Non-Ablative Allo HSCT For Hematologic Malignancies or SAA

OBJECTIVES:

• Determine the rates of durable full donor hematologic engraftment in patients with high-risk hematologic malignancies or severe aplastic anemia treated with non-myeloablative conditioning using fludarabine, cyclophosphamide, and anti-thymocyte globulin followed by allogeneic peripheral blood stem cell transplantation.
• Determine the acute and delayed toxic effects of this non-myeloablative conditioning regimen in this patient population.
• Determine the event-free and overall survival of patients treated with this regimen.
• Determine the incidence and severity of acute and chronic graft-versus-host disease in patients treated with this regimen.
• Determine the rate and quality of immune reconstitution in patients treated with this regimen.
• Determine the rate of disease relapse and incidence of post-transplantation lymphoproliferative disease in these patients.

OUTLINE: Patients are stratified according to disease category (malignant vs non-malignant) and graft source (unrelated vs HLA-matched sibling).

Beginning at least 4 weeks after conventional-dose chemotherapy, patients receive non-myeloablative conditioning comprising fludarabine IV over 30 minutes on days -8 to -4, cyclophosphamide IV over 2 hours on days -3 to -2, and anti-thymocyte globulin IV over at least 4 hours on days -2 and -1. Patients undergo filgrastim (G-CSF)-mobilized allogeneic peripheral blood stem cell transplantation on day 0.

Patients are followed weekly for 3 months, every 2 weeks for 3 months, monthly for 6 months, and then every 2 months thereafter.

PROJECTED ACCRUAL: A minimum of 30 patients will be accrued for this study within 4 years.

DISEASE CHARACTERISTICS:

• Histologically proven high-risk hematologic malignancy

• Acute non-lymphocytic leukemia (ANLL) after induction failure, or in first complete remission (CR) with high-risk features, including any of the following:

• Stem cell or biphenotypic classification (AML-M0)
• Erythroleukemia (AML-M6)
• Acute megakaryocytic leukemia (AML-M7)
• Cytogenetic markers indicative of poor prognosis
• Failure to achieve CR after standard induction therapy
• Acute lymphocytic leukemia (ALL) or ANLL in relapse or second or subsequent remission
• Chronic myelogenous leukemia (CML) in chronic or accelerated phase

• Patients with CML in blast crisis are eligible after reinduction chemotherapy places them in chronic phase
• High-risk ALL in first CR with high risk defined by presence of t(4;11), t(9;22) translocation, hyperleukocytosis (initial WBC greater than 30,000/mm^3), or failure to achieve CR by day 28 after standard induction

• No T-cell ALL or t(8;14) positive B-cell ALL in first remission with hyperleukocytosis
• Myelodysplastic syndrome by peripheral blood smear and bone marrow examination

• Refractory to medical management OR
• Cytogenetic abnormalities predictive of transformation into acute leukemia including 5q-, 7q-, monosomy 7, and trisomy 8 OR
• Evidence of evolution to AML (e.g., refractory anemia with excess blasts (RAEB) or RAEB in transformation)
• Multiple myeloma, non-Hodgkin's lymphoma (NHL), ANLL, or ALL with recurrent disease after autologous stem cell transplantation (SCT)

• At least 3 months since prior autologous SCT
• Hodgkin's lymphoma, NHL, or multiple myeloma beyond first CR or primary induction failures whose disease has demonstrated sensitivity to pre-transplantation cytoreduction (defined as greater than 50% reduction in tumor burden)

• Mantle zone NHL allowed after induction therapy
• Myeloproliferative disorder that is non-responsive to medical management and requires allografting, unless evidence of grade 3 or worse myelofibrosis on marrow biopsy OR
• Histologically proven acquired severe aplastic anemia (SAA) that is recurrent or unresponsive after anti-thymocyte globulin and/or cyclosporine

• SAA defined by at least 2 of the following conditions:

• Granulocyte count less than 500/mm^3
• Platelet count less than 20,000/mm^3
• Absolute reticulocyte count less than 20,000/mm^3 after correction for hematocrit
• Ineligible for full ablative conditioning due to any of the following conditions:

• Prior extensive therapy (more than 2 salvage chemotherapy regimens and/or autologous transplantation)
• Over age 55 OR
• Under age 55 with comorbid disease (e.g., suboptimal cardiac, pulmonary, or renal function and/or prior life-threatening infection)
• HLA-A, B, and DR phenotypically identical sibling donor OR
• HLA-A, B, and DR identical genetically matched unrelated donor
• No ANLL in first CR (less than 5% blasts in marrow) with translocations t(8;21) and inv(16) unless failed first-line induction therapy OR
• No ANLL in first CR (less than 5% blasts in marrow) with translocations t(15;17) abnormality unless failed first-line induction therapy OR molecular evidence of persistent disease
• No active CNS disease

PATIENT CHARACTERISTICS:

Age:

• 0 to 70

Performance status:

• Zubrod 0-1
• Karnofsky 80-100%

Life expectancy:

• At least 3 months

Hematopoietic:

• See Disease Characteristics

Hepatic:

• ALT/AST no greater than 4 times normal
• Bilirubin no greater than 2.0 mg/dL

Renal:

• See Disease Characteristics
• Creatinine clearance at least 50 mL/min

Cardiovascular:

• See Disease Characteristics
• Shortening fraction or ejection fraction at least 40% of normal for age by echocardiogram or radionuclide scan
• No clinically significant comorbid illnesses (e.g., myocardial infarction or cerebrovascular accident)

Pulmonary:

• See Disease Characteristics
• FVC and FEV_1 at least 60% of predicted for age
• DLCO at least 60% of predicted for adults

Other:

• No severe neurosensory symptoms (i.e., peripheral neuropathy)
• HIV negative
• Active infection allowed if controlled by appropriate drug therapy
• Not pregnant or nursing
• Negative pregnancy test

PRIOR CONCURRENT THERAPY:

Biologic therapy:

• See Disease Characteristics

Chemotherapy:

• See Disease Characteristics

Endocrine therapy:

• Not specified

Radiotherapy:

• Not specified

Surgery:

• Not specified

Other:

• Recovered from prior therapy
• No concurrent investigational agents unless approved by protocol investigators