Sirolimus, Cyclosporine, and Mycophenolate Mofetil in Preventing Graft-versus-Host Disease in Treating Patients With Blood Cancer Undergoing Donor Peripheral Blood Stem Cell Transplant
Condition: Adult Acute Lymphoblastic Leukemia; Adult Acute Myeloid Leukemia; Adult Diffuse Large B-Cell Lymphoma; Adult Myelodysplastic Syndrome; Adult Non-Hodgkin Lymphoma; Aggressive Non-Hodgkin Lymphoma; Childhood Acute Lymphoblastic Leukemia; Childhood Acute Myeloid Leukemia; Childhood Diffuse Large B-Cell Lymphoma; Childhood Myelodysplastic Syndrome; Childhood Non-Hodgkin Lymphoma; Chronic Lymphocytic Leukemia; Chronic Lymphocytic Leukemia in Remission; Chronic Phase Chronic Myelogenous Leukemia, BCR-ABL1 Positive; Hematopoietic and Lymphoid Cell Neoplasm; Mantle Cell Lymphoma; Plasma Cell Myeloma; Prolymphocytic Leukemia; Recurrent Chronic Lymphocytic Leukemia; Refractory Chronic Lymphocytic Leukemia; T-Cell Prolymphocytic Leukemia; Waldenstrom Macroglobulinemia; Recurrent Diffuse Large B-Cell Lymphoma; Recurrent Hodgkin Lymphoma
MeSH terms: Lymphoma; Leukemia; Leukemia, Myeloid; Leukemia, Myeloid, Acute; Lymphoma, Non-Hodgkin; Preleukemia; Precursor Cell Lymphoblastic Leukemia-Lymphoma; Leukemia, Lymphoid; Lymphoma, B-Cell; Leukemia, Lymphocytic, Chronic, B-Cell; Lymphoma, Mantle-Cell; Lymphoma, Large B-Cell, Diffuse; Leukemia, Myelogenous, Chronic, BCR-ABL Positive; Waldenstrom Macroglobulinemia; Leukemia, Myeloid, Chronic-Phase; Multiple Myeloma; Leukemia, Prolymphocytic; Leukemia, Prolymphocytic, T-Cell; Myelodysplastic Syndromes; Syndrome; Recurrence
Intervention: Allogeneic Hematopoietic Stem Cell Transplantation; Cyclosporine; Fludarabine Phosphate; Laboratory Biomarker Analysis; Mycophenolate Mofetil; Peripheral Blood Stem Cell Transplantation; Sirolimus; Total-Body Irradiation
Intervention description: Undergo allogeneic peripheral blood stem cell transplant; Given PO or IV; Given IV; Correlative studies; Given PO; Undergo allogeneic peripheral blood stem cell transplant; Given PO; Undergo total-body irradiation
Intervention MeSH terms: Cyclosporine; Sirolimus; Mycophenolic Acid; Fludarabine; Fludarabine phosphate; Cyclosporins
Phase: Phase 2
Study type: Interventional
Primary purpose: Treatment
Intervention model: Single Group Assignment
Masking: None (Open Label)
Enrollment: 77.0
Sex: All
Healthy volunteers: No

Summary:

      This phase II trial studies how well sirolimus, cyclosporine and mycophenolate mofetil works
      in preventing graft-vs-host disease (GVHD) in patients with blood cancer undergoing donor
      peripheral blood stem cell (PBSC) transplant. Giving chemotherapy and total-body irradiation
      before a donor 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. When the
      healthy stem cells from a donor are infused into the patient they may help the patient's bone
      marrow make stem cells, red blood cells, white blood cells, and platelets. Sometimes the
      transplanted cells from a donor can make an immune response against the body's normal cells.
      Giving total-body irradiation together with sirolimus, cyclosporine, and mycophenolate
      mofetil before and after transplant may stop this from happening.
    

Eligibility criteria:

        Inclusion Criteria:

          -  Ages > 50 years with hematologic malignancies treatable by related or unrelated HCT

          -  Ages =< 50 years of age with hematologic diseases treatable by allogeneic HCT who
             through pre-existing medical conditions or prior therapy are considered to be at high
             risk for regimen related toxicity associated with a high dose transplant (> 40% risk
             of transplant-related mortality [TRM]); this criterion can include patients with a
             HCT-comorbidity index (CI) score of >= 1; transplants should be approved for these
             inclusion criteria by the principal investigators at the collaborating centers and at
             Fred Hutchinson Cancer Research Center (FHCRC); all children < 12 years must be
             discussed with the FHCRC principal investigator (PI) prior to registration

          -  Ages =< 50 years of age with chronic lymphocytic leukemia (CLL)

          -  Ages =< 50 years of age with hematologic diseases treatable by allogeneic HCT who
             refuse a high-dose HCT; transplants must be approved for these inclusion criteria by
             the principal investigators at the collaborating centers and at FHCRC

          -  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

          -  CLL: must have either 1) failed to meet National Cancer Institute (NCI) Working Group
             criteria for complete or partial response after therapy with a regimen containing
             fludarabine (FLU) (or another nucleoside analog, e.g. cladribine [2-CDA], pentostatin)
             or experience disease relapse within 12 months after completing therapy with a regimen
             containing FLU (or another nucleoside analog); 2) failed FLU-cyclophosphamide
             (CY)-Rituximab (FCR) combination chemotherapy at any time point; or 3) have "17p
             deletion" cytogenetic abnormality; patients should have received induction
             chemotherapy but could be transplanted in first (1st) CR; 4) patients with a diagnosis
             of CLL (or small lymphocytic lymphoma) that progresses to prolymphocytic leukemia
             (PLL); or 5) 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 in chronic phase 1 (CP1) must have failed or
             be intolerant of tyrosine kinase inhibitors (TKIs); patients beyond CP1 will be
             accepted if they 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 with related or unrelated donors for whom the best available donor is: a)
             mismatched at antigen level for any single class I locus (HLA-A, -B, -C) +/- an
             additional class I mismatch at the allele level OR mismatched at the allele level for
             any 2 class I loci (if typed at the molecular level) OR mismatched at the antigen or
             allele level for class II loci HLA-DRB1 and/or - DQB1; must be matched for at least
             one DRB1 allele and one DQB1 allele; b) there is a likelihood of rapid disease
             progression while HLA typing and results of a preliminary search and the donor pool
             suggests that a 10/10 HLA-A, B, C, DRB1 and DQB1 matched donor will not be found; c)
             there is no HLA-A, -B or -C one locus allelic mismatched donor available

          -  DONOR: Related or unrelated volunteer donors who are mismatched with the recipient
             within one of the following limitations:

               -  Mismatch for one HLA class I antigen with or without an additional mismatch for
                  one HLA-class I allele, but matched for HLA-DRB1 and HLA-DQ, OR

               -  Mismatched for two HLA class I alleles, but matched for HLA-DRB1 and HLA-DQ, OR

               -  HLA class I HLA-A, -B, -C allele matched donors allowing for any one or two DRB1
                  and/or DQB1 antigen allele mismatch

          -  DONOR: HLA-matching must be based on results of high resolution typing at HLA-A, -B,
             -C, -DRB1, and -DQB

          -  DONOR: If the patient is homozygous at the mismatch HLA class I locus or II locus, the
             donor must be heterozygous at that locus and one allele must match the patient (i.e.,
             patient is homozygous A*01:01 and donor is heterozygous A*01:01, A*02:01); this
             mismatch will be considered a one-antigen mismatch for rejection only

          -  DONOR: Donors are excluded when preexisting immunoreactivity is identified that would
             jeopardize donor hematopoietic cell engraftment; this determination is based on the
             standard practice of the individual institution; the donor should be excluded if any
             of the flow cytometric B and T cell cytotoxic cross match assays are positive

          -  DONOR: Only filgrastim (G-CSF) mobilized PBSC only will be permitted as a
             hematopoietic stem cell (HSC) source on this protocol

        Exclusion Criteria:

          -  Patients for whom the best available donor is mismatched at both HLA class I and class
             II

          -  A positive cross-match exists between the donor and recipient

          -  Patients with rapidly progressive intermediate or high grade NHL

          -  Patients with a diagnosis of chronic myelomonocytic leukemia (CMML)

          -  Patients with refractory anemia with excess blasts (RAEB)-2 who have not received
             myelosuppressive chemotherapy i.e. induction chemotherapy

          -  Presence of circulating leukemic blasts (in the peripheral blood) detected by standard
             pathology for patients with AML, ALL or CML

          -  Presence of >= 5% circulating leukemic blasts (in the peripheral blood) detected by
             standard pathology for patients with MDS/MPS

          -  Central nervous system (CNS) involvement with disease refractory to intrathecal
             chemotherapy

          -  Fertile men or women unwilling to use contraceptives during and for up to 12 months
             following treatment

          -  Female patients who are pregnant or breast-feeding

          -  Human immunodeficiency virus (HIV) positive patients

          -  Patients with active non-hematologic malignancies (except non-melanoma skin cancers)
             or those with non-hematologic 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

          -  Fungal infections with radiological progression after receipt of amphotericin B or
             active triazole for greater than 1 month

          -  Patients with active bacterial or fungal infections unresponsive to medical therapy

          -  Cardiac ejection fraction < 35% (or, if unable to obtain ejection fraction, shortening
             fraction of < 26%); ejection fraction is required if the patient is > 50 years of age,
             or history of cardiac disease or anthracycline exposure; patients with a shortening
             fraction < 26% may be enrolled if approved by a cardiologist

          -  Corrected diffusion capacity of carbon monoxide (DLCO) < 40%, total lung capacity
             (TLC) < 40%, forced expiratory volume in one second (FEV1) < 40% and/or receiving
             supplementary continuous oxygen; if unable to perform complete pulmonary function
             tests (PFTs), patients will be excluded if their oxygen saturation is < 95% with a
             formal six-minute walk test (ambulatory oximetry)

          -  The FHCRC PI of the study must approve of enrollment of all patients with pulmonary
             nodules

          -  Patients with clinical or laboratory evidence of liver disease would be evaluated for
             the cause of liver disease, its clinical severity in terms of liver function, 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,
             alcoholic hepatitis, esophageal varices, a history of bleeding esophageal varices,
             hepatic encephalopathy, uncorrectable hepatic synthetic dysfunction evinced by
             prolongation of the prothrombin time, ascites related to portal hypertension, bridging
             fibrosis, bacterial or fungal liver abscess, biliary obstruction, chronic viral
             hepatitis with total serum bilirubin > 3 mg/dL, or symptomatic biliary disease

          -  Patients with poorly controlled hypertension on multiple antihypertensives

          -  Karnofsky scores < 60 or Lansky score < 50

          -  All patients receiving antifungal therapy voriconazole, posaconazole, or fluconazole
             must have sirolimus reduced according to the Standard Practice Antifungal Therapy
             Guidelines

          -  The addition of cytotoxic agents for "cytoreduction" with the exception of tyrosine
             kinase inhibitors (such as imatinib), cytokine therapy, hydroxyurea, low dose
             cytarabine, chlorambucil, or Rituxan will not be allowed within three weeks of the
             initiation of conditioning

          -  DONOR: Donor (or centers) who will exclusively donate marrow

          -  DONOR: Donors who are HIV-positive and/or, medical conditions that would result in
             increased risk for G-CSF mobilization and harvest of PBSC

          -  DONOR: Patients who are homozygous at the mismatched HLA class I locus or II locus,
             the donor is excluded if homozygous at the mismatched locus (i.e., patient is
             homozygous A*01:01 and donor is homozygous A*02:01); this type of mismatch is
             considered a two-antigen mismatch and is not allowed