Alemtuzumab, Busulfan, and Cyclophosphamide Followed By a Donor Stem Cell Transplant in Treating Patients With Hematologic Cancer

A Prospective Trial to Evaluate the Role of In Vivo T Cell Depletion by Campath® (Alemtuzumab) in Reduction of Transplant Related Mortality in Transplantation From HLA-Class I or Class II Mismatched, Unrelated Donors

RATIONALE: Monoclonal antibodies, such as alemtuzumab, can find cancer cells and either kill them or deliver cancer-killing substances to them without harming normal cells. Giving chemotherapy drugs, such as busulfan and cyclophosphamide, before a donor stem cell transplant helps stop the growth of 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. Sometimes the transplanted cells from a donor can make an immune response against the body's normal cells. Giving tacrolimus and methotrexate after the transplant may stop this from happening.

PURPOSE: This phase I/II trial is studying the best dose of alemtuzumab when given together with busulfan and cyclophosphamide followed by a donor stem cell transplant and to see how well it works in treating patients with hematologic cancer.

OBJECTIVES:

Primary

• Identify the lowest dose of alemtuzumab that is associated with day 180 transplant-related mortality ≤ 45%.

Secondary

• Determine the incidence of life-threatening infection in patients receiving this treatment.
• Determine the incidence of grades III-IV acute graft-vs-host disease (GVHD) in patients receiving this treatment.
• Determine the survival at 1 year in patients receiving this treatment.
• Determine the incidence of disease relapse at 1 year in patients receiving this treatment.
• Determine the incidence of extensive chronic GVHD at 1 year in patients receiving this treatment.
• Determine the incidence of graft failure at day 100 in patients receiving this treatment.

OUTLINE:

• Chemotherapy: Patients receive alemtuzumab IV over 2 hours on days -10 to -6, busulfan IV over 3 hours on days -7 to -4, and cyclophosphamide IV on days -3 and -2.
• Peripheral blood stem cell (PBSC) transplantation: Patients undergo allogeneic filgrastim (G-CSF)-mobilized PBSC transplantation on day 0.
• Graft-vs-host disease prophylaxis: Patients receive tacrolimus IV continuously or orally twice daily on days -1 to 50 and methotrexate IV on days 1, 3, 6, and 11.

After completion of study therapy, patients are followed periodically.

DISEASE CHARACTERISTICS:

• Confirmed diagnosis of one of the following:

  • Primary acute myeloid leukemia (AML) meeting any of the following criteria:

    • First complete remission (CR; defined as < 5% blasts in marrow) with high-risk features as defined by failure to achieve remission by day 21 after induction chemotherapy, or the presence of chromosomal abnormalities involving any of the following:

      • -5/del(5q)
      • -7/del(7q)
      • Inversion 3q
      • Abnormalities of 11q23, 20q, 21q, del(9q),
      • Translocation 6;9
      • Translocation 9;22
      • Abnormalities of 17p
      • Complex karyotype with ≥ 3 abnormalities

    • Second CR or subsequent in remission

    • Refractory or relapsed disease

  • Secondary AML in remission or relapse

  • Chronic myelogenous leukemia (CML) in accelerated or blast phase meeting the following criteria:

    • Accelerated phase is defined by any one of the following:

      • Blasts 10% to 19% of peripheral blood white cells or bone marrow cells
      • Peripheral blood basophils ≥ 20%
      • Persistent thrombocytopenia (< 100,000/mm³) unrelated to therapy, or persistent thrombocytosis (> 1,000,000/mm³) unresponsive to therapy
      • Increasing spleen size and increasing WBC count unresponsive to therapy
      • Cytogenetic evidence of clonal evolution (i.e., the appearance of an additional genetic abnormality that was not present in the initial specimen at the time of diagnosis of chronic phase CML)

    • Blast phase is defined by any of the following:

      • Blasts ≥ 20% of peripheral blood white cells or bone marrow cells
      • Extramedullary blast proliferation
      • Large foci or clusters of blasts in bone marrow biopsy

  • Primary myelodysplastic syndromes (MDS) with an IPSS score > 1.5

  • Secondary MDS with any IPSS score

  • Primary acute lymphoblastic leukemia meeting any of the following criteria:

    • First CR (< 5% blasts in marrow) with high-risk features as defined by 1 of the following:

      • Failure to achieve remission after first induction chemotherapy
      • Presence of chromosomal abnormalities including hypodiploidy or abnormalities of 11q23 or translocation 9;22

    • Second CR or subsequent in remission

    • Refractory or relapsed disease

• No patients for whom a suitable HLA genotypically identical sibling or fully matched HLA-A, -B, -C, and -DRB1 unrelated donor is available

• No active CNS involvement with disease

• Donors must meet the following criteria:

  • Unrelated volunteer donors who are mismatched for more than one HLA-class I alleles or antigens or for one HLA-class I antigen, but matched by high-resolution typing at HLA-DRB1 and -DQB1, OR who are mismatched for one or more HLA-class II alleles or antigens, but matched by high-resolution typing at HLA-A, -B, and -C

    • No two-antigen mismatch at a single HLA-A, -B, or -C locus
    • No mismatching of class I and class II HLA
    • Matching must be based on results of high-resolution typing at HLA-A, -B, -C, - DRB1, and -DQB1

PATIENT CHARACTERISTICS:

• Karnofsky performance status 50-100%
• No symptomatic coronary artery disease or symptomatic congestive heart failure
• No hepatic disease with transaminases or bilirubin > 2 times upper limit of normal except for isolated hyperbilirubinemia attributed to Gilbert's syndrome
• No severe hypoxemia with room air P_AO_2 < 70, supplemental oxygen-dependence, or DLCO < 60% predicted
• No impaired renal function with creatinine > 2 times upper limit of normal or creatinine clearance < 50% normal
• Not HIV seropositive
• Not pregnant or breast-feeding
• Fertile patients must use effective contraception
• No active infections that are untreated or failing to respond to appropriate therapy

PRIOR CONCURRENT THERAPY:

Inclusion criteria:

• See Disease Characteristics

Exclusion criteria:

• Prior allogeneic or autologous bone marrow, peripheral blood stem cell, or umbilical cord blood transplantation using a high-dose total-body irradiation regimen