Reduced-Intensity Busulfan and Fludarabine With or Without Antithymocyte Globulin Followed by Donor Stem Cell Transplant in Treating Patients With Hematologic Cancer or Other Disease
NCT ID: NCT00448201
Last Updated: 2017-05-30
Study Results
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View full resultsBasic Information
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COMPLETED
PHASE2
71 participants
INTERVENTIONAL
2011-01-07
2012-05-23
Brief Summary
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PURPOSE: This clinical trial is studying the side effects and how well giving busulfan and fludarabine with or without antithymocyte globulin followed by donor stem cell transplant works in treating patients with hematologic cancer or other disease.
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Detailed Description
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Primary
* Determine the clinical efficacy and toxicity profiles of a nonmyeloablative preparative regimen comprising busulfan and fludarabine with or without anti-thymocyte globulin followed by allogeneic hematopoietic stem cell transplantation in patients with hematologic cancers or other diseases.
* Determine the feasibility of this regimen in these patients.
* Establish a treatment-related mortality during the first 6 months that is less than 20% in patients treated with this regimen.
Secondary
* Determine the response rates (disease-specific partial response and complete response) in patients treated with this regimen.
* Determine overall and progression-free survival of patients treated with this regimen.
* Determine the percent donor chimerism and immunologic recovery, including dendritic cell recovery, in patients treated with this regimen.
* Determine the risk of acute and chronic graft-versus-host disease and other toxicities in patients treated with this regimen.
* Assess the overall nonhematologic grades 3 and 4 toxicity of this regimen, including the incidence of veno-occlusive disease and pulmonary toxicity, in these patients.
OUTLINE: Patients are assigned to 1 of 4 treatment groups according to disease type and donor type.
* Preparative regimen:
* Group 1 (patients with acute myeloid leukemia (AML), acute lymphoblastic leukemia (ALL), IPSS (International Prognostic Scoring System score) high-risk myelodysplastic syndromes (HR MDS), or chronic myelogenous leukemia (CML) with an human leukocyte antigen (HLA)-matched related donor (MRD): Patients receive fludarabine phosphate IV over 30 minutes on days -7 to -3 and busulfan IV continuously over 48 hours on days -6 and -5.
* Group 2 (patients with AML, ALL, IPSS HR MDS, or CML with an HLA-matched unrelated donor (MUD) or mismatched related donor (MMRD)): Patients receive fludarabine phosphate and busulfan as in group 1 and anti-thymocyte globulin IV over 4 hours on day -8.
* Group 3 (patients with all other diseases with a MRD): Patients receive fludarabine phosphate and busulfan as in group 1 and anti-thymocyte globulin as in group 2.
* Group 4 (patients with all other disease with a MUD or MMRD): Patients receive fludarabine phosphate and busulfan as in group 1 and anti-thymocyte globulin IV over 4 hours on days -8 and -7.
* Allogeneic stem cell transplantation: All patients undergo allogeneic peripheral blood stem cell transplantation on day 0. Patients then receive sargramostim (GM-CSF) subcutaneously once daily beginning on day 5 (groups 1 and 2) or day 7 (groups 3 and 4) and continuing until blood counts recover.
* Graft-vs-host disease (GVHD) prophylaxis: All patients receive oral tacrolimus twice daily on days -1 to 120 followed by a taper until day 180. Patients in groups 1 and 2 also receive methotrexate IV on days 1, 3, and 6.
* Donor lymphocyte infusion (DLI): After day 120, patients with progressive disease or stable disease while off immunosuppression and with no evidence of active GVHD may receive DLI. Treatment with DLI may repeat every 8 weeks for up to 3 total infusions in the absence of disease response or GVHD.
Peripheral blood and/or bone marrow samples are collected at baseline and then at 30, 60, 90, 120, and 180 days post-transplantation. Chimerism (including the following subsets: whole blood, T-cells as defined by cluster of differentiation 3 (CD3) positivity, B-cells as defined by Cluster of Differentiation 19 (CD19) positivity, and myeloid cells as defined by Cluster of Differentiation 14 (CD14) and Cluster of Differentiation 15 (CD15) positivity is analyzed by polymerase chain reaction technology.
After restaging between Days 90 and 100 and between Days 150 to 180, patients are followed every 6 months for 1 years and then yearly for a maximum of 5 years from study entry.
Conditions
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Study Design
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NON_RANDOMIZED
SINGLE_GROUP
TREATMENT
NONE
Study Groups
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Methotrexate Only Arm
GVHD Prophylaxis with Methotrexate
sargramostim
GM-CSF 500 ug everyday (QD) subcutaneously will be given to recipients who remain with an Absolute neutrophil count (ANC) \< 1000/microliter (uL) past day 20
therapeutic allogeneic lymphocytes
A minimum total cluster of differentiation 34 (CD34)+ cell dose of 3 x 10\^6 cells/kg and a maximum 8 x 10\^6 cells/kg will be infused on day 0
busulfan
6.4 mg/kg by continuous IV infusion over 48 hours on Days -6 and -5
fludarabine phosphate
fludarabine 30 mg/m\^2/day x 5 days IV piggyback (IVPB) over 30 minutes on Days -7 through -3
methotrexate
Methotrexate 5 mg/m\^2 per day on days +1, +3 and +6
tacrolimus
Suggested starting dose is 0.03 mg/kg po bid starting on Day -1
nonmyeloablative allogeneic hematopoietic stem cell transplantation
Minimum total CD34+ cells of 3 x 10\^6 cells/kg and a maximum of 8 x 10\^6 cells/kg will be infused on Day 0
peripheral blood stem cell transplantation
Minimum total CD34+ cells of 3 x 10\^6 cells/kg and a maximum of 8 x 10\^6 cells/kg will be infused on Day 0
2 Doses ATG + Methotrexate
GVHD prophylaxis with antithymocyte globulin (ATG) + Methotrexate
anti-thymocyte globulin
0.5 mg/kg on day -3, 2.5 mg/kg on day -2 (groups 2, 3 and 4) and 3 mg/kg on day -1 (group 4 only)
sargramostim
GM-CSF 500 ug everyday (QD) subcutaneously will be given to recipients who remain with an Absolute neutrophil count (ANC) \< 1000/microliter (uL) past day 20
therapeutic allogeneic lymphocytes
A minimum total cluster of differentiation 34 (CD34)+ cell dose of 3 x 10\^6 cells/kg and a maximum 8 x 10\^6 cells/kg will be infused on day 0
busulfan
6.4 mg/kg by continuous IV infusion over 48 hours on Days -6 and -5
fludarabine phosphate
fludarabine 30 mg/m\^2/day x 5 days IV piggyback (IVPB) over 30 minutes on Days -7 through -3
methotrexate
Methotrexate 5 mg/m\^2 per day on days +1, +3 and +6
tacrolimus
Suggested starting dose is 0.03 mg/kg po bid starting on Day -1
nonmyeloablative allogeneic hematopoietic stem cell transplantation
Minimum total CD34+ cells of 3 x 10\^6 cells/kg and a maximum of 8 x 10\^6 cells/kg will be infused on Day 0
peripheral blood stem cell transplantation
Minimum total CD34+ cells of 3 x 10\^6 cells/kg and a maximum of 8 x 10\^6 cells/kg will be infused on Day 0
2 Doses ATG
GVHD prophylaxis with 2 doses ATG
anti-thymocyte globulin
0.5 mg/kg on day -3, 2.5 mg/kg on day -2 (groups 2, 3 and 4) and 3 mg/kg on day -1 (group 4 only)
sargramostim
GM-CSF 500 ug everyday (QD) subcutaneously will be given to recipients who remain with an Absolute neutrophil count (ANC) \< 1000/microliter (uL) past day 20
therapeutic allogeneic lymphocytes
A minimum total cluster of differentiation 34 (CD34)+ cell dose of 3 x 10\^6 cells/kg and a maximum 8 x 10\^6 cells/kg will be infused on day 0
busulfan
6.4 mg/kg by continuous IV infusion over 48 hours on Days -6 and -5
fludarabine phosphate
fludarabine 30 mg/m\^2/day x 5 days IV piggyback (IVPB) over 30 minutes on Days -7 through -3
tacrolimus
Suggested starting dose is 0.03 mg/kg po bid starting on Day -1
nonmyeloablative allogeneic hematopoietic stem cell transplantation
Minimum total CD34+ cells of 3 x 10\^6 cells/kg and a maximum of 8 x 10\^6 cells/kg will be infused on Day 0
peripheral blood stem cell transplantation
Minimum total CD34+ cells of 3 x 10\^6 cells/kg and a maximum of 8 x 10\^6 cells/kg will be infused on Day 0
3 Doses ATG
GVHD prophylaxis with 3 doses ATG
anti-thymocyte globulin
0.5 mg/kg on day -3, 2.5 mg/kg on day -2 (groups 2, 3 and 4) and 3 mg/kg on day -1 (group 4 only)
sargramostim
GM-CSF 500 ug everyday (QD) subcutaneously will be given to recipients who remain with an Absolute neutrophil count (ANC) \< 1000/microliter (uL) past day 20
therapeutic allogeneic lymphocytes
A minimum total cluster of differentiation 34 (CD34)+ cell dose of 3 x 10\^6 cells/kg and a maximum 8 x 10\^6 cells/kg will be infused on day 0
busulfan
6.4 mg/kg by continuous IV infusion over 48 hours on Days -6 and -5
fludarabine phosphate
fludarabine 30 mg/m\^2/day x 5 days IV piggyback (IVPB) over 30 minutes on Days -7 through -3
tacrolimus
Suggested starting dose is 0.03 mg/kg po bid starting on Day -1
nonmyeloablative allogeneic hematopoietic stem cell transplantation
Minimum total CD34+ cells of 3 x 10\^6 cells/kg and a maximum of 8 x 10\^6 cells/kg will be infused on Day 0
peripheral blood stem cell transplantation
Minimum total CD34+ cells of 3 x 10\^6 cells/kg and a maximum of 8 x 10\^6 cells/kg will be infused on Day 0
Interventions
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anti-thymocyte globulin
0.5 mg/kg on day -3, 2.5 mg/kg on day -2 (groups 2, 3 and 4) and 3 mg/kg on day -1 (group 4 only)
sargramostim
GM-CSF 500 ug everyday (QD) subcutaneously will be given to recipients who remain with an Absolute neutrophil count (ANC) \< 1000/microliter (uL) past day 20
therapeutic allogeneic lymphocytes
A minimum total cluster of differentiation 34 (CD34)+ cell dose of 3 x 10\^6 cells/kg and a maximum 8 x 10\^6 cells/kg will be infused on day 0
busulfan
6.4 mg/kg by continuous IV infusion over 48 hours on Days -6 and -5
fludarabine phosphate
fludarabine 30 mg/m\^2/day x 5 days IV piggyback (IVPB) over 30 minutes on Days -7 through -3
methotrexate
Methotrexate 5 mg/m\^2 per day on days +1, +3 and +6
tacrolimus
Suggested starting dose is 0.03 mg/kg po bid starting on Day -1
nonmyeloablative allogeneic hematopoietic stem cell transplantation
Minimum total CD34+ cells of 3 x 10\^6 cells/kg and a maximum of 8 x 10\^6 cells/kg will be infused on Day 0
peripheral blood stem cell transplantation
Minimum total CD34+ cells of 3 x 10\^6 cells/kg and a maximum of 8 x 10\^6 cells/kg will be infused on Day 0
Eligibility Criteria
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Inclusion Criteria
* Any World Health Organization (WHO) class histologic subtype allowed
* Core biopsies are acceptable provided they contain adequate tissue for primary diagnosis and immunophenotyping
* Bone marrow biopsies as sole means of diagnosis are not allowed for follicular lymphoma
* Hodgkin's lymphoma, meeting the following criteria:
* Any WHO class histologic subtype allowed
* Core biopsies are acceptable provided they contain adequate tissue for primary diagnosis and immunophenotyping
* Multiple myeloma, meeting the following criteria:
* Active disease requiring treatment (Durie-Salmon stages I, II, or III)
* Acute myeloid leukemia with documented control, defined as \< 10% bone marrow blasts and no circulating blasts
* Acute lymphoblastic leukemia, meeting the following criteria:
* In early first relapse or beyond OR in first complete remission and has 1 of the following high-risk features:
* t(9;22) or t(4;11)
* WBC count \> 30,000/mm³ at presentation
* Non-T-cell phenotype
* More than 30 years of age
* Agnogenic myeloid metaplasia/myelofibrosis
* Patients who are transfusion dependent or who have evolving myelodysplastic or leukemic features or high-risk cytogenetic abnormalities are eligible
* Myelodysplastic syndromes (MDS) as defined by WHO criteria
* Meets 1 of the following criteria:
* Over 55 years of age
* Ineligible for busulfan-based therapy based on diminished organ function or poor performance status
* Indolent and chemotherapy-responsive CLL, low-grade NHL, small lymphocytic lymphoma, or PLL
* Patients who have undergone prior autologous stem cell transplantation are preferentially enrolled on clinical trial CALGB-100002, if available and patient is eligible
* HLA-matched or mismatched related donor or HLA-matched unrelated donor available
* HLA-identical sibling (6/6 or 9/10) (minimal serologic typing required for class I \[A, B\]; molecular typing required for class II (DRB1))
* 9/10 matched unrelated donor (MUD) (molecular analysis at HLA A, B, C, DRB1, and DQB1 by high resolution typing required)
* 5/6 MUD (molecular analysis at HLA A, B, and DRB1 required)
* No syngeneic donors
PATIENT CHARACTERISTICS:
* Creatinine clearance ≥ 40 mL/min
* Bilirubin ≤ 3 times upper limit of normal (ULN)
* aspartate aminotransferase (AST) ≤ 3 times ULN
* Diffusing capacity of the lungs for carbon monoxide (DLCO) \> 40% with no symptomatic pulmonary disease
* Left ventricular ejection fraction (LVEF) ≥ 30% by multigated acquisition scan (MUGA)
* No uncontrolled diabetes mellitus or active serious infection
* No known hypersensitivity to Escherichia coli-derived products
* No HIV infection
* Not pregnant or nursing
* Negative pregnancy test
* Fertile patients must use effective contraception
PRIOR CONCURRENT THERAPY:
* See Disease Characteristics
* More than 4 weeks since prior chemotherapy, radiotherapy (except prophylactic cranial x-ray therapy), or surgery
10 Years
ALL
No
Sponsors
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National Cancer Institute (NCI)
NIH
UNC Lineberger Comprehensive Cancer Center
OTHER
Responsible Party
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Principal Investigators
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Thomas C. Shea, MD
Role: PRINCIPAL_INVESTIGATOR
UNC Lineberger Comprehensive Cancer Center
Locations
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Lineberger Comprehensive Cancer Center at University of North Carolina - Chapel Hill
Chapel Hill, North Carolina, United States
Countries
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Related Links
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University of North Carolina (UNC) Lineberger Comprehensive Cancer Center
Other Identifiers
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LCCC 0306
Identifier Type: -
Identifier Source: org_study_id
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