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Pilot Study of Non-Myeloablative, HLA-Matched Allogeneic Stem Cell Transplantation for Pediatric Hematopoietic Malignancies

Primary Purpose

Hodgkin Lymphoma, Lymphocytic Leukemia, Mixed Cell Leukemia

Status
Completed
Phase
Early Phase 1
Locations
United States
Study Type
Interventional
Intervention
Stem cell transplantation
Sponsored by
National Cancer Institute (NCI)
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Hodgkin Lymphoma focused on measuring Leukemia, Myelodysplastic Syndrome, Bone Marrow Transplant, Pediatric Oncology, Lymphoma, Efficacy, Safety, Childhood Cancer

Eligibility Criteria

4 Years - 20 Years (Child, Adult)All SexesDoes not accept healthy volunteers

INCLUSION CRITERIA PATIENTS: Patients with the following diagnoses will be considered: Hodgkin's and Non-Hodgkin's Lymphoma: Refractory (non-CR) to primary treatment regimen; Refractory (non-CR) to or relapse after salvage regimen. Acute Myelogenous Leukemia (AML): History of bone marrow relapse it CR number 2 or greater. Acute Lymphocytic Leukemia (ALL): History of bone marrow relapse in CR number 2 or greater; complete remission #1 with Philadelphia chromosome positive or prior induction failure (subsequent induction regimen required to achieve CR). Acute hybrid leukemia including mixed lineage, biphenotypic, and undifferentiated (AUL): History of bone marrow relapse in CR number 2 or greater; Complete remission #1 with Philadelphia chromosome positive or prior induction failure (second induction regimen required to achieve (CR). Myelodysplastic Syndrome (MDS) excluding refractory anemia (RA) and RA with ringed sideroblasts (RARS): blasts less than 10% in marrow and blood. Chronic Myelogenous Leukemia (CML): Chronic Phase; Accelerated Phase with blasts less than 10% in marrow and blood. Juvenile Myelomonocytic Leukemia (JMML, J-CML): Blasts less than 10% in marrow and blood. Patients must be greater than or equal to 4 years and less than 22 years of age. Prior chemotherapy: Chemotherapy to achieve above noted criteria allowed. Prior autologous BMT allowed. Prior allogeneic BMT allowed as long as at least day +100 post-prior BMT, and no evidence of ongoing active GVHD. Availability of 5 or 6 antigen genotypic HLA-matched first-degree relative donor (single HLA-A or B locus mismatch allowed). Performance status of 0,1, or 2. Life expectancy greater than 3 months. Liver function: serum direct bilirubin less than 2.0 mg/dL, and serum ALT and AST values less than or equal to 2.5 times the upper limit of normal. Values above these levels may be accepted, at the discretion of the PI, if such elevations are thought to be due to malignancy (excluding acute leukemia). Renal function: age-adjusted normal serum creatinine or a creatinine clearance greater than or equal to 60 mL/min/1.73 m(2). Pulmonary function: DLCO corrected for hemoglobin and alveolar volume greater than or equal to 50% of predicted. Left ventricular function: Ejection fraction greater than or equal to 45% by MUGA or shortening fraction greater than or equal to 28% by ECHO. Ability to give informed consent. For patients less than 18 years old their legal guardian must give informed consent. Pediatric patients will be included in age appropriate discussion in order to obtain verbal assent. Durable power of attorney form completed (patients greater than 18 years of age only). Patients must not have an active CNS malignancy as defined by: lymphoma (tumor mass on CT scan or leptomeningeal disease), Leukemia (CNS 2 or CNS 3 classification), or NB (History of CNS involvement with no current evidence of CNS malignancy is NOT an exclusion). Patients must not be HIV positive. Patients must not have active hepatitis B or C infection as defined by seropositive for hepatitis B (HbSAg) or hepatitis C and elevated liver transaminases. Female patients must not be lactating or pregnant (due to risk to fetus or newborn). Patients must not have high risk of inability to comply with transplant protocol as determined by principal investigator, social work, and BMT team. Patients must not have Fanconi Anemia (FA): patients with MDS must have a negative FA test. INCLUSION CRITERIA DONOR: First degree relative with genotypic identity at 5 or 6 HLA loci (single HLA-A or B locus mismatch allowed). Weight of greater than or equal to 15 kilograms. Adequate venous access for peripheral apheresis, or consent to use a temporary central venous catheter for apheresis (on Cohort #2, for possible future cell collection if needed). Ability to give informed consent. For donors less than 18 years of age, he/she must be the oldest eligible donor, their legal guardian must give informed consent, the donor must give verbal assent, and he/she must be cleared by social work and a mental health specialist to participate. Donor selection criteria will be in accordance with NIH/CC Department of Transfusion Medicine standards. EXLCUSION CRITERIA PATIENT: Active CNS malignancy as defined by: Lymphoma: tumor mass on CT scan or leptomeningeal disease Leukemia: CNS 2 or CNS 3 classification NB: History of CNS involvement with no current evidence of CNS malignancy is NOT an exclusion. HIV positive. Active hepatitis B or C infection as defined by seropositive for hepatitis B (HbsAg) or hepatitis C and elevated liver transaminases. Lactating or pregnant females. High risk of inability to comply with transplant protocol as determined by principal investigator, social work, and BMT team. Fanconi Anemia (FA): Patients with MDS must have a negative FA test. EXCLUSION CRITERIA DONOR: History of medical illness which in the estimation of the PI or DTM physician poses prohibitive risk to donation including, but not limited to stroke, hypertension that is not controlled by medication, or heart disease. Individuals with symptomatic angina or a history of coronary artery bypass grafting or angioplasty will not be eligible. History of congenital hematologic, immunologic, or metabolic disorder which in the estimation of the PI poses prohibitive risk to the recipient. Anemia (Hb less than gm/dl) or thrombocytopenia (less than 100,000/ul). Lactating or pregnant females. HIV positive. Seropositive for hepatitis B (HbsAg) or hepatitis C. High risk of inability to comply with transplant protocol as determined by principal investigator, social work, and BMT team.

Sites / Locations

  • National Institutes of Health Clinical Center, 9000 Rockville Pike

Arms of the Study

Arm 1

Arm Type

Experimental

Arm Label

1

Arm Description

Transplant with Induction Therapy

Outcomes

Primary Outcome Measures

To determine the efficacy and safety of this chemotherapy regimen in facilitating donor engraftment after allogeneic bone marrow transplantation (BMT).
Safety/Efficacy

Secondary Outcome Measures

Toxicity of regimen
To determine the toxicity of this non-myelablative allogeneic BMT regimen.
fludarabine-based induction reducing T-cells
immune suppression
IL-7 levels
cytokine profiles
response rates and DFS
incidence and severity of GVHD
response rates, DFS rates, and incidence and severity ofGVHD following withdrawal of immunosuppression and donorlymphocyte infusions (DLI) for patients who developprogressive disease after day +28 post-transplant

Full Information

First Posted
March 20, 2001
Last Updated
December 13, 2019
Sponsor
National Cancer Institute (NCI)
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1. Study Identification

Unique Protocol Identification Number
NCT00013533
Brief Title
Pilot Study of Non-Myeloablative, HLA-Matched Allogeneic Stem Cell Transplantation for Pediatric Hematopoietic Malignancies
Official Title
Pilot Study of Non-Myeloablative, HLA-Matched Allogeneic Stem Cell Transplantation for Pediatric Hematopoietic Malignancies
Study Type
Interventional

2. Study Status

Record Verification Date
May 7, 2015
Overall Recruitment Status
Completed
Study Start Date
March 14, 2001 (undefined)
Primary Completion Date
March 1, 2008 (Actual)
Study Completion Date
May 7, 2015 (Actual)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Sponsor
Name of the Sponsor
National Cancer Institute (NCI)

4. Oversight

5. Study Description

Brief Summary
Background: Allogeneic blood and marrow stem cell transplantation (BMT) plays an important role in the curative treatment of a number of pediatric malignancies. Unfortunately, the success of conventional allogeneic BMT is limited in part by the multiple toxicities associated with myeloablative preparative regimens. Non-myeloablative pre-transplant regimens are associated with less toxic side effects than standard BMT. Recently, a novel immunosuppressive, non-myeloablative pre-transplant chemotherapy regimen has been shown to facilitate complete donor engraftment in an adult trial at the NCI. Objectives: The primary objective of this protocol is to evaluate the efficacy and safety of this treatment approach in pediatric patients with hematopoietic malignancies Eligibility: Inclusion Criteria Age: Patient must be greater than or equal to 5 years and less than 22 years of age. Diagnosis: Hodgkin s and Non-Hodgkin s Lymphoma: Refractory disease or relapse after salvage regimen. Acute Myelogenous Leukemia: History of bone marrow relapse in remission (CR) #2 or greater. Acute Lymphocytic Leukemia: History of bone marrow relapse in CR #2 or greater (CR#1 with Philadelphia chromosome positive or prior induction failure). Acute Hybrid Leukemia including mixed lineage, biphenotypic and undifferentiated: History of bone marrow relapse in CR #2 or greater (CR#1 with Philadelphia chromosome positive or prior induction failure). Myelodysplastic Syndrome: RAEB or RAEB-t with less than 10% blasts in marrow and blood. Chronic Myelogenous Leukemia: Chronic phase or accelerated phase with less than 10% blasts in marrow and blood. Juvenile Myelomonocytic Leukemia: less than 10% blasts in marrow and blood. Prior Therapy: Chemotherapy to achieve above criteria allowed. Prior BMT allowed as long as at least day 100+ post-prior BMT, no evidence of GVHD, and no detectable residual donor chimerism. Donor: First degree related donors, who are HLA matched (single HLA-A or B locus mismatch allowed), weight greater than or equal to 15 kilograms, and who meet standard donation criteria will be considered. The same donor from a prior BMT is allowed. ECOG Performance Status: 0, 1, or 2. and life expectancy: greater than 3 months. Liver Function: Serum direct bilirubin less than 2.0 mg/dL and serum ALT and AST values less than or equal to 2.5x upper limit of normal. (Values above these levels may be accepted if due to malignancy.) Renal Function: Age adjusted normal serum creatinine or Cr clearance greater than or equal to 60 mL/min/1.73 m(2). Pulmonary Function: DLCO greater than or equal to 50%. Cardiac Function: LVEF greater than or equal to 45% by MUGA or LVSF greater than or equal to 28% by ECHO Exclusion Criteria Active CNS malignancy: Tumor mass on CT or leptomeningeal disease. (Patients with a history of CNS involvement and no current evidence of CNS disease are allowed.) HIV infection, active hepatitis B or C infection: HbSAg or HCV seropositive and elevated liver transaminases. Fanconi Anemia. Lactating or pregnant females. Design: Pilot Study Initial evaluation: Patient and donor will be screened for eligibility. G-CSF primed bone marrow derived stem cells will be collected from the donor. Induction/Consolidation chemotherapy: 1 to 3 cycles will be given every 22 days depending on disease response, CD4 count, and toxicities. Lymphoma: fludarabine, etoposide, doxorubicin, vincristine, cyclophohamide, prednisone, and filgrastim (EPOCH-fludarabine). Leukemia and MDS: Fludarabine, cytarabine, and filgrastim (FLAG). Transplantation: Fludarabine and cyclophosphamide will be administered over 4 days followed by bone marrow transplant. Patients will remain hospitalized until bone marrow recovery. Patients will be monitored closely at the NIH for at least 100 days post-BMT. Post-transplant CNS prophylaxis for ALL: Standard post-transplant CNS prophylaxis will be employed with intrathecal methotrexate to decrease the risk of CNS relapse for all patients with ALL. Total number of recipient and donors to be accrued is 56.
Detailed Description
Background: Allogeneic blood and marrow stem cell transplantation (BMT) plays an important role in the curative treatment of a number of pediatric malignancies. Unfortunately, the success of conventional allogeneic BMT is limited in part by the multiple toxicities associated with myeloablative preparative regimens. Non-myeloablative pre-transplant regimens are associated with less toxic side effects than standard BMT. Recently, a novel immunosuppressive, non-myeloablative pre-transplant chemotherapy regimen has been shown to facilitate complete donor engraftment in an adult trial at the NCI. Objectives: The primary objective of this protocol is to evaluate the efficacy and safety of this treatment approach in pediatric patients with hematopoietic malignancies Eligibility: Inclusion Criteria Age: Patient must be greater than or equal to 5 years and less than 22 years of age. Diagnosis: Hodgkin s and Non-Hodgkin s Lymphoma: Refractory disease or relapse after salvage regimen. Acute Myelogenous Leukemia: History of bone marrow relapse in remission (CR) #2 or greater. Acute Lymphocytic Leukemia: History of bone marrow relapse in CR #2 or greater (CR#1 with Philadelphia chromosome positive or prior induction failure). Acute Hybrid Leukemia including mixed lineage, biphenotypic and undifferentiated: History of bone marrow relapse in CR #2 or greater (CR#1 with Philadelphia chromosome positive or prior induction failure). Myelodysplastic Syndrome: RAEB or RAEB-t with less than 10% blasts in marrow and blood. Chronic Myelogenous Leukemia: Chronic phase or accelerated phase with less than 10% blasts in marrow and blood. Juvenile Myelomonocytic Leukemia: less than 10% blasts in marrow and blood. Prior Therapy: Chemotherapy to achieve above criteria allowed. Prior BMT allowed as long as at least day 100+ post-prior BMT, no evidence of GVHD, and no detectable residual donor chimerism. Donor: First degree related donors, who are HLA matched (single HLA-A or B locus mismatch allowed), weight greater than or equal to 15 kilograms, and who meet standard donation criteria will be considered. The same donor from a prior BMT is allowed. ECOG Performance Status: 0, 1, or 2. and life expectancy: greater than 3 months. Liver Function: Serum direct bilirubin less than 2.0 mg/dL and serum ALT and AST values less than or equal to 2.5x upper limit of normal. (Values above these levels may be accepted if due to malignancy.) Renal Function: Age adjusted normal serum creatinine or Cr clearance greater than or equal to 60 mL/min/1.73 m(2). Pulmonary Function: DLCO greater than or equal to 50%. Cardiac Function: LVEF greater than or equal to 45% by MUGA or LVSF greater than or equal to 28% by ECHO Exclusion Criteria Active CNS malignancy: Tumor mass on CT or leptomeningeal disease. (Patients with a history of CNS involvement and no current evidence of CNS disease are allowed.) HIV infection, active hepatitis B or C infection: HbSAg or HCV seropositive and elevated liver transaminases. Fanconi Anemia. Lactating or pregnant females. Design: Pilot Study Initial evaluation: Patient and donor will be screened for eligibility. G-CSF primed bone marrow derived stem cells will be collected from the donor. Induction/Consolidation chemotherapy: 1 to 3 cycles will be given every 22 days depending on disease response, CD4 count, and toxicities. Lymphoma: fludarabine, etoposide, doxorubicin, vincristine, cyclophohamide, prednisone, and filgrastim (EPOCH-fludarabine). Leukemia and MDS: Fludarabine, cytarabine, and filgrastim (FLAG). Transplantation: Fludarabine and cyclophosphamide will be administered over 4 days followed by bone marrow transplant. Patients will remain hospitalized until bone marrow recovery. Patients will be monitored closely at the NIH for at least 100 days post-BMT. Post-transplant CNS prophylaxis for ALL: Standard post-transplant CNS prophylaxis will be employed with intrathecal methotrexate to decrease the risk of CNS relapse for all patients with ALL. Total number of recipient and donors to be accrued is 56.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Hodgkin Lymphoma, Lymphocytic Leukemia, Mixed Cell Leukemia, Myelodysplastic Syndrome, Non Hodgkin's Lymphoma, CML, ALL, AML, Lymphoma
Keywords
Leukemia, Myelodysplastic Syndrome, Bone Marrow Transplant, Pediatric Oncology, Lymphoma, Efficacy, Safety, Childhood Cancer

7. Study Design

Primary Purpose
Treatment
Study Phase
Early Phase 1
Interventional Study Model
Single Group Assignment
Masking
None (Open Label)
Allocation
N/A
Enrollment
30 (Actual)

8. Arms, Groups, and Interventions

Arm Title
1
Arm Type
Experimental
Arm Description
Transplant with Induction Therapy
Intervention Type
Procedure
Intervention Name(s)
Stem cell transplantation
Intervention Description
>3 x 106/kg CD34+ stem cells by IV infusion
Primary Outcome Measure Information:
Title
To determine the efficacy and safety of this chemotherapy regimen in facilitating donor engraftment after allogeneic bone marrow transplantation (BMT).
Title
Safety/Efficacy
Time Frame
5 years
Secondary Outcome Measure Information:
Title
Toxicity of regimen
Time Frame
5 years
Title
To determine the toxicity of this non-myelablative allogeneic BMT regimen.
Title
fludarabine-based induction reducing T-cells
Time Frame
5 years
Title
immune suppression
Time Frame
5 years
Title
IL-7 levels
Time Frame
5 years
Title
cytokine profiles
Time Frame
5 years
Title
response rates and DFS
Time Frame
5 years
Title
incidence and severity of GVHD
Time Frame
5 years
Title
response rates, DFS rates, and incidence and severity ofGVHD following withdrawal of immunosuppression and donorlymphocyte infusions (DLI) for patients who developprogressive disease after day +28 post-transplant
Time Frame
5 years

10. Eligibility

Sex
All
Minimum Age & Unit of Time
4 Years
Maximum Age & Unit of Time
20 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
INCLUSION CRITERIA PATIENTS: Patients with the following diagnoses will be considered: Hodgkin's and Non-Hodgkin's Lymphoma: Refractory (non-CR) to primary treatment regimen; Refractory (non-CR) to or relapse after salvage regimen. Acute Myelogenous Leukemia (AML): History of bone marrow relapse it CR number 2 or greater. Acute Lymphocytic Leukemia (ALL): History of bone marrow relapse in CR number 2 or greater; complete remission #1 with Philadelphia chromosome positive or prior induction failure (subsequent induction regimen required to achieve CR). Acute hybrid leukemia including mixed lineage, biphenotypic, and undifferentiated (AUL): History of bone marrow relapse in CR number 2 or greater; Complete remission #1 with Philadelphia chromosome positive or prior induction failure (second induction regimen required to achieve (CR). Myelodysplastic Syndrome (MDS) excluding refractory anemia (RA) and RA with ringed sideroblasts (RARS): blasts less than 10% in marrow and blood. Chronic Myelogenous Leukemia (CML): Chronic Phase; Accelerated Phase with blasts less than 10% in marrow and blood. Juvenile Myelomonocytic Leukemia (JMML, J-CML): Blasts less than 10% in marrow and blood. Patients must be greater than or equal to 4 years and less than 22 years of age. Prior chemotherapy: Chemotherapy to achieve above noted criteria allowed. Prior autologous BMT allowed. Prior allogeneic BMT allowed as long as at least day +100 post-prior BMT, and no evidence of ongoing active GVHD. Availability of 5 or 6 antigen genotypic HLA-matched first-degree relative donor (single HLA-A or B locus mismatch allowed). Performance status of 0,1, or 2. Life expectancy greater than 3 months. Liver function: serum direct bilirubin less than 2.0 mg/dL, and serum ALT and AST values less than or equal to 2.5 times the upper limit of normal. Values above these levels may be accepted, at the discretion of the PI, if such elevations are thought to be due to malignancy (excluding acute leukemia). Renal function: age-adjusted normal serum creatinine or a creatinine clearance greater than or equal to 60 mL/min/1.73 m(2). Pulmonary function: DLCO corrected for hemoglobin and alveolar volume greater than or equal to 50% of predicted. Left ventricular function: Ejection fraction greater than or equal to 45% by MUGA or shortening fraction greater than or equal to 28% by ECHO. Ability to give informed consent. For patients less than 18 years old their legal guardian must give informed consent. Pediatric patients will be included in age appropriate discussion in order to obtain verbal assent. Durable power of attorney form completed (patients greater than 18 years of age only). Patients must not have an active CNS malignancy as defined by: lymphoma (tumor mass on CT scan or leptomeningeal disease), Leukemia (CNS 2 or CNS 3 classification), or NB (History of CNS involvement with no current evidence of CNS malignancy is NOT an exclusion). Patients must not be HIV positive. Patients must not have active hepatitis B or C infection as defined by seropositive for hepatitis B (HbSAg) or hepatitis C and elevated liver transaminases. Female patients must not be lactating or pregnant (due to risk to fetus or newborn). Patients must not have high risk of inability to comply with transplant protocol as determined by principal investigator, social work, and BMT team. Patients must not have Fanconi Anemia (FA): patients with MDS must have a negative FA test. INCLUSION CRITERIA DONOR: First degree relative with genotypic identity at 5 or 6 HLA loci (single HLA-A or B locus mismatch allowed). Weight of greater than or equal to 15 kilograms. Adequate venous access for peripheral apheresis, or consent to use a temporary central venous catheter for apheresis (on Cohort #2, for possible future cell collection if needed). Ability to give informed consent. For donors less than 18 years of age, he/she must be the oldest eligible donor, their legal guardian must give informed consent, the donor must give verbal assent, and he/she must be cleared by social work and a mental health specialist to participate. Donor selection criteria will be in accordance with NIH/CC Department of Transfusion Medicine standards. EXLCUSION CRITERIA PATIENT: Active CNS malignancy as defined by: Lymphoma: tumor mass on CT scan or leptomeningeal disease Leukemia: CNS 2 or CNS 3 classification NB: History of CNS involvement with no current evidence of CNS malignancy is NOT an exclusion. HIV positive. Active hepatitis B or C infection as defined by seropositive for hepatitis B (HbsAg) or hepatitis C and elevated liver transaminases. Lactating or pregnant females. High risk of inability to comply with transplant protocol as determined by principal investigator, social work, and BMT team. Fanconi Anemia (FA): Patients with MDS must have a negative FA test. EXCLUSION CRITERIA DONOR: History of medical illness which in the estimation of the PI or DTM physician poses prohibitive risk to donation including, but not limited to stroke, hypertension that is not controlled by medication, or heart disease. Individuals with symptomatic angina or a history of coronary artery bypass grafting or angioplasty will not be eligible. History of congenital hematologic, immunologic, or metabolic disorder which in the estimation of the PI poses prohibitive risk to the recipient. Anemia (Hb less than gm/dl) or thrombocytopenia (less than 100,000/ul). Lactating or pregnant females. HIV positive. Seropositive for hepatitis B (HbsAg) or hepatitis C. High risk of inability to comply with transplant protocol as determined by principal investigator, social work, and BMT team.
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Terry J Fry, M.D.
Organizational Affiliation
National Cancer Institute (NCI)
Official's Role
Principal Investigator
Facility Information:
Facility Name
National Institutes of Health Clinical Center, 9000 Rockville Pike
City
Bethesda
State/Province
Maryland
ZIP/Postal Code
20892
Country
United States

12. IPD Sharing Statement

Citations:
PubMed Identifier
8338938
Citation
Kantarjian HM, Deisseroth A, Kurzrock R, Estrov Z, Talpaz M. Chronic myelogenous leukemia: a concise update. Blood. 1993 Aug 1;82(3):691-703. No abstract available.
Results Reference
background
PubMed Identifier
9718381
Citation
Pui CH, Evans WE. Acute lymphoblastic leukemia. N Engl J Med. 1998 Aug 27;339(9):605-15. doi: 10.1056/NEJM199808273390907. No abstract available.
Results Reference
background
PubMed Identifier
3523250
Citation
Rivera GK, Buchanan G, Boyett JM, Camitta B, Ochs J, Kalwinsky D, Amylon M, Vietti TJ, Crist WM. Intensive retreatment of childhood acute lymphoblastic leukemia in first bone marrow relapse. A Pediatric Oncology Group Study. N Engl J Med. 1986 Jul 31;315(5):273-8. doi: 10.1056/NEJM198607313150501.
Results Reference
background

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Pilot Study of Non-Myeloablative, HLA-Matched Allogeneic Stem Cell Transplantation for Pediatric Hematopoietic Malignancies

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