Phase II Trial of Extracorporeal Photopheresis (ECP) Plus Low Dose IL-2 for Treatment of Steroid Refractory Chronic Graft-versus-Host Disease (cGVHD)
Phase: PHASE2
Conditions: Chronic Graft Versus Host Disease
Sponsor: City of Hope Medical Center

 
IRB 15125 
 
04/23/19 
Version: 10 
CITY OF HOPE NATIONAL MEDICAL CENTER 
1500 E. DUARTE ROAD 
DUARTE, CA 91010 
 
DEPARTMENT OF HEMATOLOGY AND HEMATOPOIETIC CELL TRANSPLANTATION 
 
TITLE: Phase II trial of Extracorporeal Photopheresis (ECP) plus Low Dose IL-2 for Treatment of Steroid 
Refractory Chronic Graft-Versus-Host Disease (cGVHD) 
 
 
CITY OF HOPE PROTOCOL NUMBER/VERSION: IRB # 15125  
 
 
 
VERSION: 10  
 
DATE(S)/ OF AMENDMENT(S)/REVISION(S): 
 
COH Initial Approval 
Protocol Dated 12/14/2015 
Version: 00 
COH Amendment 01  
Title page Dated 2/11/2016  
 
 
 
 
Version: 01 
COH Amendment 02  
Title page Dated 4/19/16 
 
 
 
 
 
Version: 02 
COH Amendment 03  
Protocol Dated 08/08/16 
 
 
 
 
 
Version: 03 
COH Amendment 04  
Title Page Dated 01/17/2017  
 
 
 
 
Version: 04 
COH Amendment 05  
Title Page Dated 02/13/2017  
 
 
 
 
Version: 05 
COH Amendment 06  
Protocol Dated 02/08/2017 
 
 
 
 
 
Version: 06 
COH Amendment 07  
Protocol Dated 03/30/2017 
 
 
 
 
 
Version: 07 
COH Amendment 08  
Protocol Dated 07/31/2017 
 
 
 
 
 
Version: 08 
COH Amendment 09  
Title Page Dated 07/20/2018  
 
 
 
 
Version: 09 
COH Amendment 10  
Title Page Dated 04/23/19 at continuation 
 
 
 
Version: 10 
 
SITE: 
Chronic GVHD involving skin, hepatic and GI Tract 
 
 
 
 
STAGE: 
Steroid-refractory  
 
 
 
MODALITY: 
Subcutaneous (IL-2) and apheresis (ECP 
 
 
TYPE: 
Phase II 
 
 
PRINCIPAL INVESTIGATOR: 
Amandeep Salhotra, M.D. 
 
 
 
COLLABORATING INVESTIGATORS: Ryotaro Nakamura, M.D., Sierra Min Talley, PhD, Guido Marcucci, 
M.D. 
 
 
 
PARTICIPATING CLINICIANS: 
Haris Ali, M.D., Ahmed Aribi, M.D., Elizabeth Budde, M.D., Ph.D., 
Stephen Forman, M.D., Alex Herrera, M.D., Myo Htut, M.D., 
Chatchada Karanes, M.D., Samer Khaled, M.D, Amrita Krishnan, 
M.D., Matthew Mei, M.D., Auayporn Nademanee, M.D., Nitya 
Nathwani, M.D., Leslie Popplewell, M.D., Vinod Pullarkat, M.D., 
Michael Rosenzweig, M.D.,Tanya Siddiqi, M.D., David Snyder, M.D., 
Anthony Stein, M.D., Jasmine Zain, M.D., Jae Jung, M.D., Faoud 
Kandeel, M.D., Henry Lin, M.D., Ibrahim  Aldoss, M.D., Monzr Al Malki, 
M.D., Ji-Lian Cai, M.D. Thai Cao, M.D., Len Farol, M.D., Firoozeh 
Sahebi, M.D., Eileen Smith, M.D.,  Ricardo Spielberger, M.D., 
Karamjeet Sandhu, M.D., Anna Pawlowska, M.D., Joseph Rosenthal, 
M.D.,  Nicole Karras M.D., Shirong Wang, M.D., Yuan Shan, M.D., 
Badri Modi, M.D. 

 
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Nicole Karras, M.D., Shirong Wang, M.D., Yuan Shan, 
M.D. 
Experimental Design Schema 
 
This single center/single arm, phase II clinical trial is designed to evaluate the anti-cGVHD activity of 
extracorporeal photopheresis (ECP) when combined with low dose IL-2, in patients with steroid 
refractory cGVHD, as assessed by overall cGVHD response rate (CR+PR+SD). 
 
 
 
 
 

 
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Protocol Synopsis 
 
Protocol Title: 
A Phase II trial of extracorporeal photopheresis (ECP) plus low dose IL-2 for the treatment of 
steroid refractory chronic graft-versus-host disease (cGVHD) 
Brief Protocol Title for the Lay Public (if applicable): 
Immunotherapy with IL-2 and ECP for refractory chronic graft versus host disease 
Study Phase: 
Phase II, non-randomized single institution trial. 
Participating Sites: 
City of Hope National Medical Center 
Rationale for this Study: 
Impaired immune reconstitution due to alteration in the ratio of regulatory T cells (Tregs) and 
conventional T cells (Tcon) post hematopoietic cell transplant is responsible for clinical 
manifestations of chronic GVHD. We propose that the combination of ECP and IL-2 will have a 
synergistic effect on increasing the proportion of Tregs, leading to normalization of Treg: Tcon 
ratio. This should lead to improved overall response rates (CR, PR and stable disease) when IL-2 
and ECP are used in combination, compared to historical controls when either modality is used 
alone. 
Objectives: 
Primary: To evaluate the anti-cGVHD activity of extracorporeal photopheresis (ECP) when 
combined with low dose IL-2, in patients with steroid refractory cGVHD, as assessed by overall 
cGVHD response rate (CR+PR+SD). 
Secondary:   
 
Characterize and evaluate toxicities, including type, frequency, severity, attribution, time 
course and duration. 
 
Estimate overall and failure-free survival, non-relapse mortality (NRM) and relapse, 
through 1 year after initiation of treatment.  
 
Characterize the chronic GVHD Symptom Scale scores 
 
Determine ongoing prednisone use with IL-2 and ECP combination therapy.  
 
Assess the immunologic effects of low-dose daily SC IL-2 + ECP.  
 
Correlate clinical endpoints of response with ECP performance parameters. 
Study Design: 
Single-arm, single institution Phase II trial to estimate the activity of low dose IL-2 and ECP in 
patients with steroid refractory GVHD. 
Endpoints: 
Overall response rate to a 12-week course of subcutaneous low-dose daily IL-2 plus ECP in 
patients with steroid-refractory cGVHD. The primary endpoint of overall response is as defined 
in Section 11.0. Responses will be assessed at 3 weekly intervals while on IL-2 + ECP.  
Sample Size: 

 
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The trial is expected to enroll 24 patients . Using a Simon two-stage design with type I error of 
0.05 and 80% power a minimum of 24 patients are needed for enrollment  to discriminate a 
promising response rate of 50% from current response rate of 25%  
Estimated Duration of the Study 
4years  (per section 5.3) 
Summary of Subject Eligibility Criteria: 
Inclusion Criteria: 
1. Recipients of allogeneic stem cell transplantation (sibling/unrelated/UCB/Haplo) with 
myeloablative or non-myeloablative conditioning regimens. 
2. Participants must have steroid-refractory cGVHD. Steroid-refractory cGVHD is defined 
as having persistent signs and symptoms of cGVHD despite the use of prednisone at ≥ 
0.20 mg/kg/day (or 0.5 mg/kg every other day) for at least 4 weeks (or equivalent dosing 
of alternate corticosteroids) without complete resolution of signs and symptoms. Patients 
with either extensive chronic GVHD or limited chronic GVHD requiring systemic 
therapy are eligible. 
3. Patient age  18 years old. Because no dosing or adverse event data are currently 
available on the use of IL-2 in participants <18 years of age, children are excluded from 
this study. 
4. Estimated life expectancy greater than 3 months. 
5. Karnofsky performance status of 70-100 %. 
6. Stable dose of corticosteroids for 2 weeks prior to enrollment. 
7. Ability to understand and the willingness to sign a written informed consent document. 
8. Adequate organ function as defined below. 
 
Hepatic: Adequate hepatic function (total bilirubin <2.0 mg/dl-exception permitted in 
patients with Gilbert’s Syndrome; AST (SGOT)/ALT (SGPT) ≤2x ULN), unless 
hepatic dysfunction is a manifestation of presumed cGVHD Abnormal LFTs in the 
context of active cGVHD involving other organ systems may also be permitted if the 
treating physician documents the abnormal LFTs as being consistent with hepatic 
cGVHD and a liver biopsy will not be mandated in this situation.  
 
 Renal: Serum creatinine within normal institutional limits or creatinine clearance > 
60 mL/min/1.73 m2 for participants with creatinine levels above institutional normal.  
 
 Adequate bone marrow function indicated by ANC>1000/mm3 and 
platelets>50,000/mm3 without growth factors or transfusions. 
Exclusion Criteria: 
1. Patients should not have any uncontrolled illness including ongoing or active infection.  
Ongoing prednisone requirement >1 mg/kg/day (or equivalent). 
2. History of thrombotic microangiopathy, hemolytic-uremic syndrome or thrombotic 
thrombocytopenic purpura. 
3. Exposure to any new immunosuppressive medication in the 4 weeks prior to enrollment. 
4. Donor lymphocyte infusion within 100 days prior to enrollment 
5. Active malignant relapse. 
6. Inability to comply with IL-2 treatment or ECP regimen. 
7. Uncontrolled cardiac angina or symptomatic congestive heart failure (NYHA Class III or 
IV) 
8. HIV-positive individuals on combination antiretroviral therapy are ineligible because of 

 
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the potential for pharmacokinetic interactions with the agents used after allogeneic 
HSCT. In addition, these individuals are at increased risk of lethal infections.  
9. Patients may not be receiving any other parenteral investigational agents, or concurrent 
biological, chemotherapy, or radiation therapy.  Oral chemotherapeutic agents or 
biologics –for example ruxolitinib therapy (either past or current exposure) - is allowed. 
10. History of allergic reactions attributed to compounds of similar chemical or biologic 
composition to IL-2. 
11. Patients must not have received prior chemotherapy (e.g. pentostatin) within 4weeks 
before study enrollment, or those who have not recovered from the adverse events due to 
agents administered more than 4 weeks earlier are excluded.   
12. Pregnant women are excluded from this study.  Because there is an unknown but 
potential riskfor adverse events in nursing infants secondary to treatment of the mother 
with IL-2, breastfeeding should be discontinued if the mother is treated with IL-2.    
13. Patients with other active malignancies are ineligible for this study, other than superficial 
localized skin cancer (Basal or Squamous cell carcinoma).  
 
Investigational Product Dosage and Administration: 
Recombinant human IL-2 (Proleukin®) will be supplied as a sterile, lyophilized cake in single-
use vials containing 22 MIU of aldesleukin intended for intravenous (IV) administration. The 
drug will be prepared by investigational pharmacy under aseptic conditions. The dose of 1 x 106 
IU/m2/day for 12 weeks will be calculated based on actual body weight at screening. IL-2 will be 
self-administered by daily subcutaneous injection and vials will be stored at 2-8 ºC. (36-46 degree 
F). ECP will be administered as per COH SOP.  The drug will be provided by Prometheus labs 
and dispensed to patients by IDS pharmacy in prefilled syringes. 
Clinical Observations and Tests to be Performed: 
Patients will be evaluated for response to intervention (ECP + IL-2) at baseline and at weeks 3, 7, 
9, 12 and 16. NIH clinical scoring forms will be used to document responses. Markers of immune 
activation will be monitored at the same time points from blood samples taken on scheduled 
clinic visits. Quality of Life Assessments will also be performed at baseline and in weeks 7 and 
12.  
Statistical Considerations: 
The trial is expected to enroll 24 patients. Using a Simon two-stage design with type I error of 
0.05 and 80% power a minimum of 24 patients are needed for enrollment  to discriminate a 
promising response rate of 50% from current response rate of 25% 
Sponsor/Licensee: 
N/A  
Case Report Forms 
Medidata Rave EDC® 

 
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Table of Contents 
 
SECTION .............................................................................................................................. PAGE 
1.0 
Study Objectives ............................................................................................................... 10 
1.1 
Primary Objective ................................................................................................ 10 
1.2 
Secondary Objectives .......................................................................................... 10 
2.0 
Background ....................................................................................................................... 10 
2.1 
Introduction/Rationale for Development ............................................................. 10 
2.1.1 
Chronic GVHD ....................................................................................... 10 
2.1.2 
Extracorporeal photopheresis (ECP)....................................................... 11 
2.1.3 
Interleukin-2 (IL-2) ................................................................................. 13 
2.1.4 
Rationale for combination of ECP and IL2 for cGVHD ........................ 13 
2.1.5 
Immune correlative studies ..................................................................... 14 
2.2 
Overview of Proposed Study ............................................................................... 16 
2.3 
Preclinical Studies ................................................................................................ 16 
2.4 
Human Studies ..................................................................................................... 17 
2.4.1 
. Interleukin -2......................................................................................... 17 
2.4.2 
Extracorporeal Photopheresis: ................................................................ 18 
3.0 
Patient Eligibility .............................................................................................................. 19 
3.1 
Inclusion Criteria ................................................................................................. 19 
3.1.1 
Disease Status ......................................................................................... 19 
3.1.2 
Age Criteria, Performance Status and Life Expectancy ......................... 19 
3.1.3 
Child Bearing Potential ........................................................................... 19 
3.1.4 
Protocol-Specific Criteria ....................................................................... 20 
3.1.5 
Informed Consent/Assent ....................................................................... 20 
3.1.6 
Prior Therapy: ......................................................................................... 20 
Exclusion Criteria ............................................................................................................. 20 
3.2 
Non-Compliance .................................................................................................. 21 
3.3 
Inclusion of Women and Minorities .................................................................... 21 
4.0 
Screening and Registration Procedures............................................................................. 21 
4.1 
Screening Procedures ........................................................................................... 21 
4.2 
Informed Consent ................................................................................................ 21 
4.3 
Registration Requirements/Process ..................................................................... 21 
4.4 
Randomization and/or Dose Level Assignment................................................... 22 

 
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5.0 
Treatment Program ........................................................................................................... 22 
5.1 
Treatment Overview ............................................................................................ 22 
5.2 
Treatment Schedule ............................................................................................. 22 
5.2.1 
IL-2 Therapy ........................................................................................... 22 
5.2.2 
ECP Therapy ........................................................................................... 23 
5.2.3 
Observations and Tests to be Performed ................................................ 23 
5.2.4 
Documentation of compliance to therapy ............................................... 23 
5.3 
Planned Duration of Therapy: .............................................................................. 24 
5.4 
Extended-duration therapy: .................................................................................. 24 
5.5 
Criteria for Removal from Treatment .................................................................. 24 
5.6 
Subject Follow-Up ............................................................................................... 24 
5.7 
Supportive Care, Other Concomitant Therapy, Prohibited Medications ............. 25 
5.8 
Additional Studies: .............................................................................................. 25 
5.8.1 
Immune Cell Subsets: ............................................................................. 25 
5.8.2 
Inflammatory Markers: ........................................................................... 25 
5.9 
Definition of Dose-Limiting Toxicity (DLT) ...................................................... 25 
6.0 
Dose Delays/Modifications for Adverse Events ............................................................... 26 
6.1 
IL-2 Therapy ........................................................................................................ 26 
6.2 
Extracorporeal photopheresis: ............................................................................. 26 
7.0 
Data and Safety Monitoring, Unanticipated Problems and Adverse Event Reporting ..... 27 
7.1 
Definition of Risk Level ...................................................................................... 27 
7.2 
Monitoring and Personnel Responsible for Monitoring ...................................... 27 
8.0 
Agent Information and Risks ............................................................................................ 30 
8.1 
Interleukin-2 (IL-2) .............................................................................................. 30 
8.1.1 
Description .............................................................................................. 30 
8.1.2 
Toxicology .............................................................................................. 30 
8.1.3 
Expected Toxicities with IL-2 ................................................................ 32 
8.1.4 
Pharmacology – Handling, Storage, Dispensing and Disposal ............... 33 
8.2 
Extracorporeal Photopheresis .............................................................................. 34 
8.2.1 
ECP Expected Toxicities (Incidence less than 5%) ................................ 34 
9.0 
Correlative/Special Studies ............................................................................................... 35 
9.1 
Immune Correlative Studies: ............................................................................... 35 
9.1.1 
Immune Cell Subsets: ............................................................................. 35 
9.1.2 
Inflammatory Markers: ........................................................................... 35 
9.2 
Methods ............................................................................................................... 36 

 
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9.2.1 
Immunologic Assays............................................................................... 36 
9.2.2 
MicroRNA analysis: ............................................................................... 36 
9.2.3 
Cytokine assays: ..................................................................................... 37 
10.0 
Study Calendar .................................................................................................................. 38 
11.0 
Endpoint Evaluation Criteria/Measurement of Effect....................................................... 40 
11.1 
Primary Endpoint ................................................................................................. 40 
11.1.1 Response Definitions: ............................................................................. 40 
11.2 
Secondary Endpoints ........................................................................................... 40 
12.0 
Data Reporting .................................................................................................................. 42 
12.1 
Confidentiality and Storage of Records ............................................................... 42 
12.1.2 Subject Consent Form ............................................................................... 42 
12.1.3 Data Collection Forms and Submission Schedule .................................... 42 
13.0 
Statistical Considerations .................................................................................................. 42 
13.1 
Study Design, Sample Size, and Accrual Rate .................................................... 42 
Safety Analysis and Stopping Rules for Excessive Toxicity ............................................ 43 
13.2 
Statistical Analysis Plan ....................................................................................... 43 
14.0 
Human Subject Issues ....................................................................................................... 44 
14.1 
Institutional Review Board .................................................................................. 44 
14.2 
Recruitment of Subjects: ...................................................................................... 44 
14.3 
Advertisements .................................................................................................... 44 
14.4 
Study location and Performance Sites ................................................................. 44 
14.5 
Confidentiality ..................................................................................................... 44 
14.6 
Financial Obligations and Compensation ............................................................ 44 
14.7 
Informed Consent Processes ................................................................................ 45 
15.0 References .............................................................................................................................. 46 
 

 
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Abbreviations 
Abbreviation 
Meaning 
AE 
Adverse Event 
Allo-HCT 
Allogeneic Hematopoietic Stem Cell Transplantation 
COH 
City of Hope 
cGVHD 
Chronic Graft-Versus-Host Disease 
CR 
Complete Response 
CRC 
Clinical Research Coordinator 
CRF 
Case Report Form 
CTCAE 
Common Terminology Criteria for Adverse Events 
CTEP 
Cancer Therapy Evaluation Program 
DLT 
Dose Limiting Toxicity 
DSMC 
Data Safety Monitoring Committee 
ECP 
Extracorporeal Photopheresis 
FFS 
Failure Free Survival 
ICF 
Informed Consent Form 
IDS 
Investigational Drug Services 
IL-2 
Interleukin-2 
IND 
Investigational New Drug  
IRB 
Institutional Review Board 
MTD 
Maximum Tolerated Dose 
NCI 
National Cancer Institute 
PD 
Progressive Disease 
PI 
Principal Investigator 
PMT 
Protocol Monitoring Team 
PR 
Partial Response 
SAE 
Serious Adverse Event 
SC 
Subcutaneous 
SD 
Stable Disease 

 
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1.0 Study Objectives 
1.1 Primary Objective  
To evaluate the anti-cGVHD activity of extracorporeal photopheresis (ECP) when combined with low 
dose IL-2, in patients with steroid refractory cGVHD, as assessed by overall cGVHD response rate 
(CR+PR+SD). 
  
1.2 Secondary Objectives  
 Characterize and evaluate toxicities, including type, frequency, severity, attribution, time course 
and duration. 
 Estimate overall and failure-free survival, non-relapse mortality (NRM) and relapse, through 1 
year after initiation of treatment.  
 Characterize chronic GVHD Symptom Scale scores -self-report (with assistance from RNs and 
MDs). 
 Determine ongoing prednisone use with IL-2 and ECP combination therapy.  
 To assess efficacy of protocol therapy ( IL-2+ECP) in helping to decrease the steroid dosage.   
 Assess the immunologic effects of low-dose daily SC IL-2 + ECP.  
 Correlate clinical endpoints of response with ECP performance parameters. 
2.0 Background 
2.1 Introduction/Rationale for Development 
2.1.1 
Chronic GVHD 
Allogeneic hematopoietic stem cell transplantation (allo-HCT) is a proven effective immunotherapy for 
aggressive hematologic cancers that is used increasingly worldwide. Clinical outcomes post allo-HCT, 
including relapse, non-relapse mortality and overall long term survivorship have been improving for the 
past two decades and this is attributed to better donor selection, supportive care, less toxic conditioning 
regimens and advancements in management of acute and chronic graft versus host disease (GVHD)1. 
Despite these advances, allo-HCT continues to be associated with clinically significant morbidity and 
mortality, most of which is attributed to acute and chronic GVHD2. Glucocorticoids are the first line of 
therapy and responses are seen in about one-third of patients with cGVHD. Patients with cGVHD that is 
refractory to steroids are particularly difficult to treat as there is currently no standard of care. Effective 
therapies for steroid-refractory cGVHD are an unmet medical need and new strategies should be aimed 
towards alleviating symptoms and improving long term survivorship. 
The underlying pathophysiologic mechanisms of cGVHD are complex and are related to the transplanted 
donor T-cells recognizing the recipient as “non-self” based on a variety of factors, the most important of 
which is degree of HLA disparity between donor-recipient pair. ChronicGVHD is comprised of an early 
initiating phase, followed by gradual evolution to the full blown syndrome, which can involve multiple 
organs. The “prime targets” are skin, GI tract and liver, which undergo tissue damage as part of the 
preceding chemotherapy and conditioning regimens. Other organs such as lung, salivary and lacrimal 
glands, oral mucosa, skin and subcutaneous tissues can also be involved and contribute to morbidity 
associated with cGVHD. During the initiation phase of cGVHD, recipient antigen presenting cells 
(rAPC’s) engage Donor CD8+ T cells by presenting self antigens in conjunction with the MHC class I 
complex. Donor CD4+ T cells are activated by the MHC class II pathway, wherein, shed donor proteins 
and apoptotic cells are processed by endosomes and presented to Donor CD4+ cells by rAPC’s. After 
antigen presentation and appropriate co-stimulatory signaling, donor CD4+ and CD8+ T cells undergo 
activation and expansion. In the evolution phase, donor APC’s continue the ongoing activation of donor-

 
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derived T cells by presenting recipient antigens via MHC class I and II peptides. The activated T cells 
cause tissue damage by release of cytokines (TNF-α, IL-2 IFN-γ) and by direct tissue infiltration3. 
Steroid refractory cGVHD is treated by a number of second-line immunosuppressive drugs including 
calcineurin inhibitors, sirolimus, mycophenolate mofetil, alemtuzumab, rituxan, tyrosine kinase 
inhibitors, proteosome inhibitors, etanercept and infliximab. There is no current standard of care for 
second-line therapy, so development of new agents and novel combinations of existing therapies for 
second-line GVHD therapy is an urgent need.  
Evaluation of patients with cGVHD using validated and standardized response criteria is lacking at the 
present time and this is a major drawback while evaluating response to therapy across clinical trials. 
Inamoto et al.4 recently described a new outcome measure, failure-free survival (FFS), to access response 
to second-line agents in patients with cGVHD. Failure events include non-relapse mortality, recurrent 
malignancy, and change in systemic therapy. FFS is a meaningful clinical metric that could be used as a 
shorter-term success end point for clinical trials. In their analysis of 312 patients with cGVHD who were 
on at least 0.5 mg/kg of prednisone equivalent and started on second-line immunosuppressive therapy, the 
6 month FFS was 56%. The majority of failures were due to initiation of third line therapy (34%) 
indicating progression of cGVHD, 7 % were due to NRM and 3% due to disease relapse. Predictors of 
treatment failure were high-risk disease at HCT, lower GI involvement and high NIH global score at 
initiation of second-line therapy. FFS will be included as a secondary end point in our cohort. 
 
2.1.2 
Extracorporeal photopheresis (ECP) 
Extracorporeal photopheresis (ECP) has emerged as a promising modality to treat steroid refractory 
cGVHD5. The procedure entails ex vivo treatment of leukapheresed patient lymphocytes with a 
photoactivatable compound and irradiation by ultraviolet A (UVA), followed by reinfusion of treated 
white blood cells (WBCs) back into the patient. ECP was initially applied in the treatment of cutaneous T-
cell lymphoma (CTCL) and subsequently also in the treatment of acute and chronic graft-versus-host 
disease (GVHD), autoimmune disorders, and heart and lung transplant rejection. The clinical efficacy of 
ECP has been attributed to an immune modulatory effect and selective immune tolerance in some cases. 
The exact mechanism remains unknown; however, the following mechanisms of action are proposed; 
 
Clearance of apoptotic cells by antigen-presenting cells results in differentiation of those cells 
into a more tolerogenic phenotype leading to decreased stimulation of effector T cells or their 
deletion. 
 
Production of anti-inflammatory cytokines, especially interleukin 10, is increased 
 
Production of pro-inflammatory cytokines, especially interleukin 12 and TNFα, is decreased. 
 
Generation of CD4+, CD25+, GITR+, Foxp3+, CD62L+ T-regulatory cells.  
 
Generation of monocyte-derived, tolerogenic dendritic cells has been postulated to contribute to 
the downregulation of immune response in GVHD.  
One study evaluated the percentage of functional T-regs after 6 ECP procedures demonstrating an 
increase from 8.9 to 29% of the total circulating CD4+ cells6. ECP is an apheresis-based therapy, where 
approximately 5 x 109 transplant-recipient leukocytes are treated with a photoactivatable 8-
methoxypsoralen (8-MOP), followed by exposure to approximately 1.5 Joules/cm2 of UVA light 0and 
reinfusion of treated leukocytes to recipients in a closed-loop system.  
Flowers et al.7 reported a multicenter Phase II randomized study of ECP for patients with cGVHD. 95 
patients with refractory cutaneous cGVHD were enrolled to this trial that compared standard therapy to 
standard therapy plus ECP given for 12-24 weeks. The median percentage improvement in total skin 
score (TSS) at week 12 was 14.5% for the ECP arm and 8.5% for the control arm (P= .48). No complete 
remissions were seen. The proportion of patients who had at least a 50% reduction in steroid dose and at 
least a 25% decrease from baseline in TSS was 8.3% in the ECP arm at week 12 and 0% in the control 

 
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arm (P = .04). The authors concluded that ECP was a well-tolerated modality and was associated with a 
significant steroid sparing effect. The short duration of therapy (12 weeks) contributed to the lack of 
statistically significant reductions in TSS and authors recommended longer duration of therapy for up to 
24 weeks.  Infections were the most serious side effect occurring in 18.4% of patients on ECP arm versus 
26% in patients assigned standard therapy.  Pneumonia and sepsis were the most common infectious 
complications. 2% mortality was noted in this study in the ECP arm and 6% in standard therapy arm.  
Improvements were also noted in extracutenaous sites of involvement including eye (30% ORR) and oral 
cGVHD (53%).  
Malik et al.5 reported a meta-analysis of 18 trials to access the efficacy of ECP in the steroid refractory 
cGVHD setting. Their analysis included one randomized controlled trial, two single arm prospective 
studies and the remainder were retrospective studies. The pooled complete response rates were 29% (CI, 
19-42%) and overall response rates were 64% (CI, 65-82%). The responses varied according to organ 
involvement with response rates of 74%, 68%, 60%, 48%, 72% and 53% for skin, liver, ocular, lung, oral, 
and GI steroid refractory-cGVHD respectively. The main drawbacks in this study were the limited 
number of prospective trials and variability in duration and frequency of ECP schedules. Moreover there 
was variability in cGVHD assessment and endpoints.  Despite these pitfalls, the authors concluded that 
the analysis supported the use of ECP in cGVHD especially in patients with cutaneous, oral and hepatic 
involvement.  
Apisarnthanarax et al.8 retrospectively analyzed their database of 32 Allogeneic HCT patients with steroid 
dependent (SD) and steroid resistant (SR) cutaneous cGVHD who were treated with ECP. Patients 
received a median of 36 ECP sessions over a median of 5.3 months. The complete response rate was 22% 
and partial response rate was 34%. 64% of patients who were steroid dependent were able to achieve a 
50% reduction in steroid dosage while on ECP therapy. On long term follow up, 11patients (34%) have 
died due to progression of cGVHD symptoms or infectious complications.  Durable CR’s were seen in 5 
of 7 patients. Patients who presented with progressive cGVHD fared worse that those presenting with de 
novo cGVHD. 
In a recent meta-analysis by abu-Dalle9 et al. the response rate of ECP after failure of corticosteroid 
therapy in chronic GVHD was reported as 64%, but responses varied by site of involvement with 
cGVHD; poor responses were noted in lung (15%). In this meta-analysis significant inter-trial differences 
were noted in organ-specific response rates and responses based on severity of GVHD were not reported. 
In a prospective trial by Foss et al.10, 25 patients with extensive steroid-refractory chronic GVHD with 
cutaneous and visceral involvement were assigned to once or twice weekly ECP therapy. The median 
duration of ECP therapy was 9 months.  20 patients with cutaneous cGVHD and 6 patients with oral 
cGVHD benefitted from therapy. Steroid sparing and reduction of systemic immunosuppressive therapy 
was possible in 80% of patients studied. Patients presenting with progressive cGVHD (with history of 
prior aGVHD) fared much worse that patients who presented with de novo cGVHD. Once or twice 
weekly ECP had similar outcomes. Overall response rate was reported as 71% for cutaneous cGVHD and 
61% in visceral cGVHD. 13 patients developed serious adverse effects from ECP therapy including 
pneumonia ( n=7),CMV colitis ( n=1),GI bleed ( n=1), urosepsis ( n=1), line infection ( n=1), catheter 
associated thrombus ( n=1) and disease relapse ( n=1). 
There are few randomized controlled trials for use of ECP in cGVHD and most physicians use clinical 
experience and patient response to formulate institutional guidelines regarding frequency and duration of 
ECP usage. Based on in-house physician expertise in the COH Department of Transfusion Medicine, who 
have performed thousands of ECP procedures, we utilize an ECP schedule of: 2 procedures per week for 
the first month, followed by 2 procedures every 2 weeks for the next 3 months. For the purpose of this 
trial, we will continue using this regimen based on extensive local experience.    
In conclusion, ECP is an important tool for use of therapy in steroid refractory and steroid dependent 
cGVHD with overall response rates of approximately 30% and partial responses in a majority of patients 

 
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treated. Responses depend on site of involvement with better outcomes in skin, hepatic, oral and ocular 
involvement. Patients presenting with de novo cGVHD, without history of preceding aGVHD also tend to 
respond better. Treatment responses improve with duration of therapy and most patients can gradually be 
tapered off ECP in 4-6 months.  Treatment outcomes are better if instituted early in the course of cGVHD. 
However, enthusiasm for ECP in patients with cGVHD has to be tempered by the fact that large 
randomized controlled trials are lacking and few prospective trials have been done in this hard to treat 
patient population. Moreover, few patients achieve complete remissions, although a majority derives 
clinical benefit after ECP therapy from disease stabilization and partials responses. In most trials, ECP 
also helps patients to reduce the amount of steroid use. We believe that the complete and partial response 
rates should be improved upon by combining this therapy with other agents such as low dose IL-2.   
 
2.1.3 
Interleukin-2 (IL-2)  
Interleukin-2 (IL-2) is a cytokine crucial to regulatory T cell (T-reg) proliferation, activation and 
survival11. It has been safely administered in patients without GVHD undergoing allo-HCT with T-cell 
depletion. IL-2 can augment the numbers of T-regs and NK cells without inducing GVHD.  
T-reg cells (CD4+, CD25+, FOXP3+) account for approximately 5 to 10% of circulating CD4+ T cells12. 
T-regs can modulate immune responses by suppressing auto- and allo-reactive lymphocytes, thus 
controlling innate and adaptive arms of the immune response. Loss of T-reg function is associated with 
autoimmune diseases and cGVHD12. Cell-mediated immunomodulation may be beneficial in patients with 
chronic GVHD. In preclinical models, adoptive transfer of T-reg cells has been shown to ameliorate 
GVHD, but the clinical application of this approach has been challenging. In patients with active cGVHD, 
low-dose IL-2 can enhance T-regs without increasing the relapse rate of the underlying malignancy and 
hence may have a role in tipping the balance of the immune system to a more tolerant state. Calcineurin 
inhibitors, which are standard therapy for most allo-HCT for prevention and treatment of chronic GVHD 
may impair T-reg expansion and delay immune reconstitution.   
Koreth and colleagues13 conducted a phase I trial of low-dose IL-2 for patients with steroid-refractory 
chronic GVHD. A total of 29 patients were enrolled. The highest dose level induced unacceptable 
constitutional symptoms. The maximum tolerated dose of interleukin-2 was 1×106 IU per square meter. 
Of the 23 patients who could be evaluated for response, 12 had major responses involving multiple sites. 
None had progression of chronic GVHD or relapse of a hematologic cancer. The numbers of CD4+ T-reg 
cells were preferentially increased in all patients, with a peak median value, at 4 weeks, that was more 
than eight times the baseline value (P<0.001), without affecting CD4+ conventional T cells (T-con). The 
T-reg:T-con ratio increased to a median of more than five times the baseline value (P<0.001). The T-reg 
cell count and T-reg:T-con ratio remained elevated at 8 weeks (P<0.001 for both comparisons with 
baseline values), then declined when the patients were no longer receiving interleukin-2. The increased 
numbers of T-reg cells expressed the transcription factor forkhead box P3 (FOXP3) and were able to 
inhibit autologous T-con cells. Immunologic and clinical responses were sustained in patients who 
received IL-2 for an extended period, permitting the glucocorticoid dose to be tapered by a mean of 60% 
(range, 25- 100). Additionally we have in house experience with use of single agent IL-2 (n=7) in patients 
who have been treated with ECP in the past. In these patients with steroid refractory cGVHD, all patients 
have derived clinical benefit, either partial response or stable disease, with no serious Grade III/IV 
adverse events noted at the dose level of 1 million Units /m2 
 
2.1.4 
Rationale for combination of ECP and IL2 for cGVHD 
As demonstrated in the literature reviewed above, cGVHD is a multisystem disorder caused by impaired 
immune reconstitution post Allo-HCT with allorecative T cells from donor causing immune mediated 
organ damage in skin, liver and GI tract. This condition is characterized by relative paucity of T regs 

 
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compared to Tcons leading to decline in Treg:Tcon ratio. Normalization of Treg:Tcon ratio is associated 
with objective clinical improvement in signs and symptoms of cGVHD. ECP has been used successfully   
in patients with chronic steroid-refractory GVHD, with complete responses noted in 30% of patients. 
Improvement in cGVHD symptoms in responding patients has been co-related with a concurrent   
increment in Tregs.  Hence ECP is a proven treatment modality in patients with steroid refractory 
cGVHD and responding patients demonstrate a normalization of Treg;Tcon ratio.  
 
 More recently, IL-2 has shown promising results in a phase I dose escalation trial, wherein it was shown 
to be safe at a dose level of 1x106 units/m2 when used in patients with steroid refractory cGVHD. Clinical 
benefit (partial response and stable disease) 52% of patients on low dose IL-2 therapy.  In this trial no 
complete responses were noted. Co-relative studies demonstrated that patients with cGVHD responding 
clinically had a significant expansion of T reg pool while on therapy, with responses noted as early as 2 
weeks into therapy. This expansion of T regs persisted during the remaining duration of therapy and 
declined to baseline levels 4 weeks after discontinuation of subcutaneous IL-2. Relapse of cGVHD is 
noted after discontinuation of IL-2 therapy and this may be related to gradual decline in T regs after 
stopping IL-2 therapy.  
 
In this phase II prospective trial in patients with steroid-refractory cGVHD, we propose to combine low 
dose IL-2 with ECP, based on the following:  
A. We hypothesize that combination therapy with IL-2 and ECP will lead to a greater increase in 
Tregs compared to historic controls when either modality was alone. This is beaause both ECP 
and IL-2 boost regulatory T cells (Tregs). The effect of combining ECP and IL-2 on the Treg: 
Tcon ratio has not been studied in humans and correlative studies will be performed on all 
patients enrolled on this protocol to evaluate effect of combination therapy on normalizing 
immune reconstitution post-HCT in patients with steroid refractory cGVHD.  
B. ECP and IL-2 have non-overlapping toxicities; hence, combination of the two should be well 
tolerated in patients with cGVHD. This combination is already being used off protocol(n=7) at 
COH after case review and approval by the GVHD committee in patients with cGVHD and the 
combination is well tolerated in patients treated so far. Patients on this combination have not 
experienced disease progression and all have derived clinic benefit from disease stabilization or 
partial responses.  
C. Relapse of cGVHD is frequently noted after discontinuation of IL-2 therapy, possibly related to 
decline in Tregs to baseline after stopping low dose IL-2 therapy. After completion of protocol 
specified therapy at 12 weeks , responding patients will continue daily low dose subcutaneous IL-
2 (commercial supply)  and ECP ( per SOP) till clinical benefit is no longer maintained. The 
decision to continue commercial supply of IL-2 will be per discretion of the treating primary 
physician in consultation with specialists in cGVHD clinic. No protocol specific monitoring or 
follow up data will be collected. Monitoring of these patients will be according to acceptable 
standard of care for patients on cytokine therapy. Ongoing responses will be monitored by the 
NIH consensus criteria guidelines, again off protocol. We hypothesize that maintenance therapy 
with IL-2 and ECP will maintain elevated T reg: Tcon ratio, thereby translating into fewer clinical 
relapses and improved clinical outcomes.  
 
2.1.5 
Immune correlative studies 
Immune markers of cGVHD will be assessed in this trial using peripheral blood samples to correlate 
clinical response with changes in immune cell subsets. Immune cell subsets have been studied extensively 
in patients with cGVHD to determine their predictive value in chronic GVHD. 

 
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Most studies have focused on CD4+ (post-thymic) T cell subsets. Human peripheral blood CD4+ T cells 
are classified into 3 broad populations: i) naive CD45RA+ CCR7+, and 2 memory subsets, ii) CD45RA- 
CCR7+ (central memory), and iii) CD45RA- CCR7- (effector memory). Yamashita et al.14 studied 
relative proportions of CD4 effector memory T cells (CCR7- CD62Llow) in patients with established 
cGVHD and compared the distribution of this T cell subset in healthy controls and patients with no 
clinical signs of cGVHD. Chronic GVHD patients had a significantly higher percentage of CD4 effector 
memory T cells compared with healthy controls (35.5% vs 13.8 respectively; P < .0001) or stem cell 
transplantation patients without cGVHD (35.5 vs 21.7% respectively; P <.01) in the total CD4+T cell 
population. This finding indicates that effector memory T cells (CD45RA- CCR7- CD62Llow) may 
potentially be used as a marker of cGVHD.     
Dander et al.15 studied the role of IL-17-producing CD4+ T cells (TH17) in cGVHD in the serum of 51 
patients post allo-HCT with clinical manifestations of cGVHD, and compared this to 15 healthy donors 
(HD). Patients with cGVHD showed an increase of TH17 population compared with HD (mean 
SFU=178/25000 cells, n=18, ANOVA P<0.001). Importantly, by analyzing the proportion of TH17 cells 
according to the activation status of cGVHD (active vs. inactive phases), the authors were able to 
demonstrate that patients with active cGVHD, show an increase in the TH17 population (mean spot 
forming units [SFU] =237/25000 cells, n=13, ANOVAP<0.001). Inflammatory cytokines produced by 
TH17 cells - IL-6, TNF- α and IL-8 - were also significantly elevated in patients with active cGVHD. 
Hence the TH17 T cell subset by virtue of its secreted cytokines may be a useful adjunct to cGVHD 
assessment. In this analysis, CD 4+ T cells were selected by immunomagnetic beads using the Miltenyi 
system, plated in graded numbers and stimulated by 12-phorbol 13-myristic acid (50 ng/mL) and 
ionomycin (2g/mL) for 16 hr to elicit IFN-γ production.  
T-regs constitute 5-10% of circulating CD4+ T cells and suppress auto- and allo-reactive T cell clones. 
Loss of T-regs has also been associated with clinical symptoms of cGVHD. Phenotypically, T-regs are 
CD4+ and CD25+ and express forkhead transcription factor FOXP3.  Zorn et al.16 evaluated CD4+CD25+ 
T-regs in 30 patients with cGVHD after allogeneic HSCT, 27 patients without active cGVHD, and 26 
healthy controls. They also evaluated TREC (T cell receptor excision circles) by peripheral blood PCR as 
a marker of thymic activity in post HCT patients. Patients with active cGVHD had significantly lower 
expression of FOXP3 when compared with patients without cGVHD (P = 0.009) or healthy donors (P = 
0.01). Patients with cGVHD showed a significant decrease in TRECs compared with healthy donors (P < 
0.001); supporting that thymic function is substantially impaired following allogeneic HCT. 
Natural Killer cells (NK cells), B cells and T cell subsets were studied as part of immune reconstitution 
post allo-HCT prospectively by Abrahamsen et al.17 in 57 patients. Blood and bone marrow samples were 
collected 3, 6, and 12 months after transplantation for analysis of immune reconstitution. Flow cytometric 
analysis was used for phenotyping T cell subsets. To assess the effect of chronic GVHD on immune 
reconstitution, patients with extensive cGVHD were compared to patients with no or limited chronic 
GVHD. The authors noted that extensive cGVHD is associated with elevated CD3+ T cells with relative 
decline in CD19+ B cells and CD3-CD16+/56+ NK-cells.  
Inflammatory biomarkers have also been used to follow patients with cGVHD. Dander et al.15 studied 
peripheral blood samples obtained from 51 patients post allogeneic cell transplantation and patients 
developing GVHD were monitored for presence of TH-17 cells by ELISPOT or flow cytometry. The TH-
17 cell population was increased (up to 4.8% of peripheral blood CD4+T lymphocytes) in patients with 
acute GVHD and (up to 2.4%) in patients with active chronic GVHD along with an inflammatory process. 
TNF-α was significantly increased in patients presenting with aGVHD (mean 49 pg/mL, range 3.6–176 
pg/mL, n=10) and cGVHD (mean 28 pg/mL, range 4.8–77 pg/mL, n=14). Similarly, IL-6 levels were 
strongly enhanced in patients with aGVHD (mean 62 pg/mL, range 1–407 pg/mL) and active cGVHD.  
IL-8 cytokine levels were significantly elevated in patients with aGVHD (mean 20.8 pg/mL, range 3.9–
49.1 pg/mL) and active cGVHD (mean 22.4 pg/mL, range 3.8–125 pg/mL) compared with healthy 
donors.  

 
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B cell activating factor (BAFF) is known to be a key regulator of normal B-cell homeostasis in humans18. 
Sarantopoulous et al.19  studied 104 patients who had undergone allo-HCT between 1994 and 2005 for 
hematologic malignancies. ELISA was used to measure plasma BAFF levels and flow cytometry was 
used to assess BAFF receptor expression on B cells in patients with or without chronic GVHD. BAFF 
levels were significantly higher in patients with active chronic GVHD compared with those without 
disease (P = 0.02 and 0.0004, respectively). Patients treated with glucocorticoids showed reduction in 
BAFF levels indicating that this correlated with disease severity.  Furthermore, it was noted that BAFF 
levels were high post HCT and declined in patients who never developed chronic GVHD. In contrast, 
BAFF levels remained elevated in patients who developed clinical manifestations of cGVHD.  Six-month 
BAFF levels ≥10 ng/mL were strongly associated with subsequent development of chronic GVHD (P < 
0.0001). Following transplant, plasma BAFF levels correlated inversely with BAFF receptor expression 
on B cells (P = 0.01), suggesting that soluble BAFF affected B cells through this receptor. 
Rozmus et al.20 prospectively studied mRNA levels of IFN, IL-2, IL-4 and IL-10 in peripheral blood 
mononuclear cells after non-specific mitogen stimulation with PMA/ionomycin or T cell stimulation with 
anti CD-3 in patients with cGVHD, and compared age matched controls of post-HCT patients without 
GVHD. In their analysis, early onset cGVHD was characterized by decreased expression of IFN and IL-
2 mRNA after PMA/ionomycin stimulation. Late cGVHD was associated with decreased IL-2 and IL-4 
mRNA expression after anti CD-3 antibody stimulation. Interestingly, elevated IFN mRNA expression 
predicted absence of early cGVHD and elevated IL-2 and IL-4 mRNA predicted absence of late cGVHD. 
Hence, early cGVHD was associated with decreased Th1 cytokine response and late cGVHD was 
associated with decreased Th2 cytokine response. 
Recent studies also identified several biomarkers for acute and chronic GVHD as listed below. 
1. IL-2 receptor α (IL2Ra), tumor necrosis factor receptor 1 (TNFR1), hepatocyte growth factor 
(HGF), interleukin 6 (IL-6) and interleukin-8 (IL-8) for systemic GVHD21 
2. Elafin for skin GVHD22  
3. Regenerating islet-derived 3α (REG3α) for gastrointestinal GVHD21 
4. Suppression of tumorigenicity 2 (ST2) for steroid-refractoriness23  
5. CXCL9  for chronic GVHD24 
Based on this literature, inflammatory markers and immune cell subsets will be assessed in patients 
enrolled on protocol at baseline and at multiple time points during treatment with IL-2 + ECP as 
described in Section 9.0.  
 
2.2 Overview of Proposed Study 
In this Phase II prospective trial in patients with steroid refractory cGVHD, we propose to combine low 
dose IL-2 with ECP as both modalities promote immunologic tolerance by increasing the proportion of 
Tregs and the two therapies have non-overlapping toxicities. We anticipate that combination therapy will 
lead to better overall response rates (CR, PR and stable disease) compared to historical rates of either 
modality used alone. Eligible patients will receive 12 weeks of the combination therapy with daily IL-2 
and ECP (administered per COH SOP), with clinical and immune evaluation every 3 weeks. Given the 
lack of effective therapies for steroid-refractory cGVHD, this prospective trial will help us evaluate the 
activity of this novel combination therapy in this difficult-to-treat patient population.  
 
2.3 Preclinical Studies 
Not applicable. 
 

 
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2.4 Human Studies 
2.4.1 
. Interleukin -2 
2.4.1.1 IL-2 therapies in various diseases 
Low-dose IL-2, administered subcutaneously (s.c.) for extended periods, has been evaluated in patients 
with HIV infection and cancer. In one study of ultra-low-dose IL-225, seven patients with HIV and non-
Hodgkin lymphoma in first remission received 1 x 106 IU/m2 daily of IL-2.  After ~8 weeks of treatment, 
single-agent IL-2 therapy led to statistically significant, proportional increases in NK cells (1.6-fold) and 
T-regs (9-fold). Other lymphocyte subsets were not significantly changed. Toxicity was mild (fatigue, 
local pruritis, myalgia, increased transaminases etc.), with no grade 3 adverse events.  
In cancer clinical trials, high-dose recombinant IL-2 (e.g. IV bolus dose of 600,000 international units 
(IU)/kg every 8 hours for up to 14 doses) demonstrated antitumor activity in metastatic renal cell 
carcinoma (RCC) and metastatic melanoma. IL-2 was approved for the treatment of metastatic RCC in 
Europe in 1989 and in the US in 1992. In 1998, approval was obtained to treat patients with metastatic 
melanoma. Recombinant human IL-2 (Aldesleukin) (Proleukin®-Novartis Inc. & Prometheus Labs Inc.) 
is currently approved by the United States Food and Drug Administration (US FDA). 
Low-dose IL-2 has also been safely used in patients with hematologic malignancy after allo-HCT. In one 
study, IL-2 was administered by continuous IV infusion to 29 asymptomatic patients after CD6+ T-cell 
depleted (TCD) allo-HCT at doses ranging from 2-6 x 105 IU/m2/d, for periods of up to 3 months26. Low 
dose IL-2 was well tolerated, with only 4 patients withdrawn early due to toxicity. Interestingly, acute 
GVHD developed in only 1 of the 29 patients. In addition to the expected NK cell expansion, in 7 of 8 
patients evaluated, a 45% median increase in CD4+ CD25+ T lymphocytes occurred, likely representing 
T-regs. Further, a median ~8.5 fold increase of FOXP3 expression was noted, also indicating substantial 
T-reg enhancement. 
 
2.4.1.2 Toxicity prolife of IL-2 in patients with cGVHD  
The safety and immunologic activity of low-dose interleukin-2 in patients with active steroid-refractory 
cGVHD was assessed in a phase I trial, whose primary objective was to determine the MTD and toxicity 
profile of an 8-week course of IL-213. Eligibility included patients with cGVHD requiring systemic 
therapy that had not responded to at least 0.25 mg/kg prednisone for a 4 week period, absence of 
infection, and stable doses of immune suppression for 4 weeks. The study had a Phase 1 dose escalation 
design with 3 dose levels (0.3, 1, 3; x 106 IU/m2/day for 56 days). 29 patients were accrued on protocol 
with subjects, 28 were evaluable for toxicity and 23 were evaluable for response. The interval between 
onset of chronic GVHD and initiation of IL-2 was 803 days (range, 117-2624). Patients were on a median 
of 3 concurrent agents (range, 1-3) for cGVHD. Skin (26 patients) and fascia (16 patients) were primary 
sites of involvement, but lung, liver, oral, and ocular sites were involved as well. Dose-level-C (3 x 106 
IU/m2/day) was declared unsafe due to constitutional side-effects (fever, malaise, and arthralgia). Dose-
level-B (1 x 106 IU/m2/day) was determined to be maximum-tolerated-dose in this patient population. 
Two patients developed dose-limiting-toxicity (thrombotic microangiopathy). CTCAE Grade IV 
toxicities included: TTP/HUS n=2; Dyspnea n=1, myocardial infarction n=1 and MRSA Pneumonia n=1.  
Grade III toxicities included induration n=3, lower GI Bleed n=1, deep vein thrombosis n=1, MRSA 
abscess n=1, and hemophilus bacteremia =1. Grade II toxicities included: constitutional symptoms n=1, 
increase in serum creatinine n=1, thrombocytopenia n=1. None experienced GVHD flare. There was no 
malignant disease relapse. 12/23 patients had major responses. These results suggest that low-dose IL-2 
given at 1 x 106 IU/m2/day for 8 weeks can be administered safely in patients with active chronic GVHD. 
 

 
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2.4.2 
Extracorporeal Photopheresis:  
2.4.2.1 Initial use of ECP:  
Phototherapy involves the use of psoralen followed by exposure of skin to UVA radiation (PUVA). This 
form of treatment has been used for many years to treat cutaneous conditions such as vitiligo, eczema and 
psoriasis.  ECP is a therapeutic procedure in which peripheral blood mononuclear cells are extracted by 
apheresis and exposed to 8-methoxypsoralen (8-MOP) followed by ultraviolet A (UVA) radiation.  It was 
initially developed as an immunomodulatory therapy for treatment of cutaneous T cell Lymphoma 
(CTCL). This treatment damages DNA and induces apoptosis in circulating lymphocytes27.  Edelson et 
al.28 first reported on the use of this therapy in 37 patients with CTCL treated with oral methoxsalen 
followed by ex vivo photoactivation of lymphocytes with ultraviolet A (UVA) light. 27 of the original 37 
patients responded to therapy with 64 % decline in cutaneous involvement after a mean of 22 weeks of 
therapy. Currently, ECP is used worldwide in the treatment of a variety of clinical conditions such as 
acute allograft rejection after cardiac, lung, renal and liver transplantation29. It is also used for treating 
steroid refractory acute and chronic graft versus host disease.  ECP has also been used to treat a variety of 
autoimmune conditions including, scleroderma, rheumatoid arthritis, SLE and pemphigus vulgaris30. The 
role of ECP has been established in patients with steroid refractory and steroid dependent cGVHD. Please 
refer to the discussion presented in section 2.1.2 for further details.  
The equipment for photopheresis was developed by Therakos, a Johnson and Johnson company (Raritan, 
NJ, U.S.A.), based on Latham bowl technology. Much of the reported use of photopheresis has involved a 
second-generation model—namely, the Therakos Uvar XTS system. This discontinuous, but completely 
contained, automated procedure collects some 5%–8% of circulating white blood cells into a plastic bag. 
A UV-A photosensitizing agent, 8-methoxypsoralen, is added to the bag, and the treated cells are then 
subjected to 1.5 J of UVA light. Afterwards, the cells are re-infused into the patient. The difficulty with 
this technology is its discontinuity. 
To collect the leukocytes, the bowl first has to fill with red blood cells. There are two bowl sizes: 125 mL 
and 225 mL. If the patient’s hematocrit is low, the volume of blood needed to fill the bowl with red blood 
cells may be very large. It is recommended that the extracorporeal volume not exceed the total blood 
volume by more than 15%. A third-generation apparatus has now been introduced by Therakos. The 
Therakos Cellex still uses the Latham bowl technology, but its single- or double-needle continuous-flow 
system is completely automated. The tubing volume for the single-needle procedure is 260 mL; for the 
double-needle procedure, it is 216 mL. The average treatment time for a patient was 180 minutes using 
the Therakos Uvar XTS. With the new apparatus, a single-needle procedure takes 100 minutes, and a 
dual-needle system, only 75 minutes31. At City of Hope both Cellex and XTS devices are available.  
2.4.2.2 Toxicity prolife of ECP in patients with cGVHD  
Toxicity rates vary in studies describing ECP therapy for chronic GVHD. In their review of ECP use in 
patients with cGVHD undergoing ECP, Abu-Dalle et al.9 reported an incidence of 0.38% (95% CI, 0.06-
0.78) for any grade 3 or 4 adverse events. Seaton et al.32 reported severe complications in 5 of 28 subjects 
who received ECP for treatment of chronic GVHD: renal failure/sepsis, n = 1; acute respiratory distress 
syndrome of unknown cause, n = 1; pneumothorax/pleural effusion, n = 1; ischemic heart disease, n = 1; 
and unspecified, n = 1. Foss et al.10 described serious adverse events in 15 of 25 subjects treated with 
ECP, specifically pneumonia, n = 5; cytomegalovirus colitis, n = 1; gastrointestinal bleeding, n = 1; 
urosepsis, n = 1; line-related complications, n = 2 (line sepsis, n = 1; deep venous thrombosis, n = 1); and 
unspecified, n = 5.  In a randomized trial reported by Flowers et al7, serious adverse events were reported 
in 28.6% (n=14) patients on the ECP arm and 26% (n=13) in patients randomized to the control arm. (P-
0.78). In patients randomized to the ECP arm , infections were the most common side effects noted in 
18.4% patients. Pneumonia (4.1%) and sepsis (4.1%) were the leading infectious complications. The 
majority of patients on the ECP arm (90%) developed adverse events (Grade 1 or 2) compared to 92% on 
control arm (P-0.78).  These included diarrhea (20.4%), anemia (24.5%) and nausea (18.4%). Adverse 

 
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events that led to withdrawal from the ECP arm included thrombocytopenia, hypoglycemic coma, tremor, 
mental status changes, progressive GVHD, Pseudomonas sp lung infection, and catheter-related 
complications (1 patient each). In the control arm, patients discontinued participation in the study because 
of progressive tendinous contracture, bacterial (Pseudomonas sp) pneumonia, or fungal pneumonia (1 
patient each). 
In conclusion, ECP use is associated with serious adverse events in approximately 30 % of patients 
treated; however this is not significantly more that complication rates noted in control patients on 
standard GVHD therapies. The reason for high rates of infectious complications noted in this group of 
patients is that they are immunocompromised given prolonged exposure to steroids and other 
immunosuppressive agents used to treat cGVHD. Pneumonia and sepsis are the most important infectious 
complications –the latter complication seen most likely due to frequent central line access for ECP.   
Most of the studies that have been reported on use of ECP in cGVHD were published from 1993-2010. 
Supportive care has improved upon since then - with better understanding of infection risk, improved 
infection surveillance and newer antimicrobials. These changes have led to improvements in non-relapse 
mortality and hence improved survival of patients 1 
Patients enrolled on this trial will be on standard prophylaxis with bactrim (or mepron for sulfa allergic 
patients) and acyclovir for prevention of PJP (Pneumocystis jiroveci pneumonia) and herpes zoster 
reactivation respectively. Patients who become neutropenic (ANC < 1000) will receive growth factor 
support with G-CSF and antibiotic (levofloxacin) prophylaxis. Central line care will be according to SOP 
mentioned under guidelines for supportive care of the HCT patient (D.001.05). See supportive care 
section 5.6 for further details.  
 
3.0 Patient Eligibility 
3.1 Inclusion Criteria  
3.1.1 
Disease Status 
 
Recipients of allogeneic stem cell transplantation with myeloablative or non-myeloablative 
conditioning regimens. Alternative donor transplants (Umbilical cord blood and haploidentical) 
are allowed.  
 
Patients with chronic GVHD requiring systemic therapy are eligible. 
 
Participants must have steroid-refractory cGVHD, which is defined as having persistent signs and 
symptoms of cGVHD despite the use of prednisone at 0.20 mg/kg/day (or 0.5 mg/kg every other 
day) for at least 4 weeks (or equivalent dosing of alternate corticosteroids) without complete 
resolution of signs and symptoms.  
3.1.2 
Age Criteria, Performance Status and Life Expectancy  
 
Patient age  18 years old. Because no dosing or adverse event data are currently available on the 
use of IL-2 in participants <18 years of age, children are excluded from this study. 
 
Karnofsky performance status of 70-100 %. 
 
Estimated life expectancy greater than 3 months. 
 
3.1.3 
Child Bearing Potential 
The effects of IL-2 on the developing fetus are unknown.  For this reason, women of child-bearing 
potential and men must agree to use adequate contraception (hormonal or barrier method of birth control 
or abstinence) prior to study entry and for six months following duration of study participation.  Should a 

 
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woman become pregnant or suspect that she is pregnant while participating on the trial, she should inform 
her treating physician immediately.     
 
3.1.4 
Protocol-Specific Criteria 
 
Stable dose of corticosteroids for 2 weeks prior to enrollment, i.e. the patient’s steroid dose 
(mg/kg) will remain unchanged (eg 0.5 mg/kg) in the 2 weeks preceding enrollment. Allowances 
will be made for up or down titrating the dose based on changes in body weight. 
 
Adequate organ function as defined below. 
o Hepatic: Adequate hepatic function (total bilirubin <2.0 mg/dl-exception permitted in 
patients with Gilbert’s Syndrome; AST (SGOT)/ALT (SGPT) ≤2x ULN), unless hepatic 
dysfunction is a manifestation of presumed cGVHD. Abnormal LFTs in the context of active 
cGVHD involving other organ systems may also be permitted if the treating physician 
documents the abnormal LFTs as being consistent with hepatic cGVHD and a liver biopsy 
will not be mandated in this situation.  
o  Renal: Serum creatinine within normal institutional limits or creatinine clearance > 60 
mL/min/1.73 m2 for participants with creatinine levels above institutional normal.  
o  Adequate bone marrow function: indicated by ANC>1000/mm3 and platelets>50,000/mm3. 
 
3.1.5 
Informed Consent/Assent 
All subjects must have the ability to understand and the willingness to sign a written informed consent. 
3.1.6 
Prior Therapy: 
Patients with steroid refractory cGVHD typically have received salvage with multiple lines of therapy; 
hence in this trial there will be no restriction in terms of prior lines of therapy received. Prior ECP 
exposure is allowed, however prior IL-2 use is excluded.  
 
Exclusion Criteria 
 
Patients should not have any uncontrolled illness including ongoing or active infection.  Patients 
with an ongoing prednisone requirement of >1 mg/kg/day (or equivalent) will be excluded.  
 
History 
of 
thrombotic 
microangiopathy, 
hemolytic-uremic 
syndrome 
or 
thrombotic 
thrombocytopenic purpura. 
 
Exposure to any new immunosuppressive medication in the 4 weeks prior to enrollment. 
 
Donor lymphocyte infusion within 100 days prior to enrollment 
 
Active malignant relapse. 
 
Uncontrolled cardiac angina or symptomatic congestive heart failure (NYHA Class III or IV) 
 
HIV-positive individuals on combination antiretroviral therapy are ineligible because of the 
potential for pharmacokinetic interactions with the agents used after allogeneic HCT. In addition, 
these individuals are at increased risk of lethal infections.  
 
Patients may not be receiving any other investigational agents, or concurrent parenteral 
biological, chemotherapy, or radiation therapy.  Oral chemotherapeutic agents or biologics –
for example ruxolitinib therapy (either past or current exposure) - is allowed. 
 
History of allergic reactions attributed to compounds of similar chemical or biologic composition 
to IL-2. 
 
Patients must not have received prior chemotherapy (pentostatin) within 4weeks before study 
enrollment, and those who have not recovered from the adverse events due to agents administered 
more than 4 weeks earlier are excluded.   

 
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 
Pregnant women are excluded from this study because IL-2 is an agent with the potential for 
teratogenic or abortifacient effects.  Because there is an unknown but potential risk for adverse 
events in nursing infants secondary to treatment of the mother with IL-2, breastfeeding should be 
discontinued if the mother is treated with IL-2. 
 
Patients with other active malignancies are ineligible for this study, other than superficial 
localized skin cancer (basal or squamous cell carcinoma).  
 
3.2 Non-Compliance 
Subjects, who in the opinion of the investigator may not be able to comply with IL-2 or ECP treatment 
requirements or the safety monitoring requirements of the study, will be excluded from participation . 
3.3 Inclusion of Women and Minorities 
The study is open to anyone regardless of gender or ethnicity.  Efforts will be made to extend the accrual 
to a representative population, but in a trial that will accrue between 17-37 subjects, a balance must be 
struck between subject safety considerations and limitations on the number of individuals exposed to 
potentially toxic or ineffective treatments on the one hand and the need to explore gender, racial, and 
ethnic aspects of clinical research on the other.  If differences in outcome that correlate to gender, racial, 
or ethnic identity are noted, accrual may be expanded or additional studies may be performed to 
investigate those differences more fully. 
4.0 Screening and Registration Procedures 
4.1 Screening Procedures 
The following evaluations must be performed within four weeks prior to IL-2 +ECP treatment for all 
patients on protocol:  
 
Medical history and documentation of rationale for enrollment on IL-2 + ECP therapy on 
protocol.  
 
Physical examination, documentation of vital signs and KPS. 
 
Chronic GVHD assessment based on NIH consensus criteria – see Appendix C.  
 
Baseline lab work including CBC with differential, CMP and TSH/Vitamin D screen.  
 
Serum samples and mononuclear cells to be collected for immune assessment.  
 
Pregnancy test for women of childbearing age.  
 
Pulmonary function tests for patients with pulmonary manifestations of cGVHD.  
 
Dermatologic assessment for patients with cutaneous cGVHD. 
 
Flexion assessment of affected joints for individuals with contractures or musculoskeletal 
involvement secondary to cGVHD. 
 
4.2 Informed Consent  
The investigational nature and objectives of the trial, the procedures and treatments involved and their 
attendant risks and discomforts, and potential alternative therapies will be carefully explained to the 
subject and a signed informed consent will be obtained.  Documentation of informed consent for 
screening will be maintained in the subject’s research chart and medical record.   
4.3 Registration Requirements/Process 
Following informed consent, the patient will be registered through the Clinical Trials Office (CTO) prior 
to the initiation of therapy. Any participant not registered to the protocol before treatment begins will be 
considered ineligible and registration will be denied. A member of the study team will confirm eligibility 
criteria and complete the protocol-specific eligibility checklist.  

 
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Following registration, participants may begin protocol treatment. Issues that would cause treatment 
delays should be discussed with the Principal Investigator. If a participant does not receive protocol 
therapy following registration, notify the CTO of participant status changes as soon as possible. 
 
4.4 Randomization and/or Dose Level Assignment  
NA. This is a phase II single-arm trial. There is no dose escalation or randomization. 
 
5.0 Treatment Program 
5.1 Treatment Overview 
 
 
GVHD and Immune Assessment and QOL will be performed at week 7 instead of week 6. 
(NB: Patients deriving clinical benefit after initial 12 week therapy have the option to go on a 
maintenance phase .   
 
5.2 Treatment Schedule 
5.2.1 
IL-2 Therapy 
D. IL-2 will be self-administered by patients as a daily subcutaneous injection. Teaching 
will be provided before the first subcutaneous injection. The pharmacist, or the primary 
pharmacy technician working under the supervision of the pharmacist, will prepare the 
drug under aseptic conditions. The amount (in IU) of drug to be administered will be 
determined based on body surface area (BSA).  The dose should be calculated based on 
body weight at screening, at a dose of 1 x 106 IU/m2/day for 12 weeks. All treatments 
will be outpatient based. If however, patients live within a 15 mile distance of the 
medical center and /or insurance mandates that the IL-2 be given in physician office- IL-2 
injections will be given in the infusion center. After completion of 12 weeks of protocol 
therapy, responding patients will have the option of continuation of therapy till clinical 
benefit is no longer maintained. IL-2 will be provided by Prometheus Labs for this study.  
No protocol specific monitoring or follow up data will be collected after initial 12 week period. 
Monitoring of these patients will be according to acceptable standards of care for patients on 
cytokine therapy with IL-2. Ongoing responses will be monitored by the NIH consensus criteria 
guidelines , again off protocol . We hypothesize that maintenance therapy with IL-2 and ECP will 

 
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maintain elevated T reg: Tcon ratio, thereby translating into fewer clinical relapses and improved 
clinical outcomes.  
 
5.2.2 ECP Therapy 
ECP will be performed on an outpatient basis in the Amini Building at COH medical Campus according 
to the following schedule.  All patients will have baseline evaluation in the cGVHD clinic prior to 
initiation of ECP.  
 
Weeks 1-4: twice weekly ECP  
 
Weeks 5-12: two ECP treatments every two weeks ( weeks 5,7,9 and 11)   
ECP treatments will be preferably given on consecutive days of the week (eg Monday and 
Tuesday) however this is not always possible. Schedule will be determined based on availability of 
ECP in the Apheresis center.   
 
5.2.3 
Observations and Tests to be Performed 
Patients will be evaluated for response to intervention (ECP + IL-2) at baseline and at weeks 37, 9, 12 and 
16. NIH clinical scoring forms will be used to document responses. Markers of immune activation will be 
monitored at the same time points from blood samples taken on scheduled clinic visits. Quality of Life 
Assessments will also be performed at baseline and in weeks 7 and 12. 
5.2.4 
Documentation of compliance to therapy 
Each participant will be given explicit instructions for taking IL-2  subcutaneous injections at home. 
.Compliance to IL-2 home therapy will be closely monitored while they are on protocol therapy and 
patient will be given detailed instructions by the physician and research nurse in terms of 
administration of IL-2 subcutaneously and anticipated side effects . All enrolled patients will be 
given a drug diary (provided by the research nurse)  at enrollment where they will document daily 
drug use and any missed doses and reasons thereof. The diary will be returned to the Research Nurse 
every 2 weeks while on protocol therapy and a new one will be issued at the same time.. IL-2 
typically is supplied in 22 X 106  units multidose vials and these will be individually dispensed in 
single dose syringes to enrolled patients every 2 weeks for home administration.  
DO NOT ADMINISTER IL-2 AS INTRAVENOUS PUSH OR BOLUS.  
Pre-medications are not required prior to the first dose or later doses. 
All treatment including IL-2 administration and ECP procedures will be conducted in the outpatient 
setting, unless patient is hospitalized for some other medical condition unrelated to underlying 
hematologic disease or adverse effects of therapy (e.g. therapy will continue while inpatient for pain 
control, failure to thrive etc. ). ICU admission, respiratory and hemodynamic compromise will be grounds 
for withholding therapy. See section 6.0 for dose modification and stoppage rules.  
Prednisone (or equivalent steroid) will be continued concomitantly with IL-2 without dose modification. 
Taper of prednisone, or any other immune suppression medications, will not be permitted during the 
initial 6 weeks of the study, but can be reduced thereafter in responders at the discretion of the treating 
physician.  
Of note, clinically stable cGVHD during taper of other immune suppression medications will be 
considered evidence of IL-2 efficacy; and progression of cGVHD during taper of other 
immunosuppressive therapy will not be considered evidence of IL-2 toxicity or lack of efficacy. 
 

 
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5.3 Planned Duration of Therapy: 
IL-2 and ECP combination therapy will be given for 12 weeks, with final immune assessment occurring 
at 16 weeks post-initiation of therapy. Patients deemed to be benefiting from combination therapy (i.e. in 
complete remission, partial remission, minor response or stable disease), will have the options to continue 
onto the extended duration per discretion of treating physician.  
5.4 Optional Extended-duration therapy:  
As mentioned in the section above, patients who are responding to upfront therapy with IL-2 and ECP 
will be eligible to continue combination therapy with daily subQ IL-2 and ECP per SOP guidelines till  
clinical benefit is no longer maintained or toxicities develop. While on the optional maintenance 
therapy,these patients will be monitored for response and toxicity profile in the GVHD clinic on a 
monthly basis. This monitoring will not require data collection from research staff   for response  or 
adverse effect monitoring.  Best clinical judgment will be used to determine on each monthly visit  on 
rationale  to continue commercial supply IL-2 or not based on clinical benefit and adverse effect profile of 
IL-2.  
 
5.5 Criteria for Removal from Treatment 
 
Subject withdraws consent  
 
Non-compliance  
 
Administrative reasons (insurance loss or no coverage of IL-2 or ECP by third party payors) 
 
Any Grade 4 non hematologic adverse event  
 
Life threatening anaphylactic reaction to IL-2  
 
Recurrent or non-resolving grade 3 toxic event  
 
Malignant relapse  
 
Clinical worsening of GVHD requiring the addition of a new immunosuppressive medication. A 
50% increase in the corticosteroid dose will be considered evidence of worsening GVHD. 
Changes in other immunosuppressive medication doses to maintain a therapeutic level alone will 
not be criteria for removal from the trial.  
 
5.6 Subject Follow-Up 
While on the first twelve weeks of therapy, participants will be undergo clinical (including cGVHD) and 
immunologic evaluations every 3 weeks. cGVHD severity/response will be assessed using the NIH 
scoring criteria (see Appendix).  
Toxicity assessments will be performed using the CTEP Version 4.03 of the NCI Common Terminology 
Criteria for Adverse Events (CTCAE) which is identified and located on the CTEP website at: 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm.  
If possible, adverse effects should be managed symptomatically. In the case of toxicity, appropriate 
medical treatment should be used (including anti-emetics, anti-diarrheals, etc.). All CTCAE grade 3 and 
higher adverse events experienced by participants will be collected from the time of the first dose of study 
treatment, through the study and until the final study visit.  
Participants removed from the study for unacceptable adverse events will be followed until resolution or 
stabilization of the adverse event. Follow-up for participants benefiting on extended-duration therapy will 
continue on monthly basis in the GVHD clinic.    
  

 
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5.7 Supportive Care, Other Concomitant Therapy, Prohibited Medications 
Antiviral, antifungal and antibacterial prophylaxis and monitoring should follow institutional practice for 
routine cGVHD management guidelines. These typically include: daily acyclovir (or equivalent) for HSV 
prophylaxis, bactrim (or equivalent) for PCP prophylaxis, IV gammaglobulin for hypo-
gammaglobulinemia, and optional azole use for fungal prophylaxis in higher risk patients; as well as 
monitoring of CMV viral load, beta-glucan and galactomannan levels. 
5.8 Additional Studies: 
Baseline evaluations, tests or exams are valid 3 weeks prior to the start of treatment. 
At baseline, weeks 3, 7,9,12 and 16, an additional 30ml of whole blood will be collected in EDTA tube 
(lavender top) for flow cytometry of immune cell subsets and 5 ml in serum separator tube (yellow top) 
for cytokine analysis. 
5.8.1 
Immune Cell Subsets: 
 
Effector memory cells ( CD 45RA-CCR7-/CD62-)14 
 
Th17 cells15 
 
Tregs ( CD4+CD25+CD127-)16 
 
TRECS (T cell receptor excision circles)16 
 
CD3+ Cells ( T con)17 
 
CD 19+( B cell marker )1 
 
CD3-CD16+CD56+( NK cells)12 
 
FoxP3 gene methylation status  
 
5.8.2 
Inflammatory Markers: 
 
IFN-γ, TNF α15 
 
IL-2,IL-4,IL-6,IL-815,20 
 
IFN-γ, TNF 15 
 
BAFF19 
 
IL-2 receptor  (IL2R) and hepatocyte growth factor (HGF)  for systemic GVHD21 
 
 
Elafin for skin GVHD22 
 
Regenerating islet-derived 3α (REG3α) for gastrointestinal GVHD21 
 
Suppression of tumorigenicity 2 (ST2) for steroid-refractoriness23  
 
CXCL924  
 
Micro RNA analysis40 
 
Plasma banking to be done for microRNA analysis for cGVHD43. 
 
Skin biopsy specimens will be taken at beginning and end of therapy as clinically appropriate.  
 
5.9 Definition of Dose-Limiting Toxicity (DLT) 
Not applicable. See section 6.0 for dose and schedule modifications for toxicity. 
 

 
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6.0 Dose Delays/Modifications for Adverse Events 
Dose delays and modifications will be made using the following recommendations as described below. 
Toxicity assessments will be done using the CTEP Version 4.03 of the NCI Common Terminology 
Criteria for Adverse Events (CTCAE) which is identified and located on the CTEP website at: 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm.33  
6.1 IL-2 Therapy 
The dose modifications as described below are required for patients in the first 12 weeks of study and 
recommended but not mandatory for participants proceeding on extended duration therapy at the end of 
the 12-week study. 
.  
 
Unexpected CTC Grade 3 toxicity: IL-2 will be withheld for unexpected non-hematologic 
toxicities that are grade 3. Expected IL-2 toxicities are listed in Section 8.1.3 If the toxicity 
resolves to grade 1 or below within 2 weeks, IL-2 can be restarted at a 50% reduced dose that will 
not be re-escalated. If the toxicity does not resolve in 2 weeks to grade 1 or below, or recurs to 
grade 3 or above after restarting IL-2, IL-2 will be discontinued.  
 
Expected non-hematologic toxicity: IL-2 can be withheld and/or restarted at a 50% reduced dose 
for less than grade 3 toxicity (e.g. local site reactions, persistent constitutional symptoms) in the 
interest of patient tolerability and at the discretion of the treating physician.  
 
Severe (grade-4) hematologic toxicity: IL-2 will be withheld for severe declines in peripheral 
counts (ANC<500, Plts<10,000) not related to malignant disease relapse, infection or other 
etiologies. If counts improve (ANC>1000, Plts>20,000) within 2 weeks, IL-2 will be restarted at 
a 50% reduced dose and not re-escalated. If peripheral counts do not improve within 2 weeks, or 
drop again (ANC<500, Plts<10,000) after restarting IL-2, it will be discontinued. Use of myeloid 
growth factors and transfusion of platelet and PRBC’s will be per standard institutional guidelines 
and is allowed while patients are on trial. 
 
Infection: Of note, infection during IL-2 treatment is not considered IL-2 related, since both 
cGVHD and the concurrent use of immune suppression medications are known risk factors for 
infection. Infection is therefore considered an expected complication of cGVHD. However, 
patients who develop a CTC grade 3 or higher infection prior to week 12 of IL-2 therapy will 
have IL-2 withheld. They can be considered for restarting IL-2 at their prior dose after control of 
infection, at the discretion of the treating physician.  
 
Treatment Interruption: Within the first 12 weeks of IL-2 therapy, a ≥6-week interruption will 
result in the participant being considered unevaluable for response (or lack thereof), unless 
objective improvement of cGVHD is documented with a shorter course of IL-2.  
6.2 Extracorporeal photopheresis: 
The incidence of ECP reported side effects is extremely low at less than 0.003% especially in cGVHD 
patient population31. The procedural risks with new third generation ECP devices is even smaller34. Many 
of the complications attributable to ECP are related to vascular access. It would be preferable to use 
peripheral veins, but patients with cGVHD frequently have poor veins, and alternative access must 
therefore be used. When central venous catheters are used, complications such as infection, clotting in the 
catheters, deep venous thrombosis, and vessel stenosis can occur. 
For this study, modifications of ECP therapy as described below are required for patients in the first 12 
weeks of study. Infection: Of note, infection during ECP+ IL-2 treatment is not considered intervention-
related, since both cGVHD and the concurrent use of immune suppression medications are known risk 

 
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factors for infection. Infection is therefore considered an expected complication of cGVHD. However, 
patients who develop a CTC grade 3 or higher infection prior to week 12 of ECP+ IL-2 therapy will have 
therapy withheld during active infection. They can be considered for restarting ECP after control of 
infection, at the discretion of the treating physician. CVP line infection and bacteremia/sepsis requiring 
line removal will result in temporary stoppage of ECP therapy.  
 
Severe (grade-4) hematologic toxicity: ECP+IL-2 will be withheld for severe declines in 
peripheral counts (ANC<500, Plts<10,000) not related to malignant disease relapse, infection or 
other etiologies. If counts improve (ANC>1000, Plts>20,000) within 2 weeks, ECP will be 
restarted per schedule. If peripheral counts do not improve within 2 weeks, or drop again 
(ANC<500, Plts<10,000) after restarting ECP + IL-2, it will be discontinued. Use of myeloid 
growth factors and transfusion of platelet and PRBC’s will be per standard institutional guidelines 
and is allowed while patients are on trial. 
 
Central Line associated venous thrombosis: If adequate flow volumes can be generated with clot 
in situ and patient has platelet counts >50,000/mm3, patients will receive systemic anticoagulation 
with warfarin, enoxaparin or similar anticoagulant and ECP therapy will be continued per 
schedule. If, however, platelet counts are less than 50,000/mm3, precluding anticoagulation 
therapy, the central line will be removed and therapeutic intervention stopped. ECP will be 
continued if peripheral access is available.  
  
 
Unexpected CTC Grade 3 toxicity: ECP+IL-2 will be withheld for unexpected non-hematologic 
toxicities that are grade 3. Expected ECP toxicities are listed in Section 8.1.4.  If the toxicity 
resolves to grade 1 or below within 2 weeks, ECP+IL-2 can be restarted If the toxicity does not 
resolve in 2 weeks to grade 1 or below, or recurs to grade 3 or above after restarting ECP+IL-2 
will be discontinued. 
 
7.0 Data and Safety Monitoring, Unanticipated Problems and Adverse Event Reporting  
7.1 Definition of Risk Level 
This is a Risk Level 3 study as defined in the City of Hope Institutional Data and Safety Monitoring Plan 
[policy dated 07/09/2014].  This determination was made because it is a Phase II clinical trial where the 
risks are at least balanced by the potential benefit to subjects and the importance of the knowledge that 
may result. 
 
7.2 Monitoring and Personnel Responsible for Monitoring 
The Protocol Management Team (PMT) consisting of the PI, Collaborating Investigator, CRA, protocol 
nurse, and statistician is responsible for monitoring the data and safety of this study, including 
implementation of any stopping rules for safety and efficacy. 
The PMT is required to submit periodic status reports (i.e., the PMT Report) according to the frequency 
prescribed in the City of Hope Institutional Data and Safety Monitoring Plan [policy dated 07/09/2014].  
Important decisions made during PMT meetings (i.e., dose escalation, de-escalation, etc.) only need to be 
noted in the PMT Report submitted to the Data and Safety Monitoring Committee (DSMC). 
 
Adverse Events and Serious Adverse Events 

 
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The PI will be responsible for determining the event name, assessing the severity (i.e., grade), 
expectedness, and attribution of all adverse events. 
 
Adverse Event (AE) - An adverse event is any untoward medical experience or change of an existing 
condition that occurs during or after treatment, whether or not it is considered to be related to the protocol 
intervention.  
Reporting - Participating investigators will assess the occurrence of AEs and SAEs at all 
participant evaluation time points during the study. All CTC grade 3 or higher AEs and all 
SAEs whether reported by the participant, discovered during questioning, directly 
observed, or detected by physical examination, laboratory test or other means, will be 
recorded in the participant’s medical record and on the appropriate study-specific case 
report forms from day 1 of treatment until 30 days after the last IL-2 injection.  
The descriptions and grading scales found in the CTEP Version 4.0 of the NCI Common 
Terminology Criteria for Adverse Events (CTCAE) will be utilized for AE reporting. The 
CTEP Version 4.0 of the CTCAE is identified and located on the CTEP website at:  
https://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm 
 
Reporting Non-serious Adverse Events – Adverse events will be collected after the patient is given the 
study treatment or any study related procedures.  Adverse events will be monitored by the PMT.  Adverse 
events that do not meet the criteria of serious OR are not unanticipated problems will be reported only in 
the PMT Report. 
 
Serious Adverse Event (SAE) [Modified from the definition of unexpected adverse drug experience in 
21 CFR 312.32] - defined as any expected or unexpected adverse events that result in any of the following 
outcomes: 
 
Death 
 
Is life-threatening experience (places the subject at immediate risk of death from the event as it 
occurred) 
 
Unplanned hospitalization (equal to or greater than 24 hours) or prolongation of existing 
hospitalization 
 
A persistent or significant disability/incapacity 
 
A congenital anomaly/birth defect 
 
Secondary malignancy 
 
Any other adverse event that, based upon appropriate medical judgment, may jeopardize the 
subject’s health and may require medical or surgical intervention to prevent one of the outcomes 
listed above (examples of such events include allergic bronchospasm requiring intensive 
treatment in the emergency room or at home, blood dyscrasias of convulsions that do not result in 
inpatient hospitalization, or the development of drug dependency or drug abuse). 
 
Reporting Serious Adverse Events - begins after study treatment or any study related procedures.  All 
SAEs occurring during this study, whether observed by the physician, nurse, or reported by the patient, 
will be reported according to the approved City of Hope’s Institutional policy [policy effective date:  
05/14/14].  Serious Adverse Events that require expedited reporting will be submitted electronically using 
iRIS. 

 
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Adverse Event Name and Severity 
The PI will determine the adverse event name and severity (grade) by using the CTCAE version 4.03. 
GVHD assessments by NIH consensus criteria will also be used. 
 
Expected Adverse Event - Any event that does not meet the criteria for an unexpected event, OR is an 
expected natural progression of any underlying disease, disorder, condition, or predisposed risk factor of 
the research participant experiencing the adverse event. 
 
Unexpected Adverse Event [21 CFR 312.32 (a)] – An adverse event is unexpected if it is not listed in 
the investigator’s brochure and/or package insert; is not listed at the specificity or severity that has been 
observed; is not consistent with the risk information described in the protocol and/or consent; is not an 
expected natural progression of any underlying disease, disorder, condition, or predisposed risk factor of 
the research participant experiencing the adverse event. 
 
Adverse Event Attribution 
The following definitions will be used to determine the causality (attribution) of the event to the study 
agent or study procedure. 
 
Definite - The AE is clearly related to the investigational agent or study procedure and unrelated to 
any other cause. 
 
Probable - The AE is likely related to the investigational agent or study procedure and unlikely 
related to other cause(s). 
 
Possible -The AE may be related to the investigational agent or study procedure and may be related 
to another cause(s). 
 
Unlikely -The AE is doubtfully related to the investigational agent or study procedure and likely 
related to another cause(s). 
 
Unrelated -The AE is clearly not related to the investigational agent or study procedure and is 
attributable to another cause(s). 
 
 
Deviations and Unanticipated Problems 
Deviation - A deviation is a divergence from a specific element of a protocol that occurred without prior 
IRB approval.  Investigators may deviate from the protocol to eliminate immediate hazard(s) for the 
protection, safety, and well-being of the study subjects without prior IRB approval.  For any such 
deviation, the PI will notify the COH DSMC and IRB within 5 calendar days of its occurrence via iRIS 
in accordance with the Clinical Research Protocol Deviation policy [policy effective date:  11/07/11].   

 
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Single Subject Exception (SSE) 
An SSE is a planned deviation, meaning that it involves circumstances in which the specific procedures 
called for in a protocol are not in the best interests of a specific patient.  It is a deviation that is anticipated 
and receives prior approval by the PI and the IRB.  The SSE must be submitted as a “Single Subject 
Exception Amendment Request” via iRIS in accordance with IRB guidelines and the Clinical Research 
Protocol Deviation policy [policy effective date:  11/07/11].  An IRB approved SSE does not need to be 
submitted as a deviation to the DSMC. 
 
Unanticipated Problem (UP) – Any incident, experience, or outcome that meets all three of the 
following criteria: 
 
1. Unexpected (in terms of nature, severity, or frequency) given the following: a) the research 
procedures described in the protocol-related documents such as the IRB approved research 
protocol, informed consent document or Investigator Brochure (IB); and b) the characteristics of the 
subject population being studied; AND 
2. Related or possibly related to participation in the research (possibly related means there is a 
reasonable possibility that the incident, experience, or outcomes may have been caused by the 
drugs, devices or procedures involved in the research); AND 
3. Suggests that the research places subjects or others at greater risk of harm (including physical, 
psychological, economic, or social harm) than previously known or recognized. 
 
Any UP that occurs during study conduct will be reported to the DSMC and IRB in accordance with the 
City of Hope’s Institutional policy [policy effective date:  05/14/14] using iRIS.   
 
 
8.0 Agent Information and Risks 
8.1 Interleukin-2 (IL-2) 
8.1.1 
Description 
Chemical name: Recombinant human Interleukin 2 /IL-2 (Proleukin®)  
Classification: Cytokine   
Mechanism of action:  Lymphocyte Growth factor.  
IL-2 primarily promotes effector T cell responses in vivo, and is now known to be a cytokine critical for 
the development, expansion, survival and peripheral activity of regulatory T cells (Treg)13,25. 
8.1.2 
Toxicology 
IL-2 administration by the SC route has been evaluated in several multiple-dose studies in rats for up to 
13 weeks of daily. They confirmed that the SC high-dose toxicity profile in rats was comparable to the 
high-dose toxicity profile after IV administration. IL-2-related findings included lymphocytosis, 
eosinophilia, slight anemia, extramedullary hematopoiesis, lymphoid hyperplasia, hepatomegaly and 
splenomegaly. Infiltrative and proliferative changes were seen in many organs, including liver, lung, 
lymph nodes, kidney, spleen and bone marrow35.  

 
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In summary, the toxicity of IL-2 in animals has been shown to be dose- and duration-related, with all 
toxic effects being directly or secondarily related to IL-2 pharmacological activity. In animal species, 
treatment-related effects were fully or partially reversible after a treatment-free period of 2-4 weeks. 
Findings were comparable after repeated IV or SC administration of IL-2. The severity of target organ 
toxicity has been correlated with the extent of inflammatory cell infiltration into these organs. Biological 
effects in animals were generally similar to effects reported in clinical trials. However, these MTD studies 
relate to the high-dose IL-2 used for treatment of metastatic RCC and melanoma, rather than the low-dose 
IL-2 proposed for in-vivo Treg enhancement in our study. Additional information regarding the 
nonclinical pharmacology and toxicology of IL-2 may be found in the full prescribing information36.  
Low-dose IL-2, administered s.c. for extended periods, has been evaluated in patients with HIV infection. 
In one study of ultra-low-dose in 11 patients with HIV infection37, s.c. IL-2 in doses ranging from 0.4-1.4 
million Units /m2/day, s.c. IL-2 was well absorbed after administration, with a Tmax of 4.4 ± 1.5 hours and 
was undetectable 24 hours after injection.  
Low-dose IL-2 has also been safely used in patients with hematologic malignancy after allogeneic HSCT. 
Rizzieri et al.38 reported use of IL-2 starting six weeks post Allo-HCT using T depleted grafts at dose of 1 
million units/m2. Patients were treated on a four-weeks-on and 2-weeks-off schedule for up to a year to 
determine if relapse rates were reduced in the setting of non-myeloablative HCT with immune modulation 
by post HCT IL-2. Fatigue was the main side effect noted with this dose of IL-2. Seven of the 8 patients 
completed at least 2 cycles, though 1 patient withdrew after cycle 1 and 3 patients withdrew after 2 cycles 
(3 months) due to excessive fatigue, and 1 withdrew after 6 cycles due to persistent skin GVHD. One 
further patient had early progressive disease (relapse) after 2 cycles of therapy. Though only 2 completed 
the maximum of 8 cycles of therapy over the 1 year period, only 1 patient was unable to tolerate at least 2 
cycles (3 months) of therapy. Both patients with a mismatched donor tolerated only 2 cycles of therapy, 
though 1 remains in a long term remission. 
In one study by Soiffer et al.39 , IL-2 was administered by continuous IV infusion to 13 patients with T-
cell depleted (TCD) allogeneic HSCT (n=6) and (n=7) patients post autologous HCT. IL-2 was infused at 
a dose of 0.2 million IU/m 2 /day by hickman catheter for 90 days using a portable pump beginning at a 
median of 85 days. The majority of patients who received prolonged continuous infusion of low-dose rIL-
2 post-BMT tolerated treatment without severe toxicities. No patient developed pulmonary capillary leak 
syndrome, severe hypotension requiring pressors, oliguria, azotemia, or hyperbilirubinemia during the 90-
day course. Two individuals, both recipients of T-depleted allogeneic marrow, developed fever (38.5º C), 
nausea, and vomiting within 72 hours of initiation of IL-2. When therapy was interrupted, symptoms 
resolved within 3 days. Fatigue was the most common complaint and occurred in six patients-it did not 
interfere with daily activities. A 5% to 7% gain in body weight was documented in 5 of 13 individuals, all 
of whom had peripheral edema. Five patients developed a nonproductive cough; however, only one (with 
preexisting emphysema) complained of subjective dyspnea on exertion. Cough abated within 1 week of 
completing treatment in all patients. Localized rashes occurred in six patients, but were transient and 
resolved before discontinuing IL-2. Immunophenotypic analysis of PBMC was performed routinely while 
patients received IL-2. The fraction of lymphocytes expressing the NK cell-associated antigen NKHl 
(CD56) increased steadily over time, rising from a median of 15% initially to 70% within 8 weeks of 
initiating IL-2 therapy and there was a concomitant increase in the absolute number of NK cells as well.   
In DFCI 07-08313, the safety and immunologic activity of low-dose interleukin-2 in patients with active 
cGVHD was assessed. The primary objective of this study was to determine the MTD and toxicity profile 
of an 8 week course of IL-2 in patients with chronic GVHD who had an inadequate response to steroids. 
Eligibility included patients with cGVHD requiring systemic therapy that had not responded to at least 
0.25 mg/kg prednisone for a 4 week period, absence of infection, and stable doses of immune suppression 
for 4 weeks. The study has a Phase 1 dose escalation design with 3 dose levels (0.3, 1, and 3 x 106 
IU/m2/day for 56 days). 29 patients were accrued on protocol; with 28 subjects evaluable for toxicity and 
23 evaluable for response. The interval between onset of chronic GVHD and initiation of IL-2 was 803 

 
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days (range, 117-2624). Patients were on a median of 3 concurrent agents (range, 1-3) for cGVHD. Skin 
and fascia were primary sites of involvement, but lung, liver, oral, and ocular sites were involved as well. 
Dose-level-C (3 x 106 IU/m2/day) was infeasible due to persistent constitutional side-effects requiring 
dose reduction. Dose-level-B (1 x 106 IU/m2/day) was determined to be maximum-tolerated-dose in this 
patient population.  2 patients developed dose-limiting-toxicity (thrombotic microangiopathy). 3 had CTC 
grade ≥3 infections unrelated to IL-2. None experienced GVHD flare. There was no malignant disease 
relapse. 12/23 patients had major responses. These results suggest that low-dose IL-2 can be administered 
safely in patients with active inflammation of chronic GVHD. 
8.1.3 
Expected Toxicities with IL-2 
A list of the adverse events and potential risks associated with the agents administered in this study 
appear below and will determine whether dose delays and modifications will be made or whether the 
event requires expedited reporting in addition to routine reporting. 
Local Reactions (expected in 10% patients): Patients receiving daily SC low-dose IL-2 have been 
reported to develop injection site reactions, typically focal erythema that resolved in a few days; and 
induration that resolved after 2-3 weeks. Dose interruptions may occasionally be required in patients with 
more marked induration (CTCAE 4.0; Grade 3). Lengthy dose interruptions may result in patients being 
unevaluable for response (Section 6.1)  
Constitutional symptoms (expected in 5% patients): In the allo-HCT setting, some patients on low-dose 
IL-2 developed fever, nausea and arthralgia within 72 hours of starting IL-2. Interruption of therapy for 3 
days is recommended if symptoms reported are severe and affecting ADL’s i.e. Fatigue ≥ Grade 3 per 
CTCAE 4.0 criteria. If symptoms of fatigue resolve in 72 hours; IL-2 may be restarted at 50% of prior 
dose. If however symptoms of fatigue persist and patient is unwilling to continue therapy on protocol, 
they will be removed from study. Secondary/reversible causes of fatigue, such as sepsis, hypotension, 
hypothyroidism will be ruled out prior to attributing this to IL-2. 
Thyroid dysfunction (expected in 5% patients): Thyroid function test abnormalities were noted in some 
allo-HCT patients on low-dose IL-2. Only one patient however developed clinical hypothyroidism 
necessitating therapy while on IL-213. After cessation of IL-2, thyroid function returned to normal. Hence, 
a thyroid panel (TSH, T4, free T4) levels will be checked at study entry and week 12 while on study. 
Patients with evidence for hypothyroidism will be worked up (antimicrosomal, antithyroglobulin 
antibodies) and given replacement thyroxine as clinically indicated.  
Hematologic (expected in 5% patients): Early post-HSCT, low-dose IL-2 caused an initial decrease in the 
absolute lymphocyte count in patients after 1 week of therapy. Thereafter, with continued infusion, a 
steady increase in lymphocyte count occurred in all patients.  
 
Low dose IL-2 also caused an initial increase in eosinophil counts (peak at 3 weeks) followed by 
a gradual decline. 
 
The platelet count decreased by >20% in some allo-HCT patients on low-dose IL-2. This 
decrease was noted within the first 2 weeks on IL-2, and continued treatment was not associated 
with further declines in platelet count. No patients had >40% decline in platelet counts, and none 
required platelet transfusions or had bleeding episodes. 
 
No changes in monocyte or neutrophil counts were observed. No significant impact of low-dose 
IL-2 on hemoglobin levels or reticulocyte counts was noted.  
Thrombotic Microangiopathy (TMA) (expected in 7% patients): Koreth et al.13 reported 2 patients on 
daily SC low-dose IL-2 who developed SAE of thrombotic microangiopathy (thrombocytopenia, 
microangiopathic hemolytic anemia with schistocytosis, renal dysfunction) that was thought possibly 
related to IL-2. TMA is also a known complication of calcineurin-inhibitor and of sirolimus (both of 
which both the patients were on). One of the patients has required long-term hemodialysis for 
management of renal dysfunction. 

 
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8.1.4 
Pharmacology – Handling, Storage, Dispensing and Disposal 
8.1.4.1 Form: 
Recombinant human IL-2 (Proleukin®) is supplied as a sterile, white to off-white, lyophilized cake in 
single-use vials containing 22 MIU of aldesleukin intended for intravenous (IV) or subcutaneous (SC) 
administration. Store vials of lyophilized IL-2 in a refrigerator at 2-8ºC (36-46ºF). Do not use beyond the 
expiration date printed on the label. 
For the 22 million international unit (MIU) vial, when reconstituted with 1.2 mL Sterile Water for 
Injection (SWFI), each mL contains 18 MIU (1.1mg) IL-2, 50 mg mannitol and ~180 mcg sodium 
dodecyl sulphate, buffered with ~170 mcg sodium phosphate monobasic and 890 mcg sodium phosphate 
dibasic to a pH of 7.5 (range: 7.2-7.8) 
 
8.1.4.2 Storage and Stability: 
Store vials of lyophilized IL-2 in a refrigerator at 2-8ºC (36-46ºF). Do not use beyond the expiration date 
printed on the label. Vials should be entered only once for reconstitution to minimize the chances of 
contamination. If not used immediately, in-use storage times should normally not be longer than 24 hours 
at 2-8ºC, unless reconstitution has been performed under controlled and validated aseptic conditions in a 
laminar airflow hood. 
Data support stability and sterility of reconstituted diluted IL-2 preparations (reconstituted with SWFI and 
further diluted with D5W); and the stability and sterility of product reconstituted with SWFI but not 
further diluted, for up to 14 days at 2-8ºC (36-46ºF) when single-use syringes for daily use are prepared 
by qualified health-care professionals under aseptic conditions (per Proleukin® Investigator’s Brochure 
(Chiron Corporation, 10 Sep 2003, pp113). IL-2 should be reconstituted with sterile water for injection 
(SWFI) plus D5W. Reconstitution or dilution with Bacteriostatic Water for Injection or 0.9% Sodium 
Chloride for Injection should be avoided due to increased aggregates. 
Therefore, reconstitution and dilution of lyophilized IL-2 is to be performed under controlled and 
validated aseptic conditions in a laminar flow hood per COH pharmacy policy and procedure manual. The 
dose or doses thus prepared and stored at 2-8ºC (36-46ºF) need to be used within 14 days. 
 
8.1.4.3 Compatibility: 
IL-2 is not given IV, hence compatibility issues with other concomitant IV drugs are not applicable.IL-2 
has been used in combination with steroids, mycophenolate mofetil, calcineurin inhibitors, sirolimus and 
imatinib without any adverse effects. 
 
8.1.4.4 Handling 
The single-daily-use syringes containing reconstituted and diluted solutions should be stored in a 
refrigerator at 2-8ºC. DO NOT FREEZE. The product should be inspected visually for particulate matter 
or discoloration and brought to room temperature before administration. 
 
8.1.4.5 Preparation: 
IL-2 will be reconstituted in 1 ml Becton Dickinson single use syringes. All IL-2 syringes for daily SC 
outpatient use should be prepared in the pharmacy at the same time, after diluting the 22 MIU IL-2 vial 
with 1.2 ml SWFI and 4.8 ml D5W (final IL-2 concentration=3.6 MIU/mL), and any remaining product 

 
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should be immediately discarded. During reconstitution the SWFI should be directed at the sides of the 
vial to avoid foaming, and the contents of the vial should be gently swirled. THE VIAL SHOULD NOT 
BE SHAKEN. 
 
8.1.4.6 Administration: 
After reconstitution, an up to 2-week IL-2 supply will be provided in single-use syringes (in a cool-pack if 
necessary), for home refrigerator storage at 2-8 C. One single-use syringe will be used each day during 
home SC self-administration, and discarded in the sharps containers provided. Participants will be 
instructed to rotate injection sites, if feasible. 
 
8.1.4.7 Accountability: 
The investigator, or a responsible party designated by the investigator, must maintain a careful record of 
the inventory and disposition of the agent (investigational or free of charge) using the NCI Drug 
Accountability Record or another comparable drug accountability form. 
 
8.1.4.8  Destruction and Return: 
At the end of the study, unused supplies of IL-2 should be destroyed according to institutional policies. 
Destruction will be documented in the Drug Accountability Record Form. 
 
8.2 Extracorporeal Photopheresis 
8.2.1 
ECP Expected Toxicities (Incidence less than 5%)  
Hypotension: Transient hypotension is noted with ECP related to intravascular volume depletion 
associated with ECP. Vitals signs will be monitored closely per SOP and volume resuscitation with 
normal saline (500mL over 30 minutes) or 5% albumin will be used per recommendations of Transfusion 
medicine physician. 
Numbness and Tingling: This is related to hypocalcemia related to ECP secondary to anticoagulant. 
Patients will be given TUMS to swallow and IV calcium gluconate 10mL of 10% solution slow iv over 
10 mins to be given in patients not responding to PO calcium supplementation. All patients will have 25 
Hydroxycholecalciferol levels checked and patients with vitamin D deficiency will receive replacement 
therapy with ergocalciferol.  
Fatigue: This is noted in patients post ECP session and in setting of refractory cGVHD may be 
multifactorial and related to underlying condition, chronic steroid use and debilitation. If KPS declines to 
the point that ADL’s cannot be sufficiently performed, patients will continue ECP on protocol. They will 
be encouraged to be ambulatory and do light exercise as tolerated to combat fatigue.  
Central Line Infection: This is related to immunocompromised status of patients with cGVHD and 
frequent VAD access. Standard antimicrobial prophylaxis and surveillance cultures will be drawn per 
clinical guidelines. Catheter related blood stream infection will require intravenous antimicrobial therapy 
and infectious disease service will be consulted as appropriate.  
Central Line associated thrombosis: This will be treated with systemic anticoagulation if platelet counts 
are greater than 50,000/mm 3 or line removal if systemic anticoagulation can’t be given. 
Cytopenias: This is expected from combination therapy with ECP and IL-2. Transfusion and growth 
factor support per institutional guidelines is permitted.  See section 6.2 for detailed management of 
hematologic toxicities anticipated from ECP. 

 
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Tenderness at needle site: This is a common occurrence, but rarely produces more than temporary 
inconvenience.  
Hematoma: Leakage of blood from vein into the surrounding tissues causes bruising. This could occur 
with any needle puncture into a vein and could produce pain or even limit the full use of the affected arm 
for a few days. Such a leak can occur at any point or after the treatment. Pressure bandage applied after 
treatments are intended to limit the occurrence of this complication.  
Loss of blood: Leakage/breakage of the plastic tubing rarely occurs but may develop during the treatment. 
This would result in potential contamination of the portion of blood in the cell separator. As a safety 
measure, this blood will not be returned to the patient.  
 
9.0 Correlative/Special Studies 
9.1 Immune Correlative Studies:  
Chronic GVHD is associated with a deficiency of T-regs, NK cells and naive CD8+ T cells. Studies 
support increased pro-inflammatory cytokines in chronic GVHD cases, including TNF-α, IL-6, IL-1β, IL-
8, soluble alpha chain of the IL-2 receptor shed by activated T cells (sIL-2R) and IL-1R, among others 
and decrease in anti-inflammatory cytokines such as IL-10 . Early-onset chronic GVHD had increased 
soluble B cell activating factor (sBAFF), anti-dsDNA, sIL-2R and sCD13. Late-onset chronic GVHD 
cases had increased sBAFF and anti-dsDNA. Additionally, early onset chronic GVHD demonstrates 
decreased IFN-γ and IL-2, while late-onset chronic GVHD had decreased IL-4, IL-2 and FOXP3.CRP 
and C3 and C4 complement levels are also elevated in cGVHD.  
The primary immunologic endpoint is a fold-increase in T-reg and the T-reg/-Tcon ratio at 3 months of 
(ECP+IL2) therapy. Protocol-specified immunophenotypic analyses will be performed at baseline and at 
3, 7, 9 & 12 weeks during treatment with ECP +IL-2 and 4 weeks after discontinuation of combination 
therapy (week 16 for those who complete treatment).   
The following analysis will be performed: 
9.1.1 
Immune Cell Subsets: 
 
Effector memory cells ( CD 45RA-CCR7-/CD62-)14 
 
Th17 cells15 
 
Tregs ( CD4+CD25+CD127-)16 
 
TRECS (T cell receptor excision circles)16 
 
CD3+ Cells ( T con)17 
 
CD 19+( B cell marker )1 
 
CD3-CD16+CD56+( NK cells)12 
 
FoxP3 gene methylation status  
 
9.1.2 
Inflammatory Markers: 
 
IFN-γ, TNF α15 
 
IL-2,IL-4,IL-6,IL-815,20 
 
IFN-γ, TNF 15 
 
BAFF19 
 
IL-2 receptor  (IL2R) and hepatocyte growth factor (HGF)  for systemic GVHD21 
 
 
Elafin for skin GVHD22 

 
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 
Regenerating islet-derived 3α (REG3α) for gastrointestinal GVHD21 
 
Suppression of tumorigenicity 2 (ST2) for steroid-refractoriness23  
 
CXCL924  
 
Micro RNA analysis40 
 
9.2 Methods 
9.2.1 
Immunologic Assays 
Immune cell subset analysis will be performed on peripheral blood mononuclear cells (PBMCs) using the 
Ficoll density gradient separation. Approximately 15 ml of whole blood will be collected from patients on 
each visit in EDTA (lavender top) tubes and sent to the research lab for testing. Blood will transferred 
under a laminar flow hood into a 50mL tube and diluted 1:1 with PBS. The diluted blood will be layered 
on Ficoll medium by gently pipetting. The 50mL tube will be placed in a swinging bucked centrifuge and 
spun at 833xg for 20 minutes at 20ºC, acceleration 9 and no brake. 50,000 PBMCs will then be incubated 
with fluorophore-conjugated monoclonal antibodies:  Immunophenotyping will be done for the following 
markers surface markers (CD 4, CD16, CD 25, CD127, CD45RA, CD62, CD3, CD19 and CD56 to 
distinguish T cell subsets at baseline and with therapy. Cell analysis will be performed with the use of the 
FACS Canto II system (BD Biosciences) and FACS Diva software (BD Biosciences).  
9.2.2 
MicroRNA analysis:  
1) Evaluate changes in miR signature in patients with steroid refractory cGVHD on combination therapy 
with IL-2 and ECP. Experimental Approach: Plasma samples (1 mL) will be collected at baseline (at 
enrollment) and at 12 weeks (completion of treatment) - from all patients enrolled on protocol. Samples 
will be stored at -70C freezer. Total RNAs will be extracted from batched samples using 400μL plasma 
by mirVana PARIS kit (Ambion) according to manufacturer’s instructions. Caenorhabditis elegans 
miRNA (cel-miR-39) will be used as spiked in control. Plasma miRNAs will be quantified using SYBR 
green-based quantitative reverse-transcriptase polymerase chain reaction (qRT-PCR). To compare the 
plasma miR profiles of the two groups of patients, we will use qPCR-based high throughput miRNA array 
that contains primers specific for 345 well-characterized human miRNAs. Cel-miR-39 will be used for 
normalization to obtain relative miRNA expression. Statistical Analysis: Hierarchical clustering analysis 
will be performed using Cluster 3.0.The Mann-Whitney test will be used to compare differences in 
plasma miR expression between responders and non-responders. Receiver operative characteristic (ROC) 
curves and area under the ROC curve will be used to assess the sensitivity and specificity of miR 
biomarkers and logistic regression analysis will be used to develop a miRNA panel predictive of response 
to therapy. Based on the literature we will focus our analysis on up regulation of miR-146a and down 
regulation of miR-106b and miR-21.  
2) Evaluate miR signature in patients with cGVHD versus matched post HCT controls without cGVHD. 
Experimental approach. 1 ml plasma sample will be extracted upon enrollment from (n=20) patients with 
severe steroid refractory cGVHD and a control group of patients without manifestations of cGVHD 
(n=20) who have similar HCT characteristics (obtained through the Protocol #09050. PI: Nakamura). 
Plasma samples will be batched and tested for differential miR expression as described in section above-
to analyze differential miR expression pattern.  
3) Study miRNA expression in Tcon with or without Treg suppression: Experimental approach: 
Peripheral blood mononuclear cell (PBMC’s) from all enrolled patients will be extracted from whole 
blood using Ficoll paque density gradient centrifugation (GE healthcare) at baseline. The PBMC’s will 
then be flow sorted into 95% pure population of Tregs (CD4+CD25+CD127-) and Tcons 
(CD4+CD25+CD127-) using FACSAria cell sorter (BD Biosciences).  Co-culture of Tregs and Tcons 
will be done in 96 well round bottom plates (Corning star, Cambridge, MA). Cells will be plated at 

 
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density of 1X105/cells/well in RPMI 1640 media (0.2mL/well) and incubated at 37C for 72 hours. 
Cultures will be stimulated by 1μgm/mL anti-CD3 antibody (BD PharMingen, San Diego, CA). miRNA 
expression of Treg suppressed and Treg unsuppressed Tcons will be investigated by miRCURY LNATM 
microRNA Array (Exiqon, Vedbaek, Denmark). The intensity of signal will be calculated after 
background subtraction. The threshold value to screen up or down regulation of miRNAs will be a fold 
change≥2.0 or ≤ 0.5. Analysis Plan: The specific time trend for each cell subset, cytokine and miR will be 
assessed using linear mixed effects modeling. The overall fit of the model will be evaluated graphically 
by taking a scatter plot of data for each and applying an overlay of the line generated by the model. An 
evaluation of the regulation patterns over time will be assessed by examining the slope patterns. To assess 
the possible impact of changes in expression on T cells, functional regression modeling will be used. 
Similar modeling techniques will be used to assess the impact of clinical events on expression.  
9.2.3 
Cytokine assays: 
Serum separator tubes will be used (yellow top) will be used to collect samples (5 ml) on each visit. 
Samples will be allowed to clot for 30 minutes at room temperature before centrifugation for 15 minutes 
at 1000 x g. Serum will be removed aliquotted and stored samples at ≤ -20 °C for batched analysis as 
described below.  
REG3 ELISA kits will be purchased from MBL International (Ab-Match Assembly Human PAP1 kit and 
Ab-Match Universal kit), and measurements will be performed according to the manufacturer’s protocol. 
Samples (diluted 1:10) and standards will be run in duplicate, absorbance will be measured with a    
SpectraMax M2 (Molecular Devices), and results calculated with SoftMax Pro Version 5.4 (Molecular 
Devices). Elafin, IL2R, HGF, TNFR1, and IL-8 ELISAs will performed in duplicate using the quantikine 
immunoassay (R&D Diosystems). The quantikine assay is a 3.5-4.5 hour solid phase ELISA designed to 
measure human cytokines (TNF-α, Elafin, IL2R, HGF, IL-2, IL-4,IL-6, IL-8, BAFF, IFN-γ and CXCl-4 ) 
in cell culture supernates, serum, and plasma. It contains E. coli-derived recombinant human 
cytokine/protein and antibodies raised against these specific this proteins. This assay employs the 
quantitative sandwich enzyme immunoassay technique. A monoclonal antibody specific for the pre-
specified cytokine is pre-coated onto a microplate. Standards and samples are pipetted into the wells and 
any cytokine present is bound by the immobilized antibody. After washing away any unbound substances, 
an enzyme-linked polyclonal antibody specific for the cytokine is added to the wells. Following a wash to 
remove any unbound antibody-enzyme reagent, a substrate solution is added to the wells and color 
develops in proportion to the amount of TNF-α bound in the initial step. The color development is 
stopped and the intensity of the color is measured.  
 

 
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10.0  Study Calendar 
*Only done for patients with pulmonary and cutaneous cGVHD, respectively. 
Patients will undergo standardized cGVHD assessment per NIH guidelines (See Appendix C for forms), at baseline and week 3, 7, 9, 12 and 
16 on study. cGVHD response will be assessed per NIH consensus criteria. Of note, oral and ocular sites will not be included in determination 
of response, as additional topical therapy is permitted for those sites. 
Procedure/Test 
Pre-
Study 
Wk
1 
Wk 
2 
Wk 
3 
Wk 
4 
Wk 
5 
Wk 
6 
Wk 
7 
Wk 
8 
Wk 
9 
Wk 
10 
Wk 
11 
Wk 
12 
Wk 
16 
IL-2 (Daily throughout) 
 
------------------------------------------------------------------------------------------------------------------------ 
---------- 
ECP 
 
X2 
X2 
X2 
X2 
X1 
 
X1 
 
X1 
 
X1 
 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical history 
R 
R 
 
R 
 
 
 
R 
 
R 
 
 
R 
R 
Physical Exam  
R 
R 
 
R 
 
 
 
R 
 
R 
 
 
R 
R 
cGVHD Symptom score  
X 
 
 
X 
 
 
 
X 
 
X 
 
 
X 
X 
Pregnancy test  
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pulmonary Function * 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
 
Dermatologic assessment * 
R 
R 
 
R 
 
 
 
R 
 
R 
 
 
R  
R  
Weight 
R 
R 
 
R 
 
 
 
R 
 
R 
 
 
R 
R 
Performance Status 
X 
X 
 
X 
 
 
 
X 
 
X 
 
 
X 
X 
CBC w/diff, 
R 
R 
 
R 
 
 
 
R 
 
R 
 
 
R 
R 
Serum chemistry 
R 
R 
 
R 
 
 
 
R 
 
R 
 
 
R 
R 
Immune assessment 
R 
 
 
R 
 
 
 
R 
 
R 
 
 
R 
R 
Thyroid function/Vitamin 
D level   
X 
 
 
 
 
 
 
 
 
 
 
 
X 
 
Steroid dose assessment 
X 
X 
 
X 
 
 
 
X 
 
X 
 
 
X 
X 
Adverse event evaluation 
 
X ------------------------------------------------------------------------------------------------------ X 
X 
Drug Diary  
 
X 
 
X 
 
 
 
X 
 
X 
 
 
X 
 
QOL self assessment 
(FACT-BMT Version 4)   
X 
 
 
 
 
 
 
X 
 
 
 
 
X 
 
Correlative studies 
X 
 
 
X 
 
 
 
X 
 
X 
 
 
X 
X 

 
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X2 Indicates ECP will be administered two times a week.X1 Indicates twice weekly ECP treatment 
R  Indicates medical exam, blood draw or tests to be done as routine standard of care. 
Immune assessment This includes monitoring immunoglobulin levels and CMV PCR titers 
X Indicates that proposed test, medical evaluation, blood draw or questionnaire is for research purposes 
 

 
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11.0 Endpoint Evaluation Criteria/Measurement of Effect 
11.1 Primary Endpoint 
The primary activity endpoint is cGVHD response, based on the 2014 cGVHD NIH Consensus criteria41. 
Confirmation of CR/PR or SD assessed by NIH Consensus criteria. 
  
11.1.1 Response Definitions: 
Complete Response: 
Organ response: resolution of all reversible manifestations related to cGVHD in a specific organ. 
Overall response: resolution of all reversible manifestations in each organ or site of cGVHD 
involvement. Depending on relevant organ system involvement, patients will undergo repeat detailed 
assessment of oral, cutaneous, musculoskeletal and pulmonary systems.  
 
Partial Response: 
Organ response: at least 50% improvement in the scale used to measure disease manifestations related to 
cGVHD (e.g. a 50% decrease in skin rash from 80% BSA to 40% BSA), with a minimum of 25% 
improvement in the full scale as opposed solely to a percentage of the starting value (Appendix F; Section 
17.6) 
Overall Response:  
Improvement in measure at least one organ or site, without progression in measures at any other organ or 
site. The NIH global severity of chronic GVHD assessment criteria will be used to evaluate the response 
to therapeutic intervention in one or more involved organs 37. Of note, for global ratings and categorical 
scales, a 1-point change in a 3- or 7- point scale or a 2- to 3- change on a 0- to 10- point scale (0.5 SD 
change) would be considered clinically meaningful. Additionally, the hallmark for response to therapy for 
bronchiolitis obliteraans syndrome (BOS) is stabilization of lung function with no further decrease in 
FEV1 during a 3-month period. 
  
Progressive Disease: Organ progression: an absolute increase of at least 25% in the scale used to 
measure disease manifestations related to cGVHD. Of note, for global ratings and categorical scales, a 1-
point change in a 3- or 7- point scale or a 2- to 3- change on a 0- to 10- point scale (0.5 SD change) would 
be considered clinically meaningful. Additionally, clinical worsening of cGVHD‟ is not synonymous 
with progressive cGVHD per NIH criteria, as patients may experience worsening symptoms that do not 
meet objective NIH criteria for progression. If so, they still have the option of discontinuation of IL-2 and 
initiating additional immunosuppression for lack of IL-2 efficacy; at the judgment of the treatment 
physician. 
11.2 Secondary Endpoints 
Toxicity: 
Toxicity will be graded according to the NCI-Common Terminology Criteria for Adverse Events 
version 4.0333. Unacceptable toxicity will be defined as any toxicities that are at least possibly 
related to either ECP or IL-2 and occur during cycle 1 (within 10 days of initiation of therapy).   
Overall Survival: 
Defined as the time interval from date of first dose of study drug to date of death from any cause. 

 
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Failure-free Survival: 
Defined as the time interval from date of first dose of study drug to first documented cGVHD progression 
(necessitating change of treatment), malignancy relapse or progression or death from any cause, 
whichever occurs first. 
Non-Relapse Mortality:  
Defined as time interval from date of first dose of study drug to death from any cause among patients 
without active disease. 
Chronic GVHD Symptom Score: 
Patients will self-report symptoms and signs of cGVHD using the validated chronic GVHD Symptom 
Scale. Self-Reported symptom Scales will be obtained at baseline and weeks 3, 7, 9, 12 and 16. 
Steroid Use for Chronic GVHD: 
Patients will have their total daily dose of corticosteroids recorded at baseline, and at 3, 7, 9 12 and 16 (or 
4 weeks after end of treatment) weeks of IL-2+ ECP therapy. In the case of alternate daily dosing of 
corticosteroids, the average daily dose will be recorded for study purposes. 
Immune Assessment: 
Patients will undergo testing for immunologic function, performed at baseline and at weeks 3, 7, 9, 12 and 
16 (or 4 weeks after end of treatment). Testing will include: quantitative immune globulins; plasma 
banking; and storage of additional mononuclear cells. 
ECP Performance Parameters: Clinical Response to therapy will be co-related with ECP performance 
parameters which will include median time spent on ECP machine, second versus third generation device 
( Cellex vs XTS) and flow rates.   
 
 

 
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12.0 Data Reporting 
12.1 Confidentiality and Storage of Records 
This protocol uses Electronic Data Collection, and the data will be stored in encrypted, password 
protected, secure computers that meet all HIPAA requirements.  When results of this study are reported in 
medical journals or at meetings, identification of those taking part will not be disclosed.  Medical records 
of subjects will be securely maintained in the strictest confidence, according to current legal requirements.  
They will be made available for review, as required by the FDA, HHS, or other authorized users such as 
the NCI, under the guidelines established by the Federal Privacy Act and rules for the protection of 
human subjects. 
12.1.2 Subject Consent Form 
At the time of registration, the original signed and dated Informed Consent form, HIPAA research 
authorization form, and the California Experimental Subject’s Bill of Rights (for the medical record) and 
three copies (for the subject, the research record, and the Coordinating Center) must be available.  All 
Institutional, NCI, Federal, and State of California requirements will be fulfilled. 
12.1.3 Data Collection Forms and Submission Schedule  
All data will be collected on Medidata Rave®.  Data will be stored in encrypted, password protected, 
secure computers that meet all HIPAA requirements. 
Form 
Submission Timeline 
Eligibility Checklist 
Complete prior to registration 
On Study Forms 
Within 10 business days of registration 
Baseline Assessment Forms 
Within 10 business days of registration 
Treatment Forms 
Within 10 business days of treatment administration 
Adverse Event Report Forms 
Within 5 business days, but only through day 60 (DLT period) 
Response Assessment Forms 
Within 10 business days of response assessment 
Other assessment forms (e.g. concomitant 
meds, chemistry, hematology, neuro exam, 
physical exam) 
Within 10 business days of the assessment 
Off Treatment/Off Study Forms 
Within 10 business days of completing treatment or being 
taken off study for any reason 
Follow up/Survival Forms 
Within 10 business days of the protocol defined follow up visit 
date or call 
 
13.0 Statistical Considerations 
13.1 Study Design, Sample Size, and Accrual Rate 
This single center/single arm, phase II clinical trial is designed to evaluate the anti-cGVHD activity of 
extracorporeal photopheresis (ECP) when combined with low dose IL-2, in patients with steroid 
refractory cGVHD, as assessed by overall cGVHD response rate (CR+PR+SD). The primary endpoint 
overall response (CR+PR+SD) is based on the NIH cGVHD consensus criteria; calculated as the percent 
of evaluable patients that have confirmed CR/PR or SD  
This study will implement a Simon, optimal, two-stage design to evaluate the anti-cGVHD activity of the 
ECP/IL-2 regimen. The trial is expected to enroll 24 patients e sample size is based on the desire to 
discriminate a promising response rate of 50% from a current response rate of 25%. The null hypothesis 

 
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that the true response rate is 25% will be tested against a one-sided alternative. In the first stage, 9patients 
will be accrued. If there are 2 or fewer responses in these 9 patients, the study will be stopped. Otherwise, 
15 additional patients will be accrued for a total of 24. The null hypothesis will be rejected if 10 or more 
responses are observed in 24 patients. This design yields a type I error rate of 0.05 and power of .80 when 
the true response rate is 50%. Currently, about 20-25 new patients are referred to ECP per year. We 
expect that 6 patients to be enrolled per year with the expected completion of accrual in 4years.   
Evaluable for Response: As part of the primary analysis, patients will be considered evaluable for 
response if they are eligible, have baseline disease assessments, and receive protocol treatment of any 
duration. All such patients will be evaluated for clinical response..  Our primary outcome will be the 
clinical response rate measured in all patients who are enrolled and receive any amount of protocol 
therapy.  
Patients who are consented for the study but withdraw for any reason (progression of GVHD, infectious 
complications, insurance denial etc) prior to initiation of protocol therapy will not be eligible for response 
evaluation.   
Evaluable for Toxicity: Patients will be considered evaluable for toxicity if they receive any study drug.  
Safety Analysis and Stopping Rules for Excessive Toxicity 
The following table will be consulted as relevant toxicities are encountered. The early stopping rule for 
safety/toxicity will be assessed for each patient after 3 weeks of treatment. The expected rate of 
unacceptable toxicity should not be ≥33%. See the table below for detailed early stopping rules. These 
rules are in addition to the quarterly review of all toxicities submitted to the COH DSMC. Patients with 
ongoing toxicity (toxicity persisting beyond day +21) will be followed until resolution or stability.  If 
more than the specified number of patients has significant treatment related toxicities, patient accrual will 
be halted and a full review of the data by the Data Safety Monitoring Committee (DSMC) will be 
mandated. Patient accrual will not resume until approved by the DSMC to do so. 
# of patients 
treated at 
phase II dose 
# of patients with 
unacceptable 
toxicity to halt 
enrollment1 
# of patients 
expired due to 
treatment related 
causes that 
would stop the 
study2 
Given the following toxicity rates, 
cumulative probability of early 
stopping: 
15% 
33% 
45% 
6 
2 
2 
0.22 
0.64 
0.84 
9 
3 
3 
0.25 
0.72 
0.89 
12 
4 
4 
0.26 
0.75 
0.93 
18 
6 
6 
0.27 
0.80 
0.95 
1: For each unacceptable toxicity, halt enrollment and evaluate if the cumulative # of patients 
reaches or exceeds the specified limits. 
2: Expected treatment related mortality should not exceed 33%. 
In addition, cumulative safety data will be reviewed on a quarterly basis in order to identify safety 
concerns that may emerge due to cumulative exposure.  
 
13.2 Statistical Analysis Plan  
Patient demographic and baseline characteristics, including age, gender, medical history, and prior 
cGVHD therapy, will be summarized using descriptive statistics. For continuous variables, descriptive 

 
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statistics (number [n], mean, standard deviation, standard error, median (range) will be provided. For 
categorical variables, patient counts and percentages will be provided. 
The overall response rate (CR+PR) will be calculated as the percent of evaluable patients; exact 95% 
confidence intervals will be calculated for these estimates. Response rates will also be evaluated based on 
number and type of prior therapy(ies). Time to response, duration of response, and survival will be 
estimated using the product-limit method of Kaplan and Meier. 
Observed toxicities will be summarized in terms of type (organ affected or laboratory determination), 
severity, time of onset, duration, probable association with the study treatment and reversibility or 
outcome. Baseline information (e.g. the extent/type of prior therapy) and demographic information will be 
presented as well to describe the patients treated in this study. 
 
14.0 Human Subject Issues 
14.1 Institutional Review Board 
In accordance with City of Hope policies, an Institutional Review Board (IRB) that complies with the 
federal regulations at 45 CFR 46 and 21 CFR 50, 56 and State of California Health and Safety code, Title 
17,  must review and approve this protocol and the informed consent form prior to initiation of the study.  
All institutional, NCI, Federal, and State of California regulations must be fulfilled. 
14.2 Recruitment of Subjects: 
Subjects will be recruited from City of Hope  
14.3 Advertisements  
Although none are planned, advertisements to include print, media (radio, television, billboards), 
telephone scripts, lay summary to be posted on City of Hope’s public Clinical Trials On-LineSM website, 
etc., will be reviewed and approved by the IRB prior to their use to recruit potential study subjects. 
14.4 Study location and Performance Sites 
This study will be performed at COH.   
14.5 Confidentiality  
This research will be conducted in compliance with federal and state of California requirements relating 
to protected health information (PHI).  
The study will record individual immunological, clinical response and side effect profile to IL-2 and ECP 
combination therapy and the information collected will be linked to the subject’s identity using a coded 
study number.  In addition, results of screening tests to rule out HIV, HBC, and HCV performed in the 
Department of Transfusion Medicine will be used with the participant’s permission if performed in the 
past 4 months.  The principal investigator, co-investigators, and laboratory technicians will have access to 
this information, but all information will be treated confidentially.  No identifiers will be used in any 
subsequent publication of these results.   
14.6 Financial Obligations and Compensation 
Cost for IL-2 and ECP will be covered by third party payers the enrolled subjects will not bear the cost of 
treatment. The cost for immunologic studies will be covered by in house funding support. Intramural 
funding will also be used to cover cost of personnel and biostatistical analysis of data generated from this 
clinical trial. Our past experience suggests that insurance coverage rate is 60%. Patients who sign consent 
but are not eligible for IL-2 in case insurance is unwilling to pay for IL-2 will be deemed as screen failures 

 
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and will not be eligible for final evaluation. They will continue regular follow up and standard of care 
treatment.  
The standard of care drug(s) and procedures provided will be the responsibility of the research participant 
and/or the insurance carrier.  The research participant will be responsible for all copayments, deductibles, 
and other costs of treatment and diagnostic procedures as set forth by the insurance carrier.  The research 
participant and/or the insurance carrier will be billed for the costs of treatment and diagnostic procedures 
in the same way as if the research participant were not in a research study.  However, neither the research 
participant nor the insurance carrier will be responsible for the research procedures related to this study. 
In the event of physical injury to a research participant, resulting from research procedures, appropriate 
medical treatment will be available at the City of Hope to the injured research participant, however, 
financial compensation will not be available. 
The research participant will not be paid for taking part in this study. 
14.7 Informed Consent Processes  
The Principal Investigator or IRB approved named designate will explain the nature, duration, purpose of 
the study, potential risks, alternatives and potential benefits, and all other information contained in the 
informed consent document.  In addition, they will review the experimental subject’s bill of rights and the 
HIPAA research authorization form.  Research subjects will be informed that they may withdraw from the 
study at any time and for any reason without prejudice, including as applicable, their current or future 
care or employment at City of Hope or any relationship they have with City of Hope.  Research subjects 
will be afforded sufficient time to consider whether or not to participate in the research. 
Should sufficient doubt be raised regarding the adequacy of comprehension, further clarifications will be 
provided.  Prospective research subjects who cannot adequately comprehend the fundamental aspects of 
the research study with a reasonable amount of discussion, education and proctoring will be ineligible for 
enrollment.  For those subjects who do comprehend the fundamental aspects of the study, consent will be 
obtained and documented, followed by eligibility testing.  The research team will review the results of 
eligibility testing and determine if the subject is a candidate for study enrollment. No subjects will be 
enrolled into the study without first demonstrating full comprehension of the study and their rights as 
research subjects.  
 
 

 
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