This phase I studies the side effects and best dose of total marrow and lymphoid irradiation when given together with fludarabine and melphalan before donor stem cell transplant in treating participants with high-risk acute leukemia or myelodysplastic syndrome. Giving chemotherapy, such as fludarabine and melphalan, and total marrow and lymphoid irradiation before a donor stem cell transplant helps stop the growth of cells in the bone marrow, including normal blood-forming cells (stem cells) and cancer cells. When the healthy stem cells from a donor are infused into the patient they may help the patient's bone marrow make stem cells, red blood cells, white blood cells, and platelets.
PRIMARY OBJECTIVES: I. To determine the maximum tolerated dose/recommended phase II dose (MTD/RP2D) of total marrow and lymphoid irradiation (TMLI) with fixed doses of fludarabine and melphalan (FM100) as a preparative regimen in patients undergoing allogeneic hematopoietic stem cell transplantation (alloHCT) and who are not eligible for standard myeloablative regimens, with either a matched donor (Arm A) or a haploidentical donor (Arm B). II. To describe toxicities attributable to TMLI by dose level in patients treated under this regimen. SECONDARY OBJECTIVES: I. To evaluate the safety of the regimen, at each dose level, by assessing the following: type, frequency, severity, attribution, time course and duration of adverse events, including acute/chronic graft versus host disease (GVHD), infection and delayed engraftment. II. To investigate the temporal effect of bone marrow residual damage in alloHCT patients after TMLI/FM100. III. To estimate overall survival (OS), event-free survival (EFS), cumulative incidence (CI) of relapse/progression, and non-relapse mortality (NRM) at 100 days, 1 year and 2 years. IV. Assess minimal residual disease (MRD) from bone marrow aspirates on days 30, 100, and 180 post-transplant and describe its relation to TMLI dose level and patient disease status. V. To evaluate effect of TMLI/FM100 conditioning on immune reconstitution after alloHCT in patients receiving stem cells from matched or haploidentical donors. OUTLINE: This is a dose-escalation study of TMLI. Participants undergo TMLI twice daily (BID) on days -8 to -5, and receive fludarabine intravenously (IV) on days -4 to -2 and melphalan on day -2. Participants then undergo alloHCT on day 0. After completion of study treatment, participants are followed up twice weekly for 100 days, twice monthly for 6 months, and then monthly or yearly for up to 2 years.
Study Type
INTERVENTIONAL
Allocation
NA
Purpose
TREATMENT
Masking
NONE
Enrollment
36
Given IV
Correlative studies
Given as per City of Hope Standard Operating Procedure
Undergo TMLI
City of Hope Medical Center
Duarte, California, United States
RECRUITINGIncidence of toxicity
Toxicity will be scored on both the Bearman scale and National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) version 5 scale. Toxicity information recorded in each patient will include the type, severity, and the probable association with the study regimen. Tables will be constructed to summarize the observed incidence by severity and type of toxicity, and dose levels in each arm.
Time frame: Up to 2 years
Overall survival
Participants are considered a failure for this endpoint if they die, regardless of cause. Survival estimates will be calculated using the Kaplan-Meier method.
Time frame: From start of protocol therapy up to 2 years
Event-free survival
Participants are considered a failure for this endpoint if they relapse/progress or die, regardless of cause. Survival estimates will be calculated using the Kaplan-Meier method.
Time frame: From start of protocol therapy up to 2 years
Relapse/progression
Death without relapse/progression is considered a competing risk.
Time frame: From start of protocol therapy up to 2 years
Complete remission proportion
Time frame: At day 30
Non-relapse mortality
Participants are considered a failure for this endpoint if they die from causes other than disease relapse or progression.
Time frame: Up to 2 years
Incidence of infection
Microbiologically documented infections will be reported by site of disease, date of onset, severity and resolution, if any. These data will be captured via case report form.
Time frame: Up to day 100 post-transplant
Incidence of toxicities/adverse events (AEs)
Toxicities that meet grade 3, 4, or 5 per the Bearman scale and CTCAE v 4.03 from day -9 to day -1, from day 0 to day +30, and again from day +31 to +100 post-transplant will be collected. Any AEs occurring from day -9 to day +30 will be followed until they resolve. Start and stop dates will also be recorded for any grade 4 neutropenia.
Time frame: Up to 100 days post-transplant
Neutrophil recovery
This will be measured from stem cell infusion to the first to three consecutive days with neutrophil count greater than 0.5 x 10\^9/l.
Time frame: Up to 2 years
Acute graft versus host disease of grades 2-4 and 3-4
Documented/biopsy proven acute graft versus host disease is graded according to National Institutes of Health (NIH) consensus staging. This measurement will be used to estimate the cumulative incidence.
Time frame: Up to 100 days post-transplant
Chronic graft versus host disease
This will be scored according to NIH consensus staging and will be used to estimate the cumulative incidence.
Time frame: Up to 2 years
CD4+, CD8+ and CD56+16+
Immunophenotyping of lymphocyte subsets will be determined by flow cytometry.
Time frame: Up to 2 years
Bone marrow (BM) residual damage
BM cellularity will be assessed using histology and clonogenic in vitro assays.
Time frame: Up to 2 years
Immune reconstitution
This will be monitored by flow cytometry analysis of peripheral blood mononuclear cells.
Time frame: Up to 2 years
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