Alemtuzumab, Fludarabine, and Busulfan Followed By Donor Stem Cell Transplant in Treating Young Patients With Hematologic Disorders

Study Overview
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Brief Summary
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RATIONALE: Monoclonal antibodies, such as alemtuzumab, can block cancer growth in different ways. Some block the ability of cancer cells to grow and spread. Others find cancer cells and help kill them or carry cancer-killing substances to them. Drugs used in chemotherapy, such as fludarabine and busulfan, work in different ways to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. A peripheral stem cell, bone marrow , or umbilical cord blood transplant may be able to replace blood-forming cells that were destroyed by chemotherapy. Sometimes the transplanted cells from a donor can make an immune response against the body's normal cells. Giving cyclosporine together with methotrexate and methylprednisolone may stop this from happening. PURPOSE: This phase II trial is studying how well giving alemtuzumab together with fludarabine and busulfan works when given before donor stem cell transplant in treating young patients with hematologic disorders.

Detailed Description
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OBJECTIVES: Primary Determine the engraftment rate with reduced toxicity ablative conditioning regimen comprising alemtuzumab, fludarabine, and busulfan followed by allogeneic stem cell transplantation in pediatric patients with stem cell defects, marrow failure syndromes, hemoglobinopathy, severe immunodeficiency syndromes (nonsevere combined immunodeficiency disorders), myelodysplastic syndromes, or myeloid leukemia. Secondary Determine the acute reactions, incidence of infections, and rate of immune reconstitution in patients treated with this regimen. OUTLINE: This is a multicenter study. Conditioning regimen: Patients receive alemtuzumab IV over 6 hours on days -12 to -10, high-dose busulfan IV over 2 hours 4 times daily on days -9 to -6, and fludarabine IV over 30 minutes on days -5 to -2. Allogeneic stem cell transplantation: Two days after the completion of conditioning regimen, patients undergo allogeneic bone marrow, peripheral blood stem cell, or umbilical cord blood transplantation on day 0. Patients receive filgrastim (G-CSF) subcutaneously beginning on day 5 and continuing until blood counts recover. Graft-vs-host disease (GVHD) prophylaxis: Most transplantations (bone marrow or peripheral blood stem cell transplantation): Patients receive cyclosporine IV continuously beginning on day -1 until at least day 50 followed by a taper at either 2 months, 9 months, or 1 year in the absence of GVHD. Patients also receive methotrexate on days 1, 3, and 6. Umbilical cord blood transplantation: Patients receive cyclosporine as in most transplantations, and methylprednisolone IV twice daily on days 0-21 followed by a weekly taper. After transplantation, patients are followed periodically for up to 20 years. PROJECTED ACCRUAL: A total of 35 patients will be accrued for this study.

Official Title
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Evaluation of Fludarabine, Busulfan and Alemtuzumab as a Reduced Toxicity Ablative Bone Marrow Stem Cell Transplant Regimen for Children With Stem Cell Defects, Marrow Failure Syndromes, or Myelodysplastic Syndrome (MDS)/Leukemia

Conditions
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Congenital Amegakaryocytic Thrombocytopenia, Diamond-blackfan Anemia, Leukemia, Myelodysplastic Syndromes, Severe Congenital Neutropenia

Intervention / Treatment
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* Biological: alemtuzumab
* Drug: busulfan
* Drug: cyclosporine
* Drug: fludarabine phosphate
* Drug: methotrexate
* Drug: methylprednisolone
* Procedure: allogeneic bone marrow transplantation
* Procedure: allogeneic hematopoietic stem cell transplantation
* Procedure: peripheral blood stem cell transplantation
* Procedure: umbilical cord blood transplantation


Participation Criteria
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Eligibility Criteria
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DISEASE CHARACTERISTICS: Diagnosis of 1 of the following hematologic conditions: Aplastic anemia with marrow aplasia, meeting all of the following criteria: Absolute neutrophil count < 500/mm^3 Platelet and/or red cell transfusion dependent Chronic aplastic anemia, meeting all of the following criteria: Transfusion dependent Unresponsive to immunosuppressive therapy Alternative matched unrelated donor has been identified Congenital marrow failure syndrome, including any of the following (with closely matched related or unrelated donor): Primary red cell aplasia (Diamond-Blackfan syndrome) Congenital neutropenia (Kostmann's syndrome) Amegakaryocytic thrombocytopenia Congenital dyserythropoietic anemias Other severe acquired cytopenias in which a transplantation using a combined busulfan/cyclophosphamide conditioning regimen is indicated Hemoglobinopathy (with closely matched related or unrelated donor) β-thalassemia major Sickle cell anemia Hemoglobin E/β-thalassemia Severe immunodeficiency disease Chediak-Higashi disease Wiskott-Aldrich syndrome Combined immunodeficiency disease (Nezelof's) Hyper immunoglobulin M (IgM) syndrome Bare lymphocyte syndrome Chronic granulomatous disease Familial erythrohemophagocytic lymphohistiocytosis Other stem cell defects (e.g., osteopetrosis) Severe immune dysregulation/autoimmune disorders Achieved a transient response to prior immunosuppressive therapy Chronic myelogenous leukemia Disease in first chronic phase Acute myeloid leukemia Disease in first remission Myelodysplastic syndromes Inborn errors of metabolism Histiocytosis No severe combined immunodeficiency disease Matched related or unrelated donor available by high resolution DNA typing Related donor, meeting both of the following criteria: Matched at both human leukocyte antigen (HLA)-Drβ1 alleles No more than 1 mismatch at the 4 HLA-A and -B alleles Unrelated donor, meeting 1 of the following criteria: Marrow matched at both HLA-Drβ1 alleles AND no more than 1 mismatch at the 4 HLA-A and -B alleles Umbilical cord blood matched at 5/6 HLA-A, -B, and -DRβ1 alleles with at least 1 -DRβ1 match AND there are ≥ 3x10^5 CD34+ (Cluster of differentiation 34-positive) cells per kg body weight of recipient available at the time of cryopreservation PATIENT CHARACTERISTICS: Cardiac ejection fraction ≥ 27% Creatinine clearance ≥ 50 mL/min by 24-hour urine collection or glomerular filtration rate DLCO (diffusion capacity of lung for carbon monoxide) ≥ 50% of predicted (corrected for anemia/lung volume) PRIOR CONCURRENT THERAPY: No prior transplantation for leukemia from which patient remains engrafted and alemtuzumab is not needed as part of the conditioning regimen

Ages Eligible for Study
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Maximum Age: 21 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: Single arm - conditioning and transplant<br>Alemtuzumab 0.5 mg/kg (maximum 15 mg) daily for 3 days; Busulfan i.v. every 6 hours from day -9 to day -6 for 16 total doses; Fludarabine phosphate from day -5 for 4 days at 1.3 mg/kg (if patient was less than 12 kg) or 40 mg/m*2 per dose; Cyclosporine continuous infusion 3 mg/kg/Day beginning day -1 for GVHD prophylaxis; Methotrexate at 15 mg/m*2 on day +1, 10 mg/m*2 on days +3, +6, and (only for MUDs) day +11 also for GVHD prophylaxis; Methylprednisolone only as required for GVHD prophylaxis; allogeneic bone marrow transplantation or allogeneic hematopoietic stem cell transplantation or peripheral blood stem cell transplantation or umbilical cord blood transplantation. | Biological: alemtuzumab<br> <br> Drug: busulfan<br> <br> Drug: cyclosporine<br> <br> Drug: fludarabine phosphate<br> <br> Drug: methotrexate<br> <br> Drug: methylprednisolone<br> <br> Procedure: allogeneic bone marrow transplantation<br> <br> Procedure: allogeneic hematopoietic stem cell transplantation<br> <br> Procedure: peripheral blood stem cell transplantation<br> <br> Procedure: umbilical cord blood transplantation<br> <br> |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of Participants Achieving Durable Engraftment (Presence of Donor Cells) at 6 Weeks Post Transplantation | Peripheral blood chimerism studies were performed by quantitative real time polymerase chain reaction (qPCR) evaluation of differential short tandem repeat DNA sequences | 6 weeks post-transplant | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Treatment-related Mortality at 100 Days and 1 Year Post Transplantation |  | 100 days and 1 year | 
| Toxicity Grade ≥ 3 From Start of Conditioning Through the First Year Post Transplantation |  | 1 year post-transplantation | 
| Cytomegalovirus (CMV) Viral Infection and Disease Symptoms | polymerase chain reaction testing for presence of CMV weekly until at least day +100 then every 2 weeks until T-cell reconstitution as defined by cluster of differentiation 4 (CD4) > 200 cells/mm3. Median time to T-cell reconstitution was 6 months. | Up to one year post-transplant | 
| Disease-free Survival With Correction of Disease at One Year Post Transplantation | Patients deemed alive and well at follow-up timepoint later than 1-year post-transplantation | 1 year post-transplantation | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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de novo myelodysplastic syndromes, previously treated myelodysplastic syndromes, secondary myelodysplastic syndromes, childhood acute myeloid leukemia in remission, childhood chronic myelogenous leukemia, congenital amegakaryocytic thrombocytopenia, Diamond-Blackfan anemia, severe congenital neutropenia, secondary acute myeloid leukemia, chronic phase chronic myelogenous leukemia, childhood myelodysplastic syndromes