Reduced Intensity, Partially HLA Mismatched BMT to Treat Hematologic Malignancies
Reduced Intensity, Partially HLA Mismatched BMT to Treat Hematologic Malignancies
If transplantation using mismatched unrelated donors or non-first-degree relatives could be
 performed with an acceptable toxicity profile, an important unmet need would be served.
 Towards this goal, the current study extends our platform of nonmyeloablative, partially
 HLA-mismatched bone marrow transplant (BMT) and Peripheral Blood Stem Cell Transplant (PBSCT)
 to the use of such donors, investigating up to several postgrafting immunosuppression
 regimens that incorporate high-dose Cy. Of central interest is the incorporation of sirolimus
 into this postgrafting immunosuppression regimen.

 The primary goal for phase 1 is to identify a transplant regimen associated with acceptable
 rates of severe acute GVHD and NRM by Day 100 and for phase 2 estimate the 6-month
 probability of survival without having had acute grade III- IV GVHD or graft failure.
Patient Inclusion Criteria:

 -  Patient age 0.5-75 years

 -  Absence of a suitable related or unrelated bone marrow donor who is molecularly
 matched at HLA-A, B, Cw, DRB1, and DQB1.

 -  Absence of a suitable partially HLA-mismatched (haploidentical), first-degree related
 donor.

 -  Eligible diagnoses:

 -  Relapsed or refractory acute leukemia in second or subsequent remission, with
 remission defined as <5% bone marrow blasts morphologically

 -  Poor-risk acute leukemia in first remission, with remission defined as <5% bone
 marrow blasts morphologically:

 -  AML with at least one of the following:

 -  AML arising from MDS or a myeloproliferative disorder, or secondary AML

 -  Presence of Flt3 internal tandem duplications

 -  Poor-risk cytogenetics: Complex karyotype [> 3 abnormalities], inv(3),
 t(3;3), t(6;9), MLL rearrangement with the exception of t(9;11), or
 abnormalities of chromosome 5 or 7

 -  Primary refractory disease

 -  ALL (leukemia and/or lymphoma) with at least one of the following:

 -  Adverse cytogenetics such as t(9;22), t(1;19), t(4;11), or MLL rearrangement

 -  Clear evidence of hypodiploidy

 -  Primary refractory disease

 -  Biphenotypic leukemia

 -  MDS with at least one of the following poor-risk features:

 -  Poor-risk cytogenetics (7/7q minus or complex cytogenetics)

 -  IPSS score of INT-2 or greater

 -  Treatment-related MDS

 -  MDS diagnosed before age 21 years

 -  Progression on or lack of response to standard DNA-methyltransferase
 inhibitor therapy

 -  Life-threatening cytopenias, including those generally requiring greater
 than weekly transfusions

 -  Interferon- or imatinib-refractory CML in first chronic phase, or non-blast
 crisis CML beyond first chronic phase.

 -  Philadelphia chromosome negative myeloproliferative disease.

 -  Chronic myelomonocytic leukemia.

 -  Juvenile myelomonocytic leukemia.

 -  Low-grade non-Hodgkin lymphoma (including SLL and CLL) or plasma cell neoplasm
 that has progressed after at least two prior therapies (excluding single agent
 rituximab and single agent steroids), or in the case of lymphoma undergone
 histologic conversion

 -  Poor-risk CLL or SLL

 -  Aggressive non-Hodgkin lymphoma as follows, provided there is stable disease or
 better to last therapy:

 -  NK or NK-T cell lymphoma, hepatosplenic T-cell lymphoma, or subcutaneous
 panniculitic T-cell lymphoma, blastic/ blastoid variant of mantle cell
 lymphoma

 -  Hodgkin or aggressive non Hodgkin lymphoma that has failed at least one
 multiagent regimen, and the patient is either ineligible for autologous BMT
 or autologous BMT is not recommended. Eligible subtypes of aggressive
 non-Hodgkin lymphoma include:

 -  mantle cell lymphoma

 -  follicular grade 3 lymphoma

 -  diffuse large B-cell lymphoma or its subtypes, excluding primary CNS
 lymphoma

 -  primary mediastinal large B-cell lymphoma

 -  large B-cell lymphoma, unspecified

 -  anaplastic large cell lymphoma, excluding skin-only disease

 -  peripheral T-cell lymphoma, including angioimmunoblastic T-cell
 lymphoma

 -  Burkitt's lymphoma or atypical Burkitt's lymphoma (high-grade B-cell
 lymphoma, unclassifiable, with features intermediate between diffuse
 large B-cell lymphoma and Burkitt's), in complete remission

 -  Patients with CLL, SLL, or prolymphocytic leukemia must have < 20% bone marrow
 involvement by malignancy (to lower risk of graft rejection).

 -  One of the following, in order to lower risk of graft rejection:

 -  Cytotoxic chemotherapy, an adequate course of 5-azacitidine or decitabine, or
 alemtuzumab within 3 months prior to start of conditioning; or

 -  Previous BMT within 6 months prior to start of conditioning. NOTE:Patients who
 have received treatment outside of these windows may be eligible if it is deemed
 sufficient to reduce graft rejection risk; this will be decided on a case-by-case
 basis by the PI or co-PI.

 -  Any previous BMT must have occurred at least 3 months prior to start of conditioning.

 -  Adequate end-organ function.

 -  ECOG performance status < 2 or Karnofsky or Lansky score > 60

 Patient Exclusion Criteria:

 -  Not pregnant or breast-feeding.

 -  No uncontrolled bacterial, viral, or fungal infection.

 -  Note: HIV-infected patients are potentially eligible. Eligibility of HIV-infected
 patients will be determined on a case-by-case basis.

 -  No previous allogeneic BMT (syngeneic BMT permissible).

 -  Active extramedullary leukemia or known active CNS involvement by malignancy. Such
 disease treated into remission is permitted.

 Donor Inclusion Criteria:

 -  Potential donors consist of:

 -  Unrelated donors

 -  Second-degree relatives

 -  First cousins

 -  The donor and recipient must be identical at at least 5 HLA alleles based on high
 resolution typing of HLA-A, -B, -Cw, -DRB1, and -DQB1, with at least one allele
 matched for a HLA class I gene (HLA-A, -B, or -Cw) and at least one allele matched for
 a class II gene (HLA-DRB1 or -DQB1).

 -  Meets institutional selection criteria and medically fit to donate.

 -  Lack of recipient anti-donor HLA antibody. Note: In some instances, low level,
 non-cytotoxic HLA specific antibodies may be permissible if they are found to be at a
 level well below that detectable by flow cytometry. This will be decided on a
 case-by-case basis by the PI and one of the immunogenetics directors. Pheresis to
 reduce anti-HLA antibodies is permissible; however eligibility to proceed with the
 transplant regimen would be contingent upon the result.

 Donor Exclusion Criteria:

 -  Donor must not be HLA identical to the recipient.

 -  Has not donated blood products to recipient.