Trial Information

Gemcitabine/Clofarabine/Busulfan and Allogeneic Transplantation for Aggressive Lymphomas

Study Drug Administration and Pharmacokinetic (PK) Testing:

The days before you receive your stem cells are called minus days, such as Day -2, Day -1.
The day you receive the stem cells is called Day 0. The days after you receive the stem
cells are called plus days, such as Day +1, Day +2.

Between Days -15 and -8, you will receive a low-level "test" dose of busulfan by vein over
about 45 minutes to 1 hour. Test doses are used to study how your body breaks down busulfan
and decide the dose of busulfan that you will receive. You may receive the test dose before
Day -8 as an outpatient in the clinic, or on Day -8 as an inpatient in the hospital.

Blood (about 1 teaspoon each time) will then be drawn for PK testing up to 11 times over the
11 hours after the busulfan test dose. PK testing measures the amount of study drug in the
body at different time points. The study staff will tell you more about the PK testing
schedule.

A heparin lock line will be placed in your vein before the PK testing to lower the number of
needle sticks needed for these draws. If for any reason it is not possible for the PK tests
to be performed, you will receive the standard dose of busulfan.

On Day -9 or Day -7, you will be admitted to the hospital and given fluids by vein to
hydrate you.

On Days -6 and -4, you will receive gemcitabine by vein over 40-180 minutes. The dose you
receive will be based on when you join the study. The length of time it takes to infuse the
gemcitabine will be based on when you join this study and the dose amount you are assigned.
Up to 6 dose levels of gemcitabine will be tested. Up to 3 participants will be enrolled at
each dose level. The first group of participants will receive the lowest dose level. Each
new group will receive a higher dose than the group before it, if no intolerable side
effects were seen. This will continue until the highest tolerable dose of gemcitabine is
found. After the highest dose is found, additional participants will be enrolled at that
dose. The number of patients in the group that receives the highest tolerable dose will
depend on how many have been enrolled in the other groups.

On Days -6 through -3, you will receive clofarabine by vein over 1 hour, followed by your
dose of busulfan by vein over 3 hours. If for any reason you could not have the PK tests
performed, you will receive the standard busulfan dose on these days.

On Days -3 through -1, if your stem cell donor is not related to you, you will receive
antithymocyte globulin (ATG) by vein over 4 hours each day. ATG is designed to weaken your
immune system in order to lower the risk that your body will reject the transplant. If your
stem cell donor is related to you, you will not receive this drug.

Beginning on Day -2, you will receive tacrolimus by vein over 24 hours every day until you
are able to take it by mouth. Tacrolimus is designed to weaken the immune system and lower
the risk of graft-versus-host-disease (GVHD - a reaction of the donor's immune cells against
your body). After you are able to take tacrolimus by mouth, you will take it every day for
about 6 months, or until the doctor thinks it is safe to stop.

On Day 0, you will receive the donor's stem cells by vein. The infusion will last anywhere
from about 30 minutes to several hours.

On Days +1, + 3, +6, and +11, you will receive methotrexate by vein over about 15 minutes.
Methotrexate is also designed to weaken the immune system and lower the risk of GVHD.

Starting 1 week after the transplant (Day +7), you will receive filgrastim (G-CSF) as an
injection under the skin 1 time each day until your blood cell levels return to normal.
Filgrastim is designed to make white blood cells grow, which may help to fight infections.

You may be given other standard drugs to help lower the risk of side effects. You may ask
the study staff for more information about how the drugs are given and their risks.

Study Visits:

Within 30 days of receiving the stem cells, you will have a positron emission tomography
(PET) scan to check the status of the disease.

About 4 weeks after the stem cell transplant:

- You will have a physical exam, including measurement of your height, weight, and vital
signs (blood pressure, heart rate, temperature, and breathing rate).

- You will be asked about how you are feeling and about any side effects you may be
having.

- You will be checked for possible reactions to the study treatment, including GVHD.

- Blood (about 4 tablespoons) will be drawn for routine tests, to see how the transplant
has taken, and to check the status of the disease.

Follow-Up Visits:

About 3, 6, and 12 months after the transplant, and then every 6 months for 4 more years:

- You will have a physical exam, including measurement of your vital signs.

- You will be asked about how you are feeling and about any side effects you may be
having.

- You will be checked for possible reactions to your treatment, including GVHD.

- Blood (about 4 tablespoons) will be drawn for routine tests, to see how well the
transplant has taken, and to check the status of the disease.

- At any point that your doctor thinks they are needed, you will have a bone marrow
aspiration and computed tomography (CT) and/or PET scans to check the status of the
disease. To collect a bone marrow aspirate, an area of the hip or other site is numbed
with anesthetic, and a small amount of bone marrow is withdrawn through a large needle.

The study staff will also stay in contact with your local doctor to find out if the disease
comes back and to check how you are doing.

Length of Treatment:

You will be on study for about 5 years. After 1 year, there is no study specific testing
you will be required to complete. Your transplant doctor will perform routine standard of
care follow-up that all patients receiving allogeneic stem cell transplantation receive.

You may be removed from the study early if the doctor thinks it is in your best interest, if
the disease gets worse or comes back, if intolerable side effects occur, if you have graft
failure (the transplanted cells do not grow), or if you are unable to follow study
directions.

If for any reason you want to leave the study early, you must talk to the study doctor. It
may be life-threatening to leave the study after you have started to receive the study drugs
but before you receive the stem cell transplant because your blood cell counts will be
dangerously low.

This is an investigational study. Gemcitabine and clofarabine are FDA approved and
commercially available for the treatment of lymphoma. Busulfan is FDA approved and
commercially available for use in stem cell transplantation. The combination of gemcitabine
given in combination with busulfan and clofarabine before an allogeneic stem cell transplant
is investigational.

Up to 30 patients will take part in this study. All will be enrolled at MD Anderson.