Fludarabine, Cyclophosphamide, and Total-Body Irradiation in Treating Patients Who Are Undergoing a Donor Bone Marrow Transplant for Hematologic Cancer

Study Overview
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Brief Summary
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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
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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.

Official Title
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A Phase II Trial of Non-Myeloablative Conditioning and Transplantation of Partially HLA-Mismatched Bone Marrow for Patients With Hematologic Malignancies

Conditions
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Chronic Myeloproliferative Disorders, Leukemia, Lymphoma, Multiple Myeloma and Plasma Cell Neoplasm, Myelodysplastic Syndromes

Intervention / Treatment
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* Drug: cyclophosphamide
* Drug: fludarabine phosphate
* Drug: mycophenolate mofetil
* Drug: tacrolimus
* Procedure: allogeneic bone marrow transplantation
* Radiation: radiation therapy


Participation Criteria
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Eligibility Criteria
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DISEASE CHARACTERISTICS: Diagnosis of 1 of the following hematologic malignancies: Acute leukemia In second or subsequent complete remission (CR), as defined by absence of abnormal blast population by flow cytometry In first CR with any of the following poor-risk cytogenetic features: Alteration of chromosome 5 or 7 Multiple abnormalities Philadelphia chromosome positive Chronic phase chronic myelogenous leukemia (CML) In first chronic phase and refractory to interferon alfa or imatinib mesylate In second or subsequent chronic phase Chronic lymphocytic leukemia, meeting 1 of the following criteria: Received prior chemotherapy with a nucleoside analog and had remission lasting < 6 months Received 1 prior therapy and has any of the following high-risk features: Cytogenetic abnormalities of 17p, 11q Mutations of the Zap70 gene Somatically unmutated immunoglobulin heavy chain variable region genes Hodgkin's lymphoma Ineligible for autologous stem cell transplantation (SCT) due to any of the following exclusion factors: LVEF < 45% FEV_1 or FVC < 50% of predicted (75% of predicted in patients with prior thoracic or mantle radiotherapy) Total bilirubin > 2.0 mg/dL (unless documented Gilbert's disease) Creatinine > 2.0 mg/dL Non-Hodgkin's lymphoma (NHL) Low-grade NHL allowed provided patient had a remission duration of < 1 year after administration of any established, multi-agent chemotherapy regimen (e.g., CVP, CHOP, or rituximab in combination with CHOP) Intermediate- or high-grade NHL allowed provided patient is ineligible for autologous SCT according to the criteria listed above Multiple myeloma Myelodysplastic syndromes Paroxysmal nocturnal hemoglobinuria Chronic myeloproliferative disorders other than CML, including any of the following: Chronic myelomonocytic leukemia Agnogenic myeloid metaplasia (or myeloid metaplasia with myelofibrosis), with hemoglobin < 10 g/dL OR WBC < 4,000/mm^3 or > 30,000/mm^3 Polycythemia vera or essential thrombocythemia in spent phase, with a history of 2 of the following: Marrow fibrosis Splenomegaly Cytopenia (i.e., absolute neutrophil count < 1,500/mm^3, platelet count < 100,000/mm^3, hemoglobin < 10 g/dL) Polycythemia vera or essential thrombocythemia with transformation to myelodysplastic syndromes or acute myeloid leukemia (requires treatment to achieve < 20% blasts in marrow) No smoldering myeloma Patients with acute myeloid leukemia or myelodysplastic syndromes must have had comprehensive cytogenetic evaluation of bone marrow specimen during active disease Ineligible for or refused bone marrow transplantation from an HLA-matched sibling or unrelated donor Ineligible for or refused autologous SCT Must have an HLA mismatched (i.e., 3/6, 4/6, or 5/6) related (first-degree relative)* donor available Donor ≥ 18 years of age NOTE: *Patients with an inherited recombinant HLA haplotype may receive marrow from the parent in whose gamete the recombination occurred NOTE: A new classification scheme for adult non-Hodgkin's lymphoma has been adopted by PDQ. The terminology of indolent or aggressive lymphoma will replace the former terminology of low, intermediate, or high grade lymphoma. However, this protocol uses the former terminology. PATIENT CHARACTERISTICS: Age 6 months to 74 years Performance status ECOG 0-1 Life expectancy Not specified Hematopoietic See Disease Characteristics Hepatic See Disease Characteristics Bilirubin < 3.1 mg/dL Renal See Disease Characteristics Cardiovascular See Disease Characteristics LVEF ≥ 35% Pulmonary See Disease Characteristics FEV_1 or FVC ≥ 40% of predicted in patients without prior thoracic or mantle radiotherapy (60% of predicted in patients with prior thoracic or mantle radiotherapy) Other Not pregnant or nursing Negative pregnancy test Fertile patients must use effective contraception HIV negative Geographically accessible No debilitating medical or psychiatric illness that would preclude giving informed consent or receiving optimal treatment or follow-up PRIOR CONCURRENT THERAPY: Biologic therapy See Disease Characteristics No prior transfusions from donor Chemotherapy See Disease Characteristics Endocrine therapy Not specified Radiotherapy See Disease Characteristics Surgery Not specified

Ages Eligible for Study
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Minimum Age: 6 Months
Maximum Age: 74 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Mini-haplo Transplant<br>Non-myeloablative haploidentical bone marrow transplant with a fludarabine, cyclophosphamide (Cy), TBI (total body irradiation) preparative regimen and post-transplant Cy, mycophenolate mofetil (MMF), and tacrolimus as GVHD prophylaxis. | Drug: cyclophosphamide<br> <br> Drug: fludarabine phosphate<br> <br> Drug: mycophenolate mofetil<br> <br> Drug: tacrolimus<br> <br> Procedure: allogeneic bone marrow transplantation<br> <br> Radiation: radiation therapy<br> <br> |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Transplant-related Mortality | Percentage of participants who die for any reason other than recurrence of disease. | Cumulative incidence for the entire study, up to 11 years | 
| Relapse Rate | Percentage of participants who experience disease relapse. | Cumulative incidence for the entire study, up to 11 years | 
| Progression-free Survival | Percentage of participants who do not experience disease relapse, disease progression, or death. | 2 years | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Graft Failure Rate | Percentage of participants who experienced failure to engraft (also called graft failure or graft rejection). Failure to engraft is defined as <5% donor chimerism and absence of relapse or any other reason for that chimerism value. All participants who met this criterion were included in this outcome measure. | Cumulative incidence for the entire study, up to 11 years | 
| Hematologic and Non-hematologic Toxicities as Measured by NCI Common Toxicity Criteria for Adverse Events, v 3.0 Weekly Until 1 Year After Transplantation | Percentage of study participants who experienced a serious adverse event (SAE) within 1 year of bone marrow transplant. Complete data is provided in the Adverse Event tables. | 1 year | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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stage III marginal zone lymphoma, polycythemia vera, essential thrombocythemia, 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, 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 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 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