Fludarabine, Cyclophosphamide, and Total-Body Irradiation in Treating Patients Who Are Undergoing a Donor Bone Marrow Transplant for Hematologic Cancer
Condition: Chronic Myeloproliferative Disorders; Leukemia; Lymphoma; Multiple Myeloma and Plasma Cell Neoplasm; Myelodysplastic Syndromes
MeSH terms: Lymphoma; Leukemia; Multiple Myeloma; Neoplasms, Plasma Cell; Preleukemia; Plasmacytoma; Myelodysplastic Syndromes; Myeloproliferative Disorders; Syndrome
Study type: Interventional
Phase: Phase 2

Summary: 
      RATIONALE: Giving low doses of chemotherapy, such as fludarabine and cyclophosphamide, and
      radiation therapy before a donor bone marrow transplant helps stop the growth of cancer
      cells. Giving chemotherapy or radiation therapy before or after transplant also stops the
      patient's immune system from rejecting the donor's bone marrow stem cells. The donated stem
      cells may replace the patient's immune system 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 mycophenolate
      mofetil after the transplant may stop this from happening.

      PURPOSE: This phase II trial is studying how well giving fludarabine and cyclophosphamide
      together with total-body irradiation works in treating patients who are undergoing a donor
      bone marrow transplant for hematologic cancer.
    

Detailed description: 
      OBJECTIVES:

        -  Determine transplant-related mortality, risk of relapse, and progression-free survival
           of patients with standard- or high-risk hematologic malignancies undergoing
           nonmyeloablative conditioning comprising fludarabine, cyclophosphamide, and total-body
           irradiation followed by HLA-haploidentical allogeneic bone marrow transplantation.

        -  Determine donor hematopoietic chimerism in patients' peripheral blood at 30, 60, and 180
           days after transplantation.

        -  Determine hematologic and nonhematologic toxic effects of this regimen in these
           patients.

        -  Determine, when feasible, surface expression of HLA molecules and death receptors,
           sensitivity to cytotoxic lymphocytes, and expression of anti-apoptotic genes (e.g.,
           Bcl-2, Bcl-xL, X-IAP, and c-FLIP) in cancer cells from patients who relapse after
           treatment with this regimen.

      OUTLINE: This is a multicenter study. Patients are stratified according to risk of relapse
      (standard [defined as ≤ 30% risk] vs high [defined as ≥ 70% risk]).

        -  Nonmyeloablative conditioning regimen: Patients receive fludarabine IV over 30 minutes
           on days -6 to -2 and cyclophosphamide IV over 1-2 hours on days -6 and -5. Patients
           undergo total body irradiation on day -1.

        -  Allogeneic bone marrow transplantation: Patients undergo donor bone marrow infusion on
           day 0.

        -  Post-transplantation therapy: Patients receive cyclophosphamide IV over 1-2 hours on
           days 3 and 4.

        -  Graft-vs-host disease prophylaxis: Beginning on day 5, patients receive oral
           mycophenolate mofetil 3 times daily until day 35 and tacrolimus IV (then changing to
           orally) twice daily until day 180.

      Treatment continues in the absence of disease progression.

      After completion of study transplantation, patients are followed on days 30, 60, 100, and
      180; at 1 year; and then annually for 4 additional years.

      PROJECTED ACCRUAL: A total of 75-100 patients will be accrued for this study within 3-4
      years.
    

Intervention name(s): cyclophosphamide; fludarabine phosphate; mycophenolate mofetil; tacrolimus; allogeneic bone marrow transplantation; radiation therapy
Intervention type(s): Drug; Drug; Drug; Drug; Procedure; Radiation
Intervention MeSH terms: Mycophenolic Acid; Cyclophosphamide; Fludarabine; Fludarabine phosphate; Tacrolimus
Intervention model: Single Group Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: adult acute lymphoblastic leukemia in remission; adult acute myeloid leukemia in remission; childhood acute lymphoblastic leukemia in remission; childhood acute myeloid leukemia in remission; childhood chronic myelogenous leukemia; chronic phase chronic myelogenous leukemia; refractory chronic lymphocytic leukemia; extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue; adult acute myeloid leukemia with 11q23 (MLL) abnormalities; adult acute myeloid leukemia with inv(16)(p13;q22); adult acute myeloid leukemia with t(15;17)(q22;q12); adult acute myeloid leukemia with t(16;16)(p13;q22); adult acute myeloid leukemia with t(8;21)(q22;q22); chronic idiopathic myelofibrosis; chronic myelomonocytic leukemia; de novo myelodysplastic syndromes; previously treated myelodysplastic syndromes; noncontiguous stage II adult Burkitt lymphoma; noncontiguous stage II adult diffuse large cell lymphoma; noncontiguous stage II adult diffuse mixed cell lymphoma; noncontiguous stage II adult diffuse small cleaved cell lymphoma; noncontiguous stage II adult immunoblastic large cell lymphoma; noncontiguous stage II adult lymphoblastic 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 mantle cell lymphoma; noncontiguous stage II marginal zone lymphoma; noncontiguous stage II small lymphocytic lymphoma; recurrent adult Burkitt lymphoma; recurrent adult diffuse large cell lymphoma; recurrent adult diffuse mixed cell lymphoma; recurrent adult diffuse small cleaved cell lymphoma; recurrent adult Hodgkin lymphoma; recurrent adult immunoblastic large cell lymphoma; recurrent adult lymphoblastic lymphoma; recurrent/refractory childhood Hodgkin lymphoma; recurrent childhood large cell lymphoma; recurrent childhood lymphoblastic lymphoma; recurrent childhood small noncleaved cell lymphoma; nodal marginal zone B-cell lymphoma; recurrent grade 1 follicular lymphoma; recurrent grade 2 follicular lymphoma; recurrent grade 3 follicular lymphoma; recurrent mantle cell lymphoma; recurrent marginal zone lymphoma; recurrent small lymphocytic lymphoma; refractory multiple myeloma; relapsing chronic myelogenous leukemia; secondary myelodysplastic syndromes; splenic marginal zone lymphoma; stage I multiple myeloma; stage II multiple myeloma; stage III multiple myeloma; stage III adult Burkitt lymphoma; stage III adult diffuse large cell lymphoma; stage III adult diffuse mixed cell lymphoma; stage III adult diffuse small cleaved cell lymphoma; stage III adult Hodgkin lymphoma; stage III adult immunoblastic large cell lymphoma; stage III adult lymphoblastic lymphoma; stage III grade 1 follicular lymphoma; stage III grade 2 follicular lymphoma; stage III grade 3 follicular lymphoma; stage III mantle cell lymphoma; stage III marginal zone lymphoma; polycythemia vera; essential thrombocythemia; stage III small lymphocytic lymphoma; stage IV mantle cell lymphoma; stage IV marginal zone lymphoma; stage IV grade 1 follicular lymphoma; stage IV grade 2 follicular lymphoma; stage IV grade 3 follicular lymphoma; stage IV adult Burkitt lymphoma; stage IV adult diffuse large cell lymphoma; stage IV adult diffuse mixed cell lymphoma; stage IV adult diffuse small cleaved cell lymphoma; stage IV adult immunoblastic large cell lymphoma; stage IV adult lymphoblastic lymphoma; stage IV small lymphocytic lymphoma; stage IV adult Hodgkin lymphoma; childhood myelodysplastic syndromes