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Chemotherapy, Stem Cell Transplantation, and Graft-Versus-Host-Disease Prevention in Treating Patients With Refractory or Relapsed Hematologic Cancer, Myelodysplastic Syndrome, or Myeloproliferative Disorder
This study is ongoing, but not recruiting participants.
First Received: March 6, 2003   Last Updated: February 6, 2009   History of Changes
Sponsor: National Cancer Institute (NCI)
Information provided by: National Cancer Institute (NCI)
ClinicalTrials.gov Identifier: NCT00055744
  Purpose

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. Sometimes the transplanted cells can make an immune response against the body's normal tissues. Cyclosporine and methotrexate may prevent this from happening.

PURPOSE: Phase II trial to study the effectiveness of combining cyclosporine with methotrexate in preventing graft-versus-host disease following chemotherapy and allogeneic stem cell transplantation in patients who have refractory or relapsed hematologic cancer, myelodysplastic syndrome, or myeloproliferative disorder.


Condition Intervention Phase
Chronic Myeloproliferative Disorders
Graft Versus Host Disease
Leukemia
Lymphoma
Multiple Myeloma and Plasma Cell Neoplasm
Myelodysplastic Syndromes
Myelodysplastic/Myeloproliferative Diseases
Biological: filgrastim
Biological: rituximab
Biological: therapeutic allogeneic lymphocytes
Drug: cyclophosphamide
Drug: cyclosporine
Drug: doxorubicin hydrochloride
Drug: etoposide
Drug: fludarabine phosphate
Drug: methotrexate
Drug: prednisone
Drug: vincristine sulfate
Procedure: peripheral blood stem cell transplantation
Phase II

Study Type: Interventional
Study Design: Supportive Care
Official Title: A Pilot Study of EPOCH-F/R Induction Chemotherapy and Reduced-Intensity, HLA-Matched, Related Allogeneic Hematopoietic Stem Cell Transplantation for Refractory or Relapsed Hematologic Malignancies, With Cyclosporine & Methotrexate for Graft-Versus-Host Disease Prophylaxis

Resource links provided by NLM:


Further study details as provided by National Cancer Institute (NCI):

Study Start Date: December 2002
Detailed Description:

OBJECTIVES:

Primary

  • Determine the efficacy of cyclosporine and mini-dose methotrexate as prophylaxis for acute graft-versus-host disease (GVHD) following allogeneic hematopoietic stem cell transplantation (HSCT) after a modified induction chemotherapy regimen comprising etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, fludarabine, and rituximab (EPOCH-F/R) and reduced-intensity conditioning comprising fludarabine and cyclophosphamide in patients with refractory or relapsed hematologic malignancies or myelodysplastic syndromes or myeloproliferative disorders.

Secondary

  • Determine the toxicity of EPOCH-F/R in these patients.
  • Determine the impact of this GVHD prophylaxis regimen on hematologic recovery and donor/recipient chimerism in these patients.
  • Determine the efficacy of EPOCH-F/R, in terms of anti-tumor activity and sequential host immune depletion prior to allogeneic HSCT, in these patients.
  • Determine the overall response rate of patients with disease progression after allogeneic HSCT treated with salvage therapies.

OUTLINE: This is a pilot study.

  • Induction chemotherapy: Patients receive fludarabine IV over 30 minutes, etoposide IV continuously over 24 hours, doxorubicin IV continuously over 24 hours, and vincristine IV continuously over 24 hours on days 1-4. Patients also receive oral prednisone on days 1-5 and cyclophosphamide IV over 30 minutes on day 5. Patients receive filgrastim (G-CSF) subcutaneously (SC) daily beginning on day 6 and continuing until blood counts recover. Patients with CD20+ B-cell malignancies receive rituximab IV on day 1. Treatment repeats every 21 days for up to 3 courses in the absence of unacceptable toxicity or disease progression.
  • Transplantation conditioning: Within 7-21 days after the completion of induction chemotherapy, patients receive fludarabine IV over 30 minutes and cyclophosphamide IV over 2 hours daily on days -6 to -3.
  • Allogeneic stem cell transplantation (ASCT): Patients undergo allogeneic stem cell transplantation on day 0. Patients receive G-CSF SC beginning on day 0 and continuing until blood counts recover.
  • Graft-versus-host disease prophylaxis: Patients receive cyclosporine IV over 2 hours or orally every 12 hours on day -1 until day 180. Patients also receive methotrexate IV over 15 minutes on days 1, 3, 6, and 11.

Patients with persistent or progressive disease after ASCT or mixed chimerism that does not improve after tapering or discontinuing immune suppression may receive donor lymphocyte infusions.

Patients are followed twice weekly for 3 months, monthly for 3 months, every 3 months for 2 years, and then annually thereafter.

PROJECTED ACCRUAL: A total of 8-40 patients will be accrued for this study within 2 years.

  Eligibility

Ages Eligible for Study:   18 Years to 75 Years
Genders Eligible for Study:   Both
Accepts Healthy Volunteers:   No
Criteria

DISEASE CHARACTERISTICS:

  • Diagnosis of a hematologic malignancy of 1 of the following types:

    • Chronic lymphocytic leukemia, meeting 1 of the following criteria:

      • Relapsed after fludarabine therapy
      • No complete remission (CR) after salvage regimen
    • Hodgkin's or non-Hodgkin's lymphoma (all types, including mantle cell lymphoma and hepatosplenic gamma/delta T-cell lymphoma) or multiple myeloma, meeting 1 of the following criteria:

      • Primary treatment failure*
      • Relapsed after autologous stem cell transplantation (SCT)*
      • No CR after salvage regimen (for multiple myeloma only) NOTE: *Requirement waived for patients with hepatosplenic gamma/delta T-cell lymphoma
    • Acute myeloid leukemia*, meeting 1 of the following criteria:

      • First CR with high-risk cytogenetics (abnormalities other than t [8;21], t [15;17], or inv [16])
      • Second CR or greater
    • Acute lymphoblastic leukemia*, meeting 1 of the following criteria:

      • First CR with high-risk cytogenetics (e.g., t [4;11], t [1;19], t [8;14], t [9;22], or bcr-abl rearrangement)
      • Second CR or greater NOTE: *Patients with acute leukemia must be in hematologic remission, defined as less than 5% blasts in blood or bone marrow

OR

  • Diagnosis of a myelodysplastic syndrome of 1 of the following types:

    • Refractory anemia with excess blasts (RAEB)
    • RAEB in transformation (if blasts are less than 10% in marrow and blood after induction chemotherapy) OR
  • Diagnosis of a myeloproliferative disorder of 1 of the following types:

    • Idiopathic myelofibrosis
    • Polycythemia vera
    • Essential thrombocytosis
    • Chronic myelomonocytic leukemia
    • Chronic myelogenous leukemia, meeting 1 of the following criteria:

      • Chronic or accelerated phase (in patients 50 to 75 years old)
      • Not eligible for myeloablative allogeneic hematopoietic SCT (in patients 18 to 50 years old)
  • No active CNS involvement
  • First-degree relative matched donor available

    • Matched at 6/6 HLA antigens (A, B, and DR)

PATIENT CHARACTERISTICS:

Age

  • 18 to 75

Performance status

  • ECOG 0-2 OR
  • Karnofsky 60-100%

Life expectancy

  • At least 3 months

Hematopoietic

  • See Disease Characteristics
  • Absolute neutrophil count at least 1,000/mm^3*
  • Platelet count at least 20,000/mm^3* (without transfusion) NOTE: Values below these levels may be acceptable at the discretion of the principal investigator if thought to be due to bone marrow involvement by the malignancy

Hepatic

  • Bilirubin less than 2.5 mg/dL
  • AST and ALT no greater than 2.5 times upper limit of normal* (higher levels accepted if there is liver involvement)
  • No chronic active hepatitis B

    • Hepatitis B core antibody positive allowed if surface antigen negative and no evidence of active infection
  • No hepatitis C infection NOTE: *If these values do not normalize during induction chemotherapy, patients will not be eligible for the transplantation phase, and thus will be taken off study

Renal

  • Creatinine no greater than 1.5 mg/dL
  • Creatinine clearance at least 50 mL/min

Cardiovascular

  • LVEF greater than 45% by MUGA or 2-D echocardiogram

Pulmonary

  • DLCO greater than 50% of expected (corrected for hemoglobin)

Other

  • Not pregnant or nursing
  • Negative pregnancy test
  • Fertile patients must use effective contraception
  • HIV negative
  • No active infection not responding to antimicrobial therapy
  • No psychiatric disorder that would preclude study compliance or ability to give informed consent

PRIOR CONCURRENT THERAPY:

Biologic therapy

  • See Disease Characteristics

Chemotherapy

  • See Disease Characteristics
  • At least 2 weeks since prior cytotoxic chemotherapy

Endocrine therapy

  • Not specified

Radiotherapy

  • Not specified

Surgery

  • Not specified

Other

  • At least 2 weeks since prior anticancer therapy and recovered
  • No concurrent combination of trimethoprim and sulfamethoxazole (i.e., co-trimoxazole) or nonsteroidal anti-inflammatory drugs during methotrexate therapy
  Contacts and Locations
Please refer to this study by its ClinicalTrials.gov identifier: NCT00055744

Locations
United States, Maryland
Warren Grant Magnuson Clinical Center - NCI Clinical Studies Support
Bethesda, Maryland, United States, 20892-1182
Sponsors and Collaborators
Investigators
Study Chair: Daniel Fowler, MD National Cancer Institute (NCI)
  More Information

Additional Information:
No publications provided

Study ID Numbers: CDR0000271137, NCI-03-C-0077
Study First Received: March 6, 2003
Last Updated: February 6, 2009
ClinicalTrials.gov Identifier: NCT00055744     History of Changes
Health Authority: United States: Federal Government

Keywords provided by National Cancer Institute (NCI):
graft versus host disease
adult acute lymphoblastic leukemia in remission
adult acute myeloid leukemia in remission
refractory chronic lymphocytic leukemia
recurrent adult diffuse large cell lymphoma
recurrent adult diffuse mixed cell lymphoma
recurrent adult diffuse small cleaved cell lymphoma
recurrent adult Burkitt lymphoma
recurrent adult Hodgkin lymphoma
recurrent adult immunoblastic large cell lymphoma
recurrent adult lymphoblastic lymphoma
recurrent grade 1 follicular lymphoma
recurrent grade 2 follicular lymphoma
recurrent grade 3 follicular lymphoma
recurrent mantle cell lymphoma
refractory anemia with excess blasts in transformation
refractory anemia with excess blasts
chronic phase chronic myelogenous leukemia
accelerated phase chronic myelogenous leukemia
chronic idiopathic myelofibrosis
polycythemia vera
essential thrombocythemia
chronic myelomonocytic leukemia
refractory multiple myeloma
de novo myelodysplastic syndromes
previously treated myelodysplastic syndromes
secondary myelodysplastic syndromes
recurrent adult T-cell leukemia/lymphoma
recurrent cutaneous T-cell non-Hodgkin lymphoma
recurrent mycosis fungoides/Sezary syndrome

Additional relevant MeSH terms:
Anti-Inflammatory Agents
Anti-Infective Agents
Prednisone
Antimetabolites, Antineoplastic
Cyclosporine
Molecular Mechanisms of Pharmacological Action
Physiological Effects of Drugs
Hormones, Hormone Substitutes, and Hormone Antagonists
Hormones
Cyclosporins
Preleukemia
Hemorrhagic Disorders
Pathologic Processes
Therapeutic Uses
Abortifacient Agents
Methotrexate
Cardiovascular Diseases
Dermatologic Agents
Etoposide
Nucleic Acid Synthesis Inhibitors
Immunoproliferative Disorders
Antineoplastic Agents, Hormonal
Immune System Diseases
Hematologic Diseases
Rituximab
Myeloproliferative Disorders
Vincristine
Abortifacient Agents, Nonsteroidal
Glucocorticoids
Doxorubicin

ClinicalTrials.gov processed this record on November 05, 2009