Hematopoietic Stem Cell Transplantation for the Treatment of Patients With Fanconi Anemia Lacking a Genotypically Identical Donor, Using a Chemotherapy Only Cytoreduction With Busulfan, Cyclophosphamide and Fludarabine
Condition: Aplastic Anemia; Leukemia; Myelodysplastic Syndrome
MeSH terms: Anemia; Myelodysplastic Syndromes; Anemia, Aplastic; Fanconi Anemia
Intervention: Busulfan, fludarabine, & cyclophosphamide with immunosuppression with ATG and cyclosporine.; CliniMACS device
Intervention description: There are three parts in this transplant study. 1) There will be a pre-transplant - preparation - period to see if patient qualifies for the transplant study. This will be done as an outpatient and lasts 2-4 weeks. Once this is completed, there will be 2) the transplant period itself, during which the patient will be admitted and will be an inpatient. This period usually last for 4-6 weeks. Following that, there will be a 3) post transplant period, during which the patient will be watched carefully and monitored in clinic as an out patient. The post transplant period lasts from three months to one year.; CD34+ T-cell depleted peripheral blood stem cell transplant
Intervention MeSH terms: Cyclosporine; Cyclophosphamide; Busulfan; Fludarabine; Cyclosporins
Phase: Phase 2
Study type: Interventional
Primary purpose: Treatment
Intervention model: Single Group Assignment
Masking: None (Open Label)
Enrollment: 45.0
Sex: All
Healthy volunteers: Accepts Healthy Volunteers
Keywords: Stem Cell Transplantation; Anemia; Busulfan; Cyclophosphamide; Fludarabine; 08-031

Summary:

      This is a genetic disease (transmitted through the parents' genes) called Fanconi Anemia.
      Because of that genetic disease, the bone marrow has changed and now has failed, or has given
      rise to a preleukemia called myelodysplastic syndrome (MDS) or leukemia (acute myelogenous
      leukemia or AML).

      Without treatment these complications of Fanconia anemia (FA) are fatal. The only treatment
      that can cure these complications is an allogeneic transplant of stem cells, meaning, giving
      the patient bone marrow cells from a healthy donor that can produce normal blood cells that
      will replace the bone marrow that is sick.

      What has been given for the treatment of FA in the past is to use a combination of low doses
      of radiation to the whole body (total body irradiation) and low doses of the chemotherapy
      drugs (cyclophosphamide and fludarabine) before the transplant. However, the use of radiation
      can, later on, increase the chances of getting a second cancer of the skin, head or the neck.
      These chances of a second cancer are higher than normal in patients with FA.

      The purpose of this study is to find out if the doctors can do the same thing with the same
      chemotherapy drugs used in the past. However physicians will use another chemotherapy drug
      called busulfan instead of the radiation. The goal of this study is to get rid of the short
      term and long term risks of the radiation. The first new part of this treatment will be to
      replace drugs for radiation with chemotherapy drugs.
    

Eligibility criteria:

        Inclusion Criteria:

          -  Patients must have a diagnosis of Fanconi anemia (confirmed by mitomycin C or
             diepoxybutane [DEB] chromosomal breakage testing at an approved laboratory).

          -  Hematologic Diagnosis and Status - Patients must have one of the following hematologic
             diagnoses:

               -  Severe Aplastic Anemia (SAA) with bone marrow cellularity of <25%, or Severe
                  Isolated Single lineage Cytopenia

        AND at least one of the following features:

          -  Platelet count <20 x 109/L or platelet transfusion dependence*

          -  ANC <1000 x 109/L

          -  Hgb <8 gm/dl or red cell transfusion dependence*

          -  Myelodysplastic Syndrome (MDS) (Appendix 1: MDS Classification) - MDS at any stage,
             based on either one of the following classifications:

               -  WHO Classification

               -  Refractory anemia and transfusion dependence*

               -  Any of other stages

               -  IPSS Classification

               -  Low risk (score 0) and transfusion dependence*

               -  Any other risk groups Score > or = to 0.5

          -  Acute Myelogenous Leukemia

               -  Patients with acute leukemia are included in this trial in remission, refractory
                  or relapsed disease.

               -  Transfusion dependence will be defined as greater than ONE transfusion of
                  platelets or red blood cells in the last year prior to evaluation on protocol.

                    -  Donors:

          -  Donor choices will be determined by the investigators at each of the centers according
             to their own institutional criteria.

          -  All patients evaluated at trial sites and eligible for this trial by virtue of disease
             and lack of an HLA-genotypically matched related donor will be captured in the
             database of this trial. Patients who will be enrolled on this protocol must have one
             of the following donor choices:

               -  HLA-compatible Unrelated volunteer donors

               -  Patients who do not have a related HLA-matched donor but have an unrelated donor
                  who is either matched at all A, B, C and DRB1 (8/8) loci or who is mismatched at
                  1/8 loci (A, B, C or DRB1) (7/8) as tested by DNA analysis (high resolution),
                  will be eligible for entry on this protocol.

               -  HLA-mismatched Related donors

               -  Patients who do not have a related or unrelated HLA-compatible donor must have a
                  healthy family member who is at least HLA-haplotype identical to the recipient.
                  First degree related donors must have a normal DEB test.

               -  The donor must be healthy and willing and able to receive a 4-6 day course of
                  G-CSF and undergo 1-3 daily leukaphereses.

               -  Related and Unrelated donors must be medically evaluated and fulfill the criteria
                  for collection of PBSCs as per institutional guidelines.

                    -  Patients:

          -  Patients and donors may be of either gender or any ethnic background.

          -  Patients must have a Karnofsky adult, or Lansky pediatric performance scale status >
             or = 70%.

          -  At the time of referral for transplantation, patients must have no co-existing medical
             problems that would significantly increase the risk of the transplant procedure.

          -  Patients must have adequate physical function measured by :

               -  Cardiac: asymptomatic or if symptomatic then 1) LVEF at rest must be > or = to
                  50% and must improve with exercise or 2) Shortening Fraction > or = to 29%

               -  Hepatic: < 5 x ULN SGOT and < 2.0 mg/dl total serum bilirubin.

               -  Renal: serum creatinine < or = to 1.5 mg/dl or if serum creatinine is outside the
                  normal range, then CrCl > 60-ml/min/1.73 m2

               -  Pulmonary: asymptomatic or if symptomatic, DLCO > 50% of predicted (corrected for
                  hemoglobin)

          -  Each patient must be willing to participate as a research subject and must sign an
             informed consent form. Parent or legal guardians of patients who are minors will sign
             the informed consent form. Assents will be obtained as age appropriate.

          -  Female patients and donors must not be pregnant or breastfeeding at the time of
             signing consent. Women must be willing to undergo a pregnancy test prior to transplant
             and avoid becoming pregnant while on study.

        Exclusion Criteria:

          -  Active CNS leukemic involvement

          -  Female patients who are pregnant (positive serum or urine HCG) or breast-feeding.
             Women of childbearing age must avoid becoming pregnant while on study.

          -  Active uncontrolled viral, bacterial or fungal infection

          -  Patient seropositive for HIV-I/II; HTLV -I/II