The purpose of this study is to determine if double autologous then allogeneic hematopoietic cell transplant may offer an improved treatment option for patients with relapsed diffuse large B-cell lymphoma (DLBCL) who are not likely to be cured by the conventional transplantation regimen.
This study tests a tandem transplant approach that starts with transplantation of the participant's own hematopoietic (blood) cells, eg, autologous hematopoietic cell transplant (auto-HCT) as preparation for an subsequent matched-donor allogeneic HCT (allo-HCT). Participants will be have progenitor cells (stem cells) mobilized into the peripheral blood with rituximab, chemotherapy (cyclophosphamide or etoposide), and filgrastim (G-CSF); undergo apheresis to collect autologous peripheral blood stem cells (PBSC, aka hematopoietic cells); and be re-infused with ≥ 3 x 10e6 CD34+ cells/kg (auto-HCT). Subsequently, participants will receive therapeutic, non-myeloablative chemotherapy (carmustine + cyclophosphamide + etoposide), then transplant conditioning \[total lymphoid irradiation (TLI) + anti-thymocyte globulin (ATG)\] followed by ≥ 2 x 10e6 CD34+ cells/kg allogeneic PBSC obtained from a human leukocyte antigen (HLA)-matched or HLA single allele / antigen-mismatched donor (allo-HCT). Donors will be mobilized with 16 µg/kg filgrastim. Participant allo-HCT transplant is to occur within 150 days of auto-HCT. Post-allo-HCT infusion treatment includes cyclosporine and mycophenolate mofetil (MMF) Subject's participation ends if a suitable matched donor is not identified within the 150 days. Pre-medication treatments administered during this study may include acetaminophen; diphenhydramine; hydrocortisone; and methylprednisolone.
Study Type
INTERVENTIONAL
Allocation
NA
Purpose
TREATMENT
Masking
NONE
Enrollment
3
Auto-HCT involves an intravenous infusion of a participant's previously collected and frozen white blood cells collected after treatment with mobilizing agents
Allo-HCT involves an intravenous infusion of a donor's white blood cells collected after treatment with mobilization with filgrastim (G-CSF)
TLI is administered in 80cGy fractions on Days -11 to Day-7 relative to allo-HSCT
Stanford University School of Medicine
Stanford, California, United States
Event-free Survival (EFS) Per Protocol
Event-free survival (EFS) through 4 years, as assessed in participants with poor-risk recurrent or primary refractory DLBCL treated with TLI and ATG followed by matched allogeneic hematopoietic cell transplantation as a consolidation to HCT. Event is defined as tumor progression or death.
Time frame: 48 months
Median Time to Neutrophil Engraftment After Autologous Transplant
Reported as neutrophil engraftment after autologous transplant, defined as absolute neutrophil count (ANC) \> 500/µL, counting from the day of transplant.
Time frame: within 1 month
Median Time to Platelet Engraftment After Autologous Transplant
Reported as platelet engraftment after autologous transplant, defined as platelet count \> 20,000/µL, counting from the day of transplant.
Time frame: within 1 month
Median Time to Neutrophil Engraftment After Allogeneic Transplant
Reported as neutrophil engraftment after allogeneic transplant, defined as absolute neutrophil count (ANC) \> 500/µL, counting from the day of transplant.
Time frame: within 1 month
Median Time to Platelet Engraftment After Allogeneic Transplant
Reported as platelet engraftment after allogeneic transplant, defined as platelet count \> 20,000/µL, counting from the day of transplant.
Time frame: within 1 month
Incidence of Chronic Graft vs Host Disease (GvHD)
The incidence of chronic graft vs host disease (GvHD) is reported as any events within 3 years. Note that GvHD was assessed per investigator judgement. There was no protocol-specified criteria of GvHD.
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375 mg/m2 IV days 1 and 7 over 4 to 8 hours
Based on body weight, unless its more than 15 kg greater than the idal body 15mg/kg (max dose 550 mg/m2) day -6 over 2 hours. Males IBW = 50 kg + 2.3 kg/inch over 5 feet Females IBW = 45.5 kg + 2.3 kg/inch over 5 feet Adjusted IBW = IBW + 50% (actual weight - IBW)
60 mg/kg over 4 hours day -4 and alternatively VP-16 2 Gm/m² may be used (for mobilization)
10 µg/kg/day subcutaneous starting Day 9 until last day of apheresis. 5 ug/kg actual body weight per day will be started at Day +6 after allo-HCT until hematologic recovery
1.5 mg/kg/day for 5 days
5.0 mg/kg twice daily from day -3 until after day +56
250 mg (total) twice daily, oral 15 mg/kg po on day 0, at 5-10 hours after mobilized PBPC infusion is complete. On day +1 MMF is taken at 15 mg/kg po b.i.d. (30 mg/kg/day) if transplantation was using a matched related donor and 15 mg/kg po t.i.d if from a matched unrelated donor or a one antigen mismatched donor.
100 mg/kg will be administered over 2 hours on day -2
Pre-medication for rituximab and PBPC infusion. Administered at 650 mg by mouth 1 hour prior to infusion
Pre-medication for rituximab and PBPC infusion. Administered at 50 mg intravenous 1 hour prior to infusion
Pre-medication for the PBPC infusion. Administered at 100 mg intravenous 1 hour prior to infusion
Anti-reaction medication for the ATG infusion. Administered at 1 mg/kg, Day-11 to Day-7
Time frame: 3 years
Overall Survival (OS)
To evaluate the overall and transplant related mortality rate, reported as the number of subjects remaining alive 3 years after transplant.
Time frame: 3 years