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Bone Marrow Transplant

High-Dose Cyclophosphamide and Anti-Thymocyte Globulin Followed by Peripheral Blood Stem Cell Transplant for Systemic Scleroderma (2533)
A Phase II Multi-Center Study of High-Dose Cyclophosphamide and Antithymocyte Globulin Followed by Autologous Hematopoietic Cell Transplantation for the Treatment of Systemic Sclerosis
Status Conditions Phase Study ID
Closed Systemic Scleroderma Phase II 2533

Purpose This phase II trial studies how well giving cyclophosphamide and anti-thymocyte globulin together followed by peripheral blood stem cell transplant (PBSCT) works in treating patients with systemic Sclerosis. Stem cells are collected from the patient's blood and stored prior to treatment. To store the stem cells patients are given colony-stimulating factor, filgrastim (G-CSF) or chemotherapy (cyclophosphamide) to help stem cells move from the bone marrow to the blood so they can be collected and stored. After storage, patients are then given high-dose chemotherapy, cyclophosphamide, and immunosuppression with anti-thymocyte globulin to suppress the immune system. The stem cells are then returned to the patient to replace the blood-forming cells that were destroyed by the chemotherapy and immunosuppression.

George Georges, MD
Seattle Cancer Care Alliance 800-804-8824  
Eligibility Criteria (must meet the following to participate in this study)
  • GROUP 1: Patients must have 1) both a and b below; and 2) at least one of c, d or e
  • a) Diffuse cutaneous scleroderma as defined by skin thickening proximal to the elbows and knees and/or involving the torso in addition to distal extremity involvement; a skin score will be obtained but not used to determine eligibility
  • b) Duration of systemic sclerosis =< 7 years from the onset of first non-Raynaud's symptom; for those patients with disease activity between 5-7 years from the onset of first non-Raynaud's symptom, recent progression or activity of disease must be documented for evaluation by the evaluation resource center (ERC)
  • c) Presence of SSc-related pulmonary disease with forced vital capacity (FVC) < 80% or hemoglobin-adjusted diffusing capacity for carbon monoxide (DLCO)1 < 70% of predicted AND evidence of alveolitis by high-resolution chest computed tomography (CT) scan and/or by bronchoalveolar lavage (BAL) (if high resolution computed tomography [HRCT] fails to show ground glass, then BAL for diagnosis of alveolitis must be confirmed); alveolitis by BAL cell count will be defined based on a BAL cell differential count (> 3% neutrophils and/or > 2% eosinophils) from any lavaged lobe
  • d) History of SSc-related renal disease that may not be active at the time of screening; stable serum creatinine must be documented for a minimum of 3 months post-renal crisis at the time of the baseline visit; history of scleroderma hypertensive renal crisis is included in this criterion and is defined as follows:
  • e) History of new-onset hypertension based on any of the following (measurements must be repeated and confirmed at least 2 hours apart within 3 days of first event-associated observation, with a change from baseline):
  • Systolic blood pressure (SBP) >=140 mmHg
  • Diastolic blood pressure (DBP) >= 90 mmHg
  • Rise in SBP >= 30 mmHg compared to baseline
  • Rise in DBP >= 20 mmHg compared to baseline
  • AND one of the following 5 laboratory criteria:
  • Increase of >= 50 % above baseline in serum creatinine
  • Proteinuria: >= 2+ by dipstick confirmed by protein:creatinine ratio > 2.5
  • Hematuria: >= 2+ by dipstick or > 10 red blood cell (RBC)s/hematopoietic-promoting factor (HPF) (without menstruation)
  • Thrombocytopenia: < 100,000 plts/mm3
  • Hemolysis: by blood smear or increased reticulocyte count
  • The above definition of SSc hypertensive renal crisis is independent of whether concomitant anti-hypertensive medications are used
  • Subjects who present with solely skin and renal disease in the absence of other organ involvement, except classic SSc renal crisis as described above and including non-hypertensive renal crisis, must see a nephrologist to confirm that their renal disease is secondary to only SSc
  • Note: Subjects may be re-screened if they fail to meet inclusion criteria on initial evaluation
  • GROUP 2:
  • Progressive pulmonary disease as defined by a decrease in the FVC or DLCO-adjusted by 10 or 15 percent or greater, respectively, from a prior FVC or DLCO-adjusted in the previous 18-month period
  • Patients will have diffuse cutaneous disease and may have both FVC and DLCOcorr >= 70% at screening for the study
  • Patients must also have evidence of alveolitis as defined by abnormal chest CT or BAL
  • GROUP 3:
  • Diffuse scleroderma with disease duration =< 2 years since development of first sign of skin thickening plus modified Rodnan skin score >= 25 plus either
  • Erythrocyte sedimentation rate (ESR) > 25 mm/1st hour and/or hemoglobin (Hb) < 11 g/dL, not explained by causes other than active scleroderma
  • Lung involvement (either FVC or DLCO < 80% and evidence of interstitial lung disease by CT scan or alveolitis by BAL)
  • Patients in group 3 must have a left ventricular ejection fraction of > 50% by Doppler echocardiography or multi gated acquisition scan (MUGA) scan
  • If arrhythmias are evident clinically, then an evaluation by a cardiologist is required
  • GROUP 4:
  • Diffuse scleroderma with disease duration =< 2 years and skin score >= 30
  • Patients in group 4 must have a left ventricular ejection fraction of > 50% by Doppler echocardiography or MUGA scan
  • If arrhythmias are evident clinically, then an evaluation by a cardiologist is required
  • GROUP 5:
  • Limited cutaneous scleroderma and SSc-related pulmonary disease with FVC < 80% or hemoglobin-adjusted DLCO < 70% of predicted
  • AND evidence of alveolitis by high-resolution chest CT scan and/or by BAL (if HRCT fails to show ground glass, then BAL for diagnosis of alveolitis must be confirmed)
  • Alveolitis by BAL cell count will be defined based on a BAL cell differential count (> 3% neutrophils and/or > 2% eosinophils) from any lavaged lobe
Exclusions (conditions that would prevent participation in this study)
  • Subjects with pulmonary, cardiac, hepatic, or renal impairment that would limit their ability to receive cytoreductive therapy and compromise their survival; this includes, but is not restricted to, subjects with any of the following:
  • Pulmonary dysfunction defined as:
  • Severe pulmonary dysfunction with (1) a hemoglobin corrected DLCO < 45% of predicted at the Clinical Review, (2) a hemoglobin-correct DLCO < 40% of predicted at the Baseline Screening visit, or (3) FVC < 45% of predicted at the Clinical review or Baseline Screening visit, or
  • pO2 < 70 mmHg or pCO2 >= 45 mmHg without supplemental oxygen, or
  • O2 saturation < 92% at rest without supplemental oxygen as measured by forehead pulse oximeter
  • Significant pulmonary artery hypertension (PAH) defined as:
  • Peak systolic pulmonary artery pressure > 50 mmHg by resting echocardiogram will require right heart catheterization; if pulmonary artery pressure (PAP) is not evaluable on echocardiogram due to lack of a Tricuspid regurgitant jet, then normal anatomy and function as evidenced by normal right atrium and ventricle size, shape and wall thickness and septum shape must be documented to rule-out PAH; otherwise, right heart catheterization is indicated; prior history of PAH but controlled with medications will not exclude patients from the protocol
  • Mean pulmonary artery pressure by right heart catheterization exceeding 30 mmHg at rest; if mean PAP is elevated and pulmonary vascular resistance and transpulmonary gradient are normal then the patient is eligible for the protocol
  • New York Heart Association (NYHA)/World Health Organization Class III or IV
  • Cardiac: Uncontrolled clinically significant arrhythmias; clinical evidence of significant congestive heart failure (CHF) (NYHA Class III or IV); left ventricular ejection fraction (LVEF) < 50% by echocardiogram; or prior insertion of a pacemaker or cardioverter-defibrillator
  • History/presence of arrhythmia (even controlled) on chemical anti-arrhythmic(s) must have cardiac consult prior to randomization to ensure the subject could safely proceed with protocol requirements
  • Significant renal pathology defined as:
  • Estimated creatinine clearance (CrCl) < 40 mL/min (using Cockcroft-Gault formula based on actual body weight ) and serum creatinine > 2.0 mg/dL; OR
  • Active, untreated SSc renal crisis at the time of enrollment
  • Hepatic: Active hepatitis (alanine aminotransferase [ALT], aspartate aminotransferase [AST], or bilirubin > 2 times the upper limit of normal [ULN]) or evidence of moderate to severe periportal fibrosis by liver biopsy
  • Active or clinically significant Gastric Antral Vascular Ectasia (GAVE, "watermelon stomach")
  • Unwilling or unable to discontinue disallowed disease-modifying antirheumatic drugs (DMARDs) for treatment of SSc at time of randomization
  • History or presence of a 2nd autoimmune disease requiring immunosuppressive therapy that has substantial risk of immunosuppressive treatment beyond transplant with the following exceptions:
  • History and/or presence of Sjogren's Syndrome is allowed
  • Stable myositis (A history of myositis that is clinically stable as defined by lack of progressive proximal muscle weakness and a stable or decreasing creatine phosphokinase [CPK] < 3x ULN) is allowed
  • The presence of anti-ds-deoxyribonucleic acid (DNA) without clinical systemic lupus erythematosus in a patient with a diagnosis of otherwise "pure" SSc is allowed
  • Concomitant rheumatoid arthritis without extra-articular disease characteristic of rheumatoid arthritis is allowed
  • Active uncontrolled infection that would be a contraindication to safe use of high-dose therapy
  • Positive study for Hepatitis B surface antigen or Hepatitis B or C confirmed by polymerase chain reaction (PCR)
  • Positive serology for human immunodeficiency virus (HIV)
  • Absolute neutrophil count (ANC) < 1500 cells/uL
  • Platelets < 100,000 cells/uL
  • Hematocrit < 27%
  • Hemoglobin < 9.0 g/dL
  • Malignancy within the 2 years prior to randomization, excluding adequately treated squamous cell skin cancer, basal cell carcinoma, and carcinoma in situ; treatment must have been completed (with the exception of hormonal therapy for breast cancer) with cure/remission status verified for at least 2 years at time of randomization
  • Presence of other comorbid illnesses with an estimated median life expectancy < 5 years
  • Evidence of myelodysplasia (MDS); subjects with history of receiving any prior chemotherapy and/or radiotherapy for the treatment of malignant disease, history of greater than 2 months total prior cyclophosphamide for any condition (regardless of dose and route) and/or subjects presenting with abnormal peripheral blood counts require unilateral bone marrow aspiration for pathology, flow cytometry, cytogenetics, and fluorescence in situ hybridization (FISH) MDS panel (per institutional profile) to rule out MDS
  • Pregnancy
  • Inability to give voluntary informed consent
  • Unwilling to use contraceptive methods for at least 15 months after starting treatment
Last Updated
May 12, 2014
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