Combination Chemotherapy and Total-Body Irradiation Followed by Peripheral Stem Cell or Bone Marrow Transplantation in Treating Patients With Acute Lymphoblastic Leukemia

Fred Hutchinson Cancer Center (FHCC)

Status and phase

Completed

Phase 2

Phase 1

Conditions

Leukemia

Treatments

Drug: fludarabine phosphate

Drug: cyclosporine

Biological: therapeutic allogeneic lymphocytes

Drug: cytarabine

Drug: mycophenolate mofetil

Radiation: radiation therapy

Procedure: allogeneic bone marrow transplantation

Procedure: peripheral blood stem cell transplantation

Drug: methotrexate

Study type

Interventional

Funder types

Other

NIH

Identifiers

NCT00027547

FHCRC-1586.00

CDR0000069042 (Registry Identifier)

NCI-H01-0080

1586.00

Details and patient eligibility

About

RATIONALE: Drugs used in chemotherapy use different ways to stop cancer cells from dividing so they stop growing or die. Peripheral stem cell transplantation may be able to replace immune cells that were destroyed by chemotherapy and radiation therapy. Sometimes the transplanted cells are rejected by the body's normal tissues. Mycophenolate mofetil and donor white blood cells may prevent this from happening.

PURPOSE: Phase I/II trial to determine the effectiveness of combination chemotherapy and total-body irradiation followed by peripheral stem cell transplantation in treating patients who have acute lymphoblastic leukemia.

Full description

OBJECTIVES:

Determine if a one-year disease free survival of 40% and a day 200 transplant-related mortality of less than 25% can be achieved in patients with high-risk acute lymphoblastic leukemia in complete remission treated with a nonmyeloablative conditioning regimen comprising fludarabine and total body irradiation followed by allogeneic peripheral blood stem cell or bone marrow transplantation.
Evaluate the efficacy and toxicity of donor lymphocyte infusion in the treatment of minimal residual disease after nonmyeloablative allografting in these patients.

OUTLINE: This is a multicenter study.

Patients receive a nonmyeloablative conditioning regimen comprising fludarabine IV on days -4 to -2 and total body irradiation (TBI) on day 0. Children undergo allogeneic peripheral blood stem cell transplantation (PBSCT) or bone marrow transplantation after TBI on day 0. Adults undergo filgrastim (G-CSF)-mobilized allogeneic PBSCT after TBI on day 0.

Patients also receive graft-versus-host disease (GVHD) prophylaxis therapy comprising oral cyclosporine twice daily on days -3 to 56 and then tapered and oral mycophenolate mofetil once at 5-10 hours after transplantation on day 0 and then twice daily on days 1-27.

Patients who have no evidence of grade 2 or greater acute GVHD or clinically extensive chronic GVHD, have been off GVHD prophylaxis therapy for 1-2 weeks, and have stable or increasing minimal residual disease after discontinuation of GVHD prophylaxis therapy receive donor lymphocyte infusion (DLI) IV over 30 minutes. DLI repeats every 4 weeks for a total of 3 doses (if necessary).

Patients without a history of CNS leukemia and patients with a history of CNS leukemia previously treated with prophylactic craniospinal irradiation receive methotrexate (MTX) or cytarabine (ARA-C) intrathecally (IT) for a total of 2 doses before transplantation and for a total of 6 doses beginning on day 32 after transplantation. Patients with a history of CNS leukemia not previously treated with craniospinal irradiation undergo craniospinal irradiation for 11 days before conditioning regimen and then MTX or ARA-C IT for a total of 6 doses beginning on day 32 after transplantation. Male patients also undergo testicular radiotherapy for 7 days.

Patients are followed at 1, 2, 3, 6, 12, 18, and 24 months.

PROJECTED ACCRUAL: A total of 30 patients (20 adults and 10 children) will be accrued for this study within 2 years.

Sex

All

Ages

Under 75 years old

Volunteers

No Healthy Volunteers

Inclusion and exclusion criteria

DISEASE CHARACTERISTICS:

Diagnosis of acute lymphoblastic leukemia (ALL)
Adult patients must meet 1 of the following criteria:
- Age 50 to 75 with high-risk ALL in complete remission (CR) (less than 5% blasts by morphology on bone marrow aspirate and absence of peripheral blasts) or ALL in second CR (CR2) or greater
- Age 18 to 50 with high-risk ALL in first CR (CR1) and either ineligible for conventional allogeneic transplantation (based on general medical condition) or refused conventional transplantation
  - High-risk adult ALL in CR1 includes patients meeting 1 or more of the following criteria:
    - Age 30 and over
    - Non-T-cell phenotype
    - Cytogenetic abnormalities including t(9;22), t(4;11), trisomy 8, or monosomy 7
    - Failure to achieve CR after 4 weeks of induction chemotherapy
- Age 18 to 50 with ALL in CR2 or greater and ineligible for conventional allogeneic transplantation based on general medical condition
- Age 18 to 50 with high-risk ALL in CR2 or greater and refused conventional allogeneic transplantation
Pediatric patients must meet 1 of the following criteria:
- Under age 18 with high-risk ALL in CR1 and ineligible for conventional allogeneic transplantation based on general medical condition
  - High-risk pediatric ALL in CR1 includes patients meeting 1 or more of the following criteria:
    - Cytogenetic abnormalities
      - t(9;22) with WBC at least 25,000/mm3 at diagnosis
      - t(4;11) in patients under age 1 or age 10 and over
      - Hypodiploidy (no more than 45 chromosomes)
    - Failure to achieve CR after 4 weeks of induction chemotherapy
    - Persistent peripheral blasts after 1 week of induction chemotherapy
- Under age 18 with CR2 or greater and ineligible for conventional allogeneic transplantation based on general medical condition
- Age 12 and under allowed if approved by the principle investigator
No active CNS disease
Availability of a sibling donor (excluding an identical twin)
- HLA genotypically identical for at least 1 haplotype
- HLA-A, -B, -C, -DRB1, and -DQB1 genotypically or phenotypically identical

PATIENT CHARACTERISTICS:

Age:

See Disease Characteristics
75 and under

Performance status:

Karnofsky 50-100% (adults)
Lansky 40-100% (children)

Life expectancy:

Not specified

Hematopoietic:

See Disease Characteristics

Hepatic:

No fulminant liver failure
No alcoholic hepatitis
No history of bleeding esophageal varices
No grade II or greater hepatic encephalopathy
No hepatic synthetic dysfunction evidenced by prolongation of PT with INR greater than 2.5
No intractable ascites related to portal hypertension
No bacterial or fungal liver abscess
No chronic viral hepatitis with bilirubin greater than 5 mg/dL
No biliary obstruction with bilirubin greater than 5 mg/dL
No concurrent symptomatic biliary disease

Renal: