Allogeneic Stem Cell Transplant After ATG, High-Dose Melphalan, and Fludarabine for Patients With Breast Cancer

Study Overview
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Brief Summary
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RATIONALE: Giving chemotherapy, such as fludarabine and melphalan, before a donor peripheral blood stem cell transplant helps stop the growth of tumor cells. It also stops the patient's immune system from rejecting the donor's stem cells. The donated stem cells may replace the patient's immune system and help destroy any remaining tumor cells (graft-versus-tumor effect). Giving an infusion of the donor's T cells (donor lymphocyte infusion) after the transplant may help increase this effect. Sometimes the transplanted cells from a donor can also make an immune response against the body's normal cells. Giving antithymocyte globulin, cyclosporine, and methotrexate before or after the transplant may stop this from happening. PURPOSE: This phase II trial is studying how well antithymocyte globulin, high-dose melphalan, fludarabine, and allogeneic peripheral stem cell transplant work in treating patients with metastatic adenocarcinoma of the breast.

Detailed Description
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OBJECTIVES: Primary Determine the toxicity and tolerability of allogeneic peripheral blood stem cell transplantation after a nonmyeloablative preparative regimen comprising anti-thymocyte globulin, high-dose melphalan, and fludarabine in women with chemotherapy-refractory or poor-prognosis metastatic adenocarcinoma of the breast. Determine the ability of this preparative regimen to facilitate long-term engraftment of allogeneic stem cells and lymphocytes in these patients. Determine the response in measurable/evaluable disease and its temporal relationship to the preparative chemotherapy used and to the onset of clinical graft-versus-host disease (GVHD) in patients treated with this regimen. Secondary Determine the progression-free and overall survival of patients treated with this regimen. Determine the tumor response and its temporal relationship to administration of high-dose chemotherapy and to the onset of GVHD in patients treated with this regimen. Determine the frequency and durability of the induction of full donor chimerism of lymphocytes in patients treated with this regimen. OUTLINE: This is a nonrandomized, pilot study. Nonmyeloablative preparative regimen: Patients receive fludarabine IV over 30 minutes on days -8 to -4, anti-thymocyte globulin IV over 4 hours on days -7 to -4, and high-dose melphalan IV over 30 minutes on days -3 and -2. Graft-versus-host disease (GVHD) prophylaxis: Patients receive cyclosporine IV (and then orally when tolerated) every 12 hours beginning on day -4 and tapered after day 42 (if no GVHD occurs) or after day 90 (if grade I acute GVHD occurs). Patients also receive methotrexate IV on days 1, 3, and 6. Allogeneic peripheral blood stem cell transplantation (PBSCT): Patients undergo allogeneic PBSCT on day 0. Patients also receive filgrastim (G-CSF) IV or subcutaneously beginning on day 0 and continuing until blood counts recover. Donor lymphocyte infusion (DLI): Patients who show disease progression or fail to achieve full donor type T-cell chimerism (at least 90% donor derived T-cells) by the 90-day assessment posttransplantation, and have no evidence of active GVHD may receive DLI. Patients who have unresponsive disease with no active GVHD receive subsequent DLIs every 6-8 weeks. Patients are followed at 1, 3, 6, 12, 18, 24, 30, and 36 months. PROJECTED ACCRUAL: A total of 10 patients will be accrued for this study.

Official Title
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Pilot Study Of Allogeneic Peripheral Blood Progenitor Cell Transplantation In Patients With Chemotherapy-Refractory Or Poor-Prognosis Metastatic Breast Cancer

Conditions
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Breast Cancer

Intervention / Treatment
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* Biological: anti-thymocyte globulin
* Biological: filgrastim
* Biological: graft-versus-tumor induction therapy
* Biological: therapeutic allogeneic lymphocytes
* Drug: cyclosporine
* Drug: fludarabine phosphate
* Drug: melphalan
* Drug: methotrexate
* Procedure: peripheral blood stem cell transplantation


Participation Criteria
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Eligibility Criteria
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DISEASE CHARACTERISTICS: Histologically confirmed adenocarcinoma of the breast Metastatic disease Meets 1 of the following criteria: Chemotherapy-unresponsive disease defined as 1 of the following: Less than a partial response to 2 consecutive chemotherapy regimens that included an anthracycline and a taxane in combination or succession Progression of disease during or within 3 months of completion of a taxane, anthracycline, or platinol-based regimen Histologically confirmed tumor involvement on bone marrow biopsy Measurable or evaluable disease* defined as the following: Bidimensionally reproducible measurable mass by physical examination, ultrasonography, radiography, CT scan, or MRI Evaluable lesions apparent on clinical exam, x-ray, CT scan, or MRI which do not fit the criteria for measurability (e.g., ill-defined post-surgical masses or masses assessable in 1 dimension only) Elevation of biological markers (e.g., CA 27.29) is considered evaluable disease NOTE: *Bone lesions or pleural or peritoneal effusion alone are not considered measurable or evaluable disease Appropriate candidate for allogeneic stem cell transplantation No active CNS metastases Available HLA-identical sibling donor 6/6 antigen match Donor CD34 cells at least 2 times 10^6/kg recipient weight Hormone receptor status: Estrogen receptor negative or positive Estrogen receptor positive tumors must demonstrate progression on at least 1 hormonal manipulation PATIENT CHARACTERISTICS: Age 18 to 60 Sex Female Menopausal status Not specified Performance status Karnofsky 70-100% OR ECOG 0-1 Life expectancy Not specified Hematopoietic WBC at least 1,500/mm^3 Platelet count at least 30,000/mm^3 Hepatic Bilirubin less than 3 times normal* AST and ALT less than 3 times normal* NOTE: *Unless abnormality due to malignancy Renal Creatinine no greater than 1.6 mg/dL Cardiovascular LVEF greater than 40% by echocardiography or MUGA No myocardial infarction within the past 6 months Pulmonary DLCO greater than 40% of predicted Other Not pregnant or nursing Negative pregnancy test Fertile patients must use effective contraception HIV negative No serious localized or systemic infection No hypersensitivity to E. coli-derived products No history of non-breast malignant disease within the past 5 years except completely excised nonmelanoma skin cancer or carcinoma in situ of the cervix No chronic inflammatory disorder requiring concurrent glucocorticosteroids or other immunosuppressive medication No psychological condition or social situation that would preclude study participation PRIOR CONCURRENT THERAPY: Biologic therapy Not specified Chemotherapy See Disease Characteristics Endocrine therapy No concurrent glucocorticoids Radiotherapy No prior radiotherapy to an indicator lesion unless the lesion shows evidence of progression after discontinuation of the therapy Surgery Not specified Other No concurrent immunosuppressive medication

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 60 Years

Sexes Eligible for Study
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Female

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<br> | Biological: anti-thymocyte globulin<br> <br> Biological: filgrastim<br> <br> Biological: graft-versus-tumor induction therapy<br> <br> Biological: therapeutic allogeneic lymphocytes<br> <br> Drug: cyclosporine<br> <br> Drug: fludarabine phosphate<br> <br> Drug: melphalan<br> <br> Drug: methotrexate<br> <br> Procedure: peripheral blood stem cell transplantation<br> <br> |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of Participants With Adverse Events |  | 5 years post transplant | 
| Number of Participants With Long-term Engraftment of Allogeneic Stem Cells and Lymphocytes | Long-term Engraftment of Allogeneic Stem Cells and Lymphocytes based on cell counts of ANC >1000 for 3 consecutive days and platelet count of >50,000 | 30 days post transplant | 
| Number of Participants With Acute and Chronic Graft-versus-host Disease (GVHD) |  | 100 days post transplant | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Progression-free Survival | Progression assessed by CT scan | From date of transplant until the date of first documented progression or date of death from any cause, whichever came first, assessed up to 6 months | 
| Overall Survival |  | 1 year from the time of transplant | 
| Response as Measured at 12 Months Post Allografting | response (partial and complete) assessed by CT scan at 12 months post allografting | From date of transplant until the date of first documented progression or date of death from any cause, whichever came first, assessed up to 12 months | 
| Frequency of the Induction of Full Donor Chimerism of Lymphocytes as Measured at 1 Month Post Allografting |  | 1 month post allografting | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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recurrent breast cancer, stage IV breast cancer