Clinical trial NCT01814475: Study to Compare Busulfan-fludarabine With Thiotepa-fludarabine Regimen in Allogeneic Transplantation for Myelofibrosis
Official title: Prospective, Phase II Randomized Study to Compare Busulfan-fludarabine Reduced-intensity Conditioning (RIC) With Thiotepa-fludarabine RIC Regimen Prior to Allogeneic Transplantation of Hematopoietic Cells for the Treatment of Myelofibrosis
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: PHASE2
Conditions: Myelofibrosis
Keywords: myelofibrosis
unfavourable prognostic factors
Allogeneic stem cell transplantation
Progression Free Survival
thrombocythemia vera
polycythemia vera
Reduced-intensity conditioning
Lead sponsor: Gruppo Italiano Trapianto di Midollo Osseo
Sponsor class: OTHER
First posted: 2013-03-20
Enrollment: 62
Sex: ALL
Minimum age (years): 18
Maximum age (years): 70
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Primary purpose: TREATMENT

Brief summary: This study will be performed as a prospective multicenter phase II trial for compare busulfan-fludarabine reduced-intensity conditioning (RIC) with thiotepa-fludarabine RIC regimen prior to allogeneic transplantation of hematopoietic cells for the treatment of myelofibrosis.

The primary endpoint for this study is to compare Progression Free Survival of two different RIC regimens for allogeneic stem cell transplantation in myelofibrosis.

Progression Free Survival is defined as the time from the date of randomization to the date of the first documented disease progression or relapse (according to the International Working Group Consensus Criteria) or death due to any cause. Patients who have neither progressed nor died at the time of study completion or who are lost to follow-up are censored at the data of the last follow up for progression of disease for this study.

Detailed description: This is the first study to explore the efficacy of two different Reduced-intensity conditioning (RIC) regimens for allogeneic stem cell transplantation in myelofibrosis. The choice of 60 patients is based on feasibility reasons. GITMO data at hand points to an estimated accrual of twenty patients per year over a tree-year enrolment period. Criteria for defining sample size do not follow statistical power estimates in order to demonstrate the difference of lack of it between two treatments. However, the criteria reflect the overall efficacy and safety of comparing the two treatments among all patients requiring the treatment within the health system. This criterion offers the best estimate for power of study.

Myelofibrosis is a clonal hematopoietic stem cell disorder that is clinically characterized by progressive anemia, marked splenomegaly, extramedullary hematopoiesis, constitutional symptoms and a significant risk of evolution into acute leukaemia myelofibrosis can appear as a primitive or idiopathic disorder or, less frequently, as a secondary complication of essential thrombocythemia or polycythemia vera, with a clinical presentation and course similar to the idiopathic form. The disease affects mainly elderly people, with a median age at diagnosis of about 65 years. It is a heterogeneous disorder in term of presentation and evolution, with a median overall survival (OS) varying between 2 and 15 years, depending on the presence or absence of clinically defined prognostic factors. Adverse prognostic factors for survival have included advanced age, marked anemia, leukocytosis or leukopenia, abnormal karyotype, constitutional symptoms and presence of circulating blasts. Moreover, the prognostic value of cytogenetic abnormalities, increased number of circulating cluster of differentiation 34 cells in peripheral blood and Janus kinase 2 mutational status has been also evaluated. The available prognostic score systems are mainly based on clinical variables. The most widely used is the 'Lille score' (Dupriez et al.) which is based on hemoglobin level and leukocyte count. The Mayo Clinic Group tried to improve the Lille score by adding thrombocytopenia and monocytosis. The International Working Group for Myelofibrosis Research and Treatment recently proposed a new scoring system analyzing the largest patient population and recognized 5 main unfavourable variables which were: age \> 65 years, presence of constitutional symptoms, and circulating blasts cells ≥ 1%, anemia and leucocytosis. All these prognostic systems could clearly separate intermediate or high risk patients (with a median survival ranging between 1 and 4 years) from patients with a favourable prognosis (median survival of 8-10 years).

Kroger on behalf of the European Group for Blood and Marrow Transplantation reported data on 104 patients mainly with intermediate or high risk score who received a conditioning regimen based on fludarabine 180 mg/mq and busulfan 8 mg/kg i.v or 10 mg/Kg p.o and hematopoietic stem cells coming from sibling or unrelated donors. Engraftment was 99%; 1-year transplant-related mortality was 16% and was significantly increased in patients older than 50 years, in cases with intermediate and high-risk myelofibrosis and after transplants from mismatched donors. Five-year overall survival was 67% and 5 -year event-free-survival was 51%. Relapse rate was higher in splenectomized patients and if disease duration prior transplant was \>24 months. Moreover, Kroger reported that this conditioning regimen induced a Janus kinase 2 negativity in 78% of patients carrying the V617-JAK2 mutation before transplant and produced a rapid regression of bone marrow fibrosis in 59% of patients al day +100 and in 100% of patients at day +360. At present, the busulfan-fludarabine regimen could be considered as the Reduced-intensity conditioning regimen that has been tested on the largest patient population and demonstrated the best results in terms of feasibility and clinical, molecular and histological responses.

The Principal Investigator has recently reported data on a population of 100 patients with myelofibrosis who underwent allogeneic hematopoietic stem cell transplantation in 26 transplant centers that are part of the GITMO in a 20-year period between 1986 and 2006 and we retrospectively analyzed the influence of patient and disease clinical features before stem cell transplantation and of transplant procedures on transplant-related mortality (TRM) and overall survival. We confirmed that myelofibrosis remains a rare indication for stem cell transplantation with the recruitment of about 15-17 cases per year since 2002 and observed a great heterogeneity in terms of conditioning regimens, Graft versus Host Disease prophylaxis and supportive measures. Although we observed a significative and progressive improvement of transplant-related mortality after 1996, we couldn't recognized any significative difference in outcome either between patients treated with myeloablative versus reduced- intensity regimens or among those treated with different Reduced-intensity conditioning regimen. The lack of any association between intensity of conditioning or type of drugs included in the preparative regimen could be in part due to the great heterogeneity of transplant procedures. However, we showed that the regimens including thiotepa were administered to 24 out 52 patients (46%), whereas the other patients received heterogeneous preparative regimens. The combination of thiotepa and cyclophosphamide was originally described for autologous transplants; then thiotepa was used with a 30% dose reduction as Reduced-intensity conditioning regimen in association with Cyclophosphamide and/or fludarabine followed by haematopoietic stem cells in elderly patients with acute leukemias, in heavily pretreated relapsed or refractory lymphomas and in myelodysplastic syndromes, showing to be highly feasible and effective. Both these protocols were used in Italy by researchers and physicians participating to GITMO.

In conclusion, the rational of the present study are the following:

* myelofibrosis is a rare indication for allogeneic transplantation with a limited number of patients recruitable in the whole Italian region.
* At the present time there are not available sufficient data to support a standard conditioning regimen for these patients.
* Italian hematologists grouped in the GITMO intend to overcome the general uncertainty in the choice of the conditioning regimen and to test prospectively in a controlled study a uniform strategy of transplant procedures for this rare condition.
* Therefore, we want to compare two Reduced-intensity conditioning regimens, the thiotepa-fludarabine regimen, that has been the most common one used in Italy in the last 5 years , and the busulfan-fludarabine one, that has been reported in the literature to achieve the best results in terms of feasibility and clinical responses . A randomized comparison is likely to increase our knowledge on safety and efficacy of these conditioning regimens and consolidate assumption for the planning of a phase II trial.

Eligibility criteria: Inclusion Criteria:

* Age ≥ 18 ≤ 70 years
* Primary or secondary myelofibrosis after essential thrombocythemia or polycythemia vera
* One of the following unfavourable prognostic factors: Hb \< 10 g/dL or leukocytes \>25x109/L or \> 1% circulating blasts in the peripheral blood or constitutional symptoms
* Performance Status (Karnofsky)≥ 60%
* Hematopoietic Cell Transplantation Comorbidity Score ≤ 5
* Written informed consent

Exclusion Criteria:

-≥ 20% blasts in peripheral blood and/or bone marrow

* Positive serologic markers for human immunodeficiency virus (HIV)
* Acute hepatitis B virus (HBV) or acute hepatic C virus (HCV) infection
* Severe irreversible renal, hepatic, pulmonary or cardiac disease, such as: --total bilirubin, Serum Glutamate Oxaloacetate Transaminase (SGOT) or Serum Glutamate Pyruvate Transaminase (SGPT) \> 5 the upper normal limit;

  * Left ventricular ejection fraction \< 40%;
  * Clearance creatinine \< 30 ml/min;
  * Diffusing Capacity of Lung for Carbon monoxide (DLCO) \< 30% and/or receiving supplementary oxygen.
* Pregnancy or lactation
* Any active, uncontrolled infection

Donors:

* Age ≥ 18 \< 65 years
* human leukocyte antigen (HLA)-identical sibling donor by high resolution DNA-based HLA-A, -B, -C, -DRB1, typing
* human leukocyte antigen (HLA)-identical unrelated donor by high resolution DNA-based human leukocyte antigen-A, human leukocyte antigen-B, human leukocyte antigen-C, human leukocyte antigen-DRB1 typing. One allele mismatched (class I) can be accepted for recipients up to 60 years.

Primary outcomes:
measure: Progression -free survival at one year
timeFrame: Assessment at 1 year post randomization
Secondary outcomes:
measure: Safety and efficacy profile: The non relapse mortality
timeFrame: Assessment at 1 year post randomization
measure: Safety and efficacy profile: Overall survival
timeFrame: Assessment at 1 year post randomization
measure: Safety and efficacy profile: responses
timeFrame: Assessment at 1 year post randomization
measure: Safety and efficacy profile: molecular remissions
timeFrame: Assessment at 1 year post randomization
measure: Safety and efficacy profile: engraftment
timeFrame: participants will be followed for the duration of hospital stay, an expected average of 30 days
measure: Acute Graft-versus-Host Disease (aGvHD)
timeFrame: from date of transplant to until the date of first event of aCGVD assessed up to 100 days post transplant
measure: Chronic Graft-versus-Host Disease (cGvHD)
timeFrame: from day +100 post transplant to until the date of first event to cGVHD assessed up to 1 years post enrolment
Other outcomes:
Locations:
city: Alessandria
country: Italy
facility: Azienda Ospedaliera SS Antonio e Biagio
city: Ancona
country: Italy
facility: Clinica di Ematologia - Ospedali Riuniti di Ancona
city: Bergamo
country: Italy
facility: Divisione di Ematologia - Ospedali Papa Giovanni XXIII
city: Brescia
country: Italy
facility: AO Spedali Civili di Brescia- USD - TMO Adulti
city: Catania
country: Italy
facility: Ospedale Ferrarotto - Ematologia
city: Firenze
country: Italy
facility: Cattedra di Ematologia - Azienda Ospedaliera di Careggi
city: Foggia
country: Italy
facility: Ematologia e Centro Trapianti Midollo Osseo - Ospedale IRCCS Casa Sollievo della Sofferenza
city: Genova
country: Italy
facility: AOU IRCCS San Martino - IST
city: Lecce
country: Italy
facility: Ospedale Panico
city: Milano
country: Italy
facility: Divisione di Ematologia - Istituto Nazionale dei Tumori
city: Modena
country: Italy
facility: Divisione Ematologia - Azienda Ospedaliera Universitaria - Policlinico -
city: Palermo
country: Italy
facility: AO Ospedali Riuniti Villa Sofia - Cervello
city: Palermo
country: Italy
facility: Dipartimento Oncologico La Maddalena
city: Pavia
country: Italy
facility: Fondazione IRCCS San Matteo
city: Pescara
country: Italy
facility: Dip. di Ematologia - Unità di Terapia Intensiva Ematologica per il Trapianto Emopoietico - Ospedale Civile di Pescara
city: Reggio Calabria
country: Italy
facility: Centro Unico Regionale Trapianti di Midollo Osseo - Ospedale Bianchi-Melacino-Morelli
city: Reggio Emilia
country: Italy
facility: Arciospedale S. M. Novella
city: Roma
country: Italy
facility: Cattedra di Ematologia - Università La Sapienza
city: Taranto
country: Italy
facility: Ospedale San Giuseppe Moscato
city: Torino
country: Italy
facility: Ematologia 2 - ASO San Giovanni Battista
city: Udine
country: Italy
facility: A.O. Santa Maria della Misericordia
Study officials:
affiliation: Azienda Ospedaliera Santa Maria della Misericordia di Udine
name: Francesca Patriarca, MD
role: PRINCIPAL_INVESTIGATOR
References: