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 BMT 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
is to identify a transplant regimen associated with acceptable rates of severe acute GVHD and
NRM by Day 100.
Patient Inclusion Criteria:
1. Patient age 0.5-75 years
2. Absence of a suitable related or unrelated bone marrow donor who is molecularly
matched at HLA-A, B, Cw, DRB1, and DQB1.
3. Absence of a suitable partially HLA-mismatched (haploidentical), first-degree related
4. Eligible diagnoses:
1. Relapsed or refractory acute leukemia in second or subsequent remission, with
remission defined as <5% bone marrow blasts morphologically
2. 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
- Clear evidence of hypodiploidy
- Primary refractory disease
- Biphenotypic leukemia
3. 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
- Life-threatening cytopenias, including those generally requiring greater
than weekly transfusions
4. Interferon- or imatinib-refractory CML in first chronic phase, or non-blast
crisis CML beyond first chronic phase.
5. Philadelphia chromosome negative myeloproliferative disease.
6. Chronic myelomonocytic leukemia.
7. Juvenile myelomonocytic leukemia.
8. 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
9. Poor-risk CLL or SLL
10. 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
- 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
- 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
- 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
5. Patients with CLL, SLL, or prolymphocytic leukemia must have < 20% bone marrow
involvement by malignancy (to lower risk of graft rejection).
6. 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.
7. Any previous BMT must have occurred at least 3 months prior to start of conditioning.
8. Adequate end-organ function.
9. ECOG performance status < 2 or Karnofsky or Lansky score > 60
Patient Exclusion Criteria:
1. Not pregnant or breast-feeding.
2. HIV positive.
3. No uncontrolled bacterial, viral, or fungal infection.
4. No previous allogeneic BMT (syngeneic BMT permissible).
5. Active extramedullary leukemia or known active CNS involvement by malignancy. Such
disease treated into remission is permitted.
Donor Inclusion Criteria:
1. Potential donors consist of:
- Unrelated donors
- Second-degree relatives
- First cousins
2. 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).
3. Meets institutional selection criteria and medically fit to donate.
4. 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:
1. Donor must not be HLA identical to the recipient.
2. Has not donated blood products to recipient.