Zevalin Before Stem Cell Transplant in Treating Patients With Non-Hodgkin Lymphoma

PRIMARY OBJECTIVES:

I. To measure the response conversion (progressive disease \[PD\]/stable disease \[SD\] to partial response \[PR\] and complete response \[CR\]).

SECONDARY OBJECTIVES:

I. To assess the time to engraftment/chimerism. II. To assess the rate of acute and chronic graft-versus-host disease (GVHD). III. To assess toxicity. IV. To determine the overall survival. V. To investigate immune functional and phenotypic analysis. VI. To measure two year event free survival (EFS).

OUTLINE:

CONDITIONING REGIMEN: Patients receive rituximab intravenously (IV) on days -21 and 14, ibritumomab tiuxetan IV on day -14, TLI on days -11 to -7 and -4 to -1, and antithymocyte globulin IV over 4-6 hours on days -11 to -7. Patients also undergo TLI on days -11 to -7 and -4 to -1.

TRANSPLANT: Patients undergo allogeneic peripheral blood stem cell transplant (PBSCT) on day 0.

GVHD PROPHYLAXIS: Patients receive cyclosporine orally (PO) twice daily (BID) or IV on days -3 to 56 with taper to 6 months and mycophenolate mofetil PO BID or IV on days 0-28.

After completion of study treatment, patients are followed up periodically.

• rituximab (Biological), also known as IDEC-C2B8, Mabthera, Rituxan: Given IV
• ibritumomab tiuxetan (Biological), also known as Zevalin: Given IV
• anti-thymocyte globulin (Biological), also known as ATG, ATGAM, lymphocyte immune globulin, Thymoglobulin: Given IV
• total nodal irradiation (Radiation), also known as TLI, total lymphoid irradiation: Undergo TLI
• peripheral blood stem cell transplantation (Procedure), also known as PBPC transplantation, PBSC transplantation, peripheral blood progenitor cell transplantation, transplantation, peripheral blood stem cell: Undergo allogeneic peripheral blood stem cell transplant
• allogeneic hematopoietic stem cell transplantation (Procedure): Undergo allogeneic peripheral blood stem cell transplant
• cyclosporine (Drug), also known as cyclosporin, cyclosporin A, CYSP, Sandimmune: Given PO or IV
• mycophenolate mofetil (Drug), also known as Cellcept, MMF: Given PO or IV

Primary outcomes

• Response conversion rate (PD/SD to PR and CR) [Up to 60 days post-transplant]: Calculated along with 95% confidence intervals (CI). Logistic regression will be used to assess the impact of patient characteristics (e.g., low/high lactate dehydrogenase isoenzyme-3 \[LDH\] or immunologic correlates) on the response conversion rate.

Secondary outcomes

• Time to engraftment/chimerism [Up to 3 years]: Estimated using the method of Kaplan and Meier. Comparison of time-to-event endpoints by important subgroups of patients will be made using the logrank test. Cox (proportional hazards) regression will be used to evaluate multivariable predictive models of time-to-event outcomes when proper.
• Rate of acute GVHD [Up to day 730]
• Rate of chronic GVHD [Up to day 730]
• Overall survival [Up to day 730]: Estimated using the method of Kaplan and Meier. Comparison of time-to-event endpoints by important subgroups of patients will be made using the logrank test. Cox (proportional hazards) regression will be used to evaluate multivariable predictive models of time-to-event outcomes when proper.
• EFS [2 years]: Comparison of time-to-event endpoints by important subgroups of patients will be made using the logrank test. Cox (proportional hazards) regression will be used to evaluate multivariable predictive models of time-to-event outcomes when proper.
• Toxicities [Up to day 730]: Toxicities as measured by National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events v4.0

Sex: All, ages: 19 Years to 75 Years

Inclusion Criteria:

* Histologically or cytologically confirmed relapsed cluster of differentiation (CD)20+ non-Hodgkin's lymphoma (NHL) (included in this category are follicular grade I, II, III, marginal zone, mantle cell, diffuse large B cell, small lymphocytic lymphoma) and CD20+ Hodgkin's disease for which standard curative therapy does not exist or is no longer effective
* Patients must have had at least one prior chemotherapeutic regimen; steroids alone and local radiation do not count as regimens; radiotherapy must have been completed at least 4 weeks prior to entry into the study; Rituxan alone does not count as a regimen; however, Bexxar or Zevalin (ibritumomab tiuxetan) do and patients must have completed radioimmunotherapy (RIT) > 12 months prior to enrollment
* Karnofsky performance status of ≥ 60%
* Life expectancy of greater than 3 months
* Total bilirubin within institutional normal limits
* Aspartate aminotransferase (AST) (serum glutamic oxaloacetic transaminase \[SGOT\])/alanine aminotransferase (ALT) (serum glutamate pyruvate transaminase \[SGPT\]) =< 2.5 times institutional upper limit of normal
* Creatinine within normal institutional limits OR creatinine clearance >= 60 ml/min/1.73 m\^2 for patients with creatinine levels above institutional normal
* Blood counts no restrictions
* Patients who had anything less than a CR (PR, SD or progressive disease) to their last salvage regimen
* Ability to understand and the willingness to sign a written informed consent document
* Patients fit for non-myeloablative transplantation or best treatment that have an available matched (9/10 or better) related or unrelated donor
* Patients who are considered rituximab refractory (defined as progression within 6 months of their last rituximab-containing regimen)

Exclusion Criteria:

* Patients who have had chemotherapy or radiotherapy within 4 weeks (6 weeks for nitrosoureas or mitomycin C) prior to entering the study, rituximab within three months (unless there is evidence of progression), or those who have not recovered from adverse events due to agents administered more than 4 weeks earlier are excluded; this does not include the use of steroids which may continue until two days prior to enrollment
* Patients may not be receiving any other investigational agents
* Failure to obtain insurance/payment authorization for Zevalin, unless the subject agrees to cover the cost
* Patients with known active brain metastases, other neurological disorders/dysfunction or a history of seizure disorder, or other neurological dysfunction should be excluded from this clinical trial because of their poor prognosis
* Patients who have an uncontrolled infection (presumed or documented) with progression after appropriate therapy for greater than one month
* Patients with symptomatic coronary artery disease, uncontrolled congestive heart failure; left ventricular ejection fraction is not required to be measured, however if it is measured, patient is excluded if ejection fraction is < 30%
* Patients requiring supplementary continuous oxygen; diffusion capacity of the lung of carbon monoxide (DLCO) is not required to be measured, however if it is measured, patient is excluded if DLCO < 35%
* Patients with clinical or laboratory evidence of liver disease will be evaluated for the cause of liver disease, its clinical severity in terms of liver function and histology, and for the degree of portal hypertension
* Patients with any of the following liver function abnormalities will be excluded:

  * Fulminant liver failure
  * Cirrhosis with evidence of portal hypertension or bridging fibrosis
  * Alcoholic hepatitis
  * Esophageal varices
  * A history of bleeding esophageal varices
  * Hepatic encephalopathy
  * Uncorrectable hepatic synthetic dysfunction evidenced by prolongation of the prothrombin time
  * Ascites related to portal hypertension
  * Chronic viral hepatitis with total serum bilirubin > 3 mg/dL
  * Symptomatic biliary disease
* Pregnant women are excluded from this study
* Human immunodeficiency virus (HIV)-positive patients

• Joseph Tuscano, Principal investigator, UC Davis Comprehensive Cancer Center