Fludarabine Phosphate, Cyclophosphamide, Total-Body Irradiation, and Donor Bone Marrow Transplant Followed by Donor Natural Killer Cell Therapy, Mycophenolate Mofetil, and Tacrolimus in Treating Patients With Hematologic Cancer

PRIMARY OBJECTIVES:

I. Identification of the maximal feasible dose of NK cells that can be infused one week after
nonmyeloablative, human leukocyte antigen (HLA)-haploidentical hematopoietic cell transplant
(HCT). (Phase I)

SECONDARY OBJECTIVES:

Once the maximal feasible dose has been identified, accrual will be limited to the cohort
containing this cell dose to determine:

I. Incidence of relapse. (Phase II)

II. Incidence of grades III-IV acute graft-versus-host disease (GVHD). (Phase II)

III. Incidence of non-relapse mortality. (Phase II)

OUTLINE: This is a phase I, dose-escalation study of donor NK cell therapy followed by a
phase II study.

CONDITIONING: Patients receive fludarabine intravenously (IV) over 30 minutes on days -6 to
-2 and cyclophosphamide IV over 1 hour on days -6 and -5. Patients undergo total-body
irradiation on day -1.

DONOR BONE MARROW TRANSPLANTATION: Patients undergo donor bone marrow transplantation on day
0.

POST-TRANSPLANTATION IMMUNOSUPPRESSION: Patients receive cyclophosphamide IV over 1 hour on
day 3 and mycophenolate mofetil orally (PO) thrice daily (TID) on days 4 to 40, followed by a
taper until day 84 in the absence of GVHD. Patients also receive tacrolimus IV continuously
or IV once daily (QD) over 1-2 hours or PO twice daily (BID) on days 4 to 84, followed by a
taper until day 180 in the absence of GVHD.

DONOR NK CELL INFUSION: Patients undergo donor lymphocyte infusion of NK cells on day 7.

After completion of study treatment, patients are followed up at 6 months, 1 year, 1.5 years,
and then every year thereafter.

Inclusion Criteria:

- Patients with the following hematologic malignancies will be permitted although other
diagnoses can be considered if approved by Patient Care Conference (PCC) and the
principal investigators:

- Aggressive non-Hodgkin lymphomas (NHL) and other histologies such as diffuse large B
cell (DLBC) NHL - a) not eligible for autologous HCT, b) not eligible for high-dose
HCT, c) after failed autologous HCT, or d) be part of a tandem auto-allo approach for
high risk patients

- Mantle cell NHL must be beyond first complete response (CR)

- Low-grade NHL with < 6 month duration of CR between courses of conventional therapy

- Chronic lymphocytic leukemia (CLL) must have either

- 1) Failed to meet National Cancer Institute (NCI) Working Group criteria for
complete or partial response after therapy with a regimen containing FLU
(fludarabine phosphate) (or another nucleoside analog, e.g.
2-chlorodeoxyadenosine [2-CDA], pentostatin) or experience disease relapse within
12 months after completing therapy with a regimen containing FLU (or another
nucleoside analog)

- 2) Failed FLU- CY (cyclophosphamide)-rituximab (FCR) combination chemotherapy at
any time point; or

- 3) Have "17p deletion" cytogenetic abnormality and relapsed at any time point
after any initial chemotherapy

- Hodgkin lymphoma - must have received and a) failed frontline therapy, b) not be
eligible for autologous HCT, or c) or be part of a tandem auto-allo approach for high
risk patients

- Multiple myeloma or plasma cell leukemia must have received more than one line of
prior chemotherapy; consolidation of chemotherapy by autografting prior to
nonmyeloablative HCT is permitted

- Acute myeloid leukemia (AML) must have < 5% marrow blasts at the time of HCT

- Acute lymphocytic leukemia (ALL) must have < 5% marrow blasts at the time of HCT

- Chronic myeloid leukemia (CML) accepted if they are beyond chronic phase (CP)1 and if
they have received previous myelosuppressive chemotherapy or HCT and have < 5% marrow
blasts at time of transplant

- Myelodysplasia (MDS)/myeloproliferative syndrome (MPS) - (> intermediate 1 [int-1] per
International Prognostic Scoring System [IPSS]) after > or = 1 prior cycle of
induction chemotherapy; must have < 5% marrow blasts at time of transplant

- Waldenstrom's macroglobulinemia must have failed 2 courses of therapy

- Patients must be expected to have disease controlled for at least 60 days after HCT

- Patients for whom HLA-matched unrelated donor search could not be initiated or
completed due to insurance reasons, concerns of rapidly progressive disease, and/or
discretion of attending physician are eligible for this protocol

- DONOR: Related, HLA-haploidentical donors who are identical for one HLA haplotype and
mismatched for any number of HLA-A, -B, -C, DRB1 or DQB1 loci of the unshared
haplotype

- DONOR: Marrow will be the only allowed hematopoietic stem cell source

- DONOR: Haploidentical donor selection will be based on standard institutional
criteria, otherwise no specific prioritization will be made amongst the suitable
available donors; donors will not be selected based on killer cell immunoglobulin-like
receptor (KIR) status

Exclusion Criteria:

- Patients with available HLA-matched related donors

- Patients eligible for a curative autologous HCT

- Significant organ dysfunction that would prevent compliance with conditioning, GVHD
prophylaxis, or would severely limit the probability of survival:

- 1) Symptomatic coronary artery disease or ejection fraction < 35% or other
cardiac failure requiring therapy (or, if unable to obtain ejection fraction,
shortening fraction of < 26%); if shortening fraction is < 26% a cardiology
consult is required with the principal investigator (PI) having final approval of
eligibility

- 2) Diffusion capacity of the lung for carbon monoxide (DLCO) < 40% total lung
capacity (TLC) < 40%, forced expiratory volume in one second (FEV1) < 40% and/or
receiving supplementary continuous oxygen; the Fred Hutchinson Cancer Research
Center (FHCRC) study PI must approve enrollment of all patients with pulmonary
nodules

- 3) Liver function abnormalities: patient with clinical or laboratory evidence of
liver disease will be evaluated for the cause of liver disease, its clinical
severity in terms of liver function, bridging fibrosis, and the degree of portal
hypertension; the patient will be excluded if he/she is found to have fulminant
liver failure, cirrhosis of the liver with evidence of portal hypertension,
alcoholic hepatitis, esophageal varices, a history of bleeding esophageal
varices, hepatic encephalopathy, uncorrectable hepatic synthetic dysfunction
evinced by prolongation of the prothrombin time, ascites related to portal
hypertension, bacterial or fungal liver abscess, biliary obstruction, chronic
viral hepatitis with total serum bilirubin > 3 mg/dL, or symptomatic biliary
disease

- Human immunodeficiency virus (HIV) seropositive patients

- Patients with poorly controlled hypertension despite multiple antihypertensive
medications

- Fertile females who are unwilling to use contraceptive techniques during and for the
twelve months following treatment, as well as females who are pregnant or actively
breast feeding

- Fertile males who are unwilling to use contraceptive techniques during and for the
twelve months following treatment

- Patients with active non-hematologic malignancies (except non-melanoma skin cancers)
or those with non-hematologic malignancies (except non-melanoma skin cancers) who have
been rendered with no evidence of disease, but have a greater than 20% chance of
having disease recurrence within five years; this exclusion does not apply to patients
with non-hematologic malignancies that do not require therapy

- Active infectious disease concerns

- Karnofsky performance score < 60 Lansky performance score < 60

- Life expectancy severely limited by diseases other than malignancy

- Patients with a diagnosis of chronic myelomonocytic leukemia (CMML)

- Central nervous system (CNS) involvement with disease refractory to intrathecal
chemotherapy

- Patients with AML, MDS, ALL, or CML must not have presence of circulating leukemic
blasts detected by standard pathology

- Patients with aggressive lymphomas (such as DLBC) must not have bulky, rapidly
progressive disease immediately prior to HCT

- Patients who have received a prior allogeneic HCT must have no active GVHD requiring
immunosuppressive therapy for at least 21 days prior to start of conditioning

- DONOR: Children less than 12 years of age.

- DONOR: Children greater than or equal to 12 years of age who have not provided
informed assent in the presence of a parent and an attending physician who is not a
member of the recipient's care team

- DONOR: Children greater than or equal to 12 years of age who have inadequate
peripheral vein access to safely undergo apheresis

- DONOR: Donors unable or unwilling to undergo marrow harvest for the initial HCT,
storage of autologous blood prior to marrow harvest or apheresis one week after marrow
harvest

- DONOR: Donors who are not expected to meet the minimum target dose of marrow cells (1
x 10^8 nucleated cells/kg recipient ideal body weight [IBW]) for the initial HCT; the
average nucleated cell content of harvested marrow is 22 x 10^6 nucleated cells/mL or
220 x 10^8 nucleated cells/Liter

- DONOR: HIV-positive donors

- DONOR: Donors who are cross-match positive with recipient