Pentostatin and Lymphocyte Infusion in Preventing Graft Rejection in Patients Who Have Undergone Donor Stem Cell Transplant
|Acute Lymphoblastic Leukemia Acute Myeloid Leukemia Chronic Lymphocytic Leukemia Chronic Myelogenous Leukemia, BCR-ABL1 Positive Graft Versus Host Disease Hodgkin Lymphoma Myelodysplastic/Myeloproliferative Neoplasm Non-Hodgkin Lymphoma Plasma Cell Myeloma Waldenstrom Macroglobulinemia||Drug: Cyclosporine Drug: Mycophenolate Mofetil Drug: Pentostatin Biological: Therapeutic Allogeneic Lymphocytes||Phase 2|
|Study Design:||Intervention Model: Single Group Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
|Official Title:||Pentostatin and Donor Lymphocyte Infusion for Low Donor T-cell Chimerism After Hematopoietic Cell Transplantation - A Multi-center Trial|
- Percentage Patients With an Increase of at Least 10 Percentage Points in Donor T-cell Chimerism [ Time Frame: From the time of enrollment maintained to day 56 after the last DLI, up to Day 112 ]
A regimen will be considered successful if 20 patients are enrolled, at least 13 demonstrate improved chimerism. If fewer than 5 patients have shown improvement in chimerism then it can be at least 75% confident that the true rate of improvement is less than 0.53. Enrollment to the regimen will stop and the next regimen will be opened. Enrollment to a regimen may also be stopped at any time it becomes impossible to achieve 5 of 10 or 13 of 20 successful improvements.
"Chimerism" in hematopoietic cell transplant derives from this idea of a "mixed" entity, referring to someone who has received a transplant of genetically different tissue. A test for chimerism after a hematopoietic cell transplant involves identifying the genetic profiles of the recipient and of the donor and then evaluating the extent of mixture in the recipient's blood cells or marrow cells.
- Incidence of Grade IV Acute GVHD [ Time Frame: Within 100 days after the last DLI ]
Clinical Stage of acute GVHD according to Organ System
- - Maculopapular rash <25% of body surface
- - Maculopapular rash 25-50% of body surface
- - Maculopapular rash >50% body surface area or generalized erythroderma
- - Generalized erythroderma with bullous formation and desquamation
- - Bilirubin 2-3 mg/dl
- - Bilirubin 3.1-6 mg/dl
- - Bilirubin 6.1-15 mg/dl
- - Bilirubin >15 mg/dl
- - >500-1000 mL diarrhea per day or (nausea, anorexia or vomiting with biopsy (EGD) confirmation of upper GI GVHD
- - >1000 -1500 mL diarrhea per day
- - >1500 mL diarrhea per day
- - >1500 mL diarrhea per day plus severe abdominal pain with or without ileus
Overall Clinical Grading of Severity of acute GVHD Grade IV: 0-4 Skin, 2-4 Liver, and/or 2-4 GI
- Incidence of GVHD [ Time Frame: 1 year after DLI ]
Percentage patients with acute or chronic GVHD.
The diagnosis of chronic GVHD requires at least one manifestation that is distinctive for chronic GVHD as opposed to acute GVHD. In all cases, infection and others causes must be ruled out in the differential diagnosis of chronic GVHD.
- Incidence of Infections [ Time Frame: 100 days after DLI ]
- Incidence of Relapse/Progression [ Time Frame: 1 year after DLI ]
CML Acquisition of a new cytogenetic abnormality and/or development of accelerated phase or blast crisis. Criteria for accelerated phase: unexplained fever >38.3° C, new clonal cytogenetic abnormalities in addition to a single Ph-positive chromosome, BM blasts and promyelocytes >20%.
AML, ALL, CMML >30% BM blasts w/ deteriorating performance status, or worsening of anemia, neutropenia, or thrombocytopenia.
CLL Progressive disease: ≥1 of: physical exam/imaging studies (nodes, liver, and/or spleen) ≥50% increase or new, circulating lymphocytes by morphology and/or flow cytometry ≥50% increase, and lymph node biopsy w/ Richter's transformation.
NHL >25% increase in the sum of the products of the perpendicular diameters of marker lesions, or the appearance of new lesions.
≥100% increase of the serum myeloma protein from its lowest level, or reappearance of myeloma peaks that had disappeared w/ tx; or definite increase in the size/number of plasmacytomas or lytic bone lesions.
- Survival [ Time Frame: 1 year after DLI ]Percentage patients surviving.
|Study Start Date:||May 2003|
|Primary Completion Date:||February 2015 (Final data collection date for primary outcome measure)|
Experimental: pentostatin, DLI, mycophenolate mofetil, cyclosporine
Group I (pentostatin, DLI): Patients receive pentostatin IV over 20-30 minutes on day -2 and DLI over 15-30 minutes on day 0. Treatment may repeat once beginning with an escalated or same CD3-dose at least 4 weeks if persistent donor T-cells are documented, no GvHD has developed, and the chimerism status worsens or, if chimerism status is unchanged after at least 8 weeks with two subsequent tests of chimerism 4 weeks apart.
Group II (pentostatin, DLI, mycophenolate mofetil, cyclosporine): Patients receive treatment as in group I. Patients also receive cyclosporine PO BID on days -3 to 56 and mycophenolate mofetil PO QD on days 0 to 27. Treatment continues in the absence of GvHD.
Other Names:Drug: Mycophenolate Mofetil
Other Names:Drug: Pentostatin
Other Names:Biological: Therapeutic Allogeneic Lymphocytes
Other Name: Allogeneic Lymphocytes
I. To assess the safety and efficacy of the combined use of pentostatin and donor lymphocyte infusion (DLI) in patients with low or falling donor T-cell chimerism to prevent graft rejection after transplantation both from matched related donors (MRDs) or unrelated donors (URDs).
I. To determine the incidence of graft-versus-host disease (GvHD) infections and disease response, if persistent disease is present.
OUTLINE: This is a dose-escalation study of donor lymphocyte infusion.
GROUP I: Patients receive pentostatin intravenously (IV) over 20-30 minutes on day -2 and DLI over 15-30 minutes on day 0. Treatment may repeat once beginning with an escalated or same cluster of differentiation (CD)3-dose at least 4 weeks if persistent donor T-cells are documented, no GvHD has developed, and the chimerism status worsens or, if chimerism status is unchanged after at least 8 weeks with two subsequent tests of chimerism 4 weeks apart.
GROUP II (initiated if patients in group I do not achieve sustained engraftment and improved chimerism): Patients receive treatment as in group I. Patients also receive cyclosporine orally (PO) twice daily (BID) on days -3 to 56 and mycophenolate mofetil PO once daily (QD) on days 0 to 27. Treatment continues in the absence of GvHD.
After completion of study treatment, patients are followed up every 6 months for 2 years and then annually thereafter.
Please refer to this study by its ClinicalTrials.gov identifier: NCT00096161
|United States, Utah|
|Huntsman Cancer Institute/University of Utah|
|Salt Lake City, Utah, United States, 84112|
|Salt Lake City, Utah, United States, 84143|
|United States, Washington|
|VA Puget Sound Health Care System|
|Seattle, Washington, United States, 98101|
|Fred Hutch/University of Washington Cancer Consortium|
|Seattle, Washington, United States, 98109|
|University of Torino|
|Torino, Italy, 10126|
|Principal Investigator:||Brenda Sandmaier||Fred Hutch/University of Washington Cancer Consortium|