• Risk of acute graft-vs-host disease (aGVHD) and chronic graft-vs-host disease (cGVHD) [ Designated as safety issue: Yes ]
• Risk of infections [ Designated as safety issue: Yes ]
• Engraftment maintenance on day 28 post-transplant [ Designated as safety issue: No ]
• Risk of progression and relapse as assessed by nonrelapse-related mortality on day 100 post-transplant [ Designated as safety issue: Yes ]

• Risk of acute graft-vs-host disease (aGVHD) and chronic graft-vs-host disease (cGVHD)
• Risk of infections
• Engraftment maintenance on day 28 post-transplant
• Risk of progression and relapse as assessed by nonrelapse-related mortality on day 100 post-transplant

RATIONALE: Giving chemotherapy and total body irradiation before a donor peripheral blood 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. Also, monoclonal antibodies, such as alemtuzumab, can find cancer cells and either kill them or deliver cancer-killing substances to them without harming normal cells. When the healthy stem cells from a donor are infused into the patient they may help the patient's bone marrow make stem cells, red blood cells, white blood cells, and platelets. Sometimes the transplanted cells from a donor can make an immune response against the body's normal cells. Giving cyclophosphamide and mycophenolate mofetil after transplant may stop this from happening.

PURPOSE: This phase II trial is studying the side effects and best dose of alemtuzumab when given together with total-body irradiation and fludarabine followed by donor peripheral blood stem cell transplant in treating patients with hematologic cancer.

OBJECTIVES:

Primary

• Determine the optimum dose of alemtuzumab administered with low-dose total body irradiation and fludarabine followed by HLA class I mismatched allogeneic peripheral blood stem cell transplantation in patients with hematologic malignancies.
• Determine whether stable allogeneic engraftment can be safely achieved in patients treated with this regimen.

Secondary

• Determine the risk of occurrence of acute and chronic graft-vs-host disease in patients treated with this regimen.
• Determine the risk and incidence of infections in patients treated with this regimen.
• Determine whether engraftment can be maintained in patients treated with fludarabine, mycophenolate mofetil, and cyclosporine.
• Determine the risk of disease progression and relapse in patients treated with this regimen.

OUTLINE: This is a multicenter, dose-escalation study of alemtuzumab*.

Patients receive alemtuzumab* IV over 2 hours on days -8 to -5 and fludarabine IV on days -4 to -2. Patients undergo low-dose total body irradiation followed by allogeneic peripheral blood stem cell transplantation (PBSCT) on day 0. Patients receive graft-vs-host disease (GVHD) prophylaxis comprising oral cyclosporine twice daily on days -3 to 180 followed by a taper until day 365 and oral mycophenolate mofetil three times daily on days 0 to 100 followed by a taper until day 156.

Cohorts of 7-14 patients receive escalating doses of alemtuzumab* until the optimum dose is determined. The optimum dose is defined as the dose at which no more than 2 of 14 patients (1 in each of 2 cohorts of 7 patients) experience graft rejection or unacceptable toxicity.

NOTE: *Alemtuzumab is only added after the first cohort of patients experiences a rejection rate of > 20%.

After completion of PBSCT, patients are followed monthly for 4 months, at 6 months, every 6 months until year 2, and then annually for 3 years.

PROJECTED ACCRUAL: A total of 60 patients will be accrued for this study within 4 years.

• Chronic Myeloproliferative Disorders
• Leukemia
• Lymphoma
• Multiple Myeloma and Plasma Cell Neoplasm
• Myelodysplastic Syndromes
• Myelodysplastic/Myeloproliferative Diseases

• Biological: alemtuzumab
• Drug: cyclosporine
• Drug: fludarabine phosphate
• Drug: mycophenolate mofetil
• Procedure: peripheral blood stem cell transplantation
• Radiation: radiation therapy

DISEASE CHARACTERISTICS:

• Diagnosis of hematologic malignancy that is ineligible for (or patient refused) conventional transplantation and expected to be stable for at least 100 days without chemotherapy

  • Diffuse large B-cell non-Hodgkin's lymphoma (NHL), meeting 1 of the following criteria:

    • Ineligible for autologous stem cell transplantation (SCT)
    • Ineligible for conventional myeloablative SCT
    • Failed prior autologous SCT

  • Low-grade NHL

    • Less than 6 months duration of complete remission between courses of prior conventional therapy

  • Mantle cell lymphoma

    • First complete remission allowed

  • Chronic lymphocytic leukemia

    • Failed 2 lines of prior conventional therapy
    • Refractory to fludarabine

  • Hodgkin's lymphoma

    • Failed prior frontline therapy
    • Failed or ineligible for prior autologous transplantation

  • Multiple myeloma, meeting 1 of the following criteria:

    • Received prior chemotherapy

    • Failed prior autografting

      • No autografting immediately prior to nonmyeloablative SCT

  • Acute myeloid leukemia

    • Less than 5% marrow blasts
    • No circulating leukemic blasts in the peripheral blood

  • Acute lymphoblastic leukemia

    • Less than 5% blasts
    • No circulating leukemic blasts in the peripheral blood

  • Chronic myelogenous leukemia

    • Beyond first chronic phase if failed prior therapy with myelosuppressive chemotherapy or SCT and less than 5% blasts
    • No circulating leukemic blasts in the peripheral blood

  • Myelodysplastic syndromes/myeloproliferative disorders

    • Failed prior myelosuppressive chemotherapy
    • Less than 5% marrow blasts

  • Waldenstrom's macroglobulinemia

    • Failed 2 prior courses of therapy
• No rapidly progressive intermediate- or high-grade NHL

• Related or unrelated donor available

  • Best available match is an HLA class II DRB1 and DQB1 matched donor who is incompatible for 1 of the following:

    • Any single serologically detectable class I HLA-A, -B, or -C mismatch

      • Patient and donor must not be homozygous at the mismatched MHC class I locus
      • One additional allele level class I mismatch allowed
    • Any combination of 2 allele level mismatches
  • Likelihood of rapid disease progression during HLA typing exists and a completely matched unrelated donor is not found
  • No HLA-A, -B, or -C single locus allelic mismatched related donor available
  • No positive crossmatch between donor and patient
• No indication for autologous transplantation as a treatment option OR patient refused treatment on a conventional SCT protocol
• No CNS involvement with disease refractory to intrathecal chemotherapy NOTE: A new classification scheme for adult non-Hodgkin's lymphoma has been adopted by PDQ. The terminology of "indolent" or "aggressive" lymphoma will replace the former terminology of "low", "intermediate", or "high" grade lymphoma. However, this protocol uses the former terminology.

PATIENT CHARACTERISTICS:

Age:

• Under 75

  • Patients under 12 years of age must be approved by the principal investigator

Performance status:

• Karnofsky 70-100% (adults) OR
• Lansky 50-100% (children)

Life expectancy:

• Not severely limited by diseases other than malignancy

Hematopoietic:

• See Disease Characteristics

Hepatic:

• No fulminant liver failure
• No liver cirrhosis with evidence of portal hypertension
• No alcoholic hepatitis
• No chronic viral hepatitis (bilirubin greater than 3 mg/dL)
• No hepatic encephalopathy
• No biliary obstruction
• No symptomatic biliary disease
• No bacterial or fungal liver abscess
• No uncorrectable hepatic synthetic dysfunction (prolonged PT)
• No ascites related to portal hypertension
• No esophageal varices
• No history of bleeding esophageal varices

Renal:

• Not specified

Cardiovascular:

• No symptomatic coronary artery disease
• No poorly controlled hypertension despite multiple antihypertensives
• No other cardiac failure requiring therapy
• Ejection fraction at least 35% (required if patient is > 50 years of age, received prior anthracyclines, or had prior cardiac disease)

Pulmonary:

• No requirement for supplementary continuous oxygen
• DLCO at least 35%
• Total lung capacity at least 35%
• FEV_1 at least 35%

Other:

• HIV negative
• No severe limitation of life expectancy due to diseases other than malignancy
• No fungal infections with radiological progression after amphotericin B or active triazole for more than 1 month
• No active bacterial or fungal infections unresponsive to medical therapy

• No active nonhematologic malignancy except nonmelanoma skin cancer

  • Patients with a history of a nonhematologic malignancy (except nonmelanoma skin cancer) currently in complete remission, who are < 5 years from the time of complete remission, and have a > 20% risk of disease recurrence are not eligible
• Not pregnant or nursing
• Fertile patients must use effective contraception during and for up to 1 year after study treatment

PRIOR CONCURRENT THERAPY:

Biologic therapy:

• See Disease Characteristics
• No concurrent post-transplantation growth factors during the first 28 days of mycophenolate mofetil administration

Chemotherapy:

• See Disease Characteristics
• At least 3 weeks since prior intensive chemotherapy

Endocrine therapy:

• Not specified

Radiotherapy:

• Not specified

Surgery:

• Not specified