Donor Stem Cell Transplant After Chemotherapy for the Treatment of Recurrent or Refractory High-Risk Solid Tumors in Pediatric and Adolescent-Young Adults

A Pilot Study of Allogeneic Hematopoietic Stem Cell Transplantation for Pediatric and Adolescent-Young Adults Patients With High Risk Solid Tumors

This phase II trial investigates side effects and how well donor stem cell transplant after chemotherapy works in treating pediatric and adolescent-young adults with high-risk solid tumor that has come back (recurrent) or does not respond to treatment (refractory). Chemotherapy drugs, such as fludarabine, thiotepa, etoposide, melphalan, and rabbit anti-thymocyte globulin work in different ways to stop the growth of tumor cells, either by killing the cells, by stopping them from dividing, or by stopping them from spreading. Giving chemotherapy before a donor stem cell transplant helps kill cancer cells in the body and helps make room in the patient's bone marrow for new blood-forming cells (stem cells) to grow. When the healthy stem cells from a donor are infused into a patient, they may help the patient's bone marrow make more healthy cells and platelets and may help destroy any remaining cancer cells.

Study Overview

• Status: Recruiting
• Conditions: Refractory Malignant Solid Neoplasm; Recurrent Malignant Solid Neoplasm; Recurrent Neuroblastoma; Recurrent Rhabdomyosarcoma; Refractory Neuroblastoma; Refractory Rhabdomyosarcoma; Desmoplastic Small Round Cell Tumor; Recurrent Malignant Peripheral Nerve Sheath Tumor; Ewing Sarcoma/Peripheral Primitive Neuroectodermal Tumor; Recurrent Desmoplastic Small Round Cell Tumor; Refractory Desmoplastic Small Round Cell Tumor; Refractory Malignant Peripheral Nerve Sheath Tumor
• Intervention / Treatment: Drug: Etoposide; Drug: Melphalan; Drug: Tacrolimus; Drug: Fludarabine Phosphate; Biological: Lapine T-Lymphocyte Immune Globulin; Drug: Thiotepa; Drug: Mycophenolate Mofetil; Procedure: Allogeneic Hematopoietic Stem Cell Transplantation; Drug: Cyclosporine

Detailed Description

PRIMARY OBJECTIVE:

I. To assess tolerability of allogeneic hematopoietic stem cell transplantation (HCT) for patients with chemo-responsive recurrent/refractory solid tumors as defined by transplant-related mortality (TRM) at day 30 and the rate of grade III or higher organ toxicity (Bearman Regimen-Related Toxicities Scale) attributable to conditioning occurring within 30 days.

SECONDARY OBJECTIVES:

I. Assess median time to platelet and neutrophil engraftment. II. Assess incidence of acute graft-versus-host disease (aGVHD) by day 100. III. Assess incidence of chronic GVHD (cGVHD) at day 100 and one year. IV. Assess rate of grade II organ toxicity through day 100. V. Assess rate of graft failure (primary and secondary) through day 100. VI. Assess rate of infectious complications through day 100. VII. Assess progression free survival (PFS) at day 100,180 and 365. VIII. Assess cumulative incidence of relapse, overall survival (OS) at 100 days and 1 year.

OUTLINE:

CONDITIONING REGIMEN: Patients receive thiotepa intravenously (IV) over 2-4 hours and etoposide IV over 60 minutes on days -8 to -6, melphalan IV over 20 minutes on days -5 and -4, and fludarabine phosphate IV over 1 hour on days -5 to -3 in the absence of disease progression or unacceptable toxicity. Patients receiving umbilical cord transplant also receive rabbit anti-thymocyte globulin IV on days -4 and -3.

TRANSPLANT: Patients undergo HSCT on day 0.

GVHD PROPHYLAXIS: Beginning day -2, patients receive tacrolimus or cyclosporine IV continuously until able to receive orally (PO). Patients continue tacrolimus or cyclosporine PO to day 60 and tapered to day 100. Patients also receive mycophenolate mofetil PO or IV every 8 hours until day 40 and tapered to day 90.

After completion of HSCT, patients are followed up for up to 1 year.

• Study Type: Interventional
• Enrollment (Estimated): 40
• Phase: Phase 2

Contacts and Locations

• Study Contact: Name: Jeremy S Connors, MD; Phone Number: (713) 792-6624; Email: jsconnors@mdanderson.org

Study Locations

• United States
  • Texas
    • Houston, Texas, United States, 77030
      • Recruiting
      • M D Anderson Cancer Center
      • Contact: Jeremy S Connors, MD; Phone Number: 713-792-6624; Email: jsconnors@mdanderson.org
      • Principal Investigator: Jeremy S Connors, MD

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: No older than 25 years (Child, Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Pathological criteria, including malignant recurrent/refractory solid tumors. This would include:

  • Ewing's/peripheral primitive neuroectodermal tumor (PNET)
  • Malignant peripheral nerve sheath tumor, neurofibrosarcoma
  • Rhabdomyosarcoma
  • Neuroblastoma (patients who are ineligible for tandem autologous transplant or who are at least 3 months post autologous HCT)
  • Desmoplastic small round cell tumor (DSRCT)- both new diagnoses as well as recurrent/refractory disease
• Patients must have chemo-responsive disease, defined as; 30% or greater decrease in the tumor target lesions when compared to its pre-treatment evaluation. Patients with complete response will be eligible to participate
• Available suitable HCT donor
• Creatinine clearance or glomerular filtration rate (GFR) >= 50 ml/min/1.73m^2, and not requiring dialysis
• Diffusing capacity of lung for carbon monoxide (DLCO) (corrected for hemoglobin) >= 50% predicted. If unable to perform pulmonary function tests, then oxygen (O2) saturation >= 92% in room air
• Bilirubin =< 3 x upper limit of normal (ULN) and alanine aminotransferase (ALT) and aspartate aminotransferase (AST) =< 5 x for age (with the exception of isolated hyperbilirubinemia due to Gilbert's syndrome)
• DONOR: Matched related donor bone marrow (10 of 10 HLA alleles [HLA-A, B, C, DR, and DQ]. Matched related donor peripheral blood stem cell (PBSC) is allowed only if collection of bone marrow (BM) is not available or refused by parents/donor

• DONOR: Matched allogeneic umbilical cord blood (UCB): related

  • High-resolution matching at A,B, DRB1 (minimum 4/6)
  • KIR major histocompatibility complex (MHC) class 1 preferential mismatch (minimum 4/6)

• DONOR: Matched allogeneic umbilical cord blood: unrelated

  • High-resolution matching at A,B, DRB1 (minimum 4/6) •*KIR MHC class 1 preferential mismatch (minimum 4/6)

Exclusion Criteria:

• Lack of histocompatible suitable related donor/ graft source
• End-organ failure that precludes the ability to tolerate the transplant procedure, including conditioning regimen
• Renal failure requiring dialysis
• Congenital heart disease resulting in congestive heart failure
• Ventilatory failure: requires invasive mechanical ventilation
• Human immunodeficiency virus (HIV) infection
• Uncontrolled bacterial, viral, or fungal infections (currently taking medication yet clinical symptoms progress); stable, controlled disease with treatment is not an exclusion criteria
• A female of reproductive potential who is pregnant, planning to become pregnant during the study, or is nursing a child
• Any patient who does not fulfill the inclusion criteria listed above

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: Treatment (conditioning regimen, HSCT); CONDITIONING REGIMEN: Patients receive thiotepa IV over 2-4 hours, etoposide IV over 60 minutes on days -8 to -6, melphalan IV over 20 minutes on days -5 and -4, and fludarabine phosphate IV over 1 hour on days -5 to -3 in the absence of disease progression or unacceptable toxicity. Patients receiving umbilical cord transplant also receive rabbit anti-thymocyte globulin IV on days -3 and -4. TRANSPLANT: Patients undergo HSCT on day 0. GVHD PROPHYLAXIS: Beginning day -2, patients receive tacrolimus or cyclosporine IV continuously until able to receive PO. Patients continue tacrolimus or cyclosporine PO to day 60 and tapered to day 100. Patients also receive mycophenolate mofetil PO or IV every 8 hours until day 40 and tapered to day 90.

Drug: Etoposide; Given IV; Other Names: Demethyl Epipodophyllotoxin Ethylidine Glucoside; EPEG; Lastet; Toposar; Vepesid; VP 16; VP 16-213; VP-16; VP-16-213; VP16; Drug: Melphalan; Given IV; Other Names: CB-3025; L-PAM; L-Sarcolysin; Alanine Nitrogen Mustard; L-Phenylalanine Mustard; L-Sarcolysin Phenylalanine mustard; L-Sarcolysine; Melphalanum; Phenylalanine Mustard; Phenylalanine Nitrogen Mustard; Sarcoclorin; Sarkolysin; WR-19813; Drug: Tacrolimus; Given IV and PO; Other Names: Prograf; Hecoria; FK 506; Fujimycin; Protopic; Drug: Fludarabine Phosphate; Given IV; Other Names: 2-F-ara-AMP; Beneflur; Fludara; 9H-Purin-6-amine, 2-fluoro-9-(5-O-phosphono-.beta.-D-arabinofuranosyl)-; SH T 586; Biological: Lapine T-Lymphocyte Immune Globulin; Given IV; Other Names: Thymoglobulin; Anti-Thymocyte Globulin Rabbit; Grafalon; Rabbit Anti-Human Thymocyte Globulin (RATG); Rabbit Anti-Thymocyte Globulin; Rabbit Antithymocyte Globulin; Rabbit ATG; rATG; Drug: Thiotepa; Given IV; Other Names: Tepadina; Oncotiotepa; STEPA; TESPA; Tespamin; TSPA; Girostan; Tespamine; Thio-Tepa; Thiofosfamide; Thiofozil; Thiophosphamide; Thiophosphoramide; Thiotef; Tifosyl; TIO TEF; Tio-tef; Triethylene Thiophosphoramide; Triethylenethiophosphoramide; Tris(1-aziridinyl)phosphine sulfide; WR 45312; 1,1'',1''''-Phosphinothioylidynetrisaziridine; N,N'', N''''-Triethylenethiophosphoramide; Drug: Mycophenolate Mofetil; Given IV or PO; Other Names: CellCept; MMF; Procedure: Allogeneic Hematopoietic Stem Cell Transplantation; Undergo HSCT; Other Names: Allogeneic Hematopoietic Cell Transplantation; Allogeneic Stem Cell Transplantation; HSC; HSCT; Stem Cell Transplantation, Allogeneic; Drug: Cyclosporine; Given IV and PO; Other Names: 27-400; Sandimmune; Ciclosporin; CsA; Neoral; Gengraf; Cyclosporin; Cyclosporin A; OL 27-400; SangCya; Cyclosporine Modified

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Transplant-related mortality (TRM)	The proportion of patients with 30-day TRM will be reported together with the corresponding 95% Bayesian credible interval.	At 30 days
Rate of grade III or higher organ toxicity attributable to conditioning	Assessed using the Bearman Regimen-Related Toxicities Scale. The proportion of patients with 30-day grade III or higher organ toxicity will be reported together with the corresponding 95% Bayesian credible interval.	Up to 30 days

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Time to platelet and neutrophil engraftment	Will be calculated and illustrated from the time of transplant by the method of Kaplan and Meier.	Up to 1 year post transplant
Incidence of acute graft versus host disease (aGVHD)	The 100-day rates of acute with the competing risk of relapse will be estimated using the method of Gooley.	At 100 days post transplant
Incidence of chronic GVHD	The 100-day rates of chronic GVHD with the competing risk of relapse will be estimated using the method of Gooley	At 100 days post transplant
Incidence of chronic GVHD	The 1 year rates of chronic GVHD with the competing risk of relapse will be estimated using the method of Gooley.	At 1 year post transplant
Rate of grade II organ toxicity	The 100-day rates of grade II organ toxicity will be reported as counts with percentages.	Up to 100 days post transplant
Rate of graft failure (primary and secondary)	The 100-day rates of primary and secondary graft failure will be reported as counts with percentages.	Up to 100 days post transplant
Rate of infectious complications	The 100-day rates of infectious complications will be reported as counts with percentages.	Up to 100 days post transplant
Progression-free survival (PFS)	Will be assessed using the method of Kaplan and Meier.	At 180 days post transplant
PFS	Will be calculated and illustrated from the time of transplant by the method of Kaplan and Meier.	At 100 days post transplant
PFS	Will be calculated and illustrated from the time of transplant by the method of Kaplan and Meier.	At 1 year post transplant
Incidence of relapse	Will be calculated and illustrated from the time of transplant by the method of Kaplan and Meier.	At 100 days post transplant
Incidence of relapse	Will be calculated and illustrated from the time of transplant by the method of Kaplan and Meier.	At 1 year post transplant
Overall survival (OS)	Will be calculated and illustrated from the time of transplant by the method of Kaplan and Meier.	At 100 days post transplant
OS	Will be calculated and illustrated from the time of transplant by the method of Kaplan and Meier.	At 1 year post transplant

Collaborators and Investigators

• Sponsor: M.D. Anderson Cancer Center
• Investigators: Principal Investigator: Jeremy S Connors, MD, M.D. Anderson Cancer Center

Publications and helpful links

Helpful Links

• MD Anderson Cancer Center

Study record dates

Study Major Dates

• Study Start (Actual): August 19, 2020
• Primary Completion (Estimated): May 9, 2025
• Study Completion (Estimated): May 9, 2025

Study Registration Dates

• First Submitted: August 25, 2020
• First Submitted That Met QC Criteria: August 25, 2020
• First Posted (Actual): August 28, 2020

Study Record Updates

• Last Update Posted (Actual): April 11, 2024
• Last Update Submitted That Met QC Criteria: April 10, 2024
• Last Verified: April 1, 2024

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Pathologic Processes; Nervous System Diseases; Neoplasms, Connective and Soft Tissue; Neoplasms by Histologic Type; Neoplasms, Glandular and Epithelial; Disease Attributes; Neuromuscular Diseases; Neoplasms, Neuroepithelial; Neoplasms, Germ Cell and Embryonal; Neoplasms, Nerve Tissue; Peripheral Nervous System Diseases; Nervous System Neoplasms; Osteosarcoma; Neoplasms, Bone Tissue; Neoplasms, Connective Tissue; Sarcoma; Neoplasms, Muscle Tissue; Peripheral Nervous System Neoplasms; Myosarcoma; Neoplasms, Fibrous Tissue; Fibrosarcoma; Neurofibroma; Neoplasms; Recurrence; Sarcoma, Ewing; Neuroblastoma; Nerve Sheath Neoplasms; Rhabdomyosarcoma; Neuroectodermal Tumors; Neuroectodermal Tumors, Primitive; Neuroectodermal Tumors, Primitive, Peripheral; Neurofibrosarcoma; Desmoplastic Small Round Cell Tumor; Physiological Effects of Drugs; Molecular Mechanisms of Pharmacological Action; Anti-Infective Agents; Enzyme Inhibitors; Antirheumatic Agents; Antimetabolites, Antineoplastic; Antimetabolites; Antineoplastic Agents; Immunosuppressive Agents; Immunologic Factors; Tubulin Modulators; Antimitotic Agents; Mitosis Modulators; Antineoplastic Agents, Alkylating; Alkylating Agents; Myeloablative Agonists; Antineoplastic Agents, Phytogenic; Topoisomerase II Inhibitors; Topoisomerase Inhibitors; Dermatologic Agents; Anti-Bacterial Agents; Antibiotics, Antineoplastic; Antifungal Agents; Keratolytic Agents; Antitubercular Agents; Antibiotics, Antitubercular; Calcineurin Inhibitors; Etoposide; Etoposide phosphate; Antibodies; Podophyllotoxin; Immunoglobulins; Immunoglobulins, Intravenous; Melphalan; Fludarabine; Fludarabine phosphate; Tacrolimus; gamma-Globulins; Rho(D) Immune Globulin; Mycophenolic Acid; Thiotepa; Thymoglobulin; Antilymphocyte Serum; Cyclosporine; Cyclosporins; Mechlorethamine; Nitrogen Mustard Compounds
• Other Study ID Numbers: 2020-0496 (Other Identifier: M D Anderson Cancer Center); NCI-2020-05879 (Registry Identifier: CTRP (Clinical Trial Reporting Program))

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: Yes
• Studies a U.S. FDA-regulated device product: No