Reduced Intensity BMT for Solid Cancer

Recruiting in Palo Alto (17 mi)

+4 other locations

Overseen by Heather Symons, MD, MHS

Age: < 65

Sex: Any

Travel: May Be Covered

Time Reimbursement: Varies

Trial Phase: Phase 2

Recruiting

Sponsor: Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins

Disqualifiers: HIV-positive, Pregnancy, Uncontrolled infections, others

No Placebo Group

Prior Safety Data

Trial Summary

What is the purpose of this trial?

The purpose of this study is to see if giving reduced intensity chemotherapy, haploidentical bone marrow, post-transplant cyclophosphamide and shortened duration tacrolimus is safe and feasible for patients with very high-risk solid tumors.

Do I have to stop taking my current medications for the trial?

The trial protocol does not specify whether you need to stop taking your current medications. It's best to discuss your specific situation with the trial coordinators or your doctor.

What data supports the effectiveness of the drug Melphalan in the treatment of solid cancer?

Research shows that high-dose Melphalan is effective as a conditioning regimen for autologous stem cell transplantation in patients with multiple myeloma, suggesting its potential effectiveness in other cancer treatments. ^{1 2 3 4 5}

Is the reduced intensity BMT treatment generally safe for humans?

The studies on melphalan, a component of the treatment, show it has an acceptable safety profile in patients with multiple myeloma undergoing stem cell transplantation, with no treatment-related deaths and manageable side effects like mucositis (mouth sores). ^{4 6 7 8 9}

How is the drug combination of Cyclophosphamide and Melphalan unique for treating solid cancer?

The combination of Cyclophosphamide and Melphalan for solid cancer is unique because it uses a reduced intensity approach, which may offer a less aggressive treatment option compared to traditional high-dose regimens. This approach is novel as it potentially reduces side effects while still aiming to be effective, especially since there are no standard treatments for solid cancers using this specific combination. ^{2 4 5 6 10}

Research Team

Heather Symons, MD, MHS

Principal Investigator

Johns Hopkins University

Eligibility Criteria

This trial is for patients with high-risk solid tumors who have a low chance of survival and haven't responded well to standard treatments. They need normal kidney function, decent heart function, and good overall health status. Participants must have a related donor who's partially genetically matched for bone marrow donation.

Inclusion Criteria

I have been diagnosed with neuroblastoma or ganglioneuroblastoma.

- Patients with high risk disease as defined in Appendix 1 whose autologous peripheral blood stem cell product is contaminated with neuroblastoma or who do not have an autologous product available

I have recovered from the side effects of my previous cancer treatments.

Exclusion Criteria

Donors must meet the selection criteria as defined by the Foundation for the Accreditation of Hematopoietic Cell Therapy (FACT).

My family and I prefer a specific donor for my treatment.

- Medically and psychologically fit and willing to donate

Trial Timeline

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

Pre-treatment Evaluation

Documentation of detailed history, physical examination, and standard evaluation of cardiac, pulmonary, liver, and renal function

1 week

Preparative Regimen

Administration of Fludarabine, Melphalan, and Total Body Irradiation before bone marrow transplantation

7 days

Bone Marrow Transplantation

Bone marrow harvested and infused, followed by post-transplantation cyclophosphamide and immunosuppression regimen

90 days

Follow-up

Participants are monitored for safety, effectiveness, and incidence of GVHD and other complications

up to 2 years

Treatment Details

Interventions

• Cyclophosphamide (Chemotherapy)
• Fludarabine (Chemotherapy)
• Low Dose Total Body Irradiation (Radiation)
• Melphalan (Chemotherapy)
• Tacrolimus (Immunosuppressant)

Trial Overview The study tests whether reduced intensity chemotherapy combined with haploidentical bone marrow transplant, post-transplant cyclophosphamide, and shortened tacrolimus treatment is safe and effective in patients with very high-risk solid tumors.

Participant Groups

Group I: Reduced intensity conditioning Experimental Treatment 5 Interventions

Fludarabine IV infusion over 30 minutes on D-7 to D-3. The dose will be 30 mg/m2/dose (adjusted for renal function). Melphalan: IV infusion over 30-60 minutes, depending on volume, on D-2. The dose will be 100mg/m2.Total body irradiation: 200 cGy AP/PA with 4MV or 6MV photons at 8 12 cGy/min at the point of prescription (average separation of measurements at mediastinum, abdomen, and hips) will be administered in a single fraction on day -1. Bone Marrow will be harvested and infused on day 0. Post-transplantation Cyclophosphamide 50mg/kg will be given on D+3 post-transplant (within 60-72 hr of marrow infusion) and on D+4 post-transplant. Tacrolimus begins on Day 5, at least 24 hours after completion of posttransplantation Cy at 0.015mg/kg IBW/dose IV over 3 hours every 12 hours. Mycophenolic acid mofetil (MMF) F will be given at a dose of 15 mg/kg PO TID (based upon actual body weight) with the maximum total daily dose not to exceed 3 grams (1 g PO TID).

Cyclophosphamide is already approved in Canada, Japan for the following indications:

Approved in Canada as Neosar for:

• Breast cancer
• Ovarian cancer
• Multiple myeloma
• Leukemia
• Lymphoma
• Rheumatoid arthritis

Approved in Japan as Endoxan for:

• Breast cancer
• Ovarian cancer
• Multiple myeloma
• Leukemia
• Lymphoma

Who Is Running the Clinical Trial?

Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins

Lead Sponsor

Trials

578

Recruited

33,600+

Dr. William G. Nelson

Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins

Director since 1992

MD, PhD

Dr. Elizabeth Jaffee

Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins

Chief Medical Officer since 2023

MD

National Cancer Institute (NCI)

Collaborator

Trials

14,080

Recruited

41,180,000+

Dr. Douglas R. Lowy

National Cancer Institute (NCI)

Chief Executive Officer since 2023

MD from New York University School of Medicine

Dr. Monica Bertagnolli

National Cancer Institute (NCI)

Chief Medical Officer since 2022

MD from Harvard Medical School

Findings from Research

In a study of 101 lymphoma patients undergoing autologous stem cell transplantation, the mitoxantrone-melphalan (Mx-Mel) regimen showed similar efficacy to the BEAM regimen while being less toxic, making it a promising alternative for patients who cannot tolerate high cytotoxic treatments.

Although the BEAM regimen resulted in a statistically shorter time to neutrophil engraftment (10 days) compared to Mx-Mel (12 days), both regimens did not lead to significant differences in transplant-related complications, indicating that Mx-Mel is a safe option with effective outcomes.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Comparison of Mitoxantrone-Melphalan and BEAM Conditioning Regimens in Patients with Lymphoma. Gunes, AK., Serin, I., Demir, I., et al.[2023]

A study involving 63 multiple myeloma patients showed that the pharmacokinetics (PK) of generic melphalan (MEL) is comparable to that of the innovator formulation, indicating that both formulations behave similarly in the body.

Clinical outcomes, such as the severity of mucositis and the time to neutrophil and platelet engraftment, were not significantly different between patients receiving generic and innovator MEL, suggesting that the generic version is equally effective for autologous stem cell transplantation.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Pharmacokinetics and Efficacy of Generic Melphalan Is Comparable to Innovator Formulation in Patients With Multiple Myeloma Undergoing Autologous Stem Cell Transplantation. Pai, AA., Devasia, AJ., Panetta, JC., et al.[2022]

Autologous stem cell transplant (ASCT) significantly improved outcomes for multiple myeloma (MM) patients, with an overall response rate of 80% and 64% survival rate over a 50-month follow-up period.

Patients who underwent ASCT in the early phase of MM showed better results, with a higher likelihood of achieving complete remission (CR) or very good partial remission (VGPR), which were predictive factors for longer overall survival.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

[Autologous stem cell transplantation in the treatment of multiple myeloma--single center experience]. Marjanović, S., Stamatović, D., Tukić, L., et al.[2019]

In a meta-analysis of 10 studies involving 2855 patients with multiple myeloma, BUMEL-based conditioning was associated with longer progression-free survival (PFS) compared to high-dose melphalan (HDMEL), although overall survival (OS) was similar between the two regimens.

Patients receiving BUMEL experienced less gastrointestinal toxicity, while those on HDMEL had lower rates of mucositis and infections, suggesting that BUMEL may be a safer alternative for improving outcomes in autologous hematopoietic stem cell transplantation.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Long-term outcomes of busulfan plus melphalan-based versus melphalan 200&#160;mg/m2 conditioning regimens for autologous hematopoietic&#160;stem cell transplantation in patients with multiple myeloma: a systematic review and meta-analysis. Gao, F., Lin, MS., You, JS., et al.[2021]

High-dose melphalan is the preferred chemotherapy for autologous stem cell transplantation in multiple myeloma patients, supported by earlier randomized trials.

Alternative treatment regimens involving different combinations of drugs and radiation have not shown better results than high-dose melphalan alone, according to multiple published studies.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Multiple myeloma preparative regimens for high-dose therapy and autologous transplantation: what's new? Aljitawi, OS., McGuirk, JP.[2013]

EVOMELA, a new formulation of melphalan that is free from propylene glycol, has been shown to be safe and effective for high-dose conditioning in autologous stem cell transplantation for multiple myeloma, with a 100% overall response rate in a study of 61 patients.

The study reported low incidences of severe side effects, such as grade 3 mucositis (10%) and stomatitis (5%), indicating that EVOMELA has an acceptable safety profile compared to traditional formulations.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

A Phase IIb, Multicenter, Open-Label, Safety, and Efficacy Study of High-Dose, Propylene Glycol-Free Melphalan Hydrochloride for Injection (EVOMELA) for Myeloablative Conditioning in Multiple Myeloma Patients Undergoing Autologous Transplantation. Hari, P., Aljitawi, OS., Arce-Lara, C., et al.[2017]

In a study of 514 multiple myeloma patients, the propylene glycol-free formulation of melphalan (PGF-mel) showed similar efficacy to the conventional propylene glycol-based formulation (PG-mel) in terms of relapse rates after high-dose melphalan with autologous hematopoietic cell transplantation.

However, PGF-mel was associated with fewer severe adverse events like mucositis and febrile neutropenia, leading to a preference for PG-mel despite the potential benefits of PGF-mel, due to cost considerations and other factors.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Comparison of Patient Outcomes With Two Different Formulations of Melphalan as Conditioning Chemotherapy for Autologous Hematopoietic Cell Transplantation in Multiple Myeloma. Khan, AM., Yucebay, F., Zhao, Q., et al.[2023]

High-dose melphalan (HDMel) is commonly used for conditioning in autologous stem cell transplantation for multiple myeloma, and most studies classify its risk for causing chemotherapy-induced nausea and vomiting (CINV) as moderate to high.

An aprepitant-based three-drug regimen (including aprepitant, a serotonin receptor antagonist, and dexamethasone) is more effective for preventing CINV compared to a two-drug regimen, without increasing adverse events, making it the recommended choice for patients undergoing this treatment.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Prevention of chemotherapy-induced nausea and vomiting after high-dose melphalan and stem cell transplantation: review of the evidence and suggestions. Tendas, A., Marchesi, F., Mengarelli, A., et al.[2020]

In a phase II study involving 24 patients with multiple myeloma, a single dose of 200 mg/m2 of Evomela (PG-Free Melphalan) was found to be safe and resulted in a high overall response rate of 96%, with 75% achieving a very good partial response.

The study revealed significant variability in pharmacokinetics (PK) among patients, indicating that some individuals had much higher drug exposure, suggesting that future research could focus on optimizing dosing strategies to enhance treatment effectiveness.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Pharmacokinetics of High-Dose Propylene Glycol-Free Melphalan in Multiple Myeloma Patients Undergoing Autologous Hematopoietic Cell Transplantation. Dhakal, B., D'Souza, A., Lakshman, A., et al.[2019]

Melphalan has been a key drug in hematopoietic stem cell transplantation (SCT) for over 50 years due to its strong myeloablative properties and effectiveness against various cancers, particularly multiple myeloma and lymphomas.

Combining melphalan with newer agents like bortezomib or lenalidomide may enhance its antitumor effects, while its low toxicity profile makes it a promising backbone for future cellular therapies.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Fifty years of melphalan use in hematopoietic stem cell transplantation. Bayraktar, UD., Bashir, Q., Qazilbash, M., et al.[2021]

References

1. Saudi Arabia pubmed.ncbi.nlm.nih.gov

Comparison of Mitoxantrone-Melphalan and BEAM Conditioning Regimens in Patients with Lymphoma. [2023]

2. United States pubmed.ncbi.nlm.nih.gov

Pharmacokinetics and Efficacy of Generic Melphalan Is Comparable to Innovator Formulation in Patients With Multiple Myeloma Undergoing Autologous Stem Cell Transplantation. [2022]

3. Serbia pubmed.ncbi.nlm.nih.gov

[Autologous stem cell transplantation in the treatment of multiple myeloma--single center experience]. [2019]

4. England pubmed.ncbi.nlm.nih.gov

Long-term outcomes of busulfan plus melphalan-based versus melphalan 200&#160;mg/m2 conditioning regimens for autologous hematopoietic&#160;stem cell transplantation in patients with multiple myeloma: a systematic review and meta-analysis. [2021]

5. England pubmed.ncbi.nlm.nih.gov

Multiple myeloma preparative regimens for high-dose therapy and autologous transplantation: what's new? [2013]

6. United States pubmed.ncbi.nlm.nih.gov

A Phase IIb, Multicenter, Open-Label, Safety, and Efficacy Study of High-Dose, Propylene Glycol-Free Melphalan Hydrochloride for Injection (EVOMELA) for Myeloablative Conditioning in Multiple Myeloma Patients Undergoing Autologous Transplantation. [2017]

7. United States pubmed.ncbi.nlm.nih.gov

Comparison of Patient Outcomes With Two Different Formulations of Melphalan as Conditioning Chemotherapy for Autologous Hematopoietic Cell Transplantation in Multiple Myeloma. [2023]

8. Germany pubmed.ncbi.nlm.nih.gov

Prevention of chemotherapy-induced nausea and vomiting after high-dose melphalan and stem cell transplantation: review of the evidence and suggestions. [2020]

9. United States pubmed.ncbi.nlm.nih.gov

Pharmacokinetics of High-Dose Propylene Glycol-Free Melphalan in Multiple Myeloma Patients Undergoing Autologous Hematopoietic Cell Transplantation. [2019]

10. United States pubmed.ncbi.nlm.nih.gov

Fifty years of melphalan use in hematopoietic stem cell transplantation. [2021]