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Bone Marrow Transplant

Graft-Versus-Host Disease Prophylaxis in Treating Patients With Hematologic Malignancies Undergoing Unrelated Donor Peripheral Blood Stem Cell Transplant (FHCRC-2448)
A Randomized Phase II Study to Determine the Most Promising Postgrafting Immunosuppression for Prevention of Acute GVHD after Unrelated Donor Hematopoietic Cell Transplantation using Nonmyeloablative Conditioning for Patients with Hematologic Malignancies: A Multi-Center Trial
Status Conditions Phase Study ID
Recruiting Hematologic Malignancies Phase II FHCRC-2448

RATIONALE: Giving chemotherapy and total-body irradiation before a donor peripheral blood stem cell transplant helps stop the growth of cancer cells. It may also 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 total-body irradiation together with fludarabine phosphate, cyclosporine, mycophenolate mofetil, or sirolimus before transplant may stop this from happening. PURPOSE: This phase II trial is studying how well graft-vs-host disease prophylaxis works in treating patients with hematologic malignancies undergoing unrelated donor peripheral blood stem cell transplant.

Brenda Sandmaier, MD
Seattle Cancer Care Alliance 800-804-8824  
Eligibility Criteria (must meet the following to participate in this study)

Genders Eligible for Study:   Both
Accepts Healthy Volunteers:   No


Inclusion Criteria:

  • Ages > 50 years with hematologic malignancies treatable by unrelated HCT
  • Ages >= 50 years of age with hematologic diseases treatable by allogeneic HCT who through pre-existing medical conditions or prior therapy are considered to be at high risk for regimen related toxicity associated with a high dose transplant (> 40% risk of TRM); this criterion can include patients with a HCT-CI score of >= 1; transplants should be approved for these inclusion criteria by both the participating institutions' patient review committees such as the Patient Care Conference (PCC) at the FHCRC and by the principal investigators at the collaborating centers; patients =< 50 years of age who have received previous high-dose transplantation do not require patient review committee approvals; all children < 12 years must be discussed with the FHCRC PI (Brenda Sandmaier, MD 206 667 4961) prior to registration
  • Ages =< 50 years of age with chronic lymphocytic leukemia (CLL) (these patients do not require patient review committee approvals)
  • Ages =< 50 years of age with hematologic diseases treatable by allogeneic HCT who refuse a high-dose HCT; transplants must be approved for these inclusion criteria by both the participating institutions' patient review committee such as PCC at the FHCRC and by the principal investigators at the collaborating centers
  • Aggressive non-Hodgkin lymphomas (NHL) and other histologies such as Diffuse large B cell NHL not eligible for autologous HCT, not eligible for high-dose allogeneic HCT, or after failed autologous HCT
  • Mantle Cell NHL: may be treated in first CR (Diagnostic LP required pre-transplant)
  • Low grade NHL: with < 6 month duration of CR between courses of conventional therapy
  • CLL : must have either 1) failed to meet NCI Working Group criteria for complete or partial response after therapy with a regimen containing FLU (or another nucleoside analog, e.g. 2-CDA, pentostatin) or experience disease relapse within 12 months after completing therapy with a regimen containing FLU (or another nucleoside analog); 2) failed FLU-CY-Rituximab (FCR) combination chemotherapy at any time point; or 3) have "17p deletion" cytogenetic abnormality; patients should have received induction chemotherapy but could be transplanted in 1st CR
  • Hodgkin Lymphoma: must have received and failed frontline therapy
  • Multiple Myeloma: must have received prior chemotherapy; consolidation of chemotherapy by autografting prior to nonmyeloablative HCT is permitted
  • Acute Myeloid Leukemia (AML): must have < 5% marrow blasts at the time of transplant
  • Acute Lymphocytic Leukemia (ALL): must have < 5% marrow blasts at the time of transplant
  • Chronic Myeloid Leukemia (CML): Patients will be accepted if they are beyond CP1 and if they have received previous myelosuppressive chemotherapy or HCT, and have < 5% marrow blasts at time of transplant
  • Myelodysplasia (MDS)/Myeloproliferative Syndrome (MPS): Patients must have < 5% marrow blasts at time of transplant
  • Waldenstrom's Macroglobulinemia: must have failed 2 courses of therapy
  • DONOR: Matched for HLA-A, B, C, DRB1 and DQB1 by high resolution typing
  • DONOR: Only a single allele disparity will be allowed for HLA-A, B, or C as defined by high resolution typing
  • DONOR: Donors are excluded when preexisting immunoreactivity is identified that would jeopardize donor hematopoietic cell engraftment; this determination is based on the standard practice of the individual institution; the recommended procedure for patients with 10 of 10 HLA allele level (phenotypic) match is to obtain a panel reactive antibody (PRA) screens to class I and class II antigens for all patients before HCT; if the PRA shows > 10% activity, then flow cytometric or B and T cell cytotoxic cross matches should be obtained; the donor should be excluded if any of the cytotoxic cross match assays are positive; for those patients with an HLA Class I allele mismatch, flow cytometric or B and T cell cytotoxic cross matches should be obtained regardless of the PRA results; a positive anti-donor cytotoxic crossmatch is an absolute donor exclusion
  • DONOR: Patient and donor pairs homozygous at a mismatched allele in the graft rejection vector are considered a two-allele mismatch, i.e., the patient is A*0101 and the donor is A*0102, and this type of mismatch is not allowed
  • DONOR: Only G-CSF mobilized PBSC only will be permitted as a HSC source on this protocol
Exclusions (conditions that would prevent participation in this study)

Exclusion Criteria:

  • Patients with rapidly progressive intermediate or high grade NHL
  • Patients with a diagnosis of CMML
  • Patients with RAEB who have not received myelosuppressive chemotherapy i.e. induction chemotherapy
  • CNS involvement with disease refractory to intrathecal chemotherapy
  • Presence of circulating leukemic blasts (in the peripheral blood) detected by standard pathology for patients with AML, MDS, ALL or CML
  • Fertile men or women unwilling to use contraceptive techniques during and for 12 months following treatment
  • Females who are pregnant or breast-feeding
  • Patients with active non-hematological malignancies (except non-melanoma skin cancers) or those with non-hematological malignancies (except non-melanoma skin cancers) who have been rendered with no evidence of disease, but have a greater than 20% chance of having disease recurrence within 5 years
  • Fungal infections with radiological progression after receipt of amphotericin B or active triazole for greater than 1 month
  • Cardiac ejection fraction < 35%; ejection fraction is required if age > 50 years or there is a history of anthracycline exposure or history of cardiac disease
  • DLCO < 40%, TLC < 40%, FEV1 < 40% and/or receiving supplementary continuous oxygen
  • The FHCRC PI of the study must approve of enrollment of all patients with pulmonary nodules
  • Patients with clinical or laboratory evidence of liver disease would be evaluated for the cause of liver disease, its clinical severity in terms of liver function, and the degree of portal hypertension; patients will be excluded if they are found to have fulminant liver failure, cirrhosis of the liver with evidence of portal hypertension, alcoholic hepatitis, esophageal varices, a history of bleeding esophageal varices, hepatic encephalopathy, uncorrectable hepatic synthetic dysfunction evinced by prolongation of the prothrombin time, ascites related to portal hypertension, bridging fibrosis, bacterial or fungal liver abscess, biliary obstruction, chronic viral hepatitis with total serum bilirubin > 3 mg/dL, or symptomatic biliary disease
  • Karnofsky scores < 60 or Lansky Score < 50
  • Patient has poorly controlled hypertension and on multiple antihypertensives
  • HIV positive patients
  • Active bacterial or fungal infections unresponsive to medical therapy
  • All patients receiving voriconazole therapy and who are then randomized to Arm 2 or Arm 3 must have voriconazole reduced by 90% of starting dose
  • The addition of cytotoxic agents for "cytoreduction" with the exception of tyrosine kinase inhibitors (such as imatinib), cytokine therapy, hydroxyurea, low dose cytarabine, chlorambucil, or rituxan will not be allowed within three weeks of the initiation of conditioning
  • DONOR: Donor (or centers) who will exclusively donate marrow
  • DONOR: HIV-positive and/or, medical conditions that would result in increased risk for G-CSF mobilization and harvest of PBSC
Last Updated
October 25, 2011
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