A Multi-centre Phase I/II Trial of Granulocyte-augmented Cord Blood Transplantation for Young Adults With Very Poor Risk Acute Myeloid Leukaemia.
Phase: PHASE1
Conditions: Acute Myeloid Leukemia, Stem Cell Transplantation, Stem Cell Transplantation, Hematopoietic, Cord Blood Stem Cell Transplantation, Cellular Therapy
Sponsor: University of Manchester

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
1
 
 
 
 
A multi-centre Phase I/II trial of granulocyte-augmented cord blood transplantation for young 
adults with very poor risk acute myeloid leukaemia. 
 
 
STUDY PROTOCOL 
 
 
Short Title:  GRanulocyte Augmented Cord blood transplantation for poor risk leukaEmia 
(GRACE) 
 
Chief Investigator:  
 
Dr Mark Williams 
Sponsor: 
 
 
 
University of Manchester 
Version 1.0:  
 
 
02/07/2025 
ClinicalTrials.gov number:  
<insert number> 
IRAS number: 
 
 
 
357519 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
2
 
KEY TRIAL CONTACTS 
 
Trial Management Group 
 
Dr Mark Williams (Chief Investigator) 
CRUK Manchester Institute & The Christie NHS Foundation Trust 
mark.williams-4@cruk.manchester.ac.uk 
 
Professor Rob Wynn (Co-Investigator) 
Royal Manchester Children’s Hospital 
robert.wynn@mft.nhs.uk 
 
Dr Mili Shah (Co-Investigator) 
King’s College Hospital NHS Foundation Trust 
milinaresh.shah@nhs.net 
 
Dr Victoria Potter (Co-Investigator) 
King’s College Hospital NHS Foundation Trust 
victoriapotter@nhs.net 
 
Dr Emma Nicholson (Co-Investigator) 
The Royal Marsden NHS Foundation Trust 
Emma.Nicholson@rmh.nhs.uk 
 
Dr Chloe Anthias (Co-Investigator) 
The Royal Marsden NHS Foundation Trust 
chloe.anthias@rmh.nhs.uk 
 
Professor Adrian Bloor (Co-investigator) 
The Christie NHS Foundation Trust 
a.bloor1@nhs.net 
 
Professor Simon Stanworth (Co-Investigator) 
Consultant Haematologist for NHS Blood and Transplant 
Professor of Haematology and Transfusion Medicine, University of Oxford 
simon.stanworth@nhsbt.nhs.uk 
 
Professor Kay Poulton (Co-Investigator) 
Transplantation Laboratory, Manchester University NHS Foundation Trust 
Kay.Poulton@mft.nhs.uk  
 
Professor Christina Yap (Co-Investigator & Lead Statistician) 
Clinical Trials and Statistics Unit, The Institute of Cancer Research 
christina.yap@icr.ac.uk 
 
Dr Xinjie Hu (Trial Statistician) 
Clinical Trials and Statistics Unit, The Institute of Cancer Research 
Xinjie.Hu@icr.ac.uk 
 
[insert Lead Research Nurse/Trial Manager details] 
 
[insert Data Manager details] 
 
 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
3
NHS Blood & Transplant (Granulocyte supply) 
Dr Suzy Morton 
Consultant Haematologist for NHS Blood and Transplant 
Suzy.Morton@nhsbt.nhs.uk 
 
Manchester Cancer Research Centre (MCRC) Biobank (Study research samples) 
Jane Rogan  
Business Manager (MCRC Biobank) 
jane.rogan@nhs.net 
 
University of Manchester (Sponsor) 
Research Governance, Ethics and Integrity Manager 
The University of Manchester 
0161 275 2725 
clinicaltrials@manchester.ac.uk 
 
Blood Cancer UK (Funder) 
Blood Cancer UK Research Office 
grants@bloodcancer.org.uk 
 
Patient and Public Involvement and Engagement (PPIE) 
[insert details] 
 
Joint Committee (TSC/DMC) 
[insert details] 
 
GRACE Trials Office Contact Details 
[insert address] 
[insert telephone] 
[insert study email] 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
4
 
SIGNATURE PAGE 
 
The undersigned confirm that the following protocol has been agreed and accepted and that the Chief 
Investigator agrees to conduct the trial in compliance with the approved protocol and will adhere to the 
principles outlined in the Medicines for Human Use (Clinical Trials) Regulations 2004 (SI 2004/1031), 
amended regulations (SI 2006/1928) and any subsequent amendments of the clinical trial regulations, 
GCP guidelines, the Sponsor’s (and any other relevant) SOPs, and other regulatory requirements as 
amended. 
 
I agree to ensure that the confidential information contained in this document will not be used for any 
other purpose other than the evaluation or conduct of the clinical investigation without the prior written 
consent of the Sponsor 
 
I also confirm that I will make the findings of the trial publicly available through publication or other 
dissemination tools without any unnecessary delay and that an honest accurate and transparent 
account of the trial will be given; and that any discrepancies and serious breaches of GCP from the trial 
as planned in this protocol will be explained. 
 
 
For and on behalf of the Trial Sponsor: 
Signature:  
...................................................................................................... 
 
Date: 
....../....../...... 
Name (please print): 
...................................................................................................... 
 
 
Position: 
...................................................................................................... 
 
 
 
 
Chief Investigator: 
Signature: 
...................................................................................................... 
 
Date: 
....../....../...... 
Name: (please print): 
...................................................................................................... 
 
 
 
 
Statistician: 
 
 
Signature: 
...................................................................................................... 
 
Date: 
....../....../...... 
Name: (please print): 
...................................................................................................... 
 
 
 
 
Position: 
...................................................................................................... 
 
 
 
 
 
 
 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
5
AMENDMENTS 
 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
6
I. CONTENTS 
 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
7
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
8
 
 
 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
9
II. ABBREVIATIONS 
 
AE 
Adverse Event 
AML 
Acute Myeloid Leukaemia 
AR 
Adverse Reaction 
BSA 
Body Surface Area 
BSBMTCT 
British Society of Blood and Marrow Transplantation and 
Cellular Therapy 
BSH 
British Society for Haematology 
CA 
Competent Authority 
CI 
Chief Investigator 
CMV 
Cytomegalovirus 
CNS 
Central Nervous System 
CRF 
Case Report Form 
CRO 
Contract Research Organisation 
CRP 
C-Reactive Protein 
CRS 
Cytokine-Release Syndrome 
CT 
Computed Tomography 
CTA 
Clinical Trial Authorisation 
CTCAE 
Common Terminology Criteria for Adverse Events 
 
CTU 
Clinical Trials Unit 
DLT 
Dose-Limiting Toxicity 
DMC 
Data Monitoring Committee 
DSUR 
Development Safety Update Report 
EBV 
Epstein-Barr Virus 
ECG 
Electrocardiogram 
ECOG 
Eastern Cooperative Oncology Group 
eCRF 
Electronic Case Report Form 
EDC 
Electronic Data Capture 
FBC 
Full Blood Count 
FEV1 
Forced Expiratory Volume in the first second 
FISH 
Fluorescence In-Situ Hybridisation 
GCP 
Good Clinical Practice 
G-CSF 
Granulocyte Colony Stimulating Factor 
GFR 
Glomerular Filtration Rate 
GMP 
Good Manufacturing Practice 
GvHD 
Graft-versus-Host-Disease 
HHV6 
Human Herpesvirus 6 
HLA 
Human Leucocyte Antigen 
HRA 
Health Research Authority 
IB 
Investigator Brochure 
ICC 
International Consensus Classification 
ICF 
Informed Consent Form 
IRAS 
Integrated Research Application System 
ISF 
Investigator Site File (This forms part of the TMF) 
ISRCTN 
International Standard Randomised Controlled Trials 
 
Number 
MHRA 
Medicines and Healthcare products Regulatory Agency 
MMF 
Mycophenolate Mofetil 
MTD 
Maximum Tolerated Dose 
NCI 
National Cancer Institute 
NGS 
Next-Generation Sequencing 
NHSBT 
National Health Service Blood & Transplant 
NHS R&D 
National Health Service Research & Development 
NRM 
Non-Relapse Mortality 
OS 
Overall Survival 
PFS 
Progression-Free Survival 
PI 
Principal Investigator 
PIC 
Participant Identification Centre 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
10
PIS 
Participant Information Sheet 
PPIE 
Patient and Public Involvement and Engagement 
PTLD 
Post-Transplant Lymphoproliferative Disorder 
QA 
Quality Assurance 
QC 
Quality Control 
QoL 
Quality of Life 
QP 
Qualified Person  
REC 
Research Ethics Committee 
RR 
Response Rate 
RP2D 
Recommended Phase II Dose 
RFS 
Relapse-Free Survival 
SAE 
Serious Adverse Event 
SAR 
Serious Adverse Reaction 
SDV 
Source Data Verification 
SOP 
Standard Operating Procedure 
SOS 
Sinusoidal Obstruction Syndrome  
SmPC 
Summary of Product Characteristics  
SSI 
Site Specific Information 
SUSAR 
Suspected Unexpected Serious Adverse Reaction 
TBI 
Total Body Irradiation 
TITE-CRM 
Time-to-Event Continual Reassessment Method 
TMF 
Trial Master File 
TMG 
Trial Management Group 
TRM 
Transplant-Related Mortality 
TSC 
Trial Steering Committee 
VAF 
Variant Allele Frequency 
 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
11
III. TRIAL SYNOPSIS 
 
Title 
A multi-centre Phase I/II trial of granulocyte-augmented cord blood transplantation for young adults with 
very poor risk acute myeloid leukaemia. 
 
Trial Design 
This is a prospective phase I/II study of granulocyte-augmented cord blood transplantation for young 
adults (16-55 years) with very poor risk acute myeloid leukaemia. The target population is high-risk AML 
with TP53 mutations, MECOM rearrangements or chemoresistant phenotypes - defined by partial 
response to 2 cycles of induction chemotherapy or MRD positive disease by flow cytometry (>0.1%) 
after 2 cycles of induction for those with adverse risk AML or early relapse after intensive chemotherapy. 
Participants will receive a T-replete cord blood transplant with a standardised protocol consisting of 
centralised cord unit selection, mid-intensity conditioning and GvHD prophylaxis. A single pool of 
irradiated granulocytes will be given daily for a variable number of days (1, 3, 5 or 7 days) starting on 
the day of transplant. 
The study consists of two phases. Phase I has two components: dose-escalation and dose-optimisation 
to identify the Recommended Phase II Dose (RP2D) of granulocytes. Phase 2 will assess preliminary 
efficacy at the RP2D, based on relapse-free survival (RFS) at 1 year, using a single-stage Bayesian 
design. All patients will be followed-up for a minimum of one year. 
 
Objectives 
See Table 2 for full descriptions of objectives and endpoints. 
 
Primary Objectives 
Phase 1: 
1. To determine the safety of peri-transplant granulocyte infusion for adult recipients of T replete cord 
blood transplants. 
2. To determine the optimal dosing schedule (RP2D) for granulocyte administration using measures 
of activity and dose-limiting toxicity. 
 
Phase 2: 
3. To assess preliminary efficacy at the RP2D, based on relapse-free survival (RFS) at 1 year. 
 
Secondary Objectives (Phases 1 & 2) 
 
To assess relapse and survival in terms of relapse-free survival (RFS), non-relapse mortality (NRM), 
overall survival (OS), cumulative incidence of relapse and GvHD-free and relapse-free survival 
(GRFS). 
 
To assess safety and tolerability in terms of the cumulative incidence of acute grade II-IV and III-IV 
GvHD, cumulative incidence of moderate or severe chronic GvHD, cytokine release syndrome rate, 
immune suppression-free rate, cumulative incidence of intestinal failure, number of inpatient days, 
QoL within the first 12 months, and the incidence of ≥ grade 3 toxicities. The measures of activity 
and dose-limiting toxicity assessed in Phase 1 will also be assessed in Phase 2. 
 
To assess engraftment and immune reconstitution in terms of the cumulative incidence of 
engraftment, incidence of full donor chimerism, cumulative incidence of infection requiring 
admission and cumulative incidence of viral infection or reactivation requiring treatment. 
 
Exploratory Objectives 
The scientific research associated with the study will attempt to describe the mechanism of peri-
transplant granulocyte administration, identify key features of successful transplantation and investigate 
whether responders can be identified to allow targeted application of this approach. Specifically, the 
research will aim to address the following questions: 
1. Does disease response require priming of donor T-cells against HLA mismatched shared between 
the recipient and the granulocyte product? 
2. Does granulocyte-induced inflammation induce leukaemic differentiation? 
3. Does pre-treatment sensitivity of leukaemia to interferon-gamma identify responders? 
4. Can plasma proteomics identify novel biomarkers of treatment response?  

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
12
5. When transplanting patients with detectable disease, can immune clearance of residual disease be 
detected using cell-free DNA methylation analysis? 
 
Patient Population 
Young adults (16-55 years) with acute myeloid leukaemia with TP53 mutations, MECOM 
rearrangements or chemoresistant phenotypes, defined by poor response to induction chemotherapy 
or early relapse. 
 
Sample Size 
The trial will enrol up to 30 patients across 4 dose levels in Phase I and up to 20 patients in Phase 2.  
Notably, evaluable patients who received RP2D in phase I will also contribute to the phase 2 activity 
evaluation. 
 
 
Inclusion Criteria 
1. Availability of a suitable cord blood unit 
2. Age between 16 and 55 years 
3. Primary diagnosis of Acute Myeloid Leukaemia (AML) or MDS/AML (as defined by ICC 2022) 
fitting one or more of the following criteria: 
a. TP53 mutation (single- or multi-hit) 
b. Presence of inv(3) (q21.3q26.2) or t(3;3)(q21.3;q26.2)  
c. Adverse risk (as per ICC 2022) and >0.1% MRD by flow cytometry after 2 cycles of 
induction  
d. AML (any risk) with partial remission (<10% blasts) after 2 cycles induction 
e. Early relapse (<6 months) after chemotherapy alone (excluding t(16;16), inv(16) or 
t(8;21)) 
4. Disease status at transplant (disease assessment will be performed within 28 days of starting 
conditioning chemotherapy) 
a. All patients must have <10% blasts 
b. >10% blasts with a hypocellular background may be discussed with the trial team 
5. Suitable fitness and organ function as per the following criteria: 
a. Glomerular filtration rate >50 mL/min/1.73m2 
b. Ejection fraction >50% 
c. FEV1 >65% without dyspnoea on mild activity 
d. AST/ALT <3 x ULN 
e. Bilirubin <1.5 x ULN (excluding Gilbert’s syndrome) 
f. 
Performance Status (ECOG) of 0 or 1 
6. Females of and male patients of reproductive potential (i.e., not post-menopausal or surgically 
sterilised) must agree to use appropriate, highly effective, contraception from the point of 
commencing therapy until 12 months after transplant 
 
Exclusion criteria 
• 
AML secondary to a myeloproliferative neoplasm 
• 
Active CNS disease (extramedullary disease at other sites should be discussed with the trial team) 
• 
Prior allogeneic stem cell transplant 
• 
Participation in another clinical trial that would alter any aspect of the transplant protocol or that 
aims to reduce the subsequent risk of relapse (discuss with trial team if unsure) 
• 
History of cardiac arrhythmia 
• 
Ischaemic heart disease, valvular heart disease or congestive cardiac failure 
• 
Transient ischaemic attack or cerebrovascular accident 
• 
Rheumatologic disease (SLE, RA, polymyositis, mixed CTD or polymyalgia rheumatica) 
• 
Ulcerative colitis or Crohn’s disease 
• 
Liver cirrhosis 
• 
Presence of an active second malignancy 
• 
Uncontrolled infection, including viral reactivation (CMV, EBV) 
• 
HIV positive 
• 
Hepatitis B/C active infection with measurable viral load (patients with chronic hepatitis B or C 
infection require clear documentation of absence of cirrhosis by either fibroscan or biopsy, 
regardless of viral load) 
• 
Pregnancy, breastfeeding, unwilling to use contraception 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
13
• 
Contraindications to administration of pooled granulocytes  
• 
Previous history of sensitivity to granulocytes 
• 
Inability of patient to give informed consent 
• 
Any other organ dysfunction or co-morbidity that precludes transplant in the opinion of the 
investigator 
• 
Any concern by PI 
 
Trial Duration 
Patients will be recruited over 36 months. Patients will be followed up for a minimum of 1 year. 
 
GRACE Trials Office Contact Details 
[insert address] 
[insert telephone] 
[insert study email] 
 
 
IV. FUNDING 
Funding for this study was provided by Blood Cancer UK (Grant reference: 25003). 
 
Blood Cancer UK (Funder) 
Blood Cancer UK Research Office 
grants@bloodcancer.org.uk 
 
 
V. ROLE OF SPONSOR AND FUNDER 
 
Sponsor 
The trial will be sponsored by the University of Manchester. The responsibilities of the sponsor are as 
defined in the UK Policy Framework for Health and Social Care Research. The University of 
Manchester, as the sponsor, has delegated a number of responsibilities to King’s College Hospital 
(KCH), these are trial management, monitoring and data management. Full details of the role and 
responsibilities of KCH are outlined in the Delegation of Responsibilities section of the research 
agreement signed between the Sponsor and KCH. 
 
The sponsor has legal responsibilities that cannot be delegated. 
 
Funder 
GRACE is funded by Blood Cancer UK. The roles and responsibilities of the funder are defined within 
the funding agreement. 
 
 
VI. ROLES & RESPONSIBILITIES OF TRIAL MANAGEMENT COMMITTEES, GROUPS 
AND INDIVIDUALS   
 
As this is a Phase I/II study, the Trial Steering Committee (TSC) and the Data Monitoring and Ethics 
Committees (DMC) will be combined to aid decision making during the adaptive phase, which includes 
both safety and preliminary efficacy assessments. 
 
Joint committee (TSC/DMC) 
The joint committee will provide overall supervision for the trial and provide advice through its 
independent chair. Recommendations for the continuation of the trial lies with the joint committee. Data 
analyses will be supplied in confidence to the committee, which will be asked to give advice on whether 
the accumulated data from the trial, together with the results from other relevant research, justifies the 
continuing recruitment of further patients.  
 
Additional meetings may be called if recruitment is faster than anticipated and the committee may, at 
their discretion, request to meet more frequently or continue to meet following completion of recruitment. 
An emergency meeting may also be convened if a safety issue is identified. The joint committee will 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
14
report directly to the TMG who will convey findings to the funders, and/or sponsors as applicable. The 
committee may recommend discontinuation of the trial if the recruitment rate or data quality are 
unacceptable or if any issues are identified which may compromise patient safety. 
 
The joint committee will operate in accordance with a trial specific charter based upon the template 
created by [insert details]. The role of the joint committee will vary according to the phase of the study: 
 
Phase 1: In the safety phase of this study the joint committee will meet with members of the TMG to 
discuss safety data and make decisions regarding dosing and study continuation. These meetings will 
be open, with discussion and consensus decisions reached via voting. 
 
Phase 1 to 2 Transition Review Meeting: Once phase I has been completed and an RP2D identified, 
we will convene a special “Phase I to II Transition Review Meeting” to serve as a checkpoint for 
progression from phase I to II. This meeting will include the TSC/DMC and a representative from the 
grant body to review important factors including:  
 
 
The number of evaluable patients treated at the RP2D during Phase I 
 
Remaining grant duration 
 
Available resources  
 
Any other important parameters 
 
Phase 2: As the second phase of the study has the potential to be practice changing, the TMG (except 
the statistician(s)) will remain blinded to the long-term efficacy data. In phase II, there will be open and 
closed sessions. Members of the TMG will attend open sessions where safety data will be shared. 
Efficacy data regarding RFS, or other outcome measures, will only be showed in the closed session to 
the independent members. 
 
Trial Management Group (TMG) 
The TMG will be responsible for the set up and management of the clinical trial. The group will meet 
regularly to ensure that all practical details of the trial are progressing, working well and that everyone 
within the trial understands them. The TMG will closely monitor toxicity and adverse events during 
Phase 1. The TMG includes the PIs and clinicians from all three study sites. Sharing direct clinical 
experience and discussing study data will be important to inform decisions about dose 
escalation/reduction and study continuation. Clinical experience may also have implications for the 
management of treatment complications and will be shared. 
 
 
VII. PROTOCOL CONTRIBUTORS 
This protocol was written by the study Trial Management Group which included expertise in the original 
paediatric study that led to this study (Professor Rob Wynn), cord blood transplantation (Professor Rob 
Wynn, Dr Chloe Anthias and Professor Kay Poulton), acute myeloid leukaemia and adult stem cell 
transplantation (Dr Victoria Potter, Dr Mili Shah, Dr Mark Williams and Dr Emma Nicholson), granulocyte 
supply and biology (Professor Simon Stanworth), translational research (Dr Mark Williams), early phase 
and adaptive trials methodology (Professor Christina Yap) and statistics (Professor Christina Yap and 
Xinjie Hu). 
 
Patient and Public Involvement and Engagement 
During the initial design phase, a virtual event was held with 25 attendees including leukaemia patients, 
friends and families of those who had died, and patient representatives from Anthony Nolan, MDS UK, 
and Blood Cancer UK. Feedback from this group led to broadening the inclusion criteria and raising of 
the upper age limit. The patient representative lead reviewed the funding application documents and 
the patient information leaflet. The latter has also been reviewed and edited by the patient 
representative team from Anthony Nolan. 
 
VIII. KEYWORDS 
Cord blood transplantation; acute myeloid leukaemia; graft-versus-leukaemia; granulocytes.

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
15 
IX. TRIAL SCHEMA 
 
 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
16 
X. SCHEDULE OF EVENTS 
 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
17 
1. 
All baseline assessments and transplant work-up investigations should be performed within 8 weeks of initiating conditioning chemotherapy 
2. 
Pregnancy test for female patients with reproductive potential should be performed using serum 
3. 
Full blood count should include white blood cell differential. Biochemistry should include urea, electrolytes, creatinine, LDH, CRP, magnesium, bilirubin, AST/ALT and ALP. Lipid profile 
testing to include total cholesterol, high density lipoprotein cholesterol, non-DL cholesterol and triglycerides 
4. 
Lymphocyte subsets for CD3, CD4, CD8, CD19 and CD56 
5. 
Quality of life assessments as per FACT-BMT 
6. 
Cytokine Release Syndrome (CRS) assessment as per ASTCT Consensus Grading for CRS (see study CRS SOP for more information) 
7. 
GvHD (acute and chronic) should be assessed continually until the end of the trial, with formal assessments weekly for the first month post-transplant (day 7, day 14, day 21, day 28), day 
56, day 100 and months 6, 9 and 12 post-transplant. GvHD grading as per the modified Glucksberg criteria (revised by MAGIC) and the NIH criteria (see Appendix 2 for more information) 
8. 
Peripheral blood research samples will be collected at baseline, D0, D1, D3, D5, D7, D14, D21, D28, D56, D100 and at disease relapse (if applicable). 
9. 
Bone marrow aspirate research samples will be collected at the time of clinical bone marrow assessment (at baseline, D28 and months D100, D180, D270 and D360 post-transplant, and 
when there is suspicion of disease recurrence). An additional bone marrow procedure will be performed in the first few days post-transplant (see lab manual for details). 
10. As granulocyte supply is limited to particular days of the week, the day of stem cell infusion must be a Tuesday to accommodate the granulocyte treatment schedules shown below. 
Participants should therefore be admitted the day before conditioning begins, to avoid delays. Patients will be allocated to one of the following granulocyte treatment schedules: 
 
 
 
 
 
 
 
 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
18
1. 
BACKGROUND AND RATIONALE 
 
1.1 
Background 
 
Allogeneic stem cell transplantation is the only potentially curative therapy for patients with high-risk 
acute myeloid leukaemia (AML), but relapse is common and remains the leading cause of death. 
Patients with TP53 mutations, MECOM rearrangements and those transplanted without first achieving 
remission have especially poor outcomes, with 5-year survival of less than 10-20%1-4. Most relapse 
within the first 100 days following transplant and then face a life expectancy of weeks to months. Due 
to these poor outcomes, many centres do not offer transplants to this group of patients. 
 
Transplantation succeeds when donor immune cells eliminate residual disease, a process termed the 
graft-versus-leukaemia effect. Recent observations suggest that this therapeutic effect can be 
enhanced to deliver durable responses for those with highly resistant disease. Umbilical cord blood is 
an alternative stem cell source with unique properties, including low rates of chronic graft-versus-host 
disease and reduced relapse for those with residual disease. Our group has reported leukaemia-free 
survival of ~50% in children with residual disease who received T-replete cord blood transplant, 
compared to ~10% using other cell sources5. Similar results have been described for adults6-8. 
 
In addition, we recently reported that the administration of third-party granulocytes following cord blood 
transplant caused a systemic inflammatory response with rapid expansion of donor-derived T cells and 
induction of  durable responses in children with highly refractory AML9,10. We have since expanded our 
cohort and of 28 children, many referred from palliative care pathways, 24 achieved molecular remission 
and 14 remain alive and disease free after a median follow-up of 19 months (Figure 1). 
 
 
 
Figure 1. Relapse-free survival for 28 children with relapsed-refractory AML treated with granulocyte-augmented 
T-replete cord blood transplantation. 24 achieved molecular remission and 14 remain alive and disease free after 
a median follow-up of 19 months. 
 
Our peri-transplant granulocyte approach has been reproduced by a team in Seattle (US), that used 
pooled, expanded cord blood units to generate a mismatch myeloid product that could be given as a 
single dose immediately following cord blood transplant (pooled granulocytes are not routinely available 
in North America). The Seattle cohort consisted of 15 adult patients, 10 with AML and 5 with acute 
lymphoblastic leukaemia. They observed a similar response to infusion of unmatched myeloid cells, 
with fever and transient lymphocyte expansion. All patients remain alive and in remission with a median 
follow-up of ~1 year, with no severe acute GvHD and no chronic GvHD11. This cohort had less resistant 
disease than our original paediatric patients, who had relapsed/refractory disease and most had already 
received and failed a first transplant. Whereas the Seattle cohort had not been previously transplanted 
and most had standard risk disease, with all being in morphological remission and 75% being minimal 
residual disease (MRD) negative at the point of transplant. Nonetheless, these results support the 
potential utility of this approach and demonstrate the safety and feasibility of delivering this treatment 
to adults. 
 
This multi-centre, phase I/II trial will assess the safety and effectiveness of granulocyte-augmented 
cord blood transplantation in young adults (<55 years) with very high-risk AML. 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
19
 
 
1.2 
Trial Rationale 
 
1.2.1 
Justification for patient population 
Relapse remains the leading cause of death following allogeneic stem cell transplantation. Patients with 
TP53 mutations, MECOM rearrangements and those transplanted without first achieving remission 
have especially poor outcomes, with 5-year survival of less than 10-20%1-4. Recent studies suggest that 
AML patients with ‘single-hit’ TP53 alterations have similar outcomes to those with ‘multi-hit’ or biallelic 
alterations, in contrast to previous findings in myelodysplastic syndrome12-14. Relapse of non-core 
binding factor AML within 6 months of intensive chemotherapy identifies another group of patients that 
have dismal outcomes with conventional transplantation15. 
 
The addition of peri-transplant granulocyte infusions to T-replete cord blood transplantation led to 
remarkable outcomes in children with highly resistant AML9,10. This trial will assess the safety and 
efficacy of this approach in young adults (<55 years) with very high-risk AML. This trial therefore 
addresses a major unmet need and has the potential to change clinical practice if the approach is well 
tolerated and the outcomes observed in children are replicated. 
 
1.2.2 
Justification for design 
In our original paediatric cohort, peri-transplant granulocyte infusions were associated with a transient 
inflammatory state characterised by high fever, rash and peripheral blood lymphocyte expansion9,10. 
The magnitude and timing of granulocyte-induced inflammation was associated with transplant 
outcome, suggesting that reliable induction of this reaction is a key part of the therapeutic strategy 
(Figure 2). The first part of this trial therefore aims to determine a granulocyte dosing schedule that 
reliably induces this inflammatory response whilst being safe and tolerable for patients. 
 
 
 
Figure 2. Peri-transplant granulocytes were administered to 28 children. Most experienced a putative cytokine 
release syndrome (CRS), with high fever and elevated CRP in the days following stem cell infusion. This was well 
tolerated, with most requiring either no additional support or fluid boluses and/or oxygen delivered in a ward setting. 
CRS was accompanied by a transient, early lymphocyte expansion and was closely correlated with disease 
response. 3 children who did not experience CRS did not remit, whilst an early CRP rise (A), CRP peak >200 and 
lymphocyte peak >1.0 (B) was associated with relapse-free survival (RFS). 
 
This trial utilises an innovative early phase seamless design, integrating dose-escalation and 
randomised dose-optimisation, which is built on the latest FDA and MDICT guidance16,17. This design 
maximises efficiency and leverages all key data in real-time, ensuring identification of an optimal dose, 
whilst also providing the flexibility to rigorously assess treatment efficacy within the same trial 
framework. 
 
Phase I (up to 30 patients) will include two components: dose-escalation and dose-optimisation to 
identify the Recommended Phase II Dose (RP2D). In the dose-escalation component, a modified 2-
stage Bayesian Time-to-event Continual Reassessment Method (TITE-CRM) will be used to determine 
the maximum tolerated dose and tolerable doses among 4 dose schedules (daily granulocyte infusions 
for 1, 3, 5 or 7 days)18,19. Once there are 9 patients at the proposed initial maximum tolerated dose 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
20
(MTD) and the model still recommends the next cohort to be recruited at that initial MTD,  dose 
optimization will be triggered. In the dose optimisation component, subsequent patients will be 
randomised to selected tolerable doses to determine the RP2D based on both treatment tolerability and 
activity. A Bayesian framework will be used, including an interim futility analysis after the first 6 patients 
at each dose to potentially eliminate any dose deemed futile. The final RP2D would be selected based 
on tolerability, activity and other key secondary endpoints, in consultation with the joint committee 
(TSC/DMC). 
 
Phase 2 (20 patients) will assess preliminary efficacy at the RP2D, based on relapse-free survival (RFS) 
at 1 year, using a single-stage Bayesian design. Notably, evaluable patients who received RP2D in 
phase I will also contribute to the phase 2 activity evaluation. We have based our power calculations 
on the expected outcomes for the target population as reported in the literature1-4,12-15. However, we will 
also conduct an additional analysis in which we will construct a historical comparator group matched 
for the patient, transplant and disease characteristics of our study population. Whilst universally poor, 
the outcomes for patients of differing ages with specific high-risk mutations or varying levels of residual 
disease nonetheless vary. There is a risk that our study population becomes more or less high-risk than 
our power calculation assumes. It would be unethical to randomise patients to receive the 
investigational transplant protocol, because the target population has such poor outcomes with 
conventional transplantation that many clinicians advocate palliation. In collaboration with The British 
Society of Blood and Marrow Transplantation and Cellular Therapy (BSBMTCT), we will therefore 
construct a comparator cohort that is well matched for other patient and transplant characteristics. In 
the absence of randomisation, this represents a robust method for determining the efficacy of peri-
transplant granulocytes. 
 
1.2.3 
Choice of treatment 
Participants will receive a T-replete cord blood transplant with a standardised protocol consisting of 
centralised cord unit selection, mid-intensity conditioning (cyclophosphamide 50 mg/kg, fludarabine 150 
mg/m2, thiotepa 10 mg/kg, total body irradiation 4Gy20) and graft-versus-host disease (GvHD) 
prophylaxis (ciclosporin and MMF). A single pool of irradiated granulocytes will be given daily for a 
variable number of days (see above) starting on the day of transplant. Children in our original cohort 
ranged from 2 to 17 years of age and granulocyte dose was 10ml/kg capped at a single pool (~200mls). 
We found no effect of age (and hence granulocyte dose per kilo) on the magnitude or timing of 
granulocyte-induced inflammation, engraftment or outcome (Table 1). However, we did observe that 
some children who did not receive all 7 doses of granulocytes nonetheless responded, suggesting that 
7 daily doses may not be necessary. The study will therefore assess the safety and activity of four 
different granulocyte administration schedules that vary the number of daily granulocyte doses (1, 3, 5 
and 7 days). The design does not assume that higher doses will be more effective, because prolonged 
antigen exposure has the potential to induce T-cell anergy. 
 
 
Table 1. Data from 24 evaluable patients (those with complete CRS and engraftment data) split into 2 cohorts to 
examine the effects of age on granulocyte-induced CRS, engraftment and outcome. Data displayed as mean 
(range) where appropriate. Children in our original cohort ranged from 2 to 17 years of age and granulocyte dose 
was 10ml/kg capped at a single pool (~200mls). Per kilogram granulocyte dose therefore varied significantly from 
10ml/kg to <2.5ml/kg. However, we found no effect of age (and hence granulocyte dose per kilo) on the magnitude 
or timing of granulocyte-induced inflammation, engraftment or outcome.

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
21 
2. 
OBJECTIVES & ENDPOINTS 
 
2.1 
Table 2. Objectives & endpoints 
 
Primary objectives 
Primary endpoints 
Phase 1: To determine the safety of 
peri-transplant granulocyte infusion 
for adult recipients of T replete cord 
blood transplants 
Safety will be determined by assessing the frequency, causality and severity of the following: 
I. 
Cytokine Release Syndrome (CRS) 
II. 
Acute Graft vs Host Disease (GvHD) 
III. 
Primary graft failure 
IV. 
Transplant Related Mortality (TRM) defined as death due to any transplantation-related cause other than disease relapse 
within the first 100 days following stem cell infusion 
V. 
Other adverse events 
Phase 1: To determine the optimal 
dosing 
schedule 
(RP2D) 
for 
granulocytes administration using 
measures of activity and dose-
limiting toxicity 
Occurrence of dose-limiting toxicities (DLTs). Patients would be considered to have experienced a DLT if they experience any of 
the toxicity events: 
I. 
Severe CRS (intensive care admission requiring intubation >7days) 
II. 
Primary graft failure (failure of count recovery and absent donor DNA at day 28 bone marrow) 
III. 
Severe acute graft-versus-host disease (death from GvHD in the first 100 days) 
 
Evidence of clinical activity. Patients would be considered to show early indicators of clinical activity if they experience any of the 
events: 
I. 
CRS (fever in the first 7 days following stem cell infusion) 
II. 
Lymphocyte expansion (>0.5 x109/L in the first 12 days) 
III. 
Maximum CRP >150 mg/L on days 5-10 following stem cell infusion 
IV. 
Early evidence of disease response (MRD negative on day 28 bone marrow) 
 
The maximum tolerated dose (MTD) will be the dose with an estimated DLT rate closest to 30% using a Bayesian Time-to-Event 
Continual Reassessment Method (TITE-CRM). The final optimal dosing schedule (RP2D) will be based upon an integrated assessment 
of the MTD or the maximum administered schedule (if no DLTs occurs), clinical activity, tolerability and other key secondary endpoints, 
in consultation with the Joint TSC/DMC. 
Phase 2: To assess preliminary 
efficacy at the RP2D, based on 
relapse-free survival (RFS) at 1 year 
Relapse-free survival (RFS) rate is defined as proportion of patients who remain relapse-free and alive within 1 year from transplant. 
 
 
 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
22 
 
Secondary objectives 
Secondary endpoints 
Relapse and survival 
Phases 1 & 2: To assess relapse 
and survival in terms of relapse-free 
survival (RFS), non-relapse mortality 
(NRM), 
overall 
survival 
(OS), 
cumulative incidence of relapse and 
GvHD-free and relapse-free survival 
(GRFS) 
Relapse-free survival (RFS) is defined as the time from day 0 to date of first relapse or death from any cause. Patients who are alive 
and relapse free will be censored at the date of last follow-up. 
Non-relapse mortality (NRM), defined as the time from day 0 to date of death without relapse. Patients who relapse will be considered 
a competing risk at their date of relapse will be considered a competing risk at their date of relapse and patients alive and relapse free 
will be censored at the date of last follow-up. 
Overall survival (OS), defined as the time from day 0 to date of death, from any cause. Patients who are alive will be censored at the 
date of last follow-up. 
Cumulative incidence of relapse, defined as the time from day 0 to date of relapse. 
GvHD-free, relapse-free survival (GRFS) defined as the time from day 0 (ie. the day of stem cell infusion) to the first occurrence of 
any of the following events: acute grade III-IV and/or chronic GvHD requiring systemic immune suppressive treatment, disease relapse 
or progression, or death from any cause. Patients who are alive and free of any of these event will be censored at the date of last 
follow-up. 
Safety and tolerability 
Phases 1 & 2: To assess safety and 
tolerability in terms of the cumulative 
incidence of acute grade II-IV and III-
IV GvHD, cumulative incidence of 
moderate or severe chronic GvHD, 
cytokine release syndrome rate, 
immune 
suppression-free 
rate, 
cumulative incidence of intestinal 
failure, number of inpatient days, 
QoL within the first 12 months and 
the incidence of ≥ grade 3 toxicities. 
The measures of activity and dose-
limiting toxicity assessed in Phase 1 
will also be assessed in Phase 2. 
Cumulative incidence of acute grade II-IV and III-IV GvHD, defined as time from day 0 to date of onset of aGvHD. Patients who 
relapse/progress or die without relapse, progression or aGvHD will be considered a competing risk at date of relapse/progression for 
the former and date of death for the latter. Patients, who are alive, relapse and aGvHD free will be censored at the date of last 
follow-up. 
Cumulative incidence of moderate or severe chronic GvHD, defined as time from day 0 to date of onset of cGvHD. Patients who 
relapse/progress or die without relapse, progression or cGvHD will be considered a competing risk at date of relapse/progression for 
the former and date of death for the latter. Patients, who are alive, relapse and cGvHD free will be censored at the date of last 
follow-up. 
Cytokine release syndrome (CRS) rate defined as proportion of patients who developed grades 1, 2, 3 and 4 CRS within 28 days of 
transplant. 
Immune suppression-free rate at 1 year, defined to be patients who are alive, relapse free and do not require ongoing immune 
suppression to control or suppress GvHD at 1-year post transplant. Patients who discontinue immune-suppression within 15 days or 
less prior to the 1-year time point will not be considered immune-suppression free. 
Cumulative incidence of intestinal failure at 1 year 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
23 
The number of inpatient days during first 12 months 
QoL measured by FACT-BMT questionnaire at baseline, 6 months and 12 months  
Incidence of ≥grade 3 toxicities reported as per the National Cancer Institute Common Terminology Criteria for Adverse Events (NCI 
CTCAE) V5.0 
Measures of activity and dose-limiting toxicity as defined above 
Engraftment and immune reconstitution 
Phases 
1 
& 
2: 
To 
assess 
engraftment 
and 
immune 
reconstitution 
in 
terms 
of 
the 
cumulative incidence of engraftment, 
incidence of full donor chimerism, 
cumulative incidence of infection 
requiring admission and cumulative 
incidence 
of 
viral 
infection 
or 
reactivation requiring treatment 
 
Cumulative incidence of engraftment defined as time from day 0 to date of engraftment (Neutrophil engraftment defined to be the 
first of 3 consecutive days a neutrophil count ≥0.5 x109/L is reached and platelet engraftment defined to be the first of 3 consecutive 
days an unsupported platelet count ≥ 20 x109/L is reached). Patients who relapse/progress or die prior to relapse, progression or 
engraftment will be considered a competing risk at their date of relapse/progression for the former and date of death for the latter. 
Patients alive and engraftment free will be censored at the date of last follow-up. 
Incidence of full donor chimerism (lineage specific chimerism will be determined at the indicated time points by local testing and % 
donor chimerism in each lineage will be recorded on the appropriate CRF), at 100 days. 
Cumulative incidence of infection requiring inpatient admission at 1 year, defined as the time from day 0 to date of inpatient 
admission due to infection. 
Cumulative incidence of viral infection or reactivation requiring treatment, defined as time from Day 0 to date of commencing anti-
viral treatment. Patients who die without viral infection or reactivation requiring treatment will be considered a competing risk at their 
date of death. Patients alive and free of viral infection or reactivation requiring treatment will be censored at the date of last follow-
up. 
 
2.2 
Exploratory Objectives 
 
The scientific research associated with the study will attempt to describe the mechanism of peri-transplant granulocyte administration, identify key features of 
successful transplantation and investigate whether responders can be identified to allow targeted application of this approach. Specifically, the research will aim 
to address the following questions: 
1. Does disease response require priming of donor T-cells against HLA mismatched shared between the recipient and the granulocyte product? 
2. Does granulocyte-induced inflammation induce leukaemic differentiation? 
3. Does pre-treatment sensitivity of leukaemia to interferon-gamma identify responders? 
4. Can plasma proteomics identify novel biomarkers of treatment response?  

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
24 
5. When transplanting patients with detectable disease, can immune clearance of residual disease be detected using cell-free DNA methylation analysis? 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
25
3. 
TRIAL DESIGN 
 
This is prospective phase I/II study of granulocyte-augmented cord blood transplantation for young 
adults (16-55 years) with very poor risk acute myeloid leukaemia. The target population is high-risk AML 
with TP53 mutations, MECOM rearrangements or chemoresistant phenotypes (defined by partial 
response to 2 cycles of induction chemotherapy or MRD positive disease by flow cytometry (>0.1%) 
after 2 cycles of induction for those with adverse risk AML or early relapse after intensive 
chemotherapy). 
Participants will receive a T-replete cord blood transplant with a standardised protocol consisting of 
centralised cord unit selection, mid-intensity conditioning and GvHD prophylaxis. A single pool of 
irradiated granulocytes will be given daily for a variable number of days (1, 3, 5 or 7 days) starting on 
the day of transplant. 
 
The study consists of two phases. Phase I (up to 30 patients) has two components: dose-escalation 
and dose-optimisation to identify the Recommended Phase II Dose (RP2D). Phase 2 (20 patients) will 
assess preliminary efficacy at the RP2D, based on relapse-free survival (RFS) at 1 year, using a single-
stage Bayesian design. All patients will be followed-up for a minimum of one year. 
 
Further details about the trial design are provided in section 12. 
 
Starting dose & dose levels  
Children in our original cohort ranged from 2 to 17 years of age and granulocyte dose was 10ml/kg 
capped at a single pool (~200mls). We found no effect of age (and hence granulocyte dose per kilo) on 
the magnitude or timing of granulocyte-induced inflammation, engraftment or outcome (Table 1). 
However, we did observe that some children who did not receive all 7 doses of granulocytes 
nonetheless responded, suggesting that 7 daily doses may not be necessary. The study will therefore 
assess the safety and activity of four different granulocyte administration schedules that vary the 
number of daily granulocyte doses (1, 3, 5 and 7 days). The design does not assume that higher doses 
will be more effective, because prolonged antigen exposure has the potential to induce T-cell anergy. 
However, it is possible that fewer days of granulocyte exposure will reduce the duration of the 
associated inflammatory state. Given that tolerance of granulocyte-induced CRS is the major safety 
concern of this trial, the starting dose will be the 3-day regimen. 
 
 
 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
26
4. 
ELIGIBILITY 
 
4.1 
Inclusion criteria 
 
7. Availability of a suitable cord blood unit 
8. Age between 16 and 55 years 
9. Primary diagnosis of Acute Myeloid Leukaemia (AML) or MDS/AML (as defined by ICC 2022) 
fitting one or more of the following criteria: 
a. TP53 mutation (single- or multi-hit) 
b. Presence of inv(3) (q21.3q26.2) or t(3;3)(q21.3;q26.2)  
c. Adverse risk (as per ICC 2022) and >0.1% MRD by flow cytometry after 2 cycles of 
induction  
d. AML (any risk) with partial remission (<10% blasts) after 2 cycles induction 
e. Early relapse (<6 months) after chemotherapy alone (excluding t(16;16), inv(16) or 
t(8;21)) 
10. Disease status at transplant (disease assessment will be performed within 28 days of starting 
conditioning chemotherapy) 
a. All patients must have <10% blasts 
b. >10% blasts with a hypocellular background may be discussed with the trial team 
11. Suitable fitness and organ function as per the following criteria: 
a. Glomerular filtration rate >50 mL/min/1.73m2 
b. Ejection fraction >50% 
c. FEV1 >65% without dyspnoea on mild activity 
d. AST/ALT <3 x ULN 
e. Bilirubin <1.5 x ULN (excluding Gilbert’s syndrome) 
f. 
Performance Status (ECOG) of 0 or 1 
12. Females of and male patients of reproductive potential (i.e., not post-menopausal or surgically 
sterilised) must agree to use appropriate, highly effective, contraception from the point of 
commencing therapy until 12 months after transplant 
 
4.2 
Exclusion criteria 
 
• 
AML secondary to a myeloproliferative neoplasm 
• 
Active CNS disease (extramedullary disease at other sites should be discussed with the trial team) 
• 
Prior allogeneic stem cell transplant 
• 
Participation in another clinical trial that would alter any aspect of the transplant protocol or that 
aims to reduce the subsequent risk of relapse (discuss with trial team if unsure) 
• 
History of cardiac arrhythmia 
• 
Ischaemic heart disease, valvular heart disease or congestive cardiac failure 
• 
Transient ischaemic attack or cerebrovascular accident 
• 
Rheumatologic disease (SLE, RA, polymyositis, mixed CTD or polymyalgia rheumatica) 
• 
Ulcerative colitis or Crohn’s disease 
• 
Liver cirrhosis 
• 
Presence of an active second malignancy 
• 
Uncontrolled infection, including viral reactivation (CMV, EBV) 
• 
HIV positive 
• 
Hepatitis B/C active infection with measurable viral load (patients with chronic hepatitis B or C 
infection require clear documentation of absence of cirrhosis by either fibroscan or biopsy, 
regardless of viral load) 
• 
Pregnancy, breastfeeding, unwilling to use contraception 
• 
Contraindications to administration of pooled granulocytes  
• 
Previous history of sensitivity to granulocytes 
• 
Inability of patient to give informed consent 
• 
Any other organ dysfunction or co-morbidity that precludes transplant in the opinion of the 
investigator 
• 
Any concern by PI 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
27
5. 
RECRUITMENT, SCREENING AND CONSENT 
 
5.1 
Recruitment pathway 
 
The aim of this section is to give referring clinicians and study centres guidance as to when patients 
should to be referred and when/where study investigations should be performed. The study envisages 
recruiting patients who are already being treated at study centres as well as those referred from 
secondary care or other UK transplant centres. When and where investigations are performed will 
therefore vary, and the study aims to avoid duplication and disruption to patients. A key goal is to avoid 
patients travelling to study centres for assessment who are subsequently found to be ineligible, as this 
would be distressing for patients and create additional workload for study centres. In practice, this 
means ensuring that patients meet study disease eligibility criteria, are likely to be fit enough and have 
suitable single cord options before assessment at a study centre. 
 
 
 
Figure 3. Flow chart illustrating the identification, pre-screening and screening of potential study participants. 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
28
5.2 
Participant identification 
 
The study will be discussed regularly at AML and transplant sub-groups and clinical networks to ensure 
that all UK centres are familiar with the study. 
 
Treating centres will be: 
 
 
The Christie NHS Foundation Trust 
 
Kings College Hospital NHS Foundation Trust 
 
The Royal Marsden NHS Foundation Trust 
 
Following initial discussion at local multidisciplinary team meetings, patients will likely be highlighted at 
the following timepoints: 
 
 
Initial diagnosis for those with poor-risk genetics (TP53 or MECOM) 
 
After poor response to first induction chemotherapy 
 
When meeting study disease eligibility criteria after second induction 
 
These patients will be referred to the ‘GRACE Clinical Team’ for initial review of eligibility and the patient 
information leaflet will be sent to the patient, where appropriate. Pre-screening will then ensure that 
patients are likely to meet study fitness/organ function criteria and that suitable single cord units are 
available. The patient will then be reviewed at one of the above centres for further assessment and 
suitability review. Cord blood options will be reviewed, and a suitable unit requested. 
 
 
5.3 
Pre-screening 
 
Preliminary cord search 
Once a patient has been identified as having potentially eligible disease, HLA typing and HLA antibody 
screening should be performed (if not already done). Anthony Nolan should then be contacted and 
asked to conduct a cord search. Searches may be requested by either the referring centre or a study 
centre depending on local arrangements. The purpose of the screen is not to select a unit, but to ensure 
that the patient has potential cord options prior to review at a study centre. 
 
Anthony Nolan will use study-specific criteria to identify suitable units. Search requests must therefore 
specify that the search is for the GRACE trial. This will also allow the proportion of study searches 
that yield suitable units to be reported, information that is crucial for understanding both study 
recruitment and the wider applicability of this approach once the study concludes. 
 
Patient fitness 
The study aims to recruit only patients who are fit enough to safely tolerate granulocyte-associated 
CRS. Whilst the transplant work-up may not be complete at this point, the patient should be highly likely 
to meet the study fitness and organ function criteria. In practice, this means good performance status 
(ECOG 0-1), off oxygen, normal liver and renal function, no active infection and no other concerns. 
 
 
5.4 
Screening 
 
Participating centres are required to maintain a Screening Log of all potential study candidates. A patient 
information sheet (PIS) will be given to potential trial patients and sufficient time should be given for 
patients to make an informed decision about entering the study. The Investigator will then formally 
assess whether the patient fully satisfies the inclusion and exclusion criteria. Assessments that are 
performed as standard of care for transplant work-up do not require informed consent. 
 
Patients who meet initial eligibility, will go on to be screened for the trial. The following procedures 
should be performed: 
 
 
Medical history and demographics 
 
Disease assessment (see below) 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
29
 
Transplant workup (see below) 
 
Virology testing of donor and recipients should be performed as per local transplant policy and 
requirements of the Human Tissue Authority but should include appropriate surveillance for 
CMV, EBV and adenovirus. Patients with active HBV or HCV infection are excluded from the 
trial. 
 
Pregnancy test for women of childbearing potential (serum) 
 
Physical examination, ECOG evaluation vital signs, height, weight and body 
 
Surface area measurements (as per institutional guidelines) 
 
Haematology - FBC with differential 
 
 
5.4.1 
Disease assessment 
 
Disease assessment should be via bone marrow aspirate and trephine biopsy within 28 days of starting 
conditioning chemotherapy. This must be performed at the treating study centre. The following 
investigations should be performed: 
 
1. Aspirate for morphology assessment 
2. Aspirate for flow cytometry in accredited laboratory 
3. Aspirate for flow MRD (all patients) and molecular MRD (where available) 
4. Aspirate for the following genomic testing (if not available at baseline and residual disease 
is anticipated): 
a. FISH 
b. Cytogenetics 
c. Myeloid Gene Panel by NGS 
5. Aspirate for research (see Section 7.4) 
6. Trephine biopsy (at least 2cm in size) for histology assessment  
 
 
5.4.2 
Patient fitness for transplant 
 
All patients will be assessed to determine fitness for transplant. This will be done by an in-person 
assessment by the treating study centre as well as the investigations below. These investigations can 
be performed at either the referring or the treating study centre, provided results are available to 
investigators and the assessments were performed after the last cycle of intensive chemotherapy and 
within 8 weeks of the planned date of transplant: 
 
1. Echocardiogram 
2. ECG 
3. Lung function tests 
4. Glomerular Filtration Rate (GFR) 
 
 
5.4.3 
Cord unit selection  
 
Cord unit selection will be performed by the local transplant team using study-specific guidance (see 
Cord Selection SOP) and consulting with the trial team, when required. The selected cord must be on 
site at the treating centre at least 14 days prior to starting conditioning chemotherapy.  
 
 
 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
30
5.5 
Consent 
 
It is the responsibility of the Investigator to obtain written informed consent for each patient prior to 
performing any trial related procedure. A PIS is provided to facilitate this process. Investigators must 
ensure that they adequately explain the aim, trial treatment, anticipated benefits and potential hazards 
of taking part in the trial to the patient. The Investigator should also stress that the patient is completely 
free to refuse to take part or withdraw from the trial at any time. The patient should be given ample time 
(at least 24 hours) to read the PIS and to discuss their participation with others outside of the site 
research team. The patient must be given an opportunity to ask questions which should be answered 
to their satisfaction. The right of the patient to refuse to participate in the trial without giving a reason 
must be respected. 
 
If the patient expresses an interest in participating in the trial they should be asked to sign and date the 
latest version of the Informed Consent Form (ICF). The Investigator must then sign and date the form. 
When complete, copies should be 1.) provided to the patient, 2.) placed in the medical notes, 3.) sent 
to the MCRC Biobank, 4.) sent to the central trial office. The copy sent to the central trial office should 
have patient identifiable information redacted. The original should be kept in the Investigator Site File. 
 
The informed consent process is expected to involve an interview between the investigator team and 
the patient which should facilitate two-way communication. It is possible for this interview to be 
conducted remotely. Where this occurs, the patient can be sent the Patient Information Sheet in 
advance in the post. The Informed Consent Form should be wet-ink signed by the patient and the 
Investigator when the patient attends for their first clinic appointment, but this must be prior to their entry 
onto the trial. 
 
Once the patient is entered into the trial the patient’s trial number should be entered on the ICF 
maintained in the ISF and the copy sent to the MCRC Biobank. Details of the informed consent 
discussions should be recorded in the patient’s medical notes, this should include date of, and 
information regarding, the initial discussion, the date consent was given, with the name of the trial and 
the version number of the PIS and ICF. 
 
Throughout the trial the patient should have the opportunity to ask questions about the trial and any 
new information that may be relevant to the patient’s continued participation should be shared with them 
in a timely manner. On occasion it may be necessary to re-consent the patient in which case the process 
above should be followed and the patient’s right to withdraw from the trial respected. 
 
Details of all patients approached about the trial should be recorded on the Patient Screening/Enrolment 
Log and, with the patient’s prior consent, their General Practitioner (GP) should also be informed that 
they are taking part in the trial. A GP Letter is provided for this purpose. 
 
It is expected that patients will undergo the standard local transplant consent process in 
addition to consenting to the study. 
 
 
 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
31
6. 
TRIAL ENTRY 
 
Patients must be allocated to a treatment schedule (below) prior to admission for transplant. An eligibility 
checklist must be completed via the electronic case report form (eCRF) prior to treatment allocation.  
 
Patients will be allocated to one of the following granulocyte treatment schedules: 
 
 
Table 3. Granulocyte dosing schedules. 
 
Patients will be allocated to treatment based on an algorithm prepared by the trial statistician and 
following review of safety data by the TMG and joint committee, where appropriate. 
 
Eligible patients should be allocated to treatment before admission for transplant, but ONLY 
after transplant work up has been completed and the relevant disease evaluations have been 
performed. 
 
Treatment allocation will be conducted via the eCRF by logging onto:  
[insert study website] 
 
Login details will be provided by the Trials Office as part of the Site Initiation. 
 
GRACE Trials Office Contact Details 
[insert address] 
[insert telephone] 
[insert study email] 
 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
32
7. 
TREATMENT DETAILS 
 
7.1 
Trial treatment 
 
7.1.1 
Granulocytes 
 
Optimised pooled granulocytes will be provided by NHS Blood & Transplant (NHSBT). This is a 
standardised component, available to participating hospitals with ordering through the Blood Bank. A 
single pool of irradiated granulocytes will be given daily for a variable number of days (see Table 3) 
starting on the day of transplant. 
 
7.1.2 
Cord blood stem cells 
 
Un-manipulated cord blood stem cells will be infused on day 0 according to local transplant policy. 
 
 
7.2 
Treatment schedule 
 
There should be no change in the timing, dose and route of administration of the specified transplant 
protocol. Dose modifications for organ dysfunction can be made according to local policies, but any 
other changes to the schedule must be agreed with the CI prior to commencing the transplant schedule. 
Where drugs are to be administered by IV, infusion rates should be as per local policy. 
 
As granulocyte supply is limited to particular days of the week, the day of stem cell infusion must be a 
Tuesday to accommodate the granulocyte treatment schedules shown in Table 3. Participants should 
therefore be admitted the day before conditioning begins, to avoid delays. For all schedules, day 0 is 
the day of cord blood stem cell infusion, days before this are marked as negative. 
 
7.2.1 
Transplant Conditioning Regimen 
 
Mid-intensity conditioning (cyclophosphamide 50 mg/kg, fludarabine 150 mg/m2, thiotepa 10 mg/kg, 
total body irradiation (TBI) 4Gy, single fraction20). G-CSF will be given from Day +5. TBI should be 
administered on a Monday with stem cell infusion the following day (Tuesday). 
 
7.2.2 
Granulocyte administration 
 
A single pool of irradiated granulocytes will be given daily for a variable number of days (Table 3) starting 
on the day of transplant (D0). Patients with a previous history of sensitivity to granulocyte transfusion 
will be excluded from the study. Patients with HLA-antibodies will not be excluded, but cases will be 
discussed with clinical staff at NHSBT. Granulocytes will be prescribed for patients on the fluid and 
blood component prescription charts in accordance with local policy for blood component prescription 
and administration. 
 
7.2.2.1 Component ordering 
 
 
Notice to request granulocytes should be provided a soon as possible to relevant liaison staff with 
NHSBT [insert contact details]. This will support early advanced planning and advice in unexpected 
situations of lack of availability. 
 
Standard hospital and blood bank procedures will be followed for ordering granulocytes.  
 
Donations from CMV-seronegative donors are required for CMV-seronegative recipients. 
 
NHSBT aims to provide the granulocyte component daily up to 6 days a week from Monday to 
Saturday. Whole blood donations are routinely collected from Monday to Friday with fewer 
collections taking place at weekends. Granulocyte availability is likely to be lower from Sunday until 
late Monday. Days where daily transfusion is not possible will be recorded. 
 
Granulocytes often arrive in the evening (~18-19:00) and participating centres must make provision 
to administer on the day of receipt. 
 
7.2.2.2 Issue and Prescribing 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
33
The hospital blood bank will process granulocytes as per existing local practices, including red cell 
compatibility testing and labelling. Optimised pooled granulocytes must be prescribed using the usual 
ordering and prescribing pathways in participating hospitals (electronic patient records or manually). 
Local guidelines for safe administration of granulocytes must be followed. 
 
Prescribing will define: 
 
 
A single pool of irradiated granulocytes will be given on each of a variable number of days starting 
on the day of transplant (D0), as defined by the trial (Table 3). 
 
The first dose of granulocytes (D0) should be given after stem cell infusion 
 
For Phase 1, the granulocyte dosing schedule will be allocated by the trial office and communicated 
pre-transplant. 
 
The Phase 2 granulocyte dosing schedule will be the RP2D determined by Phase 1. 
 
7.2.2.3 Administration Schedule 
 
 
The granulocyte component will be transfused to patients in accordance with BSH guidelines and 
the approved Trust standard operating procedure (SOP) for infusion at the bedside. 
 
The component will be administered intravenously over 30-60 minutes, via a dedicated infusion 
line. The product may by infused via a peripheral IV device or via a central IV device. Granulocytes 
must be transfused at least 6 hours apart from the administration of amphotericin. 
 
All local processes for documentation of transfusion, and occurrence of transfusion reactions (and 
responses) will be followed. 
 
Further guidance on the recognition and management of granulocyte transfusion reactions are 
detailed in a separate document that describes the study approach to both granulocyte-induced 
CRS and transfusion reactions. 
 
 
7.2.3 
Graft-versus-host-disease prophylaxis 
 
Ciclosporin (1.5mg/kg IV BD) and Mycophenolate Mofetil (MMF) (1gram IV BD) will start on D-3. 
 
 
Ciclosporin target trough levels are 150-250 μg/L. 
 
In the absence of GvHD, MMF should be stopped at D35 or 7 days after engraftment - whichever 
is later. 
 
Ciclosporin wean should be initiated at D50-D60, with an aim to stop by D90-D100 in the absence 
of GvHD. 
 
 
7.2.4 
Cytokine-release syndrome (CRS) management 
 
In our original paediatric cohort, peri-transplant granulocyte infusions were associated with a transient 
inflammatory state characterised by high fever, rash and peripheral blood lymphocyte expansion9,10. 
Plasma levels of CRP, IFN and IL-6 were increased, and we term this reaction granulocyte-associated 
cytokine release syndrome (grans-CRS). The magnitude and timing of grans-CRS was associated with 
transplant outcome, suggesting that reliable induction of this reaction is a key part of the therapeutic 
strategy. Supressing this reaction may compromise treatment, but it is also unclear how grans-CRS will 
manifest in adults and how well it will be tolerated. Ultimately it will be important to define an approach 
that avoids overtreatment whilst ensuring patient safety, but currently optimum management has not 
been defined. We have therefore created a guideline that describes the previous clinical experience in 
children and the rationale for a suggested management approach in adults (see Grans-CRS guideline). 
The guidance is not prescriptive, the treatment suggestions are not protocol-mandated and are 
not intended to replace clinical judgement. 
 
 
7.3 
Assessments 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
34
Every effort should be made for participants to attend on the scheduled visit days, however, if a 
participant is unable to attend on the specified day, visits may be arranged at ±3 days for the first 28 
days and ±10 days for months 3 (D100), 6 (D180), 9 (D270) and 12 (D360). In the event a visit is moved, 
subsequent visits should be performed on the days/months specified by the protocol. 
 
7.3.1 
Haematology 
Haematology will be assessed at baseline, daily from D0 to D14, then at D21, D28, D56, D100, D180, 
D270 and D360. A full blood count (haemoglobin, white blood cells (with differential), neutrophils, 
platelets and lymphocytes) should be assessed.  
 
7.3.2 
Blood chemistry 
Blood chemistry will be assessed at baseline, daily from D0 to D14, then at D21, D28, D56, D100, D180, 
D270 and D360. Assessments should include urea, electrolytes, creatinine, LDH, CRP, magnesium, 
bilirubin, AST or ALT and ALP. 
 
7.3.3 
Virology 
Patients should be monitored for EBV and CMV reactivation as per local policy and reported in the 
event of a re-activation. 
 
7.3.4 
Physical examination/symptom assessment 
A physical examination, vital signs (blood pressure, pulse, oxygen saturation and temperature), weight, 
and assessment of ECOG performance status (Appendix 1) at baseline, daily from D0 to D14, then at 
D21, D28, D56, D100, D180, D270 and D360. 
 
7.3.5 
Cytokine release syndrome (CRS) assessment 
CRS assessment should be performed daily from D0 to D14 then at D21 and D28. 
 
7.3.6 
Disease assessment (including MRD) 
Disease assessment (bone marrow aspirate and trephine) will be performed at baseline, D28, D100, 
D180, D270 and D360 post-transplant. These assessments should include flow cytometric MRD for all 
patients and molecular MRD where available. 
 
7.3.7 
Graft-versus-host-disease (GvHD) assessment 
GvHD (acute and chronic) should be assessed continually until the end of the trial; with formal 
assessment weekly for the first month post-transplant (day 7, day 14, day 21, day 28), day 56, day 100 
and months 6, 9 and 12 post-transplant. aGvHD will be assessed using the modified Glucksberg 
criteria21 and cGvHD will be assessed using the National Institutes of Health (NIH) criteria22, see 
Appendix 2. The aGvHD and cGvHD score is recommended to be calculated using the eGvHD App 
(www.uzleuven.be/egvhd)23. The app can be accessed as a webpage or as an app for both android and 
apple devices. The use of the app is intended as a tool to aid with the calculation of the GvHD score. 
Information (including all organ specific source information) should be documented in the patient’s notes 
and treatment decisions should be based on the Investigator’s assessment. 
 
7.3.8 
Chimerism assessment 
Engraftment will be assessed by lineage specific chimerism measurements. Lineage specific chimerism 
in both whole blood and T-cell compartments (where possible) will be assessed at D28, D56, D100, 
D180, D270 and D360. Tests should be performed in local laboratories. 
 
7.3.9 
Quality of Life assessments 
Quality of Life will be assessed using the FACT-BMT questionnaire (Appendix 3) at baseline, D100, 
D180 and D360 post-transplant. 
 
7.3.10 Collection of lymphocyte subsets 
Numbers of CD3, CD4, CD8, CD19 and CD56 cells should be collected at D28, D56, D100, D180, D270 
and D360 post-transplant. 
 
7.3.11 Pregnancy testing 
For women of childbearing potential, a pregnancy test should be performed at baseline (serum). 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
35
7.3.12 Concomitant medication assessment 
All concomitant medications, including blood transfusions (platelet and red cell) and G-CSF 
administration, to be recorded at baseline, daily from D0 to D14, then at D21, D28, D56, D100, D180, 
D270 and D360. 
 
 
7.4 
Research sample collection 
 
In addition to clinical assessments, the following research samples will be taken. All samples will be 
shipped to the Manchester Cancer Research Centre Biobank for processing and storage (see lab 
manual for detailed instructions). 
 
7.4.1 
Bone marrow 
Bone marrow aspirate research samples will be collected at the time of clinical bone marrow 
assessment (at baseline, D28 and months D100, D180, D270 and D360 post-transplant, and when 
there is suspicion of disease recurrence). Participants will also be consented to allow routinely stored 
bone marrow trephine material that is surplus to clinical requirement to be used for research, including 
samples taken prior to recruitment (where available). An additional bone marrow procedure will be 
performed in the first few days post-transplant to address the trial’s exploratory endpoints. Samples will 
be shipped to the Manchester Cancer Research Centre biobank for processing and storage (see lab 
manual for detailed instructions). 
 
7.4.2 
Peripheral blood 
Peripheral blood research samples will be collected at baseline, D0, D1, D3, D5, D7, D14, D21, D28, 
D56, D100 and at disease relapse (if applicable). Samples will be processed for storage of 
cryopreserved peripheral blood mononuclear cells and plasma (see lab manual for detailed 
instructions). 
 
 
7.5 
Supportive Treatment 
 
 
Patients should receive appropriate supportive care measures (including blood product support and 
anti-emetics) at the discretion of the local Investigator.  
 
Infectious disease prophylaxis/therapy to be provided as below: 
o 
Antibacterial prophylaxis: Quinolone or suitable alternative, as per local policy 
o 
Antifungal prophylaxis: Start from D0 until neutrophils >1.0x109/l (or longer if on steroids) 
 
Recommend: Posaconazole 300mg BD (loading) followed by 300mg OD or 
alternative as per local policy 
o 
Antiviral prophylaxis: Aciclovir 400mg BD 
o 
CMV prophylaxis: Letermovir 480mg OD (240mg OD in patients taking ciclosporin) PO/IV 
from D0 to at least D100 for recipients who are CMV seropositive at transplant. Consider 
extended Letermovir prophylaxis if ongoing need for immunosuppression 
o 
PCP prophylaxis: Pentamidine (nebulised) at D28, and every 4 weeks until counts stable 
 
Consider switching to co-trimoxazole (960mg Mon/Wed/Fri) when Platelets >75 
and Neutrophils >1.0 unsupported 
 
Alternatives as per local policy if intolerant of the above 
 
Sinusoidal obstruction syndrome (SOS) prophylaxis (if required): Ursodeoxycholic acid 
 
Filgrastim start at D+5 - dose based on body weight as below: 
o 
300 micrograms (<80kg) 
o 
480 micrograms(>/= 80kg) 
 
In the event of hypomagnesaemia, magnesium supplementation should be given. 
 
Patients developing acute-pattern GvHD grade II-IV or moderate-severe chronic GVHD should be 
treated as per local policy. 
 
 
7.6 
Concomitant medication 
 
Concomitant medication may be given as medically indicated. Administration of live vaccines is 
prohibited throughout the trial. 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
36
 
 
7.7 
Patient follow-up 
 
Patients will be followed-up for a minimum of 1-year post-transplant according to the trial assessment 
schedule. Follow-up visits are scheduled at day 100 and then at months 6-, 9- and 12-months post- 
transplant. In the event of relapse/progression before 12-months post-transplant patients will be 
followed up for survival information only, at the time-points specified in the assessment schedule. Where 
appropriate, care may be shared with the referring centre with scheduled trial visits to the treating 
hospital and routine clinical care delivered locally.  
 
 
7.8 
Patient withdrawal 
 
The Investigator will make every reasonable effort to keep each patient on trial treatment. However, if 
the Investigator removes a patient from the trial treatment or if the patient declines further treatment the 
patient should be followed-up according to the trial schedule unless they withdraw specific consent. All 
results of the evaluations and observations, together with a description of the reasons for withdrawal 
from treatment, must be recorded in the eCRF. 
 
If a patient were to lose capacity during the trial (for example, requiring sedation for intubation and 
ventilation), clinical data collection should continue, but research sample collection should cease until 
the patient regains capacity and is willing/able to reconsent. 
If a patient were to lose capacity during the trial (for example, requiring sedation for intubation and 
ventilation), all trial procedures (administering granulocytes and collecting research samples) should 
cease until the patient regains capacity and is willing/able to reconsent. If a patient were to permanently 
lose capacity all trial procedures (administering granulocytes and collecting research samples) should 
cease, but clinical data should continue to be collected from the medical record. Research samples 
already collected will be retained and used in the study. 
 
Patients who stop study therapy due to adverse experiences (clinical or laboratory) will be treated and 
followed according to the trial schedule where possible. All pertinent information concerning the 
outcome of such treatment must be recorded in the eCRF. 
 
The following are justifiable reasons for the Investigator to stop study treatment: 
 
Unacceptable toxicity 
 
Unforeseen events: any event which in the judgement of the Investigator makes further treatment 
inadvisable 
 
Withdrawal of consent for treatment 
 
Serious violation of the trial protocol 
 
Clinical reasons not related to the trial treatment 
 
Patients must stop study treatment in the event of: 
 
Unacceptable toxicity 
 
SAE requiring permanent discontinuation of treatment 
 
Pregnancy 
 
In the event of a patient’s decision to withdraw from the trial, the Investigator should ascertain from 
which aspects of the trial the patient wishes to withdraw and record the details on the appropriate eCRF. 
All information and blood/tissue samples collected up until point of retraction will be retained and 
analysed. If a patient chooses to withdraw from treatment only, the patient should discontinue treatment 
and continue to be assessed in accordance with the protocol. 
 
If a patient wishes to withdraw from the trial (i.e. including trial specific assessments) but is willing for 
further data to be supplied to the Trials Office, then further routine “follow-up” data (e.g. survival and 
further treatment data) will continue to be supplied by the Investigator to the Trials Office on a follow- 
up form. 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
37
 
 
8. 
ADVERSE EVENT REPORTING 
 
Definitions of different types of AE are listed in Appendix 4. The Investigator should assess the 
seriousness and causality (relatedness) of all AEs experienced by the patient (this should be 
documented in the source data). 
 
 
8.1 
Reporting requirements 
 
8.1.1 
Adverse Events 
AEs (see Appendix 4 for definition) are commonly encountered in patients undergoing transplant, only 
AEs that are equal to or greater than Grade 3 of the Common Terminology Criteria for Adverse Events 
(CTCAE) version 4.0 will be reported (unless the event meets the definition of an SAE). 
 
Please note this does not include abnormal laboratory findings. An abnormal laboratory value is only 
considered to be an AE if the abnormality: 
 
Results in early discontinuation of study treatment and/or 
 
Requires study treatment dose modification or interruption, any other therapeutic intervention or is 
judged to be of significant clinical importance 
 
If a laboratory abnormality is one component of a diagnosis or syndrome, then only the diagnosis or 
syndrome should be recorded. Pre-existing conditions should only be reported if the condition worsens 
by at least 1 CTCAE grade. Details of all AEs experienced by the patient should be recorded in the 
hospital notes. 
 
8.1.2 
Serious Adverse Events 
Investigators should report AEs that meet the definition of an SAE (see Appendix 4 for definition) and 
are not excluded from the reporting process as described below. 
 
8.1.2.1 Events that do not require expedited reporting 
 
Patients receiving chemotherapy may require admission to hospital for appropriate medical intervention 
following development of some of the more severe known side effects of treatment. For this reason, the 
following SAEs do not require expedited (immediate) reporting by site and are not regarded as 
unexpected for the purpose of this trial: 
 
 
Admissions for supportive treatment during an episode of myelosuppression unless this proves 
fatal or requires admission to a high dependency or intensive care facility. 
 
An SAE Form should still be completed for these events but can be emailed to the Trials Office (as 
described in Section 8.2) at any time prior to completion of chemotherapy treatment. 
 
8.1.2.2 Events that do not require reporting on a Serious Adverse Event Form 
 
The following events should not be reported on an SAE Form:  
 
 
Hospitalisations for: 
o 
Protocol defined treatment (including admission for transplant) 
o 
Pre-planned elective procedures unless the condition worsens 
o 
Treatment for progression of the patient’s cancer 
 
 
Progression or death due to the patient’s cancer, as this information is captured elsewhere 
 
 
8.1.3 
Reporting period 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
38
Details of all AEs (except those listed above) will be documented and reported from the date of 
commencement of protocol defined treatment until 28 days after the administration of the last dose of 
granulocytes. SAEs will be reported from the date of consent. 
 
 
8.2 
Reporting procedure 
 
8.2.1 
Site 
 
8.2.1.1 Adverse Events 
 
AEs should be reported on an AE Form (and where applicable on an SAE Form). An AE Form should 
be completed at each visit. 
 
AEs will be reviewed using the CTCAE version 4.0 (see Appendix 5). Any AEs experienced by the 
patient but not included in the CTCAE should be graded by an Investigator and recorded on the AE 
Form using a scale of (1) mild, (2) moderate or (3) severe. For each sign/symptom, the highest grade 
observed since the last visit should be recorded. 
 
8.2.1.2 Serious Adverse Events 
 
For more detailed instructions on SAE reporting refer to the SAE Form Completion Guidelines contained 
in the ISF. 
 
AEs defined as serious and which require reporting as an SAE (excluding events listed in Section 8.1 
above) should be reported on an SAE Form. When completing the form, the Investigator will be asked 
to define the causality and the severity of the AE which should be documented using the CTCAE version 
4.0. 
 
On becoming aware that a patient has experienced an SAE, the Investigator (or delegate) must 
complete, date and sign an SAE Form. The form should be sent together with a SAE Cover Sheet to 
the Trials Office using the options listed below as soon as possible and no later than 24 hours after first 
becoming aware of the event: 
 
To report an SAE, send the SAE Form with an SAE Cover Sheet to: 
Email: [insert study email address] 
Please ensure to add “GRACE SAE” as the subject line 
 
On receipt the Trials Office will allocate each SAE a unique reference number. This number will be 
transcribed onto the SAE Cover Sheet which will then be sent back to the site as proof of receipt. If 
confirmation of receipt is not received within 1 working day, please contact the Trials Office. The SAE 
reference number should be quoted on all correspondence and follow-up reports regarding the SAE. 
The SAE Cover Sheet completed by the Trials Office should be filed with the SAE Form in the ISF.  
 
For SAE Forms completed by someone other than the Investigator, the Investigator will be required to 
countersign the original SAE Form to confirm agreement with the causality and severity assessments. 
The form should then be returned to the Trials Office by post or secure email and a copy kept in the 
ISF. 
 
Investigators should also report SAEs to their own Trust in accordance with local practice. 
 
8.2.1.3 Provision of follow-up information 
 
Patients should be followed up until resolution or stabilisation of the event. Follow-up information should 
be provided on a new SAE Form (refer to the SAE Form Completion Guidelines for further information). 
 
8.2.2 
Trials Office 
 
On receipt of an SAE form, seriousness and causality will be determined independently by a Clinical 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
39
Coordinator. An SAE judged by the Investigator or Clinical Coordinator to have a reasonable causal 
relationship with the trial treatment will be regarded as a Serious Adverse Reaction (SAR). The Clinical 
Coordinator will also assess all SARs for expectedness. If the event meets the definition of a SAR that 
is unexpected (i.e. is not defined in the Reference Safety Information) it will be classified as a Suspected 
Unexpected Serious Adverse Reaction (SUSAR). 
 
8.2.3 
Reporting to the Health Research Authority (HRA) and Research Ethics Committee (REC) 
 
8.2.3.1 Suspected Unexpected Serious Adverse Reactions 
 
The Trials Office will report a minimal data set of all individual events categorised as a fatal or life 
threatening SUSAR to the HRA and main REC within 7 days. Detailed follow-up information will be 
provided within an additional 8 days. 
 
All other events categorised as SUSARs will be reported within 15 days. 
 
8.2.3.2 Serious Adverse Reactions 
 
The Trials Office will report details of all SARs (including SUSARs) to the HRA and main REC annually. 
 
8.2.3.3 Adverse Events 
 
Details of all AEs will be reported to the HRA on request. 
 
8.2.3.4 Other safety issues identified during the course of the trial 
 
The main REC will be notified immediately if a significant safety issue is identified during the course of 
the trial.  
 
8.2.4 
Investigators 
 
Details of all SUSARs and any other safety issue which arises during the course of the trial will be 
reported to Principal Investigators. A copy of any such correspondence should be filed in the ISF. 
 
8.2.5 
Data Monitoring Committee 
 
The Joint Committee (TSC/DMC) will review all SAEs.  
 
 
 
 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
40
9. 
DATA HANDLING AND RECORD KEEPING 
 
9.1 
Data collection 
 
This trial will use an electronic data capture (EDC) system which will be used for completion of eCRFs. 
 
Access to the EDC system will be granted to individuals via the Trials Office. SAE reporting and 
Notification of Pregnancy will be paper-based. The EDC system will comprise a set of forms capturing 
details of eligibility, baseline characteristics, treatment and outcome details. The eCRFs must be 
completed by the Investigator or an authorised member of the site research team (as delegated on the 
Site Signature and Delegation Log). 
 
Certain CRFs, including the Eligibility Form and SAE form, will require Investigator review and sign off. 
Entries on the CRF should be made in ballpoint pen, in blue or black ink, and must be legible. Any errors 
should be crossed out with a single stroke, the correction inserted and the change initialled and dated. 
If it is not obvious why a change has been made, an explanation should be written next to the change. 
 
Data reported on each form should be consistent with the source data or the discrepancies should be 
explained. If information is not known, this must be clearly indicated on the form. All missing and 
ambiguous data will be queried. All sections are to be completed before returning. QoL will be recorded 
directly onto the questionnaires provided. 
 
In all cases it remains the responsibility of the Investigator to ensure that the CRF has been completed 
correctly and that the data are accurate. The completed originals should be sent to the Trials Office and 
a copy filed in the Investigator Site File. 
 
Trial forms may be amended by the Trials Office, as appropriate, throughout the duration of the trial. 
Whilst this will not constitute a protocol amendment, new versions of the form must be implemented by 
participating sites immediately on receipt. 
 
Further details can be found in the study data management plan. 
 
 
9.2 
Electronic data capture (EDC) 
 
A web based electronic data capture (EDC) system will be created in collaboration with the CI and trial 
analyst(s), using the MACRO 4 system. This will be maintained by the King’s Clinical Trials Unit (KCTU) 
for the duration of the project. It will be hosted on a dedicated server within King’s College London 
(KCL).  
 
Data entry 
Source data will be entered in the EDC by authorised [site staff / central staff within the co-ordinating 
study team]*delete as appropriate, typically within [insert X] days of data collection by going to 
www.ctu.co.uk and clicking the link to access the MACRO 4 EDC system. 
 
A full audit trail of data entry and any subsequent changes will be automatically date and time stamped, 
alongside information about the user making the entry/changes within the system. 
 
Participant initials and possibly date of birth will be entered on the EDC. Whereas NHS number, email 
addresses, participant names, addresses and full postcodes will not be entered into the EDC system.  
 
EDC Access 
No data will be entered onto the EDC system unless a participant has signed a consent form to 
participate in the study. 
 
The CI or delegate (e.g., Trial Manager) will request usernames and passwords from KCTU for new 
staff members joining the study and will request access removal when staff members leave the project. 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
41
EDC access will be strictly restricted through user-specific passwords to the authorised research team 
members. It is a legal requirement that passwords to the EDC are not shared, and that only those 
authorised access the EDC.  
 
EDC Troubleshooting 
Site staff experiencing issues with the EDC system should contact the CI or delegate (e.g., Trial 
Manager). 
MACRO training videos are available at www.ctu.co.uk under ‘Resources – Events & Training’ tab. 
 
Data Quality Processes  
Site staff will respond to data queries (DCRs) within the EDC as required. 
[No data will be amended independently of the study site responsible for entering the data]* delete if 
single site or if central team responsible for data entry 
The KCTU will provide the study team with a Data management plan for MACRO EDC.  
 
Database Lock 
At the end of the trial, the site PI will review all the data for each participant [and provide electronic sign-
off]*delete if not using this functionality to verify that all the data are complete and correct. At this point, 
all data can be formally locked for analysis.  
 
 
9.3 
Archiving 
 
Recruiting centres are responsible for archiving trial documents at their sites or at a secure records 
facility. All essential documents (including original consent forms) required to be held by the Investigator 
should be stored in such a way that ensures that they are readily available for 10 years. Destruction of 
essential documents requires authorisation from the Sponsor. The medical files of trial subjects should 
be retained in accordance with national legislation and the minimum/maximum period of time permitted 
by the hospital. 
 
All other essential documents and the trial database will be archived in University of Manchester 
repositories for 10 years from the date of the final publication in a way that will facilitate the management 
of the trial, audit and inspection. Documents will be securely stored, and access restricted to authorised 
personnel.  
 
Once the study is completed, the cleaned and locked version of the dataset will be transferred to the 
Chief Investigator and maintained on secure University of Manchester servers and computers in 
access-controlled areas, in line with the Sponsor's (University of Manchester) policy regarding long term 
storage of research data. 
 
 
 
 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
42
10. 
QUALITY MANAGEMENT 
 
10.1 
Site set-up and initiation 
All sites will be required to sign a Clinical Study Site Agreement prior to participation. In addition, all 
participating Investigators will be asked to sign the necessary agreements, registration forms and supply 
a current CV to the Trials Office. All members of the site research team will also be required to sign the 
Site Signature and Delegation Log, which should be returned to the Trials Office. Prior to commencing 
recruitment all sites will undergo a process of initiation. Key members of the site research team will be 
required to attend either a meeting or a teleconference covering aspects of the trial design, protocol 
procedures, Adverse Event reporting, collection and reporting of data and record keeping. Sites will be 
provided with an Investigator Site File containing essential documentation, instructions, and other 
documentation required for the conduct of the trial. The Trials Office must be informed immediately of 
any change in the site research team. 
 
10.2 
On site monitoring 
Monitoring will be carried out as required following a risk assessment and as documented in the trial 
monitoring plan. Additional on-site monitoring visits may be triggered for example by poor CRF return, 
poor data quality, low SAE reporting rates, excessive number of patient withdrawals or deviations. If a 
monitoring visit is required, the Trials Office will contact the site to arrange a date for the proposed visit 
and will provide the site with written confirmation. Investigators will allow the GRACE trial staff access 
to source documents as requested. 
 
10.3 
Central monitoring 
Trials staff will be in regular contact with the site research team to check on progress and address any 
queries they may have. Trials staff will check incoming CRFs for compliance with the protocol, data 
consistency, missing data and timing. Sites will be sent Data Clarification Forms requesting missing 
data or clarification of inconsistencies or discrepancies. 
 
Sites may be suspended from further recruitment in the event of serious and persistent non-compliance 
with the protocol and/or GCP, and/or poor recruitment. Any major problems identified during monitoring 
may be reported to the Trial Management Group (TMG), the Joint Committee (TSC/DMC) and the 
relevant regulatory bodies. This includes reporting serious breaches of GCP and/or the trial protocol to 
the main REC. 
 
10.4 
Audit and inspection 
The Investigator will permit trial-related monitoring, audits, ethical review, and regulatory inspection(s) 
at their site, providing direct access to source data/documents. 
 
 
 
11. 
END OF TRIAL DEFINITION 
 
The end of trial will be 12 months following the last data capture (the last patient visit, as per the 
schedule of events). This will allow sufficient time for the completion of protocol procedures, data 
collection and data input. The Trials Office will notify the HRA and main REC that the trial has ended 
and will provide them with a summary of the clinical trial report within 12 months of the end of trial. 
 
 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
43
12. 
STATISTICAL CONSIDERATIONS 
 
12.1 
Trial design 
 
This trial utilises an innovative early phase seamless design that integrates dose-escalation with 
randomised dose-optimisation to identify a RP2D, followed by a single arm expansion cohort at the 
RP2D. This design maximises efficiency and makes use of all emerging data to determine an optimal 
dose that is safe, tolerable and shows preliminary evidence of activity. It also provides the flexibility to 
rigorously assess treatment efficacy at RP2D within the same trial framework. 
 
 
(1) Phase I: Dose Escalation and RP2D Determination 
 
The primary objective of Phase I is to identify a granulocyte dosing schedule that is both tolerable and 
shows early evidence of clinical activity. The phase utilises a seamless design, built on latest FDA and 
MDICT guidance12,13, combining dose-escalation and randomised dose-optimisation. In this setting, 
higher number of total granulocyte infusions (from 1 to 7 days) may increase DLT risk, while activity 
might plateau, so the RP2D could be the MTD or a lower dose.  
 
Phase I (up to 30 patients) consists of two components to identify the Recommended Phase II Dose 
(RP2D). 
 
 
Part 1: Dose escalation: 
 
A two-stage modified Bayesian TITE-CRM design will be used, targeting a 30% target DLT rate14,15. 
Four dose schedules will be evaluated: daily granulocyte infusions for 1, 3, 5 or 7 days. The DLT 
assessment period includes a 28-day acute toxicity window and an extended 100-day period to 
capture risks of graft failure/CRS and acute GvHD, respectively. 
 
Key design features include: 
 
No dose skipping during escalation or de-escalation 
 
Backfilling permitted at lower doses (up to three patients) of lower dose levels in Stage 1 to 
further explore activity. 
 
Safety stopping rule: If all dose levels are deemed excessively toxic – defined as P(true DLT 
rate at lowest dose>0.3|data)>0.9 – the trial will stop early for safety. This will be evaluated 
using a beta-binomial conjugate analysis with a Beta(0.3,0.7) prior. For example, early stopping 
would be triggered by 3 DLTS in 3 patients or ≥ 4 DLTs in 6 patients at the lowest dose. 
 
Stage 1: Patients will be recruited in cohorts of 3, starting at dose 2, d(2). If no DLT are observed 
at any tested levels (d(2), d(3) and d(4)), subsequent patients may be recruited continuously at the 
highest dose - d(4) until an initial MTD is determined, with optional backfilling at lower doses (see 
Figure 4). If a DLT occurs, Stage 2 will commence. 
 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
44
 
 
Figure 4: This figure illustrates the operation of the Stage 1 dose-escalation design in the absence of any 
DLTs among the first 18 patients, including backfilling at lower dose levels previously deemed tolerable. 
 
 
Stage 2: Once a DLT occurs, the TITE-CRM model will guide subsequent dosing.  With a 28-day 
acute and 100-day full DLT periods, we use a piecewise linear weighted measure assigning 90% 
weight to days 1-28 and 10% to days 28-100. 
 
Once 9 patients are treated at the proposed initial MTD (and the next recommended dose is the 
same dose), we will proceed to Part 2. The TITE-CRM model will continue to be updated throughout 
Part 2 to adjust the initial MTD if needed. 
 
 
Part 2: Dose optimisation: 
 
In consultation with the Joint TSC/DMC, doses selected from Part 1 – typically including the MTD 
and one lower dose – will undergo further evaluation. In this dose optimisation component, patients 
will be randomised equally between the selected doses to avoid selection bias and allow a fair 
comparison of tolerability and preliminary efficacy, ultimately to identify the RP2D. 
 
A Bayesian framework will be used, incorporating an interim futility analysis after the first 6 patients 
at each dose arm. If fewer than 4 responses are observed among the initial 6 patients, that dose 
arm may be discontinued due to futility. This decision rule is based on a response rate (RR) at 28 
days being considered promising, aligned with the high rate of early remission observed in our 
paediatric cohort. 
 
Due to the trial’s adaptive nature, the number of patients at each dose will vary, depending on 
observed DLTs and patients treated in Part 1. We expect 9-15 patients will be treated at the RP2D. 
With 12 patients, a dose will be declared promising if we observe at least 8 responses. The decision 
boundary is derived from a beta-binomial conjugate analysis (interim: P(RR>0.5|data) < 0.34, final: 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
45
P(RR>0.5|data) ≥ 0.69) with a weaky informative (0.5,0.5) prior, giving 87% power and 16% type 1 
error. 
 
The final RP2D would be selected based on an overall assessment of tolerability, activity and other 
key secondary endpoints, in consultation with the Joint TSC/DMC. Full technical details and 
simulation results are provided in the Statistical Simulation Plan. 
 
The key measures of safety, tolerability and activity used in Phase I are: 
 
Safety: Safety will be determined by assessing the frequency, causality and severity of the following: 
1. Cytokine Release Syndrome (CRS) 
2. Acute Graft vs Host Disease (GvHD) 
3. Primary graft failure 
4. Transplant Related Mortality (TRM) defined as death due to any transplantation-related cause other 
than disease relapse within the first 100 days following stem cell infusion 
5. Other adverse events 
 
Toxicity: Patients would be considered to have experienced a DLT if they experience any of the toxicity 
events: 
1. Severe CRS (intensive care admission requiring intubation >7days) 
2. Primary graft failure (failure of count recovery and absent donor DNA at day 28 bone marrow) 
3. Severe acute graft-versus-host disease (death from GvHD in the first 100 days) 
 
Activity: Patients would be considered to show early indicators of clinical activity if they experience any 
of the events: 
1. CRS (fever in the first 7 days following stem cell infusion) 
2. Lymphocyte expansion (>0.5 x109/L in the first 12 days) 
3. Maximum CRP >150 mg/L on days 5-10 following stem cell infusion 
4. Early evidence of disease response (MRD negative on day 28 bone marrow) 
 
 
(2)  Phase II: Efficacy assessment at RP2D based on relapse-free survival (RFS) at 1 year 
 
Phase 2 (minimum 20 evaluable patients, including evaluable patients from Phase 1) will assess 
preliminary efficacy at the RP2D, based on relapse-free survival (RFS) at 1 year, using a single-stage 
Bayesian design. Notably, evaluable patients who received RP2D in phase I will also contribute to the 
phase 2 activity evaluation. We have based our power calculations on the expected outcomes for the 
target population of 1-year RFS of 20% as reported in the literature1-4. The decision criterion is to declare 
treatment as promising if 𝑃𝑟(𝜃> 0.2|𝑑𝑎𝑡𝑎)≥0.82 (GO if ≥6 successes/20 patients), ensuring 87% power 
(with 1-year RFS=40%) and 20% type I error. This uses a weakly informative prior of Be(0.2, 0.8).  
Because evaluable patients at RP2D in Phase I will also be evaluated in Phase II, we will only need to 
recruit additional (20–number at RP2D) patients. Continuation to the full planned total of 50 patients 
(Phase 1 and 2 combined) may be considered in consultation with the TSC/DMC if results are 
encouraging and where feasible within the available time and funding, as this would add value to the 
exploratory subgroup analyses. 
 
We will also construct a historical comparator group that is matched for the patient, transplant and 
disease characteristics of our study population. Whilst universally poor, the outcomes for patients of 
differing ages with specific high-risk mutations or varying levels of residual disease nonetheless vary. 
There is a risk that our study population becomes more or less high-risk than our sample size assumes. 
It would be unethical to randomise patients to receive the investigational transplant protocol, because 
the target population has such poor outcomes with conventional transplantation that many clinicians 
advocate palliation. In collaboration with The British Society of Blood and Marrow Transplantation and 
Cellular Therapy (BSBMTCT), we will therefore construct a comparator cohort that is well matched for 
other patient and transplant characteristics. In the absence of randomisation, this represents a robust 
method for determining the efficacy of peri-transplant granulocytes. 
 
 
12.2 
Analysis population 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
46
 
Analysis 
Set 
Description 
Safety 
All participants who received at least one dose of study intervention 
DLT 
The DLT analysis set will include all patients who received at least one dose of study 
intervention and meet at least one of the following criteria: 
 
Experienced a DLT within 100 days of treatment initiation, regardless of the 
number of doses received or whether the DLT period was completed. Patients 
will generally be analysed according to the dose level of the total doses 
received (i.e. 1, 3, 5 or 7 doses). 
 
Received the planned total doses of the study intervention within the initial 28-
day DLT period, completed at least 28 days of follow-up, and did not experience 
a delay of more than 1 day in administration. 
 
Did not receive the planned total dose, but received the full dose corresponding 
to a lower dose level and had at least 28 days of DLT follow-up. These patients 
will be eligible for DLT analysis at that lower dose level. 
 
Patient evaluability for DLT and DLT outcomes will be reviewed and confirmed by the 
Joint TSC/DMC, considering any relevant deviations such as from the planned dosing 
schedule and clinical circumstances. Non-evaluable patients will be replaced. 
Response 
All participants who received at least one dose of study intervention and had a 28-day 
bone marrow response assessment. Participants will be analysed per the actual dose 
level (total doses) received.  
Efficacy 
All participants who received at least 80% of intended doses and had a 1-year bone 
marrow response assessment. 
 
 
12.3 
Analysis of outcome measures 
 
A separate statistical analysis plan (SAP) which includes a more technical and detailed description of 
the statistical analyses described in this section will be provided and finalised prior to the first interim 
analysis. This section is a summary of the planned statistical analyses of the most important endpoints, 
including primary and key secondary endpoints. 
 
In general, analysis will primarily be descriptive in nature. Continuous variables will typically be 
summarised using appropriate measures of central tendency (e.g., mean or median) and variability 
(e.g., standard deviation, interquartile range (25th to 75th percentile), minimum and maximum). 
Categorical variables will be described using frequency counts and percentages. Patients will be 
analysed according to the total number of doses received. 
 
1. Safety Analyses 
Safety variables will be summarised by descriptive statistics and based on the safety analysis set. 
Laboratory variables will be described using the National Cancer Institute (NCI) Common Terminology 
Criteria for Adverse Events (CTCAE) Version 5.0. Please see section 9 for exceptions to this. 
 
Adverse events (AEs) will be reported for each dose level and presented as tables of frequency of AEs 
by body system and by worst severity grade observed. Tables should indicate related and unrelated 
events. Laboratory data will be presented by dose level at each observation time. Values outside normal 
limits will be identified and summarised by frequency. 
 
 
 
2. Phase I Dose-Escalation and Dose-Optimisation 
Analysis for the Bayesian dose escalation (Part 1) will be performed using the DLT analysis set. Dose 
escalation decisions will typically be made after all participants in the most recent cohort have 
completed the initial 28-day DLT period or dropped out, incorporating mature data from any backfill 
patients. However, the Joint TSC/DMC committee may recommend an earlier model update – for 
example, after at least two participants have completed their 28-day DLT period, without waiting for 28-

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
47
day follow-up data from a third participant. However, data of such evaluable participants will be included 
in the subsequent Joint TSC/DMC meeting. 
 
At the end of Part 1, the MTD (defined as the dose level with estimated DLT rate closest to the target 
toxicity level of 30%) will be reported with its associated DLT rate and 90% credible intervals. 
 
Activity analysis will be performed on the response-evaluable analysis set. The number of patients 
achieving a response (any of the activity outcomes specified above) will be presented, and the overall 
response rate will be presented with its 95% confidence interval. 
 
An interim futility analysis will be conducted after the first 6 evaluable patients at each dose level. The 
posterior probability P(RR>0.5|data) will be computed using a weaky informative (0.5,0.5) prior. If this 
probability is <0.34 (equivalent to observing fewer than 4 observed responses among the initial 6 
evaluable patients) the corresponding dose arm may be discontinued for futility. 
 
For the final activity analysis at the RP2D, the posterior probability P(RR>0.5|data) will again be 
computed. If this probability is at least 69%, the dose arm will be considered promising. 
 
The final RP2D will be selected based on an integrated assessment of tolerability, activity and other key 
secondary endpoints, in consultation with the Joint TSC/DMC.  
 
3. Phase II Efficacy Analysis 
The primary efficacy endpoint is the proportion of patients who remain relapse-free and alive at 1-year. 
The primary analysis will be conducted using the Efficacy-evaluable analysis set. A secondary analysis 
will include all treated patients (i.e. the safety analysis set). 
 
Other time-to-event endpoints, including GvHD-free, relapse-free survival and overall survival 
probabilities, will be calculated using the Kaplan-Meier estimator and displayed graphically. Median 
progression-free survival and median overall survival will be reported with their 95% confidence 
intervals.  
 
Full details will be specified in a Statistical Analysis Plan, which will be developed by the study 
statisticians and approved before any formal interim analysis is conducted. 
 
 
12.4 
Planned subgroup analysis 
 
Sub-group analysis will be conducted on the primary outcome by the stratification factors of CRS grade 
and disease risk score. This analysis has not been powered and therefore, due to the lack of power, 
will be interpreted with caution and considered as hypothesis generating.  
 
 
12.5 
Planned interim analysis 
 
The joint committee (TSC/DMC) will convene a pre-planned interim analysis during Phase I after 6 
patients are evaluable for response at each dose arm, as detailed in Section 12.2. 
 
Once phase I has been completed and an RP2D identified, we will convene a special “Phase I to II 
Transition Review Meeting” to serve as a checkpoint for progression from phase I to II. This meeting 
will include the TSC and a representative from the grant body to review important factors including: 
 
 
The number of efficacy-evaluable patients treated at the RP2D during Phase I 
 
Remaining grant duration 
 
Available resources  
 
Any other important parameters 
 
 
12.6 
Planned final analysis 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
48
The final analysis will be conducted after one of the following conditions is met. 
 
The trial is terminated early (for example, due to toxicity or futility). 
 
All patients have completed their ‘off-study’ visit and have been followed up for a minimum 
period of 12 months, and data collection has been completed. 
 
 
12.7 
Sample size 
 
The trial will enrol up to 30 patients across 4 dose levels in Phase I and up to 20 patients in Phase II, 
using an adaptive seamless design that combines dose-finding (based on tolerability and activity) and 
efficacy analysis for enhanced speed and efficiency. 
 
A target sample size of 30 evaluable patients will be recruited in Phase I and this target sample size is 
anticipated to be sufficient to determine the RP2D as per the modified 2-stage TITE-CRM seamless 
design. 
 
With patients dosed at RP2D in phase 1, we will anticipate up to 20 additional patients in Phase II to 
assess the 1-year RFS rate based on a single-stage Bayesian design. A weakly informative prior of 
(0.2, 0.8) will be used. The decision criterion is to declare treatment as promising if 𝑃𝑟(𝜃> 0.2|𝑑𝑎𝑡𝑎) ≥ 
0.82 (GO if ≥6 successes/20 patients), ensuring 87% power (with 1-year RFS=40%) and 20% type I 
error. Because evaluable patients at RP2D in Phase I will also be evaluated in Phase II, we will only 
need to recruit additional (20–number at RP2D) patients. Continuation to the full planned total of 50 
patients (Phase 1 and 2 combined) may be considered in consultation with the TSC/DMC if results are 
encouraging and where feasible within the available time and funding, as this would add value to the 
exploratory subgroup analyses. 
 
Full simulation results are provided in the Statistical Simulation Plan. 
 
 
 
 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
49
13. 
TRIAL ORGANISATIONAL STRUCTURE 
 
13.1 
Sponsor 
The trial is sponsored by the University of Manchester.  
 
13.2 
Co-ordinating centre 
The trial is being conducted under the auspices of King’s College Hospital NHS FT, according to their 
local procedures and in line with University of Manchester (Sponsor) processes. 
 
13.3 
Trial Management Group (TMG) 
The TMG will be responsible for the set up and management of the clinical trial. The group will meet 
regularly to ensure that all practical details of the trial are progressing, working well and that everyone 
within the trial understands them. A subgroup of the TMG, the cord selection committee, will also meet 
regularly to identify suitable cord units for participants. The TMG will closely monitor toxicity and adverse 
events during Phase 1. The TMG includes the PIs and clinicians from all three study sites. Sharing 
direct clinical experience and discussing study data will be important to inform decisions about dose 
escalation/reduction and study continuation. Clinical experience may also have implications for the 
management of treatment complications and will be shared. 
 
13.4 
Trial Steering Committee and Data Monitoring Committee 
As this is a Phase I/II study, the Trial Steering Committee (TCS) and the Data Monitoring and Ethics 
Committees (DMC) will be combined to aid decision making during the adaptive safety phase. 
 
Joint committee (TSC/DMC) 
The joint committee will provide overall supervision for the trial and provide advice through its 
independent chair. The ultimate decision for the continuation of the trial lies with the joint committee. 
Data analyses will be supplied in confidence to the committee, which will be asked to give advice on 
whether the accumulated data from the trial, together with the results from other relevant research, 
justifies the continuing recruitment of further patients.  
 
Additional meetings may be called if recruitment is faster than anticipated and the committee may, at 
their discretion, request to meet more frequently or continue to meet following completion of recruitment. 
An emergency meeting may also be convened if a safety issue is identified. The joint committee will 
report directly to the TMG who will convey findings to the funders, and/or sponsors as applicable. The 
committee may recommend discontinuation of the trial if the recruitment rate or data quality are 
unacceptable or if any issues are identified which may compromise patient safety. 
 
The joint committee will operate in accordance with a trial specific charter based upon the template 
created by [insert details]. The role of the joint committee will vary according to the phase of the study: 
 
Phase 1: In the safety phase of this study the joint committee will meet with members of the TMG to 
discuss safety data and make decisions regarding study continuation. These meetings will be open, 
with discussion and consensus decisions reached via voting. 
 
Phase 1 to 2 Transition Review Meeting: Once phase I has been completed and an RP2D identified, 
we will convene a special “Phase I to II Transition Review Meeting” to serve as a checkpoint for 
progression from phase I to II. This meeting will include the TSC/DMC and a representative from the 
grant body to review important factors including:  
 
 
The number of evaluable patients treated at the RP2D during Phase I 
 
Remaining grant duration 
 
Available resources  
 
Any other important parameters 
 
Phase 2: As the second phase of the study has the potential to be practice changing, the TMG (except 
the statistician) will remain blinded to the long-term efficacy data. In phase II, there will be open and 
closed sessions. Members of the TMG will attend open sessions where safety data will be shared. 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
50
Efficacy data regarding RFS, or other outcome measures, will only be showed in the closed session to 
the independent members. 
 
 
13.5 
Finance 
 
This is a clinician-initiated and clinician-led trial funded by Blood Cancer UK. No individual per patient 
payment will be made to NHS Trusts, Investigators or patients. This trial is an NIHR CRN portfolio study. 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
51
14. 
ETHICAL AND REGULATORY CONSIDERATIONS 
 
14.1 
Regulatory compliance and REC review 
The trial will be performed in accordance with the recommendations guiding physicians in biomedical 
research involving human subjects, adopted by the 18th World Medical Association General Assembly, 
Helsinki, Finland, June 1964, amended at the 48th World Medical Association General Assembly, 
Somerset 
West, 
Republic 
of 
South 
Africa, 
October 
1996 
(website: 
http://www.wma.net/en/30publications/10policies/b3/index.html). 
 
The trial will be conducted in accordance with the Research Governance Framework for Health and 
Social Care, the applicable UK Statutory Instruments (the General Data Protection Regulation (GDPR) 
and Human Tissue Act 2008) and Good Clinical Practice (GCP). The protocol will be submitted to and 
approved by the main Research Ethics Committee (REC) prior to circulation. 
 
Before any patients are enrolled into the trial, the Principal Investigator at each site is required to confirm 
local capability and capacity. Sites will not be permitted to enrol patients until written confirmation of 
local capability and capacity is received by the Trials Office. 
 
14.2 
Peer review 
The study background, trial design, aims and objectives were peer reviewed by the funder (Blood 
Cancer UK). Review consisted of assessment and feedback from four independent experts and two lay 
assessors. 
 
14.3 
Patient and Public Involvement and Engagement (PPIE) 
During the initial design phase, a virtual event was held with 25 attendees including leukaemia patients, 
friends and families of those who had died, and patient representatives from Anthony Nolan, MDS UK, 
and Blood Cancer UK. Feedback from this group led to broadening the inclusion criteria and raising of 
the upper age limit to 55 years. The patient representative lead reviewed the funding application 
documents and the patient information leaflet. The latter has also been reviewed and edited by the 
patient representative team from Anthony Nolan. 
 
14.4 
Notification of serious breaches 
The Sponsor of the trial is responsible for notifying the HRA and main REC in writing of any serious 
breach of: 
 
 
The conditions and principles of GCP in connection with that trial or; 
 
The protocol relating to that trial, within 7 days of becoming aware of that breach 
 
For the purposes of this regulation, a “serious breach” is a breach which is likely to effect to a significant 
degree: 
 
 
The safety or physical or mental integrity of the subjects of the trial; or 
 
The scientific value of the trial 
 
Sites are therefore requested to notify the Trials Office of a suspected trial-related serious breach of 
GCP and/or the trial protocol. Where the Trials Office is investigating whether or not a serious breach 
has occurred sites are also requested to cooperate with the Trials Office in providing sufficient 
information to report the breach to the HRA where required and in undertaking any corrective and/or 
preventive action.  
 
14.5 
Confidentiality and data protection 
 
Personal data recorded on all documents will be regarded as strictly confidential and will be handled 
and stored in accordance with the General Data Protection Regulation and the Data Protection Act 
(2018). With the patient’s consent, their initials and date of birth will be collected at trial entry. Patients 
will be identified using only their unique trial number, initials and date of birth in correspondence 
between the Trials Office and participating sites. It is expected that trial number alone will be sufficient 
in most cases, but date of birth may be required in some instances (eg. SAE forms). Signed consent 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
52
forms that have had patient identifiable information redacted will be collected by the central trial office 
to allow in-house monitoring of the consent process. 
 
The Investigator must maintain documents not for submission to the Trials Office (e.g. Patient 
Identification Logs) in strict confidence. In the case of specific issues and/or queries from the regulatory 
authorities, it will be necessary to have access to the complete trial records, provided that patient 
confidentiality is protected. 
 
The Trials Office will maintain the confidentiality of all patient’s data and will not disclose information by 
which patients may be identified to any third party other than those directly involved in the treatment of 
the patient and organisations for which the patient has given explicit consent for data transfer (e.g. 
laboratory staff). Representatives of the GRACE trial team may be required to have access to patient’s 
notes for quality assurance purposes, but patients should be reassured that their confidentiality will be 
respected at all times. 
 
 
14.6 
Insurance and indemnity 
 
University of Manchester employees are indemnified by the University insurers for negligent harm 
caused by the design or co-ordination of the clinical trials they undertake whilst in the University’s 
employment. 
 
In terms of liability at a site, NHS Trust and non-Trust hospitals have a duty to care for patients treated, 
whether or not the patient is taking part in a clinical trial. Compensation is therefore available via NHS 
Resolution in the event of clinical negligence having been proven. 
 
The University of Manchester cannot offer indemnity for non-negligent harm. The University of 
Manchester is independent of any pharmaceutical company, and as such it is not covered by the 
Association of the British Pharmaceutical Industry (ABPI) guidelines for patient compensation. 
 
 
14.7 
Protocol compliance 
 
As stated in the UK Clinical Trials Regulations, planned deviations or waivers to the trial protocol are 
not permitted, unless the deviation/non-compliance is being performed as an urgent safety measure to 
protect a participant from immediate harm. 
 
Accidental protocol non-compliances can happen at any time. Non-compliances vary in incidence and 
impact and are classified accordingly as minor, major or as a serious breach. The sponsor will 
subsequently advise on any further action or information required. 
 
The trial team will maintain a log of all protocol non-compliances to enable these events to be monitored 
for frequency. 
 
 
 
15. 
PUBLICATION POLICY 
 
Results of this trial will be submitted for publication in a peer reviewed journal. The manuscript will be 
prepared by the Trial Management Group (TMG) and authorship will be determined by mutual 
agreement and will usually be in accordance with ICMJE guidance. The current plan is to publish the 
combined results of Phase 1 and 2 together at the end of the study. However, Phase I results may be 
published separately if they provide important insights into the safety profile, optimal dosing, or 
preliminary signs of clinical activity that could inform ongoing or future research. In the meantime, Phase 
1 safety and activity data (once the phase is completed) may be shared with other investigators where 
it would inform the design of related studies. 
 
Any secondary publications and presentations prepared by Investigators must be reviewed by the TMG. 
Manuscripts must be submitted to the TMG in a timely fashion and in advance of being submitted for 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
53
publication, to allow time for review and resolution of any outstanding issues. Authors must 
acknowledge that the trial was performed with the support of the University of Manchester. 
 
Intellectual property rights will be addressed in the Clinical Study Site Agreement between Sponsor and 
site.  
 
 
 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
54
16. 
REFERENCE LIST 
 
1. Zhao D, et al. TP53 Mutations in AML Patients Are Associated with Dismal Clinical Outcome 
Irrespective of Frontline Induction Regimen and Allogeneic Hematopoietic Cell Transplantation. 
Cancers (Basel). 2023 Jun 16;15(12):3210. doi: 10.3390/cancers15123210. 
 
2. Richard-Carpentier G, et al. Characteristics and clinical outcomes of patients with acute myeloid 
leukemia with inv(3)(q21q26.2) or t(3;3)(q21;q26.2). Haematologica. 2023 Sep 1;108(9):2331-2342. 
doi: 10.3324/haematol.2022.282030. 
 
3. UK NCRI AML Working Group. An operational definition of primary refractory acute myeloid leukemia 
allowing early identification of patients who may benefit from allogeneic stem cell transplantation. 
Haematologica. 2016 Nov;101(11):1351-1358. doi: 10.3324/haematol.2016.148825.  
 
4. Freeman SD, et al. Measurable Residual Disease at Induction Redefines Partial Response in Acute 
Myeloid Leukemia and Stratifies Outcomes in Patients at Standard Risk Without NPM1 Mutations. J 
Clin Oncol. 2018 May 20;36(15):1486-1497. doi: 10.1200/JCO.2017.76.3425. Epub 2018 Mar 30. 
 
5. Horgan C, et al. T-cell replete cord transplants give superior outcomes in high-risk and 
relapsed/refractory pediatric myeloid malignancy. Blood Adv. 2023 May 23;7(10):2155-2165. doi: 
10.1182/bloodadvances.2022009253. 
 
6. Milano F, et al. Cord-Blood Transplantation in Patients with Minimal Residual Disease. N Engl J Med. 
2016 Sep 8;375(10):944-53. doi: 10.1056/NEJMoa1602074. 
 
7. Shimomura Y, et al. Comparing cord blood transplantation and matched related donor transplantation 
in non-remission acute myeloid leukemia. Leukemia. 2022 Apr;36(4):1132-1138. doi: 10.1038/s41375-
021-01474-0. 
 
8. Scaradavou A, Boelens JJ. Lower probability of relapse after myeloablative cord blood 
transplantation for patients with refractory AML. Br J Haematol. 2023 Mar;200(5):676-677. doi: 
10.1111/bjh.18622. 
 
9. Hiwarkar P, et al. Cord blood CD8+ T-cell expansion following granulocyte transfusions eradicates 
refractory 
leukemia. 
Blood 
Adv. 
2020 
Sep 
8;4(17):4165-4174. 
doi: 
10.1182/bloodadvances.2020001737. 
 
10. Borrill R, et al. Granulocyte transfusion during cord blood transplant for relapsed, refractory AML is 
associated with massive CD8+ T-cell expansion, significant cytokine release syndrome and induction of 
disease remission. Br J Haematol. 2023 Aug;202(3):589-598. doi: 10.1111/bjh.18863. 
 
11. Milano F, et al. Dilanubicel, a Non-HLA-Matched Pooled Universal Product, Transforming Single 
Cord 
Blood Transplantation 
Success 
Rates. 
Blood. 
2024; 
144 
(Supplement 
1): 
377. 
https://doi.org/10.1182/blood-2024-206088. 
 
12. Tazi, Y, et al. Unified classification and risk-stratification in Acute Myeloid Leukemia. Nat 
Commun 13, 4622 (2022). https://doi.org/10.1038/s41467-022-32103-8. 
  
13. Badar T, et al. Prognostic impact of ‘multi-hit’ versus ‘single hit’ TP53 alteration in patients with acute 
myeloid leukemia: results from the Consortium on Myeloid Malignancies and Neoplastic Diseases. 
Haematologica. 2024;109:3533–42.  
  
14. Grob T, et al. Molecular characterization of mutant TP53 acute myeloid leukemia and high-risk 
myelodysplastic syndrome. Blood. 2022;139:2347–54. 
  
15. Breems DA, et al. Prognostic index for adult patients with acute myeloid leukemia in first relapse. J 
Clin Oncol. 2005 Mar 20;23(9):1969-78. doi: 10.1200/JCO.2005.06.027. 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
55
16. Optimizing the Dosage of Human Prescription Drugs and Biological Products for the Treatment of 
Oncologic Diseases. FDA Guidance document. Docket Number: FDA-2022-D-2827 
https://www.fda.gov/regulatory-information/search-fda-guidance-documents/optimizing-dosage-
human-prescription-drugs-and-biological-products-treatment-oncologic-diseases 
 
17. Araujo D, et al. Oncology phase I trial design and conduct: time for a change - MDICT Guidelines 
2022. Ann Oncol. 2023 Jan;34(1):48-60. doi: 10.1016/j.annonc.2022.09.158. 
 
18. Cheung YK, Chappell R. Sequential designs for phase I clinical trials with late-onset toxicities. 
Biometrics. 2000 Dec;56(4):1177-82. doi: 10.1111/j.0006-341x.2000.01177.x. 
 
19. Yin Z, et al. Handling Incomplete or Late-Onset Toxicities in Early-Phase Dose-Finding Clinical 
Trials: Current Practice and Future Prospects. JCO Precis Oncol. 2024 Jan;8:e2300441. doi: 
10.1200/PO.23.00441. 
 
20. Hough R, et al. Recommendations for a standard UK approach to incorporating umbilical cord blood 
into clinical transplantation practice: an update on cord blood unit selection, donor selection algorithms 
and conditioning protocols. Br J Haematol. 2016 Feb;172(3):360-70. doi: 10.1111/bjh.13802. 
 
21. Harris A, et al. International, Multicenter Standardization of Acute Graft-versus-Host Disease Clinical 
Data Collection: A Report from the Mount Sinai Acute GVHD International Consortium. Biol Blood 
Marrow Transplant, 2016. 22(1): p. 4-10. 
 
22. Jagasia M, et al. National Institutes of Health Consensus Development Project on Criteria for Clinical 
Trials in Chronic Graft-versus-Host Disease: I. The 2014 Diagnosis and Staging Working Group report. 
Biol Blood Marrow Transplant, 2015. 21(3): p. 389-401 e1. 
 
23. Schoemans H, et al. The eGVHD App has the potential to improve the accuracy of graft- versus-
host disease assessment: a multicenter randomized controlled trial. Haematologica, 2018. 103(10): p. 
1698-1707. 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
56
17. 
APPENDICES 
 
Appendix 1 
Eastern Cooperative Oncology Group (ECOG) Performance Status 
 
 
 
 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
57
Appendix 2 
Assessment of GVHD 
 
Acute GvHD Scoring – modified Glucksberg criteria21 
 
 
 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
58
Chronic GVHD Scoring - National Institutes of Health criteria22 
 
 
 
 
 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
59
  

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
60
 
 
 
 
 
 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
61
Appendix 3 
FACT-BMT Questionnaire 
 
Below is a list of statements that other people with your illness have said are important. Please circle 
or mark one number per line to indicate your response as it applies to the past 7 days.  
 
 
 
 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
62
Please circle or mark one number per line to indicate your response as it applies to the past 7 
days.  
 
 
 
 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
63
Please circle or mark one number per line to indicate your response as it applies to the past 7 
days.  
 
 
 
 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
64
Appendix 4 
Definition of Adverse Events 
 
Adverse Event 
Any untoward medical occurrence in a patient or clinical trial subject administered a medicinal product 
and which does not necessarily have a causal relationship with this treatment. 
 
Comment: An AE can therefore be any unfavourable and unintended sign (including abnormal 
laboratory findings), symptom or disease temporally associated with the use of an investigational 
medicinal product, whether or not related to the investigational medicinal product.  
 
Adverse Reaction  
All untoward and unintended responses to an IMP related to any dose administered.  
 
Comment: An AE judged by either the reporting Investigator or Sponsor as having causal relationship 
to the IMP qualifies as an AR. The expression reasonable causal relationship means to convey in 
general that there is evidence or argument to suggest a causal relationship. 
 
Serious Adverse Event  
Any untoward medical occurrence or effect that at any dose:  
  Results in death  
  Is life-threatening*  
  Requires hospitalisation** or prolongation of existing inpatients’ hospitalisation  
  Results in persistent or significant disability or incapacity  
  Is a congenital anomaly/birth defect  
  Or is otherwise considered medically significant by the Investigator*** 
 
Comments:  
The term severe is often used to describe the intensity (severity) of a specific event. This is not the 
same as serious, which is based on patients/event outcome or action criteria. 
 
* Life threatening in the definition of an SAE refers to an event in which the patient was at risk of death 
at the time of the event; it does not refer to an event that hypothetically might have caused death if it 
were more severe. 
 
**Hospitalisation is defined as an unplanned, formal inpatient admission, even if the hospitalisation is a 
precautionary measure for continued observation. Thus hospitalisation for protocol treatment (e.g. line 
insertion), elective procedures (unless brought forward because of worsening symptoms) or for social 
reasons (e.g. respite care) are not regarded as an SAE. 
 
*** Medical judgment should be exercised in deciding whether an AE is serious in other situations. 
Important AEs that are not immediately life threatening or do not result in death or hospitalisation but 
may jeopardise the subject or may require intervention to prevent one of the other outcomes listed in 
the definition above, should be considered serious. 
 
Serious Adverse Reaction  
An Adverse Reaction which also meets the definition of a Serious Adverse Event. 
 
Suspected Unexpected Serious Adverse Reaction  
A SAR that is unexpected i.e. the nature, or severity of the event is not consistent with the applicable 
product information. 
 
A SUSAR should meet the definition of an AR, UAR and SAR. 
 
Unexpected Adverse Reaction 
An AR, the nature or severity of which is not consistent with the applicable product information (e.g. 
Investigator Brochure for an unapproved IMP or (compendium of) Summary of Product Characteristics 
(SmPC) for a licensed product). 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
65
When the outcome of an AR is not consistent with the applicable product information the AR should be 
considered unexpected.  
 
 
Appendix 5 
Common Toxicity Criteria Gradings 
 
Toxicities will be recorded according to the Common Terminology Criteria for Adverse Events (CTCAE), 
version 4.0. The full CTCAE document is available on the National Cancer Institute (NCI) website, the 
following address was correct when this version of the protocol was approved:  
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm  
 
 
 
 
 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
66
Appendix 6 
WMA Declaration of Helsinki 
 
 
 
 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
67
 
 
 

PROTOCOL 
Version 1.1, 27/08/2025 
IRAS ID: 357519 
 
 
68