Post Transplant Cyclophosphamide for Unrelated and Related Allogeneic Hematopoietic Stem Cell Transplantation for Hematological Malignancies
Phase: PHASE2
Conditions: Hematological Malignancies
Sponsor: Sidney Kimmel Comprehensive Cancer Center at Thomas Jefferson University

11D.51 Protocol v25.0 (22 December 2021) 
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Post Transplant Cyclophosphamide for Unrelated and Related Allogeneic Hematopoietic 
Stem Cell Transplantation for Hematological Malignancies 
 
 
 
Principal Investigator 
John L. Wagner, MD 
Department of Medical Oncology 
 
 
 
Co-Investigators 
Seyfettin Alpdogan, MD 
Matthew Carabasi, MD 
Beth Colombe, PhD 
Neal Flomenberg, MD 
Usama Gergis, MD 
Dolores Grosso, DNP, CRNP 
Chetan Jeurkar, MD 
Margaret Kasner, MD 
Lisa Kearns, CRNP 
Joanne Filicko-OHara, MD 
William O’Hara, Pharm-D 
Weyin Shi, MD 
Ubaldo Martinez-Outschoorn, MD 
Thomas Klumpp, MD 
Neil Palmisiano, MD 
Pierluigi Porcu, MD 
Shaik Rashid, MD 
Maria Werner-Wasik, MD 
 
 
Statistician 
Inna Chervoneva, PhD 
 
 
Version Date: 
January 3, 2011 (Original) 
February 21, 2011 (Removing Rosetta Dennis, CRNP) 
April 13, 2011 (Amendment 1.0) 
June 13, 2011 (Amendment 2.0) 
September 2, 2011 (Amendment 3.0) 
November 28, 2011 (Amendment 4.0) 
May 30, 2012 (Amendment 5.0) 
September 4, 2012 (Amendment 6.0) 

11D.51 Protocol v25.0 (22 December 2021) 
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September 6, 2013 (Removing Dr. Gitelson) 
November 19, 2013 (Version 10) 
May 21, 2014 (Version 11) 
January 15, 2015 (Version 12) 
January 16, 2015 (Adding Dr. Sharma and Dr. Klumpp) 
December 1, 2015 (Adding Dr. Gaballa) 
April 18, 2016 (Version 15) 
July 13, 2016 (Removing Dr. Sharma and Dr. Weiss) 
August 10, 2016 (Adding Dr. Palmisiano) 
September 30, 2016 (Version 17.1) 
March 07, 2017 (Version 18.0) 
March 28, 2017 (Version 18.1) 
August 18, 2017 (Version 19.0.1) 
March 2, 2018 (Version 20.0) 
August 02, 2018 (Version 21.0) 
February 19, 2019 (Version 22.0) 
December 12, 2019 (Version 23.0) 
September 15, 2021 (Version 24.0) 
December 22, 2021 (Version 25.0) 

11D.51 Protocol v25.0 (22 December 2021) 
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Table of Contents 
1.0 
Introduction and Objectives ..................................................................................... 4 
2.0 
Rationale .................................................................................................................. 4 
3.0 
Patient Selection ....................................................................................................... 7 
4.0 
Informed Consent ..................................................................................................... 9 
5.0 
Treatment Plan ......................................................................................................... 9 
6.0 
Study Measurements .............................................................................................. 10 
7.0 
Supportive Care ..................................................................................................... 12 
8.0 
Drug Information and Administration ................................................................... 16 
9.0 
Patient Safety ......................................................................................................... 20 
10.0 Statistical Analyses ................................................................................................ 25 
11.0 References .............................................................................................................. 27 
12.0 Appendices ............................................................................................................. 29 

11D.51 Protocol v25.0 (22 December 2021) 
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1.0 
Introduction and Objectives 
1.1 Introduction 
Post transplant cyclophosphamide has been utilized in a number of trials as a means to 
reduce graft versus host disease (GVHD) after allogeneic marrow transplantation. At 
Thomas Jefferson University (TJU), we have developed an approach where the transplant 
is administered in two separate steps, one being the lymphoid portion of the graft and the 
second being the stem cell portion of the graft. These protocols which have been quite 
successful to date administer cyclophosphamide after the lymphoid portion but before the 
stem cell portion of the graft. These trials use an investigational device for stem cell 
separation requiring an Investigational Drug Exemption (IDE) from the Food and Drug 
Administration (FDA). The entry criteria are quite restrictive, disenfranchising many 
patients who would otherwise be reasonable transplant candidates. In addition, recipients 
of unrelated donor transplants cannot be treated in this fashion because of the extra logistics 
that are required for donation which are not feasible in the unrelated donor setting. This 
protocol attempts to enfranchise these various patient groups using a simpler post 
transplant cyclophosphamide approach. 
 
1.2 Primary 
This study will encompass two patient groups – those transplanted using related donors 
and those transplanted using unrelated donors and recruitment to both arms will start 
simultaneously. The principle objective of the related donor arm is to determine whether 
post-transplant cyclophosphamide can be used to successfully engraft patients with Human 
Leukocyte Antigen (HLA) identical or HLA mismatched related donors after preparation 
with either an ablative or nonmyeloablative conditioning regimen who are not candidates 
for the TJU two step protocols for the reasons specified above. The objective of the 
unrelated donor arm of the study is to determine if patients with HLA matched unrelated 
donors and, if successful, patients with one or two antigen mismatched unrelated donors 
can successfully engraft using cyclophosphamide post transplant. Since one patient has 
successfully engrafted using a matched unrelated donor (on study) and two patients have 
successfully engrafted (off study) using one antigen mismatched unrelated donors we will 
consider after one additional patients with one antigen mismatched unrelated donors have 
engrafted using patients with two antigen mismatched unrelated donors 
 
1.3 Secondary 
1. Assess incidence of Grade III-IV GHVD; goal is less than 10%. 
2. Assess incidence of GVHD unresponsive to corticosteroids and photopheresis; goal 
is less than 15%. 
3. Assess day 100 transplant related mortality; goal is less than 15%. 
 
2.0      Rationale 
High-dose chemoradiotherapy followed by hematopoietic allogeneic stem cell 
transplantation (HSCT) is a potentially curative modality for a variety of hematological 
disorders, including acute and chronic leukemia, myelodysplastic syndrome (MDS), 
multiple myeloma (MM), and lymphoma that are incurable with conventional dose 
chemotherapy.1 The ability of HSCT to control an underlying hematological malignancy 
is based on three variables, the intrinsic sensitivity/resistance of the malignancy, treatment 

11D.51 Protocol v25.0 (22 December 2021) 
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regimen intensity, and graft versus tumor (GVT) effects. Disease sensitivity/resistance is 
not something that can be changed when patients present for treatment, and transplant 
regimen intensity can be further increased only over a narrow additional range since 
treatment intensity is near maximal in many transplant regimens. Consequently, it is 
difficult if not impossible to manipulate the first two variables to effect substantial 
improvements for many HSCT candidates. Thus the third variable the GVT effect may be 
the easiest variable to manipulate. Therefore manipulating the GVT effect will be a major 
focus of this trial and expanding the pool of potential candidates for transplant will be the 
second focus of this trial. 
 
Just as there are three major variables to determine the ability of an HSCT to control an 
underlying hematological malignancy so too there are three traditional therapeutic 
components of a conventional allogeneic HSCT. The first component is the use of a high- 
dose myeloablative-conditioning regimen to eradicate the underlying malignancy and to 
suppress the host immune system in preparation to receive the donor stem cell graft. This 
is followed by the infusion of donor stem cells to both rescue the host from the lethality of 
the conditioning regimen as well as to eliminate residual tumor cells and host resistance to 
donor stem cells by graft-versus-tumor reactions (GVT). The third component is pre- 
grafting T-cell depletion of donor stem cells or post-grafting immunosuppression to 
regulate the development of graft-versus-host disease (GVHD). 2, 3 While a variety of 
agents can be used for the conditioning regimen, the dose intensity may be limited by the 
patient’s condition at presentation for an HSCT. The second and third components can be 
altered by either strategies that involve graft engineering or by the use of a variety of 
immunosuppressive agents. The consequence to one degree or another, of all types of 
transplants, 
is 
a 
period 
of 
immunosuppression 
either 
from 
post-grafting 
immunosuppressant medication or the removal of T-cells from the donor inoculum. 
 
It is now understood that, in some diseases such as follicular lymphoma, a GVT effect, not 
regimen intensity, is the primary mechanism for long-term disease control after allogeneic 
transplantation. In other diseases, both treatment intensity and GVT effects contribute to 
disease eradication. This principle has been firmly established by analysis of transplant 
outcomes from identical twins4, the success of reduced intensity HSCT2 and disease 
eradication after donor lymphocyte infusions3. Unfortunately, despite the potent GVT 
effects associated with HSCT, death due to relapsed disease remains the greatest barrier to 
long-term survival for patients with resistant disease undergoing matched donor HSCT. 
For patients without HLA matched related donors GVHD also remains a significant 
problem. For all of these reasons this trial was conceived. 
 
In recent years, administration of cyclophosphamide (CY) after a T replete (i.e. non T cell 
depleted) marrow graft in order to preferentially eliminate proliferating alloreactive T cells 
has been successfully utilized in non-myeloablative haploidentical HSCT5, 6. With this 
approach, patients avoid profound immunoincompetence due to the remaining donor T 
cells which, because they are not alloreactive and proliferating early after transplant, are 
less affected by CY. In contrast, stem cells are not affected by CY due to their high levels 
of aldehyde dehydrogenase which rapidly metabolizes the active CY derivatives. This 
approach was described in a reduced intensity conditioning murine model by Luznik et al. 

11D.51 Protocol v25.0 (22 December 2021) 
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7. In this experiment mice received pretransplant CY or fludarabine and TBI with 
cyclophosphamide post stem cell infusion. The use of CY post transplant was described in 
a phase I clinical trial at Johns Hopkins University by O’Donnell et al.5. In this study ten 
patients with partially mismatched related donors received conditioning with fludarabine 
and low dose TBI followed by post transplantation cyclophosphamide. All patients initially 
engrafted although two patients later rejected. Six patients developed GVHD that was fatal 
in one patient. A larger study was later published by the same group (with patients added 
from Seattle) with 68 patients 6. In this study nine of the 66 patients (14% of the evaluable 
patients) rejected. The incidence of grade II-IV and III-IV acute GVHD was 34% and 6% 
respectively. Like the initial phase I trial this study used only reduced intensity 
conditioning and used only related donors.5 
 
Recently another study by Meade et al. at University College London Medical School was 
published using a different reduced intensity regimen with alemtuzumab, fludarabine, and 
melphalan and using HLA matched and mismatched unrelated donors.8 This trial of 50 
HLA mismatched unrelated transplants compared to 107 HLA matched unrelated donor 
transplants was limited to patients under 70 and most had chemosensitive disease. In 
addition the study used only a nonmyeloablative conditioning regimen and 29 of 157 
patients required donor lymphocyte infusions for disease relapse. The graft failure rate was 
8% and the incidence of grade II-IV acute GVHD was 22%. 
 
In order to improve upon the results of the above haploidentical trials (for example lack of 
a published myeloablative regimen), we developed a 2-step myeloablative approach to 
HSCT from haploidentical donors at TJU which we have successfully applied to patients 
with hematological malignancies. We refer to this as a 2-step approach because the 
lymphoid and stem cell portions of the graft are collected and administered at different time 
points during the conditioning regimen. Our approach does not involve ex vivo T cell 
depletion, but uses CY to tolerize donor lymphocytes. We have been sufficiently pleased 
with the outcomes of this trial that we now use haploidentical family donors as our 
alternative donor of choice when a matched related donor is not available, rather than 
searching for unrelated donors. Our results from the myeloablative portion of those trials 
are as follows: Of the first 27 patients only two rejected (7%) and both had preformed anti- 
donor antibodies and only 8% developed grade III-IV acute GVHD.9 For this trial we 
would like to include additional potential patients using the Hopkins’ approach as well as 
what we have learned from our two step approach. Thus we will use cyclophosphamide 
post stem cell infusion as in the Hopkins trial5 and at the same time allow both 
myeloablative and nonmyeloablative conditioning regimen as we do in our 2-step trials. 
Furthermore, we will include an unrelated arm as well as was in the University College 
London Medical School trial8 for two reasons. One is that not everyone has an HLA- 
matched or even an HLA mismatched related donor. Furthermore, despite the fact that there 
are now over 13 million potential donors in the various unrelated donor registries, many 
patients still cannot find a fully matched unrelated donor. Therefore, if three patients with 
HLA one antigen mismatched unrelated donors engraft then patients with unrelated donors 
with two antigen mismatches will be entered on the study. If successful this will allow 
more patients to have access to unrelated donors. This is important especially if we can 
demonstrate a mortality risk similar to the TJU 2-step protocol which currently is 

11D.51 Protocol v25.0 (22 December 2021) 
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similar to what one might expect using matched sibling donors.9 As has been shown in a 
large National Marrow Donor Program study a single antigen mismatch causes a 9% 
increase in mortality.10 The TJU 2-step protocol would not be feasible for patients with 
unrelated donors as the donor would have to go through two separate collection processes, 
one for lymphocytes and a second for hematopoietic stem cells. The ability to engraft 
patients with two antigen mismatched unrelated donors with minimal GVHD would greatly 
increase the number of potential unrelated transplants especially for minorities (from 30% 
to greater than 90%).11 
 
We are allowing patients with related donors with slightly more/worse comorbidities than 
on our 2-step study into this study to see if we can offer haploidentical related transplants 
to more patients as well. The entry criteria required by the FDA are quite strict and exclude 
patients who would otherwise be deemed appropriate candidates here at TJU. Furthermore 
a one-step approach if successful would allow more centers without CD34 selection 
devices to perform haploidentical transplants. We will also exclude people with resistant 
disease until we have a better understanding of the engraftment rate, GVHD incidence, etc. 
 
January 14, 2015 Update 
 
The Substitution of Alkylating Agents 
This protocol opened in 2011 and 13 patients has been treated to date on the current 
conditioning regimen of Fludarabine, Thiotepa, 2 Gy TBI and CY. Thiotepa has been used 
in the 2 step RIC approaches since 2008 and in cancer chemotherapy for over 50 years. It 
was designated as an orphan drug in 2007, and a critical shortage of Thiotepa was identified 
in 2013, originating from market forces which have affected many oncology medications. 
The drug is no longer manufactured in the United States and purchasing the drug from 
overseas has been associated with increasing cost. Therefore, the current expense of the 
drug makes its use in HSCT at TJUH (and most other centers) no longer feasible, and a 
drug substitution in the regimen is required. Busulfan has been used in HSCT for over 30 
years and is commonly used in RIC HSCT. 
 
3.0 
Patient Selection 
3.1 Inclusion Criteria 
Any patient with a hematological or oncological diagnosis in which allogeneic HSCT is 
thought to be beneficial. 
- 
Patients without morphological or molecular evidence of disease or 
- 
For patients with “indolent diseases” if the patient has evidence of disease the 
disease burden must be minimal (at least PR) and the disease must be 
chemoresponsive. Thus for example patients with acute leukemia (not an indolent 
disease) must be in a morphological CR or CRp. 
 
For patients with MDS the inclusion criteria is specifically as follows: 
o For patients with RA or RARS or isolated 5q- they can proceed to 
transplant without any treatment. 
o For patients with RAEB-1, RCMD+/-RS, or MDS NOS must have stable 
disease for 6 months (as documented by serial bone marrow examinations) 

11D.51 Protocol v25.0 (22 December 2021) 
8 
 
in the absence of any therapy but growth factors or transfusion support. 
Patients who require treatment to “control their disease” must show 
chemo-responsiveness. 
o For patients with CMML or RAEB-2 they must demonstrate chemo- 
responsiveness. 
o Chemo-responsiveness is defined as a blast percentage decrease by at least 
5 percentage points and there must be less than 10% blasts after treatment 
and at the time of transplant, if there are more than 10% blasts at any point 
during the disease course. 
o Chemo-responsiveness must also include at least one of the following if 
applicable 
 A cytogenetic response 
 A well-documented decrease in transfusion requirements. 
 
Patients must have a related donor who is zero, one, two, three, or four antigen mismatched 
at the HLA-A; B; C; DR loci or an unrelated donor up to a two antigen mismatch. DNA 
will be retained by the tissue typing laboratory for possible typing for DQ and DP. When 
multiple related donor options are available donor selection will be determined the same 
as in the TJU two-step protocols. When multiple unrelated donors are available care will 
be made to avoid HLA-A and HLA-B mismatches if possible based on data from the 
Japanese Marrow Donor Registry studies.12, 13 An HLA antibody screen will be performed 
on each patient.The hematopoietc progenitor cells from unrelated donors may be 
cryopreserved prior to infusion as circumstances require such as during the COVID-19 
pandemic. Recently published data has shown that cryopreservation has no adverse effect 
on survival. 13A 
 
All patients must have adequate organ function: 
1) Patients with related donors must have an LVEF of >35%. Patients with unrelated 
donors must have an LVEF >45%. Patients with LVEF ≤50% and all patients with 
symptoms or history of heart failure or coronary artery disease must have a stress 
echo or equivalent test and a cardiological evaluation. 
2) Patients with related donors must have a DLCO >35% of predicted corrected for 
hemoglobin. Patients with unrelated donors must have a DLCO >45% of predicted 
corrected for hemoglobin. For related donors if the DLCO is less than 45% the EF 
must be greater than 45% and vice versa. 
3) Patients with related donors must have an adequate liver function as defined by a 
serum bilirubin <3.0, AST and ALT <3.0X upper limit of normal. Patients with 
unrelated donors must have an adequate liver function as defined by a serum 
bilirubin <1.8, AST and ALT < 2.5X upper limit of normal. Exceptions may be 
granted for patients with “benign” liver disorders such as Gilbert’s disease. 
4) Patients with related donors or with unrelated donors must have a creatinine 
clearance of > 60 ml/min/1.73 m2. 
5) Patients with related donors must have a performance status > 60% (TJU 
Karnofsky14) (Appendix A). Patients with unrelated donors must have a 
Performance status > 70% (TJU Karnofsky). 

11D.51 Protocol v25.0 (22 December 2021) 
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6) Patients with related donors must have a HCT-CI Score15 < 6 Points (Appendix B). 
Patients with unrelated donors must have a HCT-CI Score < 5 Points. 
7) Patients must be willing to use contraception if they are of childbearing potential. 
8) Patients must be able to give informed consent or have a care-giver who can give 
consent. 
 
3.2 Patient Exclusion Criteria 
1) Patients with related donors who have a combination of Performance status of < 
70% (TJU Karnofsky) and an HCT-CI of 4 points or more. Patients with unrelated 
donors with a combination of Performance status of < 80% (TJU Karnofsky) and 
an HCT-CI of 4 points or more. 
2) Patients with active involvement of the central nervous system with malignancy. 
This can be documented as an abnormal neurological exam and/or a positive CSF 
analysis. 
3) Patients with a psychiatric disorder that would preclude patients from complying 
with the protocol even with a caregiver. 
4) Pregnancy 
5) Patients with life expectancy of < 6 months for reasons other than their underlying 
hematological/oncological disorder. 
6) Patients who have received alemtuzumab or ATG within 8 weeks of the transplant 
admission. 
 
7) Patients with evidence of another malignancy, exclusive of a skin cancer that 
requires only local treatment, should not be enrolled on this protocol. 
 
8) Patients with clinically significant preformed antibodies to their donors. 
9) Patients who require supplemental oxygen other than for sleep apnea will be 
excluded. 
 
4.0      Informed Consent 
Patients referred for the trial will have their eligibility criteria verified. On meeting the 
eligibility for the trial as outlined, informed consent will be obtained using forms approved 
by the Thomas Jefferson University Hospital Institutional Review Board and following 
guidelines related to the use of human subjects in research. The risks and hazards of the 
procedure, as well as alternative forms of therapy will be presented to the patient in detail. 
In addition, donors will be asked to sign a consent form after they have been fully informed 
about the procedures and risks of donating. Patients will receive a signed copy of the 
consent form after the consent interview. 
 
5.0 
Treatment Plan 
While the days of radiation and drug administration are fixed, the exact timing of these 
treatments on the day they are due is not specified because of expected variations in 
clinical care. 
 
Schema For Myeloablative HSCT 
-3 
-2 
-1 
0 
+1 
+2 
+3 
+4 
+5 

11D.51 Protocol v25.0 (22 December 2021) 
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AM 
TBI 
1.5 Gy 
TBI 
1.5 Gy 
TBI 
1.5 Gy 
TBI 
1.5 Gy 
Rest 
Rest 
Cy 60 
mg/kg 
Cy 60 
mg/kg 
Tacrolimus 
&MMF* 
PM 
TBI 
1.5 Gy 
TBI 
1.5 Gy 
TBI 
1.5 Gy 
TBI 
1.5 Gy 
HSCT 
 
Schema For Reduced Intensity HSCT** 
 
 
-5 
-4 
-3 
-2 
-1 
0 
+1 
+2 
+3 
+4 
+5 
AM 
Fludarabine 
30 
mg/m2 
Fludarabine 
30 
mg/m2 
Fludarabine 
30 
mg/m2 
Fludarabine 
30 
mg/m2 
Rest 
TBI 
2 Gy 
Rest 
Rest 
Cy 60 
mg/kg 
Cy 60 
mg/kg 
Tacrolimus & 
MMF* 
PM 
Busulfan 
3.2 mg/kg 
Busulfan 
3.2 mg/kg 
HSCT 
*Mycophenolate Mofetil (MMF) 
**Patients will receive ablative transplants or nonmyeloablative transplant depending on their disease type 
(per TJU standard practice guidelines). Patients who have received a previous transplant, patients who have 
received dose limiting radiation, and patients with a DLCO <45% will receive the reduced intensity 
conditioning regimen. The cyclophosphamide will be administered on days +3 and +4 after the stem cell 
infusion. 
 
5.1 Administration of Immunosuppressive Agents during Conditioning 
There should be no administration of agents that suppress lymphocyte reactivity from 
admission until day -1 in this protocol. This includes steroids, calcineurin inhibitors, MMF, 
or monoclonal antibodies that affect lymphocyte number or function. Absence from the 
medication list of these agents serves as documentation that they were not given. Patients 
must be off steroids (aside from premedication for transfusion) for at least 7 days prior to 
admission. If patients have previously required steroids as a premedication for transfusion, 
they may receive a dose of steroid equivalent to 5 mg of prednisone on the first day of TBI. 
After this, no steroids at all should be given through day -1 of the transplant regimen. 
Diphenhydramine and meperidine may be used if necessary. Any use of steroids after the 
first day of TBI through day -1 should not be administered without approval from the PI. 
 
6.0 
Study Measurements 
The tables below outline the measurements and time points specific to this study. Only 
the day +28 studies are mandatory. The other elements are recommended. The attending 
physican may perform assessments/labs more or less frequently based on the patient’s 
unique course. 
 
General Testing for all patients: 

11D.51 Protocol v25.0 (22 December 2021) 
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Baseline 
assessment 
During 
conditioning 
After 
Condition 
-ing 
through 
Day + 28 
Days 28-90 
Days 90- 
180 
Day 180 
Days 180- 
365 
History and 
physical with vital 
signs, including 
SPO2. 
Assessment of 
infectious signs, 
pregnancy test 
for females of 
childbearing 
potential done on 
baseline 
assessment 
X 
Every 1-2 
days 
Daily if in 
hospital 
weekly 
until day 
28 after 
discharge 
Monthly 
As 
clinically 
indicated 
As clinically 
indicated 
Laboratory 
Studies* 
X 
Every 1-2 
days 
Daily if in 
hospital 
weekly 
until day 
28 after 
discharge 
Twice 
monthly or 
as clinically 
indicated 
As 
clinically 
indicated 
As 
clinically 
indicated 
Quantitative 
cytomegalovirus 
CMV by 
polymerase chain 
reaction PCR 
Weekly or as 
clinically 
indicated 
Weekly 
until 
discharge 
or as 
clinically 
indicated 
Twice 
monthly or 
as clinically 
indicated 
As 
clinically 
indicated 
Monthly or 
as clinically 
indicated 
Viral throat 
gargle/sputum 
culture and 
sensitivity C&S 
If respiratory 
symptoms 
If 
respiratory 
symptoms 
If 
respiratory 
symptoms 
If respiratory 
symptoms 
If respiratory 
symptoms 
Stool culture (cx), 
viral screening & 
cx & fungal cx 
If clinically 
indicated 
If clinically 
indicated 
If clinically 
indicated 
If clinically 
indicated 
If clinically 
indicated 
If clinically 
indicated 

11D.51 Protocol v25.0 (22 December 2021) 
12 
 
Study specific testing for patients on Non-Myeloablative Arm: 
 
Baseline 
assessment 
During 
condition- 
ing 
Day + 
28 
Days 28-90 
Days 90- 
180 
Day 180 
Days 180- 
365 
GVHD Assessment 
Presence and 
degree of skin 
rash, presence 
and amount of 
diarrhea, LFT’s 
N/A 
Daily after 
engraftment 
until 
discharge 
and then 
weekly as 
indicated 
X 
Twice 
monthly 
As 
clinically 
indicated 
As 
clinically 
indicated 
Chimerism/ 
Disease 
Assessment 
Peripheral blood for 
CD3+ chimerism & 
Buffy coat 
chimerism 
X 
Twice 
monthly until 
>95% donor 
chimerism 
Once d+90 
X 
As clinically 
indicated 
Bone marrow exam 
(morphology, flow 
cytometry, 
cytogenetics, buffy 
coat chimerism) 
X 
Day +90 
Marrow 
Day +180 
Marrow 
Is optional 
Day +270 
Marrow 
Is optional 
Day +365 
Marrow 
Is optional 
Immune 
Reconstitution 
Studies 
Flow cytometry 
for lymphocyte 
subsets 
X 
Monthly 
Monthly 
X 
Quarterly 
 
 
Study specific testing for patients on the Myleoablative Arm: 
 
Day + 28 
Day + 90 
 
Day +180 
Day + 270 
 
Day +365 
GVHD Assessment 
Presence and degree of 
skin rash, presence and 
amount of diarrhea, 
LFT’s 
X 
X 
 
X 
X 
 
X 
Chimerism/ 
Disease Assessment 

11D.51 Protocol v25.0 (22 December 2021) 
13 
 
Peripheral blood for 
Total, MNC & CD3+ 
chimerism 
X 
X 
X 
X 
X 
Bone marrow exam 
(morphology, flow 
cytometry, 
cytogenetics, 
chimerism) 
On day 
+28 
At day 
+90 
Day +180 
Marrow is 
optional 
Day +270 Marrow 
is optional 
Day +365 
Marrow is 
optional 
Flow cytometry for 
lymphocyte subsets 
(IRP) 
X 
X 
X 
X 
X 
*Laboratory studies include a complete blood count with differential, comprehensive metabolic 
panel, lactic and GVHD prophylaxis drug levels when applicable. 
 
The day +28 peripheral blood, marrow studies and IRP can be obtained within 1 week before day 
28 (i.e. day +21 through day +28) and within 2 weeks after day +28 (i.e. day +28 through day 
+42) to account for scheduling factors and failed testing. 
Other post transplant studies (d+90, d+180, d+270, d+365) should be performed within one 
month of their due date. 
 
6.1 Hematopoietic engraftment: 
Will be defined as: 
ANC ≥ 0.5x10e9/L for at least 3 days. 
Platelet engraftment >20,000 with no transfusions X 7 days. 
 
6.2 Toxicity Criteria: 
Regimen-related toxicity will be graded according to the NCI Common Toxicity 
Criteria, version 4.0. These criteria can be found on the Thomas Jefferson University 
Hospital BMT website at http://bmt.tju.edu 
The NCI Common Toxicity Criteria can also be found at the following website: 
http://ctep.cancer.gov/reporting/ctcnew.html 
 
6.3 Disease Response: 
Disease response will be measured according to the National Comprehensive Cancer 
Network Guidelines (NCCN). The guidelines are disease specific and the guidelines for 
each disease can be found at: 
http://www.nccn.org/professionals/physician_gls/f_guidelines.asp#site 
 
6.4 GVHD Scoring: 
Acute GVHD will be staged and graded according to standard criteria contained in 
Appendix D. 
 
6.5 Adverse event reporting: 
All patients will be followed for adverse events (AEs) (serious and nonserious), 
regardless of relationships to study treatment, from the time of enrollment until d +100 

11D.51 Protocol v25.0 (22 December 2021) 
14 
 
after transplant. The following events are expected side effects of high-dose 
chemotherapy and transplant and will be recorded but will not be reported except as 
noted: 
 
Alopecia, dry skin 
 
Emesis from chemotherapy or other agents unless refractory to standard supportive care, 
nausea and anorexia 
 
Weight loss, cough, dry mouth and headache 
 
Neutropenia/uncomplicated neutropenic fever, grades 1-3 infectious sequellae 
 
Thrombocytopenia, petechiae, ecchymoses, minor vaginal bleeding, epistaxis, 
hemorrhoidal bleeding, or other similar bleeding eventsill not be reported. (Bleeding 
events requiring transfusion and/or intervention such as endoscopy or radiologic 
evaluation will be reported.) 
 
Anemia 
 
Grades 1-3 electrolyte imbalances 
 
Grades 1-3 abnormalities in alkaline phosphatase, AST and ALT 
Grades 1-3 Rash 
Grades 1-3 Fatigue 
Grade I - III Mucositis 
Grade I - III Diarrhea 
Allergic or other common reactions to drugs used for supportive care unless grade 4-5. 
 
After d+100, only SAEs that are considered by the investigator to be possibly or probably 
associated with the treatment regimen or deaths will be reported. 
 
6.6 Study Endpoint: 
The primary endpoint of this study is percentage of patients who engraft. 
 
This study is eligible for final closure when the last enrolled patient is three months post 
transplant. 
 
7.0 
Supportive Care 
7.1 Avoidance of Infection 

11D.51 Protocol v25.0 (22 December 2021) 
15 
 
Patients who are post HSCT are susceptible to infection. BMT Clinical Program SOPs 
CP:P050.01 and CP:P001.04 address infectious prophylaxis and management of suspected 
infection. 
 
It is recommended that IVIG 0.5 g/kg IV will be administered monthly post transplant to 
support immune function, until the IgG level is ≥ 500 mg/dL (“trough” level) on two 
consecutive monthly measurements. The first dose will be targeted for administration on 
day +13. It is recognized that fluid overload, changes in renal function, or outpatient lack 
of coverage for the IVIG may prohibit or delay this therapy. 
 
7.2 Infectious Prophylaxis-General Guidelines 
Patients post allogeneic transplantation will be maintained on antifungal prophylaxis. It is 
at the discretion of the treating attending physician and/or BMT clinical pharmacist to 
change agents as clinically indicated. 
 
Patients post allogeneic transplantation will be maintained on HSV prophylaxis. It is at the 
discretion of the treating attending physician and/or BMT clinical pharmacist to change 
agents based on culture results and sensitivities. 
 
Patients post allogeneic transplantation will be maintained on PCP prophylaxis. It is at the 
discretion of the treating attending physician and/or BMT clinical pharmacist to change 
agents based on culture results or drug intolerance. 
 
Specific medications and dosages of prophylactic antibiotics may change in response to 
changes in standard practice guidelines.  These agents will be discontinued with adequate 
immune recovery/response to vaccinations at the discretion of the treating BMT physician. 
 
7.3 Growth Factor and Transfusion Support 
To prevent inadvertent 3rd party lymphoid engraftment, all mature blood cell products 
must be irradiated. 
G-CSF 5μg/m2 can be substituted for GMCSF in the event of a GM-CSF shortage or if a 
patient has a deleterious reaction to GMCSF as determined by the BMTU attending 
physician. 
 
All red cell and platelet products will be leukodepleted to prevent alloimmunization and 
decrease the possibility of infectious complications. 
 
Packed red blood cell transfusions will be given as necessary to keep the hemoglobin ≥ 8 
g/L. A higher hemoglobin (≈10) will be maintained during cyclophosphamide 
administration per TJU BMT program guidelines. 
 
Platelet transfusions will be used as needed to keep the morning count ≥ 20x10e9/L, with 
≥10x10e9/L used for situations without an excessive bleeding risk. 

11D.51 Protocol v25.0 (22 December 2021) 
16 
 
GM-CSF 250µg/m2 will be administered daily beginning on day +5. GM-CSF will be 
weaned/discontinued at the discretion of the attending physician. Every effort should be 
made to keep the ANC ≥ 1000 for all patients post transplantation. 
 
Red cell growth factors are permissible after transplantation. 
 
8.0 
Drug Information and Administration 
(Note TBI will be given as described in Appendix C) 
 
8.1 Cyclophosphamide 
Mechanism: A multistep process activates it by conversion to 4- 
hydroxycyclophosphamide by the liver microsomal oxidase system and to 
aldophosohamide by tautomerization in the peripheral tissues. Aldophosphamide 
spontaneously degrades into acrolein and phosporamide mustard, which cause cellular 
glutathione depletion and DNA alkylation. This results in inhibition of DNA replication 
and transcription. Cells expressing high levels of aldehyde dehydrogenase (e.g. stem 
cells, L1210 leukemia cells) resist cyclophosphamide-mediated cytotoxicity as 
aldophosphamide is inactivated by this enzyme. The drug also does not affect quiescent 
cells and therefore stem cells are generally protected, an important factor if autologous 
hematopoietic recovery is relied on in the event of graft failure. 
 
Metabolism: Cyclophosphamide is broken down as described above and the break-down 
products are excreted by the kidneys. 
 
Incompatibilties: Phenobarbital or rifampin may increase the toxicity of 
cyclophosphamide. Concurrent allopurinol (administered only if the patient has a high 
tumor burden going into transplant which is unlikely on this study or on it to prevent 
gout) or thiazide diuretics may exaggerate bone marrow depression May prolong 
neuromuscular blockade from succinylcholine Cardiotoxicity may be additive with other 
cardiotoxic agents ( cytarabine, daunorubicin, doxorubicin). The drug may decrease 
serum digoxin levels. Additive bone marrow depression with other antineoplastics or 
radiation therapy can occur. It may potentiate the effects of warfarin. May decrease 
antibody response to live-virus vaccines and increase the risk of adverse reactions. It 
prolongs the effects of cocaine. 
 
Toxicity: Nausea, vomiting, water retention due to inappropriate secretion of anti- 
diuretic hormone (SIADH), cardiomyopathy with myocardial necrosis and congestive 
heart failure, hemorrhagic cystitis, alopecia, skin rash, pulmonary fibrosis, sterility and 
secondary malignancies. 
 
Administration: In this protocol, patients will receive two doses of cyclophosphamide 60 
mg/kg IV, on days +3 and +4. The dose of cyclophosphamide will be calculated 
according to the dosing body weight. MESNA (sodium-2-mercaptoethane sulfonate) will 
be administered prior to cyclophosphamide infusion and ending approximately 24 hours 
after the last dose of cyclophosphamide. The dose of MESNA will also be calculated 
based on dosing body weight. 

11D.51 Protocol v25.0 (22 December 2021) 
17 
 
 
 
Reference: Skeel R & Lachant N. Handbook of Cancer Chemotherapy, 4th Ed. Little, 
Brown & Co.: Boston. 
 
8.2 Busulfan 
Mechanism: Busulfan is an alkylating agent which reacts with the N-7 position of 
guanosine and interferes with DNA replication and transcription of RNA. Busulfan has a 
more marked effect on myeloid cells than on lymphoid cells and is also very toxic to 
hematopoietic stem cells. Busulfan exhibits little immunosuppressive activity, and 
therefore in this protocol is given with fludarabine and TBI both of which have 
lymphopenic affects. Busulfan interferes with the normal function of DNA by alkylation 
and cross-linking the strands of DNA. 
 
Metabolism: Extensively hepatic; glutathione conjugation followed by oxidation 
Incompatibilties: Busulfan does not have an extensive list of medications that cause 
problematic interactions. However, there are a few drugs, commonly used with Busulfan 
that may affect its metabolism. Phenytoin may decrease the serum concentration of 
Busulfan and Azoles may decrease the metabolism of Busulfan. Acetominophen and 
Metronidazole may increase the serum concentration of Busulfan. 
 
Toxicity: Side effects of Busulfan include but are not limited to: tachycardia, hypertension, 
insomnia, 
anxiety, 
headache, 
fever, 
vomiting, 
mucositis, 
diarrhea, 
anorexia, 
myelosupression, hyperbilirubinemia, VOD, weakness, and arthralgias. 
 
Administration: Busulfan is administered for 2 days on days -4 and -3 at a dose of 3.2 
mg/kg/day IV. The infusion can be started upon the completion of the fludarabine. 
 
Reference: 
http://online.lexi.com.proxy1.lib.tju.edu/lco/action/doc/retrieve/docid/patch_f/6487#f_ad 
verse-reactions 
 
 
8.3 Fludarabine 
Mechanism: Fludarabine phosphate is fluorinated nucleotide and analog of antiviral agent 
vidarabine, that is relatively resistant to adenosine deaminase deamination. It is actively 
dephosphorylated to 2-fluoro-ara-A and phosphorylated further by deoxycytidine kinase 
to 2-fluoro-ara-ATP, then acts by inhibiting DNA polymerase alpha, ribonucleotide 
reductase and DNA primase resulting in DNA synthesis inhibition. 
 
Metabolism: Renal Excretion 
In a pharmacokinetic study of patients treated with fludarabine for rheumatoid arthritis, 
the mean total clearance was 14.01 L/hr following a dose of 20 mg/m(2)/day, and 13.4 L 
following a dose of 30 mg/m(2)/day (Knebel et al, 1998). The median total body 
clearance was 9.6 L/hr after intravenous or subcutaneous fludarabine 30 mg/m(2) for 3 
days in 5 patients with lupus nephritis (Kuo et al, 2001). 

11D.51 Protocol v25.0 (22 December 2021) 
18 
 
 
Incompatibilities: Fludarabine has drug interactions with several vaccines and its 
simultaneous use with Rotavirus vaccine is contraindicated. 
 
Toxicities: Common: Endocrine/Metabolic: Shivering, Gastrointestinal: Loss of Appetite, 
Nausea, Vomiting, Neurologic: Asthenia, Other: Fatigue, Malaise, Serious: 
Cardiovascular: Edema (frequent), Dermatologic: Aplasia of skin (rare), Hematologic: 
Autoimmune Hemolytic Anemia, Graft versus host disease, Transfusion-associated, with 
non-irradiated blood (rare), Myelosuppression (frequent), Neurologic: Neurotoxicity, 
Respiratory: Pneumonia (frequent), Other side effects: Fever (frequent), infections. 
 
Administration: In this protocol, Fludarabine is administered for 4 days on days -5 
through – 2 at a dose of 30 mg/m2 IV daily. Creatinine should be checked prior to each 
dose of fludarabine. If renal insufficiency develops, the attending physician must be 
notified in cases where a dose adjustment needs to be made. 
 
Reference: MicroMedex Health Care Series, Thomson 
 
8.4 G-CSF 
Mechanism: G-CSF is a human granulocyte colony-stimulating factor produced by 
recombinant DNA technology. It is a glycoprotein which acts on hematopoietic cells by 
binding to specific cell surface receptors and stimulating proliferation, differentiation, 
commitment, and some end-cell functions. 
 
Metabolism: Absorption and clearance of G-CSF follows first-order pharmacokinetic 
modeling without apparent concentration dependence. The elimination half-life in both 
normal and cancer patients is 3.5 hours. 
 
Incompatibilties: Safety and efficacy of G-CSF when used simultaneously with 
chemotherapy or radiotherapy has not been evaluated. Donors receiving either of these 2 
modalities will not be permitted on study. 
 
Toxicities: Allergic reactions consisting of rash, wheezing and tachycardia. Splenic 
rupture, ARDS, and exacerbation of sickle cell disease have been reported rarely. 
 
Administration: In this protocol, G-CSF will be administered to healthy donors at a dose 
of 10 µg/kg (actual weight) subcutaneously on days -5 through day -1. 
 
Reference: Physician’s Desk Reference, Edition 58, 2004. 
 
8.5 GM-CSF 
Mechanism: GM-CSF is a recombinant human granulocyte-colony stimulating factor 
produced by recombinant DNA technology in a yeast expression system. It supports 
survival, clonal expansion, and differentiation of hematopoietic cells. GM-CSF is also 
capable of activating mature granulocytes and macrophages, and is a multilineage factor 
with effects on the myelomonocytic, erythroid, and megarkaryocytic lines. 

11D.51 Protocol v25.0 (22 December 2021) 
19 
 
 
Metabolism: GM-CSF is detected in the serum at 15 minutes after injection. Peak levels 
occur about 1 to 3 hours after injection, and it is detectable in the serum for up to 6 hours 
after injection. 
 
Incompatibilities: Interactions between GM-CSF and other drugs have not been fully 
evaluated. Drugs which may potentiate the myeloproliferative effects of GM-CSF, such 
as lithium and corticosteroids, should be used with caution. 
 
Toxicities: Allergic and anaphylactic reactions have been reported. A syndrome 
characterized by respiratory distress, hypoxia, flushing, hypotension, syncope and or 
tachycardia has been associated with the first administration of GM-CSF in a cycle. 
These signs have resolved with treatment. 
 
Administration: In this protocol, GM-CSF will be given to the patients beginning on Day 
+5 in the PM. 
 
Reference: Physician’s Desk Reference, Edition 58, 2004. 
 
8.6 Mycophenolate Mofetil (MMF) 
Mechanism: Inhibits the enzyme inosine monophosphate dehydrogenase, which is 
involved in purine synthesis. This inhibition results in suppression of T- and B- 
lymphocyte proliferation. 
 
Metabolism: Following oral and IV administration, mycophenolate is rapidly hydrolyzed 
to mycophenolic acid (MPA), its active metabolite. Distribution is unknown. MPA is 
extensively metabolized; <1% excreted unchanged in urine. Some enterohepatic 
recirculation of MPA occurs. Half Life: MPA¾17.9 hr. 
 
Incompatibilities: Combined use with azathioprine is not recommended (effects 
unknown). Acyclovir and ganciclovir compete with MPA for renal excretion and, in 
patients with renal failure, may increase each other's toxicity. Magnesium and aluminum 
hydroxide antacids decrease the absorption of MPA (avoid simultaneous administration). 
Cholestyramine and colestipol decrease the absorption of MPA (avoid concurrent use). 
Toxicity may be increased by salicylates. May interfere with the action of oral 
contraceptives (additional contraceptive method should be used). May decrease the 
antibody response to and increase risk of adverse reactions from live-virus vaccines, 
although influenza vaccine may be useful. When administered with food, peak blood 
levels of MPA are significantly decreased. MPA trough levels (goal 2-4 μg/ml) will be 
measured on day +7 and dose adjusted accordingly. 
 
Toxicities: GI: Bleeding, Diarrhea, Vomiting, Hematopoietic: Leukopenia Miscellaneous: 
Sepsis, Increased Risk of Malignancy 
 
Administration: In this protocol, MMF will be administered at a dose of 1 gram IV BID 
beginning on day +5. MMF will be discontinued on day +28 +/- 3 days in the absence of 

11D.51 Protocol v25.0 (22 December 2021) 
20 
 
GVHD. MMF may be stopped earlier if there is count suppression from the drug or other 
unforeseen circumstances in which the drug is felt to be deleterious to the plan of care. 
 
8.7 Tacrolimus 
Mechanism: Tacrolimus, it is a macrolide immunosuppressant. It inhibits lymphocytes by 
forming a complex with FKBP-12, calcium, calmodulin leading to the decrease in the 
phosphatase activity of calcineurin. This in turn prevents generation of NF-AT, a nuclear 
factor for initiating gene transcription for lymphokines like interleukin-2 and interferon. 
This drug is used with corticosteroids for prophylaxis of organ rejection in patients 
receiving allogeneic liver transplants. Its use is also currently being investigated in 
kidney, bone marrow, cardiac, pancreas, pancreatic island cell and small bowel 
transplantation. 
 
Metabolism: This drug is well absorbed orally. It is metabolized in the liver by unknown 
mechanisms and demethylation and hydroxylation has been proposed based on in vitro 
studies. The metabolized products are excreted in the urine. 
 
Incompatibilities: Nephrotoxic drugs, antifungals (azoles), calcium-channel blockers, 
cimetidine, danazol, erythromycin, methylprednisone and metoclopramide increase the 
bioavailabilty of tacrolimus. On the other hand phenobarbital, phenytoin, rifamycins and 
carbamazepine decrease tacrolimus levels. 
 
Toxicities: Adverse reactions include: tremor, headache, neurotoxicity; diarrhea, nausea; 
hypertension; TTP and renal dysfunction. 
 
Administration: Tacrolimus will be started on day +5. Tacrolimus dosing should be 
titrated to maintain a target level of 8ng/ml +/- 2, although it is recognized that there may 
be variations beyond the target range due to interpatient variability. The tacrolimus wean 
can be initiated by day +60 in the absence of GVHD. Tacrolimus may be discontinued 
earlier if there is count suppression or other significant side effects thought to be due to 
the drug. Because of the variability in patient outpatient office visit times and need for 
GVHD assessment, it is not mandatory that the taper begins on day +60. 
 
9.0 
Evaluation of Safety 
 
Specification of Safety Parameters 
Unanticipated Problems 
Unanticipated problems (UAPs) include, in general, any incident, experience, or outcome 
that meets the following criteria: 
 
• unexpected in terms of nature, severity, or frequency given (a) the research 
procedures that are described in the protocol-related documents, such as the IRB- 
approved research protocol and informed consent document; and (b) the 
characteristics of the participant population being studied; 

11D.51 Protocol v25.0 (22 December 2021) 
21 
 
UAPs are considered to pose risk to participants or others when they suggest that the 
research places participants or others at a greater risk of harm (including physical, 
psychological, economic, or social harm) than was previously known or recognized. 
Adverse Events 
An adverse event is any untoward or unfavorable medical occurrence in a human 
participant, including any abnormal sign (for example, abnormal physical exam or 
laboratory finding), symptom, or disease, temporally associated with the participant’s 
participation in the research, whether or not considered related to the participant’s 
participation in the research. 
 
Serious Adverse Events 
A serious adverse event (SAE) is one that meets one or more of the following criteria: 
 
• Results in death 
• Is life-threatening (places the participant at immediate risk of death from the event 
as it occurred) 
• Is disabling or incapacitating 
• Results in inpatient hospitalization or prolongation of existing hospitalization 
• Results in a persistent or significant disability or incapacity 
• Results in a congenital anomaly or birth defect 
• An important medical event that may not result in death, be life threatening, or 
require hospitalization may be considered an SAE when, based upon appropriate 
medical judgment, the event may jeopardize the participant or may require 
intervention to prevent one of the outcomes listed in this definition. 
Safety Assessment and Follow-Up 
The PI will follow adverse events with start dates occurring any time after informed 
consent is obtained until 7 (for non-serious AEs) or 30 days (for SAEs) after the last day 
of study participation. At each study visit, the investigator (or designee) will inquire 
about the occurrence of AE/SAEs since the last visit. Events will be followed for 
outcome information until resolution or stabilization. 
 
Recording Adverse Events 
The following subsections detail what information must be documented for each adverse 
event occurring during the time period specified in Section 0 Safety Assessment and 
Follow-Up. 
 
Relationship to Study Intervention 

11D.51 Protocol v25.0 (22 December 2021) 
22 
 
The relationship to study intervention or study participation must be assessed and 
documented for all adverse events. Evaluation of relatedness must consider etiologies 
such as natural history of the underlying disease, concurrent illness, concomitant therapy, 
study-related procedures, accidents, and other external factors. 
 
The following guidelines are used to assess relationship of an event to study intervention: 
 
1. Related (Possible, Probable, Definite) 
 
a. The event is known to occur with the study intervention. 
 
b. There is a temporal relationship between the intervention and event onset. 
 
c. The event abates when the intervention is discontinued. 
 
d. The event reappears upon a re-challenge with the intervention. 
 
2. Not Related (Unlikely, Not Related) 
 
a. There is no temporal relationship between the intervention and event 
onset. 
 
b. An alternate etiology has been established. 
 
Expectedness 
The PI is responsible for determining whether an AE is expected or unexpected. An AE 
will be considered unexpected if the nature, severity, or frequency of the event is not 
consistent with the risk information previously described for the intervention. Risk 
information to assess expectedness can be obtained from preclinical studies, the 
investigator’s brochure, published medical literature, the protocol, or the informed 
consent document. 
 
Severity of Event 
Adverse events will be graded for severity according to the Common Terminology 
Criteria for Adverse Events (CTCAE) version 4.0 
 
Intervention 
Any intervention implemented to treat the adverse event must be documented for all 
adverse events. 
 
Safety Reporting 
Reporting to IRB 
 
Unanticipated Problems 

11D.51 Protocol v25.0 (22 December 2021) 
23 
 
All incidents or events that meet criteria for unanticipated problems (UAPs) as defined in 
Section 0 Unanticipated Problems require the creation and completion of an 
unanticipated problem report form (OHR-20). 
 
UAPs that pose risk to participants or others, and that are not AEs, will be submitted to 
the IRB on an OHR-20 form via the eazUP system within 5 working days of the 
investigator becoming aware of the event. 
 
UAPs that do not pose risk to participants or others will be submitted to the IRB at the 
next continuing review. 
 
Adverse Events 
Grade 1 AEs will be reported to the IRB at continuing review. 
 
Grade 2 AEs will be reported to the IRB at the time of continuing review. 
 
Serious Adverse Events 
SAEs will be reported to the IRB on OHR-10 forms via the electronic reporting system 
(eSAEy) according to the required time frames described below. 
 
Grade 3-4 AEs that are unexpected and deemed to be at least possibly related to the study 
will be reported to the IRB within 2 working days of knowledge of the event. 
 
Grade 3-4 AEs that are deemed unrelated to the study will be reported to the IRB within 
5 working days. 
 
Grade 5 AEs will be reported to the IRB within one working day of knowledge of the 
event. 
 
All SAEs will be submitted to the IRB at continuing review, including those that were 
reported previously. 
 
Reporting to SKCC DSMC 
All AEs and SAEs, safety and toxicity data, and any corrective actions will be submitted 
to the DSMC per the frequency described in the SKCC DSMP. The report to the SKCC 
DSMC will also include any unanticipated problems that in the opinion of the PI should 
be reported to the DSMC. 
 
For expedited reporting requirements, see table below: 
DSMC 
AE/SAE Reporting Requirements 

11D.51 Protocol v25.0 (22 December 2021) 
24 
 
 

11D.51 Protocol v25.0 (22 December 2021) 
25 
 
10.0 Study Oversight 
 
In addition to the PI’s responsibility for oversight, study oversight will be under the 
direction of the SKCC’s Data and Safety Monitoring Committee (DSMC). The SKCC 
DSMC operates in compliance with a Data and Safety Monitoring Plan (DSMP) that is 
approved by the NCI. 
 
11.0 Clinical Site Monitoring and Auditing 
 
Clinical site monitoring and auditing is conducted to ensure that the rights of human 
participants are protected, that the study is implemented in accordance with the protocol 
and/or other operating procedures, and that the quality and integrity of study data and 
data collection methods are maintained. Monitoring and auditing for this study will be 
performed in accordance with the SKCC’s Data and Safety Monitoring Plan (DSMP) 
developed by the SKCC Data and Safety Monitoring Committee (DSMC). The DSMP 
specifies the frequency of monitoring, monitoring procedures, the level of clinical site 
monitoring activities (e.g., the percentage of participant data to be reviewed), and the 
distribution of monitoring reports. Some monitoring activities may be performed 
remotely, while others will take place at the study site(s). Appropriate staff will conduct 
monitoring activities and provide reports of the findings and associated action items in 
accordance with the details described in the SKCC DSMP. 
 
12.0 
Statistical Analyses 
12.1 Study Design 
This study is a two arm single center study. The first arm will recruit 18 (13+5) patients 
with related donors and will utilize the Simon optimal two-stage design. The total of 13 
patients with half-matched related donors will be recruited and included in the analysis 
population. Approximately five additional patients with related donors other than 
haploidentical will be included in the study but will only be analyzed descriptively. The 
second arm will recruit three to 23 patients with unrelated donors using the standard two- 
stage accrual design ("3+3 design") typically used for dose escalation studies. For the 
purpose of this study, the number of antigen mismatches (0 to 2) is analogous to the 
escalating dose. 
 
The primary endpoint is the percentage of patients who engraft. The secondary endpoints 
are the incidence of grade III-IV GVHD and the incidence of GVHD nonresponsive to 
corticosteroids and photopheresis. The study is designed to evaluate the primary and 
secondary endpoints separately in each arm, and there is no plan to compare the outcomes 
in two arms. The data from each arm will be analyzed separately. Within each arm there 
will be two subgroups of patients, one receiving a reduced intensity conditioning regimen 
and one receiving a myeloablative transplant. The treatment will depend on the disease 
type (per TJU standard practice guidelines). 

11D.51 Protocol v25.0 (22 December 2021) 
26 
 
We will compute the exact 90% bimonial confidence interval for the rejection rate in the 
2 antigen mismatched based on at least 10 patients. If zero rejections are observed in 10 
patients, there will be 90% confidence that the true rejection rate is at most 26% (upper 
limit of exact binomial confidence interval). Otherwise, if 1 rejection is observed in 10 
patients, there will be 90% confidence that the true rejection rate is at most 39.4%.  
 
12.2 Design and statistical analysis of the arm with related donors 
The majority of the patients in this arm will be patients with half-matched related donors. 
Only these patients will be included into analysis population to evaluate the primary and 
secondary endpoints. The total sample size of 13 patients was determined for the half- 
match related donors only. Approximately five patients with related donors other than 
haploidentical will be included in the study but not analyzed jointly with the analysis 
population of patients with haploidentical donors. 
 
The Simon optimal two-stage design16 is used with the potential for early termination in 
case of a poor engraftment rate. Choice of design is guided by a desire to stop the trial early 
if the actual engraftment rate is 65% or less. If the successful engraftment rate is 90% or 
greater, we would like to have a low probability of failing to conclude the treatment 
effective. The target Type I error rate is 10% and the target power is 80%. 
 
The Simon optimal two-stage design is: 
Look after this 
Stop if number of 
number of patients 
successes is less than 
6 
 
5 
13 
11 
 
With this design, we have no more than 18% chance of concluding ineffective (≤65% 
success rate) when the successful engraftment rate is at least 90%. Similarly, we have no 
more than 9.7% chance of concluding effective (≥90% successful engraftment rate) when 
it is ineffective. If the actual engraftment rate is 65% or worse, we have at least 68% 
probability that the trial will stop after the first 6 subjects. 
 
The estimates of the engraftment and incidence rates will be presented with corresponding 
90% binomial confidence intervals. For engraftment rates, the method of Atkinson and 
Brown17 will be used to allow for the two-stage design. In secondary analysis, we will 
evaluate the engraftment rate by treatment group (ablative versus nonmyeloablative group), 
provided that both groups have non-trivial number of patients, and evaluate any possible 
treatment differences in engraftment rates using Fisher's exact test. This analysis is 
exploratory and adjustment for two-stage design is not planned. For incidence rates, one- 
sided exact binomial confidence interval will be computed. If no events of grade III-IV 
GVHD or GVHD nonresponsive to corticosteroids and photopheresis are observed in 13 
patients, we will have 90% confidence that the true incidence rate is at most 16%. 
 
12.3 Design and statistical analysis of the arm with unrelated donors 
For the second arm, we will use a two-stage accrual design for each number of the antigen 
mismatches considered (0, 1, or 2). We will transplant three patients with full one antigen 

11D.51 Protocol v25.0 (22 December 2021) 
27 
 
mismatched unrelated donors (either on or off study). If none of the three fails to engraft 
i.e., all three engraft then we will proceed with recruitment of patients with unrelated 
donors who are a two antigen mismatch. If one patient of the first three fails to engraft, 
then an additional three patients will be recruited with fully HLA matched unrelated 
donors. If a second patient of the first six with one antigen mismatched donors fails to 
engraft then the study for this arm will be closed to patient with only mismatched unrelated 
donors. If five of the first six engraft then we will recruit patients with unrelated donors 
who are a two antigen mismatch. If at any time there are two or more patients with the 
same number of antigen mismatches fail to engraft, then there will be no further recruitment 
of patients with that or higher number of antigen mismatches. Data analysis of this arm is 
descriptive. All estimates of engraftment and incidence rates will be presented with 
corresponding confidence intervals using the exact method. 
 
12.4 Accrual and Study Duration 
It is estimated that 126 month of accrual will be necessary to enroll 23 patients with 
unrelated donors and 18 patients with related donors at the approximate rate of six 
patients per year. Up to ten additional patients will be accrued to the study in either 
cohort,, at the approximate rate of 2-3 patients per year. Patients will be followed for a 
minimum of 3 months post-transplant. 
 
As of March 2017, the related arm is closed and will no longer accrue patients. An 
additional 30 patients will be enrolled onto the mismatched arm of this trial. Of these 30 
patients, up to 10 will be accrued to the 2 antigen mismatch arm. The trial will stop 
accruing when the enrollment total of 81 has been reached. 
 
Patients who are enrolled on the study but do not receive treatment will be considered 
inevaluable and will be replaced. 
 
13.0 
References 
 
1. Thomas’ Hematopoietic Cell Transplantation 3rd edition. Malden, MA: 
Blackwell Publishing; 2004. 
 
2. Giralt, S. et al. Engraftment of allogeneic hematopoietic progenitor cells with 
purine analog-containing chemotherapy: harnessing graft-versus-leukemia 
without myeloablative therapy. Blood 89: 4531-4536, 1997. 
 
3. Bacigalupo, A. et al. Donor lymphocyte infusions (DLI) in patients with 
chronic myeloid leukemia following allogeneic bone marrow transplantation. 
Bone Marrow Transplant. 19: 927-932, 1997. 
 
4. Fefer A, Sullivan KM, Weiden P, Buckner CD, Schoch G, Storb R, Thomas 
ED. Graft versus leukemia effect in man: the relapse rate of acute leukemia is 
lower after allogeneic than after syngeneic marrow transplantation. Prog Clin 
Biol Res 244: 401-408, 1987. 

11D.51 Protocol v25.0 (22 December 2021) 
28 
 
5. O'Donnell, P. V. et al. Nonmyeloablative bone marrow transplantation from 
partially HLA-mismatched related donors using posttransplantation 
cyclophosphamide. Biology of Blood & Marrow Transplantation. 8: 377-386, 
2002. 
 
6. Luznik, L. et al. HLA-haploidentical bone marrow transplantation for 
hematologic malignancies using nonmyeloablative conditioning and high- 
dose, posttransplantation cyclophosphamide. Biology of Blood & Marrow 
Transplantation 14: 641-650, 2008. 
 
7. Luznik L, Jalia S, Engstrom LW, Iannone R, Fuchs EJ. Durable engraftment of 
major histocompatibility complex-incompatible cells after nonmyeloablative 
conditioning with fludarabine, low-dose total bodyirradiation, and 
posttransplantation cyclophosphamide. Blood 98: 3456-3564: 2001. 
 
8. Mead AJ, Thomson KJ, Morris EC, Mohamedbhai S, Denovan S, Orti G, 
Fielding AK, Kottaridis PD, Hough R, Chakraverty R, Linch D, Mackinnon S, 
Peggs KS. HLA-mismatched unrelated donors are a viable alternate graft 
source for allogeneic transplantation following alemtuzumab-based reduced- 
intensity conditioning. Blood 115: 5147-5153, 2010. 
 
9.Grosso D, Carabasi M, Brunner J, Colombe B, Filicko-O’Hara J, Finnegan EC, 
Flomenberg P, Kasner M, Mookerjee B, O’Hara W, Tedesco-Garafano N, 
Wagner JL, Werner-Wasik M, Flomenberg N. A two step myeloablative 
approach to allogeneic hematopoietic stem cell transplantation (HSCT) for 
hematological malignancies from HLA partially-matched (haploidentical) 
related donors. Blood 114: 904, 2009. 
 
10. Lee SJ, Klein J, Haagenson M, et al. High resolution donor-recipient HLA 
matching contributes to the success of unrelated donor marrow transplantation. 
Blood 110: 4576-4583, 2007. 
 
11. Beatty PG, Boucher KM, Mori M, Milford EL. Probability of finding HLA- 
mismatched related or unrelated marrow or cord blood donors. Human 
Immunology 61: 834-840, 2000. 
 
12. Morishima Y, Sasazuki T, Inoko H, et al. The clinical significance of human 
leukocyte antigen (HLA) allele compatibility in patients receiving a marrow 
transplant from serologically HLA-A, HLA-B, and HLA-DR matched 
unrelated donors. Blood 99: 4200-4206, 2002. 
 
13. Kawase T, Morishima Y, Matsuoi K, et al. High-risk HLA allele mismatch 
combinations responsible for severe acute graft-versus-host disease and 
implication for its molecular mechanism. Blood 110: 2235-2241, 2007. 

11D.51 Protocol v25.0 (22 December 2021) 
29 
 
13A Hamandi M, Zhang M-J, Tang X-Y, et al. Graft cryopreservation does not 
impact overall survival after allogeneic hematopoietc cell transplantation 
using post-trnsplantation cyclophosphamide for graft-versus-host disease 
prophylaxis. Biology of Blodd and Marrow Transplantation (in press). 
 
14. Karnofsky, D., Abelamnn, W., Craver, L. & Burchenal, J. The Use of the 
Nitrogen Mustards in the Palliative Treatment of Carcinoma. Cancer 1: 634- 
656, 1948. 
 
15. Sorror, M. L. et al. Hematopoietic cell transplantation (HCT)-specific 
comorbidity index: a new tool for risk assessment before allogeneic HCT. 
Blood 106: 2912-2919, 2005. 
 
16. Simon R. Optimal Two-Stage Designs for Phase II Clinical Trials. Controlled 
Clinical Trials 10: 1-10, 1989. 
 
17. Atkinson EN, Brown BW. Confidence limits for probability of response in 
multistage phase II clinical trials. Biometrics 41: 741-4, 1985. 
 
18. Glucksberg H, Storb R, Fefer A, et al. Clinical manifestations of graft-versus- 
host disease in human recipients of marrow from HLA-matched sibling 
donors. Transplantation 18: 295-304, 1974. 
 
19. Kang EM, de Witte M, Malech H, et al. Non-myeloablative conditioning 
followed by transplantation of genetically modified HLA-matched peripheral 
blood stem cells for hematologic malignancies in patients with acquired 
immunodeficiency syndromes. Blood 99: 698-701, 2002. 
 
14.0 
Appendices 

11D.51 Protocol v25.0 (22 December 2021) 
30 
 
 
 
 
 
 
 
 
 
 
 
Appendix A 
Modified Karnofsky Performance Scale-Web Based Tool 
The modified KPS is a Web-based tool developed in our program that builds upon the 
original KPS.14 The tool was developed to characterize each patient’s performance status 
in more depth than what was possible with the original KPS in order to determine the 
suitability of the patient for transplant. The performance status is calculated based on the 
information entered into the program. At the following website: 
http://ser0608.kcc.tju.edu/transplant_check/karnofsky/summary.php 
 
The categories “Not on immune suppression” and “At home, not self sufficient” are not 
further subdivided. The other three categories subdivide into additional questions. An 
example this further characterization is given below for the “Self sufficient at home” 
category. 

11D.51 Protocol v25.0 (22 December 2021) 
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11D.51 Protocol v25.0 (22 December 2021) 
32 
 
Appendix B 
The Hematopoietic Cell Transplantation Comorbidity Index (HCT-CI)15 
 
Comorbidity 
Definitions of the 
Comorbidity 
HCT-CI 
Weighted 
Scores 
Arrhythmia 
Atrial Fibrillation/Flutter, Sick Sinus 
Syndrome, 
Or Ventricular Arrhythmias 
1 
Cardiac 
Coronary Artery Disease, CHF, MI 
Or EF < 50% 
1 
Inflammatory 
Bowel Disease 
Crohn Disease or 
Ulcerative Colitis 
1 
Diabetes 
Requiring Treatment with Insulin 
or Oral Agent but not Diet Alone 
1 
Cerebral Vascular 
Disease 
Transient Ischemic Attack or 
Cerebral Vascular Accident 
1 
Psychiatric 
Disturbance 
Depression or Anxiety Requiring 
Psychiatric Consult or Treatment 
1 
Hepatic-Mild 
Chronic Hepatitis, Bilirubin > ULN to 1.5 
X ULN 
Or AST/ALT > ULN to 2.5 X ULN 
1 
Obesity 
Patients with Body Mass Index > 35 kg/m2 
1 
Infection 
Requiring Continuation of Antimicrobial 
Treatment after Day 0 
1 
Rheumatologic 
SLE, RA, Polymyositis, Mixed CTD 
Or Polymyalgia Rheumatica 
2 
Peptic Ulcer 
Requiring Treatment 
2 
Moderate/Severe 
Renal 
Serum Creatinine > 2 mg/dL, on Dialysis, 
Or Prior Renal Transplantation 
2 
Moderate 
Pulmonary 
DLCO and/or FEV1 66%-80%, 
Or Dyspnea on Slight Activity 
2 
Prior Solid Tumor 
Treated at any Time Point in the Patient’s 
Past 
History, Excluding Nonmelanoma Skin 
Cancer 
3 
Heart Valve Disease 
Except Mitral Valve Prolapse 
3 
Severe Pulmonary 
DLCO and/or FEV1 < 65%, or Dyspnea 
At rest or Requiring Oxygen 
3 
Moderate/Severe 
Hepatic 
Liver Cirrhosis, Bilirubin > 1.5 X ULN, 
Or AST /ALT > 2.5 X ULN 
3 

11D.51 Protocol v25.0 (22 December 2021) 
33 
 
Appendix C 
Radiation Guidelines (For myeloablative regimen except as noted) 
Modality 
Photon irradiation is to be used for the TBI in all patients. Areas beneath lung blocks will 
be supplemented with electrons to maintain the homogeneity criteria. 
 
Energy 
Either a linear accelerator or Cobalt source may be used. Dose to superficial tissues near 
skin surface will be increased by using a beam “spoiler” lucite plate close to the patient. 
Since neoplastic infiltrates may be found in the skin, it is necessary for the superficial dose 
to satisfy the same total dose requirements as other locations. 
 
Geometry 
The treatment configuration shall be such that the patient is entirely included within the 
treatment beam. It is essential that the correlation between the light field and the radiation 
field be established and verified for extended TBI distances. 
 
Dose Rate 
A dose rate of 0.05 to 0.25 Gy/minute at the prescription point shall be utilized. The 
physicist of record, involved with TBI treatments, shall be consulted to achieve correct 
range of treatment dose rate. 
 
Calibration & Beam Data Verification 
The calibration of the output of the machine, used for this protocol, shall be verified on a 
daily basis prior to start TBI treatments. All dosimetric parameters, necessary for the 
calculation of dose delivered during TBI treatments, shall be measured at the appropriate 
treatment distance. They shall be documented and made available for calculation of every 
patient treatment. 
 
Treatment Volume 
The patient shall be entirely included within the treatment beam. Care should be taken to 
guarantee that all of the patient is within the 90% decrement line at each depth. The 90% 
decrement line is defined as the line in each plane perpendicular to the central axis 
connecting the points which are 90% of the central axis dose, in that plane. 
 
Diagnostic Determination 
CT scans through the chest and abdomen will be done prior to initiating irradiation. An 
average chest wall thickness (both anteriorly and posteriorly) will be calculated and used 
in determination of electron energy for supplementing the chest wall beneath the lung 
blocks. The abdominal scan, renal ultrasound, or intravenous pyelogram will be used to 
localize the kidneys for proper placement of renal shielding. 
 
Treatment Dose 
Prescription Point 
The prescription point is defined as the midplane point along the longitudinal axis at the 
level of the umbilicus. 

11D.51 Protocol v25.0 (22 December 2021) 
34 
 
Dose Units 
All doses shall be specified in Gray (Gy) to muscle tissue. 
 
Tissue Inhomogeneity Considerations 
No inhomogeneity corrections shall be made in the calculation of the dose to the 
prescription point. 
 
Prescription Point Dose 
The total dose shall be 12.0 Gy. A hyperfractionated regimen over 4 consecutive days shall 
be used. For the nonmyeloablative regimen a single dose of 2 Gy will be given. 
 
Time-Dose Considerations 
Hyperfractionation 
For patients receiving 2 fractions per day, there is a required minimum time interval of 6 
hours between the fractions. 
 
Chest Wall Supplement 
Supplementing the chest wall dose with electrons (both anteriorly and posteriorly) shall be 
done once a day on 2 treatment days, immediately preceding or following treatment to the 
entire body. The area beneath the lung blocks shall receive an additional 6.0 Gy to dmax in 
a total of 2 fractions. 
 
Total Number of Treatment Days 
There shall be a total 4 consecutive treatment days for the myeloablative regimen and one 
day for the nonmyeloablative regimen. 
 
Treatment Interruptions 
An interruption in the radiotherapy regimen shall not be allowed. 
 
Dose Homogeneity 
The total absorbed dose along the patient's head to toe axis (in the midplane of the patient) 
shall not deviate more than 10% from the prescribed dose. 
 
Treatment Technique 
Treatment Fields 
Equally weighted parallel opposed portals shall be used. AP/PA fields shall be used. 
 
Field Size 
The collimation and treatment distance shall be such that the patient will be entirely 
included within the treatment beam and that no part of the patient extends beyond that 
region. The agreement of the light field and the radiation field should be checked 
periodically for the extended TBI treatment distance. 
 
Treatment Position 
The patient shall be treated in any position that is compatible with the homogeneity 
requirement, allowing for the reproducibility of the patient setup and dosimetry. 

11D.51 Protocol v25.0 (22 December 2021) 
35 
 
Field Shaping 
Customized blocking to the lungs is required. Customized blocking to the liver and/or 
kidneys is optional, at the discretion of each participating center with the approval of the 
coordinating center radiation oncologist. 
 
Patient specific, individually fabricated shielding blocks are required for the lung from both 
the anterior and posterior directions. A partial transmission block corresponding to a total 
dose of 8.0 Gy at midplane of the patient under the blocks shall be used. No corrections for 
inhomogeneity shall be used. 
 
Patient specific, individually fabricated shielding blocks are optional for the liver from both 
the anterior and posterior directions. A partial transmission block corresponding to a dose 
reduction to 90% of the central axis dose shall be utilized. 
 
Patient specific, individually fabricated shielding blocks are optional for the kidneys from 
the posterior direction only. A partial transmission block yielding a total dose of 10.8 Gy 
to the midplane of the kidney shall be used. 
 
Customized electron cut-outs shall also be constructed corresponding to the size of the lung 
block plus appropriate margins in all directions. 
 
Superficial Tissue Supplement Technique 
The portion of the chest wall shielded by the partial transmission lung blocks will be 
supplemented with customized (or shaped) low energy electron fields. A total of 6.0 Gy to 
dmax in 2 fractions will be given to the anterior and posterior chest wall. Electron energy 
will be determined by chest wall thickness as determined by a chest CT scan, with the depth 
of the 90% dose relative to dmax used to determine the electron energy. The dose 
prescription point will be at dmax. 
Calculations 
Central Axis Dose 
It is recommended that the dose calculation method be based upon measurements that are 
made in a unit density phantom with the following minimum dimensions: 
Length equal to top of shoulder to the bottom of the pelvis. 
Width equal to the patient width at the level of the umbilicus. 
Thickness equal to the typical patient thickness at the umbilicus. 
All measurements should be made at the appropriate extended SSD. 
 
Superficial Dose 
For the radiation beam with the Plexiglas plate in place, data should be available 
demonstrating that the skin dose is within 5% of the prescribed dose. 
 
Normal Tissue Sparing-Lung Dose 
Lung Dose 
Each patient must have a calculation performed which shows that with the lung shielding 
and chest wall supplement, the TBI delivers between 9.0 Gy and 10.0 Gy to the mid-lung 

11D.51 Protocol v25.0 (22 December 2021) 
36 
 
region without inhomogeneity corrections. The calculation will be repeated using 
inhomogeneity corrections approved by the physicist at the coordinating center. 
 
Quality Assurance Documentation 
For purposes of quality assurance the following must be performed on every patient 
undergoing TBI: 
 
A check of the monitor unit calculation by a second physicist and a radiation oncologist 
prior to first treatment. 
 
Simulation films documenting lung, liver and kidney blocks in both the anterior and/or 
posterior projections shall be taken. 
 
Portal films (both AP & PA) verifying the position of the lung, liver and kidney blocks 
shall be taken and must be approved by the supervising radiation oncologist prior to 
delivery of the first 

11D.51 Protocol v25.0 (22 December 2021) 
37 
 
Appendix D 
Acute GVHD Staging and Grading18 
 
Clinical Staging of Acute Graft-Versus-Host Disease 
Stage 
Skin 
Liver 
Gut 
+ 
Maculopapular 
rash <25% of 
body surface 
Bilirubin 2-3 mg/dl 
Diarrhea 500-1000 ml/day or 
persistent nausea 
++ 
Maculopapular 
rash 25-50% of 
body surface 
Bilirubin 3-6 mg/dl 
Diarrhea 1000-1500 ml/day 
+++ 
Generalized 
erythroderma 
Bilirubin 6-15 mg/dl 
Diarrhea >1500 ml/day 
++++ 
Desquamation 
and bullae 
Bilirubin > 15mg/dl 
Pain +/- ileus 
 
 
Clinical Grading of Acute Graft-Versus-Host Disease 
Overall Grade 
Skin 
Liver 
Gut 
Functional 
Impairment 
0 (none) 
0 
0 
0 
0 
I (mild) 
+ to ++ 
0 
0 
0 
II (moderate) 
+ to +++ 
+ 
+ 
+ 
III (severe) 
++ to +++ 
++ to +++ 
++ to +++ 
++ 
IV (life- 
threatening) 
++ to ++++ 
++ to ++++ 
++ to ++++ 
+++