Donor Stem Cell Transplant After Chemotherapy for the Treatment of Recurrent or Refractory High-Risk Solid Tumors in Pediatric and Adolescent-Young Adults

Study Overview
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Brief Summary
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This phase II trial investigates side effects and how well donor stem cell transplant after chemotherapy works in treating pediatric and adolescent-young adults with high-risk solid tumor that has come back (recurrent) or does not respond to treatment (refractory). Chemotherapy drugs, such as fludarabine, thiotepa, etoposide, melphalan, and rabbit anti-thymocyte globulin work in different ways to stop the growth of tumor cells, either by killing the cells, by stopping them from dividing, or by stopping them from spreading. Giving chemotherapy before a donor stem cell transplant helps kill cancer cells in the body and helps make room in the patient's bone marrow for new blood-forming cells (stem cells) to grow. When the healthy stem cells from a donor are infused into a patient, they may help the patient's bone marrow make more healthy cells and platelets and may help destroy any remaining cancer cells.

Detailed Description
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PRIMARY OBJECTIVE: I. To assess tolerability of allogeneic hematopoietic stem cell transplantation (HCT) for patients with chemo-responsive recurrent/refractory solid tumors as defined by transplant-related mortality (TRM) at day 30 and the rate of grade III or higher organ toxicity (Bearman Regimen-Related Toxicities Scale) attributable to conditioning occurring within 30 days. SECONDARY OBJECTIVES: I. Assess median time to platelet and neutrophil engraftment. II. Assess incidence of acute graft-versus-host disease (aGVHD) by day 100. III. Assess incidence of chronic GVHD (cGVHD) at day 100 and one year. IV. Assess rate of grade II organ toxicity through day 100. V. Assess rate of graft failure (primary and secondary) through day 100. VI. Assess rate of infectious complications through day 100. VII. Assess progression free survival (PFS) at day 100,180 and 365. VIII. Assess cumulative incidence of relapse, overall survival (OS) at 100 days and 1 year. OUTLINE: CONDITIONING REGIMEN: Patients receive thiotepa intravenously (IV) over 2-4 hours and etoposide IV over 60 minutes on days -8 to -6, melphalan IV over 20 minutes on days -5 and -4, and fludarabine phosphate IV over 1 hour on days -5 to -3 in the absence of disease progression or unacceptable toxicity. Patients receiving umbilical cord transplant also receive rabbit anti-thymocyte globulin IV on days -4 and -3. TRANSPLANT: Patients undergo HSCT on day 0. GVHD PROPHYLAXIS: Beginning day -2, patients receive tacrolimus or cyclosporine IV continuously until able to receive orally (PO). Patients continue tacrolimus or cyclosporine PO to day 60 and tapered to day 100. Patients also receive mycophenolate mofetil PO or IV every 8 hours until day 40 and tapered to day 90. After completion of HSCT, patients are followed up for up to 1 year.

Official Title
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A Pilot Study of Allogeneic Hematopoietic Stem Cell Transplantation for Pediatric and Adolescent-Young Adults Patients With High Risk Solid Tumors

Conditions
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Desmoplastic Small Round Cell Tumor, Ewing Sarcoma/Peripheral Primitive Neuroectodermal Tumor, Recurrent Desmoplastic Small Round Cell Tumor, Recurrent Malignant Peripheral Nerve Sheath Tumor, Recurrent Malignant Solid Neoplasm, Recurrent Neuroblastoma, Recurrent Rhabdomyosarcoma, Refractory Desmoplastic Small Round Cell Tumor, Refractory Malignant Peripheral Nerve Sheath Tumor, Refractory Malignant Solid Neoplasm, Refractory Neuroblastoma, Refractory Rhabdomyosarcoma

Intervention / Treatment
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* Procedure: Allogeneic Hematopoietic Stem Cell Transplantation
* Drug: Cyclosporine
* Drug: Etoposide
* Drug: Fludarabine Phosphate
* Biological: Lapine T-Lymphocyte Immune Globulin
* Drug: Melphalan
* Drug: Mycophenolate Mofetil
* Drug: Tacrolimus
* Drug: Thiotepa


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Pathological criteria, including malignant recurrent/refractory solid tumors. This would include: Ewing's/peripheral primitive neuroectodermal tumor (PNET) Malignant peripheral nerve sheath tumor, neurofibrosarcoma Rhabdomyosarcoma Neuroblastoma (patients who are ineligible for tandem autologous transplant or who are at least 3 months post autologous HCT) Desmoplastic small round cell tumor (DSRCT)- both new diagnoses as well as recurrent/refractory disease Patients must have chemo-responsive disease, defined as; 30% or greater decrease in the tumor target lesions when compared to its pre-treatment evaluation. Patients with complete response will be eligible to participate Available suitable HCT donor Creatinine clearance or glomerular filtration rate (GFR) >= 50 ml/min/1.73m^2, and not requiring dialysis Diffusing capacity of lung for carbon monoxide (DLCO) (corrected for hemoglobin) >= 50% predicted. If unable to perform pulmonary function tests, then oxygen (O2) saturation >= 92% in room air Bilirubin =< 3 x upper limit of normal (ULN) and alanine aminotransferase (ALT) and aspartate aminotransferase (AST) =< 5 x for age (with the exception of isolated hyperbilirubinemia due to Gilbert's syndrome) DONOR: Matched related donor bone marrow (10 of 10 HLA alleles [HLA-A, B, C, DR, and DQ]. Matched related donor peripheral blood stem cell (PBSC) is allowed only if collection of bone marrow (BM) is not available or refused by parents/donor DONOR: Matched allogeneic umbilical cord blood (UCB): related High-resolution matching at A,B, DRB1 (minimum 4/6) KIR major histocompatibility complex (MHC) class 1 preferential mismatch (minimum 4/6) DONOR: Matched allogeneic umbilical cord blood: unrelated High-resolution matching at A,B, DRB1 (minimum 4/6) •*KIR MHC class 1 preferential mismatch (minimum 4/6) Exclusion Criteria: Lack of histocompatible suitable related donor/ graft source End-organ failure that precludes the ability to tolerate the transplant procedure, including conditioning regimen Renal failure requiring dialysis Congenital heart disease resulting in congestive heart failure Ventilatory failure: requires invasive mechanical ventilation Human immunodeficiency virus (HIV) infection Uncontrolled bacterial, viral, or fungal infections (currently taking medication yet clinical symptoms progress); stable, controlled disease with treatment is not an exclusion criteria A female of reproductive potential who is pregnant, planning to become pregnant during the study, or is nursing a child Any patient who does not fulfill the inclusion criteria listed above

Ages Eligible for Study
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Maximum Age: 25 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: Treatment (conditioning regimen, HSCT)<br>CONDITIONING REGIMEN: Patients receive thiotepa IV over 2-4 hours, etoposide IV over 60 minutes on days -8 to -6, melphalan IV over 20 minutes on days -5 and -4, and fludarabine phosphate IV over 1 hour on days -5 to -3 in the absence of disease progression or unacceptable toxicity. Patients receiving umbilical cord transplant also receive rabbit anti-thymocyte globulin IV on days -3 and -4. TRANSPLANT: Patients undergo HSCT on day 0. GVHD PROPHYLAXIS: Beginning day -2, patients receive tacrolimus or cyclosporine IV continuously until able to receive PO. Patients continue tacrolimus or cyclosporine PO to day 60 and tapered to day 100. Patients also receive mycophenolate mofetil PO or IV every 8 hours until day 40 and tapered to day 90. | Procedure: Allogeneic Hematopoietic Stem Cell Transplantation<br>* Undergo HSCT<br>* Other names: Stem Cell Transplantation, Allogeneic;Drug: Cyclosporine<br>* Given IV and PO<br>* Other names: SangCya;Drug: Etoposide<br>* Given IV<br>* Other names: VP16;Drug: Fludarabine Phosphate<br>* Given IV<br>* Other names: SH T 586;Biological: Lapine T-Lymphocyte Immune Globulin<br>* Given IV<br>* Other names: Thymoglobulin;Drug: Melphalan<br>* Given IV<br>* Other names: WR-19813;Drug: Mycophenolate Mofetil<br>* Given IV or PO<br>* Other names: MMF;Drug: Tacrolimus<br>* Given IV and PO<br>* Other names: Protopic;Drug: Thiotepa<br>* Given IV<br>* Other names: WR 45312;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Transplant-related mortality (TRM) | The proportion of patients with 30-day TRM will be reported together with the corresponding 95% Bayesian credible interval. | At 30 days | 
| Rate of grade III or higher organ toxicity attributable to conditioning | Assessed using the Bearman Regimen-Related Toxicities Scale. The proportion of patients with 30-day grade III or higher organ toxicity will be reported together with the corresponding 95% Bayesian credible interval. | Up to 30 days | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Time to platelet and neutrophil engraftment | Will be calculated and illustrated from the time of transplant by the method of Kaplan and Meier. | Up to 1 year post transplant | 
| Incidence of acute graft versus host disease (aGVHD) | The 100-day rates of acute with the competing risk of relapse will be estimated using the method of Gooley. | At 100 days post transplant | 
| Incidence of chronic GVHD | The 100-day rates of chronic GVHD with the competing risk of relapse will be estimated using the method of Gooley | At 100 days post transplant | 
| Incidence of chronic GVHD | The 1 year rates of chronic GVHD with the competing risk of relapse will be estimated using the method of Gooley. | At 1 year post transplant | 
| Rate of grade II organ toxicity | The 100-day rates of grade II organ toxicity will be reported as counts with percentages. | Up to 100 days post transplant | 
| Rate of graft failure (primary and secondary) | The 100-day rates of primary and secondary graft failure will be reported as counts with percentages. | Up to 100 days post transplant | 
| Rate of infectious complications | The 100-day rates of infectious complications will be reported as counts with percentages. | Up to 100 days post transplant | 
| Progression-free survival (PFS) | Will be assessed using the method of Kaplan and Meier. | At 180 days post transplant | 
| PFS | Will be calculated and illustrated from the time of transplant by the method of Kaplan and Meier. | At 100 days post transplant | 
| PFS | Will be calculated and illustrated from the time of transplant by the method of Kaplan and Meier. | At 1 year post transplant | 
| Incidence of relapse | Will be calculated and illustrated from the time of transplant by the method of Kaplan and Meier. | At 100 days post transplant | 
| Incidence of relapse | Will be calculated and illustrated from the time of transplant by the method of Kaplan and Meier. | At 1 year post transplant | 
| Overall survival (OS) | Will be calculated and illustrated from the time of transplant by the method of Kaplan and Meier. | At 100 days post transplant | 
| OS | Will be calculated and illustrated from the time of transplant by the method of Kaplan and Meier. | At 1 year post transplant |