Autologous or Donor Stem Cell Transplantation in Treating Patients With Recurrent Non-Hodgkin's Lymphoma (BMT CTN 0202)

Phase 2

Terminated

Conditions: Recurrent Grade 1 Follicular Lymphoma
Recurrent Grade 2 Follicular Lymphoma
Recurrent Grade 3 Follicular Lymphoma
Follicular Lymphoma

Interventions: Drug: Cyclophosphamide and Rituximab
Drug: Filgrastim
Radiation: Chemotherapy or Radiation therapy
Drug: Non-myeloablative Conditioning regimen
Procedure: Autologous transplant
Procedure: Allogeneic transplant
Drug: GVHD Prophylaxis
Drug: Rituximab maintenance therapy

Registration Number: NCT00096460

Lead Sponsor: Medical College of Wisconsin

Brief Summary: This study is designed as a Phase II/III, multi-center trial, comparing two transplant strategies to determine whether non-myeloablative allogeneic Hematopoietic Stem Cell Transplantation (HSCT) will improve long-term progression-free survival compared to autologous HSCT. Recipients will be biologically assigned to the appropriate treatment arm depending on the availability of a Human Leukocyte Antigen (HLA) matched sibling.

Detailed Description: BACKGROUND:

Although patients with follicular non-Hodgkin's lymphoma (NHL) typically experience a relatively indolent course, the disease is rarely curable with conventional chemotherapy. Patients with follicular NHL are usually treated only when symptoms require palliation or if bulky disease exists since no survival advantage has been shown as compared to administering conventional treatment at initial diagnosis. While most patients achieve a remission with initial chemotherapy, a continuous pattern of relapse occurs, resulting in progressively shorter remission durations. Additionally, the increased response rates conferred by anthracycline-containing regimens have not translated into improved survival and thus the median survival time of 6 to 10 years has not been significantly impacted over the last decade.

DESIGN NARRATIVE:

The overall study design is a comparison of two treatment arms determined by biologic assignment, based on the availability of an HLA-matched sibling, in patients diagnosed with relapsed follicular non-Hodgkin's lymphoma. Patients without an HLA-matched sibling will receive an autologous HSCT. Patients with an HLA-matched sibling will receive a non-myeloablative allogeneic HSCT.

The overall study design is that of biologic assignment, based on the availability of an HLA-matched sibling, to one of two strategies to improve the outcome for follicular lymphoma patients with chemosensitive disease. All patients will undergo cytoreduction with cyclophosphamide 4 gm/m\^2 and rituximab 375 mg/m\^2 x 2 doses. Rituximab will be given in two doses, approximately 1 week apart, with the cyclophosphamide administered the day after the first dose of rituximab. Patients assigned to the autologous arm will have their hematopoietic stem cells mobilized from this cytoreductive regimen. Patients with an HLA-matched sibling will undergo a non-myeloablative allogeneic HSCT. Pre-transplant conditioning will consist of fludarabine 30 mg/m\^2/day and cyclophosphamide 750 mg/m\^2/day x 3 days with rituximab 375 mg/m\^2/day on Days -13 and -6 pre-HSCT and on Days +1 and +8 post-HSCT. The immunosuppressive regimen will consist of tacrolimus and methotrexate (MTX) to control graft-versus-host and host-versus-graft reactions. Patients without an HLA-matched sibling who have collected an adequate autologous hematopoietic cell graft, defined as at least 2.0 \* 10\^6 CD34+ cells/kg, will receive a preparative regimen of total body irradiation (TBI) 1200 cGy or Carmustine (BCNU) 15 mg/kg. In addition, VP-16 60 mg/kg and cyclophosphamide 100 mg/kg will be given for both autologous preparative regimens. Post-autologous HSCT therapy with rituximab 375 mg/m\^2 weekly x 4 doses will commence between Days 42-75 post-HSCT.

Recruitment & Eligibility

Status: TERMINATED

Sex: All

Target Recruitment: 30

Inclusion Criteria

Histologically confirmed recurrent Revised European American Lymphoma (REAL) classification follicle center lymphoma, follicular grades I and II, OR histologically confirmed World Health Organization (WHO) classification follicular lymphoma grades 1, 2, 3a or 3b; for either classification, the diffuse component or presence of large cleaved cells (if present) cannot be more than 50% of high power field; patients do not have to express t(14;18) to be eligible
Received three or fewer prior regimens of chemotherapy; monoclonal antibody therapy and involved field radiation therapy will not be counted as a prior therapy
Beyond first Complete Remission (CR) or first Partial Remission (PR) AND demonstrate chemosensitive disease; chemosensitive disease will be defined as less than 20% bone marrow involvement in the aspirate or core biopsy with follicular lymphoma AND lymph node size in axial diameter of less than 3 cm or a greater than 50% reduction in estimated lymph node volume to be measured as product of bi-dimensional measurements; Positron Emission Tomography (PET) scanning will not be used for staging or response purposes
- Patients with adequate organ function as measured by:
  1. Cardiac: left ventricular ejection fraction at rest at least 45%
  2. Hepatic: bilirubin less than 2 times the upper limit of normal and alanine transaminase (ALT) and aspartate aminotransferase (AST) less than 3 times the upper limit of normal
  3. Renal: creatinine clearance greater than 40 mL/min
  4. Pulmonary: Diffusing capacity of the lung for carbon monoxide (DLCO), Forced expiratory volume in one second (FEV1), and Forced vital capacity (FVC) greater than 50% of predicted (corrected for hemoglobin)
- If the patient is younger than 18 years of age and they have reached the age of assent, then they must have completed the local Institutional Review Board (IRB) assent process.
- Able to receive cyclophosphamide and rituximab mobilization chemotherapy no earlier than 3 weeks from the beginning of the most recent cycle of salvage chemotherapy and no later than 6 weeks from enrollment

Patient Inclusion Criteria for Proceeding to Hematopoietic Stem Cell Transplant (HSCT):

Collection of an autologous or allogeneic graft of at least 2.0 * 10^6 CD34+ cells/kg
Blood count recovery defined as Absolute Neutrophil Count (ANC) greater than 1000/mm3 and platelets greater than 100 * 10^9/L

Patient Inclusion Criteria for Maintenance Therapy:

Liver and renal function tests within the inclusion criteria for initial autograft
Off intravenous antibiotics and off amphotericin B formulations for proven, probable or possible fungal infections
No active Cytomegalovirus (CMV) infections or for patients with CMV infection post-autograft, treated with ganciclovir, valganciclovir, or foscarnet per institutional guidelines and CMV antigenemia negative
Mucositis resolved and off hyperalimentation

Exclusion Criteria

Karnofsky performance score less than 70%
Follicular lymphoma that show histologic evidence of transformation
Uncontrolled hypertension
Patients with uncontrolled bacterial, viral or fungal infection (currently taking medication and progression without clinical improvement).
Prior malignancies except resected basal cell carcinoma or treated cervical carcinoma in situ; cancer treated with curative intent more than 5 years previously will be reviewed on a case-by-case basis by a Protocol Chair or Medical Monitor.
Pregnant (positive Beta Human chorionic gonadotropin (β-HCG)) or breastfeeding
Seropositive for Human immunodeficiency virus (HIV)
Unwilling to use contraceptive techniques during treatment
Prior autologous or allogeneic HSCT
Known anaphylactic reaction to rituximab

Study & Design

Study Type: INTERVENTIONAL

Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Autologous Transplant	Cyclophosphamide and Rituximab	Cyclophosphamide and Rituximab with Filgrastim conditioning and chemotherapy or radiation therapy prior to autologous Hematopoietic Stem Cell Transplant (HSCT). Rituximab maintenance therapy following HSCT.
Autologous Transplant	Chemotherapy or Radiation therapy	Cyclophosphamide and Rituximab with Filgrastim conditioning and chemotherapy or radiation therapy prior to autologous Hematopoietic Stem Cell Transplant (HSCT). Rituximab maintenance therapy following HSCT.
Autologous Transplant	Autologous transplant	Cyclophosphamide and Rituximab with Filgrastim conditioning and chemotherapy or radiation therapy prior to autologous Hematopoietic Stem Cell Transplant (HSCT). Rituximab maintenance therapy following HSCT.
Allogeneic Transplant	Cyclophosphamide and Rituximab	Non-myeloablative conditioning regimen followed by allogeneic Hematopoietic Stem Cell Transplant (HSCT). Graft-versus-Host Disease (GVHD) Prophylaxis therapy following HSCT.
Allogeneic Transplant	Non-myeloablative Conditioning regimen	Non-myeloablative conditioning regimen followed by allogeneic Hematopoietic Stem Cell Transplant (HSCT). Graft-versus-Host Disease (GVHD) Prophylaxis therapy following HSCT.
Allogeneic Transplant	Allogeneic transplant	Non-myeloablative conditioning regimen followed by allogeneic Hematopoietic Stem Cell Transplant (HSCT). Graft-versus-Host Disease (GVHD) Prophylaxis therapy following HSCT.
Allogeneic Transplant	GVHD Prophylaxis	Non-myeloablative conditioning regimen followed by allogeneic Hematopoietic Stem Cell Transplant (HSCT). Graft-versus-Host Disease (GVHD) Prophylaxis therapy following HSCT.
Autologous Transplant	Rituximab maintenance therapy	Cyclophosphamide and Rituximab with Filgrastim conditioning and chemotherapy or radiation therapy prior to autologous Hematopoietic Stem Cell Transplant (HSCT). Rituximab maintenance therapy following HSCT.
Autologous Transplant	Filgrastim	Cyclophosphamide and Rituximab with Filgrastim conditioning and chemotherapy or radiation therapy prior to autologous Hematopoietic Stem Cell Transplant (HSCT). Rituximab maintenance therapy following HSCT.
Allogeneic Transplant	Filgrastim	Non-myeloablative conditioning regimen followed by allogeneic Hematopoietic Stem Cell Transplant (HSCT). Graft-versus-Host Disease (GVHD) Prophylaxis therapy following HSCT.

Primary Outcome Measures

Name	Time	Method
Lymphoma Progression-free Survival	Three years post-Hematopoietic Stem Cell Transplant (HSCT)

Secondary Outcome Measures

Name	Time	Method

Trial Locations

Locations (30): Emory University
🇺🇸
Atlanta, Georgia, United States
Baylor University Medical Center
🇺🇸
Dallas, Texas, United States
University of Pittsburgh Cancer Institute
🇺🇸
Pittsburgh, Pennsylvania, United States
University of Minnesota
🇺🇸
Minneapolis, Minnesota, United States
UCSD Medical Center
🇺🇸
La Jolla, California, United States
Loyola University
🇺🇸
Atlanta, Georgia, United States
BMT Group of Georgia
🇺🇸
Atlanta, Georgia, United States
Dana-Farber Cancer Institute
🇺🇸
Boston, Massachusetts, United States
Indiana BMT at Beech Grove
🇺🇸
Beech Grove, Indiana, United States
Washington University/Barnes Jewish Hospital
🇺🇸
Saint Louis, Missouri, United States
Duke University Medical Center
🇺🇸
Durham, North Carolina, United States
University Hospitals of Cleveland/Case Western
🇺🇸
Cleveland, Ohio, United States
Scripps Clinic
🇺🇸
La Jolla, California, United States
City of Hope National Medical Center
🇺🇸
Duarte, California, United States
Stanford Hospital and Clinics
🇺🇸
Stanford, California, United States
Hackensack University Medical Center
🇺🇸
Hackensack, New Jersey, United States
University of Pennsylvania Cancer Center
🇺🇸
Philadelphia, Pennsylvania, United States
University of Texas/MD Anderson CRC
🇺🇸
Houston, Texas, United States
University of Florida College of Medicine (Shands)
🇺🇸
Gainesville, Florida, United States
H. Lee Moffitt Cancer Center
🇺🇸
Tampa, Florida, United States
University of Michigan Medical Center
🇺🇸
Ann Arbor, Michigan, United States
Karmanos Cancer Institute/BMT
🇺🇸
Detroit, Michigan, United States
Kansas City Cancer Centers
🇺🇸
Kansas City, Missouri, United States
University of Nebraska Medical Center
🇺🇸
Omaha, Nebraska, United States
Providence Portland Medical Center
🇺🇸
Portland, Oregon, United States
Oregon Health Sciences University
🇺🇸
Portland, Oregon, United States
Vanderbilt University
🇺🇸
Nashville, Tennessee, United States
Virginia Commonwealth University MCV Hospitals
🇺🇸
Richmond, Virginia, United States
University of Wisconsin Hospital and Clinics
🇺🇸
Madison, Wisconsin, United States
Medical College of Wisconsin
🇺🇸
Milwaukee, Wisconsin, United States