Intensity-Modulated Radiation Therapy, Etoposide, and Cyclophosphamide Followed By Donor Stem Cell Transplant in Treating Patients With Relapsed or Refractory Acute Lymphoblastic Leukemia or Acute Myeloid Leukemia

Study Overview
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Brief Summary
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RATIONALE: Giving intensity modulated radiation therapy (IMRT) and chemotherapy, such as etoposide and cyclophosphamide, before a donor stem cell transplant helps stop the growth of cancer cells. It also helps 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 IMRT together with chemotherapy before transplant may stop this from happening. PURPOSE: This phase I/II trial is studying the side effects and best dose of intensity-modulated radiation therapy (IMRT) when given together with etoposide and cyclophosphamide followed by donor stem cell transplant and to see how well they work in treating patients with relapsed or refractory acute lymphoblastic leukemia (ALL) or acute myeloid leukemia (AML).

Detailed Description
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OBJECTIVES: I. To establish the maximum tolerated dose [MTD] of large field image-guided IMRT, using helical tomotherapy when given in combination with intravenous cyclophosphamide and VP-16 as a preparative regimen for allogeneic hematopoietic stem cell transplantation (HSCT) from an human leukocyte antigen (HLA)-identical sibling or unrelated donor in patients with ALL or AML with induction failure or in relapse. (Phase I) II. To describe the toxicity at each dose level standard. (Phase I) III. To collect data on the radiation dose to normal organs and bone marrow using tomotherapy targeted total-body irradiation (TBI). (Phase I) IV. To estimate the overall survival probability, disease free survival probability and relapse rate associated with this regimen. (Phase II) V. To characterize the treatment related mortality and toxicity profile (early/late) associated with this regimen. (Phase II) VI. To descriptively compare the outcomes of patients treated on this protocol to a comparable patient population conditioned with whole body radiation. (Phase II) OUTLINE: This is a phase I, dose-escalation study of intensity-modulated radiation therapy (IMRT) followed by a phase II study. PREPARATIVE REGIMEN: Patients undergo IMRT using helical tomotherapy once or twice daily on days -10 to -6 or -10 to -7. Patients also receive etoposide intravenously (IV) on day -6 or -5 and cyclophosphamide IV on day -4 or -3. TRANSPLANTATION: Patients undergo allogeneic peripheral blood stem cell or bone marrow transplantation on day -1 or day 0. After completion of study treatment, patients are followed up periodically for up to 2 years.

Official Title
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Phase I-II Study of Escalating Doses of Large Field Image-Guided Intensity Modulated Radiation Therapy (IMRT) Using Helical Tomotherapy in Combination With Etoposide (VP16) and Cytoxan as a Preparative Regimen for Allogeneic Hematopoietic Stem Cell (HSC) Transplantation for Patients With Poor Risk Acute Lymphocytic Leukemia (ALL) or Poor Risk Acute Myelogenous Leukemia (AML)

Conditions
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Leukemia

Intervention / Treatment
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* Drug: cyclophosphamide
* Drug: etoposide
* Procedure: allogeneic bone marrow transplantation
* Procedure: allogeneic hematopoietic stem cell transplantation
* Procedure: peripheral blood stem cell transplantation
* Radiation: intensity-modulated radiation therapy
* Radiation: tomotherapy


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patients with acute lymphocytic leukemia or acute myelogenous leukemia who are not in first or second remission (i.e., after failing remission induction therapy or in relapse or beyond second remission) All candidates for this study must have a human leukocyte antigen (HLA) (A, B, C, DR) identical sibling who is willing to donate bone marrow or primed blood stem cells or a 10/10 allele matched unrelated donor; a single allele mismatch at A, B, C, DR, or DQ and a KIR mismatch at C will be allowed; all ABO blood group combinations of the donor/recipient are acceptable since even major ABO compatibilities can be dealt with by various techniques Prior therapy with VP-16, Busulfan, and Cytoxan is allowed A cardiac evaluation with an electrocardiogram showing no ischemic changes or abnormal rhythm and an ejection fraction of >= 50% established by multi gated acquisition scan (MUGA) or echocardiogram Patients must have a serum creatinine of less than or equal to 1.2 or creatinine clearance > 80 ml/min A bilirubin of less than or equal to 1.5 Serum glutamic oxaloacetic transaminase (SGOT) less than 5 times the upper limit of normal Serum glutamate pyruvate transaminase (SGPT) less than 5 times the upper limit of normal Pulmonary functioning tests including diffusing capacity of carbon monoxide (DLCO) will be performed; forced expiratory volume in one second (FEV1) and DLCO should be greater than 50% of the predicted normal value The time from the end last induction or reinduction attempt should be >= 14 days Signed informed consent form approved by the Institutional Review Board (IRB) is required DONOR: Any sibling donors who are histocompatible with the prospective recipient will be considered a suitable donor Donors will be excluded if for psychological or medical reasons they are unable to tolerate the procedure Donor should be able to donate peripheral blood stem cells or bone marrow Exclusion Criteria: Prior radiation therapy that would exclude the use of total-body irradiation Patients who have undergone bone marrow transplantation previously and who have relapsed Patients with psychological or medical condition that patients physician deems unacceptable to proceed to allogeneic bone marrow transplant Pregnancy Electrocardiogram (EKG) showing ischemic changes or abnormal rhythm and/or an echocardiogram or MUGA scan showing abnormal wall motion or ejection fraction < 50%

Ages Eligible for Study
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Minimum Age: 7 Years
Maximum Age: 55 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
Allocation: Non-Randomized
Intervention Model: Sequential Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Level 1: 1200cGy<br>150cGy BID x Days 1-4. Total dose 1200cGy. | Drug: cyclophosphamide<br>* Given IV<br>* Other names: Endoxana;Drug: etoposide<br>* Given IV<br>* Other names: VP-16-213;Procedure: allogeneic bone marrow transplantation<br>* Occurs approximately 48 hours after completion of cyclophosphamide<br>Procedure: allogeneic hematopoietic stem cell transplantation<br>* Occurs approximately 48 hours after completion of cyclophosphamide<br>Procedure: peripheral blood stem cell transplantation<br>* Occurs approximately 48 hours after completion of cyclophosphamide<br>Radiation: intensity-modulated radiation therapy<br>* Undergo IMRT<br>* Other names: IMRT;Radiation: tomotherapy<br>* Undergo IMRT using helical tomotherapy<br>* Other names: helical tomotherapy;|
| Experimental: Level 2: 1350cGy<br>150cGy BID Day 1-4 then 150 cGy QD Day 5. Total dose 1350cGy. | Drug: cyclophosphamide<br>* Given IV<br>* Other names: Endoxana;Drug: etoposide<br>* Given IV<br>* Other names: VP-16-213;Procedure: allogeneic bone marrow transplantation<br>* Occurs approximately 48 hours after completion of cyclophosphamide<br>Procedure: allogeneic hematopoietic stem cell transplantation<br>* Occurs approximately 48 hours after completion of cyclophosphamide<br>Procedure: peripheral blood stem cell transplantation<br>* Occurs approximately 48 hours after completion of cyclophosphamide<br>Radiation: intensity-modulated radiation therapy<br>* Undergo IMRT<br>* Other names: IMRT;Radiation: tomotherapy<br>* Undergo IMRT using helical tomotherapy<br>* Other names: helical tomotherapy;|
| Experimental: Level 3: 1500cGy limited dose to ribs, sternum, liver, brain 1200cGy<br>150cGy BID Day 1-5. Total dose 1500Gy. | Drug: cyclophosphamide<br>* Given IV<br>* Other names: Endoxana;Drug: etoposide<br>* Given IV<br>* Other names: VP-16-213;Procedure: allogeneic bone marrow transplantation<br>* Occurs approximately 48 hours after completion of cyclophosphamide<br>Procedure: allogeneic hematopoietic stem cell transplantation<br>* Occurs approximately 48 hours after completion of cyclophosphamide<br>Procedure: peripheral blood stem cell transplantation<br>* Occurs approximately 48 hours after completion of cyclophosphamide<br>Radiation: intensity-modulated radiation therapy<br>* Undergo IMRT<br>* Other names: IMRT;Radiation: tomotherapy<br>* Undergo IMRT using helical tomotherapy<br>* Other names: helical tomotherapy;|
| Experimental: Level 4: 1500cGy limited dose to liver, brain 1200cGy<br>150cGy BID Day 1-5. Total dose 1500Gy. | Drug: cyclophosphamide<br>* Given IV<br>* Other names: Endoxana;Drug: etoposide<br>* Given IV<br>* Other names: VP-16-213;Procedure: allogeneic bone marrow transplantation<br>* Occurs approximately 48 hours after completion of cyclophosphamide<br>Procedure: allogeneic hematopoietic stem cell transplantation<br>* Occurs approximately 48 hours after completion of cyclophosphamide<br>Procedure: peripheral blood stem cell transplantation<br>* Occurs approximately 48 hours after completion of cyclophosphamide<br>Radiation: intensity-modulated radiation therapy<br>* Undergo IMRT<br>* Other names: IMRT;Radiation: tomotherapy<br>* Undergo IMRT using helical tomotherapy<br>* Other names: helical tomotherapy;|
| Experimental: Level 5: 1600cGy limited dose to liver, porta-hepatic, brain 1200cGy<br>160cGy BID Day 1-5. Total dose 1600Gy. | Drug: cyclophosphamide<br>* Given IV<br>* Other names: Endoxana;Drug: etoposide<br>* Given IV<br>* Other names: VP-16-213;Procedure: allogeneic bone marrow transplantation<br>* Occurs approximately 48 hours after completion of cyclophosphamide<br>Procedure: allogeneic hematopoietic stem cell transplantation<br>* Occurs approximately 48 hours after completion of cyclophosphamide<br>Procedure: peripheral blood stem cell transplantation<br>* Occurs approximately 48 hours after completion of cyclophosphamide<br>Radiation: intensity-modulated radiation therapy<br>* Undergo IMRT<br>* Other names: IMRT;Radiation: tomotherapy<br>* Undergo IMRT using helical tomotherapy<br>* Other names: helical tomotherapy;|
| Experimental: Level 6: 1700cGy limited dose to liver, porta-hepatic, brain 1200cGy<br>170cGy BID Day 1-5. Total dose 1700Gy. | Drug: cyclophosphamide<br>* Given IV<br>* Other names: Endoxana;Drug: etoposide<br>* Given IV<br>* Other names: VP-16-213;Procedure: allogeneic bone marrow transplantation<br>* Occurs approximately 48 hours after completion of cyclophosphamide<br>Procedure: allogeneic hematopoietic stem cell transplantation<br>* Occurs approximately 48 hours after completion of cyclophosphamide<br>Procedure: peripheral blood stem cell transplantation<br>* Occurs approximately 48 hours after completion of cyclophosphamide<br>Radiation: intensity-modulated radiation therapy<br>* Undergo IMRT<br>* Other names: IMRT;Radiation: tomotherapy<br>* Undergo IMRT using helical tomotherapy<br>* Other names: helical tomotherapy;|
| Experimental: Level 7: 1800cGy limited dose to liver, porta-hepatic, brain 1200cGy<br>180cGy BID Day 1-5. Total dose 1800Gy. | Drug: cyclophosphamide<br>* Given IV<br>* Other names: Endoxana;Drug: etoposide<br>* Given IV<br>* Other names: VP-16-213;Procedure: allogeneic bone marrow transplantation<br>* Occurs approximately 48 hours after completion of cyclophosphamide<br>Procedure: allogeneic hematopoietic stem cell transplantation<br>* Occurs approximately 48 hours after completion of cyclophosphamide<br>Procedure: peripheral blood stem cell transplantation<br>* Occurs approximately 48 hours after completion of cyclophosphamide<br>Radiation: intensity-modulated radiation therapy<br>* Undergo IMRT<br>* Other names: IMRT;Radiation: tomotherapy<br>* Undergo IMRT using helical tomotherapy<br>* Other names: helical tomotherapy;|
| Experimental: Level 8: 1900cGy limited dose to liver, porta-hepatic, brain 1200cGy<br>190cGy BID Day 1-5. Total dose 1900Gy. | Drug: cyclophosphamide<br>* Given IV<br>* Other names: Endoxana;Drug: etoposide<br>* Given IV<br>* Other names: VP-16-213;Procedure: allogeneic bone marrow transplantation<br>* Occurs approximately 48 hours after completion of cyclophosphamide<br>Procedure: allogeneic hematopoietic stem cell transplantation<br>* Occurs approximately 48 hours after completion of cyclophosphamide<br>Procedure: peripheral blood stem cell transplantation<br>* Occurs approximately 48 hours after completion of cyclophosphamide<br>Radiation: intensity-modulated radiation therapy<br>* Undergo IMRT<br>* Other names: IMRT;Radiation: tomotherapy<br>* Undergo IMRT using helical tomotherapy<br>* Other names: helical tomotherapy;|
| Experimental: Level 9: 2000cGy limited dose to liver, porta-hepatic, brain 1200cGy<br>200cGy BID Day 1-5. Total dose 2000Gy. | Drug: cyclophosphamide<br>* Given IV<br>* Other names: Endoxana;Drug: etoposide<br>* Given IV<br>* Other names: VP-16-213;Procedure: allogeneic bone marrow transplantation<br>* Occurs approximately 48 hours after completion of cyclophosphamide<br>Procedure: allogeneic hematopoietic stem cell transplantation<br>* Occurs approximately 48 hours after completion of cyclophosphamide<br>Procedure: peripheral blood stem cell transplantation<br>* Occurs approximately 48 hours after completion of cyclophosphamide<br>Radiation: intensity-modulated radiation therapy<br>* Undergo IMRT<br>* Other names: IMRT;Radiation: tomotherapy<br>* Undergo IMRT using helical tomotherapy<br>* Other names: helical tomotherapy;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Maximum Tolerated Dose of Intensity-modulated Radiotherapy (Phase I) | Toxicities will be recorded using two distinct grading systems: the modified Bearman scale and the National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE) 3.0 scale. | 30 days post transplant | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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recurrent adult acute lymphoblastic leukemia, recurrent childhood acute lymphoblastic leukemia