Lenalidomide + Azacitidine for Adaptive Immunotherapy -> Auto SCT in Multiple Myeloma

Not Applicable

Completed

Conditions: Multiple Myeloma

Interventions: Drug: Azacitidine

Registration Number: NCT01050790

Lead Sponsor: Virginia Commonwealth University

Brief Summary: RATIONALE: Lenalidomide may stimulate the immune system in different ways and stop cancer cells from growing. Drugs used in chemotherapy, such as azacitidine, work in different ways to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. An autologous stem cell transplant may be able to replace blood-forming cells that were destroyed by lenalidomide and azacitidine. Giving autologous lymphocytes after the transplant may help destroy any remaining cancer cells.

PURPOSE: This pilot trial is studying how well giving lenalidomide together with azacitidine works when followed by autologous stem cell transplant and autologous lymphocyte infusion in treating patients with multiple myeloma.

Detailed Description: OBJECTIVES:

Primary

* Determine the feasibility of mobilizing and infusing autologous lymphocytes (ALI) following immunomodulatory therapy comprising azacitidine and lenalidomide in patients with multiple myeloma.

Secondary

* Determine the ability to proceed with autologous stem cell transplantation in these patients.

* Determine the complete response rate at 6 months following transplant in patients treated with this regimen.

* Determine the progression-free survival and overall survival of patients treated with this regimen.

* Determine the time to progression in patients treated with this regimen.

* Monitor the toxicity of post-autologous stem cell infusion of autologous lymphocytes.

* Measure the pre- and post-ALI immune response to cancer testis antigens (CTA) (CTA-specific Ig and T-cell repertoire).

* Study the expression of CTA in multiple myeloma before and after azacitidine therapy.

OUTLINE:

* Immunomodulatory therapy: Patients receive azacitidine subcutaneously on days 1-5 and oral lenalidomide on days 6-21. Treatment repeats every 28 days for up to 3 courses in the absence of disease progression or unacceptable toxicity.

* Lymphapheresis: Patients undergo autologous lymphocyte harvest on day 22 of courses 2 and 3.

* Autologous stem cell transplantation (ASCT): Patients undergo single or tandem ASCT using standard protocols.

* Autologous lymphocyte infusion (ALI): Patients undergo ALI approximately 28-60 days after ASCT.

Blood samples are collected at baseline and periodically during study for correlative laboratory studies, including CTA-specific immune monitoring by RT-PCR, ELISPOT assays, and flow cytometry. Tissue samples from bone marrow aspirates are also collected at baseline, during course one, and after course three for CTA expression and methylation studies.

After completion of study therapy, patients are followed periodically.

Recruitment & Eligibility

Status: COMPLETED

Sex: All

Target Recruitment: 17

Inclusion Criteria

Not provided

Exclusion Criteria

Not provided

Study & Design

Study Type: INTERVENTIONAL

Study Design: SINGLE_GROUP

Arm && Interventions

Group	Intervention	Description
Aza Len Lymphapheresis SCT ALI	Azacitidine	Azacitidine will be administered to all the patients subcutaneously at a dose of 75 mg/m2 daily for five days(day 1-5). These cycles will be repeated at 28 day intervals depending on hematopoietic recovery. Starting on day 6 patients will receive lenalidomide 15 mg PO daily until day 21. No drug will be administered from day 22 to day 28. Lymphapheresis will occur after cycles 2 and 3.Patients will undergo a stem cell collection approximately two weeks after complete myeloid recovery from the third cycle of therapy. Stem Cell Transplant (SCT) will occur per transplant center protocols. Post-transplant single or tandem autologous lymphocyte infusions (ALI) will be performed no earlier than 30 days post-transplant and no later than 40 days.

Primary Outcome Measures

Name	Time	Method
Feasibility to Mobilize and Infuse Autologous Lymphocytes (ALI) After Immunomodulatory Therapy and After Stem Cell Transplant Engraftment	6 months	Time frame is post 2nd and 3rd cycles of rev/aza and after stem cell transplant engraftment.

Secondary Outcome Measures

Name	Time	Method
CTA Expression Before and After Azacitidine Therapy	3 months	Six patients tested have demonstrated CTA up-regulation in either unfractionated bone marrow (n = 4) or CD138+ cells (n = 2). CTA (CTAG1B)-specific T cell response has been observed in all three patients tested and persists following SCT.
Toxicity as Assessed by NCI CTCAE v3.0	6 months	Time frame includes after stem cell transplant engraftment. Toxicity post ALI infusion: 1 patient grade 1 hypertension 90 min post infusion. Toxicity post Rev maintenance: 1 patient not tolerated, 1 patient dose decreased due to counts.
Time to Progression Post Transplant	28 months	Time to progression post transplant: For patients not in Complete Response (CR), progressive disease requires one or more: \>25% increase in the level of the serum monoclonal paraprotein(absolute increase of at least 0.5 g/dL); \> 25% increase in 24-hour urinary light chain excretion(absolute increase of at least 200m/24 hours). Increase plasma cells in a bone marrow aspirate( absolute increase of at least 10%). Definite increase in the size of existing bone lesions or soft tissue plasmacytomas. Development of new bone lesions or soft tissue plasmacytomas. Development of hypercalcemia (corrected serum Ca \> 11.5 mg/dL or \> 2.65 mmol/L) not attributable to any other cause. All relapse categories require two consecutive assessments made any time before classification as relapse or progressive disease.
Complete Response Rate at 6 Months	6 months	16 of 17 patients proceeded to transplant. 6 month CR rate post transplant was 8/16 (50%).
Progression-free and Overall Survival	1 year to 2 years	Survival and event-free survival curves (any event of fatality, relapse, acute or chronic GVHD) with Kaplan-Meier curves. The incidence curve for relapse - accounting for the competing risk of fatality - is plotted with step-wise curves. The R statistical software (version 2.15) was used for all time-to-event analyses, with the survival package used for survival curves, and the cmprsk package used for all competing risk curves. Results: The one-year survival rate is 93.3% (SE = 0.4%), and the two-year survival rate is 86.1% (SE = 0.9%).
Pre- and Post-ALI Immune Response to Cancer Testis Antigens (CTA)	6 months	Not able to obtain outcome data.