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

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.

Initial Patient 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