Alemtuzumab, Fludarabine, and Busulfan Followed By Donor Stem Cell Transplant in Treating Young Patients With Hematologic Disorders

Evaluation of Fludarabine, Busulfan and Alemtuzumab as a Reduced Toxicity Ablative Bone Marrow Stem Cell Transplant Regimen for Children With Stem Cell Defects, Marrow Failure Syndromes, or Myelodysplastic Syndrome (MDS)/Leukemia

RATIONALE: Monoclonal antibodies, such as alemtuzumab, can block cancer growth in different ways. Some block the ability of cancer cells to grow and spread. Others find cancer cells and help kill them or carry cancer-killing substances to them. Drugs used in chemotherapy, such as fludarabine and busulfan, work in different ways to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. A peripheral stem cell, bone marrow , or umbilical cord blood transplant may be able to replace blood-forming cells that were destroyed by chemotherapy. Sometimes the transplanted cells from a donor can make an immune response against the body's normal cells. Giving cyclosporine together with methotrexate and methylprednisolone may stop this from happening.

PURPOSE: This phase II trial is studying how well giving alemtuzumab together with fludarabine and busulfan works when given before donor stem cell transplant in treating young patients with hematologic disorders.

Study Overview

• Status: Completed
• Conditions: Myelodysplastic Syndromes; Leukemia; Congenital Amegakaryocytic Thrombocytopenia; Severe Congenital Neutropenia; Diamond-blackfan Anemia
• Intervention / Treatment: Drug: methotrexate; Drug: methylprednisolone; Drug: fludarabine phosphate; Procedure: allogeneic bone marrow transplantation; Procedure: allogeneic hematopoietic stem cell transplantation; Drug: busulfan; Procedure: peripheral blood stem cell transplantation; Biological: alemtuzumab; Drug: cyclosporine; Procedure: umbilical cord blood transplantation

Detailed Description

OBJECTIVES:

Primary

• Determine the engraftment rate with reduced toxicity ablative conditioning regimen comprising alemtuzumab, fludarabine, and busulfan followed by allogeneic stem cell transplantation in pediatric patients with stem cell defects, marrow failure syndromes, hemoglobinopathy, severe immunodeficiency syndromes (nonsevere combined immunodeficiency disorders), myelodysplastic syndromes, or myeloid leukemia.

Secondary

• Determine the acute reactions, incidence of infections, and rate of immune reconstitution in patients treated with this regimen.

OUTLINE: This is a multicenter study.

• Conditioning regimen: Patients receive alemtuzumab IV over 6 hours on days -12 to -10, high-dose busulfan IV over 2 hours 4 times daily on days -9 to -6, and fludarabine IV over 30 minutes on days -5 to -2.
• Allogeneic stem cell transplantation: Two days after the completion of conditioning regimen, patients undergo allogeneic bone marrow, peripheral blood stem cell, or umbilical cord blood transplantation on day 0. Patients receive filgrastim (G-CSF) subcutaneously beginning on day 5 and continuing until blood counts recover.

• Graft-vs-host disease (GVHD) prophylaxis:

  • Most transplantations (bone marrow or peripheral blood stem cell transplantation): Patients receive cyclosporine IV continuously beginning on day -1 until at least day 50 followed by a taper at either 2 months, 9 months, or 1 year in the absence of GVHD. Patients also receive methotrexate on days 1, 3, and 6.
  • Umbilical cord blood transplantation: Patients receive cyclosporine as in most transplantations, and methylprednisolone IV twice daily on days 0-21 followed by a weekly taper.

After transplantation, patients are followed periodically for up to 20 years.

PROJECTED ACCRUAL: A total of 35 patients will be accrued for this study.

• Study Type: Interventional
• Enrollment (Actual): 35
• Phase: Phase 2

Contacts and Locations

Study Locations

• United States
  • California
    • San Francisco, California, United States, 94115
      • UCSF Helen Diller Family Comprehensive Cancer Center
  • Wisconsin
    • Madison, Wisconsin, United States, 53792-6164
      • University of Wisconsin Paul P. Carbone Comprehensive Cancer Center

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: No older than 21 years (Child, Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

DISEASE CHARACTERISTICS:

• Diagnosis of 1 of the following hematologic conditions:

  • Aplastic anemia with marrow aplasia, meeting all of the following criteria:

    • Absolute neutrophil count < 500/mm^3
    • Platelet and/or red cell transfusion dependent

  • Chronic aplastic anemia, meeting all of the following criteria:

    • Transfusion dependent
    • Unresponsive to immunosuppressive therapy
    • Alternative matched unrelated donor has been identified

  • Congenital marrow failure syndrome, including any of the following (with closely matched related or unrelated donor):

    • Primary red cell aplasia (Diamond-Blackfan syndrome)
    • Congenital neutropenia (Kostmann's syndrome)
    • Amegakaryocytic thrombocytopenia
    • Congenital dyserythropoietic anemias
    • Other severe acquired cytopenias in which a transplantation using a combined busulfan/cyclophosphamide conditioning regimen is indicated

  • Hemoglobinopathy (with closely matched related or unrelated donor)

    • β-thalassemia major
    • Sickle cell anemia
    • Hemoglobin E/β-thalassemia

  • Severe immunodeficiency disease

    • Chediak-Higashi disease
    • Wiskott-Aldrich syndrome
    • Combined immunodeficiency disease (Nezelof's)
    • Hyper immunoglobulin M (IgM) syndrome
    • Bare lymphocyte syndrome
    • Chronic granulomatous disease
    • Familial erythrohemophagocytic lymphohistiocytosis
  • Other stem cell defects (e.g., osteopetrosis)

  • Severe immune dysregulation/autoimmune disorders

    • Achieved a transient response to prior immunosuppressive therapy

  • Chronic myelogenous leukemia

    • Disease in first chronic phase

  • Acute myeloid leukemia

    • Disease in first remission
  • Myelodysplastic syndromes
  • Inborn errors of metabolism
  • Histiocytosis
• No severe combined immunodeficiency disease

• Matched related or unrelated donor available by high resolution DNA typing

  • Related donor, meeting both of the following criteria:

    • Matched at both human leukocyte antigen (HLA)-Drβ1 alleles
    • No more than 1 mismatch at the 4 HLA-A and -B alleles

  • Unrelated donor, meeting 1 of the following criteria:

    • Marrow matched at both HLA-Drβ1 alleles AND no more than 1 mismatch at the 4 HLA-A and -B alleles
    • Umbilical cord blood matched at 5/6 HLA-A, -B, and -DRβ1 alleles with at least 1 -DRβ1 match AND there are ≥ 3x10^5 CD34+ (Cluster of differentiation 34-positive) cells per kg body weight of recipient available at the time of cryopreservation

PATIENT CHARACTERISTICS:

• Cardiac ejection fraction ≥ 27%
• Creatinine clearance ≥ 50 mL/min by 24-hour urine collection or glomerular filtration rate
• DLCO (diffusion capacity of lung for carbon monoxide) ≥ 50% of predicted (corrected for anemia/lung volume)

PRIOR CONCURRENT THERAPY:

• No prior transplantation for leukemia from which patient remains engrafted and alemtuzumab is not needed as part of the conditioning regimen

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: N/A
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm

Intervention / Treatment

Experimental: Single arm - conditioning and transplant; Alemtuzumab 0.5 mg/kg (maximum 15 mg) daily for 3 days; Busulfan i.v. every 6 hours from day -9 to day -6 for 16 total doses; Fludarabine phosphate from day -5 for 4 days at 1.3 mg/kg (if patient was less than 12 kg) or 40 mg/m*2 per dose; Cyclosporine continuous infusion 3 mg/kg/Day beginning day -1 for GVHD prophylaxis; Methotrexate at 15 mg/m*2 on day +1, 10 mg/m*2 on days +3, +6, and (only for MUDs) day +11 also for GVHD prophylaxis; Methylprednisolone only as required for GVHD prophylaxis; allogeneic bone marrow transplantation or allogeneic hematopoietic stem cell transplantation or peripheral blood stem cell transplantation or umbilical cord blood transplantation.

Drug: methotrexate; Drug: methylprednisolone; Drug: fludarabine phosphate; Procedure: allogeneic bone marrow transplantation; Procedure: allogeneic hematopoietic stem cell transplantation; Drug: busulfan; Procedure: peripheral blood stem cell transplantation; Biological: alemtuzumab; Drug: cyclosporine; Procedure: umbilical cord blood transplantation

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number of Participants Achieving Durable Engraftment (Presence of Donor Cells) at 6 Weeks Post Transplantation	Peripheral blood chimerism studies were performed by quantitative real time polymerase chain reaction (qPCR) evaluation of differential short tandem repeat DNA sequences	6 weeks post-transplant

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Treatment-related Mortality at 100 Days and 1 Year Post Transplantation		100 days and 1 year
Toxicity Grade ≥ 3 From Start of Conditioning Through the First Year Post Transplantation		1 year post-transplantation
Cytomegalovirus (CMV) Viral Infection and Disease Symptoms	polymerase chain reaction testing for presence of CMV weekly until at least day +100 then every 2 weeks until T-cell reconstitution as defined by cluster of differentiation 4 (CD4) > 200 cells/mm3. Median time to T-cell reconstitution was 6 months.	Up to one year post-transplant
Disease-free Survival With Correction of Disease at One Year Post Transplantation	Patients deemed "alive and well" at follow-up timepoint later than 1-year post-transplantation	1 year post-transplantation

Collaborators and Investigators

• Sponsor: University of California, San Francisco
• Collaborators: National Cancer Institute (NCI)

Study record dates

Study Major Dates

• Study Start: January 1, 2005
• Primary Completion (Actual): September 1, 2011
• Study Completion (Actual): September 1, 2011

Study Registration Dates

• First Submitted: March 9, 2006
• First Submitted That Met QC Criteria: March 9, 2006
• First Posted (Estimate): March 13, 2006

Study Record Updates

• Last Update Posted (Actual): September 28, 2017
• Last Update Submitted That Met QC Criteria: August 30, 2017
• Last Verified: August 1, 2017

More Information

Terms related to this study

• Keywords: de novo myelodysplastic syndromes; previously treated myelodysplastic syndromes; secondary myelodysplastic syndromes; secondary acute myeloid leukemia; childhood acute myeloid leukemia in remission; chronic phase chronic myelogenous leukemia; severe congenital neutropenia; congenital amegakaryocytic thrombocytopenia; childhood chronic myelogenous leukemia; childhood myelodysplastic syndromes; Diamond-Blackfan anemia
• Additional Relevant MeSH Terms: Pathologic Processes; Neoplasms by Histologic Type; Neoplasms; Disease; Bone Marrow Diseases; Hematologic Diseases; Genetic Diseases, Inborn; Anemia; Blood Platelet Disorders; Precancerous Conditions; Agranulocytosis; Leukopenia; Leukocyte Disorders; Anemia, Hypoplastic, Congenital; Anemia, Aplastic; Congenital Bone Marrow Failure Syndromes; Bone Marrow Failure Disorders; Red-Cell Aplasia, Pure; Syndrome; Myelodysplastic Syndromes; Leukemia; Preleukemia; Neutropenia; Thrombocytopenia; Anemia, Diamond-Blackfan; Physiological Effects of Drugs; Molecular Mechanisms of Pharmacological Action; Anti-Infective Agents; Autonomic Agents; Peripheral Nervous System Agents; Nucleic Acid Synthesis Inhibitors; Enzyme Inhibitors; Anti-Inflammatory Agents; Antirheumatic Agents; Antimetabolites, Antineoplastic; Antimetabolites; Antineoplastic Agents; Immunosuppressive Agents; Immunologic Factors; Antiemetics; Gastrointestinal Agents; Glucocorticoids; Hormones; Hormones, Hormone Substitutes, and Hormone Antagonists; Neuroprotective Agents; Protective Agents; Antineoplastic Agents, Alkylating; Alkylating Agents; Myeloablative Agonists; Antineoplastic Agents, Immunological; Dermatologic Agents; Antifungal Agents; Reproductive Control Agents; Abortifacient Agents, Nonsteroidal; Abortifacient Agents; Folic Acid Antagonists; Calcineurin Inhibitors; Methylprednisolone; Fludarabine; Fludarabine phosphate; Methotrexate; Busulfan; Cyclosporine; Cyclosporins; Alemtuzumab
• Other Study ID Numbers: CDR0000462406; UCSF-04152 (Other Identifier: UCSF Helen Diller Family Comprehensive Cancer Center); UCSF-00452 (Other Identifier: UCSF Helen Diller Family Comprehensive Cancer Center); UCSF-H411-25738-02 (Other Identifier: UCSF Committee on Human Research (CHR))