laboratory evidence of liver disease should be evaluated in conjunction with the gastrointestinal (GI) consult service for the cause of the liver disease, its clinical severity, and the degree of portal hypertension; patients will be excluded if they are found to have fulminant liver failure, cirrhosis of the liver with evidence of portal hypertension, bridging fibrosis, alcoholic hepatitis, esophageal varices, a history of bleeding esophageal varices, hepatic encephalopathy, refractory ascites related to portal hypertension, bacterial or fungal liver abscess, chronic viral hepatitis with total serum bilirubin > 3mg/dl, or actively symptomatic biliary disease
  -  Patients with renal failure are eligible; however, patients with pre-existing renal insufficiency will likely have further compromise in renal function and may require dialysis
  -  Patients who are seropositive for human immunodeficiency virus (HIV)
  -  Women who are pregnant or breast-feeding
  -  Fertile men or women unwilling to use contraception during HCT and for 12 months afterward
  -  Patients with active non-hematological malignancies (except non-melanoma skin cancers) or those with non-hematological malignancies (except non-melanoma skin cancers) who have been rendered with no evidence of disease, but have a greater than 20% chance of having disease recurrence within 5 years; this exclusion does not apply to patients with non-hematologic malignancies that do not require therapy
  -  Karnofsky score < 60 for adult patients
  -  Lansky-play performance score < 50 for pediatric patients
  -  Patients with fungal pneumonia with radiological progression after receipt of amphotericin formulation or mold-active azoles for greater than 1 month
  -  DONOR GROUP A: Age < 18 years
  -  DONOR GROUP A: History of liver disease; a donor with a history of liver disease would be eligible if the serum alanine aminotransferase (ALT) or aspartate aminotransferase (AST) are < 2 times upper limit of normal (ULN)
  -  DONOR GROUP A: History of myopathy
  -  DONOR GROUP A: Hypersensitivity to atorvastatin
  -  DONOR GROUP A: Pregnancy
  -  DONOR GROUP A: Nursing mother
  -  DONOR GROUP A: Current serious systemic illness
  -  DONOR GROUP A: Concurrent treatment with strong inhibitors of hepatic cytochrome P450, family 3, subfamily A, polypeptide 4 (CYP 3A4) (i.e. clarithromycin, erythromycin, protease inhibitors, azole antifungals)
  -  DONOR GROUP A: Failure to meet local criteria for stem cell donation
  -  DONOR GROUP A: Total creatinine kinase > 2 times the ULN
  -  DONOR GROUP B: Age < 18 years
  -  DONOR GROUP B: History of liver disease; a donor with a history of liver disease would be eligible if the serum alanine aminotransferase (ALT) or aspartate aminotransferase (AST) are < 2 times upper limit of normal (ULN)
  -  DONOR GROUP B: History of myopathy
  -  DONOR GROUP B: Hypersensitivity to atorvastatin
  -  DONOR GROUP B: Pregnancy
  -  DONOR GROUP B: Nursing mother
  -  DONOR GROUP B: Current serious systemic illness
  -  DONOR GROUP B: Concurrent treatment with strong inhibitors of hepatic cytochrome P450, family 3, subfamily A, polypeptide 4 (CYP 3A4) (i.e. clarithromycin, erythromycin, protease inhibitors, azole antifungals)
  -  DONOR GROUP B: Current use of statin drug
  -  DONOR GROUP B: Failure to meet local criteria for stem cell donation
  -  DONOR GROUP B: Total creatinine kinase > 2 times the ULN

Relevance to patient case: definitely relevant