Low-Dose Fludarabine, Busulfan, and Anti-Thymocyte Globulin Followed By Donor Umbilical Cord Blood Transplant in Treating Patients With Advanced Hematologic Cancer

OBJECTIVES:

Primary

- Assess the feasibility of performing umbilical cord blood transplants in older patients
or younger infirm patients with advanced hematologic malignancies using a
reduced-intensity preparative regimen, as determined by > 80% engraftment rate at day
180 and a < 50% transplant-related mortality rate at day 100.

Secondary

- Describe the time to neutrophil and platelet recovery in patients treated with this
regimen.

- Determine disease-specific, event-free, and overall survival rate at days 180 and 360.

- Determine the incidence, severity, and timing of acute and chronic graft-versus-host
disease in patients treated with this regimen.

- Evaluate T-cell, B-cell, and natural killer cell recovery in patients treated with this
regimen.

- Assess lineage-specific chimerism after transplantation and describe the contribution of
each individual cord blood unit to post-transplantation hematopoiesis.

OUTLINE: This is a pilot study.

- Reduced-intensity preparative regimen: Patients receive fludarabine IV over 30 minutes
on days -8 to -4, busulfan IV over 2 hours 4 times daily on days -4 and -3, and
anti-thymocyte globulin IV over 6 hours on days -3 to -1.

- Allogeneic umbilical cord blood transplantation: Patients undergo allogeneic umbilical
cord blood transplant on day 0. Patients receive sargramostim (GM-CSF) subcutaneously or
IV beginning on day 7 and continuing until blood counts recover.

- Graft-versus-host disease (GVHD) prophylaxis: Patients receive tacrolimus IV
continuously over 24 hours or orally (as tolerated) beginning on day -2 and continuing
for approximately 9 months. Patients also receive oral mycophenolate mofetil twice daily
on days 1-50.

After completion of study treatment, patients are followed periodically for 2 years.

PROJECTED ACCRUAL: A total of 10 patients will be accrued for this study.

DISEASE CHARACTERISTICS:

- Diagnosis of 1 of the following advanced hematologic malignancies:

- Acute myeloid leukemia (AML) meeting the following criteria:

- Considered incurable with chemotherapy

- Marrow blasts ≤ 10% (may be achieved using standard chemotherapy regimen)

- Meets any of the following criteria:

- High-risk cytogenetics (-7, -7q, -5, -5q, t(6,9), t(9,11), complex [≥ 3
abnormalities], Philadelphia chromosome positive [Ph+])

- AML evolved from prior myelodysplasia

- AML secondary to prior chemotherapy

- Failed to achieve remission

- In second or subsequent remission

- Refractory relapse

- Myelodysplastic syndromes (MDS) meeting the following criteria:

- Must have high-risk features, including any of the following:

- Intermediate-2 or high risk International Prognostic Scoring System
(IPSS) score

- Chronic myelomonocytic leukemia

- Marrow blasts ≤ 20% (chemotherapy may be given to achieve target blast
levels)

- No rapidly progressive disease

- Acute lymphoblastic leukemia meeting the following criteria:

- Considered incurable with chemotherapy

- Meets any of the following criteria:

- High-risk cytogenetics (Ph+, t(4,11), 11q23 abnormalities, or monosomy
7)

- Required > 1 induction course to achieve remission

- Failed to enter remission

- In second or subsequent remission

- Marrow blasts ≤ 10% (chemotherapy may be given to achieve target blast
levels)

- Chronic myelogenous leukemia (CML) meeting 1 of the following criteria:

- Chronic phase CML that failed imatinib mesylate therapy, as defined by
progressive disease or failed to achieve a major cytogenetic response at 1
year after initiation of therapy

- Accelerated phase CML meeting 1 of the following criteria:

- Failed to achieve a complete cytogenetic remission at 1 year after
initiation of therapy

- Failed to achieve any cytogenetic response after 6 months of therapy

- Progressive disease, as demonstrated by worsening cytogenetic response
in 2 consecutive analyses separated by 4 weeks

- In blast crisis with < 10% blasts in bone marrow

- Multiple myeloma meeting the following criteria:

- Stage I-III disease

- Meets any of the following criteria:

- In relapse after autologous transplantation

- Refractory to ≥ 2 prior conventional myeloma therapies

- Chromosome 13 abnormalities (may be enrolled at diagnosis or after
initial progression)

- Lymphoma

- The following subtypes are eligible:

- Diffuse large cell

- Follicular large cell

- Mantle cell

- Peripheral T-cell

- T-natural killer (T-NK) cell

- Hodgkin's lymphoma

- Must have progressed, recurred after prior therapy, or failed to respond to
primary therapy

- Relapsed disease after autologous stem cell transplantation (SCT) allowed

- Low-grade non-Hodgkin's lymphoma meeting 1 of the following criteria:

- Relapsed or refractory disease after ≥ 2 chemotherapy-based treatment
regimens

- Relapsed after autologous SCT

- Chronic lymphocytic leukemia

- Relapsed or refractory disease after ≥ 2 chemotherapy-based treatment
regimens

- Relapsed after autologous SCT

- Meets 1 of the following criteria:

- Age 55-70 years

- Under age 55 and deemed ineligible for conventional high-dose chemotherapy, as
indicated by any of the following:

- Poor cardiac function (i.e., LVEF < 40%)

- Poor pulmonary function (i.e., DLCO < 50%)

- Hepatic dysfunction

- Prior myeloablative therapy

- Not eligible for autologous SCT or conventional therapy

- Umbilical cord blood donor available

- Matched at ≥ 4 of 6 HLA antigens (A, B, and DR)

- Has 1-3 units of umbilical cord blood available

- Must not have an HLA-identical or 1 antigen mismatched related donor or potential
HLA-matched unrelated donor readily available NOTE: A new classification scheme
for adult non-Hodgkin's lymphoma has been adopted by PDQ. The terminology of
"indolent" or "aggressive" lymphoma will replace the former terminology of "low",
"intermediate", or "high" grade lymphoma. However, this protocol uses the former
terminology.

PATIENT CHARACTERISTICS:

- ECOG performance status 0-2

- Creatinine clearance > 40 mL/min

- Creatinine < 2.0 mg/dL

- AST and alkaline phosphatase < 3 times upper limit of normal (ULN)

- Bilirubin < 2.0 mg/dL

- Hepatitis C or active hepatitis B virus (HBV) allowed if ≤ grade 2 fibrosis and/or
inflammation by liver biopsy

- Patients with history of HBV infection should be tested for hepatitis B epsilon
(HBe) antigen, anti-HBe, and HBV DNA (quantitative)

- Patients with active HBV viral replication should receive antiviral therapy

- Ejection fraction > 30%

- DLCO ≥ 40%

- Not pregnant or nursing

- Negative pregnancy test

- Fertile patients must use effective contraception

- No active infection requiring ongoing antibiotic treatment

- HIV negative

PRIOR CONCURRENT THERAPY:

- See Disease Characteristics