Modified Stem Cell Transplant Procedure to Treat Patients With Blood and Immune System Cancers

Allogeneic hematopoietic stem cell transplantation (HSCT) is potentially curative for
refractory hematologic malignancies, but its application has been limited historically by
morbidity and mortality from conventional transplant preparative regimens and
graft-versus-host disease (GVHD). Donor T cells mediate GVHD and also help to eradicate
malignancies through an immune-dependent graft-versus-tumor effect. Efforts to decrease
preparative regimen toxicity have led to reduced-intensity or 'nonmyeloablative' regimens,
facilitating the study of allogeneic HSCT in a broader population. As a promising strategy
for reducing GVHD, donor Th2 cells were shown to abrogate Th1-mediated GVHD without impairing
engraftment in murine models of allogeneic HSCT. These findings led to a phase I/II clinical
study of donor Th2 cells for the prevention of GVHD during reduced-intensity allogeneic HSCT
(CC 99-C-0143); preliminary results suggest that a randomized trial will be necessary to
evaluate donor Th2 cells further.

In CC 99-C-0143, a novel induction chemotherapy regimen, EPOCH-Fludarabine (EPOCH-F), was
well tolerated and effective for sequential host immune depletion. However, a significant
proportion of patients failed to achieve satisfactory disease control before transplant,
providing a basis for intensifying this induction regimen. Furthermore, the initial 20
patients treated on this study experienced relatively high rates of acute GVHD and
considerable morbidity associated with cyclosporine monotherapy for GVHD prevention,
indicating that future studies should use more aggressive prophylaxis. These observations
warrant modifying our approach to allogeneic HSCT before undertaking a randomized study of
donor Th2 cells.

We now propose a pilot study of HLA-matched, related, reduced-intensity allogeneic HSCT in
refractory hematologic malignancies, using an intensified EPOCH-F induction chemotherapy
regimen with rituximab added for patients with CD20+ malignancies (EPOCH-F/R). This regimen
will be evaluated for toxicity and disease control before transplantation. GVHD prophylaxis
will consist of a standard dual-agent regimen, cyclosporine/methotrexate; the impact of this
change on hematopoietic recovery, donor/recipient chimerism, and the incidence of acute GVHD
will be assessed.

Immune reconstitution following allogeneic HSCT is an important research interest among
Experimental Transplantation and Immunology Branch Investigators. Current evidence suggests a
critical role for interleukin-7 (IL-7) in CD4+ T cell homeostasis, and interleukin-15 (IL-15)
appears crucial to CD8+ T cell and NK cell homeostasis. The relationships between these
cytokines and lymphocyte subpopulations have not been studied in the setting of allogeneic
HSCT; such analysis may enhance our understanding of engraftment kinetics, graft-versus-host
disease, and immune reconstitution. We will correlate serum IL-7 and IL-15 levels with
changes in circulating T-cell and NK-cell subpopulations during EPOCH-F/R induction
chemotherapy, after transplantation, and with the development of GVHD.

- INCLUSION CRITERIA:

Inclusion Criteria Patient (Recipient):

Patients with hematologic malignancies, myelodysplasia, or myeloproliferative disorders, as
summarized below:

Disease: Chronic Lymphocytic Leukemia; Disease Status: (a) Relapse post-fludarabine, (b)
Non-CR after salvage regimen; Age: 18 to 75.

Disease: Hodgkin s and Non-Hodgkin s Lymphoma (all types, including Mantle Cell Lymphoma);
Disease Status: (a) Primary treatment failure, (b) Relapse after autologous SCT, (c)
Hepatosplenic gamma/delta T cell lymphoma; Age: 18 to 75.

Disease: Multiple Myeloma; Disease Status: (a) Primary treatment failure, (b) Relapse after
autologous SCT, (c) Non-CR after salvage regimen; Age: 18 to 75.

Disease: Acute Myelogenous Leukemia; Disease Status: (a) In Complete Remission #1, with
high-risk cytogenetics [abnormalities other than t(8;21), t(15;17), or inv(16)], (b) In
Complete Remission #2 or greater; Age: 18 to 75.

Disease: Acute Lymphocytic Leukemia; Disease Status: (a) In Complete Remission #1, with
high-risk cytogenetics [t(9;22) or bcr-abl rearrangement; t(4;11), 1(1;19), t(8;14)], (b)
In Complete Remission #2 or greater; Age: 18 to 75.

Disease: Myelodysplastic Syndrome; Disease Status: (a) RAEB, (b) RAEB-T (if blasts are less
than 10% in marrow and blood after induction chemotherapy); Age: 18 to 75.

Disease: Myeloproliferative disorders; Disease Status: (a) Idiopathic myelofibrosis, (b)
Polycythemia vera, (c) Essential thrombocytosis, (d) Chronic myelomonocytic leukemia; Age:
18 to 75.

Disease: Chronic Myelogenous Leukemia; Disease Status: (a) Chronic phase CML, (b)
Accelerated phase CML; Age 50 to 75; (c) Not eligible for myeloablative allogeneic HSCT;
Age: 18 to 50.

Patients 18-75 years of age. Patients older than 75 years of age will be considered on an
individual basis.

Consenting first degree relative matched at 6/6 HLA antigens (A, B, and DR).

Patient or legal guardian must be able to give informed consent.

All previous therapy must be completed at least 2 weeks prior to study entry, and any grade
3 or 4 non-hematologic toxicity of previous therapy must be resolved to grade 2 or less,
unless specified elsewhere.

ECOG performance status equal to 0 or 1.

Life expectancy of at least 3 months.

Patients with acute leukemia must be in hematologic remission, defined as less than 5%
blasts present in blood or bone marrow.

Left ventricular ejection fraction greater than 45% by either MUGA or 2-D echo, obtained
within 28 days of enrollment. The cumulative dose of doxorubicin received by patients will
not be considered, as the cardiac ejection fraction appears to indicate the safe cumulative
doxorubicin dose in the setting of EPOCH-based chemotherapy.

DLCO greater than 50% of the expected value when correlated for Hb, obtained within 28 days
of enrollment.

Creatinine less than or equal to 1.5 mg/dl and creatinine clearance greater than or equal
to 50 ml/min/1.73 m(2).

Serum total bilirubin less than 2.5 mg/dl, and serum ALT and AST values less than or equal
to 2.5 times the upper limit of normal. Values above these levels may be accepted, at the
discretion of the PI or study chairman, if such elevations are thought to be due to liver
involvement by malignancy. If these values do not normalize during induction chemotherapy,
such patients will not be eligible for the transplant phase of the protocol, and will thus
be taken off study.

Minimum absolute neutrophil count of 1,000 cells/microliter and minimum platelet count
(without transfusion) of 20,000/mm(3).

Inclusion Criteria Donor:

First-degree relative with genotypic identity at 6/6 HLA loci (HLA-A, B and DR).

Ability to give informed consent. For donors under 18 years of age, the donor must complete
an assent form, and the donor s legal guardian must complete an informed consent form.

Age 12-75 years. As the potential cerebrovascular and cardiac complications may potentially
increase with age, age 75 has been chosen arbitrarily as the upper age limit. However, if
it is determined after initial accrual of patients in this upper age range that this
procedure is relatively safe, the age range may be extended.

Adequate venous access for peripheral apheresis, or consent to use a temporary central
venous catheter for apheresis.

Donors must be HIV negative, hepatitis B surface antigen negative, and hepatitis C antibody
negative. This is to prevent the possible transmission of these infections to the
recipient.

A donor who is lactating must substitute formula feeding for her infant during the period
of cytokine administration. Filgrastim may be secreted in human milk, although its
bioavailability from this source is not known. Limited clinical data suggest that
short-term administration of filgrastim or sargramostim to neonates is not associated with
adverse outcomes.

EXLCUSION CRITERIA:

Exclusion Criteria Patient:

Active infection that is not responding to antimicrobial therapy.

Active CNS involvement by malignancy.

HIV infection. There is theoretical concern that the degree of immune suppression
associated with the treatment may result in progression of HIV infection.

Chronic active hepatitis B. Patients may be hepatitis B core antibody positive but must be
surface antigen negative and without evidence of active infection.

Hepatitis C infection.

Pregnant or lactating. Patients of childbearing potential must use an effective method of
contraception. The effects of chemotherapy, the subsequent transplant and the medications
used after the transplant are highly likely to be harmful to a fetus. The effects upon
breast milk are also unknown and may be harmful to the infant.

History of psychiatric disorder which may compromise compliance with transplant protocol,
or which does not allow for appropriate informed consent (as determined by principal
investigator or study chairman).

Exclusion Criteria Donor:

History of psychiatric disorder which may compromise compliance with transplant protocol,
or which does not allow for appropriate informed consent.

History of hypertension that is not controlled by medication, stroke, or severe heart
disease. Individuals with symptomatic angina will be considered to have severe heart
disease will not be eligible to be a donor.

No other medical contraindications to stem cell donation (i.e. severe atherosclerosis,
autoimmune disease, cerebrovascular accident, prior malignancy). Patients with a history of
coronary artery bypass grafting or angioplasty will receive a cardiology evaluation and be
considered on a case-by-case basis. Persons with a history of non-hematologic malignancy
must have undergone potentially curative therapy for that malignancy and (1) have had no
evidence of that disease for 5 years, and/or (2) be deemed at low risk for recurrence (less
than or equal to 20% at 5 years). Such persons will be considered eligible for stem cell
donation at the discretion of the principal investigator. Prospective donors with a history
of non-hematologic malignancy who have received potentially curative therapy and are in
remission, but whose estimated risk of recurrence is greater than 20% at 5 years, will be
considered on an individual basis in consultation with the NCI IRB.

Donors must not be pregnant. The effects of cytokine administration on a fetus are unknown.
Donors of childbearing potential must use an effective method of contraception.

Anemia (Hb less than 11 gm/dl) or thrombocytopenia (platelets less than 100,000 per
microliter).