Tacrolimus and Methotrexate With or Without Sirolimus in Preventing Graft-Versus-Host Disease in Young Patients Undergoing Donor Stem Cell Transplant for Acute Lymphoblastic Leukemia in Complete Remission
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Purpose
This randomized phase III trial is studying tacrolimus, methotrexate, and sirolimus to see how well they work compared to tacrolimus and methotrexate in preventing graft-versus-host disease in young patients who are undergoing donor stem cell transplant for intermediate-risk or high-risk acute lymphoblastic leukemia in second complete remission. Giving chemotherapy, such as thiotepa and cyclophosphamide, and total-body irradiation before a donor stem cell transplant helps stop the growth of cancer cells. It also helps stop the patient's immune system from rejecting the donor's stem cells. The donated stem cells may replace the patient's immune cells and help destroy any remaining cancer cells (graft-versus-tumor effect). Sometimes the transplanted cells from a donor can also make an immune response against the body's normal cells. Giving tacrolimus, methotrexate, and sirolimus after the transplant may stop this from happening. It is not yet known whether tacrolimus and methotrexate are more effective with or without sirolimus in preventing graft-versus-host disease.
| Condition | Intervention | Phase |
|---|---|---|
|
B-cell Childhood Acute Lymphoblastic Leukemia Childhood Acute Lymphoblastic Leukemia in Remission Graft Versus Host Disease L1 Childhood Acute Lymphoblastic Leukemia L2 Childhood Acute Lymphoblastic Leukemia T-cell Childhood Acute Lymphoblastic Leukemia |
Drug: thiotepa Drug: cyclophosphamide Drug: tacrolimus Drug: methotrexate Drug: sirolimus Radiation: total body irradiation |
Phase 3 |
| Study Type: | Interventional |
| Study Design: | Allocation: Randomized Endpoint Classification: Safety/Efficacy Study Intervention Model: Parallel Assignment Masking: Open Label Primary Purpose: Treatment |
| Official Title: | A Randomized Trial of Sirolimus-Based Graft Versus Host Disease Prophylaxis After Hematopoietic Stem Cell Transplantation in Relapsed Acute Lymphoblastic Leukemia |
- Event-free survival after transplantation as measured by the O'Brien-Fleming spending function [ Time Frame: Up to 2 years ] [ Designated as safety issue: No ]
- Rate of relapse [ Time Frame: Up to 1 year ] [ Designated as safety issue: No ]
- Rate of treatment-related mortality [ Time Frame: Up to 100 days ] [ Designated as safety issue: Yes ]A one-sided Z-test of proportions (alpha = 0.05) will be used
- Rate of acute graft-versus-host-disease (GVHD) [ Time Frame: Up to 3 months ] [ Designated as safety issue: Yes ]A two-sided Z-test of proportions (alpha = 0.05) will be used.
- Rate of chronic GVHD [ Time Frame: Up to 5 years ] [ Designated as safety issue: Yes ]A two-sided log-rank test (alpha = 0.05) will be used.
- Relative contribution of resistance by acute lymphoblastic leukemia (ALL) blasts to cytolytic therapy (e.g., chemotherapy/irradiation) as a cause of relapse post-transplantation [ Time Frame: Up to 1 year ] [ Designated as safety issue: No ]Contingency tables will be used to tabulate relapse with first complete remission (CR1) ALL blast sirolimus resistance and sirolimus biomarkers. Second complete remission (CR2) ALL blast sirolimus resistance and biomarkers will be compared to CR1 ALL blast levels with McNemar‟s test.
- Relative contribution of resistance by ALL blasts to the donor immune response as a cause of relapse post-transplantation [ Time Frame: Up to 1 year ] [ Designated as safety issue: No ]Multivariate analyses of relapse risk and treatment resistance will be performed using logistic regression.
- MRD [ Time Frame: Up to 9 months ] [ Designated as safety issue: No ]A mixed effects model will be fit with the covariates used.
- Chimerism [ Time Frame: Up to 12 months ] [ Designated as safety issue: No ]A mixed effects model will be fit with the covariates used.
| Enrollment: | 146 |
| Study Start Date: | March 2007 |
| Primary Completion Date: | October 2012 (Final data collection date for primary outcome measure) |
| Arms | Assigned Interventions |
|---|---|
|
Experimental: Arm I (experimental)
Patients will receive the designated preparative regimen of cyclophosphamide/total body irradiation (TBI)/Thiotepa starting at day -8. Patients receive tacrolimus IV continuously or orally (when able) daily beginning on day -2 followed by a taper beginning on day 42 and continuing until day 98 (for patients undergoing matched sibling donor transplantation) OR tacrolimus IV continuously or orally daily beginning on day -2 followed by a taper beginning on day 100 and continuing until day 180 (for patients undergoing related, unrelated, or cord blood donor transplantation) in the absence of GVHD. Patients also receive methotrexate IV on days 1, 3, and 6 (for patients with matched sibling and umbilical cord blood donors) OR days 1, 3, 6, and 11 (for patients with unrelated bone marrow and peripheral blood stem cell donors) and oral sirolimus daily beginning on day 0 followed by a taper beginning on day 180 and continuing until day 207.
|
Drug: thiotepa
Given IV
Other Names:
Drug: cyclophosphamide
Given IV
Other Names:
Drug: tacrolimus
Given IV or orally
Other Names:
Drug: methotrexate
Given IV
Other Names:
Drug: sirolimus
Given orally
Other Names:
Radiation: total body irradiation
Part of the transplant preparatory regimen
Other Name: TBI
|
|
Active Comparator: Arm II (control)
Patients receive tacrolimus and methotrexate as in arm I.
|
Drug: thiotepa
Given IV
Other Names:
Drug: cyclophosphamide
Given IV
Other Names:
Drug: tacrolimus
Given IV or orally
Other Names:
Drug: methotrexate
Given IV
Other Names:
Radiation: total body irradiation
Part of the transplant preparatory regimen
Other Name: TBI
|
Detailed Description:
PRIMARY OBJECTIVES:
I. Compare the post-transplant 2-year event-free survival of pediatric patients with intermediate-risk or high-risk acute lymphoblastic leukemia (ALL) in second complete remission undergoing allogeneic hematopoietic stem cell transplantation treated with graft-versus-host disease (GVHD) prophylaxis comprising tacrolimus and methotrexate with or without sirolimus.
SECONDARY OBJECTIVES:
I. Compare rates of relapses, transplant-related mortality, and acute and chronic GVHD in these patients.
II. Evaluate the relative contribution of resistance by ALL blasts to cytolytic therapy (e.g., chemotherapy/irradiation) as a cause of relapse post-transplantation by correlating ALL in vivo blast resistance with in vivo sirolimus, inhibition levels of the mTOR pathway in patients treated with sirolimus, and altered resistance pathways in ALL blasts measured by microarray analysis.
III. Evaluate the relative contribution of resistance by ALL blasts to the donor immune response as a cause of relapse post-transplantation by correlating the development of donor anti-ALL T-cell response, the development of acute and/or chronic GVHD, and the detection of altered ALL blast immunogenicity after transplant with increased minimal residual disease, persistent recipient chimerism, and relapse.
OUTLINE: This is a randomized, open-label, multicenter study. Patients are stratified according to risk (intermediate CR2 vs high CR2 vs very high CR1), donor type (matched sibling vs unrelated or mismatched vs mismatched related), and stem cell source (filgrastim [G-CSF]-primed bone marrow vs unprimed bone marrow vs bone marrow vs peripheral blood vs umbilical cord blood).
PREPARATIVE REGIMEN: Patients undergo total-body irradiation twice daily on days -8 to -6 and receive thiotepa IV on days -5 and -4 and cyclophosphamide IV on days -3 and -2.
ALLOGENEIC HEMATOPOIETIC STEM CELL TRANSPLANTATION: Patients undergo allogeneic hematopoietic stem cell transplantation on day 0.
GRAFT-VERSUS-HOST DISEASE (GVHD) PROPHYLAXIS: Patients are randomized to 1 of 2 treatment arms.
ARM I: (experimental) Patients receive tacrolimus IV continuously or orally (when able) daily beginning on day -2 followed by a taper beginning on day 42 and continuing until day 98 (for patients undergoing matched sibling donor transplantation) OR tacrolimus IV continuously or orally daily beginning on day -2 followed by a taper beginning on day 100 and continuing until day 180 (for patients undergoing related, unrelated, or cord blood donor transplantation) in the absence of GVHD. Patients also receive methotrexate IV on days 1, 3, and 6 (for patients with matched sibling and umbilical cord blood donors) OR days 1, 3, 6, and 11 (for patients with unrelated bone marrow and peripheral blood stem cell donors) and oral sirolimus daily beginning on day 0 followed by a taper beginning on day 180 and continuing until day 207.
ARM II: (control) Patients receive tacrolimus and methotrexate as in arm I.
After completion of study treatment, patients are followed periodically for approximately 10 years.
Eligibility| Ages Eligible for Study: | 1 Year to 21 Years |
| Genders Eligible for Study: | Both |
| Accepts Healthy Volunteers: | No |
Inclusion Criteria:
Histologically or cytologically confirmed acute lymphoblastic leukemia (ALL)* in second complete remission (CR2) (M1 bone marrow, < 5% blasts by morphology) meeting the following criteria:
Eligible for matched sibling transplantation AND intermediate-risk disease meeting 1 of the following criteria:
- B-lineage ALL in CR2 after a late first bone marrow (BM) relapse (≥ 36 months after the initiation of primary chemotherapy) with or without associated extramedullary disease
- B-lineage ALL in CR2 after a very early isolated extramedullary relapse**
Eligible for other related donor, unrelated donor, or matched sibling transplantation AND high-risk disease meeting 1 of the following criteria:
- In CR2 after an early first BM relapse (< 36 months from initiation of primary chemotherapy)
- T-lineage ALL in CR2 after a first BM relapse occurring at any time after initiation of primary chemotherapy
- Philadelphia chromosome-positive ALL in CR2 after a first BM relapse occurring at any time after the initiation of primary chemotherapy
- T-lineage ALL in CR2 after a very early isolated extramedullary relapse**
Enrolled on an appropriate COG relapsed ALL clinical trial meeting 1 of the following criteria:
- Must proceed directly to transplantation after completing the required study therapy (i.e., 1 induction course and 2 consolidation courses)
- Patients not on a COG relapsed ALL clinical trial are eligible provided they have received ≥ 1 round of re-induction lasting 4-6 weeks and 1 round of intensive consolidation chemotherapy lasting 3-6 weeks
- No B-cell ALL L3 morphology with evidence of myc translocation by molecular or cytogenetic technique
- No Down syndrome
- No evidence of active CNS or other extramedullary disease (i.e., no CNS2)
- Karnofsky performance status (PS) 60-100% (for patients > 16 years of age) OR Lansky PS 60-100% (for patients ≤ 16 years of age)
- Shortening fraction ≥ 27% by echocardiogram OR ejection fraction ≥ 50% by radionuclide angiogram
- ALT or AST < 5 times upper limit of normal
- Bilirubin < 2.5 mg/dL (unless an increase is attributable to Gilbert's syndrome)
- Creatinine clearance OR radioisotope glomerular filtration rate ≥ 70 mL/min
- FEV_1 ≥ 60% by pulmonary function tests (PFTs)
- FVC ≥ 60% by PFTs
- DLCO ≥ 60% by PFTs
For children who are unable to cooperate for PFTs all of the following criteria must be met:
- No evidence of dyspnea at rest
- No exercise intolerance
- No requirement for supplemental oxygen therapy
- Not pregnant or nursing
- Negative pregnancy test
- Fertile patients must use effective contraception
No HIV or uncontrolled fungal, bacterial, or viral infection
- Fungal infection acquired during induction therapy allowed provided there is a significant response to antifungal therapy with minimal or no evidence of disease by CT scan
- Other concurrent immunosuppressants allowed
- No prior allogeneic or autologous stem cell transplantation
- No prior or concurrent voriconazole unless prior voriconazole therapy is completed or a different agent is substituted for voriconazole prior to study entry
- No concurrent grapefruit juice during sirolimus administration
Contacts and Locations
Show 50 Study Locations| Principal Investigator: | Michael Pulsipher | Children's Oncology Group |
More Information
No publications provided
| Responsible Party: | Children's Oncology Group |
| ClinicalTrials.gov Identifier: | NCT00382109 History of Changes |
| Other Study ID Numbers: | ASCT0431, NCI-2009-01068, CDR0000500131, COG-PBMTC-ONCO51, COG-ASCT0431, U10CA098543 |
| Study First Received: | September 26, 2006 |
| Last Updated: | June 14, 2013 |
| Health Authority: | United States: Institutional Review Board |
Additional relevant MeSH terms:
|
Graft vs Host Disease Leukemia Leukemia, Lymphoid Precursor Cell Lymphoblastic Leukemia-Lymphoma Immune System Diseases Neoplasms by Histologic Type Neoplasms Lymphoproliferative Disorders Lymphatic Diseases Immunoproliferative Disorders Cyclophosphamide Methotrexate Thiotepa Sirolimus Everolimus |
Tacrolimus Immunosuppressive Agents Immunologic Factors Physiological Effects of Drugs Pharmacologic Actions Antirheumatic Agents Therapeutic Uses Antineoplastic Agents, Alkylating Alkylating Agents Molecular Mechanisms of Pharmacological Action Antineoplastic Agents Myeloablative Agonists Abortifacient Agents, Nonsteroidal Abortifacient Agents Reproductive Control Agents |
ClinicalTrials.gov processed this record on June 18, 2013