Haploidentical Donor Hematopoietic Progenitor Cell and Natural Killer Cell Transplantation With a TLI Based Conditioning Regimen in Patients With Hematologic Malignancies
Phase: PHASE2
Conditions: Leukemia, Lymphoma
Sponsor: St. Jude Children's Research Hospital

 
Revision 5.1, dated: 06/13/2018  
 
IRB Approval date: 10/11/2018  
 
Protocol document date: 09/06/2018  
  
  
  
St. Jude Children's Research Hospital  
HAPNK1  
Initial version, dated:  10/18/2012 (IRB approved: 03/04/2013) Activated: April 10, 2013  
Revision 0.1, dated 03/29/2013 (IRB Approved: 04/23/2013) Activated: 05/02/2013  
Revision 0.2, dated 05/02/13 (IRB Approved: 05/08/2013) Activated: 05/31/2013  
Amendment 1.0, dated 07/03/13 (IRB Approved: 09/19/13) Activated: 09/25/13  
Revision 1.1, dated 10/31/13 (IRB Approved: 1/6/14) Activated: January 14, 2014  
Revision 1.2, dated 09/23/14 (IRB Approved: 10/23/14) Activated: November 3, 2014  
Amendment 2.0, dated 8/17/15 (IRB Approved: 12/7/15) Activated: December 18, 2015  
Amendment 3.0, dated 03/16/16 (IRB Approved:07/18/16) Activated: Aug.23, 2016  
Amendment 4.0, dated 01/10/17 (IRB approved: 03/07/17) Activated: April 7, 2017  
Un-numbered Revision, dated: 11/17/2017 (IRB Approved: 11/17/2017) 
Amendment 5.0, dated 03/13/18 (IRB Approved: 5/8/2018) Activated: May 17, 2018 
Revision 5.1, dated 06/13/2018 (IRB Approved: 10/11/2018) Activated: 10/31/2018  
HAPLOIDENTICAL DONOR HEMATOPOIETIC PROGENITOR CELL AND NATURAL 
KILLER CELL TRANSPLANTATION WITH A TLI BASED CONDITIONING REGIMEN IN 
PATIENTS WITH  
HEMATOLOGIC MALIGNANCIES 
IDE #15422 
Principal Investigator 
Brandon M. Triplett, MD1 
Co-Investigators  
Renee Madden, MD  
Guolian Kang, PhD 3  
Julia Hurwitz, PhD5  
Ashok Srinivasan, MD1  
Ewelina Mamcarz, MD1  
Paul Thomas, PhD6  
Thomas Merchant, DO, PhD2  
William Janssen, PhD1  
Amr Qudeimat, MD1  
Shane Cross, PharmD4  
Aimee Talleur, MD1  
Ben Youngblood, PhD6  
Anusha Sunkara, MS3  
Paulina Velasquez, MD1 
Akshay Sharma, MD1 
Department of Bone Marrow Transplantation and Cellular Therapy1  
Division of Radiation Oncology, Department of Radiological Sciences2 
Department of Biostatistics3  
Department of Pharmaceutical Sciences4 
Department of Infectious Diseases5 
Department of Immunology6 
St. Jude Children’s Research Hospital 
262 Danny Thomas Place 
Memphis, TN  38105 
(901) 595-3300 
 This is a confidential research document.  No information may be extracted without permission of the principal investigator. 
 

 
Revision 5.1, dated: 06/13/2018  
 
IRB Approval date: 10/11/2018  
 
Protocol document date: 09/06/2018  
  
  
  
TABLE OF CONTENTS  
Study Summary  
1.0       Objectives……………………………………………...……………………………….. 
1  
            1.1       Primary Objectives…………………………………………………..…………………  
1  
  
1.2  
Secondary Objectives……………………………………………….………………….  
1  
  
1.3  
Exploratory Objectives…………………………………………….…………………..  
1  
2.0  
Background and Rationale…………………………..…………………………………  
1  
  
2.1  
Overview……………………………………………………………………………….  
1  
  
2.2  
Indications for HCT and need for alternative donors …………………………………..  
2  
            2.3       Haploidentical HCT……………………………………………………………………..  
2  
  
2.4  
Rationale for immunomagnetic T cell depletion of hematopoietic progenitor cell graft.  
4  
            2.5       Rationale for the reduced intensity regimen……………………………………………  
7  
  
2.6  
Rationale for the therapeutic NK cell graft…………………………………………….  
8  
  
2.7  
Minimal residual disease……………………………………………………………….  
9  
  
2.8    Rationale for the present study………………………………………………………… 
10 
            2.9       Experience with GVHD prior to amendment 2.0 ………………………………………     10  
3.0  
Protocol Eligibility Criteria……………………………………………………………..  11  
  
3.1  
Inclusion criteria for transplant recipients ……………………………………………..  
11  
  
3.2  
Inclusion criteria for haploidentical donors ……………………………………………  13  
3.3  
Gender and minorities…………………………………………………………………  
13  
4.0  
Treatment Plan…….………………………………………………………………………..  
14  
            4.1       Preparative regimen………………………………………….………………………..  
14  
  
4.2  
Donor selection………………………………………………………………………..  
16 
  
4.3  
Donor mobilization and graft collections …………………………………………….  
17  
            4.4       Graft preparations……………………………………………………...………………  
18  
            4.5       Additional progenitor cell graft administration ……………………………...………..  
20  
  
4.6  
Donor lymphocyte infusions………………………………………………………….  
20  
  
4.7  
Quality assurance of cellular products ………………………………………………..  
22  
5.0  
Medication and Device Information………………………………….………… 
23  
  
5.1  
Medications.…………………….…………………………………..………………..…  23  

 
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5.2  
CliniMACSTM System…………………………….…..………………….…………….  
30  
6.0  
Required Observations and Evaluations…………………………..…………… 
 31  
  
6.1  
Pre/peri/post-transplant and long-term evaluations …………………………………….  31  
  
6.2  
Long-term follow-up evaluations…………………………..…………………………..  
31  
  
6.3  
Evaluation for chimerism and engraftment ………………………………………..  
31  
  
6.4  
Evaluation for immune reconstitution …………………………………….………….  
32  
  
6.5  
General viral surveillance………………..…………………………………………….  
32  
  
6.6  
Minimal residual disease evaluations ………………………………………………….  
32  
  
6.7  
Research tests on haploidentical donor …………..…………………………………….  33  
7.0  
Evaluation Criteria…………………...………………………………………… 
 33  
  
7.1  
Adverse event monitoring……………………………………………………………..  
33  
  
7.2  
GVHD diagnosis and grading…………………………………………………………  
33  
  
7.3  
Performance Status…………………………………………………………………….  
34  
  
7.4  
Hematologic recovery………………………………………………………………….  
34  
  
7.5  
Graft failure……………………………………………………………………………..  35  
  
7.6  
Chimerism………………………………………………………………………………  35  
8.0  
Off-Study Criteria………………………………………………………………………  
35  
  
8.1  
Recipient criteria………………………………………………………………………..  35  
  
8.2  
Additional notes………………………………………………………………………..  
35  
  
8.3  
Donor criteria…………………………………………………………………………..  
36  
9.0  
Reporting Criteria and Continuing Review……………………………………………..  
36  
  
9.1  
Reporting Adverse Experiences and Deaths to St. Jude IRB ………………………  
36  
  
9.2  
Reporting to St. Jude institutional biosafety committee ………………………………  
38  
  
9.3  
Reporting to FDA………………………………………………………………………  
38  
  
9.4  
Reporting to St. Jude office of regulatory affairs ……………………………………..  
39  
  
9.5  
Continuing review reports……………………………………………………………..  
39 
  
9.6  
Data submission to Miltenyi Biotec……………………………………………………  
39  
9.7  
Reporting to the CIBMTR…………………………………………………………………  39  
10.0  Statistical Considerations………………………………………………….……………... 40  
  
10.1  Statistical design and analysis for primary objective and stopping rules ……..……….  
40  

 
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10.2  Statistical analysis for secondary objectives ……………………………….………….  
45  
  
10.3  Analysis for exploratory objectives…………………………………….………………  45  
11.0  
Data Acquisition and Quality Assurance Monitoring ……………..……….……………  46  
  
11.1  Enrollment on study….…………………………………………………………………  46  
  
11.2  Data submission ……………………………………………………………………….  
46  
  
11.3  Quality assurance monitoring…………………………………………………………..  
46  
12.0  
Obtaining Informed Consent…………………………………………………………………..  
47  
13.0  
References………………………………………………………………………………………  48  
A 
Appendix A……………………..……………………………………….……………………..  
55  
B 
Appendix B……………………..……………………………………….……………………..  
56  
C 
Appendix C……………………..……………………………………….……………………..  
64  
D 
Appendix D……………………..……………………………………….……………………..  
67 
E 
Appendix E……………………………………………………………………………………..  
68  
F 
Appendix F……………………………………………………………………………………..  
72  
G         Appendix G……………………………………………………………………………………..  
73 

 
Revision 5.1, dated: 06/13/2018  
 
IRB Approval date: 10/11/2018  
 
Protocol document date: 09/06/2018  
  
  
  
                                                                       STUDY SUMMARY 
 
Protocol Title 
Haploidentical Donor Hematopoietic Progenitor Cell and Natural Killer Cell Transplantation with a TLI 
based Conditioning Regimen in Patients with Hematologic Malignancies 
 
Principal Investigator: 
Brandon M. Triplett, MD 
 
Brief Overview Study Population: 
Patients with high-risk hematologic malignancies who would likely benefit from allogeneic hematopoietic 
cell transplantation (HCT).  Patients who do not have a suitable HLA matched related or unrelated donor will 
typically be offered enrollment on one of two alternative donor protocols that will be run in parallel.  Those 
with a suitable HLA matched sibling or unrelated donor identified will be eligible for participation ONLY if 
the donor is not available in the necessary time. 
In general, patients who have a suitable HLA matched haploidentical donor (matched ≥ 3 of 6), will be 
preferentially offered enrollment on HAPNK1.  If the patient is medically eligible, but there is no suitable 
KIR mismatched haploidentical donor available, suitable cord blood units are available, and the patient is 
eligible for an institutional cord blood protocol, then the patient will be prioritized for enrollment on the 
current institutional cord blood transplant protocol. 
Participant must be less than or equal to 21 years old.  Additional eligibility criteria are specified to assure 
sufficient multi-organ system function. 
 
Intervention, Brief Outline, and Objectives of Treatment Plan: 
In this study, participants with high-risk hematologic malignancies undergoing hematopoietic cell 
transplantation (HCT), who do not have a suitable human leukocyte antigen (HLA) matched related/sibling 
donor (MSD) or matched unrelated donor (MUD) identified, will receive a haploidentical donor HCT with 
additional natural killer (NK) cells. 
The assessments and follow-up evaluations noted in the protocol follow the St. Jude standard operating 
procedures (SOP) for all recipients of allogeneic HCT. 
The primary objective of the study is to estimate the rate of successful engraftment at day +42 posttransplant 
in patients undergoing haploidentical HCT plus NK cell transplantation with a TLI based conditioning 
regimen.  Secondary aims will assess overall survival, event-free survival, risk of relapse, graft versus host 
disease (GVHD), transplant related mortality (TRM), transplant related morbidity, and immune 
reconstitution. 
  
 
 

 
Revision 5.1, dated: 06/13/2018  
 
IRB Approval date: 10/11/2018  
 
Protocol document date: 09/06/2018  
  
  
  
IND/IDE:  
 
CliniMACS CD56+ enrichment -- IDE 15422 IDE Cross-reference:  
CliniMACS CD34+ enrichment  
 
CliniMACS CD45RA depletion Criteria for Evaluation – Safety and Efficacy  
Safety:  
The primary measures of safety will be the rate of therapy related death and the rate of severe graft versus 
host disease.  
Ongoing assessment of toxicity will be done using the NCI CTCAE version 3.0  
Acute and chronic graft-vs.-host disease will be evaluated using established staging criteria and expert 
consensus guidelines.  
  
Efficacy:  
The primary measure of efficacy will be rate of successful engraftment.    
Neutrophil and platelet engraftment will be determined using the parameters put forth by the Center for 
International Blood and Marrow Registry.  Assessments will be made upon review of daily complete blood 
count and serial chimerism studies.  
Bone marrow studies for disease status evaluation will be performed at approximately 21 days, 100 days, and 
1 year post-transplant.  Testing will include a research evaluation for minimal residual disease.  
Immune reconstitution will be determined by standard blood testing of T- and B cell subsets.  
Research tests required for participation will examine NK and T-cell function and reconstitution.  
  
Statistical Considerations and Data Analysis  
Study Design: Phase II  
Randomization: No  
Sample Size: Up to 75 evaluable patients  
  
Data Analyses:  
Anticipated primary completion date: 07/01/2019  
Anticipated study completion date: 07/01/2020  
Time frame for primary outcome measure:  42 days post-transplant  
  
  
 

 
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Protocol document date: 09/06/2018 
  
  
  
Data Management including statistical evaluations  
Protocol compliance, data collection including safety data, and reporting will be carried out by the 
Department of Bone Marrow Transplantation and Cellular Therapy Research Office.  
Statistical considerations and ongoing analysis will be conducted by Dr. Guolian Kang and designated 
associates within the St. Jude Department of Biostatistics.  
Human Subjects:  
The risks to participants are primarily related to the cellular infusions and the conditioning regimen.  
The allogeneic stem cells may induce serious and possibly fatal disorders such as GVHD, veno-
occlusive disorder and post-transplant lymphoproliferative disease.  Because of the required 
conditioning, recipients are at high-risk for serious and possibly life-threatening infection, bleeding, 
and anemia.  Adverse events will be treated, monitored, and reported appropriately.  
Possible benefits of participation include obtaining and/or sustaining disease remission.  In addition, 
there is the possibility of psychological benefit from knowing participation has helped researchers gain 
more understanding about the efficacy of haploidentical HCT.  
Alternatives to participation are identified as chemotherapy and/or irradiation without transplant, 
research treatment if available, and/or supportive therapy.  
The possible benefits, alternatives to participation, and side effects, including that there may be 
unknown side effects of treatment, are detailed in lay language within the respective informed consent 
document.   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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1.0 OBJECTIVES  
1.1 Primary objective  
1.1.1 To estimate the rate of successful engraftment at day +42 post-transplant in patients 
who receive haploidentical donor stem cell plus NK cell transplantation with TLI 
based conditioning regimen for high risk hematologic malignancy.   
  
  
1.2 Secondary objectives  
1.2.1 Estimate the incidence of malignant relapse, event-free survival, and overall survival 
at one-year post-transplantation.  
1.2.2 Estimate incidence and severity of acute and chronic (GVHD).  
1.2.3 Estimate the rate of transplant related mortality (TRM) in the first 100 days after 
transplantation.  
  
1.3 Exploratory objectives  
1.3.1 Assess the relationship between pre-transplant minimal residual disease (MRD) with 
transplant outcomes.  
1.3.2 Record immune reconstitution parameters, including chimerism analysis, quantitative 
lymphocyte subsets, T cell receptor excision circle (TREC) analysis, V-beta 
spectratyping, and lymphocyte phenotype and function.  
1.3.3 Describe the use of CD45RA-depleted DLI for recipients who have severe viral 
infections, disease recurrence or progression, or poor immune reconstitution. Assess 
and record efficacy of CD45RA-depleted DLI for these conditions, and all adverse 
events that are related to CD45RA-depleted DLI.  
2.0  BACKGROUND AND RATIONALE  
2.1  Overview  
Allogeneic HCT is a potential curative therapy for various pediatric hematologic 
malignancies, however approximately 25-60% of eligible pediatric recipients will not have 
a human leukocyte antigen (HLA)-matched related/sibling donor (MSD) or a HLA 
matched unrelated donor (MUD).1-4  The lack of an adequate MUD for a substantial 
number of patients, and the lengthy duration of the donor search process in those with high 
risk of relapse, have prompted the search for alternative donors, including haploidentical 
family donors and unrelated umbilical cord blood (UCB) grafts.3,4   
Nearly all patients have a readily available mismatched family member (haploidentical) 
donor, and haploidentical HCT is an effective therapy for patients with hematologic 
malignancies.5,6  In particular, when extensive T-cell depletion was utilized, the presence of 
KIR mismatch dramatically reduced the risk of relapse in patients who received 
haploidentical HCT for high-risk leukemia.7-9  This institution has a track record of success 
using haploidentical donors for patients with hematologic malignancies,10 and we 
hypothesize that in patients who require an alternative donor HCT, those with a KIR 
mismatched donor are likely to benefit most from haploidentical HCT.  Therefore, those 

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with only KIR matched haploidentical donors, or those without a suitable haploidentical 
donor, will be prioritized to UCB HCT.  However, with the adoptive transfer of large 
numbers of memory T-cells in this study, NK cell alloreactivity may no longer be required 
for adequate control of relapse. Therefore, patients without suitable HLA-matched or UCB 
options, and only KIR matched haploidentical donors, may enroll on this study. Here, we 
propose a single institution prospective phase II trial to estimate the efficacy of 
haploidentical HCT with additional NK cells in pediatric patients with hematologic 
malignancies.    
This study will evaluate the safety and efficacy of haploidentical donor allogeneic HCT 
with additional NK cells for patients with high risk hematologic malignancies, through the 
estimation of donor engraftment, survival, relapse, acute and chronic GVHD, chimerism, 
toxicity, disease recurrence, and post-transplant cellular therapies based on chimerism 
results.  
2.2  Indications for HCT and the need for alternative donors  
Allogeneic HCT has become a widely accepted curative therapy for many childhood 
hematologic malignancies that cannot be cured with chemotherapy alone.11-14  Studies at St. 
Jude and other institutions have demonstrated that HCT is potentially curative for patients 
with CML, AML, ALL and MDS.15-17 Furthermore, patients with non-Hodgkin or Hodgkin 
lymphoma who recur after an autologous HCT may be successfully treated with allogeneic 
HCT.18,19  
Importantly, the criteria for patients who are suitable for allogeneic HCT (i.e. would be 
expected to benefit from allogeneic transplantation) change as new outcome data are 
compiled and published.  For example, less than a decade ago, there was a clear advantage 
for allogeneic HCT for Ph+ ALL in CR1.13  However, the use of tyrosine kinase inhibitors 
combined with intensive chemotherapy may have abrogated this advantage.20,21  It is 
imperative that the transplant physician be aware of the latest data and consensus 
recommendations14,22 when assessing the suitability for allogeneic HCT.   
Unfortunately, only approximately 30% of patients with hematologic malignancies that are 
suitable for allogeneic HCT will have a suitable MSD and approximately another 30% will 
have an MUD. 1-4  Thus, a significant number of patients will not have an appropriate MSD 
or MUD donor available in a timely manner, and will require an alternative hematopoietic 
progenitor cell (HPC) source from haploidentical or unrelated UCB donors.  Although, 
alternative donors have been shown to be suitable to treat children with high-risk 
hematologic malignancies, they may be associated with increase incidences of graft failure, 
TRM, GVHD, and delayed immune reconstitution when compared to recipients of MSD or 
MUD.23,24  Novel strategies are still needed to optimize outcomes in this group.  
 
2.3  Haploidentical HCT  
Haploidentical donors are viable alternative donors since family members are highly 
motivated, easily accessible, and readily available for most patients.  Along with other 
institutions, St. Jude has shown haploidentical HCT to be an effective therapy for patients 
with hematologic malignancies.5,6,25-27 Due to the high potential for GVHD with the degree 

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of HLA mismatch seen in haploidentical HCT, haploidentical grafts are often extensively 
T-cell depleted prior to infusion.  Early results with T-cell depleted haploidentical HCT 
were disappointing due very high rates of graft failure and infections.28  Significant 
progress was achieved with the use of mega-dose of T-cell depleted HPC after high-
intensity conditioning.26 Aversa and colleagues reported successful long-term engraftment 
with minimal GVHD in 43 patients with leukemia (including 15 children) using high doses 
of CD34+ enriched haploidentical cells, purified by positive (CD34+) and negative (CD3-
lectin agglutination) selection.29,30 Utilizing haploidentical grafts and megadose cell 
therapy (>1 x 107 CD34+ cells/kg), Handgretinger and colleagues reported similar results in 
23 pediatric patients.  Prompt engraftment with rapid immune reconstitution was associated 
with a low incidence of GVHD, even without the use of pharmacologic GVHD 
prophylaxis.31  
Building on the initial studies above, St. Jude has gained considerable expertise with 
haploidentical HCT in children.8-10,32-36 Over the past decade (2001-2010), more than 220 
mismatched related donor HCT have been performed at St. Jude.  Initially, most 
haploidentical HCT performed in this institution were for patients with relapsed and 
refractory hematologic malignancies, however as it became a more successful therapeutic 
maneuver, it has become a primary transplant option for patients who lack a well matched 
donor.10    
Recent studies suggest that alloreactive NK cells play a role in graft-vs.-leukemia (GVL) 
and influence outcomes of patients with hematologic malignancies after haploidentical 
HCT.7,3742 In addition to the anti-leukemia effects, NK cells are capable of reducing the 
incidence of graft rejection and GVHD in animal models; the former is in part based on the 
mechanism of donor NK cells against patient’s T cells, and the latter on donor NK cells 
against patient’s antigen presenting cells.7,40 Taken together, the presence of alloreactive 
donor NK cells may have multiple advantageous effects, including reduction in (1) relapse 
(2) graft rejection (3)  
GVHD and (4) viral infections.43  
The NK cell alloreactivity depends on the balance of signals mediated through activating 
and inhibitory KIRs on the NK cell.  KIRs recognize their ligands, HLA Class I molecules 
on recipient antigen presenting cells.  Some of the inhibitory KIRs recognize specific HLA 
class I ligands including the well-defined specificity of KIR2DL2/3 for the HLA-Cw 
group-1 epitope, the specificity of 2DL1 for the Cw group-2 epitope, and the specificity of 
3DL1 for the HLA Bw4 epitope.  Determination of both donor KIR and recipient HLA 
typing, allows categorization of KIR match versus mismatch.  KIR genes segregate 
independently of HLA genes, such that matching for HLA does not confirm KIR matching.  
In patients who received extensively T-cell depleted haploidentical HCT for high risk 
leukemia at St. Jude, the presence of KIR mismatch dramatically reduced the risk of 
relapse.9 Thus, patients with high risk hematologic malignancies who lack an HLA-
matched donor but have a KIR mismatched haploidentical donor available would be 
expected to benefit the most from the NK cell alloreactivity in haploidentical HCT. 
Therefore, KIR mismatched donors will be prioritized when available.  

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2.4  Rationale for immunomagnetic T cell depletion of hematopoietic progenitor cell graft   
Improvements in engraftment were achieved when Handgretinger et al demonstrated that 
HLA barriers of engraftment in recipients of haploidentical grafts maybe overcome by the 
infusion of a large number of CD34+ cells (>107 CD34+ cells/kg).26 Collection of megadose 
CD34+ has become feasible with the implementation of treating donors with G-CSF before 
donation, which has been shown to increase the number CD34+ cell collected.44    
Donor T cells in the haploidentical graft play a major role in mediating GVHD - as few as 3 
x 104 Tcells/kg can cause GVHD.27  However, new methods of TCD have been developed 
to generate a graft with very low T cell content, such that the risk of GVHD is decreased. T 
cells can be removed from the HPC graft by direct removal of T cells (negative selection) 
or selection of CD34+ progenitors (positive selection).  The transplantation program at St. 
Jude has had success using either method of T-cell depletion in haploidentical donor 
transplantation.  In this study, CD34+ selection by CliniMACS will be the initial method 
used for T-cell depletion of the HPC graft.  This was used successfully in INFT2 in which 
the HPC graft was often collected early and frozen until day 0 followed by collection and 
fresh infusion of an NK cell graft the following week.  
Although positive selection allows for extensive T-cell depletion (TCD), the graft is devoid 
of other important cell populations such as NK cells and myeloid cells such as dendritic 
cells and monocytes.45,46  In addition, this extensive degree of TCD has significant negative 
effects on the time to donor immune competency.  Donor T cells are critical for 
reconstituting the allogeneic host immune system, and lymphocyte recovery is an important 
determinate of outcome post-transplant.47,48 Transplants that employ TCD result in 
elimination of most memory T cells, leading to protracted immune dysfunction- an effect 
that becomes more severe with higher intensity conditioning regimens.32,49 This results in 
an increased rate of opportunistic infections. Indeed, viral infections are the most common 
cause of death of children receiving haploidentical transplants.50 The majority of these 
infections occur within the first 6 months following transplantation, when T cell immunity 
is the lowest.51 Reconstitution of immunity can be partially restored by therapeutic 
infusions of donor cytotoxic lymphocytes.47,52-54 However, in addition to requiring 
significant resources and expertise, the cells must be engineered or selected for specific 
infections - making this approach impractical for broad application.55    
CD45, also called the leukocyte common antigen, is expressed on nearly all hematopoietic 
cells in various isoforms related to stage of development and activation.56 Among the 
various isoforms is CD45RA, which selectively identifies naïve T cells.57 Naïve T cells 
have fully matured but do not proliferate until they encounter the specific ligand that their 
receptor recognizes.58 If such a proliferative signal occurs after antigen recognition, then 
there is a marked, antigen-specific cell expansion and inflammatory response. While many 
of these cells will undergo apoptosis after the initial response, others are rescued from 
immune retraction and will persist as memory T cells, the majority of which then become 
CD45RA.59 Having responded to antigen, memory T cells are no longer naïve and are thus 
capable of more rapidly responding to future infectious challenges.60 Once generated, 
memory cells persist in the circulation as a diverse cell pool that is critical for long-term 
infection control.61  

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A more ideal cell product infusion would offer adoptive transfer of a diverse lymphocyte 
repertoire capable of effectively rejecting a variety of pathogens, as well as malignant cells. 
It is hypothesized that the elimination of only CD45RA+ naïve T cells from an infused cell 
product would not significantly negatively impact memory responses to infection. Among 
CD4+ T cells, the CD45RA- subset has equivalent “helper” functions as CD45RA+ cells in 
the generation of alloreactive cytotoxic T cells.62 Further, it is the CD45RA- memory cells 
that are responsible for aiding B-cell differentiation and antibody production.  
The various strategies thus far reported for selective T cell depletion largely spare 
CD45RA+ naïve cells, including those that target CD25. Only approximately 5% of naive 
CD4 cells are  
CD25+.55 There is potential advantage in targeting naïve T cells for lymphocyte depletion. 
Human studies have shown that sorted donor CD45RA+ naïve T cells are far more 
alloreactive than all memory subsets tested.63 In animal models, infusions of fractionated 
memory T cells do not cause physical or histologic evidence of GVHD, independent of Treg 
numbers. Naïve T cells, conversely, are potent inducers of GVHD, even despite CD25 
depletion before infusion.55 Moreover, in similar models, lymphocyte infusions specifically 
depleted of naïve T cells do not cause GVHD.64 Allografts containing high numbers of 
CD45RA+ naïve Tregs may be associated with lower risk of acute GVHD in haploidentical 
transplantation using unmanipulated, fully T cell-replete products.65 The proposed 
approach will deplete this population - potentially abrogating this effect.   
After showing such promise in animal models, selective CD45RA depletion has begun to 
be studied in human marrow transplantation, including at this institution. CD45RA 
depletion by magnetic beads is feasible and effective for naïve T-cell depletion. Data 
provided by Miltenyi has shown this method to be an effective means of depletion, with 
greater than 3-fold reduction in number of CD45RA+ cells. Experiments were performed 
in the Human Applications Laboratory to qualify the CD45RA+ depletion procedures. 
Hematopoietic progenitor cell products were purchased that were obtained from G-CSF 
mobilized normal donors by apheresis. The HPC,A products were depleted of CD45RA+ 
cells following a procedure provided by Miltenyi Biotech. Briefly, the cells were incubated 
with the CD45RA Microbead reagent followed by washing to remove unbound beads. The 
labeled cells were then applied to the CliniMACS device (Depletion Tubing Set) and the 
CD45RA+ cells removed using the Depletion 3.1 program. Flow cytometric analysis 
before and after depletion was performed following procedures provided by Miltenyi 
Biotech. The results of the experiments are presented in the table below. An example flow 
cytometric analysis of CD3+ cells is also included.  
 
 
 
 
 
 

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Experiment # 1  
Experiment #2  
Pre-depletion 
(x 106)  
Post-depletion 
(x 106)  
Pre-depletion  
(x 106)  
Post-depletion  
(x 106)  
Nucleated Cells  
29748.0  
10270.0  
26166.0  
10981.0  
CD3+  
12238.3  
4555.8  
6353.1  
1985.4  
CD3+CD45RA+  
7877.3  
4.1  
3520.8  
2.2  
CD34+  
636.6  
311.2  
693.5  
395.3  
CD3+ CD45RA+  
Log Depletion  
3.28  
3.21  
  
We hypothesize that the addition of CD45RA depleted product to a back bone of CD34 
enriched cells will provide a HPC graft with good progenitor cell content (3-5 x 106 CD34+ 
cells/kg) and a useful memory T-cell fraction to the recipients on this trial.    
For the 26 patients enrolled on this protocol prior to amendment 2.0, there was no 
maximum naïve T-cell (CD3+CD45RA+) dose.  Although there is no correlation with 
naïve T-cell dose and the occurrence of GVHD so far in this or any other institutional 
CD45RA-depleted transplant protocol, rare patients have received naïve T-cell doses in 
excess of 105/kg.  In HAPREF, which utilized CD3+ depletion, the conventional T-cell 
dose cap was raised to 1.5 x 105/kg, and the rate of acute GvHD was noted to be increased. 
Returning the maximum dose down to 1 x 105 CD3+ cells/kg in HIFLEX again provided an 
acceptably low rate of acute GVHD. Because approximately ½ of circulating T cells are 
naïve (and therefore 1 x 105 conventional T cells would contain approximately 0.5 x  105  
naïve T-cells), in this trial the naïve T-cell (CD3+CD45RA+) dose in the CD45RA-
depleted product will be capped at 0.5 x  105/kg (0.05 x 106) starting with amendment 2.0.  
Of the first 26 patients to receive transplantation and complete one year of follow-up on 
this protocol, 4 have experienced morphologic relapse.  Two of the 4 demonstrated 
haplotype loss.66 This indicates that the adoptively transferred memory T-cells have anti-
leukemia effects. In this setting then, KIR mismatch driven NK cell alloreactivity may no 
longer be required for disease control as it was in previous studies utilizing extensively T-
cell depleted haploidentical donor transplantation.  

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2.5  Rationale for the reduced intensity conditioning regimen  
The immunological effect of graft versus leukemia (GVL) after allogeneic HCT has 
allowed reduction in the intensity of conditioning as HCT was no longer reliant on the 
cytotoxicity of high dose of chemotherapy to eradicate disease.  Reduced-intensity 
conditioning (RIC) regimens have the potential to improve the outcomes of allogeneic 
HCT by decreasing the acute TRM.67-69   Fludarabine-based RIC regimens are safe and 
effective alternatives to total body irradiation (TBI) in haploidentical HCT.32,70,71 In 
addition, intensification of immunoablative conditioning using ATG, OKT3, or 
alemtuzumab, results in the decrease incidence of GVHD and graft rejection as well.71-74 In 
our first RIC haploidentical HCT protocol REFSCT, we evaluated a RIC regimen for 
pediatric patients with refractory hematological malignancies or considered at high risk for 
TRM with a full myeloablative regimen.  The RIC regimen consisted of fludarabine 
(200mg/m2), thiotepa (10mg/kg), melphalan (120 mg/m2) and Orthoclone-OKT3 and 
enrolled 25 patients from 2003-2005. Out of the 25 participants, 22 engrafted with a 
median of 10 days (range, 7-12) and 3 experienced graft failure.  The patients with graft 
failure, one patient had disease relapse and 2 were salvaged with stem cells infusions from 
their first transplant donor. The median time to platelet engraftment to 20,000/mm3 and 
50,000/mm3 was 17 days (range, 12-36) and 17 days (range, 12-76), respectively.  The 
cumulative incidence of overall grade III-IV acute GVHD and chronic GVHD was 8% and 
28%, respectively.  Of those participants who died, 13 were due to relapsed disease (at a 
median of 105 days post-HCT).  Only 4 (16%) died of TRM, despite most of the patients 
having received one prior allogeneic HCT - 1 died of GVHD, 1 of infection, 1 of 
hemorrhage, and 1 of cardiomyopathy. In summary, RIC allows for engraftment with an 
acceptable rate for graft failure, GVHD, and TRM.    
Two subsequent haploidentical HCT studies at St. Jude (HAPREF and HIFLEX) utilized 
non-TBI preparative regimens with a fludarabine, thiotepa, melphalan backbone.  
Twentyseven patients with high risk hematologic malignancies were transplanted on one of 
these two protocols with OKT3 as in vivo T-cell depletion, followed by infusion of a CD3+ 
TCD graft.  The one-year EFS was 51.9% ± 9.6%.  These studies have demonstrated the 
EFS and TRM in TCD RIC HCT from mismatched haploidentical donor compare 
favorably with reports from MUD.    
Importantly however, OKT3 was an important component of the preparative regimen for 
these transplants, and it is no longer commercially available.  Our most recent front-line 
haploidentical donor HCT trial (HIFLEX) has substituted Campath for OKT3.  Early 
results indicate that survival is similar between patients on HIFLEX treated with OKT3 
versus Campath (data not shown).  However, requirement for the use of therapeutic DLI 
has risen substantially.  Only 1 of the 11 patients who received OKT3 on HIFLEX required 
more than 2 DLI in the first 100 days post-HCT.  In contrast, 9 of the first 14 patients who 
received Campath on HIFLEX required more than 2 DLI in the first 100 days post-HCT.  
This is likely due to Campath’s anti-NK cell effects, leading to an increased clinical need 
for early T-cell add back in the form of DLI.  Unfortunately, with OKT3’s withdrawal from 
market, there is no commercially available T-cell specific (NK cell sparing) antibody.  

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Therefore, in this protocol, we plan to use total lymphoid irradiation (TLI) in the 
preparative regimen to provide bidirectional tolerance in substitution of OKT3.  
TLI was initially developed with curative intent in patients with Hodgkin Lymphoma, and 
it was its use in these patients that led to the discovery of TLI’s alteration of T-cell specific 
immune responses.  Years of pre-clinical research on TLI have shown that the use of TLI 
promotes engraftment and reduces GvHD.75  This work was then followed up with 
therapeutic trials in humans with hematologic malignancy, which showed that conditioning 
with TLI and ATG alone allowed a high rate of durable donor engraftment, a low rate of 
GvHD, and preservation of evidence of graft versus malignancy effect, in patients who 
received HLAmatched related or unrelated donor grafts.76,77  We have significant 
institutional experience using TLI-based regimens for allogeneic transplantation (n=29 as 
of June 2012).  Importantly, TLI-based conditioning has allowed successful salvage 
haploidentical transplantation in patients who failed previous allo-HCT.  Nine patients have 
received TLI-based conditioning with haploidentical donor HCT after experiencing 
previous allograft failure (3 had primary graft failure, 4 had initial engraftment with acute 
rejection, and 2 had late graft failure).  The same haploidentical donor was utilized in 5 of 
the 9 salvage HCT, with 4 patients receiving a new (haploidentical) donor.  Eight of 9 
patients (89%) experienced durable engraftment at a median of 12 days (range 10 – 27 
days).  The remaining patient had primary graft failure due to progressive disease.  This 
experience indicates that TLI is effective for facilitation of engraftment, even in patients 
receiving a mismatched haploidentical donor graft and with a history that indicates a very 
high risk of graft failure.  There is additional published experience from Germany in which 
TLI – given as a single 7Gy fraction – was utilized in 14 adult and pediatric patients for 
reconditioning after graft failure/rejection.78  Despite most of the patient having 
haploidentical donors, engraftment was obtained in all evaluable patients.  In addition, TLI 
was well tolerated in this pediatric population that had recently received another (typically 
myeloablative) preparative regimen.  Finally, 10 patients in Chile received TLI-containing 
preparative regimen, similar to our proposed regimen,  as a part of their haploidentical 
donor preparative regimen.79  TLI was given as a single dose at 7Gy.  Nine out of 10 
patients experienced rapid donor engraftment, with relapse as the cause of the one primary 
graft failure.  Six of 10 patients were alive and disease free at one year, 3 died of 
progressive disease, and one of infection.  
 
2.6  Rationale for the therapeutic NK cell graft  
Relapse, infection, and GvHD remain major concerns after HCT.  Donor lymphocyte 
infusion (DLI) containing all types of lymphocytes (B, T, and NK cells) is a viable option 
for the prevention and/or treatment of both relapse and infection, but conventional 
(unfractionated) DLI is limited by the risk of T-cell mediated GVHD.80 Another 
therapeutic option is the infusion of large number of donor-derived NK cells.43,81-83 In 
recent years, it has become clear that NK-cell alloreactivity can exert significant effects in 
allogeneic transplantation.  NK-cell alloreactive effects can include a reduction in the rate 
of rejection, a reduction in GvHD, and a reduction in rate of relapse.7,84  In addition, we 
and others have shown that patients who have a more robust post-HCT NK-cell recovery 
demonstrate reduced relapse rates.85,86 Thus, we will provide an infusion of additional NK 

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cells from the haploidentical donor as a therapeutic cell product of purified NK cells (TC-
NK).  
Donors on this study will therefore undergo additional leukapheresis on (or around) patient 
day +5 to obtain the cells for the TC-NK.  (See section 4.4).  This will be 5 days after the 
completion of G-CSF mobilization and hematopoietic progenitor cell collection if a fresh 
stem cell graft is utilized.  Donor WBC count is typically returning towards, but still 
slightly above, baseline at this timepoint.87  Importantly, peripheral blood NK-cell 
quantities are not significantly altered with G-CSF mobilization and leukapheresis 
collection in healthy donors.88   In addition, all three patients collected on HAP3R (using 
this schedule) have met target cell doses for the TC-NK products.  The TC-NK will be 
isolated from the obtained donor mononuclear cells (MNC) in a two-step process. Initially, 
the MNC will be CD3+ TCD followed by a CD56+ NK enrichment using the CliniMACS 
immunomagnetic selection program.  TC-NK have been generated using this procedure for 
the following protocols: NKHEM, INFT2, NKAML, and AML08.  The average content of 
the first 50 TC-NK generated are listed in the table below. We are able to generate a 
therapeutic cell product that is highly purified for NK cells with minimal contamination of 
T cells.  The final product volume will be approximately 10mL.    
  
TC-NK  
Average  
Standard Deviation  
Purity  
NK dose  (106 CD56+ cells/kg)  
26.6  
± 22.6  
96.5%.  
T cell (106CD3+cells)  
0.46  
± 0.69  
 
T cell dose (106CD3+ cell/kg)  
0.03  
± 0.03  
 
To date, the infusion of TC-NK has been safe and tolerable in both the transplant and cell 
therapy setting.  On INFT2, 13 patients received a TC-NK after haploidentical donor HCT 
and were evaluable for toxicity.  No patient developed an acute infusion reaction to the 
infusion of TC-NK.  One patient had NCI Grade 2 generalized edema the day following the 
TC-NK, however this is a known and common side effect of allogeneic HCT.  Fifty-two 
patients that have received TC-NK in therapeutic cell therapy protocols were evaluable for 
toxicity at this writing.  (25-NKAML, 19-NKHEM, 8-AML08)  Some received TC-NK 
following a five-day clofarabine, etoposide, cyclophosphamide regimen, while others 
received TC-NK after fludarabine, cyclophosphamide therapy.  No patient developed an 
acute infusion reaction. One patient developed hypertension that required a single dose of 
anti-hypertensive during the night after the infusion.    
 
2.7  Minimal residual disease  
Despite the fact that the vast majority of patients with high-risk leukemia are in clinical 
remission prior to HCT, relapse remains a primary cause of failure after HCT.  Detection of 
minimal residual disease (MRD) and early intervention may improve the clinical outcome. 
Detection of leukemic cells that are below the limits of detection by standard morphologic 
examination allow early interventions when the patients are MRD positive but still in 
remission.  By using flow cytometry and polymerase chain reaction (PCR) amplification of 
antigen receptor genes in tandem, investigators at our institution have been able to conduct 
MRD studies in 80 consecutive ALL cases.89 Results of St. Jude institutional studies have 

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shown that detection of MRD by immunologic techniques at any point in the treatment 
course is a powerful predictor of relapse in children with ALL.89-91 However, other studies 
suggest that eradication of all acute leukemia cells may not be a prerequisite for cure.92,93  
Similar to conventional-dose therapy, controversy also exists on the implication of MRD in 
the setting of HCT.  Unlike CML, there is a paucity of data on the natural history of AML 
and ALL patients who have MRD after HCT, and how pre-transplant MRD levels 
influence posttransplant outcomes.94,95  It is unclear whether they are also at greater risk of 
relapse; and whether further pharmacological or immunologic therapy indeed prolongs 
survival and increases cure rates.  Thus, for the participants who are enrolled in this 
protocol who are unable to proceed to posttransplant immunomodulatory protocols, we will 
gather the MRD information together with hematopoietic chimerism in a descriptive 
manner to study the relationship between MRD and chimerism in this large cohort of 
patients. The knowledge gained from this study should allow their future application to 
guide therapeutic interventions.  
2.8 Rationale for present study  
Many patients with high risk hematologic malignancies that would benefit from allogeneic 
HCT do not have an HLA-matched donor available in the necessary time.  This institution 
has had success with the use of haploidentical donor HCT for such patients.  In particular, 
when a homogenous patient population was examined, outcomes with haploidentical donor 
HCT appear to be similar to those of conventional allogeneic HCT.10  Thus haploidentical 
HCT should be offered as a viable option to candidates with high-risk hematologic 
malignancy that lack a suitable HLA-matched donor, and have a suitable haploidentical 
donor.  
 
2.9  Experience with GVHD prior to Amendment 2.0  
The GVHD syndromes experienced by patients on this protocol differ from conventional 
Tcell-replete transplantation.  Prior to amendment 2.0, 26 patients received naïve T-
celldepleted HCT (range in survivors 180 – 736 days post-HCT). Seven patients developed 
grade II-IV acute GVHD (1 - II, 4 - III, 2 - IV). GVHD prophylaxis was sirolimus in the 
first 9 patients, and MMF for the remaining patients. The median duration of GVHD 
prophylaxis was 18 (range 0 – 154) days. One patient had upper GI symptoms a few 
months posttransplant in conjunction with a rash and was diagnosed with grade II acute 
GVHD.  The six patients with severe (III-IV) GVHD presented more atypically.  One 
patient initially developed diarrhea with frank blood. Endoscopy showed severe mucosal 
injury with a broad differential diagnosis, and her prophylactic MMF was stopped. One 
week later she had fever, an elevated CRP above 20mg/dL, and a new rash. She responded 
to infliximab and systemic steroids.  A second patient developed hepatitis with an HHV6 
viral load over 5 log. One week later she developed a rash and the bilirubin continued to 
rise, therefore systemic steroids were initiated. The third patient presented with fever, 
nausea, and a rise in liver transaminases followed by increased bilirubin. Diarrhea and rash 
followed a few days later with a rise in CRP to 15mg/dL. Systemic steroids and infliximab 
were initiated, and GVHD prophylaxis was changed from sirolimus to tacrolimus. Due to 
very aggressive malignancy at diagnosis, steroids were weaned aggressively in these three 

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patients as tolerated (courses were 65, 56, and 61 days respectively). GVHD prophylaxis 
was also stopped prior to Day +100 in all. Perhaps due to this aggressive weaning schedule, 
in these 3 patients, 1 patient developed recurrent acute GVHD and the other two developed 
chronic GVHD.  The fourth patient was plagued by prolonged anorexia, and was never 
diagnosed with GVHD nor treated with prolonged systemic therapy for GVHD and yet 
recovered completely, however the consensus of extramural reviewers was that she had 
grade III acute GVHD. Another patient was diagnosed by the care team and GI consult as 
CMV enteritis, but external auditors suggested that isolated GI GvHD as a possible 
etiology, so the coding was changed to acute GvHD. The final patient was diagnosed as 
toxic epidermal necrolysis (TEN), but consensus of external reviewers felt that acute 
GvHD was the more likely etiology, therefore the coding was changed to acute GvHD. Of 
these 7 patients coded as grade II-IV acute GVHD, one died of ARDS and another of 
progressive disease, the rest remain alive as of December 2015.  
  
Although the rate of moderate to severe acute GVHD was similar to the rate on the 
previous study HIFLEX, maraviroc was added in Amendment 3.0 in an attempt to 
reduce the incidence of significant gut and liver inflammation without further inhibiting 
T-cell activation and proliferation, which had the potential to reduce acute GVHD. 
However, 4 of 5 patients who received maraviroc developed acute GVHD grade III or 
IV; this is compared to only 7 patients developing GVHD grade III or IV in the 36 
patients transplanted prior to the addition of maraviroc. Therefore, maraviroc use was 
discontinued.  Prior to amendment 5.0, as of date April 4, 2018, preliminary analysis 
showed a significantly higher rate of GVHD grade III-IV in patients who received 
maraviroc (4 of 5 = 80%) compared to those patients who did not receive maraviroc (12 
of 53 = 25%)(p = 0.02). 
 
 Prior to amendment 2.0, 8 of 26 patients (31%) have developed chronic GVHD (5 mild, 3 
moderate by NIH criteria). Six of the 8 patients had oral involvement, with all other sites 
less commonly involved.  Three have required systemic immunosuppressive therapy.  
  
3.0  PROTOCOL ELIGIBILITY CRITERIA  
  
 
3.1  Inclusion criteria for Transplant Recipient  
3.1.1  Age less than or equal to 21 years.  
3.1.2 Does not have a suitable HLA-matched sibling donor (MSD) or volunteer 
HLAmatched unrelated donor (MUD) available in the necessary time for stem 
cell donation, or is not a candidate for MSD or MUD HCT due to refractory 
disease.  
 
3.1.3  Has a suitable single haplotype matched (≥ 3 of 6) family member donor.  
 
3.1.4  High risk hematologic malignancy.  
3.1.4.1  High risk ALL in CR1.   

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 Examples include, but not limited to: t(9;22), hypodiploid, MRD >1% at the end 
of induction, M2 or greater marrow at the end of induction, Infants with 
MLL fusion or t(4;11).  
3.1.4.2  ALL in High risk CR2.   
 Examples include, but not limited to t(9;22), BM relapse <36 mo CR1, TALL, 
very early (< 6mo CR1) isolated CNS relapse.  
3.1.4.3  ALL in CR3 or subsequent.  
3.1.4.4  AML in high risk CR1 (diagnosis of AML includes myeloid sarcoma).    
Examples include but not limited to: preceding MDS, 5q-, -5, -7, FAB 
M6, FAB M7 not t(1;22), MRD > or = 5% on day 22 (AML08), MRD > 
0.1% after two cycles of induction, M3 marrow after once cycle of 
induction, M2 marrow after two cycles of induction, FLT3-ITD.  
3.1.4.5  AML in CR2 or subsequent.  
3.1.4.6  AML in relapse with <25% blasts in BM  
3.1.4.7  Therapy related AML, with prior malignancy in CR > 12mo  
3.1.4.8  MDS, primary or secondary  
 
3.1.4.9  NK cell, biphenotypic, or undifferentiated leukemia in CR1 or subsequent.  
3.1.4.10 CML in accelerated phase, or in chronic phase with persistent molecular 
positivity or intolerance to tyrosine kinase inhibitor.  
3.1.4.11 Hodgkin lymphoma in CR2 or subsequent after failure of prior 
autologous HCT, or unable to mobilize stem cells for autologous HCT.  
3.1.4.12 Non-Hodgkin lymphoma in CR2 or subsequent after failure of prior 
autologous HCT, or unable to mobilize stem cells for autologous HCT.  
3.1.4.13 JMML  
3.1.4.14 One of the following hematologic malignancies that are refractory 
(includes chemoresistant relapse or primary induction failure).  
• 
ALL  
• 
AML  
• 
CML (blast crisis)  
• 
Hodgkin or non-Hodgkin lymphoma  
3.1.5  If prior CNS leukemia, it must be treated and in CNS CR  
3.1.6  Does not have any other active malignancy other than the one for which this 
HCT is indicated.  
3.1.7  No prior allogeneic HCT, and no autologous HCT within the previous 12 months.  
 
3.1.8  Patient must fulfill pre-transplant evaluation:  
3.1.8.1  Left ventricular ejection fraction > 40%, or shortening fraction ≥ 25%.  

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3.1.8.2  Creatinine clearance (CrCl) or glomerular filtration rate (GFR) ≥ 50 
ml/min/1.73m2.  
3.1.8.3  Forced vital capacity (FVC) ≥ 50% of predicted value; or pulse oximetry 
≥  92% on room air if patient is unable to perform pulmonary function 
testing.  
3.1.8.4  Karnofsky or Lansky (age-dependent) performance score ≥ 50 (See 
APPENDIX A).  
3.1.8.5  Bilirubin ≤ 3 times the upper limit of normal for age.  
3.1.8.6  Alanine aminotransferase (ALT) ≤ 5 times the upper limit of normal for 
age.  
3.1.8.7  Not pregnant.  If female with child bearing potential, must be confirmed 
by negative serum or urine pregnancy test within 14 days prior to 
enrollment.  
 
3.1.8.8  Not breast feeding  
3.1.8.9  Does not have current uncontrolled bacterial, fungal, or viral infection.  
  
3.2  Inclusion criteria for Haploidentical Donor  
3.2.1   At least single haplotype matched (≥ 3 of 6) family member  
  
3.2.2  At least 18 years of age.  
 
3.2.3  HIV negative.  
3.2.4 Not pregnant as confirmed by negative serum or urine pregnancy test within 14 
days prior to enrollment (if female).  
 
3.2.5  Not breast feeding.  
 
3.2.6  Regarding eligibility, is identified as either:  
3.2.6.1 Completed the process of donor eligibility determination as outlined in 21 
CFR 1271 and agency guidance; OR  
3.2.6.2 Does not meet 21 CFR 1271 eligibility requirements, but has a 
declaration of urgent medical need completed by the principal 
investigator or physician sub-investigator per 21 CFR 1271.  
3.3  Gender and minorities  
According to institutional and NIH policy, this study will accession patients regardless of 
gender and ethnic background. Institutional experience confirms broad representation in 
this regard.  However, pregnant and lactating females are excluded from participation as 
the short and long-term effects of the preparative agents, study infusion (recipients) as 
well as the long-term effects of mobilization and apheresis procedure (donors) on a fetus 
and a nursing child through breast milk are not entirely known at this time.  
  
  

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4.0  TREATMENT PLAN  
 
4.1  Preparative regimen  
DAY  MEDICATION  
DOSE  
DOSE #  
-9  
Total Lymphoid Irradiation 
(TLI)  
2Gy per fraction x 2 fractions  
1,2 of 4  
-8  
Total Lymphoid Irradiation 
(TLI)  
2Gy per fraction x 1 fraction  
3 of 4  
Fludarabine  
30 mg/m2 intravenous once daily   
1 of 5  
-7  
Total Lymphoid Irradiation 
(TLI)  
2Gy per fraction x 1 fraction  
4 of 4  
Fludarabine  
30 mg/m2 intravenous once daily   
2 of 5  
-6  
Cyclophosphamide  
60 mg/kg intravenous once daily   
1 of 1  
Fludarabine  
30 mg/m2 intravenous once daily   
3 of 5  
-5  
Fludarabine  
30 mg/m2 intravenous once daily   
4 of 5  
-4  
Fludarabine  
30 mg/m2 intravenous once daily   
5 of 5  
-3  
Thiotepa  
5 mg/kg intravenous twice daily   
1,2 of 2  
-2  
Melphalan  
70 mg/m2 intravenous once daily  
1 of 2  
-1  
Melphalan  
70 mg/m2 intravenous once daily   
2 of 2  
0  
HPC,A Infusion(CD34+ 
selected)  
  
  
+1  
HPC,A infusion (CD45RA 
depleted)  
  
  
+2-5  --  
  
  
+6  
TC-NK Infusion  
  
  
+7  
G-CSF  
5mcg/kg subcutaneous or intravenous daily until  
ANC >2000 for 2 consecutive days, and then as 
clinically indicated  
+13  Mycophenylate mofetil  
15 mg/kg intravenously three times daily.  
Cellular infusion procedures and monitoring:  
For the proper infusion procedures and monitoring of the HPC product please refer to  
BMT&CT SOP 40.02 “Hematopoietic Progenitor Cell Infusion – FRESH (Allogeneic): IV 
Push and IV Drip” or SOP 40.03 “Hematopoietic Progenitor Cell Infusion – FROZEN: IV  
Push”.  For the TC-NK infusion, please see BMT&CT SOP 40.04 “Therapeutic Cell 
Infusion”.  Importantly, for TC-NK infusion, steroid pre-medications should not be 
given unless specified by an attending transplant physician.  The TC-NK product will be 
infused by slow IV push over 3 to 15 minutes.  Please note that all relevant SOPs can be 
found 
on 
the 
BMT&CT 
Clinical 
Transplant 
Program 
intranet 
page:                             
http://home.web.stjude.org/bone_marrow/clinicalHome.shtml  

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Importantly, during the cellular infusions, monitoring of vital signs, breath sounds, heart 
rate, pulse oximetry, and I/O will be done per the established transplant nursing 
procedure, as well as appropriate Department of BMT&CT SOPs, then documented on 
the Cellular Product Infusion Record.  If a reaction is suspected at any time during the 
infusion, the nurse will 1. Stop the infusion, 2. Notify the Attending Transplant 
Physician immediately, 3. NOT discard the product until physician orders are given.  
Proper documentation (symptoms of patient, vital signs, actions taken, outcome, and 
follow-up) will be completed in the Cellular Product Infusion Record.  
General comments:  
The Hematopoietic Progenitor Cell, Apheresis (HPC,A) infusion may be delayed by 
approximately 24 hours in order to accommodate progenitor cell collection with the 
donor, the Blood Donor Center and/or HAL as well as the research participant clinical 
condition.  
The administration of the TC-NK infusion may also be adjusted in order to 
accommodate NK-cell collection with the donor, the Blood Donor Center and/or HAL as 
well as the research participant clinical condition.  Depending on date of NK-cell 
collection, it will be acceptable for the TC-NK infusion to occur between and including 
days +5 and +9 post progenitor cell infusion.  In the event that the date of NK-cell 
infusion is adjusted, the mycophenylate mofetil (MMF) would typically be similarly 
adjusted such that dosing is initiated seven days post NK-cell infusion.  
The term “every” used in tables is an approximate term meaning that these medications 
noted will be administered approximately “every” 12 hours.  The drug administration 
timing in the case of “every 12 hours” may be modified by approximately +/- 4 hours or 
as clinically indicated such as in the case of surgical procedures or to accommodate other 
necessary medication, blood product delivery, or procedures (such as a needed CT scan). 
The term “day” does not refer to an absolute calendar day.  It refers to a general 24-hour 
period. Dosing for the medications cyclophosphamide, fludarabine, thiotepa, and 
melphalan may be modified for research recipients based upon actual body weight or 
adjusted ideal body weight when clinically indicated. Mesna will be administered for 
prevention of hemorrhagic cystitis from the medication cyclophosphamide.  In general, 
mesna is administered at 15 mg/kg/dose prior to cyclophosphamide and at approximately 
3, 6, and 9 hours after the cyclophosphamide infusion, to give a 1:1 ratio of 
mesna:cyclophosphamide.  Mesna dose and administration schedule may vary based on 
physician recommendation.  
Criteria for medication calculations based on body weight/body surface area and other 
medication related information can be found in the St. Jude Formulary 
http://www.crlonline.com/crlsql/servlet/crlonline or the St. Jude Dept of Pharmaceutical 
Sciences intranet website http://home.web.stjude.org/pharmaceutical_ser/drugInfo.shtml. 
Medication doses may be rounded to the nearest integer or to the nearest appropriate 
quantity when clinically or pharmaceutically indicated as per the MD and PharmD.   
TLI will be given at 800cGy total dose in 4 fractions over 2 or 3 days.  Fractions are 
given at a minimum of 6 hours apart from beam on to beam on.  In order to facilitate 

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scheduling, the general procedure for administering TLI has been defined here and in the 
above table.  It should be noted that TLI can be administered at any point during the 
preparative regimen prior to the progenitor cell infusion, and over as many days as 
needed to further accommodate scheduling issues in collaboration with the Division of 
Radiation Oncology and will not be considered a variance in protocol if the total dose of 
800 cGy is met.  
G-CSF will generally start on Day +7, but initial dose may be moved to an earlier or 
later day as to not interfere with NK cell infusion. G-CSF may also be dose adjusted or 
stopped early if rapid engraftment is considered to be potentially harmful to the patient 
(such as with engraftment syndrome) in the opinion of the PI or transplant care provider.  
MMF for GVHD prophylaxis: MMF will start one week after the NK cell infusion. In 
the event NK cells cannot be given, MMF may start Day 0, or as soon as it is known that 
the NK cell graft is unavailable (if later than Day 0). MMF is typically given IV initially, 
but may be converted to oral dosing when the patient is tolerating oral medications.  In 
the absence of GVHD, MMF will be discontinued approximately Day +60.  However, 
this regimen may be modified as clinically indicated in the presence of other factors 
including but not limited to persistent neutropenia, mixed or decreasing donor 
chimerism, graft rejection/failure or persistent/recurrent malignancy.  In the event the 
participant develops GVHD, treatment will be according to the SOPs of the St. Jude 
Department of BMT&CT.  
 
4.2  Donor Selection  
If more than one family member donor is acceptable, then donor selection will be based 
on the preference of the primary transplant attending.  Factors in selection will include 
donorrecipient matching of CMV serology, donor-recipient red blood cell compatibility, 
degree of HLA matching, size of the potential donor, previous use as a donor, presence 
of donorspecific antibody, and overall health of the potential donor.  
Donor eligibility for cell collection will be determined through the guidelines outlined in 
21 CFR 1271 and the Guidance for Industry: Eligibility Determination for Donors of 
Human Cells, Tissues, and Cellular and Tissue-Based Products (HCT/Ps).  Potential 
donors will undergo an initial screening process that will include at least a complete 
physical exam, history and testing for relevant communicable diseases.  Physical exams 
to evaluate donor candidacy will be conducted by a non-Department of BMTCT 
physician (St. Jude or non-St. Jude).  For subsequent therapeutic cell collection 
procedures, if a complete screening procedure has been performed within the previous 6 
months, an abbreviated donor screening procedure may be used for these repeat 
donations.  The abbreviated screening procedure must determine and document any 
changes in the donor’s medical history since the previous donation that would make the 
donor ineligible, including changes in relevant social behavior.  
If a donor is determined to be ineligible, the donor is not automatically excluded. Part 21 
CFR 1271.65 (b)(1)(i) allows use of ineligible donors who are first or second degree 
blood relatives. In this situation, the physician will document the necessity of using the 
ineligible donor by providing a statement of "Urgent Medical Need" as explained in the 

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21 CFR 1271.3 (u).  The cell therapy products will be labeled as required in 21 CFR 
1271.65 (b)(2). Recipients or their legal guardians will be informed of the use of an 
ineligible donor.  
Please see Departmental SOP 30.05 “Determination of Eligibility and Suitability for Stem 
Cell and Therapeutic Cell Allogeneic and Autologous Donors” for additional information.  
 
4.3  Donor Mobilization and Graft Collections  
A G-CSF mobilized peripheral blood stem cell (PBSC) product (identified as HPC,A) is 
the preferred progenitor cell graft source.  Our desired target goal will be 3-5 x 106 
CD34+ cells/kg.  This number of cells will be necessary to provide an adequate graft, 
following the various ex vivo manipulations, for prompt reconstitution. Two days of 
collection are typically needed to achieve this goal.  However, on rare occasions, 
additional days may be necessary.  Donors will undergo a standard hematopoietic stem 
cell mobilization regimen consisting of 6 days of G-CSF given subcutaneously at 10 
micrograms/kilogram. The graft will be collected by leukapheresis on days 5 and 6.  The 
HPC product will typically be collected and infused fresh, however there may be patients 
or logistical situations that require the HPC product to be collected early, processed, and 
stored frozen.  The NK-cell product will always be collected, processed, and infused 
fresh.   
The decision to use a fresh versus frozen HPC will be made by the PI and/or primary 
transplant attending based on patient and donor factors, as well as potential scheduling 
conflicts.   
DONOR MOBILIZATION TIME LINE (if fresh HPC product)  
DAYS  
MEDICATION  
APHERESIS  
Day -5  
G-CSF 10 mcg/kg/day SC*  
  
Day -4  
G-CSF 10 mcg/kg/day SC*  
  
Day -3  
G-CSF 10 mcg/kg/day SC*  
  
Day -2  
G-CSF 10 mcg/kg/day SC*  
  
Day -1  
G-CSF 10 mcg/kg/day SC*  
Apheresis for HPC graft  
Day 0  
G-CSF 10 mcg/kg/day SC*  
Apheresis for HPC graft  
Day +1-4  
  
Rest day  
Day +5  
  
Apheresis for TC-NK  
* G-CSF may be reduced if the donor’s WBC is >75.0 x 106/mL  
The dose of G-CSF may require modification based on the complete blood counts 
(CBC).  If the donor’s white blood count (WBC) is >75.0 x 106/ml the dose of cytokine 
administered will be reduced.  The guidelines for dose modification can be found in the 
St. Jude Children's Research Hospital Department of BMT and CT SOP 30.06.00 “The 
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mobilized with growth factor.” Ongoing updates of this document can be located at the 
following St. Jude intranet website: http://home.web.stjude.org/bone_marrow/  
The daily leukapheresed volumes for PBSC collection is generally 3–4 total blood 
volumes based on CD34+ cell counts.  Two additional days of leukapheresis may be 
performed at the physician’s discretion (no more than 4 total) to reach the cell dose 
target, however, this is expected to be rare.    
The TC-NK will be collected by the same leukapheresis procedures as the HPC product.  
However the donor will not undergo a mobilization procedure for this product collection.  
NK cell product collection will be limited to one day.  Collection will typically occur on 
day +5, but may occur anywhere from day +4 to day+8 depending on patient and donor 
factors.  
Leukapheresis may be terminated early upon request of donor, or when deemed 
medically necessary per the judgment of the treating sub-investigator physician or 
principal investigator.  All PBSC products will be collected as per Foundation for the 
Accreditation of Cellular Therapy (FACT) guidelines. Donors will be monitored during 
the period of the mobilization and leukapheresis procedure with appropriate laboratory 
evaluation (Appendix D).  
If we are unable to collect the minimum dose of 2 x 106 CD34+ cells/kg of recipient 
weight from the first donor, and the recipient has not yet initiated the preparative 
regimen, then an alternative family member may be used if he/she fulfills all the donor 
criteria described in section 3.2.  If the donor is unwilling or unable to complete the 
mobilization process or leukapheresis procedure, a BM product may be used.  The BM 
product will be processed using the same cell selection methodology on the CliniMACS 
device.   
 
4.4  Graft Preparation  
Graft evaluation and preparation will take place in the Human Applications Laboratory 
(HAL) in the Department of Therapeutics Production and Quality (TPQ) using 
established SOP.   
The initial HPC product(s) will be TCD using the investigational CliniMACS device and 
CD34 Microbead reagent as directed by the manufacturer (Miltenyi Biotech).  See 
section 5.2 for additional CliniMACS device information.  Briefly, hematopoietic 
progenitor cells collected by apheresis (HPC,A) from the mobilized donor will be 
initially assessed in the HAL and stored overnight at 4oC.  The next morning, the product 
will be washed to remove platelets and adjusted to an appropriate cell concentration for 
incubation with the CliniMACS CD34 Microbead reagent in the manufacturer provided 
media.  The cells will be washed to remove unbound microbeads.  These cells will be 
applied to the CliniMACS device and the enrichment will be performed using the 
program “CD34 Enrichment 2.1” as described by the manufacturer.  
After enrichment is complete, the cells will be washed and resuspended in an infusion 
grade solution. The graft product will be enumerated and assessed for viable CD34+ cell 
and CD3+ T-cell content by flow cytometry. The processed HPC,A product will be 
infused fresh or frozen for future use after completion of release testing and evaluation. 

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Cryopreservation will be performed per SOPs of the Human Applications Laboratory.  
Target cell doses are listed in the following table:  
HPC Graft  
Target Dose  
Minimum Dose  
Maximum Dose  
CD34+ cells/kg  
≥ 2 x 106  
2 x 106  
50 x 106  
CD3+ cells/kg  
≤ 0.05 x 106  
0.001 x 106  
0.1 x 106  
If the target dose is not achieved in a single collection, up to two additional collections 
will be performed for CD34+ enrichment (see Section 4.3).  Once the target dose is 
obtained for the CD34+ enriched product, one additional day of apheresis will be 
performed.  This HPC product will be processed for CD45RA+ depletion using the 
investigational CliniMACS device as directed by the manufacturer (Miltenyi Biotech). 
See section 5.2 for additional CliniMACS device information.  Briefly, therapeutic cells 
collected by apheresis (HPC,A) from the mobilized donor will be initially assessed in the 
HAL and stored overnight at 4oC.  The next morning, the product will be washed to 
remove platelets and adjusted to an appropriate cell concentration for incubation with the 
CliniMACS CD45RA Microbead reagent in the manufacturer provided media.  The cells 
will be washed to remove unbound microbeads. These cells will be applied to the 
CliniMACS device and the depletion will be performed using the "Depletion 3.1" 
software as described by the manufacturer.  There is no target CD34+ dose for the 
CD45RA depleted product.  Given that the previously infused CD34+ enriched 
product(s) will provide a minimum dose of 2 x 106/kg, once the CD45RA depleted 
product is infused, the patient is likely to have received  3-5 x 106 CD34+ cells/kg.   
There is no CD3+ cell target dosing on the CD45RA+ depleted product, the goal of this 
depletion is a ≥ 2 log10 depletion of CD45RA+ cells, however a depletion that does not 
achieve this target level may still be released to the patient as long as the maximum 
CD3+CD45RA+ dose is not exceeded. The maximum dose of CD3+CD45RA+ cells 
will be limited to no greater than 0.05x106/kg.  
HPC Graft  
Target Dose  
Minimum Dose  
Maximum Dose  
CD34+ cells/kg  
3-5 x 106(combined)  2 x 106(combined)  50 x 106(combined)  
CD45RA+  
≥ 2 log10 depletion (CD45RA+ depleted graft only)  
CD3+CD45RA+ cells/kg  
≤0.05 x 106  
N/A  
0.05x106  
In rare instances, the progenitor cell dose from the first day collection may be so high 
that it is feasible to split that product in two aliquots such that one aliquot may undergo 
CD34 enrichment, and the second aliquot may undergo CD45RA-depletion, thereby 
deriving both progenitor cell grafts from a single collection. This is allowed at the 
discretion of the PI, and both products may be infused on the same day when derived 
from a single collection.  
The therapeutic NK-cell product (TC-NK) will be processed using the investigational 
CliniMACS device as directed by the manufacturer (Miltenyi Biotech). See section 5.2 
for additional CliniMACS device information.  Briefly, therapeutic cells collected by 
apheresis (TC,A) from the non-mobilized donor will be initially assessed in the HAL and 
stored overnight at 4oC.  The next morning, the product will be washed to remove 

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platelets and adjusted to an appropriate cell concentration for incubation with the 
CliniMACS CD3 Microbead reagent in the manufacturer provided media.  The cells will 
be washed to remove unbound microbeads. These cells will be applied to the 
CliniMACS device and the depletion will be performed using the "Depletion 2.1" 
software as described by the manufacturer.  In the second purification step, the CD3+ 
depleted product will be enriched for CD56+ cells using the CliniMACS 
immunomagnetic enrichment program 1.1 with the CliniMACS CD56 Microbead 
reagent.  
For this protocol, our goal will be to infuse immediately after processing (Day +6) all the 
NK cells collected to give >2x106 CD56+ cells/kg of recipient body weight, but allowing 
for a CD3+ CD56- cell dose of no greater than 0.05x106/kg. The target doses for the NK-
cell product are as follows:  
TC-NK  
Target Dose  
Minimum Dose  
Maximum Dose  
CD56+ cells/kg  
> 2 x 106  
0.1 x 106  
400 x 106  
CD3+ cells/kg  
≤0.05 x 106  
N/A  
0.05 x 106  
 
4.5  Additional Progenitor Cell Graft Administration  
Infusion of an additional HPC graft from the original or an alternative haploidentical 
donor may be performed for participants when clinically indicated for graft failure, poor 
immune reconstitution, or poor hematopoietic recovery. The use of and content of a 
conditioning regimen is left to the discretion of the PI and/or primary transplant 
attending such that the most appropriate therapy is chosen for the clinical situation.  
The HPC graft will typically be obtained by apheresis (HPC,A) and be infused fresh.  
The target dose for this additional CD 34+ infusion is ≥5 x 106 cells/kg.  If the participant 
has quiescent or active BOOP, acute Grade III-IV GVHD, or any other reason that a 
severely T-cell depleted graft may be indicated, then a graft from the donor processed on 
the CliniMACSTM device using either CD34+ selection (using established SOPs) or 
CD3+ depletion methodology may be utilized. The boost target dose for these patients is 
≥10 x 106 CD34+cells/kg with a CD3+ cell/kg dose of ≤ 0.5 x 105 CD3+ cells/kg.    
 
4.6  Donor Lymphocyte Infusions  
Donor lymphocyte infusions (DLI) may be given with or without preceding 
lymphodepleting chemotherapy.  Recipients who are further out from transplant and with 
substantial lymphocyte engraftment may quickly tolerize the newly infused donor 
lymphocytes.  In such patients, lymphodepleting chemotherapy may be needed for effective 
DLI activity.  Regimen will vary based on patient condition, underlying disease, etc.  
Regimen will be determined by attending physician and/or PI, but in general would be low 
dose, expected to have minimal direct toxicity, and have limited or very transient effects on 
ANC.  Regimens for lymphodepleting chemotherapy will be defined in a separate 
document (non-protocol treatment plan-NPTP) and will require additional consent to the 
NPTP. 
4.6.1 Conventional Donor Lymphocyte Infusions  

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DLI may be administered from the original donor for decreased donor chimerism, 
serious viral reactivation or infection, or any evidence of disease.   
• Decreased donor chimerism is defined as any single chimerism test that is 
not 100% donor 
• Serious viral reactivation is defined as any virus detected in the blood by 
PCR, with a 1 log increase in viral load despite antiviral medication. 
• Serious viral infection is defined as any infectious disease from an 
identified virus that has progressed in severity despite antiviral therapy (if 
available) or shows no improvement despite 1 week of antiviral therapy (if 
available) 
• Any evidence of disease is defined as any flow cytometry, PCR, NGS 
(such as RNAseq), cytogenetic, or any other validated molecular testing 
that detects the presence of the original hematologic malignancy within the 
limits of that particular test. 
The DLI may be collected as a whole blood unit donation or by leukapheresis. If 
the DLI is collected by standard phlebotomy, the volume to be collected would be 
approximately 300 ml whole blood.  If the DLI is collected by leukapheresis, the 
amount to be processed would be approximately 2 total blood volumes.  
Prior to administration of DLI, the immunosuppression should be withdrawn and 
the recipient should have no active GVHD.  The initial dose will typically be 2.5 x 
104 CD3+/kg.  Subsequent doses will be administered at approximately 2 to 4-
week intervals with escalating doses of T cells if no moderate or severe GVHD 
occurs with the prior DLIs.  The typical initial dose escalation for patients on this 
protocol is presented in the following table:  
CONVENTIONAL DLI DOSE AND SCHEDULE  
DLI  
Dose(104 CD3+/kg)  
Comments  
Initial Dose  
2.5  
Approximately 2-4 week interval  
If no moderate or severe GVHD  
Dose #2  
5  
Dose #3  
10  
Although this algorithm will be appropriate for a majority, the treating transplant 
attending physician may alter the dose and/or interval of DLI based on response to 
previous DLI, the severity of the clinical situation, and the condition of the 
patient.  There is a low threshold for providing an initial dose of 2.5 x 104 
CD3+/kg.  DLI at this dose level have not been associated with GVHD.  
Therefore, DLI may be initiated for any chimerism less than 100% in a patient 
who is off immune suppression.  The risk of GvHD increases with increasing 
doses.  In the last 5 years, no patient has developed moderate or severe GVHD 
after haploidentical DLI dosed at 5 x 104 CD3+/kg, though mild GVHD has 
occasionally occurred.  Doses of 10 x 104 CD3+/kg should be considered to carry 
a risk of severe GVHD.  Therefore dose escalation to this level must incorporate 
the appropriate risk/benefit analysis by the treating transplant physician.  

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4.6.2 CD45RA-depleted donor lymphocyte infusions  
Low dose conventional DLI has been found to be very effective for treatment of 
low level mixed chimerism, but it’s efficacy in serious viral infections and 
recurrent disease (even at MRD levels) is poor. Although a median of 108 memory 
T-cells are adoptively transferred at the time of transplant on this study, and rapid 
donor immune reconstitution has been previously demonstrated, some patients 
may have recurrence or persistence of lymphopenia due to infections or post-
transplant immunosuppressive drugs (such as corticosteroids). Therefore selected 
patients may benefit from additional adoptive transfer of donor memory cell 
populations in the post-transplant setting.  This would include: 1. Patients with 
viral infections that are not responding to antiviral therapy or historically have a 
poor response to antiviral therapy; 2. Patients who have evidence of relapse, 
particularly molecular or MRD levels of relapse; 3. Patients who are severely 
lymphopenic, such as ALC <500/uL and/or T-cell count <300/uL. These patients 
will be allowed to receive CD45RA-depleted DLI in the following doses:  
 
CD45RA-DEPLETED DLI DOSE AND SCHEDULE  
DLI  
Dose(106 CD3+/kg)  
Comments  
Initial Dose  
0.1  
Approximately 2-4 week interval  
If no moderate or severe GVHD  
Dose #2  
1  
Dose #3  
10  
The DLI may be collected as a whole blood unit donation or by leukapheresis. If 
the DLI is collected by standard phlebotomy, the volume to be collected would be 
approximately 300 ml whole blood.  If the DLI is collected by leukapheresis, the 
amount to be processed would be approximately 2 total blood volumes. The 
collected donor lymphocytes would then undergo CD45RA depletion as decribed 
for the HPC,A graft (section 4.4).  
The release criteria of the CD45RA-depleted DLI will include at least a ≥ 2 log10 
depletion of CD45RA+ cells. The maximum dose of CD3+CD45RA+ cells will 
be limited to no greater than 0.05x106/kg for any CD45RA-depleted DLI.  
Conventional DLI and CD45RA-depleted DLI cannot be given within 14 days of 
each other.  
4.7 Quality Assurance of Cellular Products  
Quality assurance for cell products is overseen by the TPQ Quality Assurance division, 
which authorizes release of all products. Only trained stem cell processors will process 
the cell products. A labeling and product tracking system is in place to ensure that the 
correct cells are infused into the research participant.  
Assays of cell numbers and immunophenotyping will be performed both before cell 
processing and at critical stages of the process.  These values will be recorded according 
to SOP of the HAL.  All products will be tested for viability and sterility (culture and 

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Gram stain). Culture results are not available before infusion of cell products. If the gram 
stain is positive, the research participant/parent and/or guardian will be informed of this 
event and of the risks of proceeding prior to infusion.  Positive results will be 
investigated as per the variance procedures of the HAL.  The IRB and FDA will be 
notified, if at any time after infusion, cell product was determined to be contaminated.  
  
   
   
 
   
 
5.0  MEDICATION AND DEVICE INFORMATION  
 
5.1  Medications  
Cyclophosphamide (Cytoxan)  
Source  
& 
Pharmacology  
Cyclophosphamide is a nitrogen mustard derivative.  It acts as an 
alkylating agent that causes cross-linking of DNA strands by binding with 
nucleic acids and other intracellular structures, thus interfering with the 
normal function of DNA. It is cell cycle, phase non-specific. 
Cyclophosphamide is well absorbed from the GI tract with a 
bioavailability of >75%.  It is a prodrug that requires activation. It is 
metabolized by mixed function oxidases in the liver to 4-
hydroxycyclophosphamide, which is in equilibrium with aldophosfamide. 
Aldofosfamide spontaneously splits into nitrogen mustard, which is 
considered to be the major active metabolite, and acrolein. In addition, 
4hydroxycy-clophosphamide may be enzymatically metabolized to 
4ketocyclophosphamide and aldophosfamide may be enzymatically 
metabolized to carboxyphosphamide that is generally considered inactive. 
Cyclophosphamide and its metabolites are excreted mainly in the urine. 
Dose adjustments should be made in patients with a creatinine clearance 
of <50 ml/min.  
Formulation 
and Stability  
Cyclophosphamide is available in vials containing 100, 200, 500, 1000 
and 2000mg of lyophilized drug and 75 mg mannitol per 100 mg of 
cyclophosphamide.  Both forms of the drug can be stored at room 
temperature. The vials are reconstituted with 5, 10, 25, 50 or 100 ml of 
sterile water for injection, respectively, to yield a final concentration of 20 
mg/ml.  Reconstituted solutions may be further diluted in either 5% 
dextrose or 0.9% NaCl containing solutions.  Diluted solutions are 
physically stable for 24 hours at room temperature and 6 days if 
refrigerated, but contain no preservative, so it is recommended that they 
be used within 24 hours of preparation.  

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Supplier  
Commercially available  
Toxicities  
Dose limiting toxicities of cyclophosphamide includes BM suppression 
and cardiac toxicity.  Cardiac toxicity is typically manifested as 
congestive heart failure, cardiac necrosis or hemorrhagic myocarditis and 
can be fatal.  Hemorrhagic cystitis may occur and necessitates 
withholding therapy. The incidence of hemorrhagic cystitis is related to 
cyclophosphamide dose and duration of therapy. Forced fluid intake 
and/or the administration of mesna decreases the incidence and severity of 
hemorrhagic cystitis.  Other toxicities reported commonly include nausea 
and vomiting (may be mild to severe depending on dosage), diarrhea, 
anorexia, alopecia, immunosuppression and sterility.  Pulmonary fibrosis,  
SIADH, anaphylaxis and secondary neoplasms have been reported rarely.    
Route   
Intravenous infusion   
  
 Fludarabine (Fludara)  
Source  
&
Pharmacology  
Fludarabine phosphate is a synthetic purine nucleoside analog.  It acts by 
inhibiting DNA polymerase, ribonucleotide reductase and DNA primase 
by 
competing 
with 
the 
physiologic 
substrate, 
deoxyadenosine 
triphosphate, resulting in inhibition of DNA synthesis.  In addition, 
fludarabine can be incorporated into growing DNA chains as a false base, 
thus interfering with chain elongation and halting DNA synthesis.  
Fludarabine is rapidly dephosphorylated in the blood and transported 
intracellularly via a carrier-mediated process. It is then phosphorylated 
intracellularly by deoxycytidine kinase to the active triphosphate form.  
Approximately 23% of the dose is excreted as the active metabolite in the 
urine (with dosages of 18-25 mg/m2/day for 5 days).  Renal clearance 
appears to become more important at higher doses, with approximately 
41-60% of the dose being excreted as the active metabolite in the urine 
with dosages of 80-260 mg/m2.  
Formulation 
and Stability  
Fludarabine is supplied in single-dose vials containing 50 mg fludarabine 
as a white lyophilized powder and 50 mg of mannitol.  The intact vials 
should be stored under refrigeration.  Each vial can be reconstituted by 
adding 2 ml of sterile water for injection resulting in a final concentration 
of 25 mg/ml. Because the reconstituted solution contains no antimicrobial 
preservative, the manufacturer recommends that it should be used within 8 
hours of preparation.  The solution should be further diluted in 5% 
dextrose or 0.9% NaCl prior to administration.  
Supplier  
Commercially available.  

H A P N K 1 2 5 
A me n d me nt 5. 1, date d: 0 6/ 1 3/ 2 0 1 8  
 
I R B A p pr o val date: 1 0/ 1 1/ 2 0 1 8   
  
Pr ot oc ol d oc u me nt date: 0 9/ 0 6/ 2 0 1 8  
  
  
  
T o xicities  
T he  maj or  d ose -li miti n g  t o xicit y  of  fl u dara bi ne  is  m yel os u p pressi o n.   
Na usea a n d v o miti n g are us uall y mil d.  Si de effects re p orte d c o m m o nl y 
i ncl u de a n ore xia, fe v er a n d c hills, al o pecia a n d ras h.  Ne ur ot o xicit y ca n be 
ma nifeste d b y s o m n ole n ce, fati g ue, p eri p heral n e ur o pat h y, me nt al stat us 
c ha n ges, c ortical bli n d ness a n d c o ma a n d is m ore c o m m o n at hi g h d oses.  
Ne ur ot o xicit y  is  us uall y  dela ye d,  occ urri n g  2 1 -6 0  da ys  aft er  t h e  
c om pleti o n of a c o urse of t hera p y a n d m a y be irre versi ble.  Si de effects 
re p orte d  less  c o m m o nl y  i ncl u de  diarr hea,  st o matitis,  i ncrease d  li ver  
f u ncti o n  tests,  li ver  fail ure,  c hest  pai n,  arr h yt h mias  a n d  seiz ures.   
P ul m o nar y t o xicit y i ncl u des aller gic p ne u m o nitis c haracteri ze d b y c o u g h, 
d ys p nea, h y p o xia a n d p ul m o nar y i nfiltrates.  Dr u g i n d uce d p ne u m o nitis is 
a dela ye d eff ect, occ urri n g 3 -2 8 da ys after t he a d mi nistrati o n of t he t hir d 
or  later  c o urse  of  t hera p y.   A d mi nistrati o n  of  c ortic oster oi ds  us u all y  
res ults in res ol uti o n of t hese s y m pt o ms.  
R o ute     
I ntr a ve n o us  
  
  
 
  G- C S F ( Fil gr asti m, Ne u p o ge n)   
S o urce &  
P har mac ol o g y  
G -C S F  ( gra n ul oc ytic  c ol o n y  sti m ulati n g  fact or),  is  a  bi os y nt hetic  
he mat o p oietic a ge nt t hat is ma de usi n g rec o m bi na nt D N A tec h n ol o g y i n 
c ult ures of Esc h eric hi a c oli.  G- C S F sti m ulates pr o d ucti o n, mat urati o n 
a n d acti vati o n of ne utr o p hils.  I n a d diti o n, e n d o ge n o us G -C S F e n ha n ces 
certai n  f u ncti o ns  of  mat ure  ne utr o p hils,  i ncl u di n g  p ha g oc yt osis,  
c he m ota xis a n d a nti b o d y --de pe n d e nt cell ular c yt ot o xicit y.   
F or m ulati o n 
a n d Sta bilit y   
G -C S F is s u p plie d i n vials c o ntai ni n g 3 0 0 mc g a n d 4 8 0  mc g of G -C S F at 
a c o nce ntrati o n of 3 0 0 mc g/ ml. T he i ntact vials s h o ul d be st ore d u n d er 
refri gerati o n.  T he vi als ca n b e left o ut of refri gerati o n f or 2 4 h o urs, b ut 
s h o ul d be discar de d if left at r o o m te m perat ure f or l o n ger peri o ds of ti me.  
G- C S F ca n be dr a w n u p i nt o t u berc uli n s yri n ges f or a d mi nistrati o n a n d 
st ore d u n der refri gerati o n f or u p t o 7 da ys pri or t o usa ge.  G-C S F ca n be 
f urt her dil ute d f or i ntra v e n o us i nf usi o n i n 5 % de xtr ose.  D o n ot dil ute i n 
sali ne---pr eci pitate m a y f or m. If t h e fi nal c o nce ntr ati o n of t his pr o d uct is 
< 1 5  mc g/ ml,  it  is  rec o m me n de d  t hat  al b u mi n  be  a d de d  t o  a  fi nal  
c o nce ntr ati o n of 2 m g/ ml ( 0. 2 %) t o mi ni mize a ds or pti o n of t he dr u g t o 
i nf usi o n c o ntai ners a n d e q ui p me nt.    
S u p plier   
C o m merciall y a vaila ble.   

HAPNK1 26 
Amendment 5.1, dated: 06/13/2018 
 
IRB Approval date: 10/11/2018  
  
Protocol document date: 09/06/2018 
  
  
  
Toxicities  
G-CSF causes marked leukocytosis.  Adverse reactions reported 
commonly include bone pain, thrombocytopenia, diarrhea, nausea, rash, 
alopecia, fever, anorexia and pain or bruising at the injection site.  
Allergic reactions, MI, atrial fibrillation, and splenomegaly have been 
reported rarely. G-CSF is contraindicated in research participants with 
allergy to E. coli derived products.  
Route  
Intravenous or subcutaneous.  
 Melphalan (L-phenylalanine mustard, phenylalanine mustard, L-PAM, L-sarcolysin,  
Alkeranâ)  
Source  
&
Pharmacology   
Melphalan, a derivative of nitrogen mustard, is a bifunctional alkylating 
agent.  Its chemical name is 4-[bis(2-chloroethyl)amino]-L-phenylalanine, 
and it has a molecular weight of 305.20.  Melphalan is active against 
tumor cells that are actively dividing or at rest.  Its cytotoxicity is thought 
to be due to inter-strand cross-linking with DNA, probably by binding at 
the N7 position of guanine.  Melphalan is highly protein bound and does 
not penetrate well into the cerebral spinal fluid. Elimination half-life after 
intravenous administration in adults is approximately 75 minutes. 
Elimination appears to be primarily by chemical hydrolysis, but caution 
should be used in patients with renal impairment.  Plasma concentrations 
of melphalan after oral administration are highly variable, possibly due to 
incomplete absorption, variable “first pass” hepatic metabolism or rapid  
 
hydrolysis. Area under the plasma concentration-time curves for orally 
administered melphalan is approximately 60% of intravenously 
administered melphalan in adult studies.   
Formulation 
and Stability  
Available as 2 mg tablets for oral administration. This medication is stable 
at room temperature until expiration date on the packaging.  Intravenous 
formulation is supplied as 50 mg freeze dried glass vial. Each 50 mg vial 
is supplied in a carton containing a 10 ml vial of sterile diluent. 
Lyophilized melphalan should be stored at controlled room temperature 
and protected from light. Each vial is marked with its expiration date. The 
melphalan for injection must be reconstituted immediately prior to 
infusion by rapidly adding the contents of the diluent vial (10 ml) to the 
freeze dried powder with a 20 gauge or larger sterile needle and 
immediately shaking vigorously until a clear solution is obtained.  This 
results in a 5 mg/ml solution.  The dose should then be diluted in 0.9% 
NaCl for injection to a final concentration of not greater than 0.45 mg/ml.  
The resulting admixture should be infused over a minimum of 15 minutes.   
The infusion should be completed within 60 minutes of reconstitution.  Do 
not refrigerate the reconstituted melphalan.    
Supplier  
Commercially available  

HAPNK1 27 
Amendment 5.1, dated: 06/13/2018 
 
IRB Approval date: 10/11/2018  
  
Protocol document date: 09/06/2018 
  
  
  
Toxicities   
Melphalan is cytotoxic and caution should be used in handling and 
preparing the solution or administering the tablets. Use of gloves is 
recommended, and if contact with skin or mucosa occurs, immediately 
wash thoroughly. Second cancers such as acute non-lymphocytic 
leukemia, myeloproliferative syndrome, and carcinoma have been 
reported in patients taking melphalan alone or in combination with other 
chemotherapy or radiation. Melphalan causes suppression of ovarian 
function in premenopausal women, with a significant number of patients 
having amenorrhea. Testicular suppression (reversible and irreversible) 
has been reported.  The most common adverse reaction is 
myelosuppression. 
Irreversible 
BM 
failure 
has 
been 
reported. 
Gastrointestinal side effects reported include nausea/vomiting, diarrhea 
and oral mucosa ulceration.  Hepatic toxicity has occurred, including 
veno-occlusive disease.  Acute hypersensitivity reactions occur in about 
2.4% of patients, and can include anaphylaxis. Hypersensitivity reactions 
were characterized by urticaria, pruritus, and edema.  Some patients 
exhibited tachycardia, bronchospasm, dyspnea and hypotension that 
responded to antihistamines and corticosteroids. Other side effects that 
have been reported include skin ulceration or necrosis at injection site, 
vasculitis, alopecia, hemolytic anemia, pulmonary fibrosis, and interstitial 
pneumonitis.   
Route   
Intravenous  
  
 
 
Mesna (Mesnex)  
Source  
& 
Pharmacology   
Mesna is a synthetic sulfhydryl (thiol) compound. Mesna contains free 
sulfhydryl groups that interact chemically with urotoxic metabolites of  
 
oxaza-phosphorine derivatives such as cyclophosphamide and ifosfamide. Oral 
bioavailability is 50%. Upon injection into the blood, mesna is oxidized to 
mesna disulfide, a totally inert compound.  Following glomerular filtration, 
mesna disulfide is rapidly reduced in the renal tubules back to mesna, the 
active form of the drug.  Mesna and mesna disulfide are excreted primarily via 
the urine.  
Formulation 
and Stability  
Mesna is available in 2 ml, 4 ml and 100 ml amps containing 100 mg/ml of 
mesna solution.  The intact vials can be stored at room temperature. Mesna 
may be further diluted in 5% dextrose or 0.9% NaCl containing solutions.  
Diluted solutions are physically and chemically stable for at least 24 hours 
under refrigeration.    
Supplier  
Commercially available  

H A P N K 1 2 8 
A me n d me nt 5. 1, date d: 0 6/ 1 3/ 2 0 1 8  
 
I R B A p pr o val date: 1 0/ 1 1/ 2 0 1 8   
  
Pr ot oc ol d oc u me nt date: 0 9/ 0 6/ 2 0 1 8  
  
  
  
T o xicities  
Mes na is ge ner all y well t olerate d.  Na us ea a n d v o miti n g, hea dac he, diarr hea, 
ras h, tra nsie nt h y p ote nsi o n a n d aller gic reacti o ns ha ve bee n re p orte d.  Patie nts 
ma y c o m plai n of a bitter taste i n t heir m o ut h d uri n g a d mi nistrati o n. Mes na ma y 
ca use f alse p ositi ve uri ne di pstic k rea di n gs f or ket o nes.    
D osa ge  
a n d  
A d mi nistrati o n  
Mes na is ge nerall y d ose d at a p pr o xi matel y 2 5 % of t he c ycl o p h os p ha mi de d ose.  
It  is  ge n er all y  gi ve n  i ntra ve n o usl y  pri or  t o  a n d  a gai n  at  3,  6  a n d  9  h o urs  
f oll o wi n g eac h d ose of c ycl o p h os p ha mi de.  
R o ute  
I ntr a ve n o us  
 T hi ote pa ( T hi o ple x  b y I m m u ne x) ( T E S P A, T S P A)  
S o urce &  
P har mac ol o g y   
T hi ote pa is a cell -c ycle n o ns pecific p ol yf u n cti o nal al k ylati n g a g e nt.  It reacts 
wit h D N A p h os p hate gr o u ps t o pr o d uce cr oss -li n ki n g of D N A stra n ds lea di n g 
t o i n hi biti o n of D N A, R N A a n d pr otei n s y nt hesis.  T hi ote pa is e xte nsi vel y 
meta b olize d  i n  t he  li ver  t o  meta b olites  t hat  retai n  acti vit y,  pri maril y  
triet h yle ne-p h os p h ora mi de ( T E P A).  T he mai n r o ute of eli mi nati o n is via t he 
uri ne, mai nl y a s meta b olites; t he eli mi nati o n halflife of t he t hi ote pa is 2. 5 
h o urs, a n d t hat of T E P A is 1 7. 6 h o urs.  
F or m ulati o n a n d 
Sta bilit y  
T hi ote pa  is  s u p plie d  i n  si n gle -use  vials  c o nt ai ni n g  1 5  m g  of  l y o p hilize d  
t hi ote pa, 8 0 m g Na Cl a n d 5 0 m g Na H C O 3.  T he i ntact vials s h o ul d be st ore d 
u n der  refri gerati o n  a n d  pr otecte d  fr o m  li g ht.   Eac h  vial  s h o ul d  be  
rec o nstit ute d wit h 1. 5 ml of sterile water f or i njecti o n t o yiel d a c o nce ntrati o n 
of  1 0  m g/ ml.   F urt her  dil uti o n  wit h  sterile  water  f or  i njecti o n  t o  a  
c o nce ntr ati o n of  1 m g/ ml yiel ds a n is ot o nic s ol uti o n; if lar ger v ol u mes are 
desire d  f or  i ntraca vitar y,  i ntra ve n o us  i nf usi o n,  or  perf usi o n  t hera p y,  t his  
s ol uti o n  ma y  t he n  be  dil ute d  wit h  5 %  de xtr ose  or  0. 9 %  Na Cl  c o ntai ni n g  
s ol uti o ns.  T he 1 0 m g/ ml rec o nstit ute d s ol uti o n is c he micall y sta ble w he n  
st ore d i n t he refri gerat or f or u p t o 5 da ys, h o we ver, it is rec o m me n de d t hat 
s ol uti o ns be pre pare d j ust pri or t o a d mi nistrati o n si nce t he y d o n ot c o ntai n a 
preser v ati ve.  Rec o nstit ute d s ol uti o ns s h o ul d be clear t o sli g htl y o pa q ue: t he 
s ol uti o ns ma y be filtere d  
t hr o u g h a 0. 2 2 micr o n filter t o eli mi nate haze.  
S u p plier  
C o m merciall y a vaila ble; ma n ufact ure d b y I m m u n e x  
T o xicities   
D ose li miti n g t o xicit y is m yel os u p pressi o n.  T he l e u k oc yte n a dir ma y o cc ur at 
a n y ti me fr o m 1 0 t o 3 0 da ys.  Ot her t o xicities i ncl u de pai n at t he i njecti o n site, 
na usea a n d v o miti n g, a n ore xia, m uc ositis, dizzi ness, hea dac h e, a me n orr h ea, 
i nterfer e nce  wit h  s per mat o ge nesis,  a n d  de pi g me ntati o n  wit h  t o pical  use.   
Aller gic r eacti o ns, i n cl u di n g s ki n ras h a n d hi ves,  ha ve bee n re p orte d rarel y.  
Rare cases of a p nea, he m orr ha gic c ystitis, a n d re nal fail ure ha ve occ urre d.  
T hi ote pa is m uta ge nic, carci n o ge nic, a n d terat o g e nic i n a ni mals.  Pre g na nc y 
cate g or y D.   
 R o ute  
I ntr a ve n o us i nf usi o n.  

H A P N K 1 2 9 
A me n d me nt 5. 1, date d: 0 6/ 1 3/ 2 0 1 8  
 
I R B A p pr o val date: 1 0/ 1 1/ 2 0 1 8   
  
Pr ot oc ol d oc u me nt date: 0 9/ 0 6/ 2 0 1 8  
  
  
  
M yc o p he n olate m of etil ( M M F,  Cell Ce pt )  
S o urce  
 
&  
P har mac ol o g y   
M yc o p he n olate  m ofetil  is  h y dr ol yze d  t o  m yc o p he n olic  aci d  ( M P A),  a n  
i m m u n os u p pressi ve  a ge nt.  M P A  i n hi bits  T- a n d  B-cell  pr oliferati o n,  Tcell  
s y nt hesis, a n d a nti b o d y secreti o n b y p ote nt, n o nc o m petiti ve re versi ble i n hi biti o n 
of  i n osi ne  m o n o p h os p hate  de h y dr o ge nase  (I M P D H)  i n  t he  p uri ne  bi os y nt hesis  
pat h wa y. I n hi biti o n of I M P D H res ults i n a de pleti o n of g ua n osi ne tri p h os p hate 
a n d  de o x y g ua n osi ne  tri p h os p hate,  i m p orta nt  i nter me diates  i n  t he  s y nt hesis  of  
l y m p h oc yte  D N A,  R N A, pr otei ns  a n d  gl yc o pr otei ns.  Oral  f or m ulati o ns  of  
m yc o p he n olate m ofetil are  ra pi dl y a n d e xte nsi vel y a bs or be d w he n gi ve n o n a n 
e m pt y  st o mac h.  F o o d  a n d  al u mi n u m - a n d  ma g nesi u m -c o ntai ni n g  a ntaci ds  
decrease a bs or pti o n of m yc o p he n olate m ofetil. M M F is ra pi dl y h y dr ol yze d t o t he 
acti ve meta b olite ( M P A) after oral or i ntra ve n o us a d mi nistrati o n. Free M P A is 
c o nj u gate d i n t he li ver b y gl uc ur o n yl tra nsferase t o i nacti ve m yc o p he n olic aci d 
gl uc ur o ni de  ( M P A G)  w hic h  is  e xcrete d  i n  t he  uri ne  a n d  feces.  Ti me  t o  pea k  
plas ma  c o nce ntrati o n is 0. 8 – 1. 3 h o urs, a n d t he mea n eli mi nati o n half -life is 1 7. 9 
h o urs. E nter o he patic recirc ulati o n of M P A c o ntri b utes t o plas ma c o nce ntrati o ns. 
A d mi nistrati o n  of  c h olest yra mi ne  i nterr u pts  t he  e nter o he patic  recirc ulati o n  a n d  
ca n decrease bi oa v aila bilit y b y as m uc h as 4 0 %.  Patie nts wit h re nal i ns ufficie nc y 
ha ve  i ncrease d  plas ma  c o nce ntrati o ns  of  M P A  a n d  M P A G.   Ac ycl o vir  a n d  
ga ncicl o vir  ma y  c o m pete  wit h  M P A G  f or  re nal  t u b ular  secreti o n,  res ulti n g  i n  
i ncrease d plas ma c o nce ntrati o ns of b ot h dr u gs.    
F or m ulati o n 
a n d Sta bilit y  
M yc o p he n olate m ofetil is c o m merciall y a vaila ble as 2 5 0 m g ca ps ules, 5 0 0 m g 
ta blets, 2 0 0 m g/ ml p o w der f or oral s us pe nsi o n, a n d 5 0 0 m g vials of p o w der f or 
i njecti o n.  
S u p plier  
C o m merciall y a vaila ble  
T o xicities  
A d verse  e ve nts  see n  i n  patie nts  ta ki n g  m yc o p he n olate  m ofetil  i ncl u de  
h y perte nsi o n,
 h y p ote nsi o n,
 peri p heral
 e d e ma,
 le u k o pe nia,
 a ne mia,
 
t hr o m b oc yt o pe nia,  h y p o c hr o mic  a n e mia,  le u k oc yt osis,  hea dac h e,  i ns o m nia,  
dizzi ness, tre m or, a n xiet y, parest h esia, h y per gl yce mia, h y per c h olester ole mia, 
h y p o kale mia,  h y per k al e mia,  h y p o p h os p hate mia,  diarr h ea,  c o nsti pati o n,  
na usea, v o miti n g,  a n ore xia, a b d o mi nal  pai n, d ys pe psia, uri nar y b ur ni n g or 
fre q ue n c y,  re n al  t u b ular  necr osis,  he mat uria,  i n creas e  ser u m  creati ni ne  a n d  
B U N, a variet y of i nfecti o ns d ue t o i m m u n os u p pressi o n, ras h, ac ne, o c ular 
c ha n ges
 (catar acts,
 
 ble p haritis,
 keratitis,
 gla uc o ma,
 a n d
 mac ular
 
a b n or malities) occasi o nal le g cra m ps or p ai n, b o ne pai n, m yal gias, a n d h a n d 
cra m ps.  I ntra ve n o us  i nf usi o ns  ha ve  b ee n  re p ort e d  t o  ca use  t hr o m b osis  a n d  
p hle bitis. T here ha ve bee n occasi o nal re p orts of gastr oi ntesti nal he m orr ha ge.  
Hi g h  d ose  t hera p y  wit h  m yc o p he n olate  i n  a d ults  wit h  ps oriasis  has  bee n  
ass ociate d wit h t he f oll o wi n g ne o plas ms: a de n ocarci n o ma of t he breast a n d 
c ol o n,  basal  cell  carci n o ma,  carci n o ma  of  t he  gall bla d der,  histi oc ytic  
l y m p h o ma,  gli o blast o ma  m ultif or me,  a n d  s q ua m o us  cell carci n o ma  of  t he  
e pi gl ottis. 
R o ute  
I ntr a ve n o us or oral  

HAPNK1 30 
Amendment 5.1, dated: 06/13/2018 
 
IRB Approval date: 10/11/2018  
  
Protocol document date: 09/06/2018 
  
  
  
 
5.2  CliniMACSTM System    
The mechanism of action of the CliniMACS Cell Selection System is based on 
magneticactivated cell sorting (MACS).  The CliniMACS device is a powerful tool for 
the isolation of many cell types from heterogeneous cell mixtures, (e.g. apheresis 
products).  These can then be separated in a magnetic field using an immunomagnetic 
label specific for the cell type of interest, such as CD3+ human T cells.  
The cells to be isolated are specifically labeled with super-paramagnetic particles by an 
antibody directed toward a cell surface antigen.  After magnetic labeling, the cells are 
separated using a high-gradient magnetic separation column as described below.  The 
magnetically labeled cells are retained in the magnetized column while the unlabeled 
cells flow through the column for collection.  The retained cells are eluted by removing 
the magnetic field from the column, washing the cells out and collecting them in a 
separate container from the unlabeled cells.  
The super-paramagnetic particles are small in size (about 50 nm in diameter) and are 
composed of iron oxide/hydroxide and dextran conjugated to monoclonal antibodies.  
These magnetic particles form a stable colloidal solution and do not precipitate or 
aggregate in magnetic fields.  The antibody conjugated beads used in this system are 
highly specific (e.g. CD3+ cells via OKT3 conjugated beads). High-gradient MACS 
technology has been shown to achieve rapid and highly specific depletion or enrichments 
of large numbers of target cells from BM, cord blood, and normal peripheral blood 
mononuclear cells.   
The CliniMACS device incorporates a strong permanent magnet and a separation 
column with a ferromagnetic matrix to separate the cells labeled with the magnetic 
particles. The high-gradient system allows the application of strong magnetic forces and 
a rapid demagnetization. Small ferromagnetic structures, such as the column matrix, 
placed in a magnetic field concentrate this homogenous field and thereby produce high 
magnetic gradients. In their immediate proximity, the ferromagnetic structures generate 
magnetic forces 10,000-fold greater than in the absence of those structures enabling the 
retention of magnetically labeled cells. After removing the column from the magnet, the 
rapid demagnetization of the column matrix allows the release of retained cells.   
The CliniMACS device is comprised of a computer controlled instrument incorporating 
a strong permanent magnet, a closed-system sterile tubing set containing columns with a 
coated ferromagnetic matrix and a paramagnetic, cell specific, labeling reagent. The 
instrument will separate the cells in a fully automated process yielding a cell population 
highly depleted of CD3+ cells. The CliniMACS device is not licensed by the FDA and 
therefore is investigational.  
The CliniMACS device has separate programs that allow cell selection procedures 
optimized for either depletion (e.g. CD3+ or CD45RA+) or  selection of a target cell 
population (e.g. CD34+ or CD56+ cells). The basic mechanism is the same for either 
application; target cells are "tagged" with super-paramagnetic particles and eventually 
separated from the unlabeled cells using the CliniMACS device as described above. The 
desired target cells can either be infused or discarded appropriately.    

HAPNK1 31 
Amendment 5.1, dated: 06/13/2018 
 
IRB Approval date: 10/11/2018  
  
Protocol document date: 09/06/2018 
  
  
  
6.0 REQUIRED OBSERVATIONS AND EVALUATIONS  
 
6.1  Pre/peri/post-transplant evaluations  
All pre/peri/posttransplant and long-term follow-up evaluations for these participants 
will be carried out as outlined in Appendix D, and guided by the Standard Operating 
Procedures (SOPs) of the St. Jude Children's Research Hospital, Department of BMTCT, 
for recipients of allogeneic stem cell transplantation.  Copies of these SOPs and ongoing 
updates 
can 
be 
found 
at 
the 
following 
site: 
http://home.web.stjude.org/bone_marrow/clinicalHome.shtml.  
Furthermore, to accommodate the research studies, flexibility in the date is allowed 
without a deviation from protocol.  The degree of flexibility in the timing is also 
provided in Appendix  
E.     
6.2 Long-term follow-up evaluations  
In general, recipients of allogeneic HCT at St. Jude are seen at least annually until 10 
years posttransplant in the Department of BMTCT outpatient clinic. For the purpose of 
this study, research participants will be followed to year 1 post-transplantation. All study 
participants will be eligible for enrollment in the institutional long-term follow-up 
protocol for children and young adults who have received stem cell transplantation at St. 
Jude Children’s Research Hospital (BMTFU protocol).  
6.3 Evaluation for Chimerism and Engraftment  
Evaluation for chimerism and engraftment will be performed on bone marrow or 
peripheral blood samples according to the timelines noted in Appendix E. Bone marrow 
chimerism studies will be conducted on or about the following time points: day +21, day 
+100, and year one posttransplant. However, for research participants who have less than 
100% donor chimerism at or about day +21 posttransplant, a repeat bone marrow study 
(to include chimerism) may be performed approximately one week after the initial 
procedure.    
The time to neutrophil and platelet engraftment will be recorded.  Neutrophil 
engraftment will be defined as the first of 3 consecutive days of an absolute neutrophil 
count (ANC) greater than or equal to 500/mm3. Time to platelet engraftment will be 
designated as the time to platelet count exceeding 20,000/mm3 and 50,000/mm3 without 
a platelet transfusion in the preceding seven days.  
Chimerism studies using peripheral blood will be obtained on an approximate weekly 
basis according to the evaluation schedule noted in Appendix E.  Additional bone 
marrow and/or peripheral blood chimerism studies may be performed throughout the 
course of this study when clinically indicated.  Chimerism studies derived from bone 
marrow may be used in lieu of a specified peripheral blood sample if a bone marrow 
sample is available.  In the event of graft failure/rejection, subsequent chimerism studies 
may be held as they would not be clinically indicated at that time.  
If there is an initial decrease in donor chimerism to less than 90% at any time on 
peripheral blood studies, a bone marrow examination will subsequently be performed 

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within approximately two weeks to confirm this initial decline.  In addition, chimerism 
analysis may be performed in subsets of lymphocytes, granulocytes, and monocytes for 
research participants with increasing host chimerism until the research participant attains 
100% donor chimerism. Chimerism studies will be performed in the St. Jude Department 
of Pathology using standard DNA techniques [i.e. VNTR (variable number tandem 
repeat)] and/or FISH (fluorescent in-situ hybridization) analysis.  Chimerism studies will 
be reported in the database as donor percentages.  
6.4 Evaluation for immune reconstitution  
Research participants will have immune reconstitution studies of lymphocyte subsets 
(i.e. cells, B cells, and NK cells).  These studies may be performed more often than what 
is outlined in Appendix E depending on the clinical status of the research participant.    
Immune analysis as described (Mnemonic listed in 6.4.1 through 6.4.4) will be 
performed according to the schedule outlined in Appendix D until the immune 
parameters recover to normal level or donor pattern:   
6.4.1  Lymphocyte subsets study: Flow cytometry enumeration.    
 6.4.2  VBETA/TREC Research: Thymic output and T-cell repertoire.   
 6.4.3  Lymphocyte Phenotypes Research: T-cell and NK-cell number and function.   
6.4.4  Quantitative immunoglobulins: IgG, IgM, and IgA  levels.  
6.4.5 IR-Phenotype: Immune reconstitution of memory and naïve T cells will be 
investigated in depth in the Youngblood Lab.  This may include phenotypic subset 
characterization, functional correlates, and analysis of the epigenetic signatures of 
these populations.   
6.4.6 T-Function: T-cell function will be investigated in depth in the Thomas Lab. This 
may include antigen-specific T-lymphocyte response to viral infections, such as 
herpes viruses (CMV, HSV and VZV) and respiratory viruses (influenza and 
RSV).   
6.5 General Viral Surveillance  
Serial PCR testing for CMV, adenovirus, and EBV will be done weekly to day 100 and 
then on an as needed basis.  In research participants with progressive or active infection, 
samples may be obtained more frequently (St. Jude test mnemonic BMTPCR).    
   
 
6.6  Minimal residual disease evaluation  
Minimal residual disease (MRD) assays in peripheral blood and/or BM by immunologic 
and molecular methods will be performed for those research participants who have had 
this test performed during prior therapy for their disease at St. Jude only or those for who 
samples of diseased marrow were available to identify a leukemic marker for MRD 
testing.  BM (3ml) and/or peripheral blood (5-10 ml) will be obtained from the 
participants at pre-transplant evaluation, at or about day +21, +100 and at the annual 
evaluation.  MRD assays may be performed more frequently in participants with 

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increasing host chimerism.  We will apply immunologic and molecular methods as 
previously described.54-55 Tests will be performed in the appropriate St. Jude 
laboratories.  
 
6.7  Research tests on haploidentical donor (optional)  
Donors will be offered the option for participation in research studies of immune 
reconstitution.  These tests will be obtained after consent and preferably prior to growth 
factor administration.  Lymphocyte subset analysis of the donor appears to allow for the 
prediction of the reconstitution of the lymphocyte subsets in the research participant after 
transplantation.  Data in larger donor/research participant pairs will help to verify these 
observations. A list of these optional research studies are noted in Appendix D and 
detailed below:  
6.7.1  Lymphocyte subsets study  
  
  Flow cytometry enumeration.  
6.7.2  VBETA/TREC Research  
  
  Thymic output and T-cell repertoire.  
6.7.3 Lymphocyte Phenotypes Research  
Lymphocyte number and function.   
 6.7.4  IR-PHENOTYPE, and T-FUNCTION: In depth characterization of donor  
 
lymphocytes   
  
7.0 EVALUATION CRITERIA  
 
7.1  Adverse event monitoring   
Adverse event (AE) monitoring for on-study research participants will be assessed using 
the NCI Common terminology Criteria for Adverse Events Version 3.0.  The specific 
criteria for adverse event monitoring are noted Section 9.0 and in Appendix D.  
7.2 GVHD diagnosis and grading   
Acute and chronic GVHD will be evaluated, staged, and graded using the criteria found 
in Appendix B and C respectively.  
Appendix B contains the COG stem cell committee consensus guidelines for establishing 
organ stage and overall grade of acute GVHD. In the initial 26 patients treated on this 
protocol prior to amendment 2.0, there were 3 patients initially diagnosed with 
hyperimmune response syndrome, or similar. This was due to the development of 
GVHD-like symptoms in some patients that were atypical of acute GVHD syndromes 
seen in conventional T-cellreplete transplantation. Other patients developed symptoms 
that were somewhat atypical, but also had a high degree of overlap with acute GVHD.  
Comprehensive review of the patients transplanted on HAPNK1 prior to amendment 2 
was performed by institutional monitors, at least 3 external transplant physicians, and the 
PI.  All patients previously noted to have hyperimmune response syndrome (or similar) 
were re-coded to acute GVHD. One additional patient was determined to have 

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significant GVHD by audit consensus, giving 4 of the first 26 patients with acute GVHD 
≥ grade III. Although we and others96 have noted that GVHD syndromes appear to be 
biologically different in Naïve T-cell depleted transplantation such as this, with 
amendment 2.0 any GVHD-like syndrome will be coded as GVHD until such time that a 
more specific syndrome is fully characterized.  The COG stem cell committee consensus 
guidelines for establishing organ stage and overall grade of acute GVHD has been 
adopted as the standard GVHD diagnostic guidelines for the Department of BMTCT, 
and will be applied to patients on this protocol (see Appendix B). In addition, acute 
GVHD will be assessed at least once a week for the first 100 days per BMTCT SOP 
20.01.  
Other disorders that involve donor immune dysregulation, that are distinct from GVHD 
are known to occur in transplant recipients. Interstitial pneumonitis syndrome (IPS) and 
bronchiolitis obliterans organizing pneumonia (BOOP) are two relatively common 
examples. These disorders are often associated with acute GVHD, but are not considered 
to be acute GVHD, and are often treated with steroids. These and similar disorders will 
be captured as  
AE’s and will not be considered to be acute GVHD. The risk of non-GVHD disorders of 
immune dysregulation in naïve T-cell depleted transplantation is unknown. In the 26 
patients transplanted on this study prior to amendment 2, no patient has been diagnosed 
with IPS or BOOP.  However, 3 patients have been diagnosed with toxic epidermal 
necrolysis (TEN) (n=2) or Steven-Johnson syndrome (SJS) (n=1).  TEN and SJS are 
considered to be variants of a disease continuum that is often triggered by viral infection 
or drug exposure, and is mediated by cytotoxic T cells.97  All three patients experienced 
resolution of their TEN/SJS with brief immunosuppressive therapy.98 It can be difficult 
due to overlapping symptoms, but given that therapeutic recommendations are different, 
it is important to distinguish such diseases from acute GVHD if possible. Any toxicity 
that fits criteria for a well described disorder of immune dysregulation (such as the 
examples above) will be recorded no matter the CTC CAE grade. This allows a full 
accounting of the incidence of these disorders in naïve T-cell depleted transplantation.  
Appendix C contains a summary of the NIH consensus development project on criteria 
for clinical trials in chronic GVHD.99 This table will be used for staging/grading of 
chronic  
GVHD.  
7.3 Performance status   
Performance status will be assessed by Karnofsky/Lansky Performance Scores found in 
Appendix A.  
7.4 Hematologic recovery  
Posttransplant hematologic recovery will be determined using the engraftment criteria as 
follows:   
7.4.1 Neutrophil engraftment will be defined as the first of 3 consecutive tests performed 
on different days of an ANC ≥ 500/mm3 with evidence of donor cell engraftment.  

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7.4.2 Platelet engraftment will be defined as the first of 3 consecutive tests performed on 
different days of a platelet count ≥ 20,000/mm3 with no platelet transfusions in 
the preceding 7 days.  
7.5 Graft failure  
Primary graft failure will be defined as an ANC never meeting or exceeding 500/mm3 
for 3 consecutive tests performed on different days and no evidence of donor chimerism 
(<5%) before  day +42 post-HCT.  
Secondary graft failure will be defined as a decline in ANC to<500/mm3 with a decline 
in donor chimerism to <5% in research participants with prior engraftment.  
7.6 Chimerism  
Mixed hematopoietic chimerism will be defined as between 10% and 95% donor 
chimerism in the absence of immunosuppressive therapy.  
8.0 OFF-STUDY CRITERIA  
 
8.1  Recipient criteria  
Recipient research participants will remain on study until one of the following occurs:  
8.1.1 Withdrawal from protocol.  
8.1.2 Death.  
8.1.3 Donor unable to provide the HSC required for intended recipient to undergo the 
primary HCT procedure (refer to donor off-study criteria).  
8.1.4 Unable to be contacted and/or effectively monitored by the Principal Investigator 
(PI) and/or designees for follow-up (lost to follow-up).  
8.1.5 One year after HSC infusion (i.e. has completed the year +1 post-primary 
transplant evaluation) and enrollment onto the BMTFU protocol.  
8.1.6 Development of a significant change in health status at any point of therapy which 
would render receipt of the transplantation procedure or continuation in the study 
medically unsafe or not in the participant’s best interest.  
8.1.7 Requires additional chemotherapy for morphologically confirmed disease relapse 
(generally >5%). 
 
Epigenetic or targeted therapy and low dose lymphodepleting chemotherapy with 
DLI, even if molecularly detectible disease is present, would not trigger this off-
study criteria.  
8.2 Additional notes  
Recipient research participants enrolled on this study will remain on study for 
monitoring if one of the following occurs:  
8.2.1 Experiences graft failure/rejection.  
8.2.2 Noncompliance with protocol medications/administrations and/or required follow-
up evaluations.  

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8.2.3 Positive pregnancy test post-HSC infusion.  
8.2.4 Recipient requires an additional HSC infusion, and unable to receive these cells 
due to donor issues.  
8.3 Donor Criteria  
Donor research participants will remain on study until one of the following occurs:  
8.3.1 Withdrawal from protocol.  Donor research participants may withdraw their 
consent to participate at any time.  Physician may withdraw donor at any time 
that continuation in the study is deemed medically unsafe or no longer in the 
donor’s best interest.  
8.3.2 Day of transplant recipient or transplant donor death, whichever occurs first.  
8.3.3 Development of a change in health status, including positive pregnancy test or a 
clinically significant risk for or positive testing for communicable disease, which 
in the opinion of the PI, would render the donor medically ineligible to serve (or 
continue to serve) as a therapeutic cell donor.  
8.3.4 Unable to be contacted and/or effectively monitored by PI and/or designees for 
follow-up as judged by the PI (including non-compliance and lost to follow-up).  
8.3.5 Once the PI has determined that the transplant recipient does/will not require an 
additional infusion(s) of the donor’s cells for the purpose of this protocol, the 
donor will be taken off study seven days post final cell collection procedure.   
9.0  REPORTING CRITERIA AND CONTINUING REVIEW REPORTS  
 
9.1  Reporting Adverse Experiences and Deaths to St. Jude IRB  
The principal investigator is responsible for promptly reporting to the IRB any adverse 
events that are unexpected/unanticipated, serious, and that may represent potential harm 
or increased risk to research participants.  When an unexpected death occurs, the PI 
should report it to the Director of Human Subject’s Protection immediately, by phone: 
(901) 5954359, cell: (901) 336-2894, fax: (901) 595-4361, or e-mail: hsp-1@stjude.org.  
A reportable event entry into TRACKS should follow within 48 hours of notification of 
the event.  
Serious, unexpected, and related or possibly related events must be reported within 10 
business days of notification of the event.  At the same time, the investigator will notify 
the study sponsor and/or the FDA, as appropriate.  All other SAEs, including expected 
death, and all captured AEs will be reported to the IRB at the time of the continuing 
reviews, with the following exceptions:  
• 
Any grade III-IV infusion reactions will be reported as soon as possible but every 
effort should be made to assure reporting is no more than within 10 business days 
of the event.  
• 
Any episodes of overall grade III or IV acute GVHD in participants will be 
reported to the IRB as soon as possible but no more than within 10 business days 
of the PI’s confirmation of the diagnosis/grade of the event.  

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For this research study, recipient participants will be followed for all NCI Grade III-V 
adverse events from the start of conditioning and throughout the first year post HCT, 
regardless of their relationship to the treatment given.  In addition, clinically significant 
NCI Grade I-II adverse events that are judged to be related/possibly related may be 
collected per the discretion and judgment of the PI.  Examples of “clinically significant 
Grade I-II adverse events could include, but are not limited to: events meeting criteria for 
SAE, infections requiring oral systemic therapy, VOD or hemorrhagic cystitis. GVHD 
events will be recorded on an ongoing basis regardless of stage or grade using the criteria 
defined in Appendix B, and will not be graded according to NCI criteria.  
With regard to the haploidentical donor participants, they will be followed for all SAEs 
and any clinically significant AEs, per the judgment of the PI, that are deemed related to 
the mobilization and/or apheresis procedure from the time of apheresis of NK cells, on 
through the initiation of mobilization growth factors, until 7-days post last day of the 
final apheresis procedure.  If the transplant recipient requires a second HSC infusion, 
meaning that the donor is required to undergo the mobilization and apheresis procedure 
again, collection of this donor safety data will restart upon the initiation of the 
subsequent mobilization procedure and continue until 7-days post the last day of this 
apheresis procedure. Timelines for reporting of these donor events to the institutional 
and federal governing agencies will be according to the same timelines utilized for the 
recipients.  A listing of the captured donor safety data will be provided in a separate table 
from the transplant recipients within each respective continuing review report.    
The following definitions apply with respect to reporting adverse experiences:   
Serious adverse event – any adverse event temporally associated with the participant’s 
participation in research that meets any of the following criteria:  
• 
results in death;  
• 
is life-threatening (places the participant at immediate risk of death from the 
event as it occurred);  
• 
requires inpatient hospitalization or prolongation of existing hospitalization  
• 
results in a persistent or significant disability/incapacity;  
• 
results in a congenital anomaly/birth defect; or  
• 
any other adverse event that, based upon appropriate medical judgment, may 
jeopardize the participant’s health and may require medical or surgical 
intervention to prevent one of the above outcomes.  
Unexpected adverse event – any adverse event meeting any of the following criteria:  
• 
an event for which the specificity or severity is not consistent with the protocol 
related documents, including the applicable investigator brochure, IRB approved 
consent form, IND/IDE application or any of the product labeling or package 
inserts;  
• 
an event for which the observed rate of occurrence is significantly increased 
above what is expected or credible baseline rate for comparison;  
• 
an event for which the occurrence is not consistent with the expected natural 
progression of any underlying disease, disorder, or condition of the participant(s) 

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experiencing the adverse event and the participant’s predisposing risk factor 
profile for the adverse event.  
The principal investigator is responsible for reviewing the aggregate toxicity reports and 
reporting to the IRB if the frequency or severity of serious toxicities exceed those 
expected as defined in the protocol or based on clinical experience or the published 
literature.  Any proposed changes in the consent form or research procedures resulting 
from the report are to be prepared by the study team and submitted with the report to the 
IRB for approval.  
 
9.2  Reporting to St. Jude Institutional Biosafety Committee   
Continuing review reports will be sent to the Institutional Biosafety Committee (IBC) on 
at least an annual basis using the most current version of the continuing review form 
found on the IBC website. The safety reports, sent to the IRB for both the donors and 
stem cell recipients, will be simultaneously forwarded to the IBC. Therefore, reporting 
for safety events to this committee will be according to the same timelines as reporting to 
the IRB.  This includes notification of achievement of MTD (if/when applicable).  As 
per the direction of the IBC, only those protocol revisions and amendments directly 
related to the CliniMACS processing and related reagent(s) will require review and 
consideration by the IBC.  Other revisions/amendments will be noted in the IBC 
continuing review report.  
 
9.3  Reporting to FDA (21CFR§312.32 Safety reports)  
The FDA will be notified in writing (IDE safety report) of any serious and unexpected 
AE associated with an investigational treatment or device; or any results from laboratory 
animal tests that suggest a significant risk for human subjects including reports of 
mutagenicity, teratogenicity, or carcinogenicity.  
Each notification to the FDA should be made as soon as possible and no later than 15 
calendar days after the sponsor’s initial receipt of the information. The FDA may require 
additional data to be submitted.  In each written IND safety report, the sponsor shall 
identify all safety reports previously filed with the IND concerning a similar adverse 
experience, and shall analyze the significance of the adverse experience in light of the 
previous, similar reports where applicable.  
The sponsor shall also notify the FDA by telephone or by facsimile transmission of any 
unexpected fatal or life-threatening experience associated with the use of the 
investigational device as soon as possible but no later than 7 calendar days after the 
sponsor’s initial receipt of the information.  Any grade III-IV infusion reactions will be 
reported as soon as possible but every effort should be made to assure reporting is no 
more than within 7 business days of the event.  Follow-up information to a safety report 
must be submitted as soon as the relevant information is available.  
If the results of further investigation show an AE that was not initially determined to be 
reportable should later be deemed reportable, the sponsor shall inform the FDA of the 
event in a written safety report as soon as possible, but no later than 15 calendar days 
after the determination is made.  Results of the investigation of other safety information 

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shall be submitted, as appropriate, in an information amendment or annual report.  
Continuing review reports, which will include the up-to-date clinical and safety data, 
will be submitted to the FDA at least annually.  
 
9.4  Reporting to St. Jude Office of Regulatory Affairs  
Copies of all correspondence to the St. Jude IRB, including SAE reports are provided to 
the St. Jude Regulatory Affairs Office. All FDA related correspondence and reporting 
will be conducted through the Regulatory Affairs Office. Adverse event reporting and 
annual reporting will be in accord with the FDA Title 21 CFR312.32 and Title 21 
CFR312.33, respectively. The Regulatory Affairs Office can be reached at 901-595-2347 
(secondary contact: St. Jude Vice President of Clinical Trials Administration 901-595-
2876).  
  
9.5 Continuing review reports  
Continuing review reports of protocol progress and summaries of adverse events will be 
filed with the St. Jude IRB, and IBC at least annually.  
9.6 Data submission to Miltenyi Biotec  
Clinical and safety related data will be provided to Miltenyi Biotec, the manufacturer of 
the CliniMACS system. Data will include but is not limited to the transplant research 
participant’s age and diagnosis, donor product(s) related information including donor 
type, the stem cell mobilization, selection, and infusion procedure. Outcome data 
including lymphohematopoietic reconstitution, immunological response, disease 
response and transplant complications will be shared with Miltenyi Biotec.  
Representatives from Miltenyi Biotec will be able to review the participant’s (donor and 
transplant research recipient) laboratory and medical record for data verification 
purposes.  Copies of all reports to the institutional and governing regulatory bodies will 
also be accessible upon request.  In the event that the protocol is placed on a clinical hold 
by the PI or governing regulatory authorities, representatives from Miltenyi Biotec will 
be notified as soon as possible.  
 
9.7  Reporting to the Center for International Blood and Marrow Transplant Research   
The Transplant Program at St. Jude is required by the federal government to report 
transplant information to the Center for International Blood and Marrow Transplant 
Research (CIBMTR). The CIBMTR is a research partnership of the International Bone 
Marrow Transplant Registry, the National Marrow Donor Program (NMDP), and the 
Foundation for the Accreditation of Cellular Therapy (FACT).  This organization is 
responsible for the collection and maintenance of a standardized data warehouse registry 
of autologous and all allogeneic (related and unrelated donor) transplants performed in 
the United States.  
The Office of General Counsel, U.S. Department of Health and Human Services, had 
deemed the CIBMTR not a covered entity under the Privacy Rule (45 CFR 164.512), 45 
CFR Parts 160 and 164, and the Health Insurance Portability and Accountability Act 
(HIPPA) of 1996.  For this reason, the submission and disclosure of certain protected 

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health information (PHI), including that required for CIBMTR, is allowable without the 
individual’s authorization (i.e. consent is waived) when such disclosure is made to public 
health authorities authorized by law for the purpose of preventing or controlling disease, 
injury, or disability.  
Data resulting from this transplant procedure will be sent for general registry purposes to 
comply with the federal government requirements.  This information for both donor and 
recipient is submitted using a unique participant identification number.  The information 
submitted for haploidentical recipients is less extensive than recipients of other donor 
products.  For this reason, variables submitted may include but are not limited to the 
transplant recipient’s date of birth, country/state of current residence, diagnosis, basic 
lympho-hematopoietic reconstitution (e.g. date of ANC and platelet engraftment), post-
HCT disease status, and basic AEs (e.g. GVHD- yes or no), survival status, date/cause of 
death.  
   
10.0 STATISTICAL CONSIDERATIONS  
10.1 Statistical Design and Analysis for the Primary Objectives and Stopping Rules  
This study is designed as a phase II study. The primary objective of this study is to 
evaluate the rate of successful engraftment at day +42.  Successful engraftment for the 
purposes of this objective will be patients who do not experience graft failure as defined 
in section 7.5.  
As detailed in section 2, the use of alternative donors such as haploidentical donors and 
unrelated umbilical cord blood (UCB) are frequently needed and largely successful.  
However, the use of these alternative donors is typically complicated with additional 
problems, particularly poor hematopoietic recovery and graft failure.100  Handgretinger 
et al found that improved engraftment was obtained in haploidentical donor 
transplantation with the use of a megadose (high donor CD34+ cell) T-cell depleted graft 
and administration of OKT3 instead of ATG.26  This combination has since been the 
foundation of haploidentical donor transplantation at this institution.  However, OKT3 is 
no longer clinically available.  This protocol includes a novel preparative regimen using 
TLI instead of anti-T-cell antibody to facilitate engraftment.  Therefore, the primary 
objective of this study is to assess donor engraftment, ensuring that this novel regimen 
facilitates donor engraftment at an acceptable rate.  
The majority of published experience with alternative (HLA-mismatched) donor 
transplantation in children is with umbilical cord blood grafts.  The COBALT study 
included 191 children with hematologic malignancies who received UCB transplantation 
with TBI based (1350Gy) myeloablative conditioning.101  The cumulative incidence of 
neutrophil engraftment by day 42 was 80%.  The New York Blood Center published 
outcomes on 1061 patients (78% pediatric) with hematologic malignancies who received 
myeloablative UCB transplantation with units from their bank.102  The cumulative 
incidence of neutrophil engraftment was 74% by day 77.  The CIBMTR published a 
comparison of UCB transplantation with HLA-matched unrelated donor transplantation, 
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transplantation.103  They confirmed that although the leukemia-free survival was similar, 
the rate of neutrophil engraftment (and TRM) were significantly worse with HLA-
mismatched UCB grafts than with HLA-matched bone marrow grafts.  For UCB 
recipients, the best engraftment was obtained in the rare 6/6 matched UCB recipients 
with 85% of the 35 patients achieving neutrophil recovery at day +42.  In addition, 
recipients who received a single antigen mismatch UCB unit with an appropriately high 
cell dose (n=154) had a neutrophil engraftment rate of 80% at day +42.  Recipients of 
lower cell dose or two antigen mismatch units fared worse.  
Given the data from the paragraph above, we consider a rate of successful engraftment of 
less than 80% by day +42 to be unacceptable for alternative donor transplantation.  The 
goal of our study is to develop a novel conditioning regimen to facilitate successful 
engraftment of haploidentical donor grafts at a rate of ≥91%.  We do not anticipate 
censoring during the 42 day time period and we can approximate the rate of successful 
engraftment at day +42 using a Binomial distribution. (However, patients lost for follow 
up will be counted as a failure to engraft in order to keep the validity of Binomial 
distribution approximation). Therefore, in this study, we propose to test the null 
hypothesis H0: P≤0.80 versus H1: P>0.80, where P is the proportion of research 
participants successfully engrafted at day +42 posttransplant. With type I error of 10% 
and type II error of 20%, Simon’s two stage optimum design powered at alternative 
successful engraftment rate P1=0.91 requires 21 evaluable patients at the first stage and 
49 evaluable patients in total76. The stopping rules are provided in Table 1, with the 
understanding that stopping the trial early would be suggestive of the proposed 
transplant strategy not being an effective treatment option for this group of patients. The 
interpretation is that if we observe 17 or fewer participants successfully engrafted at day 
+42 in the first 21 participants, then we would stop the trial for lack of efficacy. 
However, if we observe 18 or more patients engrafted successfully in the first 21 
participants at day +42 in stage one, then 28 more patients will be enrolled in stage two. 
If we observe 43 or more participants successfully engrafted at day +42 upon completion 
of the trial, then we conclude that the true rate of successful engraftment is at least 80% 
and our novel regimen will be proposed for further development and phase III clinical 
trial.   
Table 1: Stopping rules for lack of efficacy based on the Simon’s 2-stage optimum design 
(unacceptable low rate of successful engraftment at day +42)   
Accept H0 if the number of research participants engrafted  
P0  
P1  
(≤ r1/n1 )  
(≤ r/n )  
EN(P0)  
PET(P0)  
0.80  
0.91  
17/21  
42/49  
31  
0.63  
Note: r1 and r denote the number of patients successfully engrafted at day +42; EN(P0) denotes the expected sample size under P0; 
PET(P0) denotes the probability of early termination at stage I under P0.   
All participants who receive the prescribed transplant will be evaluable for the primary 
outcome (engraftment at day +42).  In addition, any patient who starts the conditioning 
regimen but stops prior to receiving the graft will count as a failure, if the reason for 
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toxicity after engraftment but before day +42 will count as a successful engraftment.  
Any patient who dies prior to engraftment will count as a graft failure. Any patient who 
rejects the initial graft but is successfully engrafted with another graft will still count as a 
graft failure.  
Participants who enroll but do not initiate the treatment (receive conditioning and 
infusions) due to withdrawal of participant, health status change to make the treatment 
not to the participant’s best medical interest, withdrawal of donor participant, etc. will be 
replaced.    
After the study is finished, for the first primary objective, the rate of engraftment at day 
+42 and its 95% Blyth-Still-Casella confidence interval will be estimated based on the 
binomial approximation.   
As of 1/31/17, 42 patients have received transplantation on this study, 39 had successful 
engraftment, 1 patient died prior to engraftment, and 2 patients experienced graft failure 
but were successfully grafted with a progenitor cell boost from the same donor. This 
indicates that the primary objective is likely to be satisfied (42 successful engraftment) 
prior to completion of original protocol enrollment goal of 49 recipients. To fulfill a 
critical patient need, Amendment 4.0 expands the intended enrollment beyond the 
primary objective enrollment goal. Because this protocol provides specialized T-cell 
depletion and graft manipulation techniques, a therapy that is only available under the 
protocol IDE, future patients would not be able to potentially benefit from this therapy 
once the protocol completes. Preliminary analysis (data censored 10/31/16) show the 1 
year EFS (events: death, relapse) in patients with non-refractory (e.g. <5% blasts) 
hematologic malignancy receiving first allogeneic HCT from a TCD haploidentical 
donor to be 86.6% (SE:8.2%) on this study compared to 55.6% (SE:8.1%) on the 
previous two trials (HAPREF, HIFLEX). Therefore, future patients could benefit from 
this therapy with the expanded enrollment goal of 75 evaluable patients. With past 
accrual at 12 to 15 patients per year, the study should be extended approximately 2 years. 
This provides the time necessary to develop and implement a replacement therapeutic 
protocol that builds upon the progress of this study.  
Secondary benefits to the expanded enrollment on this study include increased precision 
of the clinical outcome estimates for the primary and secondary objectives, and the 
ability to compare these outcomes based on whether the donor is KIR matched or 
mismatched. Tertiary benefits to the expanded enrollment include increased depth of the 
biologic characterization of immune reconstitution, particularly of donor memory T-
cells. Enhanced understanding of memory T-cell function has the potential to lead to the 
development of new successful therapeutics.  
        
In addition to the stopping rules based on successful engraftment, we will closely 
monitor the trial for early excessive toxicities in terms of severe acute GvHD (aGvHD), 
and therapy related death. Therapy related death is any death in remission and related to 
protocol therapy.  Therapy related death will be monitored for 100 days from the date of 
transplantation for application of the stopping rules. Most acute GVHD is expected to 

H A P N K 1 4 3 
A me n d me nt 5. 1, date d: 0 6/ 1 3/ 2 0 1 8  
 
I R B A p pr o val date: 1 0/ 1 1/ 2 0 1 8   
  
Pr ot oc ol d oc u me nt date: 0 9/ 0 6/ 2 0 1 8  
  
  
  
occ ur i n t h e first 1 0 0 d a ys, h o we v er ac ute G V H D ma y occ ur after Da y 1 0 0, a n d t h e 
G V H D s y n dr o mes i n naï ve T -cell de plete d tra ns pla ntati o n ma y differ bi ol o gicall y fr o m 
G V H D i n c o n ve nti o nal T -cell  r e plete  s etti n gs.  T heref ore  a n y  ac ute  G V H D  ≥  gra d e  III 
will c o u nt a gai nst t he st o p pi n g r ule, e v e n if it occ urs after 1 0 0 d a ys. T o xicities sec o n dar y 
t o n o n-pr ot oc ol t hera p y f or p osttra ns pla nt persiste nt or rec urre nt disease will n ot c o u nt  
t o war ds  t he  t o xicit y  st o p pi n g  r ules.  T o xicities  t hat  are  sec o n d ar y  t o  p ost-tra ns pla nt 
t hera p y t hat is defi ne d i n t he pr ot oc ol (s uc h as escalati n g D LI as descri be d i n secti o n 
4. 6)  will  c o u nt  t o war ds  t he  st o p pi n g  r ules.  T h e  safet y  e n d p oi nts  will  be  m o nit ore d 
i n de pe n de ntl y  a n d  a  c o nsi derati o n  t o  st o p pi n g  t he  trial  w o ul d  be  gi ve n  if  t here  is  
e vi de nce s u g gesti n g t hat t he r ate of gra des III -I V a G V H D is great er t ha n 2 0 %, or t he 
rate of tra ns pla nt relat e d deat h is greater t ha n 1 0 %. T he n, t he pla n ne d i nteri m e val uati o n 
ti me p oi nts a n d st o p pi n g r ules, usi n g  gr o u p se q ue ntial desi g n base d o n P oc oc k st o p pi n g 
b o u n daries after c o nsi deri n g fi ve i nteri m a nal yses ( p -val ue t hres h ol d = 0. 0 1 5 8) t o e ns ure 
a n o verall t y pe o n e err or of 0. 0 5. 1 0 4- 1 0 6, f or eac h of t he t w o e n d p oi nts are pr o vi de d i n   
 T a bles 2 a n d 3 .   
After t his a me n d m e nt 4, if t he st o p pi n g r ule f or m o nit ori n g t he e n graft me nt is n ot met i n 
t he first 4 9 e val ua bl e partici pa nts e nr olle d, t he n after 4 9 e v al ua ble partici pa nts e nr olle d 
o n t he st u d y, we will n ot m o nit or t h e e n graft me nt a n d will esti mate t he e n graft me nt rate 
usi n g  all  e val ua ble  partici pa nts  e nr olle d  o n  t he  st u d y  after  t he  st u d y  is  fi nis he d.  
H o we ver, we will c o nti n ue t o cl osel y m o nit or e xcess t o xicit y of gra d e III -I V a G V H D 
a n d T R M wit hi n t he first 1 0 0 da ys. W e will c o n d uct t hree m ore i nteri m a nal yses w he n 
6 0, 7 0 a n d 7 5 e val ua ble patie nts are e nr olle d o n t he st u d y f or m o nit ori n g t hese t o xicities 
usi n g t he ne w m o nit ori n g r ule ( Ta bles 2 -3) bas e d o n a bi n o mial distri b uti o n a n d a p -
val ue t hres h ol d of 0. 0 5.     
 
T a ble 2. St o p pi n g R ules f or T o xicities B ase d o n Gr a des III- I V a G V H D    
# of Resear c h Partici pa nts E nr olle d  
 
# Gra des III -I V a G V H D O bser ve d  
  
  
6  
2 1  
9  
3 1  
1 2  
4 1  
1 5  
4 9  
1 7  
6 0 *  
1 8  
7 0 *  
2 1  
7 5 *  
2 2  
* Base d o n a bi n o mial distri b uti o n wit h a p- val ue t hres h ol d of 0. 0 5 a d de d o n a me n d me nt 4. 0. 
  
 
 
 

H A P N K 1 4 4 
A me n d me nt 5. 1, date d: 0 6/ 1 3/ 2 0 1 8  
 
I R B A p pr o val date: 1 0/ 1 1/ 2 0 1 8   
  
Pr ot oc ol d oc u me nt date: 0 9/ 0 6/ 2 0 1 8  
  
  
  
 
 
T a ble  3. St o p pi n g R ules f or T o xicities B ase d o n T her a p y Rel ate d De at h wit hi n t he 
first 1 0 0 d a ys P ost-t r a ns pl a nt  
# of Resear c h Partici pa nts 
E nr olle d  
 
# T hera p y Relat e d Deat h O bser ve d   
  
  
5  
2 1   
6  
3 1  
8  
4 1  
1 0  
4 9  
1 1  
6 0 *  
1 1  
7 0 *  
1 2  
7 5 *  
1 3  
* Base d o n a bi n o mial distri b uti o n wit h a p- val ue t hres h ol d of 0. 0 5 a d de d o n a me n d me nt 4. 0. 
  
B ase d o n t he a b o ve T a ble 2 , if si x gra des III-I V a G V H D occ ur i n t he first ele ve n 
e val ua ble res ear c h p artici pa nts treate d, t he n a c o nsi derati o n will be gi v e n t o te m p oraril y 
st o p pi n g  t he  trial  a n d  a me n di n g  t he  st u d y  t o  i ncl u de  a d diti o nal  or  alter nati v e  
p har mac ol o gic G V H D pr o p h yla xis. Si milarl y, fr o m Ta ble 4 if we o bser ve fi ve deat hs 
relate d  t o  t h era p y  wit hin  t he  first  1 0 0  d a ys  after  tra ns pl a ntati o n  i n  t he  first  ele v e n  
e val ua ble res ear c h partici pa nts treate d, t he n a c o nsi derati o n will be gi v e n t o te m p oraril y 
st o p pi n g t he trial a n d a me n di n g t he st u d y a p pr o priatel y. Li ke wise, if ei g htee n or m ore 
t he gra d e 3-4 a G v H D wit hi n first 1 0 0 da ys p ost tra ns pla ntati o n occ ur i n t he first 6 0 
e val ua ble  res ear c h  parti ci pa nts  treate d,  a  c o nsi derati o n  will  be  gi ve n  t o  te m p oraril y  
st o p pi n g  t he  trial  a n d  a me n di n g  t he  st u d y  t o  i ncl u de  a d diti o nal  or  alter nati v e  
p har mac ol o gic G V H D pr o p h yla xis. Si milarl y, if ele ve n or m ore T R M wit hi n first 1 0 0 
da ys p ost tra ns pla ntati o n occ ur i n t he first 6 0 e val ua ble res earc h partici pa nts treate d, 
t he n a c o nsi derati o n will be gi ve n t o te m p oraril y st o p pi n g t he trial a n d a me n di n g t he 
st u d y a p pr o priatel y.   
Starti n g wit h A me n d me nt 3. 0, patie nts wit h a KI R matc he d ha pl oi de ntical d o n or are 
eli gi ble f or t his t hera p y, w hereas bef ore 3. 0, pati e nts c o ul d o nl y recei ve tra ns pla ntati o n 
fr o m a KI R mis matc he d ha pl oi de ntical d o n or. W hile t he rate of d o n or e n graft me nt, rate 
of ac ut e G v H D,  a n d rat e of t hera p y relate d  deat h are u nli kel y t o b e relate d t o KI R  
matc hi n g, wit h t his ne w p o p ulati o n bei n g a d de d wit h a me n d me nt 3. 0, t he st o p pi n g r ules 
f or effi cac y ( Ta ble 1) a n d t o xicit y ( Ta ble 2 a n d 3) will be a p plie d t o all reci pie nts, t o 
KI R matc he d d o n or reci pie nts i n de pe n de ntl y, a n d t o KI R mis matc he d d o n or reci pie nts 
i n de pe n de ntl y.  
Pri or  t o  a me n d me nt  5. 0,  as  of  date  A pril  4,  2 0 1 8,  preli mi nar y  a nal ysis  s h o we d  a  
si g nifica ntl y hi g her rate of G V H D gra d e III-I V i n patie nts w h o receive d mara vir o c ( 4 of 

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5 = 80%) compared to those patients who did not receive maraviroc (12 of 53 = 25%) (p 
= 0.02). Because the use of maraviroc in these 5 patients treated on amendment 3.0 was 
a substantive change in therapy that affected the risk of GVHD in those recipients, those 
5 patients will be excluded from analysis of the primary objective and the stopping rules 
above. For the secondary and exploratory objectives as detailed below, the groups (with 
and without maraviroc) will be analyzed separately and together. 
 
10.2 Statistical Analysis for Secondary Objectives   
10.2.1   Estimate the incidence of malignant relapse, EFS and OS at one-year 
posttransplantation  
The estimate of cumulative incidence of relapse will be estimated using 
Kalbfleisch-Prentice method. Death is the competing risk event. The analysis 
will be implemented using SAS macro (bmacro252-Excel2007\cin) available in 
the St. Jude Department of Biostatistics. The Kaplan-Meier estimate of OS and 
EFS with relapse, death due to any cause and graft failure as events along with 
their standard errors will be calculated using the SAS macro (bmacro251-
Excel2007\kme) available in the Department of Biostatistics at St. Jude, where 
OS = min (date of last follow-up, date of death) – date of HCT and all 
participants surviving after 1 year post-transplant will be considered as 
censored, and EFS = min (date of last follow-up, date of relapse, date of graft 
failure, date of death due to any cause) – date of transplant, and all participants 
surviving at the time of analysis without events will be censored. The analysis 
for this objective will be performed when the last evaluable participant has 
been followed for one-year post transplant.     
 
10.2.2   Estimate the incidence and severity of acute and chronic GVHD  
The cumulative incidence of acute and chronic GVHD will be estimated using 
Kalbfleisch-Prentice method. Death is the competing risk event. The SAS 
macro (bmacro252-Excel2007\cin) available in the Department of Biostatistics 
at St. Jude will be used for such analysis. The severity of acute GVHD and 
chronic GVHD will be described. The analysis for this objective will be 
performed when the last evaluable participant has been followed for 100 days 
post transplant.       
10.2.3  Estimate the rate of transplant related mortality in the first 100 days after 
transplantation  
The cumulative incidence of transplant related mortality will be estimated 
using the same method as used in evaluating Objective 10.2.2. Deaths before 
day 100 because of other reasons are the competing risk events. The analysis 
for this objective will be performed when the last evaluable participant has 
been followed for 100 days post transplant.  

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10.3 Analysis for Exploratory Objectives   
The final results of these exploratory objectives are expected to be available 
when the last evaluable participant has been followed for one-year post 
transplant.  
 
10.3.1   Assess the relationship between pre-transplant MRD with transplant outcomes.  
The relationship of pre-transplant MRD and transplant outcomes will be 
examined through Cox proportional hazard model or generalized linear model. 
The model can also be used to adjust for other confounding factors such as 
patient’s age at transplant.  
10.3.2   Record immune reconstitution  parameters,  
including chimerism  analysis, 
quantitative lymphocyte subsets, T-cell receptor excision circle (TREC) 
analysis,  
V-beta spectratyping, and phenotype and functional analysis of reconstituted 
lymphocyte subsets.  
All immune reconstitution measures will be descriptively analyzed.  
10.3.3 The use of CD45RA-depleted DLI for recipeints who have severe viral infections, 
disease recurrence or progression, or poor immune reconstitution will be 
recorded, including dose given, date given, and indication for use. To assess 
efficacy, the resolution of viral infection, resolution of molecular or frank 
disease, or the correction of severe lymphopenia will be noted. All adverse 
events that are at least possibly related to CD45RA-depleted DLI and any 
episode of GVHD will be recorded.  
 
11.0 DATA ACQUISITION AND QUALITY ASSURANCE MONITORING  
11.1 Enrollment on study  
A member of the study team will confirm potential participant eligibility as defined in 
Section 3.1-3.2, complete and sign the ‘Participant Eligibility Checklist’.  The study 
team will enter the eligibility checklist information into the Patient Protocol Manager 
(PPM) system. Eligibility will be reviewed, and a research participant-specific consent 
form and assent document (where applicable) will be generated. The complete signed 
consent/assent form(s) must be faxed to the CPDMO at 595-6265 to complete the 
enrollment process.  
The CPDMO is staffed 7:30 am-5:00 pm CST, Monday through Friday. A staff member 
is on call Saturday, Sunday, and holidays from 8:00 am to 5:00 pm.  Enrollments may be 
requested during weekends or holidays by calling the CPDMO “On Call” cell phone 
(901-413-8591) or referencing the “On Call Schedule” on the intranet).  
11.2 Data submission  
The St. Jude Cancer Center Clinical Research Assistants and Associates assigned to the 
Department of BMTCT will assure protocol compliance, and conduct all clinical and 

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safety data collection. Data will be entered into an institutional database. The PI will be 
responsible for review of case report forms for accuracy and completeness prior to entry 
into the secure departmental database.  
11.3 Quality assurance monitoring  
This protocol will be monitored for safety and data as per the St. Jude Data and Safety  
Monitoring Plan for Clinical Trials approved by the NCI in 2010. The Central Protocol 
and Data Monitoring Office (CPDMO) will verify 100% of the informed consent 
documentation on all participants and verify 100% of St. Jude participants’ eligibility 
status.  The study team will meet at appropriate intervals to review case histories and 
data quality summaries on all participants.  The St. Jude Clinical Research Monitor will 
assess protocol and regulatory compliance as well as the accuracy and completeness of 
all data points for the first two participants enrolled, then 15% of study enrollees (and 
their corresponding donors) every six months.  The protocol will be tracked continuously 
for the accrual of donors and recipients.    All AE and SAE reports will be reviewed by 
the study Principal Investigator for type, grade, attribution, duration, timeliness and 
appropriateness on all study participants and their corresponding donors.  All SAE 
reports will be reviewed by the monitor every 6 months.     
Protocol compliance monitoring will include participant status, eligibility, the informed 
consent process, demographics, staging, study objectives, subgroup assignment, 
treatments, evaluations, responses, participant protocol status, off-study, and off-therapy 
criteria.  The Monitor will generate a formal report which is shared with the Principal 
Investigator (PI), study team and the Internal Monitoring Committee (IMC).  Monitoring 
may be conducted more frequently if deemed necessary by the CPDMO or the IMC.  
Continuing reviews by the  
IRB and CT-SRC will occur at least annually.  In addition, SAE reports in TRACKS 
(Total  
Research and Knowledge System) are reviewed in a timely manner by the IRB.  The 
Regulatory Affairs Office will assist the PI in reporting to the FDA and other external 
oversight agencies, as necessary.  
This plan is supplemented by a focused audit plan as submitted to the FDA on 9/21/15.  
Please see appendix G for details.  
  
12.0 OBTAINING INFORMED CONSENT  
The ongoing informed consent process will be carried out per the policies and procedures put 
forth in the St. Jude Investigator’s Handbook for Clinical Research (http://home.web.stjude. 
org/ clinical research/administration/doc/handbook.pdf). The PI or physician sub-investigator 
will conduct the signature authorization portion of the consent process.  Authorization for the 
recipient procedure will be conducted in the presence of an independent witness such as the 
St. Jude Ombudsperson/Research Participant Advocate or designee, a professional staff 
member from the Department of Nursing, or Social Work.  
  
  

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17. 
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32. 
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39. 
Moretta A, Pende D, Locatelli F, et al: Activating and inhibitory killer 
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irradiation-based reconditioning regimens enable engraftment after graft rejection or 
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predictor of relapse after allogeneic bone marrow transplantation for children with 
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Langebrake C, Creutzig U, Dworzak M, et al: Residual disease monitoring in 
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APPENDIX A: 
  
 
KARNOFSKY PERFORMANCE STATUS SCALE  
≥ 16 YEARS OLD  
Score  
General Description  
100  
Normal. No complaints. No evidence of disease.  
90  
Able to carry on normal activity. Minor signs or symptoms of disease.  
80  
Normal activity with effort. Some signs or symptoms of disease.  
70  
Care of self.  Unable to carry out normal activity or to do active work.  
60  
Requires occasional assistance, but is able to care for most of his needs.  
50  
Requires considerable assistance and frequent medical care.  
40  
Disabled.  Requires special care and assistance.  
30  
Severely disabled. Hospitalization is indicated although death is not imminent.  
20  
Hospitalization necessary, very sick, active support treatment necessary.  
10  
Moribund. Fatal processes progressing rapidly.  
0  
Dead.  
  
  
 
 
LANSKY PERFORMANCE STATUS SCALE  
< 16 YEARS OLD  
Score   General Description  
100  
 Fully active, normal  
90   
Minor restrictions in physically strenuous activity  
80  
Active, but tires more quickly  
70  
Both greater restriction of and less time spent in play activity  
60  
Up and around, but minimal active play; keeps busy with quieter activities  
50  
Gets dressed but lies around much of the day, no active play but able to participate in all 
quiet play and activities  
40  
Mostly in bed; participates in quiet activities  
30  
In bed; needs assistance even for quiet play  
20  
Often sleeping; play entirely limited to very passive activities  
10  
No play; does not get out of bed  
0  
Unresponsive  
 
 
 
 
 
 

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APPENDIX B 
COG STEM CELL COMMITTEE CONSENSUS  
GUIDELINES FOR ESTABLISHING ORGAN STAGE AND OVERALL GRADE OF  
ACUTE GRAFT VERSUS HOST DISEASE (GVHD) 
Table 1 outlines standard criteria for GVHD organ staging. However, confounding clinical syndromes 
(such as non-GVHD causes of hyperbilirubinemia) may make staging GVHD in a given organ 
difficult. In addition, timing of organ specific symptoms affects whether that symptom is more or less 
likely to be true GVHD. Please refer to Tables 2 and 3 to assist you in deciding whether to attribute 
these clinical findings to GVHD, especially in situations where a biopsy is not possible. For additional 
help, please see the text which follows the tables. Table 4 reviews the approach to assessing GVHD as 
acute, chronic, or the overlap between the two.  
  
Finally, engraftment syndrome will be reported separately from the GVHD scoring presented below.  
  
Engraftment Syndrome  
A clinical syndrome of fever, rash, respiratory distress, and diarrhea has been described, just prior to 
engraftment in patients undergoing unrelated cord blood and mismatched transplantation. If, in the 
judgment of the treating physician, a patient experiences this syndrome, details of the event will be 
recorded in the medical record.  
  
Modified Glucksberg Staging Criteria for Acute Graft versus Host Disease 
  
Table 1:  Organ Staging (See tables and text below for details)  
Stage  
Skin  
Liver (bilirubin)  
Gut (stool output/day)  
0  
No GVHD rash  
< 2 mg/dL  
Adult: < 500 mL/day Child: 
< 10 mL/kg/day  
1  
Maculopapular rash < 
25% BSA  
2-3 mg/dL  
Adult: 500-999 mL/day Child: 
10-19.9 mL/kg/day.  
Or persistent nausea, vomiting, or 
anorexia, with a positive upper GI 
biopsy.  
2  
Maculopapular rash 25-
50% BSA  
3.1-6 mg/dL  
Adult: 1000-1500 mL/day Child: 
20-30 mL/kg/day  
3  
Maculopapular rash > 
50% BSA  
6.1-15 mg/dL  
Adult: > 1500 mL/day Child: 
> 30 mL/kg/day  
4  
Generalized erythroderma 
plus bullous  
formation and 
desquamation > 5% BSA  
>15 mg/dL  
Severe abdominal pain with or 
without ileus, or grossly bloody stool 
(regardless of stool volume).  

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Grade 0: No stage 1-4 of any organ   
                                                                                
Grade I: Stage 1-2 skin and no liver or gut involvement                                                               
Grade II: Stage 3 skin, or Stage I liver involvement, or Stage l GI                                                
Grade III: Stage 0-3 skin, with Stage 2-3 liver, or Stage 2-3 GI                                                        
Grade IV: Stage 4 skin, liver or GI involvement 
 
 
Table 2 Evaluating Liver GVHD in the Absence of Biopsy Confirmation  
(See Table 3.0 below)  
Establishing liver GVHD with no skin or GI GVHD 
  
No Skin/GI  GVHD 
Day 0-35  
Assume no liver GVHD, unless proven by biopsy  
No Skin/GI  GVHD  
Day 36-100  
If NO other etiology identified, 
NO improvement with stopping 
hepatotoxic medications/TPN: 
Stage as liver GVHD  
If other etiology identified or improves 
with stopping hepatotoxic drugs/TPN: 
Do not stage as liver GVHD  
  
Establishing liver GVHD with skin or GI GVHD and other cause of hyperbilirubinemia  
Skin and/or GI GVHD 
present  
Worsening bilirubin level 
(includes worsening just prior 
to onset of skin or GI tract 
GVHD) OR stable elevated 
bilirubin despite resolution of 
non-GVHD cause of increased 
bilirubin:  
Stage as liver GVHD  
Stable or improving bilirubin after 
diagnosis of skin or GI GVHD, 
irrespective of treatment:  
Do not stage as liver GVHD  
  
For GI staging: The “adult” stool output values should be used for patients > 50 kg in weight.  Use 3 day 
averages for GI staging based on stool output. If stool and urine are mixed, stool output is presumed to be 50% 
of total stool/urine mix (see 3.2 below).    
  
For Stage 4 GI:  the term “severe abdominal pain” will be defined as:  
  
a) Pain control requiring institution of opioid use, or an increase in on-going opioid use, PLUS  
b) Pain that significantly impacts performance status, as determined by the treating MD.  
  
If colon or rectal biopsy is +, but stool output is < 500 mL/day (< 10 mL/kg/day), then consider as GI stage 0.  
  
There is no modification of liver staging for other causes of hyperbilirubinemia. 
Overall Clinical Grade (based on the highest stage obtained): 

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Changing liver GVHD stage with other cause of hyperbilirubinemia  
Skin and GI GVHD  
stable, improving, or 
absent  
Liver GVHD staging is carried forward without increase in stage until 
other disease process resolves (e.g., if TTP is diagnosed in the presence 
of stage 2 liver GVHD, the liver GVHD stage 2 is carried forward 
despite rising bilirubin level until TTP is resolved.  If there is no liver 
GVHD – stage 0 – and new onset TTP, the stage 0 is carried forward 
until TTP is resolved).  
Skin and/or GI GVHD 
worsening  
Liver GVHD is staged according to the Glucksberg criteria. The 
elevated bill is attributed to GVHD alone.  
  
Thus, when skin or GI GVHD is worsening, there is no downgrading of 
liver GVHD staging for other causes of hyperbilirubinemia. (e.g., if 
TTP is diagnosed in the presence of stage 2 liver GVHD and worsening 
skin or GI GVHD, the liver is staged according to the actual bilirubin 
level even if some of the rise in bilirubin is attributed to TIP).  
  
Similarly, even if there is no liver GVHD at onset of a new process, 
(such as TPN cholestasis), but skin or GI GVHD worsen during that 
process,  then liver GVHD is diagnosed and staged according to the 
height of the bilirubin.  
  
There is one exception to this: the diagnosis of TTP, with high LDH 
and unconjugated bilirubin precludes the diagnosis and staging of new 
liver GVHD in the absence of a confirmatory liver biopsy.  
  
Table 3 Evaluating GI GVHD in the Absence of Biopsy Confirmation 
(See Table 4.0 below) 
  
Establishing GI GVHD with new onset diarrhea and no skin or liver GVHD  
No skin/liver GVHD   
Day 0 through engraftment  
Assume no GI GVHD, unless proven by biopsy  
No skin/liver GVHD 
engraftment through Day 100  
NO other etiology of diarrhea 
identified:  
Stage as GI GVHD  
Any other etiology of diarrhea 
identified:  
Do not stage as GI GVHD  
Establishing GI GVHD with pre-existing diarrhea and skin or liver GVHD  
Skin and/or liver GVHD 
present  
Worsening diarrhea (includes 
worsening just prior to onset of 
skin or liver GVHD) OR 
persistent diarrhea despite 
resolution of non-GVHD cause: 
Stage as GI GVHD  
Improving diarrhea after the 
diagnosis of skin or liver 
GVHD (irrespective of 
treatment) OR persistent 
diarrhea without resolution of 
underlying non-GVHD cause: 
Do not stage as GI GVHD  
  

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Differentiating Acute GVHD, Chronic GVHD, and Overlap Syndrome:  
There is often confusion differentiating acute from chronic GVHD, especially in the setting 
of reduced intensity transplants, DLI and new prophylactic treatments. The NIH Working 
Group recently published new classifications for GVHD:  
  
Table 4 Acute GVHD, Chronic GVHD, and Overlap Syndrome  
Category  
Time of Symptoms
after HCT or DLI  
Presence of Acute 
GVHD features  
Presence of Chronic
GVHD  features  
Acute GVHD  
 
 
 
Classic acute GVHD  
<100 d  
Yes  
No  
Persistent, recurrent, 
or late-onset acute  
>100 d  
Yes  
No  
GVHDChronic GVHD 
  
 
 
 
Classic chronic GVHD  
No time limit  
No  
Yes  
Overlap syndrome  
No time limit  
Yes  
Yes  
   
• 
Scoring of acute GVHD may need to occur past day 100.  In particular, patients 
should continue to be scored for acute GVHD when classic acute GVHD symptoms  
(maculopapular rash, nausea, vomiting, anorexia, profuse  diarrhea - particularly if 
bloody and ileus) persist past day 100 or if identical symptoms previously scored as 
acute GVHD resolve and then recur within 30 days during immunosuppression taper 
but past day 100.  
  
• 
Those patients being scored as having acute GVHD should NOT have diagnostic or 
distinctive signs of chronic GVHD.  
  
• 
Patients with both acute and chronic symptoms should be diagnosed as having 
Overlap Syndrome and scored according to their chronic GVHD score.  
  
Further Explanation of Criteria presented in Tables 2 and 3  
  
1.0 Assessment of Skin GVHD  
  
1.1 Presence or Absence of Skin GVHD: Skin GVHD will be considered present if a rash 
characteristic of acute GVHD develops after allogeneic marrow transplantation 
involving more than 25% of the body surface not clearly attributable to causes such as 
drug administration or infection.  The extent of the body surface area involved can be 
estimated by the "Rule of Nines". In estimating the extent of skin GVHD, the area 
involved is calculated for individual anatomic areas, such as the arm or leg, and then the 
total is derived from a simple summation.  Areas that are non-blanching should not be 
considered involved regardless of the overlying color of the rash (red, brown, etc.). 

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Limited distribution erythema (with the exception of palms and soles) in the absence of 
associated rash elsewhere on the body will not be considered GVHD.  
  
2.0 Assessment of Liver GVHD  
  
2.1 Assessing for the Presence or Absence of Liver GVHD  
  
A. Hyperbilirubinemia (total bilirubin > 2.0 mg/dL) in the absence of other signs of 
acute GVHD in the skin or GI tract:  
  
i) Day 0-35: If hyperbilirubinemia alone is present with no other signs of acute 
GVHD in other organ systems, acute GVHD will not be diagnosed based solely 
on laboratory abnormalities.    
  
Acute GVHD will be diagnosed if findings on histopathology studies of liver 
from a biopsy or autopsy are confirmatory.  
  
ii) Day 35-100: If hyperbilirubinemia (must be conjugated bilirubin) is not 
improving or is exacerbated (especially if serum alkaline phosphatase is 
increased), in the absence of acute GVHD in other organ systems, no other 
etiologies are identified, and does not improve with discontinuation of 
hepatotoxic drugs, acute GVHD will be diagnosed.  However, it is distinctly 
unusual to develop ascites or a coagulopathy in the early stages of acute GVHD 
of the liver alone.  In the absence of histopathology studies of liver from a biopsy 
or autopsy specimen, ascites or a coagulopathy  secondary  to liver dysfunction  
will be considered  to indicate  the  presence  of  another  disease process  (e.g., 
veno-occlusive disease).  Recommended  non-invasive studies to define an 
etiology for hyperbilirubinemia are:  
  
a. Imaging of liver (CT or ultrasound)  
b. Hepatitis screen (only if ALT is elevated)  
c. PT  
d. Blood cultures  
e. Review of medication list for potentially hepatotoxic drugs  
f. Review of risk factors for viral liver infection (HSV, CMV, VZV, 
adenovirus, EBV, HBV, and HCV)  
g. Hemolysis screen  
  
B. Pre-existing hyperbilirubinemia clearly attributed to an etiology other than acute 
GVHD in the presence of signs of acute GVHD in other organ systems.  
  
i) If pre-existing non-GVHD liver disease (documented clinically, by lab 
assessment, or by imaging studies) is stable or improving at the onset of signs of 

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acute GVHD in other organs, then acute GVHD of the liver will not be 
considered to be present unless proven by liver biopsy or autopsy.  
  
ii) If hyperbilirubinemia worsens several days before or at the time of onset of signs 
of acute GVHD in other organ systems, GVHD will be considered to be present 
unless histopathology studies of liver are available and negative on a biopsy 
during that time interval or autopsy results exclude GVHD.  
  
iii) If hyperbilirubinemia persists and is not improving after resolution of a pre-
existing non-GVHD liver disease process (e.g., localized infection of liver, 
systemic sepsis, biliary tract obstruction) when signs of acute GVHD are present 
in other organ systems or no other intervening cause has been diagnosed, then 
acute GVHD will be considered to be present in the absence of a new, clearly 
identifiable cause of nonGVHD liver disease or unless a liver biopsy or autopsy 
specimen is negative.  
 Prior acute GVHD in liver with new onset of a disease process that exacerbates preexisting or 
recently resolved hyperbilirubinemia:  
  
i) If an etiology other than acute GVHD is clearly identified as causing or 
exacerbating hyperbilirubinemia and acute liver GVHD has been diagnosed and 
has been stable, improving, or resolved, then the liver will not be restaged for 
acute GVHD until the resolution or stabilizing of the concurrent disease process 
(i.e., the liver stage prior to the onset of the new disease process will be carried 
forward until the new disease process resolves).  Example: Acute GVHD of the 
liver and gut is diagnosed on day 20. Treatment of acute GVHD results in falling 
bilirubin levels to liver stage 1. Sepsis or TTP develops with transient worsening 
of the hyperbilirubinemia. The liver stage is not increased, despite a higher 
bilirubin level, because the cause of worsening hyperbilirubinemia is attributed to 
sepsis or TTP.  
  
ii) If an etiology other than acute GVHD is clearly identified as causing or 
exacerbating hyperbilirubinemia in the presence of already worsening acute liver 
GVHD or GVHD of the skin or GI tract is simultaneously worsening, then the 
liver GVHD will be staged according to the actual bilirubin level, even though 
another cause of hyperbilirubinemia is present.  
3.0 Assessment of GVHD of the Gastrointestinal Tract  
  
3.1 Assessing for the Presence or Absence of GVHD of the Gastrointestinal Tract  
  
A. Diarrhea (>500 mL/day in adults or > 10 mL/kg in pediatric patients) in the absence 
of other signs of acute GVHD in other organ systems  
  

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i) Day 0-engraftment: If diarrhea alone is present without other signs of acute 
GVHD in other organ systems, acute GVHD will not be considered present. 
Diarrhea will be attributed to acute GVHD if histopathology studies of 
gastrointestinal tract from a biopsy or autopsy are diagnostic.  
  
ii) Engraftment-day 100: If diarrhea persists and is not improving, is exacerbated, or 
develops de novo in the absence of acute GVHD in other organ systems, 
histopathology studies of gut biopsies or from autopsy specimens are not 
available, and no other etiologies are clearly identified, acute GVHD will be 
considered to be the cause. A stool specimen should be examined to rule out 
infectious causes (e.g., rotavirus, adenovirus, and C. difficile toxin). It is 
recommended, if at all possible, that biopsies be obtained for diagnostic 
purposes.  
  
B. Pre-existing diarrhea clearly attributed to an etiology other than acute GVHD in the 
presence of signs of acute GVHD in other organ systems:  
  
i) If pre-existing diarrhea caused by a process other than GVHD has been 
documented clinically or by lab assessment and is stable or improving at the 
onset of signs of acute GVHD in the skin or liver, then acute GVHD of the 
intestine will not be considered to be present in the absence of biopsy 
confirmation or autopsy report.  
  
ii) If diarrhea or gastrointestinal symptoms are already present, but worsen 
significantly at the time of onset  of signs of acute GVHD in the skin or liver, 
GVHD will be considered present, unless biopsy or autopsy are negative.  
  
iii) If diarrhea persists after resolution of a pre-existing disease process with signs of 
acute GVHD present in other organ systems, GVHD will be considered present, 
unless biopsy or autopsy are negative.  
  
C. Prior or present acute GVHD in other organ systems with new onset of diarrhea:  
  
If diarrhea is clearly attributable to an etiology other than acute GVHD (e.g., 
infection) and a history of acute GVHD exists or acute GVHD is present in other 
organ systems and is stable, then the gastrointestinal tract will not be evaluable for 
acute GVHD until the resolution or stabilizing of the other disease process (e.g., 
infection) in the absence of biopsy or autopsy confirmation.   
  
D. Persistent anorexia, nausea or vomiting in the absence of signs of acute GVHD in 
other organ systems:  
  
Persistent anorexia, nausea or vomiting in the absence of other known causes of these 
symptoms will be considered stage I acute GVHD if confirmed by endoscopic biopsy.  

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If a biopsy is not possible (e.g. secondary to thrombocytopenia) but the clinical 
findings are compatible with acute GVHD, then the patient will be treated and 
recorded as having acute GVHD.  
  
3.2 Staging of the Gastrointestinal Tract for the Severity of Acute GVHD  
  
The severity of gastrointestinal tract GVHD will be staged according to modified 
Glucksberg criteria. To minimize errors caused by large day-to-day variation, diarrhea 
volume is measured as an average over 3 days and reported as the volume in milliliters 
per day. When urinary mixing is noted the stool volume will be considered half of the 
total volume unless nursing staff is able to give a better estimate from direct observation. 
Abdominal cramps are considered significant for staging if the severity results in a 
clinical intervention (e.g. analgesia, fasting, etc.). Blood in the stools is considered 
significant if the blood is visible or hematochezia/melena is present and not clearly 
attributed to a cause other than GVHD (e.g., epistaxis/hemorrhoids).  
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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APPENDIX C  
          CRITERIA FOR GRADING CHRONIC GVHD GRADE 
 
 
 
Score 0 
Score 1 
Score 2 
Score 3 
Performance Score: 
________ 
KPS  ECOG  LPS 
Asymptomatic 
and fully active 
(ECOG 0: KPS 
or LPS 100%) 
 Symptomatic, fully 
ambulatory, restricted 
only in physically 
strenuous activity (ECOG 
1, KPS or LPS 80-90%) 
Symtomatic, 
ambulatory, capable 
of self-care, >50% of 
waking hours out of 
bed (ECOG 2, KPS 
or LPS 60-70%) 
Symptomatic limited 
self-care, >50% of 
waking hours in bed 
(ECOG 3-4, KPS or 
LPS <60%) 
SKIN 
Clinical features: 
Maculopapular rash 
Lichen planus-like features 
Papuloquamous lesions or 
ichthyosis 
Hyperpigmentation 
Hypopigmentaion 
Keratosis pilaris 
Erythema 
Erythroderma 
Poikiloderma 
Sclerotic features 
Pruritus 
Hair involvement 
Nail involvement 
% BSA Involved _______ 
 No symptoms 
<18% BSA with 
disease signs but 
NOsclerotic features 
 19-50% BSA OR 
involvement with 
superficial sclerotic 
features “not 
hidebound” (able to 
pinch) 
>50% BSA ORdeep 
sclerotic features 
“hidebound” (unable to 
pinch) OR impaired 
mobility, ulceration or 
severe pruritus 
MOUTH 
No symptoms 
 Mild symptoms with 
disease signs but 
NOTlimiting oral intake 
significantly 
 Moderate 
symptoms with 
disease signs 
WITHpartial 
limitation of oral 
intake 
 Severe symptoms 
with disease signs on 
examination WITH 
major limitation of oral 
intake 
EYES 
 
Mean tear test (mm): 
>10 
6-10 
≥5 
Not done 
No symptoms 
 Mild dry eye 
symptoms not affecting 
ADL (requiring eyedrops) 
<3 x per day) OR    
asymptomatic signs of 
keratoconjunctivitissiccca 
 Moderate dry eye 
symptoms partially 
affecting ADL 
(requiring drops>3x 
per day or punctual 
plugs), 
WITHOUTvision 
impairment 
 Severe dry eye 
symptoms significantly 
affecting ADL (special 
eyeware to relieve pain ) 
ORunable to work 
because of ocular 
symptomsOR loss of 
vision cause by 
keratoconjunctivitissicca 
GI Tract 
No symptoms 
 Symptoms such as 
dysphagia, anorexia, 
nausea, vomiting, 
abdominal pain or 
diarrhea without 
significant weight loss 
(<5%) 
 Symptoms 
associated with mild 
to moderate weight 
loss) 5-15%) 
 Symptoms 
associated with 
significant weight loss > 
15%, requires 
nutritional supplement 
for most calorie needs 
OResophageal dilation 
LIVER 
 Normal LFT 
 Elevated Bilirubin, 
AP*, AST or ALT <2 x 
ULN 
 Bilirubin >3 
mg/dl or Bilirubin, 
enzymes 2-3 x ULN 
 Bilirubin or enzymes 
> 5 x ULN 
 
 
 
 

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APPENDIX C (continued) 
CRITERIA FOR GRADING CHRONIC GVHD GRADE 
 
SCORE 0 
SCORE 1 
SCORE 2 
SCORE 3 
Lungs† 
 
 
 
FEV1 ___________ 
 
DLCO __________ 
 No symptoms 
 
 
 
 
 
 FEV1 >80% 
OR 
LFS=2 
 Mild symptoms 
(shortness of breath after 
climbing one flight of 
steps) 
 
 
 FEV1 60-79%  
OR 
LFS 3-5 
 Moderate 
symptoms (shortness 
of breath after 
walking on flat 
ground) 
 
 FEV1 40-59% 
OR 
LFS 6-9 
Severe symptoms 
(shortness of breath 
at rest; requiring 02 
 
 
 
 FEV1 ≥39% OR 
LFS 10-12 
JOINTS AND  
FASCIA 
 No symptoms 
 Mild tightness of arms 
or legs, normal or mild 
decreased range of 
motion (ROM) AND not 
affecting ADL 
 Tightness of arms 
or legs OR joint 
contractures, 
erythema thought 
due to fasciitis, 
moderate decrease 
ROM AND mild to 
moderate limitation 
of ADL 
Contractures 
WITH significant 
decrease or ROM 
AND significant 
limitation of ADL 
(unable to tie shoes, 
button shirts, dress 
self etc.) 
GENITAL TRACT 
 No symptoms 
 Symptomatic with 
mild signs on exam AND 
no effect on coitus and 
minimal discomfort with 
gynecologic exam 
 Symptomatic 
with moderate signs 
on exam AND with 
mild dyspareunia or 
discomfort with 
gynecologic exam 
 Symptomatic 
WITH advance 
signs (stricture, labial 
agglutination or 
severe ulcerations 
AND severe pain 
with coitus or 
inability it insert 
vaginal speculum 
Other indicators, clinical manifestations or complications related to chronic GVHD (check all that apply and assign a score to its 
severity (0-3) based on its functional impact where applicable (none = 0, mild = 1, moderate =2, severe = 3. 
Esophageal stricture or web ____ 
Pericarial Effusion  ____ 
 
Pleural Effusion(s) ____ 
Ascites (serositis) ____ 
 
Nephrotic syndrome ____  
Peripheral Neuropathy ____ 
Myasthenia Gravis ____ 
 
Cardiomyopathy ____ 
 
Eosinophilia > 500/µl ____                         
Polymyositis  ____    Cardiac conduction defects ____         Coronary artery involvement ____ 
Platelets <100,000/µl ____                     Progressive Onset  ____ 
Other: Specify:      ________________________________________________________________________________ 
Organ scoring of chronic GVHD. 
* AP may be elevated in growing children, and not reflective of liver dysfunction.    
† Pulmonary scoring should be performed using both the symptom and pulmonary function testing (PFT) scale whenever possible. When 
discrepancy exists between pulmonary symptoms or PFT scores, the higher value should be used for final scoring. Scoring using the 
Lung Function Score (LFS) is preferred, but if DLCO is not available, grading using FEV1 should be used.  The LFS is a global 
assessment of lung function after the diagnosis of bronchiolitis obliterans has already been established. The percent predicted FEV1 and 
DLCO (adjusted for hematocrit but not alveolar volume) should be converted to a numeric score as follows: >80% = 1; 70-79% = 2; 60-
69% = 3; 50-59% = 4; 40-49% = 5; <40% = 6.  The LFS = FEV1 score + DLCO score, with a possible range of 2-12.  GVHD indicates 
graft versus host disease, ECOG, Eastern Cooperative Oncology Group, KPS, Karnofsky Performance Status; LPS, Lansky Performance 
Status; BSA, body surface area; ADL, activities of daily living; LFTs, liver function tests; AP, alkaline phosphatase; ALT, alanine 
aminotransferase; AST, aspartate aminotransferase; ULN, upper limit of normal. 
 
 

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APPENDIX C (continued)  
CRITERIA FOR GRADING CHRONIC GVHD GRADE 
GLOBAL GRADING OF CHRONIC GVHD84  
Final Grade  
Number of 
Organs/Sites*  
Maximum Organ 
Score**  
Lung Score  
Mild  
1 - 2  
1  
0  
Moderate  
3 or more  
1  
1  
At least 1  
2  
Severe  
At least 1  
3  
2 - 3  
  
*Determined by adding the total number of organs receiving score > 0 using Figure 1, Appendix 
B.  
**Defined as the maximum score given to any organ system amongst all organs scored using 
Figure 1, Appendix B.   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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APPENDIX D  
CRITERIA FOR ADVERSE EVENT (AE) EVALUATION AND REPORTING  
The St. Jude Department of BMTCT Clinical Research Office standard operating procedure for 
the documenting and reporting of adverse (SOP 10 Documenting and Reporting of Adverse 
Events) will provide guidance on the evaluation, collection and reporting of adverse events for 
this clinical trial.  The current version of this document, as well as ongoing updates, can be 
located at the following website: http://home.stjude.org/bmt/Pages/policies-research.aspx  

 
  
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APPENDIX E  
Recommended testing and evaluation schedule  
  
STANDARD OF 
CARE STUDIES  
SAMPLE  
VOLUME  
PRE  
MONTH 1  
MONTH 2  
MONTH 3  
MONTH 6  
MONTH 12  
Pregnancy Test  
PB  
2 ml  
X  
As clinically indicated  
Physical Exam  
N/A  
N/A  
X  
Weekly  
X  
X  
CBC with diff.  
PB  
0.5-2 ml  
X  
Daily until engrafted, then weekly  
X  
X  
Chemistry  
PB  
0.25-2ml  
X  
Weekly  
X  
X  
Viral surveillance  
(BMTPCR)  
PB  
4 ml  
X  
Weekly  
As clinically indicated  
Chimerism  
PB  
1-2 ml  
  
Weekly upon engraftment  
X  
X  
BM  
2 ml  
  
X  
  
X  
  
X  
Disease Status 
Evaluation  
N/A  
N/A  
X  
X  
  
X  
  
X  
MRD Bone  
Marrow        
BM  
3 ml  
X  
X  
  
X  
  
X  
Lymphocyte 
Subset Study  
PB  
2.5-4 ml  
X  
X  
X  
X  
X  
X  
Quantitative 
Immunoglobulins  
PB  
2 ml  
X  
  
  
X  
  
X  
  
• 
The information derived from or noted on the physical examinations, standard tests, and other assessments that comprise standard of care for recipients are not required to be 
transcribed onto case report forms and/or entered into the database. In reference to section 6.1 Evaluations, the above-indicated follow-up regimen for these evaluations is 
guided by the SOPs of the Department of BMTCT, for recipients of allogeneic stem cell transplantation. As these evaluations are considered standard clinical care 

 
  
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(nonresearch), variations in frequency (more or less frequent) of these evaluations can occur due to the participant’s current clinical condition and will not be noted as protocol 
deviations.  
• 
Disease status evaluations/BM testing results obtained prior to enrollment may be used for the baseline/pre-infusion assessments.  
• 
Additional chimerism testing may be required as clinically indicated and described in Section 6.3.  
• 
Lymphocyte subset studies may be omitted without variance when the absolute lymphocyte count (ALC) is zero.  
• 
In the event of graft failure/rejection, the post failure/rejection bone marrow, chimerism and several applicable immune studies would not be clinically indicated and these 
studies may be held.  
APPENDIX E (continued)  
Immune reconstitution testing and evaluation schedule for RECIPIENT 
RESEARCH 
STUDIES  
SAMPLE  
VOLUME  
PRE  
MONTH 1  
MONTH 2  
MONTH 3  
MONTH 6  
MONTH 12  
VBETA/TREC 
RESEARCH  
PB  
17 mL  
X  
  
  
X  
X  
X  
LYMPHOCYTE  
PHENOTYPES 
RESEARCH  
PB  
17 mL  
X  
X  
X  
X  
X  
X  
IR-PHENOTYPE    
(Youngblood Lab)  
 
PB  
5 mL  
X  
X  
X  
X  
X  
X  
T-FUNCTION       
(Thomas Lab)  
PB  
5 mL  
X  
X  
X  
X  
X  
X  
BM  
1 mL  
X  
X  
  
X  
  
  
  
  
• 
VBETA/TREC Research and Lymphocyte Phenotypes Research results will be maintained in the Immune Monitoring Core Lab.  
• 
For RESEARCH studies, the posted volumes are the minimum volumes required to perform the respective protocol evaluations.  
• 
The PRE-transplant bone marrow for T-FUNCTION are optional tests that may be omitted at the discretion of the PI or co-investigator.  

 
  
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APPENDIX E (continued) Research testing for DONOR 
Prior to initial stem cell collection procedure:  
OPTIONAL research immune studies testing schedule  
Evaluation  
Volume Requirement  
Flow cytometry enumeration  
Lymphocyte Subset Study = 4 mL  
Thymic output and T cell repertoire  
VBETA/TREC Research = 17 mL  
Donor baseline lymphocyte number and function  
Lymphocyte Phenotypes Research = 17 mL  
Donor baseline immune function (Youngblood Lab)  
IR-PHENOTYPE = 5mL  
Donor baseline immune function (Thomas Lab)  
T-FUNCTION = 5mL  
• 
All donor research testing to be collected prior to growth factor administration.  These optional research tests may be 
collected at separate times.   
• 
Research testing results will be maintained in a secured database in the respective co-investigator laboratory database.   

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APPENDIX E (continued)  
  
Research Study Evaluation Target Windows  
Several laboratory tests can only be processed on weekdays; therefore, if the scheduled evaluation 
falls on a weekend, or during a holiday period, an adjustment in the follow-up visit is expected 
and would not be noted as a protocol variation.  Additionally, in order to accommodate such 
logistical constraints, evaluation/collection dates of all protocol assessments (required and 
optional research), may be performed within a reasonable window of the intended date following 
the guidelines provided in the table below:  
If the Planned Evaluation 
Time Point is:  
Window  
Weekly  
+ 3 Days  
Month 1  
Week 2 to Week 6  
Month 2  
Week 7 to Week 11  
Month 3  
Week 12 to Month 4  
Month 6  
Month 5 to Month 7  
Month 9  
Month 8 to Month 10  
Month 12  
Month 10 to Month 14  
  
  
  
  
  
  
  
  
  
  
  
  
  

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APPENDIX F  
The St. Jude Department of BMTCT Clinical SOPs for standard of care for all allogeneic stem 
cell infusion recipients and stem cell donors will provide guidance on the evaluation, ongoing 
clinical care and follow up for this clinical trial.  The current versions of these SOPs, as well as 
ongoing updates, of these documents can be located at the following website: 
http://home.web.stjude.org /bone_marrow/clinicalHome.shtml.    

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APPENDIX G 
  
HAPNK1 Audit Plan with Amendment 2.0  
  
I. All new enrollments will monitored and audited by a designated experienced monitor from 
our CPDMO (i.e., Protocol Office). Following our institutional process, each new participant 
data will be reviewed as follows:  
  
1. On the same day of enrollment the CPMDO staff will review the completed eligibility 
checklist and informed consent document for completeness and accuracy (100% of 
enrollments).  
  
2. In support of compliance with Eligibility and Informed Consent document and process 
there will be verification of supporting source documents early post enrollment, within 5 
days (100% of enrollments).  
  
3. For the initial six subjects enrolled on Amendment 2.0 (or later protocol versions until 6  
new  participants are  enrolled post  activation of  Amendment 2.0)  the CPMDO monitor 
will evaluate the following components in each patient within 10 working days of the 
participant reaching the day +100 milestone:  
  
a. compliance with treatment including protocol directed GVHD prophylaxis  
b. adverse events and grade 3-4 toxicities including those contributing to the protocol 
stopping rules  
c. assessment and coding of acute GVHD  
d. evaluation of and reporting of deaths on study (including treatment related 
mortality, TRM)  
e. status of participant at day +100  
f. documentation of engraftment and,  
g. review of source data elements related to assessments for GHVD (for example, 
pathology biopsy results).  
  
4. In each case the monitor will compare patient data in the protocol database with source 
documents. The monitor will utilize the defined criteria as indicated in the HAPNK1 latest 
protocol version for consent, eligibility, and toxicity assessments and grading, including 
the newly incorporated COG GVHD Guidelines.  
  
II. A patient specific audit summary will be generated with findings from each of the 
components. Results of the patient-specific audit will be provided to the study Principal 
Investigator (PI) for comment and independently to the VP Clinical Trials Administration.  
In case of discrepancies related to under reporting of GVHD and TRM, those cases will be 
interpreted as assigned by the monitor in the context of operationalizing the stopping rules, 
and will remain as such (i.e. coded as GVHD) until the opinion of an external medical 
reviewer has been obtained.  

 
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III. A final consensus audit summary on the first six enrollments on Amendment 2.0 will be 
generated and provided to the PI, to the St. Jude Clinical Director. the VP Clinical Trials, St. 
Jude IRB, as well as to the FDA  
  
IV. On a monthly basis the study PI, the study CRA, and the Director of Clinical 
Trial Operations in the BMT service will meet to review ongoing data 
collection for each enrollment for accuracy, completeness, and timeliness.  
  
V. If the focused audits of the first six subjects enrolled on Amendment 2.0 reveal no major 
compliance concerns, the study will continue with an every six month review cycle as 
required by our Institutional Data Safety Monitoring Plan (with a modification that every 
other new enrollment will have data audits). In addition to the review elements noted above 
other components that occur after day +100 (chronic GVHD, other AEs, deaths, status, 
regulatory documents, etc.) will be reviewed. An overall study monitoring report will 
generated every six months, and will be reviewed independently at such time by the 
Institutional Monitoring Committee.