Now Available for Public Comment: Notice of Proposed Rulemaking (NPRM) for FDAAA 801 and NIH Draft Reporting Policy for NIH-Funded Trials

Chemotherapy Followed by Allogeneic Stem Cell Transplantation for Hematologic Malignancies

This study is ongoing, but not recruiting participants.
Sponsor:
Information provided by (Responsible Party):
Dartmouth-Hitchcock Medical Center
ClinicalTrials.gov Identifier:
NCT00741455
First received: August 25, 2008
Last updated: February 28, 2014
Last verified: February 2014
  Purpose

The purpose of this study is to determine disease-free survival, overall survival, time to progression, regimen-related toxicity and/or treatment-related mortality in patients with hematologic malignancies treated with non-myeloablative chemotherapy followed by allogeneic stem cell transplant.


Condition Intervention
Hematologic Malignancies
Procedure: Chemotherapy followed by Stem Cell Transplantation

Study Type: Interventional
Study Design: Endpoint Classification: Safety/Efficacy Study
Intervention Model: Single Group Assignment
Masking: Open Label
Primary Purpose: Treatment
Official Title: Non-Myeloablative Chemotherapy Followed by HLA-Matched Related Allogeneic Stem Cell Transplantation for Hematologic Malignancies

Resource links provided by NLM:


Further study details as provided by Dartmouth-Hitchcock Medical Center:

Primary Outcome Measures:
  • Rates of successful engraftment. [ Time Frame: Anytime after Bone Marrow Transplant ] [ Designated as safety issue: No ]

Secondary Outcome Measures:
  • Complete donor chimerism [ Time Frame: Chimeric studies will be undertaken on post-transplant days +30, +60, +100, +180 and +365 ] [ Designated as safety issue: No ]
  • Graft-versus-host disease (acute and chronic) [ Time Frame: Any time after Bone Marrow Transplant ] [ Designated as safety issue: No ]
  • Mortality [ Time Frame: Any time after Bone Marrow Transplant ] [ Designated as safety issue: No ]
  • Toxicity [ Time Frame: Until the 6th Bone Marrow Transplant ] [ Designated as safety issue: Yes ]
  • Tumor Response Rate [ Time Frame: Anytime after Bone Marrow Transplant ] [ Designated as safety issue: No ]

Estimated Enrollment: 22
Study Start Date: June 2004
Estimated Study Completion Date: December 2017
Primary Completion Date: January 2014 (Final data collection date for primary outcome measure)
Arms Assigned Interventions
Experimental: Study Treatment
Peripheral Blood Stem Cell (PBSC) Transplant. Fludarabine 25mg/m2/d IV over 30 minutes on days -6 to -2, followed by cyclophosphamide 1g/m2/d IV on days -3 and -2. This will be followed by allogeneic stem cell infusion 48 hours later.
Procedure: Chemotherapy followed by Stem Cell Transplantation

Donor: Prior to mobilization, leukapheresis to collect CD3+ cells. The donor will then receive G-CSF (10 mcg/kg/day) with leukapheresis collection of peripheral blood stem cells on days 5, 6 and 7 as needed. Goal of leukapheresis will be > 5 x 106 CD34+cells/kg of recipient.

Patient: Peripheral Blood Stem Cell (PBSC) Transplant. Fludarabine 25mg/m2/d IV over 30 minutes on days -6 to -2, followed by cyclophosphamide 1g/m2/d IV on days -3 and -2. This will be followed by allogeneic stem cell infusion 48 hours later.

Donor Lymphocyte Infusion (DLI) and Adjustment of Immunosuppression: Cyclosporine (CSA) and methotrexate (MTX) will be used for GvHD prophylaxis with target CSA levels of 200-400 ng/ml.

Other Name: HLA-Matched Related Allogeneic Stem Cell Transplantation

Detailed Description:

Allogeneic bone marrow transplantation (BMT) became feasible in the 1960s after elucidation of the Human Leukocyte Antigen (HLA) complex. Since then, the therapy has evolved into an effective treatment for many hematologic disorders. Otherwise incurable malignancies are frequently cured by this approach, with the likelihood of cure ranging from 10% to 85%, depending on the disease and the disease status. The treatment strategy incorporates very large doses of chemotherapy and often radiation to eliminate cancer cells and to immunosuppress the recipient to allow the engraftment of donor cells. Donor cells give rise to hematopoiesis within two to three weeks, rescuing the patient from the effects of high dose therapy. In the ideal situation, immune recovery and recipient-specific tolerance occurs over the following 6-18 months, and the patient is cured of their underlying malignancy, off immunosuppression, with a functionally intact donor-derived immune system. However, complications are common and include fatal organ damage from the effects of high dose chemotherapy, infection, hemorrhage, and, in particular, graft-versus-host disease (GvHD). A realistic estimate of transplant-related mortality in the standard HLA-matched sibling setting is approximately 25%. The risk of treatment-related mortality limits the success and certainly precludes its use in older patients. Thus, new strategies in transplantation are needed.

With the growing understanding that much of the curative potential of allogeneic bone marrow or stem cell transplant (SCT) is from an immune anti-tumor effect of donor cells, known as graft-versus-leukemia (GvL) or graft-versus-tumor (GvT), a new strategy is being employed that shifts the emphasis from high-dose chemo-radiotherapy to donor-derived, immune-mediated anti-tumor therapy. In this approach, patients receive preparative regimens that, while having some anti-tumor activity, are mainly designed to be immunosuppressive enough to allow engraftment of donor stem cells and lymphocytes. Engrafted lymphocytes then mediate a GvL effect; if the GvL effect of the initial transplant is not sufficient, then additional lymphocytes may be infused (achievement of engraftment allows additional lymphocytes to "take" in the recipient without requiring any additional conditioning of the recipient). The lower intensity of the preparative regimen lessens the overall toxicity by minimizing the doses of chemo-radiotherapy. In addition, less intensive preparative regimens may be associated with less GvHD, as much evidence suggests that high-dose therapy contributes to the syndrome of GvHD by causing tissue damage, leading to a cytokine milieu which enhances activation of graft-versus-host (GvH) effector cells. Thus, such an approach may allow the safer use of allogeneic transplants in standard populations and may allow extension of allogeneic transplantation to patients who could not receive standard (myeloablative) transplants because of age or co-morbidities. This protocol investigates a non-myeloablative transplant approach, using fludarabine and cyclophosphamide, to allow engraftment of allogeneic cells, which may then mediate anti-tumor effects.

  Eligibility

Ages Eligible for Study:   18 Years to 75 Years
Genders Eligible for Study:   Both
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  • Age: 18-75 years
  • Diseases

    1. Chronic myelogenous leukemia (CML)

      • First chronic phase or later
      • Accelerated phase
    2. Acute myelogenous or lymphoblastic leukemia (AML or ALL)

      • Second or subsequent remission
      • Patients who have failed an autologous PBSC transplant
      • First remission with poor risk features, including, but not limited to: For AML- complex chromosome karyotype, abnormalities of chromosome 5 or 7, 12p-, 13+, 8+, t(9;22), t(11;23) For ALL- t(9;22), t(4;11), t(1;19), myeloid antigen coexpression
    3. Myelodysplastic syndrome (MDS)
    4. Multiple myeloma - high risk myeloma (poor responders, relapse after autologous PBSCT, chromosome 13 abnormalities)
    5. Hodgkin's disease

      • Primary refractory disease
      • Relapsed disease (first relapse or later)
      • Patients who have failed an autologous PBSC transplant
    6. Non-Hodgkin's lymphoma Low grade (by Working Formulation)

      • Relapsed, progressive disease after initial chemotherapy
      • Primary refractory disease or failure to respond (>PR) to initial chemotherapy
      • Patients who have failed an autologous PBSC transplant Intermediate grade (by Working Formulation)
      • Relapsed disease
      • Primary refractory disease or failure to respond (>PR) to initial chemo
      • Mantle cell lymphoma
      • Patients who have failed an autologous PBSC transplant
    7. Chronic lymphocytic leukemia (CLL)

      • Patients newly diagnosed with poor prognostic factors, including CD38 expression, Chromosome 11 or 17 abn
      • T-CLL/PLL
      • Relapsed or progressive disease, or refractory after Fludarabine
      • Patients who have failed an autologous PBSC transplant
  • Donor Availability: Six of six matched HLA A, B and DR identical sibling (or parent or child) or 5/6 related donor with single mismatch at Class I antigen (A or B)
  • Karnofsky performance status of >70%
  • Serum bilirubin <2x upper limit of normal; transaminases <3x normal (unless due to disease)
  • 24 hr urine creatinine clearance of >40 ml/min.
  • DLCO >50% predicted
  • Left ventricular ejection fraction >35%
  • No active infection
  • Non-pregnant female
  • Signed informed consent
  • No major organ dysfunction or psychological problems that preclude compliance and completion of the clinical trial.
  Contacts and Locations
Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the Contacts provided below. For general information, see Learn About Clinical Studies.

Please refer to this study by its ClinicalTrials.gov identifier: NCT00741455

Locations
United States, New Hampshire
Dartmouth-Hitchcock Medical Center
Lebanon, New Hampshire, United States, 03756
Sponsors and Collaborators
Dartmouth-Hitchcock Medical Center
Investigators
Principal Investigator: John M Hill, MD Dartmouth-Hitchcock Medical Center
Principal Investigator: Kenneth R Meehan, MD Dartmouth-Hitchcock Medical Center
  More Information

No publications provided

Responsible Party: Dartmouth-Hitchcock Medical Center
ClinicalTrials.gov Identifier: NCT00741455     History of Changes
Other Study ID Numbers: D0345
Study First Received: August 25, 2008
Last Updated: February 28, 2014
Health Authority: United States: Institutional Review Board

Keywords provided by Dartmouth-Hitchcock Medical Center:
Non-myeloablative transplant
Chronic Myelogenous Leukemia
Acute Myelogenous Leukemia
Acute Lymphoblastic Leukemia
Multiple Myeloma
Non-Hodgkin's Lymphoma
Myelodysplastic syndrome
Chronic Lymphocytic Leukemia
Hodgkin's Disease

Additional relevant MeSH terms:
Neoplasms

ClinicalTrials.gov processed this record on November 20, 2014