Fludarabine-based Conditioning for Allogeneic Marrow Transplantation From HLA-compatible Unrelated Donors in Severe Aplastic Anemia (BMT CTN #0301)
试验速览
- 阶段
- 1 期
- 状态
- 已完成
- 入组人数
- 97
- 试验地点
- 22
- 主要终点
- Disease-free Survival (DFS)
研究概览
简要总结
The purpose of the current study is to continue to optimize conditioning regimens in high-risk patients with severe aplastic anemia transplanted with marrow from HLA-compatible unrelated donors. Specifically, the study will determine whether the addition of fludarabine to the conditioning regimen previously described by Deeg et al. will permit a reduction in the CY dose, to a point where sustained hematopoietic engraftment and survival are maintained (or improved), while the frequency of major regimen-related toxicity (RRT) and early deaths is reduced.
详细描述
BACKGROUND:
Aplastic anemia (AA) remains a life-threatening illness. Treatment options include supportive care (transfusions, growth factors, etc.), immunosuppression therapy and stem cell transplantation. Only the latter two have favorably impacted the natural history of the disease. The prognosis of AA patients, particularly severe aplastic anemia (SAA), as defined by Camitta et al., who fail to respond to immunosuppressive therapy (IS) or who relapse after an initial response to IS is poor. Although many of these patients can be supported in the short term with growth factors, transfusions and possibly rechallenged successfully with IS, the cumulative morbidity and mortality from infection, hemorrhage or transfusion-related complications is substantial.
While allogeneic bone marrow transplantation is potentially curative in AA, no more than 25% of patients have a human leukocyte antigen (HLA)-identical sibling donor. Cyclophosphamide (CY)-antithymocyte globulin (ATG) has been recommended as the preparative regimen of choice in sibling donor transplants. Results of bone marrow transplantation from alternative donors, such as matched unrelated donors and mismatched related donors in AA patients who have failed IS, have largely been unsatisfactory. The cyclophosphamide-ATG conditioning regimen has proved inadequate in ensuring engraftment in allogeneic transplants from matched, unrelated donors for AA. This was the major reason why total body radiation (TBI) has been added to the conditioning regimen.
Graft failure is a very serious and frequently life-threatening or fatal event following matched unrelated donor (MUD) allografts in aplastic anemia. It is an immunologically mediated event. Risk factors for graft failure include the use of HLA nonidentical or unrelated donors, a poor marrow nucleated cell dose as well as prolonged transfusional support prior to BMT (which increases the probability of patient sensitization to multiple antigens). While some patients may achieve autologous hematopoietic recovery, prolonged pancytopenia is common and infection-related morbidity and mortality are very substantial. Reconditioning for a second allograft from the same or a different donor is frequently not successful. While the addition of TBI and intensive pre-transplant conditioning has led to a sizable improvement in engraftment rates, this has come with a price, particularly in adult patients. Transplant-related toxicity has been a major and frequent problem. Radiation-induced pulmonary toxicity in particular has been common, usually in the form of diffuse alveolar damage or diffuse interstitial pneumonitis. In addition, Graft Versus Host Disease (GVHD)-related morbidity and mortality in these patients have also been substantial.
DESIGN NARRATIVE:
研究设计
- 研究类型
- Interventional
- 分配方式
- Non Randomized
- 干预模型
- Single Group
- 主要目的
- Treatment
- 盲法
- None
入排标准
- 年龄范围
- — 至 65 Years（Child, Adult, Older Adult）
- 性别
- All
- 接受健康志愿者
- 否
入选标准
- •Patients up to 65 years of age at time of registration with a diagnosis of SAA; SAA is defined as follows:
- •Bone marrow cellularity less than 25% or marrow cellularity less than 50% but with less than 30% residual hematopoietic cells
- •Two out of three of the following (in peripheral blood): neutrophils less than 0.5 x 10^9/L; platelets less than 20 x 10^9/L; reticulocytes less than 20 x 10^9/L
- •Patient must have an available unrelated donor with a 7/8 or 8/8 match for HLA-A, B, C, and DRB1 antigen; typing is by DNA techniques: intermediate resolution for A, B, and C, and high resolution for DRB1; HLA-DQ typing is recommended but will not count in the match
- •Patient and/or legal guardian able to provide signed informed consent
- •Matched unrelated donor must consent to provide a marrow allograft
- •Patients with adequate organ function as measured by:
- •Cardiac: left ventricular ejection fraction at rest must be greater than 40% or shortening fraction greater than 20%
- •Hepatic: serum bilirubin less than 2x upper limit of normal for age as per local laboratory) (with the exception of isolated hyperbilirubinemia due to Gilbert's syndrome), alanine transaminase (ALT) and aspartate transaminase (AST) less than 4x upper limit of normal for age (as per local laboratory)
- •Renal: serum creatinine less than 2x upper limit of normal for age (as per local laboratory)
- •Pulmonary: Forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and carbon monoxide diffusing capacity (DLCO) (corrected for Hb) greater than 50% predicted; for patients in which pulse oxymetry is performed, O2 saturation greater than 92%
- •Diagnosis of Fanconi anemia must be excluded in patients younger than 18 years of age by diepoxybutane testing on peripheral blood or comparable testing on marrow.
排除标准
- •Clonal cytogenetic abnormalities associated with myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML) on marrow examination
- •Diagnosis of other "congenital" aplastic anemias such as: Diamond-Blackfan; Shwachman-Diamond; congenital amegakaryocytosis
- •Symptomatic or uncontrolled cardiac failure or coronary artery disease
- •Karnofsky performance status less than 60% or Lansky less than 40% for patients younger than 16 years old
- •Uncontrolled bacterial, viral or fungal infections (currently taking medication and progression of clinical symptoms)
- •Seropositive for the human immunodeficiency virus (HIV)
- •Pregnant (positive total HCG) or breastfeeding
- •Presence of large accumulation of ascites or pleural effusions, which would be a contraindication to the administration of methotrexate for GVHD prophylaxis
- •Known severe or life-threatening allergy or intolerance to ATG or cyclosporine/ tacrolimus
- •Planned administration of alemtuzumab (Campath-1H) or other investigational agents as alternative agent for GVHD prophylaxis
- •Concomitant enrollment in a Phase I study
- •Positive patient anti-donor lymphocyte crossmatch in HLA-A or B mismatched transplants; the definition of match is in Section 2.2.1; the crossmatch would only apply to mismatches at HLA-A or B, not DRB1 or HLA-C
- •Prior allogeneic marrow or stem cell transplantation
- •Patients with prior malignancies except resected basal cell carcinoma or treated carcinoma in-situ; cancer treated with curative intent less than 5 years previously will not be allowed unless approved by the Medical Monitor or Protocol Chair; cancer treated with curative intent more than 5 years previously will be allowed
研究组 & 干预措施
Cyclophosphamide 150mg
Fludarabine plus 150 mg/kg Cyclophosphamide (total dose)
干预措施: Fludarabine (Drug)
Cyclophosphamide 150mg
Fludarabine plus 150 mg/kg Cyclophosphamide (total dose)
干预措施: Cyclophosphamide 150mg (Drug)
Cyclophosphamide 100mg
Fludarabine plus 100 mg/kg Cyclophosphamide (total dose)
干预措施: Fludarabine (Drug)
Cyclophosphamide 100mg
Fludarabine plus 100 mg/kg Cyclophosphamide (total dose)
干预措施: Cyclophosphamide 100mg (Drug)
Cyclophosphamide 50mg
Fludarabine plus 50 mg/kg Cyclophosphamide (total dose)
干预措施: Fludarabine (Drug)
Cyclophosphamide 50mg
Fludarabine plus 50 mg/kg Cyclophosphamide (total dose)
干预措施: Cyclophosphamide 50mg (Drug)
Fludarabine
Fludarabine only (no Cyclophosphamide administered)
干预措施: Fludarabine (Drug)
结局指标
主要结局
Disease-free Survival (DFS)
时间窗: Day 100
DFS includes graft failure, regimen-related toxicity (RRT), and early death. Graft Failure is defined by lack of neutrophil engraftment (ANC less than 0.5 x 10\^9/L for 3 consecutive days on different days). Major RRT is defined as severity of grade 4 in any organ system or grade 3 for pulmonary, cardiac, renal, oral mucosal or hepatic. Early death is defined as death prior to Day 100 post-transplant.
次要结局
- Acute Graft vs Host Disease (GVHD)(Day 100)
- Overall Survival (OS)(Day 365)
- Cumulative Incidence of Graft Failure(Day 365)
- Chronic GVHD(Day 365)