Myeloproliferative DisordersPhase 2NCT00003838
Specialized Blood Cell Transplants for Cancers of the Blood and Bone Marrow
A Phase 2 study testing T-cell replete PBPC allograft, Methotrexate and Cyclosporine in people with Myeloproliferative Disorders and Acute Myelogenous Leukemia, run by National Heart, Lung, and Blood Institute (NHLBI) at 1 site in United States.
Trial summary
The are a variety of cancerous diseases of the blood and bone marrow that can be potentially cured by bone marrow transplantation (BMT). Diseases like leukemia, lymphoma, and multiple myeloma are among the conditions that can be treated with BMT. Read more about this study
- Who is it for?
- Ages 2 to 80 years
- Conditions the study is for
- Myeloproliferative Disorders, Acute Myelogenous Leukemia, Chronic Myelogenous Leukemia
- What is being tested?
- T-cell replete PBPC allograft, Methotrexate and Cyclosporine
- Type of treatment
- Injection or infusion, Surgery or procedure
- Could I receive a placebo?
- No, everyone receives an active treatment
- How many people
- 202 participants
- Where
- 1 siteUnited States
- Study dates
- 15 Apr 1999to 18 Jun 2020
- Phase
- Phase 2
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages 2 to 80 years
- All sexes
- No healthy volunteers
- Child, Adult, Older adult
Who may be able to join
- Group A: Subjects at high risk for transplant related complications and mortality as defined below:
- Ages 10 to 75 (both inclusive) with a history of one of the following:
- Treatment with dose intensive chemotherapy and/or radiotherapy
- Previous history of allo/auto transplant
- History of multiple myeloma or extramedullary plasmacytoma
- Chronic disease or co-morbid medical condition including subjects with symptoms or signs of significant pulmonary disease, hepatic disease, kidney disease, cardiac disease or disease of other organ systems which would result in increased risk of morbidity or death from a standard myeloablative transplant.
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- Diseases to be included:
- CML chronic phase
- Acute lymphoblastic leukemia (ALL), all subjects in complete or partial remission.
- AML: AML in first complete or partial remission Exceptions: AML with good risk karyotypes: AML M3 t(15:17), AML M4Eo (inv. 16), AML t(8;21). All AML in second or subsequent complete remission.
- MDS: refractory anemia with excess blasts (RAEB), or chronic myelomonocyte leukemia (CMML).
- Myeloproliferative diseases associated with either cytopenia or uncontrolled proliferation.
- CLL or small lymphocytic lymphoma (SLL) with bulky or progressive disease despite prior treatment with chemotherapy which includes purine analogs.
- NHL
- Intermediate or high grade relapsed or progressive despite treatment with standard therapy ineligible for autologous PBSC transplant.
- NHL intermediate or high grade relapsing despite prior autologous transplant.
- Low grade follicular or small lymphocytic lymphoma (1) high risk patients who have relapsed following conventional chemotherapy, (2) relapsed following autologous marrow or PBSC transplant, or (3) chemo resistant disease.
- Mantle cell lymphoma
- NHL intermediate or high grade with concurrent BCL2 and MYC translocations who are at high risk for relapsed and who have low survival with conventional chemotherapy.
- HD, relapsed after prior autologous transplant or after 2 or more combination chemotherapy regimens and ineligible for autologous PBSC transplant.
- EBV driven lymphoproliferative disorders progressing despite standard therapies.
- MM: MM subjects must be between the ages of 8 and 65 (both inclusive)
- Mycosis fungoides, which has been shown to be amenable to allogeneic stem cell transplants.
- Group B: (Closed to enrollment Oct 2010) Subjects with hematologic diseases associated with reasonable longevity, shown to be curable by allogeneic BMT but where concern for a high procedural mortality with conventional BMT may delay or prevent such treatment.
- Ages 8 to 80 (both inclusive) with a history of one of the following
- PNH associated with either life-threatening thrombosis, cytopenia, transfusion dependence or recurrent and debilitating hemolytic crisis.
- Aplastic anemia or PRCA (acquired or congenital) in subjects associated with transfusion dependence and/or neutropenia who are not candidates for or who have failed immunosuppressive therapy
- RA or RARS MDS subjects who have associated transfusion dependence and/or neutropenia.
- Ability to comprehend the investigational nature of the study and provide informed consent. The procedure will be explained to subjects age 8-17 years with formal consent being obtained from parents or legal guardian.
- Availability of HLA identical or single HLA locus mismatched family donor
- HLA identical or single HLA mismatched family donor
- Age greater than or equal to 2 up to 80 years old
- Weight greater than or equal to 18 kg
- Ability of donor or guardian of donor to comprehend the investigational nature of the study and provide informed consent.
Who cannot join
- Pregnant or lactating
- Group A: age less than 10 or greater than 75 (multiple myeloma age less than 8 or greater than 65);
- Group B: Age less than 8 or greater than 80 years.
- ECOG performance status of 3 or more (See NIH Bone and Marrow Consortium Supportive Care Guidelines for Allogeneic Hematopoietic Stem Cell Transplant Recipients - http://intranet.cc.nih.gov/bmt/pdf/ECOGKarnofskyLanskyScales.pdf)
- Psychiatric disorder or mental deficiency severe as to make compliance with the BMT treatment unlikely and making informed consent impossible
- Major anticipated illness or organ failure incompatible with survival from PBSC transplant
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- Diffusion capacity of carbon monoxide (DLCO) less than 40% predicted.
- Left ventricular ejection fraction: less than 30%.
- Serum creatinine greater than 2.5 mg/dl or creatinine clearance less than 50 cc/min by 24 hr urine collection
- Serum bilirubin greater than 4 mg/dl, transaminases greater than 5x upper limit of normal,
- Other malignant diseases liable to relapse or progress within 5 years.
- Pregnant or lactating
- Donor unfit to receive G-CSF and undergo apheresis (uncontrolled hypertension, history of congestive heart failure or unstable angina, thrombocytopenia)
- HIV positive donor. Donors who are positive for hepatitis B (HBV), hepatitis C (HCV) or human T-cell lymphotropic virus (HTLV I/II) will be used at the discretion of the investigator following counseling and approval from the recipient
Trial locations and contacts
1 site in 1 country.
United States1 site
National Institutes of Health Clinical Center, 9000 Rockville Pike
Bethesda, Maryland, 20892
About this study
Official title: Non-Myeloablative Allogeneic Peripheral Blood Mobilized Hematopoietic Precursor Cell Transplantation for Hematologic Malignancies in High Risk Patients and in Patients With Debilitating Hematologic Diseases
The are a variety of cancerous diseases of the blood and bone marrow that can be potentially cured by bone marrow transplantation (BMT). Diseases like leukemia, lymphoma, and multiple myeloma are among the conditions that can be treated with BMT.
Some patients with these diseases can be treated with medical chemotherapy alone. However, patients who relapse following chemotherapy are usually not curable with additional chemotherapy treatments. The only option known to provide a potential cure if this occurs is BMT.
Read more
Allogenic transplants are cells collected from relatives of the patient. The transplant requires additional high intensity chemotherapy and radiation in order to destroy cancerous cells. In the process, many normal bone marrow cells are also destroyed. This is the reason for transplanting stem cells. The stem cells help to build new functioning bone marrow, red cells, white cells, and platelets. In addition, the immune cells from the donor are implanted into the recipient s body and help to fight off infection and kill remaining cancerous cells.
Unfortunately, the powerful doses of chemotherapy and radiation therapy associated with allogenic BMT have toxic side effects and often make BMTs too dangerous to attempt in many patients.
In order to reduce the complications of BMT, and make it a safer available option for patients with cancers of the blood and bone marrow, researchers have developed a new approach to the BMT.
In this study researchers plan to use stem cells collected from the blood stream of patient s relatives rather than from the bone marrow (blood progenitor/stem cell transplant). In addition, researchers plan to use low doses of chemotherapy and no radiation therapy to reduce side effects. The majority of the cancer killing effect will be the responsibility of the stem cell transplant rather than the chemotherapy.
Read the detailed description
Patients with malignant and non-malignant hematologic diseases including severe aplastic anemia (SAA), paroxysmal nocturnal hemoglobinuria (PNH), myelodysplastic syndrome (MDS), acute and chronic leukemias, Hodgkin's and non-Hodgkin's lymphoma and multiple myeloma (MM) can now be cured by allogeneic bone marrow transplantation (BMT). This curative effect has been ascribed to the use of high dose chemo-radiotherapy and the anti-tumor or anti-bone marrow effect of the allograft. Dose intensification of conditioning regimens in attempts to reduce disease recurrence has been largely unsuccessful because of increased toxicity and mortality. Indeed, most evidence now points to donor-derived T-cells as being the principal modality leading to the complete eradication of both malignant and non-malignant host hematopoietic cells.
The assumption that successful allogeneic BMT relies on the myeloablative effect of intensive but hazardous chemo-radiotherapy has largely restricted this therapeutic modality to patients with malignant or life-threatening hematologic disorders under the age of 55 years. Treatment-related mortality increases substantially with age, prior intensive treatment with chemo-radiotherapy, worsening performance status, and co-morbid medical conditions. An unacceptable risk of death from conventional BMT renders many patients ineligible for what may otherwise be curative therapy.
Several in vitro studies have demonstrated the existence of donor-derived CD4 and CD8 positive lymphocytes with specific reactivity for the patient s leukemia. These cells provide a potent graft-versus-leukemia (GVL) effect. This GVL effect is best seen in patients with CML relapsing after BMT, where a single infusion of donor lymphocytes has been shown to induce complete remission. In addition to the potent anti-leukemia effect of these cells, there is now strong evidence that donor T-cells are capable of completely eradicating residual host hematopoietic cells in a non-myeloablative transplant setting (graft-versus-marrow) leading to successful and complete donor hematopoietic engraftment.
Non-myeloablative allogenic peripheral blood stem cell transplants are currently being investigated in phase I/II trials assessing engraftment efficacy and toxicity at a number of transplant centers. Preliminary data, including our own experience with greater than 150 patients undergoing this type of procedure, have shown a high rate of complete donor engraftment with a low toxicity profile. Two recent studies investigating non-myeloablative allo-transplantation in standard risk patients revealed an extremely low rate of transplant-related complications and mortality.
The decreased risk of transplant-related complications associated with non-myeloablative transplants expands the eligibility of transplant candidates as well as opens the possibility to evaluate non-myeloablative regimens in patients at high risk for complications with standard transplantation. Besides hematologic malignancies, allogeneic BMT has been shown to be curative in a number of debilitating hematologic diseases which may behave in a relatively indolent fashion, such as paroxysmal nocturnal hemoglobinuria (PNH) and refractory anemia (RA) or refractory anemia with ringed sideroblasts (RARS). However, the 30% risk of treatment-related mortality (TRM) with standard myeloablative allotransplantation usually precludes these patients from potentially curative therapy, because of concerns about shortening life in patients with these disorders. In this protocol we investigate non-myeloablative allogeneic peripheral blood stem cell (PBSC) transplantation in two groups of subjects where standard allogeneic transplantation is considered to have unacceptable toxicity.
Group A: Subjects with hematologic malignancies with factors putting them at high risk for transplant related complications and mortality, including prior intensive chemo-radiotherapy and co-morbid diseases.
Group B: Subjects with hematologic diseases (both clonal and non-clonal) associated with reasonable longevity not currently considered for allogeneic BMT because of prohibitive procedural mortality with conventional BMT (enrollment closed October 2010).
In this protocol, eligible subjects are treated with an allogeneic PBSC transplant from an HLA identical or single HLA antigen-mismatched family donor, using an intensive immunosuppressive regimen without myeloablation in an attempt to decrease the transplant related toxicities while preserving the anti-malignancy and/or anti-host marrow effect of the graft. The low intensity non-myeloablative conditioning regimen should provide adequate immunosuppression to allow stem cell and lymphocyte engraftment. T-cell replete, donor-derived, granulocyte colony stimulating factor (G-CSF)-mobilized PBSCs will be used to establish hematopoietic and lymphoid reconstitution. We will add back lymphocytes in recipients with less than 100% donor T-cell chimerism in an attempt to prevent graft rejection and enhance a graft-versus-malignancy effect.
The primary endpoint of this study is transplant related mortality (200 day survival). Other end points include engraftment, degree of donor-host chimerism, incidence of acute and chronic graft versus host disease (GVHD), transplant related morbidity as well as disease-free and overall survival.
- Conditions
- Myeloproliferative Disorders, Acute Myelogenous Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic Syndrome, Acute Lymphoblastic Leukemia
- Being tested
- T-cell replete PBPC allograft, Methotrexate, Cyclosporine, G-CSF
- Keywords
- Graft vs. Host Disease, Peripheral Blood Stem Cells, Non-Myeloablative Bone Marrow Transplantation, Engraftment, graft versus leukemia
- Medical subject headings
- Myeloproliferative Disorders, Leukemia, Myeloid, Acute, Leukemia, Myelogenous, Chronic, BCR-ABL Positive, Myelodysplastic Syndromes, Precursor Cell Lymphoblastic Leukemia-Lymphoma, Graft vs Host Disease
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
T-cell replete PBPC allograftProcedure or surgery
Also called Peripheral blood hematopoietic progenitor cell (PBPC) transplant
Subjects will receive a non-myeloablative preparative regimen of cyclophosphamide 60mg/kg/d x 2 days, and fludarabine 25mg/m2 intravenously (IV) over 30 minutes daily x 5 days with or without ATG followed by a PBPC graft targeted to deliver >5x10^6 CD34+ cells/kg.
MethotrexateDrug
Also called MTX
IV MTX on days +1, +3, and +6 will be given
CyclosporineDrug
Also called CSA
CSA will be given beginning on day -4 for graft versus host disease prophylaxis. Participants with mixed T-cell chimerism on day 30 will begin a CSA taper. Participants with 100% donor T-cell chimerism by day 30 will be tapered off CSA from days 60 through 100 (25% reduction in dose every 10 days-off by day 100). CSA will not be tapered in any subjects with grade > II acute GVHD regardless of chimerism results. In addition, participants with evidence of disease progression without grade > II GVHD will have CSA discontinued regardless of chimerism results.
G-CSFDrug
Also called granulocyte colony-stimulating factor (G-CSF)
G-CSF will be administered based on body weight for at least 5, and up to 7 days, subcutaneously.
| Study group | Role | What they receive |
|---|---|---|
| Donor | Other | The HLA matched donor will receive granulocyte colony-stimulating factor (G-CSF) with apheresis collections of PBPC on day 5 and day 6 if required. G-CSF will be administered based on body weight for at least 5, and up to 7 days, subcutaneously. Receives: Drug: G-CSF |
| Group A: Stem Cell Transplant in High Risk for Transplant Related Complications and Mortality | Experimental | Participants at high risk for transplant related complications and mortality will receive a non-myeloablative preparative regimen of cyclophosphamide 60mg/kg/d x 2 days, and fludarabine 25mg/m^2 intravenously daily x 5 days followed by a peripheral blood hematopoietic progenitor cell graft targeted to deliver >5x10^6 CD34+ cells/kg. Receives: Procedure: T-cell replete PBPC allograft; Drug: Methotrexate; Drug: Cyclosporine |
| Group B: Stem Cell Transplant in Debilitating Hematologic Diseases | Experimental | Participants with hematologic diseases associated with reasonable longevity, shown to be curable by allogeneic Bone Marrow Transplant (BMT) but where concern for a high procedural mortality with conventional BMT will receive a non-myeloablative preparative regimen of cyclophosphamide 60mg/kg/d x 2 days, and fludarabine 25mg/m^2 intravenously daily x 5 days followed by a peripheral blood hematopoietic progenitor cell graft targeted to deliver >5x10^6 CD34+ cells/kg. Receives: Procedure: T-cell replete PBPC allograft; Drug: Methotrexate; Drug: Cyclosporine |
What is being measured
The primary outcome is the main question the study is designed to answer.
Number of Participants Who Experienced Transplant Related Mortality
Number of Participants who experienced transplant related mortality by Day 200
Measured: 200 days
Secondary outcomes (6)
Number of Participants With Complete Donor Myeloid (CD34+) and T-cell (CD3+) Chimerism
Number of participants with complete donor myeloid chimerism. Myeloid (CD34+) and T-cell (CD3+) chimerisms were determined by PCR analysis of short tandem repeats (STR). Complete donor chimerism is defined as >95% donor-derived cells in the peripheral blood in a specific lineage.
Measured: Up to Day 100
Median Days to Neutrophil Engraftment
Median days to neutrophil recovery. Neutrophil recovery is defined as the first day of two consecutive days in which the ANC was 500 K/ml or greater unsupported by growth factors or granulocyte transfusion.
Measured: Day 30
Number of Participants Who Experienced Acute GVHD Grades II-IV
Number of participants who experienced acute GVHD grades II-IV
Acute-GVHD was graded and staged prospectively using criteria from the 1994 Consensus Conference on Acute-GVHD Grading.
Grades are defined as:
Grade II: Skin = rash on 25-50 percent body surface area; Liver = Total Bilirubin 3.1-6.0 mg/dL; Lower GI = Diarrhea 1001-1500 mL/day.
Grade III: Skin = Rash on >50% of body surface; Liver = Total Bilirubin 6.1 - 15.0 mg/dL; Lower GI = Diarrhea > 1500 mL/day.
Grade IV: Skin = Generalized erythroderma plus bullous formation; Liver = Total Bilirubin >15 mg/dL; Lower GI = Severe abdominal pain with or without ileus.
Grade II GVHD as moderate, grade III as severe, and grade IV life-threatening.
Measured: Up to Day 100
Number of Participant Who Experienced Chronic Graft Versus Host Disease Following Stem Cell Transplant
Number of participant who experienced chronic graft versus host disease (GVHD) following stem cell transplant
The diagnosis of clinical features of chronic-GVHD was determined prospectively and classified retrospectively into limited or extensive based on the Revised Seattle Classification. Chronic GvHD severity categorized as "limited" is defined as: localized skin lesions with or without limited hepatic involvement and "extensive" is defined as: generalized skin involvement, major hepatic complications, or involvement of any other organ.
Measured: Day 100 up to 3 years
Number of Participants Overall Survival
Number of participants overall survival. Overall survival is defined as number participants alive following stem cell transplant
Measured: enrollment to date of death, up to 5 years
Number of Participants That Remained Disease-free Survival
Number of participants that remained Disease-free survival following stem cell transplant. Disease-free survival is defined as survival free of disease relapse or disease progression following stem cell transplant.
Measured: Up to 5 years
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted27 Jan 2003 (estimated)
- Study start15 Apr 1999
- Primary completion14 Dec 2018
- Study completion18 Jun 2020
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Posted resultsParticipant flow, outcome measures and adverse events reported by the sponsor.
- Publications (4)Papers the sponsor has linked to this study.
- Other trials for Myeloproliferative DisordersStudies of the same condition, open and under way.
- More trials run by National Heart, Lung, and Blood Institute (NHLBI)The sponsor's other registered studies.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Interventional
- Phase
- Phase 2
- Primary purpose
- Treatment
- Allocation
- Non-randomised
- Intervention model
- Parallel groups
- Masking
- None (open label)
- Enrolment
- 202 participants (actual)
Sponsor and investigators
- Sponsor type
- US National Institutes of Health
- Responsible party
- Sponsor
- Investigators
- Richard W Childs, M.D., Principal investigator, National Heart, Lung, and Blood Institute (NHLBI)
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT00003838
- Sponsor's protocol ID
- 990050
- Other IDs
- 99-H-0050
- Status last verified
- Apr 2022
- First submitted
- 1 Nov 1999
- Last updated
- 21 Sep 2023
- Results posted
- Yes, on ClinicalTrials.gov
- FDA-regulated drug
- Yes
- FDA-regulated device
- No
Publications
Buchan A, Merideth MA, Childs RW, Stratton P. Novel management of vaginal chronic graft-versus-host disease causing haematometra and haematocolpos. BMJ Case Rep. 2018 Apr 28;2018:bcr2017222720. doi: 10.1136/bcr-2017-222720.
PubMed 29705733Pantin J, Tian X, Shah AA, Kurlander R, Ramos C, Cook L, Khuu H, Stroncek D, Leitman S, Barrett J, Donohue T, Young NS, Geller N, Childs RW. Rapid donor T-cell engraftment increases the risk of chronic graft-versus-host disease following salvage allogeneic peripheral blood hematopoietic cell transplantation for bone marrow failure syndromes. Am J Hematol. 2013 Oct;88(10):874-82. doi: 10.1002/ajh.23526. Epub 2013 Sep 3.
PubMed 23813900Sri T, Merideth MA, Pulanic TK, Childs R, Stratton P. Human papillomavirus reactivation following treatment of genital graft-versus-host disease. Transpl Infect Dis. 2013 Aug;15(4):E148-51. doi: 10.1111/tid.12098. Epub 2013 May 28.
PubMed 23710698Baskar S, Suschak JM, Samija I, Srinivasan R, Childs RW, Pavletic SZ, Bishop MR, Rader C. A human monoclonal antibody drug and target discovery platform for B-cell chronic lymphocytic leukemia based on allogeneic hematopoietic stem cell transplantation and phage display. Blood. 2009 Nov 12;114(20):4494-502. doi: 10.1182/blood-2009-05-222786. Epub 2009 Aug 10.
PubMed 19667400