Dendritic Cell/Myeloma Fusion Vaccine for Multiple Myeloma (BMT CTN 1401)

• ClinicalTrials.gov Identifier: NCT02728102
• Recruitment Status: Completed
• First Posted: April 5, 2016
• Results First Posted: September 9, 2021
• Last Update Posted: December 27, 2023
• Sponsor: National Heart, Lung, and Blood Institute (NHLBI)
• Collaborators: Blood and Marrow Transplant Clinical Trials Network; National Cancer Institute (NCI); National Marrow Donor Program
• Information provided by (Responsible Party): National Heart, Lung, and Blood Institute (NHLBI)

Study Description

Brief Summary:

The study is designed as a Phase II, multicenter trial of vaccination with Dendritic cell/myeloma fusions with granulocyte macrophage colony-stimulating factor (GM-CSF) adjuvant plus lenalidomide maintenance therapy versus maintenance therapy alone or with GM-CSF following autologous transplant as part of upfront treatment of multiple myeloma (MM). It is hypothesized that the dendritic cell myeloma vaccine will result in improved response in patients with multiple myeloma after autologous Hematopoietic Cell Transplant (HCT).

Condition or disease	Intervention/treatment	Phase
Multiple Myeloma	Procedure: Tumor Cell Collection; Procedure: Autologous Stem Cell Transplant; Drug: Melphalan; Procedure: Leukapheresis; Biological: Myeloma vaccine; Drug: GM-CSF; Drug: Lenalidomide	Phase 2

Detailed Description:

The study is a three-arm, phase II randomized, open-labeled clinical trial that randomizes patients to vaccination with Dendritic Cell (DC)/myeloma fusions/GM-CSF plus lenalidomide maintenance therapy or lenalidomide maintenance therapy with or without GM-CSF following autologous transplant as part of upfront treatment for patients diagnosed with multiple myeloma. Patients are randomized approximately 2 months post transplant and will begin maintenance lenalidomide between day 90 and 100. The primary objective of this randomized trial is to compare the proportion of patients alive and in complete response (defined as CR or sCR) at one year post transplant between patients receiving DC/myeloma vaccine/GM-CSF with lenalidomide maintenance therapy to those receiving lenalidomide maintenance therapy with or without GM-CSF.

Study Design

• Study Type: Interventional (Clinical Trial)
• Actual Enrollment: 203 participants
• Allocation: Randomized
• Intervention Model: Parallel Assignment
• Masking: None (Open Label)
• Primary Purpose: Treatment
• Official Title: Phase II Multicenter Trial of Single Autologous Hematopoietic Cell Transplant Followed by Lenalidomide Maintenance for Multiple Myeloma With or Without Vaccination With Dendritic Cell/Myeloma Fusions (BMT CTN 1401)
• Actual Study Start Date: July 2016
• Actual Primary Completion Date: June 30, 2020
• Actual Study Completion Date: December 9, 2022

Arms and Interventions

Arm	Intervention/treatment
Experimental: Lenalidomide, vaccine, and GM-CSF; Patients will undergo tumor cell collection and autologous stem cell transplant with melphalan. Patients will undergo leukapheresis and then will receive maintenance lenalidomide with myeloma vaccine and GM-CSF.	Procedure: Tumor Cell Collection; Patients will undergo aspiration of 30 mL of bone marrow from which myeloma cell preparations will be generated. Myeloma cells will be isolated and frozen for subsequent vaccine generation for patients randomized to the vaccine arm (randomization occurs after transplant and recovery).; Procedure: Autologous Stem Cell Transplant; Patients will receive an autologous graft with a minimum cell dose of 2.0 x 10^6 CD34+ cells/kg patient actual body weight per autologous transplantation.; Drug: Melphalan; Autologous hematopoietic cell transplant will be done with high-dose melphalan of 200mg/m^2 at the schedule and timing according to institutional practices.; Other Name: Alkeran; Procedure: Leukapheresis; Blood samples will be collected through a catheter in the neck or chest and leukapheresis will be performed using standard clinical procedures.; Biological: Myeloma vaccine; The target dose is 3 x 10^6 fusion cells per vaccine. A minimum of 3 x 10^6 total fusion cells will be required to proceed with vaccine administration. Patients who have <3 x 10^6 total fusion cells will not proceed with vaccination. Patients will receive the DC/MM fusion vaccine on day 1 of cycles 2, 3, and 4 of lenalidomide maintenance. Vaccine will be administered by subcutaneous injection in the upper thigh.; Other Names: Dendritic cell fusion vaccine; DC/MM fusion vaccine; Drug: GM-CSF; 100 ug GM-CSF will be given subcutaneously in the upper thigh and daily for a total of 4 days of each cycle.; Other Names: Granulocyte macrophage colony-stimulating factor; Leukine; Drug: Lenalidomide; Maintenance therapy with lenalidomide will begin between 90 and 100 days after stem cell infusion. Lenalidomide will be administered initially at a dose of 10 mg per day continuously. Cycle duration during maintenance therapy is 28 days. Patients will continue lenalidomide for two years from initiation of therapy.; Other Name: Revlimid™
Active Comparator: Lenalidomide and GM-CSF; Patients will undergo tumor cell collection and autologous stem cell transplant with melphalan. Patients will receive maintenance lenalidomide with GM-CSF.	Procedure: Tumor Cell Collection; Patients will undergo aspiration of 30 mL of bone marrow from which myeloma cell preparations will be generated. Myeloma cells will be isolated and frozen for subsequent vaccine generation for patients randomized to the vaccine arm (randomization occurs after transplant and recovery).; Procedure: Autologous Stem Cell Transplant; Patients will receive an autologous graft with a minimum cell dose of 2.0 x 10^6 CD34+ cells/kg patient actual body weight per autologous transplantation.; Drug: Melphalan; Autologous hematopoietic cell transplant will be done with high-dose melphalan of 200mg/m^2 at the schedule and timing according to institutional practices.; Other Name: Alkeran; Drug: GM-CSF; 100 ug GM-CSF will be given subcutaneously in the upper thigh and daily for a total of 4 days of each cycle.; Other Names: Granulocyte macrophage colony-stimulating factor; Leukine; Drug: Lenalidomide; Maintenance therapy with lenalidomide will begin between 90 and 100 days after stem cell infusion. Lenalidomide will be administered initially at a dose of 10 mg per day continuously. Cycle duration during maintenance therapy is 28 days. Patients will continue lenalidomide for two years from initiation of therapy.; Other Name: Revlimid™
Active Comparator: Maintenance Lenalidomide; Patients will undergo tumor cell collection and autologous stem cell transplant with melphalan. Patients will receive maintenance lenalidomide.	Procedure: Tumor Cell Collection; Patients will undergo aspiration of 30 mL of bone marrow from which myeloma cell preparations will be generated. Myeloma cells will be isolated and frozen for subsequent vaccine generation for patients randomized to the vaccine arm (randomization occurs after transplant and recovery).; Procedure: Autologous Stem Cell Transplant; Patients will receive an autologous graft with a minimum cell dose of 2.0 x 10^6 CD34+ cells/kg patient actual body weight per autologous transplantation.; Drug: Melphalan; Autologous hematopoietic cell transplant will be done with high-dose melphalan of 200mg/m^2 at the schedule and timing according to institutional practices.; Other Name: Alkeran; Drug: Lenalidomide; Maintenance therapy with lenalidomide will begin between 90 and 100 days after stem cell infusion. Lenalidomide will be administered initially at a dose of 10 mg per day continuously. Cycle duration during maintenance therapy is 28 days. Patients will continue lenalidomide for two years from initiation of therapy.; Other Name: Revlimid™

Outcome Measures

Primary Outcome Measures :

1. Percentage of Participants With 1-year Response Rate of CR/sCR [ Time Frame: 1 year ]
   The primary objective of this randomized trial is to compare the proportion of patients alive and in complete response (CR or sCR) at one year post transplant between patients receiving DC/myeloma vaccine/GM-CSF with lenalidomide maintenance therapy to those receiving lenalidomide maintenance therapy with or without GM-CSF. Complete Response (CR) is defined to require all the followings: Absence of the original monoclonal paraprotein in serum and urine by routine electrophoresis and by immunofixation; Less than 5% plasma cells in a bone marrow aspirate and also on trephine bone biopsy, if biopsy is performed; No increase in size or number of lytic bone lesions on radiological investigations; Disappearance of soft tissue plasmacytomas. Stringent Complete Response (sCR) is defined to require all the followings in addition to CR: Normal free light chain ratio (FLC); Absence of clonal cells in bone marrow by immunohistochemistry or immunofluorescence.

Secondary Outcome Measures :

1. Participants Response to Treatment [ Time Frame: 6 months, 1 year, and 2 years post-transplant and at Cycles 3(Day 57), 6(Day 141), 9(Day 225), 12(Day 309), 15 (Day 393), 18(Day 477), 21(Day 561) and 24(Day 654) of maintenance therapy ]
   A participant's disease status is evaluated based on the International Uniform Response Criteria per protocol. Before disease progression (PD), all disease classifications including stringent complete response (sCR), complete response (CR), very good partial remission (VGPR), partial response (PR), stable disease (SD) are relative to participant's disease status at study entry. Disease status is 'Not Evaluable' when disease assessment is not required, or disease status is missing.
2. Percentage of Participants With Myeloma Progression of Vaccine and Non-vaccine Arms [ Time Frame: 2 years ]
   The event for this endpoint is defined as disease progression from CR/sCR or progressive disease for participants not in CR/sCR, or initiation of off protocol antimyeloma therapy. The cumulative incidence of myeloma progression will be compared between the vaccine arm and the combined non-vaccine arms using Gray's test and treating death (without documentation of disease progression) as a competing risk. Participants alive without disease progression at last observation will be censored at the date of last contact.
3. Percentage of Participants With Myeloma Progression in Pairwise Analysis [ Time Frame: 2 years ]
   This is the pairwise comparison for percentage of participants with Myeloma Progression. The event for this endpoint is defined as disease progression from CR/sCR or progressive disease for participants not in CR/sCR, or initiation of off protocol antimyeloma therapy. The cumulative incidence of myeloma progression will be compared between the vaccine arm, lenalidomide/GM-CSF arm and lenalidomide alone arm using Gray's test and treating death (without documentation of disease progression) as a competing risk. Participants alive without disease progression at last observation will be censored at the date of last contact.
4. Percentage of Participants With Treatment-related Mortality (TRM) [ Time Frame: 2 years ]
   TRM is defined as death occurring in a patient from causes other than disease relapse or progression. Disease progression is the competing event for TRM. Patients alive without disease progression at last contact are considered censored for this event. TRM from time of randomization will be compared between vaccine and no-vaccine arms combined starting at time of randomization.
5. Percentage of Participants With Progression-Free Survival [ Time Frame: 2 years ]
   Death or disease progression will be considered as events for this endpoint. The time to event will be calculated as time from randomization to disease progression, death, initiation of non-protocol anti-myeloma therapy, loss to follow-up or the end of the study, whichever comes first. The Kaplan-Meier estimator will be constructed for each treatment arm. Progression-free survival was compared between the vaccine and the combined non-vaccine arms using the log-rank test.
6. Percentage of Participants With Progression-Free Survival in Pairwise Analysis [ Time Frame: 2 year ]
   This is the pairwise comparison for percentage of participants with Progression-Free Survival. Death or disease progression will be considered as events for this endpoint. The time to event will be calculated as time from randomization to disease progression, death, initiation of non-protocol anti-myeloma therapy, loss to follow-up or the end of the study, whichever comes first. The Kaplan-Meier estimator will be constructed for each treatment arm. Progression-free survival was compared between the vaccine arm, lenalidomide/GM-CSF arm and lenalidomide alone arm.
7. Percentage of Participants With Overall Survival [ Time Frame: 2 years ]
   Death from any cause is considered as events for this endpoint. The time to event is calculated as time from randomization to death, loss to follow-up or the end of the study, whichever comes first. Patients alive at the time of last observation are considered censored. The Kaplan-Meier estimator will be constructed for each treatment arm. Overall survival are compared between the vaccine and the combined non-vaccine arms from time of randomization.
8. Percentage of Participants With Overall Survival in Pairwise Analysis [ Time Frame: 2 years ]
   This is the pairwise comparison for percentage of participants with Overall Survival. Death from any cause is considered as events for this endpoint. The time to event is calculated as time from randomization to death, loss to follow-up or the end of the study, whichever comes first. Patients alive at the time of last observation are considered censored. The Kaplan-Meier estimator will be constructed for each treatment arm. Overall survival are compared between the vaccine arm, lenalidomide/GM-CSF arm and lenalidomide alone arm from time of randomization.
9. Number of Grade ≥ 3 Toxicities [ Time Frame: 2 years ]
   Toxicities are evaluated using NCI CTCAE version 4.0 at pre-maintenance initiation and during maintenance therapy monthly for the first 4 cycles and then at cycles 6, 9, 15, 21, 24, which correspond to Day 1, 29, 57, 85, 141, 225, 393, 561, and 645 post maintenance initiation. All Grade ≥ 3 toxicities will be tabulated for treatment arms. Toxicities are categorized by organ system according to the CTCAE. Toxicities that involve multiple questions per organ system are combined in one category.
10. Participants With Grade ≥ 3 Toxicities [ Time Frame: 2 years ]
    Toxicities are evaluated using NCI CTCAE version 4.0 at pre-maintenance initiation and during maintenance therapy monthly for the first 4 cycles and then at cycles 6, 9, 15, 21, 24, which correspond to Day 1, 29, 57, 85, 141, 225, 393, 561, and 645 post maintenance initiation. The number of participants experiencing Grade ≥ 3 toxicity are displayed for the vaccine and non-vaccine arms separately. The proportion of participants experiencing Grade ≥ 3 toxicity are compared between the vaccine and non-vaccine arms combined.
11. Number of Grade 2 and 3 Infections [ Time Frame: 2years ]
    Grade 2 and 3 infections, as defined by the BMT CTN Technical MOP, occurring after randomization will be reported. The incidence of definite and probable viral, fungal and bacterial infections will be tabulated for each patient.
12. Percentage of Participants With Grade 2 and 3 Infections [ Time Frame: 2 years ]
    Grade 2 and 3 infections, as defined by the BMT CTN Technical MOP, are reported on the study. The cumulative incidence of infections post randomization, treating death as a competing risk, were compared between the vaccine and the combined non-vaccine groups using the Gray's test.
13. Percentage of Participants With Grade 2 and 3 Infections in Pairwise Analysis [ Time Frame: 2 years ]
    This is the pairwise comparison for percentage of participants with Grade 2 and 3 infections. Grade 2 and 3 infections, as defined by the BMT CTN Technical MOP, are reported on the study. The cumulative incidence of infections post randomization, treating death as a competing risk, were compared between the vaccine arm, lenalidomide/GM-CSF arm and lenalidomide alone arm using the Gray's test.
14. Number of Participants With Minimal Residual Disease (MRD) [ Time Frame: Pre-randomization, Post-randomization at Cycle 9 ]
    Minimal residual disease (MRD) is defined as the presence of malignant plasma cells detected by multicolor flow cytometry among patients who are in complete remission. Multichannel flow cytometry will be used to establish MRD based on the presence of malignant plasma cells that are CD45 (-/dim), CD38+, CD138+, CD19-, CD56+ kappa or lambda restricted. The number of patients with MRD negative (MRD-) are described using frequencies at pre-randomization and 9th cycle post-randomization and compared between the vaccine arm with the no-vaccine arms combined.

Eligibility Criteria

• Ages Eligible for Study: 18 Years to 70 Years (Adult, Older Adult)
• Sexes Eligible for Study: All
• Accepts Healthy Volunteers: No

Criteria

Initial Inclusion Criteria:

1. Patients must be considered transplant eligible by the treating physician at time of study entry.
2. Patients must meet the criteria for symptomatic multiple myeloma prior to initiating systemic anti-myeloma treatment.
3. Age >18 years and ≤ 70 years at the time of enrollment
4. Karnofsky Performance status of ≥ 70%
5. Patients must have > 20% plasma cells in the bone marrow aspirate differential <60 days prior to enrollment. The required bone marrow evaluation will need to be repeated for patients who received more than 1 cycle of anti-myeloma therapy (corticosteroid with or without other anti-myeloma agents)
6. Patients must have received ≤ 1 cycles of systemic anti-myeloma therapy.
7. Renal: Creatinine clearance of ≥ 40 mL/min, estimated or calculated.

Initial Exclusion Criteria:

1. Patients with a prior autologous or allogeneic HCT
2. Patients with purely non-secretory MM [absence of a monoclonal protein (M protein) in serum as measured by electrophoresis and immunofixation and the absence of Bence Jones protein in the urine defined by use of conventional electrophoresis and immunofixation techniques and the absence of involved serum free light chain >100 mg/L]. Patients with light chain MM detected in the serum by free light chain assay are eligible.
3. Patients with Plasma Cell Leukemia
4. Patients with disease progression prior to enrollment
5. Patients seropositive for the human immunodeficiency virus (HIV).
6. Myocardial infarction within 6 months prior to enrollment or New York Heart Association (NYHA) Class III or IV heart failure, uncontrolled angina, severe uncontrolled ventricular arrhythmias, or electrocardiographic evidence of acute ischemia or active conduction system abnormalities. Prior to study entry, any ECG abnormality at screening will be documented by the investigator as not medically relevant.
7. Patients with active clinically significant autoimmune disease, defined as a history of requiring systemic immunosuppressive therapy and at ongoing risk for potential disease exacerbation. Patients with a history of autoimmune thyroid disease, asthma, or limited skin manifestations are potentially eligible.
8. Patients receiving other investigational immunotherapy or anti-myeloma drugs within 14 days before enrollment.
9. Patients with prior malignancies except resected basal cell carcinoma or treated cervical carcinoma in situ. Cancer treated with curative intent < 5 years prior to enrollment will not be allowed unless approved by the Protocol Officer or one of the Protocol Chairs. Cancer treated with curative intent > 5 years prior to enrollment is allowed.
10. Female patients who are pregnant (positive beta-HCG) or breastfeeding.
11. Females of childbearing potential (FCBP) or men who have sexual contact with FCBP unwilling to use contraceptive techniques (Appendix D) during the length of lenalidomide maintenance therapy.
12. Patients who have received mid-intensity melphalan (>50 mg IV) as part of prior therapy.
13. Prior organ transplant requiring immunosuppressive therapy.
14. Patients who previously received lenalidomide and have experienced toxicities resulting in treatment discontinuation.
15. Patients who experienced thromboembolic events while on full anticoagulation during prior therapy with lenalidomide or thalidomide.
16. Patients unwilling to take deep vein thrombosis (DVT) prophylaxis.
17. Patients unable or unwilling to provide informed consent.
18. Patients unable or unwilling to return to the transplant center for their assigned treatments.

Randomization Inclusion Criteria:

1. Patient received transplant < 12 months of enrollment onto BMT CTN 1401.
2. No disease progression since initiation of systemic anti-myeloma therapy as determined within seven days of randomization/enrollment.
3. Received an autologous cell transplant with melphalan 200mg/m^2 with a minimum cell dose of 2x10^6 CD34+ cells/kg (actual body weight).
4. Mucositis and gastrointestinal symptoms resolved, off hyperalimentation and intravenous hydration.
5. No evidence of uncontrolled infection requiring systemic therapy. Patients who completed treatment for an infection but are continuing antibiotics, anti-viral, or anti-fungal therapy for prophylaxis are eligible to continue on protocol.
6. Platelet count ≥75,000/mm^3 (without transfusion in previous 7 days).
7. Absolute neutrophil count (ANC) ≥ 1,500/mm^3 without filgrastim administration within 7 days, or pegfilgrastim within 14 days of measurement.
8. Hepatic: bilirubin < 2x the upper limit of normal and alanine aminotransferase (ALT) and aspartate aminotransferase (AST) < 2.5x the upper limit of normal. (Patients who have been diagnosed with Gilbert's Disease are allowed to exceed the defined bilirubin value of 2x the upper limit of normal)
9. Renal: Creatinine clearance of ≥ 40 mL/min, estimated or calculated. Patients with creatinine clearance ≥30 but <40 will be considered with review/approval from the protocol chairs or officer if the cause of renal insufficiency is associated with multiple myeloma.
10. All study participants must be registered into the mandatory Revlimid REMs program, and be willing and able to comply with the requirements.
11. Females of childbearing potential (FCBP) as defined in section 2.7.1.1 must have a negative serum pregnancy test with a sensitivity of at least 50 mIU/mL within 10 - 14 days prior to and again within 24 hours of prescribing lenalidomide (prescriptions must be filled within 7 days)
12. FCBP must either commit to abstain continuously from sexual intercourse or use TWO acceptable methods of birth control, one highly effective method and one additional effective method AT THE SAME TIME, at least 4 weeks before she starts taking lenalidomide, during therapy, during dose interruptions, and continuing for 4 weeks following discontinuation of lenalidomide.
13. FCBP must agree to ongoing pregnancy testing as required by the Revlimid REMs program.
14. Men must agree to use a latex condom during sexual contact with females of child bearing potential even if they have had a successful vasectomy while taking lenalidomide, during dose interruptions and for 28 days after discontinuing lenalidomide.
15. Patients must be willing to receive DVT prophylaxis.

Contacts and Locations

Locations

United States, California

University of California, San Francisco

San Francisco, California, United States, 94143

United States, Georgia

Emory University

Atlanta, Georgia, United States, 30322

United States, Maryland

University of Maryland/Greenebaum Cancer Center

Baltimore, Maryland, United States, 21201

United States, Massachusetts

Beth Israel Deaconess Medical Center/Dana Farber Cancer Institute

Boston, Massachusetts, United States, 02215

United States, Minnesota

University of Minnesota

Minneapolis, Minnesota, United States, 55455

United States, Nebraska

University of Nebraska Medical Center

Omaha, Nebraska, United States, 68198-7680

United States, New York

Roswell Park Cancer Institute

Buffalo, New York, United States, 14263

Mount Sinai Medical Center

New York, New York, United States, 10029

Memorial Sloan-Kettering Cancer Center

New York, New York, United States, 10065

United States, Ohio

University Hospitals of Cleveland/Case Western

Cleveland, Ohio, United States, 44106

Ohio State University/Arthur G. James Cancer Hospital

Columbus, Ohio, United States, 43210

United States, Texas

University of Texas/MD Anderson Cancer Center

Houston, Texas, United States, 77030

United States, Washington

Fred Hutchinson Cancer Research Center

Seattle, Washington, United States, 98109-1024

United States, Wisconsin

University of Wisconsin Hospital & Clinics

Madison, Wisconsin, United States, 53792

Medical College of Wisconsin

Milwaukee, Wisconsin, United States, 53211

Sponsors and Collaborators

National Heart, Lung, and Blood Institute (NHLBI)

Blood and Marrow Transplant Clinical Trials Network

National Cancer Institute (NCI)

National Marrow Donor Program

Investigators

• Study Director: Mary Horowitz, MD; Center for International Blood and Marrow Transplant Research

  Study Documents (Full-Text)

Documents provided by National Heart, Lung, and Blood Institute (NHLBI):

Study Protocol  [PDF] July 24, 2018

Statistical Analysis Plan  [PDF] June 7, 2019

Informed Consent Form  [PDF] July 24, 2018

More Information

Additional Information:

National Marrow Donor Program 

• Responsible Party: National Heart, Lung, and Blood Institute (NHLBI)
• ClinicalTrials.gov Identifier: NCT02728102
• Other Study ID Numbers: BMT CTN 1401; U01HL069294 ( U.S. NIH Grant/Contract )
• First Posted: April 5, 2016
• Results First Posted: September 9, 2021
• Last Update Posted: December 27, 2023
• Last Verified: December 2023

Individual Participant Data (IPD) Sharing Statement:

• Plan to Share IPD: Yes
• Plan Description: Results will be published in a manuscript and supporting information submitted to NIH BioLINCC (including data dictionaries, case report forms, data submission documentation, documentation for outcomes dataset, etc where indicated).
• Supporting Materials: Study Protocol; Informed Consent Form (ICF)
• Time Frame: Within 6 months of official study closure at participating sites.
• Access Criteria: Available to the public
• URL: https://biolincc.nhlbi.nih.gov/home/

Keywords provided by National Heart, Lung, and Blood Institute (NHLBI):

Multiple Myeloma; Lenalidomide; Maintenance Therapy; Hematologic Disorders; Vaccine; GM-CSF; Transplant; Anti-Myeloma Agents

Additional relevant MeSH terms:

Multiple Myeloma; Neoplasms, Plasma Cell; Neoplasms by Histologic Type; Neoplasms; Hemostatic Disorders; Vascular Diseases; Cardiovascular Diseases; Paraproteinemias; Blood Protein Disorders; Hematologic Diseases; Hemorrhagic Disorders; Lymphoproliferative Disorders; Immunoproliferative Disorders; Immune System Diseases; Lenalidomide; Melphalan; Molgramostim; Vaccines; Sargramostim; Immunologic Factors; Physiological Effects of Drugs; Angiogenesis Inhibitors; Angiogenesis Modulating Agents; Growth Substances; Growth Inhibitors; Antineoplastic Agents; Antineoplastic Agents, Alkylating; Alkylating Agents; Molecular Mechanisms of Pharmacological Action; Myeloablative Agonists