A Pilot Study of EPOCH-F/R Induction Chemotherapy and Reduced-Intensity, HLA-Matched, Related Allogeneic Hematopoietic Stem Cell Transplantation, With Cyclosporine & Methotrexate GVHD Prophylaxis for Refractory or Relapsed Hematologic Malignancies
Phase: PHASE2
Conditions: Hematologic Neoplasms
Sponsor: National Cancer Institute (NCI)

1 
Abbreviated Title:  EPOCH-FR & CSA/MTX - Allo HSCT 
CC Protocol Number:  03-C-0077  
 
 
    Amendment J 
 
 
PROTOCOL TITLE: 
 A Pilot Study of EPOCH-F/R Induction Chemotherapy       
and 
Reduced-Intensity, 
HLA-Matched, 
Related 
Allogeneic 
Hematopoietic                  
Stem 
Cell 
Transplantation 
for 
Refractory 
or 
Relapsed 
Hematologic 
 
 
 
 
Malignancies, 
with 
Cyclosporine 
& 
Methotrexate 
for 
Graft-Versus-Host         
Disease Prophylaxis 
 
Principal Investigator: 
 
Daniel Fowler, M.D.1 
 
 
 
 
 
Telephone:  301-435-8641 
 
Lead Associate Investigator: 
Frances Hakim, Ph.D.1 
 
 
 
 
 
Telephone:  301-402-3627 
 
Associate Investigators: 
 
Michael R. Bishop, M.D.1 
 
Ronald Gress, M.D.1 
 
 
Claude Sportes, M.D.1  
 
 
Steven Pavletic, M.D.1 
 
 
Juan Gea-Banacloche, M.D.1 
 
 
Seth Steinberg, Ph.D.2 
 
 
            Susan Leitman, M.D.3 
 
Paula Layton, R.N.1 
 
 
 
 
1 Experimental Transplantation and Immunology Branch 
 
Center for Cancer Research, National Cancer Institute 
  
 
 
2 Biostatistics and Data Management Section 
 
Center for Cancer Research, National Cancer Institute 
 
 
3 Department of Transfusion Medicine 
 
Clinical Center, National Institutes of Health 
 
Date of Revision: 
January 27, 2011 
 
 

2 
Precis 
 
Allogeneic hematopoietic stem cell transplantation (HSCT) is potentially curative for refractory 
hematologic malignancies, but its application has been limited historically by morbidity and 
mortality from conventional transplant preparative regimens and graft-versus-host disease 
(GVHD).  Donor T cells mediate GVHD and also help to eradicate malignancies through an 
immune-dependent graft-versus-tumor effect.  Efforts to decrease preparative regimen toxicity 
have led to reduced-intensity, or “nonmyeloablative” regimens, facilitating the study of 
allogeneic HSCT in a broader population.  As a promising strategy for reducing GVHD, donor 
Th2 cells were shown to abrogate Th1-mediated GVHD without impairing engraftment in 
murine models of allogeneic HSCT.  These findings led to a phase I/II clinical study of donor 
Th2 cells for the prevention of GVHD during reduced-intensity allogeneic HSCT (CC 99-C-
0143); preliminary results suggest that a randomized trial will be necessary to evaluate donor 
Th2 cells further. 
 
In CC 99-C-0143, a novel induction chemotherapy regimen, EPOCH-Fludarabine (EPOCH-F), 
was well tolerated and effective for sequential host immune depletion.  However, a significant 
proportion of patients failed to achieve satisfactory disease control before transplant, providing a 
basis for intensifying this induction regimen.  Furthermore, the initial 20 patients treated on this 
study experienced relatively high rates of acute GVHD and considerable morbidity associated 
with cyclosporine monotherapy for GVHD prevention, indicating that future studies should use 
more aggressive prophylaxis.  These observations warrant modifying our approach to allogeneic 
HSCT before undertaking a randomized study of donor Th2 cells. 
 
We now propose a pilot study of HLA-matched, related, reduced-intensity allogeneic HSCT in 
refractory hematologic malignancies, using an intensified EPOCH-F induction chemotherapy 
regimen with rituximab added for patients with CD20+ malignancies (EPOCH-F/R).  This 
regimen will be evaluated for toxicity and disease control before transplantation.  GVHD 
prophylaxis will consist of a standard dual-agent regimen, cyclosporine/methotrexate; the impact 
of this change on hematopoietic recovery, donor/recipient chimerism, and the incidence of acute 
GVHD will be assessed. 
 
Immune reconstitution following allogeneic HSCT is an important research interest among 
Experimental Transplantation and Immunology Branch investigators.  Current evidence suggests 
a critical role for interleukin-7 (IL-7) in CD4+ T cell homeostasis, and interleukin-15 (IL-15) 
appears crucial to CD8+ T cell and NK cell homeostasis.  The relationships between these 
cytokines and lymphocyte subpopulations have not been studied in the setting of allogeneic 
HSCT; such analysis may enhance our understanding of engraftment kinetics, graft-versus-host 
disease, and immune reconstitution.  We will correlate serum IL-7 and IL-15 levels with changes 
in circulating T-cell and NK-cell subpopulations during EPOCH-F/R induction chemotherapy, 
after transplantation, and with the development of GVHD. 

3 
Table of Contents 
 
1.0 
INTRODUCTION .......................................................................................................................... 5 
1.1 
Study Objectives 
1.2 
Background and Rationale 
1.3 
Summary 
2.0 
ELIGIBILITY ASSESSMENT AND ENROLLMENT ............................................................... 20 
2.1 
Eligibility Criteria 
2.2 
Research Eligibility Evaluation 
2.3 
Patient Registration 
3.0 
STUDY IMPLEMENTATION .................................................................................................... 26 
3.1 
Study Design 
3.2 
Stem Cell Mobilization and Collection 
3.3 
Induction Chemotherapy 
3.4 
Transplant Conditioning Regimen 
3.5 
Graft-Versus-Host Disease Prophylaxis 
3.6 
Treatment of Graft-Versus-Host Disease 
3.7 
On Study Evaluation 
3.8 
Pre-Transplant Evaluation 
3.9 
Off Study Criteria 
3.10 
Immunologic Studies 
3.11 
Post Study Evaluation 
4.0 
SUPPORTIVE CARE ................................................................................................................... 35 
4.1 
Infection Prophylaxis 
4.2 
Menses Suppression and Contraception 
5.0 
DATA COLLECTION AND EVALUATION ............................................................................. 38 
5.1 
Data Collection 
5.2 
Response Criteria 
5.3 
Toxicity Criteria 
5.4 
Statistical Section 
6.0 
HUMAN SUBJECTS PROTECTIONS ....................................................................................... 44 
6.1 
Rationale for Subject Selection 
6.2 
Risks/Benefits Analysis 
6.3 
Consent and Assent Process and Documentation 
7.0 
DATA REPORTING .................................................................................................................... 45 
7.1 
Adverse Drug Reactions 
7.2 
Record Keeping 
8.0 
PHARMACEUTICAL INFORMATION ..................................................................................... 45 
8.1 
Cyclophosphamide 
8.2 
Mesna 
8.3 
Filgrastim (G-CSF) 
8.4 
Cyclosporine 
8.5 
Fludarabine 
8.6 
Etoposide, Doxorubicin, and Vincristine (in EPOCH) 
8.7 
Prednisone 
8.8 
Methotrexate 
8.9 
Rituximab 
8.10 
Diphenhydramine 
8.11 
Acetaminophen 
8.12 
Valacyclovir 
8.13 
Fluconazole 

4 
8.14 
Trimethoprim/Sulfamethoxazole 
8.15 
Medroxyprogresterone Acetate 
8.16 
Immune Globulin Intravenous 
9.0 
APPENDICES .............................................................................................................................. 58 
10.0 
REFERENCES ............................................................................................................................. 67 
 

5 
1.0 
Introduction 
1.1 
Study Objectives: 
 
1.1.1 Primary Objectives: 
 
a) To evaluate the effectiveness of cyclosporine and mini-dose 
methotrexate (CSA/mini-MTX) as prophylaxis for acute graft-versus-
host disease (GVHD) following allogeneic HSCT, after induction 
chemotherapy with EPOCH-F/R and reduced-intensity conditioning 
with cyclophosphamide and fludarabine. 
 
1.1.2 Secondary Objectives: 
 
a) To study the toxicity of a modified induction chemotherapy regimen, 
EPOCH-Fludarabine/Rituximab (EPOCH-F/R), prior to allogeneic 
hematopoietic stem cell transplantation (HSCT).  This evaluation will 
be made informally in comparison with the toxicity observed for the 
EPOCH-F regimen employed in CC 99-C-0143. 
 
b) To assess the impact on hematologic recovery and donor/recipient 
chimerism of cyclosporine and mini-dose methotrexate for GVHD 
prophylaxis in the setting of reduced-intensity allogeneic HSCT 
following sequential immunoablative chemotherapy. 
 
c) To evaluate the effectiveness of EPOCH-F/R with respect to anti-
tumor activity and sequential host immune depletion prior to 
allogeneic HSCT. 
 
d) To correlate serum interleukin-7 and interleukin-15 levels with in vivo 
changes in host lymphocyte subpopulations, both during sequential 
immunoablative chemotherapy before allogeneic HSCT and during 
immune reconstitution after transplantation. 
 
e) To determine the overall response rate to salvage therapies 
administered for disease progression after allogeneic HSCT. 
 
1.2 
Background and Rationale: 
 
1.2.1 Reduced-Intensity 
Preparative 
Regimens 
in 
Allogeneic 
HSCT:  
Conventional transplantation regimens typically contain high doses of 
alkylating agents often in combination with total body irradiation.  The use 
of such regimens, which are considered myeloablative, was once 
perceived as essential both for eradication of malignant disease and for 
suppression of the host-versus-graft marrow rejection response; however, 
recent studies have challenged both of these assumptions.  The high 
frequency of relapse observed in the setting of T-cell-depleted allogeneic 

6 
HSCT suggests that the curative potential of allogeneic HSCT results 
primarily from a T-cell-mediated graft-versus-tumor (GVT) effect, and not 
from the myeloablative doses of chemotherapy [1].  In addition, the 
delayed administration of donor lymphocytes can induce complete 
remissions remote from the preparative regimen; this clinical observation 
provides further evidence that an immune mechanism primarily mediates 
the anti-leukemic effects of allogeneic HSCT [2].  With respect to graft 
rejection, it is also now known that conventional myeloablative regimens 
do not consistently eliminate the host response to the allograft, even in 
recipients of HLA-matched allografts.  For example, 30 to 40% of patients 
will reject a T-cell-depleted, HLA-matched marrow graft after 
myeloablative conditioning [3].  These limitations of myeloablative 
preparative regimens, combined with the high levels of morbidity and 
mortality associated with myeloablation, result in a low therapeutic index 
for this aspect of allogeneic HSCT.  It has therefore been a goal of clinical 
investigators to develop regimens that reduce treatment mortality yet 
maintain the efficacy of allogeneic HSCT, by establishing allo-
engraftment without myeloablation. 
 
Recent allogeneic HSCT studies have demonstrated that fludarabine can 
contribute to the prevention of marrow rejection in reduced-intensity, or 
“nonmyeloablative”, transplant approaches [4, 5].  In the non-transplant 
setting, fludarabine can cause immunosuppression through its depletion of 
both CD4+ and CD8+ T cells [6].  Importantly, patients receiving 
fludarabine-containing combination chemotherapy are susceptible to 
developing transfusion-associated graft-versus-host disease [7].  This 
observation illustrates the potential of fludarabine-based regimens for 
preventing the rejection of even HLA-disparate lymphoid cells; such 
regimens may be considered “immunoablative”, in recognition of their 
relatively specific impact upon host cell-mediated immunity. 
 
Unfortunately, published reports indicate that allogeneic HSCT using such 
reduced-intensity regimens has been limited by incomplete donor 
chimerism or failure to engraft, which were associated with relapsed 
malignancy and higher rates of death due to progressive disease [4, 5, 8].  
For these reasons, we believe that attaining full donor chimerism early 
after transplantation is central to achieving an enhanced GVT effect, and 
that accomplishing this goal with a reduced-intensity preparative regimen 
depends upon the degree of host immunosuppression at the time of HSCT. 
 
1.2.2 Donor Th2 Cells As a Strategy to Reduce Graft-Versus-Host Disease 
Following Allogeneic HSCT:  Donor T cells in the allograft are the 
primary initiators of GVHD; this complication can be prevented by 
depletion of T cells from the allograft, but such T-cell-depleted transplants 
are associated with a high rate of graft rejection.  As an alternative 
approach, we have evaluated whether donor T cells of defined cytokine 

7 
phenotypes might differentially mediate allogeneic transplantation 
responses.  A type I immune response, mediated by CD4+, Th1 and CD8+, 
Tc1 cells, is characterized by the secretion of the pro-inflammatory 
cytokines IL-2 and IFN-gamma [9].  In contrast, the secretion of the anti-
inflammatory cytokines IL-4, IL-5, and IL-10 characterizes a type II 
immune response, mediated by CD4+, Th2 and CD8+, Tc2 cells.  Given 
that acute GVHD is typical of a type I immune response (characterized by 
an initial phase of IL-2 production, and followed by IFN-γ secretion and 
cytolytic function) [10], we hypothesized that donor T cells of type I 
cytokine phenotype would generate acute GVHD, and that donor T cells 
of type II cytokine phenotype would regulate GVHD.  In murine models, 
we demonstrated that donor CD4+ T cells of Th1 cytokine phenotype 
(defined by their secretion of IL-2 and IFN-γ) mediated GVHD.  In 
contrast, donor CD4+ T cells of Th2 phenotype (defined by their secretion 
of IL-4, IL-5, and IL-10) did not generate GVHD, and abrogated the 
ability of other donor T cell populations to initiate GVHD [11].  
Importantly, we also demonstrated in murine models that Th2-mediated 
regulation of GVHD was not associated with an increased rate of graft 
rejection [12].  Thus, the supplementation of marrow allografts with donor 
Th2 cells represents a strategy for reducing the detrimental aspect of 
allogeneic T cell administration (GVHD) while preserving the beneficial 
ability of donor T cells to prevent allograft rejection.  The clinical 
evaluation of this strategy is ongoing in a phase II NCI trial (CC 99-C-
0143); we anticipate that a randomized study will follow for further 
assessment of the impact of donor Th2 cell administration on GVHD, 
engraftment, and anti-tumor effects.  An important aspect of the design for 
the current protocol proposal is the dual-agent GVHD prophylaxis 
regimen we will use (Section 1.2.8), which will serve as a control group 
for future randomized studies involving donor Th2 cells. 
 
1.2.3 Rationale for EPOCH-Fludarabine (EPOCH-F) Induction Prior to 
Reduced-Intensity Conditioning in CC 99-C-0143:  The desire to achieve 
rapid and complete donor chimerism following allogeneic HSCT led our 
group to adopt a strategy of sequential immune depletion before transplant 
conditioning.  In CC 99-C-0143, we developed a novel induction 
chemotherapy regimen consisting of fludarabine in combination with the 
agents contained in the EPOCH regimen.  The main purpose of 
administering this induction regimen was to achieve a high level of host 
immunosuppression prior to allogeneic HSCT, in order to attain rapid 
conversion to full donor chimerism and to facilitate the development of a 
GVT effect soon after transplantation.   Murine data indicate that very 
severe levels of host T cell depletion are required for the engraftment of 
fully-MHC mismatched allografts after fludarabine-based chemotherapy 
[13].   Thus, we believe the development of induction chemotherapy 

8 
regimens that induce severe host T cell depletion without myeloablation is 
a desirable goal.  As a surrogate marker for the level of immune depletion 
necessary to achieve this goal in CC 99-C-0143, we chose a peripheral 
blood CD4 count of less than 50 cells/µl before administration of the 
transplant preparative regimen.  Our hypothesis was that this level of host 
CD4+ T cell depletion, which is associated with clinically significant 
immunosuppression and a reduced ability to reject allogeneic cells in 
patients with B cell malignancy [7, 14, 15], would predict for robust 
engraftment after allogeneic HSCT and be attainable with up to 3 cycles of 
induction chemotherapy before transplantation.   
 
Developed in the NCI Medical Oncology Clinical Research Unit, EPOCH 
is a well-tolerated chemotherapy regimen with established activity in 
refractory lymphoid malignancies [16-18].  Fludarabine, which has 
modestly immunosuppressive effects when administered as a single agent, 
can be highly immunosuppressive when given in combination with 
steroids, alkylators, or topoisomerase II inhibitors [19-21]; all of these 
categories of antineoplastic agents are represented in the EPOCH regimen.  
These observations suggested that the combination of fludarabine and 
EPOCH chemotherapy might result in severe host T cell depletion at the 
time of transplantation and have clinical activity in refractory hematologic 
malignancies. 
 
1.2.4 EPOCH-F Results in CC 99-C-0143 – Disease Control.  Through July 
2002, 48 patients with refractory and/or relapsed hematologic 
malignancies received EPOCH-F on CC 99-C-0143. 
 
Diagnosis 
(n) 
Diffuse large B cell lymphoma 
15 
Follicular NHL 
6 
Chronic lymphocytic leukemia 
(1 prolymphocytic, 1 Richter’s) 
6 
Multiple myeloma 
6 
Mantle cell lymphoma 
4 
Hodgkin’s lymphoma 
3 
Chronic myelogenous leukemia 
3 
Myelodysplasia 
3 
Acute lymphocytic leukemia 
1 
Lymphomatoid granulomatosis 
1 
 
Patients had received a median of 3 prior therapies before enrolling (range, 
1-6).  20 patients had primary refractory disease; 22 were in relapse, of 
whom 18 were refractory.  Only 2 were in remission at study entry. 
 
Responses to EPOCH-F induction are shown in the following table: 
 

9 
 
(n) 
% 
Complete response 
3 
6 
Partial response 
15 
31 
Stable disease 
15 
31 
Mixed response 
1 
2 
Progressive disease 
14 
29 
 
Thus, EPOCH-F was associated with an overall response rate of 37% in 
this relatively chemoresistant patient population, while nearly one-third of 
patients developed progressive disease while receiving this induction 
regimen.  Analysis of the 15 patients with diffuse large B cell lymphoma 
indicates that at study entry, 6 had primary refractory disease, 7 were in 
refractory relapses, and 2 were in complete remission.  After receiving 
EPOCH-F, 8 patients had disease progression, 5 had stable disease, and 1 
achieved a partial response.  1 patient remained in CR that existed before 
study entry.  Therefore, results in this subgroup were consistent with those 
of the overall study population. 
 
1.2.5 EPOCH-F Results in CC 99-C-0143 – Immune Depletion.  25 patients 
received 3 cycles of EPOCH-F before transplantation, the maximum 
number permitted by the protocol.  11 patients received only 2 cycles, and 
12 patients received only 1 cycle.  Reasons for proceeding to 
transplantation after fewer than 3 cycles of EPOCH-F included:  having 
reached CD4 < 50/µl (n=8); progressive disease on EPOCH-F (n=11); 
withdrawal from study (n=1, not transplanted); unacceptable toxicity from 
EPOCH-F (n=3).  The effect of EPOCH-F induction on circulating 
lymphocyte subpopulations is shown in the following table: 
 
  
 Median CD4 
(range) 
 Median CD8 
(range) 
Median ALC 
(range) 
Baseline 
283 (9-1697) 
261 (13-3478)  
837 (37-282,854) 
Post cycle 1  
212 (12-1004)  
117 (5-1484)  
582 (68-196,770) 
Post cycle 2  
151 (39-388)  
75 (17-571)  
487 (1-177,742) 
Post cycle 3  
97 (48-309)  
52 (2-830)  
393 (141-171,952) 
Pre-transplant  
89 (12-452)  
52 (2-830)  
380 (1-171,952) 
 
Although the goal CD4 count of less than 50 cells/µl was reached in only 
14 of 48 patients following induction, all patients who underwent 
transplantation 
demonstrated 
evidence 
of 
predominantly 
donor 
engraftment, with only one patient having < 95% donor chimerism at day 
+28 following transplantation.  Thus, the inability to reach a CD4 target of 
50 cells/µl in all patients was not an impediment to engraftment in CC 99-
C-0143; in fact, 24 of these patients had CD4 counts > 100/µl before 
receiving the transplant conditioning regimen.  This outcome suggests that 
as a surrogate marker for immune depletion, the CD4 target of 50/µl was 
lower than necessary to ensure early engraftment with full donor 

10 
chimerism in the setting of a T-cell-replete, reduced-intensity allogeneic 
HSCT.  It therefore follows that some patients with stable or responsive 
disease 
received 
more 
cycles 
of 
immune-depleting 
induction 
chemotherapy than was required to ensure engraftment, resulting in delays 
before transplantation for these patients.  Choosing a higher CD4 target 
might permit some patients to proceed to transplant with fewer cycles of 
induction therapy; this would be of particular benefit to patients with 
minimal disease or stable disease during EPOCH-F. 
 
1.2.6 EPOCH-F Results in CC 99-C-0143 – Toxicity.  EPOCH-F was a well-
tolerated regimen in this population, with no treatment-related deaths 
attributed to the induction therapy.  In 109 cycles of EPOCH-F, only 7 
patients experienced grade 4 non-hematologic toxicity, including anorexia 
(n=4), vomiting (n=1), catheter-related sepsis (n=1), and viral encephalitis 
(n=1).  Grade 4 hematologic toxicity occurred in 16 patients and lasted a 
median of 4 days per episode (range, 2-8 days).  These included 24 
episodes of neutropenia, of which 4 were associated with documented 
infections.  There were also 2 episodes of grade 4 thrombocytopenia. 
 
Grade 3 non-hematologic toxicity affected 28 patients and lasted a median 
of 4 days, including 12 episodes of neutropenic fever and 6 documented 
infections (of which 2 coincided with grade 3 or 4 neutropenia).  Other 
grade 3 events were sporadic, including:  hypoxia, motor neuropathy, 
neuropathic pain, and hyperbilirubinemia (2 episodes each); sensory 
neuropathy, hyponatremia, syncope, anorexia, diarrhea, hypotension, 
urinary frequency, thrombotic microangiopathy, bone pain, rectal pain, 
pain-other (1 episode each). 
 
To summarize, results from CC 99-C-0143 indicate that the EPOCH-F 
induction regimen provides disease control or stability in a majority of 
patients with refractory or relapsed hematologic malignancies, with an 
acceptable toxicity profile.  However, the fact that nearly one-third of 
patients had disease progression while receiving EPOCH-F provides a 
strong rationale for attempting to intensify this induction regimen, given 
the importance of disease control before transplantation in the reduced-
intensity setting.  The generally mild and reversible nature of toxicities 
observed with EPOCH-F suggests that intensification of this induction 
regimen could be achieved without an unacceptable increase in adverse 
events. 
 
1.2.7 EPOCH-Fludarabine/Rituximab (EPOCH-F/R) Induction for Disease 
Control and Sequential Immune Depletion before Reduced-Intensity 
Allogeneic HSCT:  Consistent with the above, in the current study we will 
pilot a new induction chemotherapy regimen based upon the EPOCH-F 
regimen used in CC 99-C-0143.  In that protocol, the EPOCH component 
of the induction regimen was an attenuated version of EPOCH as used in 

11 
previous NCI Medical Oncology Clinical Research Unit studies [16-18].  
Specifically, our EPOCH regimen (as a part of EPOCH-F) differed from 
other EPOCH protocols in that the infusional component was reduced 
from four days to three, prednisone was reduced from five days to four, 
and cyclophosphamide was given on day 4 (instead of day 5) at a 20% 
lower dose.  These changes were made to allow for the possibility of 
added toxicity from the addition of fludarabine to the EPOCH regimen. 
 
The differences between the EPOCH-F induction regimen of CC 99-C-
0143 and the current proposal are outlined as follows, with changes 
underlined: 
 
CC 99-C-0143 
EPOCH-F 
Current Proposal 
EPOCH-F/R 
 
Rituximab 375 mg/m2 IV, day 1 
(for patients with CD20+ malignancies) 
Fludarabine 25mg/m2 IV QD, days 1-3 
Fludarabine 25mg/m2 IV QD, days 1-4 
Etoposide 50 mg/m2 
Doxorubicin 10 mg/m2 
Vincristine 0.5 mg/m2 }CIV QD, days 1-3 
Etoposide 50 mg/m2 
Doxorubicin 10 mg/m2 
Vincristine 0.4 mg/m2 }CIV QD, days 1-4 
Prednisone 60 mg/m2 PO QD, days 1-4 
Prednisone 60 mg/m2 PO QD, days 1-5 
Cyclophosphamide 600 mg/m2 IV, day 4 
Cyclophosphamide 750 mg/m2 IV, day 5 
 
The increases in prednisone, cyclophosphamide, and the infusional 
component of EPOCH (etoposide, doxorubicin, and vincristine) are 
intended to achieve the full dose intensity of other NCI MOCRU protocols 
employing EPOCH chemotherapy.  Increasing fludarabine from three to 
four days of administration is expected to potentiate both disease control 
(many of the patients in CC 99-C-0143 were fludarabine naïve) and 
immune depletion prior to transplantation.  We anticipate that the 
proposed increases in dose intensity (including the addition of rituximab) 
will not be associated with a significant increase in toxicity over what was 
seen with EPOCH-F in CC 99-C-0143.  However, as a precaution our 
study design will allow for a reduction in dose intensity of the EPOCH-
F/R regimen if specified toxicity criteria are met (Section 3.3.6).  
 
For patients with CD20+ malignancies, adding the monoclonal antibody 
rituximab to the regimen is expected to boost the rate of response to 
EPOCH-F without significantly increasing the regimen’s toxicity.  Such 
an effect has been demonstrated in other studies where rituximab was 
administered with EPOCH or CHOP.  In a phase II study, Wilson and 
colleagues administered dose-adjusted EPOCH plus rituximab to 38 
patients with previously untreated aggressive or relapsed/resistant CD20+ 
B-cell lymphomas.   An interim report indicates an 85% complete 
response rate among 34 evaluable patients; further, no patient in remission 
had progressed, with a median follow-up of 12 months.  Hematologic 
toxicities were consistent with the dose-adjusted paradigm employed with 

12 
the EPOCH regimen, and non-hematologic toxicities were infrequent [22].  
Similarly, Vose and colleagues conducted a phase II trial of CHOP plus 
rituximab in 33 previously untreated patients with aggressive B-cell non-
Hodgkin’s lymphomas.  The overall response rate was 94%, with 
complete responses in 61%.  After a median observation time of 26 
months from remission, 29 of 31 patients who achieved CR or PR 
remained in remission.  Observed toxicities were similar to those seen in 
studies of CHOP alone [23].  In a randomized study of 399 elderly patients 
with diffuse large B-cell lymphoma, complete responses were seen in 76% 
of patients receiving CHOP plus rituximab, versus 63% of patients treated 
with CHOP.  Importantly, CHOP plus rituximab improved event-free and 
overall survival compared with CHOP alone, with no clinically significant 
difference in toxicity between the two arms [24].   
 
Rituximab has been used as part of a reduced-intensity transplant 
conditioning regimen, with no adverse effect on hematopoietic recovery 
and engraftment and no reported impact on GVHD [25].  Ratanatharathorn 
and colleagues used rituximab to treat a patient with chronic GVHD and 
refractory immune thrombocytopenic purpura (ITP), leading to 
improvement in the patient’s ITP and allowing the discontinuation of 
immunosuppression without progression of her chronic GVHD [26].  
Apart from this highly anecdotal report, no published clinical data suggest 
that rituximab has activity in the prevention or treatment of GVHD; 
moreover, our current understanding of the pathophysiology of acute 
GVHD does not support a putative role for B-lymphocytes, so there is no 
rational basis for using rituximab to prevent or modulate GVHD.  In this 
protocol, patients will receive rituximab no closer than four weeks before 
undergoing allogeneic HSCT, reducing the likelihood of an effect on 
donor B-cells after transplantation.  For these reasons, we do not anticipate 
that combining rituximab with the EPOCH-F induction regimen (as 
EPOCH-F/R) will influence the primary GVHD endpoints of the current 
study.  However, we will analyze for an effect of rituximab administration 
on 
hematopoietic 
recovery, 
donor/recipient 
chimerism, 
and 
the 
development of acute GVHD. 
 
1.2.8 Cyclosporine/Methotrexate as Graft-Versus-Host Disease Prophylaxis:  
Although the combination of cyclosporine and methotrexate represents the 
de facto “gold standard” for acute GVHD prophylaxis in allogeneic 
HSCT, the use of cyclosporine monotherapy in CC 99-C-0143 was based 
partly upon the early belief that the incidence of GVHD might be lower 
following a reduced-intensity conditioning regimen [27].  In addition, 
there were concerns that more aggressive GVHD prophylaxis might 
compromise engraftment of donor stem cells, as the approach in CC 99-C-
0143 had not previously been validated.  With single-agent cyclosporine, 
12 of the first 19 patients in CC 99-C-0143 developed grades II – IV acute 
GVHD; these patients did not receive donor Th2 cells.  In six of these 

13 
patients, acute GVHD was severe (grades III-IV); two deaths were 
attributed to GVHD, while 4 additional patients died with progressive 
disease and grade II or III acute GVHD.  Another 3 patients died of 
progressive disease with absent or grade I acute GVHD.  These 
observations suggest that cyclosporine monotherapy is inadequate 
immunosuppression in the face of relatively rapid and complete 
engraftment of donor lymphoid cells. 
 
Other studies of reduced-intensity allogeneic HSCT have also shown acute 
GVHD to contribute significantly to morbidity and mortality.  In an 
attempt to improve this clinical problem, this protocol will evaluate dual-
agent GVHD prophylaxis with cyclosporine and methotrexate as a 
potential strategy for preventing GVHD after reduced-intensity allogeneic 
HSCT.  This approach differs from our other strategy for modulating 
GVHD, combining cyclosporine and donor Th2 cells.  These two 
strategies (addition of methotrexate versus addition of donor Th2 cells) 
may have differential effects not only on GVHD modulation, but also on 
engraftment and anti-tumor effects.  To this extent, after establishing the 
cyclosporine and methotrexate approach in this protocol, it will likely be 
beneficial to compare these two approaches in a randomized study. 
 
In the ongoing study involving Th2 cells, 23 patients have received 
allogeneic HSCT and Th2 cells.  Each of these patients achieved rapid full 
donor chimerism, with median day 14 donor chimerism of 100% (range, 
85 to 100).  Recovery of hematopoiesis was rapid, with a median 
neutrophil recovery at day 9 post-SCT (range, 7 to 13 days) and median 
platelet recovery at day 11.5 post-SCT (range, 8 to 12 days).  Immune 
reconstitution research data indicates that Th2 cells promote donor T cell 
expansion and donor T cell cytokine secretion following HSCT.  Acute 
GVHD severity in Th2 recipients has been Grade 0 (9/23 cases), Grade II 
(7/23 cases), and Grade III to IV (7/23 cases); these proportions are 
similar to those receiving allogeneic HSCT without Th2 cells.  Significant 
anti-tumor responses have been observed in Th2 recipients.  Of 22 
evaluable patients after HSCT, 1/22 patients had a minor response (25 to 
50% tumor reduction), 6/22 patients entered into a PR, and 15/22 patients 
entered into a CR.  This high response rate, occurring in a patient 
population demonstrated to be chemotherapy refractory, suggests that 
allogeneic HSCT with Th2 cells is associated with a potent anti-tumor 
effect.  Overall, seven of 23 Th2 recipients have died post-SCT.  Three of 
these cases were associated with progressive disease, whereas 4 cases 
were not associated with progressive disease and were primarily related to 
transplant-related toxicity, GVHD, or immune suppression from GVHD 
therapy.  Sixteen of 23 recipients are currently alive at a median of 156 
days post-SCT (range, 47 to 606 days).  This data from Th2 recipients, 
when combined with future data generated from this protocol evaluating 
cyclosporine and methotrexate GVHD prophylaxis, will be used to 

14 
determine if a randomized study comparing these two approaches might 
be warranted. 
 
Studies comparing methotrexate with cyclosporine as single agent 
prophylaxis for GVHD showed the two agents to be roughly equivalent in 
their efficacy [28].  The methotrexate regimen administered in these 
studies was 15 mg/m2 IV on day 1, then 10 mg/m2 IV on days 3, 6, 11, and 
every 7 or 14 days thereafter until day 102 after transplantation. 
Combination regimens with methotrexate plus cyclosporine or FK506 
(tacrolimus) have been used successfully for GVHD prophylaxis in both 
myeloablative and reduced-intensity transplantation settings.  Storb and 
colleagues first compared the combination of cyclosporine and 
methotrexate with cyclosporine monotherapy, showing in a randomized 
trial that the combination reduced GVHD and improved survival [29, 30].  
In this study, a short course of methotrexate was administered at doses of 
15 mg/m2 IV on day 1 and 10 mg/m2 IV on days 3, 6, and 11 after 
transplantation; however, acute toxicity (mainly mucositis and renal 
insufficiency) still prevented completion of the full course of methotrexate 
in 42% of patients.  Modified combination regimens with reduced 
methotrexate doses and/or shortened courses have subsequently been 
studied, although not in a prospective, randomized fashion; these appear to 
decrease the acute toxicity of methotrexate administration while 
preserving the benefits with respect to GVHD [31-34].  A commonly used 
regimen that has emerged from these studies is “mini-dose” methotrexate, 
given as 5 mg/m2 on days 1, 3, 6, and 11. 
 
In the setting of reduced-intensity allogeneic HSCT, studies of 
combination regimens (cyclosporine or tacrolimus, with methotrexate) 
have not been associated with high rates of graft rejection.  GVHD 
outcomes in these studies have been inconsistent, with rates of grades III-
IV acute GVHD ranging from 5% to 29%; this variability may reflect 
differences in transplant conditioning regimens and other risk factors [25, 
35-37].  It therefore appears that dual-agent GVHD prophylaxis regimens 
containing methotrexate do not inhibit engraftment in the reduced-
intensity transplant setting and may provide better prophylaxis of acute 
GVHD than cyclosporine monotherapy.  Considering these factors, we 
intend to use cyclosporine with a mini-dose methotrexate regimen for 
GVHD prophylaxis in the current protocol.  The evaluation of this 
regimen in the current study will serve as a platform for further evaluation 
of donor Th2 cells in a subsequent randomized study (see Section 1.2.2), 
with cyclosporine and methotrexate as a control arm versus cyclosporine 
and Th2 cells. 
 
We believe (and other investigators have demonstrated) that the 
conversion to full donor chimerism after transplantation is a prerequisite 
for developing a GVT response [38].  Although engraftment kinetics and 

15 
the development of a GVT effect could be altered by the use of 
cyclosporine and methotrexate in the current study, the robust engraftment 
seen in CC 99-C-0143, with achievement of early donor chimerism in 
nearly all patients transplanted (Section 1.2.5), provides reassurance in the 
face of such concerns.  As a secondary endpoint, we will evaluate the 
effect of the combination GVHD prophylaxis regimen upon hematologic 
recovery and chimerism in this study. 
 
1.2.9 Peripheral CD4 Lymphocyte Counts as a Surrogate Marker for Immune 
Depletion before Reduced-Intensity Allogeneic HSCT:  The robust 
engraftment results observed on CC 99-C-0143 support the principle of 
sequential immune depletion with an induction regimen such as EPOCH-
F/R.  Engraftment occurred similarly in patients across a range of CD4 
counts prior to transplantation, suggesting that pre-transplant immune 
depletion was adequate within that range.  Because no episodes of graft 
rejection were observed, it is not possible to derive from our results a 
“threshold level” of CD4 lymphopenia that distinguishes between patients 
likely to engraft versus those likely to experience graft rejection.  In 
addition, 
the 
CD4 
count 
may 
underestimate 
the 
level 
of 
immunosuppression after chemotherapy, as there may be functional 
abnormalities in residual CD4+ T cells after chemotherapy that reduce the 
likelihood of a host-versus-graft response and graft failure [39].  
Nevertheless, it is likely that some patients in CC 99-C-0143 received 
induction cycles of EPOCH-F beyond the point at which engraftment 
would have occurred and without further benefit in terms of disease 
response.  For such patients (i.e., those in remission or with stable 
disease), additional cycles of EPOCH-F – administered with the goal of 
achieving a CD4 count less than 50/µl – would have provided no clinical 
benefit and may have resulted in added toxicity. 
 
It is plausible that a higher CD4 level (e.g., 200/µl or more) would be 
sufficient immune depletion to ensure engraftment; 90% of patients in CC 
99-C-0143 had a CD4 count below 200/µl after EPOCH-F, and this level 
of CD4 lymphopenia corresponds to a demonstrable reduction in cell-
mediated 
immunity 
in 
other 
clinical 
settings 
(e.g., 
human 
immunodeficiency virus infection).  However, the addition of 
methotrexate to our GVHD prophylaxis regimen (see above) could 
increase the frequency of mixed chimerism after transplantation, as well as 
the risk of graft rejection.  In the setting of T-cell-depleted allogeneic 
HSCT, the CD4 level before reduced-intensity conditioning correlates 
inversely with levels of donor lymphoid chimerism after transplantation 
(M. Bishop, personal communication).  Balancing these considerations 
with the desire to minimize toxicity from the induction regimen, we have 
empirically chosen a CD4 level below 100 cells/µl after induction therapy 
with EPOCH-F/R as a target for the current study.  Failure to reach this 
target after 3 cycles of induction therapy or due to disease progression will 

16 
not, however, prevent patients from proceeding to transplantation.  As in 
CC 99-C-0143, we will correlate the CD4 count after EPOCH-F/R with 
engraftment outcomes following transplantation, in a further effort to 
validate the CD4+ T cell count as a surrogate marker for immune 
depletion before transplantation. 
 
1.2.10 FDG-PET versus CT Scanning in Hodgkin’s and Non-Hodgkin’s 
Lymphoma:  After allogeneic HSCT for Hodgkin's disease and non-
Hodgkin's lymphoma, traditional imaging modalities such as computed 
tomography (CT) scanning are suboptimal for detecting residual or 
relapsed malignancy post-transplant.  Restaging of patients with a history 
of bulky disease using CT scanning typically does not differentiate 
between a residual non-malignant mass (CR/unconfirmed; CRu [40]) or 
persistent malignant disease.  Fluorine-18 fluorodeoxyglucose positron 
emission tomography (FDG-PET) scanning, because it measures 
biologically active tumor, may allow one to distinguish patients with CRu 
from those with persistent malignancy [41].  In addition, because of its 
greater sensitivity compared with CT scanning, the use of FDG-PET may 
permit earlier detection of malignant disease progression post-transplant.  
The ability to distinguish CRu from persistent disease and to detect early 
relapse may improve transplant therapy, as patients with disease 
persistence or progression may benefit from transplant modulation such as 
early withdrawal of immune suppression or administration of donor 
lymphocytes. 
 
In this study, we will use both FDG-PET and CT scanning in the staging 
of patients with Hodgkin's and non-Hodgkin's lymphoma.  These studies 
will be obtained at study entry; before admission for allogeneic SCT (after 
induction chemotherapy with EPOCH-F/R); and on days 28 and 100 after 
allogeneic HSCT.  Combined modality imaging will assist in 
distinguishing between CRu (PET negative) and persisent malignancy 
(PET positive) after transplantation.  In cases where patients enter into CR 
after allogeneic HSCT, FDG-PET and CT will be obtained at 6 and 12 
months post-transplant to facilitate the earlier detection of disease relapse. 
 
1.2.11 Interleukin-7 and Allogeneic HSCT:  Immune reconstitution following 
allogeneic HSCT is a prolonged process, influenced strongly by the age 
and corresponding thymic function of the transplant recipient, as well as 
the presence or absence of GVHD.  Natural killer cells recover to normal 
levels soon after immune-depleting therapy, followed closely by B-cells 
within 1 to 3 months.  Peripheral blood CD8+ T cells generally return to 
normal levels within 3 to 6 months, while CD4+ T-cell lymphopenia may 
persist for 24 months or longer [42].  Interleukin-7 (IL-7) is a major 
cytokine regulator of B-cell development and T-lymphocyte homeostasis 
[43].  Several recent reports indicate that circulating levels of IL-7 
increase in response to lymphocyte or T-cell depletion in the setting of 
bone marrow transplantation, HIV infection, and cytotoxic chemotherapy 

17 
[44-46].  This homeostatic response appears to correlate most strongly 
with circulating numbers of CD4+ T cells, and it leads to increased thymic 
output and in particular to the thymic-independent peripheral expansion of 
mature T cells.  In animal models of bone marrow transplantation or 
cytotoxic chemotherapy, administration of IL-7 increases the rate of T-cell 
immune reconstitution [47-49].  In one murine allogeneic BMT model, 
this effect was not associated with exacerbation of GVHD [49].  However, 
Sinha recently reported the finding that IL-7 significantly potentiates 
GVHD after allogeneic BMT in mice, an effect that increased with the 
number of T cells in the allograft [50]. 
 
In CC 99-C-0143, our group has studied the kinetics of CD4+ T-cell 
depletion in the setting of sequential immune depletion and reduced-
intensity allogeneic HSCT as outlined above (Section 1.2.5).  Other work 
by investigators in our branch has documented the variable recovery of 
CD4+ T cells following cytotoxic chemotherapy [39].  However, no 
published studies have specifically correlated serum IL-7 levels with 
lymphocyte subpopulations prior to transplantation and during immune 
recovery afterwards.  We will include such an analysis as a secondary 
endpoint of this study, hypothesizing that serum IL-7 levels will correlate 
strongly with changes in lymphocyte subpopulations, especially CD4+ T 
cells, during immune-depleting chemotherapy and after reduced-intensity 
transplantation.  Additionally, we will assess the relationship between IL-7 
levels and the development of clinical GVHD, as this has not been 
determined previously. 
 
1.2.12 Interleukin-15 and Allogeneic HSCT:  A second cytokine that could play a 
key role in lymphocyte recovery in the post-transplant period is interleukin 
15 (IL-15), an important cytokine in the differentiation, maintenance and 
expansion of NK and CD8+ T cells [51].  IL-15 is constitutively and 
ubiquitously produced by antigen presenting cells [52].  Its production, 
moreover, is upregulated by a variety of stimuli that evoke an 
inflammatory response [53].  Kumaki has reported that serum levels of IL-
15 were elevated following transplant conditioning with myeloablative 
chemotherapy and total body irradiation [54]; furthermore, this elevation 
was prolonged in patients who developed acute GVHD.  This work, 
however, did not assess any correlation between IL-15 levels and 
lymphocyte recovery in these patients. 
 
IL-15 enhances CD8 production by thymopoiesis [55], but its main role 
appears to be in the periphery.  IL-15, like IL-7, can stimulate homeostatic 
expansion of CD8+ T cells, particularly memory CD8+ T cells [56, 57].  
Evidence from IL-15 and IL-15Rα knock-out mice demonstrates that IL-
15 is critical to maintaining CD8+ T cell memory populations [58, 59].  
IL-15 also stabilizes activated human T cells, reducing their level of 
apoptosis [60].  Furthermore, IL-15 has been reported to reduce the high 

18 
level of spontaneous apoptosis observed in post-transplant lymphocytes 
cultured in vitro [61].  There is a marked dichotomy between the high 
frequency of CD8+ T cell apoptosis in vitro and the elevated CD8 
populations maintained in most post-transplant recipients in vivo.  The 
anti-apoptotic efficacy of IL-15 in vitro would support the hypothesis that 
in vivo IL-15 production may be maintaining CD8+ T cell viability. 
 
IL-15 may also play a role in the functional capacities of post-transplant 
CD8+ T cells.  IL-15 upregulates the expression of co-stimulatory 
receptors, such as NKG2D, on activated CD8+ T cells [62].  These 
receptors may be important in the cytotoxic responses to stress and to viral 
infection, both relevant in the post-transplant period [63].  The role of 
these receptors in the allogeneic responses of GVHD has not been studied. 
 
IL-15 is also the central cytokine in the differentiation, expansion and 
activation of NK cells [64].  NK cells are the earliest of the lymphocyte 
populations to recover to pre-treatment levels following transplantation or 
chemotherapy [39].  Cytokines such as IL-4 and IFNγ produced by NK 
cells may play a critical role in initiating type I and type II T cell 
responses [64].  Further, NK cells may be critical cytotoxic effectors in the 
graft-versus-leukemia response, without corresponding GVHD [65, 66].  
IL-15 is the central cytokine supporting the differentiation of both the 
cytokine producing and the cytotoxic subpopulations of NK cells [59, 64, 
67].  As is the case with CD8+ T cells, the expression levels of NK 
receptors involved in activating or inhibiting cytotoxicity may also be 
altered by IL-15.  The repertoire of such receptors expressed by NK cells 
following transplantation may affect their function in GVHD or GVL [65].  
The role of IL-15 in the post transplant recovery of NK cells and in the 
repertoire of receptors expressed by these cells, however, has never been 
explored. 
 
These observations suggest an important physiologic role for IL-15 in the 
recovery and maintenance of NK and CD8+ T cells after immune 
depletion related to cytotoxic chemotherapy or HSCT, with potential 
implications for tumor-specific immune responses and immune 
reconstitution following transplantation.  The additional observation that 
IL-15 levels remained elevated in patients with acute GVHD raises the 
possibility of further interactions between IL-15 and lymphocyte 
subpopulations in the pathogenesis of GVHD.  We therefore intend to 
correlate serum levels of IL-15 with circulating CD8+ T cell and NK cell 
populations, during sequential immune depletion and after reduced-
intensity allogeneic HSCT during immune recovery.  The purpose of this 
analysis will be to explore potential relationships among IL-15, 
lymphocyte subpopulations, and the development of GVHD. 
 

19 
1.3 
Summary:  The strategy proposed in this protocol has several goals.  First, we will 
pilot an intensified induction chemotherapy regimen, EPOCH-F/R, by building on 
the EPOCH-F component used in CC 99-C-0143 and adding rituximab for 
patients with CD20+ malignancies, in order to improve disease control and 
accelerate immune depletion to our CD4 target level of less than 100 cells/µl.  
Second, and most importantly, we will employ a dual-agent regimen of 
cyclosporine and methotrexate for GVHD prophylaxis, with the objective of 
improving upon the incidence of acute GVHD observed in CC 99-C-0143.  Third, 
we will correlate serum levels of IL-7 and IL-15 with changes in circulating 
lymphocyte subpopulations during sequential immune depletion with EPOCH-
F/R and after reduced-intensity allogeneic HSCT, to contribute to our 
understanding of the immunologic mechanisms that underlie immune ablation, 
activation and reconstitution in the transplant setting.  The stated goals will permit 
our group to refine our approach to reduced-intensity allogeneic HSCT for 
refractory and relapsed hematologic malignancies, setting the stage for subsequent 
research efforts such as a randomized trial of donor Th2 cells. 
 

20 
2.0 
Eligibility Assessment and Enrollment 
2.1 
Eligibility Criteria 
 
2.1.1 Inclusion Criteria – Patient (Recipient): 
a) Patients 
with 
hematologic 
malignancies, 
myelodysplasia, 
or 
myeloproliferative disorders, as summarized in the following table: 
Disease 
Disease Status 
Age 
Chronic Lymphocytic Leukemia 
a) Relapse post-fludarabine 
b) Non-CR after salvage regimen 
18 to 75 
Hodgkin’s and Non-Hodgkin’s Lymphoma 
(all types, including Mantle Cell Lymphoma) 
a) Primary treatment failure 
b) Relapse after autologous SCT 
c) Hepatosplenic gamma/delta T cell 
lymphoma 
18 to 75 
Multiple Myeloma 
a) Primary treatment failure 
b) Relapse after autologous SCT 
c) Non-CR after salvage regimen 
18 to 75 
Acute Myelogenous Leukemia 
a) In Complete Remission #1, with 
high-risk cytogenetics 
[abnormalities other than t(8;21), 
t(15;17), or inv(16)] 
b) In Complete Remission #2 or 
greater 
18 to 75 
Acute Lymphocytic Leukemia 
a) In Complete Remission #1, with 
high-risk cytogenetics 
[e.g., t(4;11), t(1;19), t(8;14); 
t(9;22) or bcr-abl rearrangement] 
b) In Complete Remission #2 or 
greater  
18 to 75 
Myelodysplastic Syndrome 
a) RAEB 
b) RAEB-T (if blasts are < 10% in 
marrow and blood after induction 
chemotherapy) 
18 to 75 
Myeloproliferative disorders 
a) Idiopathic myelofibrosis 
b) Polycythemia vera 
c) Essential thrombocytosis 
d) Chronic myelomonocytic 
leukemia 
18 to 75 
Chronic Myelogenous Leukemia 
a) Chronic phase CML 
b) Accelerated phase CML 
50 to 75 
c) Not eligible for myeloablative 
allogeneic HSCT 
18 to 50 
 
 
 

21 
b) Patients 18 - 75 years of age.  Patients older than 75 years of age will 
be considered on an individual basis [68]. 
c) Consenting first degree relative matched at 6/6 HLA antigens (A, B, 
and DR). 
d) Patient or legal guardian must be able to give informed consent. 
e) All previous cytotoxic chemotherapy must be completed at least 2 
weeks prior to study entry.  Any grade 3 or 4 non-hematologic toxicity 
of any previous therapy must have resolved to grade 2 or less, unless 
specified elsewhere in Section 2.1. 
f) ECOG performance status equal to 0, 1, or 2, and Karnofsky 
performance status greater than or equal to 60%. 
g) Life expectancy of at least 3 months. 
h) Patients with acute leukemia must be in hematologic remission, 
defined as less than 5% blasts present in blood or bone marrow. 
i) Left ventricular ejection fraction > 45% by either MUGA or 2-D echo, 
obtained within 28 days of enrollment.  The cumulative dose of 
doxorubicin received by patients will not be considered, as the cardiac 
ejection fraction appears to indicate the safe cumulative doxorubicin 
dose in the setting of EPOCH-based chemotherapy [18]. 
j) DLCO > 50% of the expected value when corrected for Hb [69], 
obtained within 28 days of enrollment. 
k) Creatinine < 1.5 mg/dl and creatinine clearance > 50 ml/min/1.73 m2. 
l) Serum total bilirubin less than 2.5 mg/dl, and serum ALT and AST 
values less than or equal to 2.5 times the upper limit of normal.  
Values above these levels may be accepted, at the discretion of the PI 
or LAI, if such elevations are thought to be due to liver involvement 
by malignancy.  If these values do not normalize during induction 
chemotherapy, such patients will not be eligible for the transplant 
phase of the protocol, and will thus be taken off study. 
m) Minimum absolute neutrophil count of 1,000 cells/μl and minimum 
platelet count (without transfusion) of 20,000/mm3.  Values below 
these levels may be accepted at the discretion of the PI or LAI, if 
thought to be due to bone marrow involvement by malignancy. 
 
2.1.2 Inclusion Criteria – Donor: 
a) First-degree relative with genotypic identity at 6/6 HLA loci (HLA- A, 
B, and DR). 
b) Ability to give informed consent.  For donors under 18 years of age, 
the donor must complete an assent form, and the donor’s legal 
guardian must complete an informed consent form. 
c) Age 12 – 75 years.  As the potential cerebrovascular and cardiac 
complications may potentially increase with age, age 75 has been 
chosen arbitrarily as the upper age limit.  However, if it is determined 
after initial accrual of patients in this upper age range that this 
procedure is relatively safe, the age range may be extended. 

22 
d) Adequate venous access for peripheral apheresis, or consent to use a 
temporary central venous catheter for apheresis. 
e) Donors must be HIV negative, hepatitis B surface antigen negative, 
and hepatitis C antibody negative.  This is to prevent the possible 
transmission of these infections to the recipient. 
f) A donor who is lactating must substitute formula feeding for her infant 
during the period of cytokine administration.  Filgrastim may be 
secreted in human milk, although its bioavailability from this source is 
not known [70].  Limited clinical data suggest that short-term 
administration of filgrastim or sargramostim to neonates is not 
associated with adverse outcomes [71]. 
 
2.1.3 Exclusion Criteria: Patient 
a) Active infection that is not responding to antimicrobial therapy. 
b) Active CNS involvement by malignancy. 
c) HIV infection.  There is theoretical concern that the degree of immune 
suppression associated with the treatment may result in progression of 
HIV infection.   
d) Chronic active hepatitis B.  Patients may be hepatitis B core antibody 
positive but must be surface antigen negative and without evidence of 
active infection. 
e) Hepatitis C infection. 
f) Pregnant or lactating.  Patients of childbearing potential must use an 
effective method of contraception. The effects of the chemotherapy, 
the subsequent transplant and the medications used after the transplant 
are highly likely to be harmful to a fetus.  The effects upon breast milk 
are also unknown and may be harmful to the infant. 
g) History of psychiatric disorder which may compromise compliance 
with transplant protocol, or which does not allow for appropriate 
informed consent (as determined by principal investigator or study 
chairman).   
 
2.1.4 Exclusion Criteria: Donor  
a) History of psychiatric disorder which may compromise compliance 
with transplant protocol, or which does not allow for appropriate 
informed consent.  
b) History of hypertension that is not controlled by medication, stroke, or 
severe heart disease.  Individuals with symptomatic angina will be 
considered to have severe heart disease and will not be eligible to be a 
donor. 
c) No other medical contraindications to stem cell donation (i.e. severe 
atherosclerosis, autoimmune disease, cerebrovascular accident, prior 
malignancy) [72].  Patients with a history of coronary artery bypass 
grafting or angioplasty will receive a cardiology evaluation and be 
considered on a case-by-case basis.  Persons with a history of non-
hematologic malignancy must have undergone potentially curative 

23 
therapy for that malignancy and (1) have had no evidence of that 
disease for 5 years, and/or (2) be deemed at low risk for recurrence 
(less than or equal to 20% at 5 years).  Such persons will be considered 
eligible for stem cell donation at the discretion of the principal 
investigator, who will evaluate the possible benefit to the potential 
transplant recipient and the risk of disease transmission in consultation 
with Department of Transfusion Medicine staff.  Prospective donors 
with a history of non-hematologic malignancy who have received 
potentially curative therapy and are in remission, but whose estimated 
risk of recurrence is greater than 20% at 5 years, will be considered on 
an individual basis in consultation with the NCI IRB.  Any prospective 
transplant recipient whose donor has a history of malignancy will be 
counseled about the theoretical risk of transmission of cancer from the 
donor to the recipient. 
d) Donors must not be pregnant.  The effects of cytokine administration 
on a fetus are unknown.  Donors of childbearing potential must use an 
effective method of contraception. 
e) Anemia (Hb less than 11 gm/dl) or thrombocytopenia (platelets less 
than 100,000 per µl). 
 
2.2 
Research Eligibility Evaluation: 
2.2.1 The following clinical, laboratory and radiologic assessments must be 
performed in the patient (recipient) within 28 days before the initiation of 
induction chemotherapy (Section 3.3) to determine disease status: 
a) Complete medical history and physical examination. 
b) Nutritional assessment (initial consult). 
c) Dental consultation to assess need for teeth cleaning or removal. 
d) Social work consultation. 
e) Typing for HLA-A, -B, and –DR. 
f) Antibody screen for hepatitis A, B, and C; HIV, HTLV-I/II, CMV, 
adenovirus, EBV, HSV, Toxoplasma, and syphilis. 
g) PPD test (if considered to be in a high-risk group). 
h) PT, PTT, and ABO typing. 
i) Urinalysis. 
Items (j) through (l) should be obtained within 48 hours before starting 
induction chemotherapy. 
j) CBC with differential. 
k) Acute care panel, hepatic panel, and mineral panel. 
l) Urine βHCG in women of childbearing potential. 
m) Unilateral bone marrow aspirate and biopsy.  Flow cytometry, 
cytogenetics, and molecular testing via polymerase chain reaction 
(PCR) should be performed on marrow aspirates as deemed clinically 
appropriate for specific diseases. 
n) Chest radiograph. 
o) Electrocardiogram. 

24 
p) CT scans of chest, abdomen, and pelvis (neck included if measurable 
disease is present). 
q) CT or MRI of the head. 
r) PET scan for recipients with non-Hodgkin’s lymphoma or Hodgkin’s 
lymphoma [41]. 
s) Skeletal survey (for multiple myeloma patients only). 
t) Other specific serum or urine diagnostic studies clinically appropriate 
for the evaluation of recipient’s malignancy (e.g., SPEP and UPEP for 
multiple myeloma). 
u) All biopsy specimens will be reviewed by the Laboratory of 
Pathology, CCR, NCI, for confirmation of the histologic diagnosis 
prior to initiation of therapy. 
v) Biopsy material or blood samples from patients with B-cell 
malignancies will be tested for CD20 expression, to confirm eligibility 
for rituximab with induction chemotherapy.  CD20 expression will be 
determined by immunohistochemistry or flow cytometry in the 
Laboratory of Pathology, CCR, NCI. 
w) Flow cytometric analysis of peripheral blood for baseline measurement 
of CD3, CD4, CD8, and CD56 positive lymphocyte populations. 
x) Baseline determination of serum IL-7 and IL-15 levels, for correlation 
with NK and T-cell subpopulations (above). 
y) PCR test of DNA mini-satellite regions for future determination of 
chimerism. 
2.2.2 The following clinical, laboratory and radiologic assessments must be 
performed in the donor within 28 days before study enrollment: 
a) Complete medical history and physical examination. 
b) Social work consultation. 
c) Typing for HLA-A, -B, and –DR. 
d) Antibody screen for hepatitis A, B, and C; HIV, HTLV-I/II, CMV, 
adenovirus, EBV, HSV, Toxoplasma, and syphilis. 
e) CBC with differential, PT, PTT, and ABO typing. 
f) Acute care panel, hepatic panel, and mineral panel. 
g) Urinalysis. 
h) Urine βHCG in women of childbearing potential. 
i) Chest radiograph. 
j) Electrocardiogram. 
k) PCR test of DNA mini-satellite regions for future determination of 
chimerism. 
2.3 
Patient Registration: 
2.3.1 The patient's entry date on protocol is considered to be the day that 
consent forms have been signed by both the donor and the recipient.  The 
treatment start date is considered to be the day the recipient begins his/her 
initial induction cycle (Section 3.5). 
2.3.2 Authorized staff must register an eligible candidate with ORKAND no 
later than 24 hours after both the donor and patient (recipient) have signed 
consent forms.  To alleviate the burden of additional travel, donors may 

25 
sign the donor consent form on a provisional basis while awaiting final 
determination of donor and patient eligibility; thus, the date on which an 
eligible donor signs consent may precede the patient’s date of consent by 
up to four weeks, in some cases.  However, the patient may not sign 
consent before both the donor and patient have been determined to be 
eligible, and neither the donor nor the patient will be registered before 
both have signed consent.  Both the patient and the donor must be 
registered.  A registration checklist from the Web site must be completed 
and faxed to ORKAND at 301-480-0757.  After confirmation of eligibility 
at ORKAND, ORKAND staff will call Pharmacy to advise them of the 
acceptance of the patient on the protocol prior to the release of any 
protocol pharmacotherapy.  For registration, authorized staff should call 
301-402-1732 between the hours of 8:30 a.m. and 5:00 p.m., Monday 
through Friday.  A recorder is available during non-working hours. 

26 
Induction Chemotherapy 
(Recipient to receive 1-3 cycles q21 days) 
 
a) Rituximab, 375 mg/m2/day IV, day 1 
(patients with CD20+ malignancies only) 
b) Fludarabine, 25 mg/m2/day IV, days 1-4 
c) Etoposide, 50 mg/m2/day CIV, days 1-4 
d) Doxorubicin, 10 mg/m2/day CIV, days 1-4 
e) Vincristine, 0.4 mg/m2/day CIV, days 1-4 
f) Cyclophosphamide, 750 mg/m2/day IV, day 5 
g) Prednisone, 60 mg/m2/day PO, days 1-5 
h) Filgrastim, 10 mcg/kg/day SC, day 6 until 
ANC > 1000 on 2 consecutive biweekly 
measurements post ANC nadir. 
(Section 3.3.2.f) 
 
Goal:  CD4 level < 100 cells/µl 
Transplant Preparative Regimen Chemotherapy 
(To start within 7-21 days after completing last cycle 
of induction chemotherapy) 
 
a) Fludarabine, 30 mg/m2/day IV x 4 days 
 
(days –6, -5, -4, -3) 
b) Cyclophosphamide, 1200 mg/m2/day IV x 4 days 
 
(days –6, -5, -4, -3) 
c) Mesna, 150 mg/m2 IV over 3 hours x 1 dose 
(Start 1 hour before cyclophosphamide, day –6.) 
d) Mesna, 1200 mg/m2/day CIV x 4 days 
 
(days –6, -5, -4, -3) 
Day –1:  GVHD Prophylaxis (Cyclosporine) 
 
Cyclosporine 2 mg/kg IV Q12h, start day –1.  
Continue IV or PO until day +180. 
3.0 
Study Implementation 
3.1 
Study Design: 
 
 
 
Donor Stem Cell Collection 
 
a) Mobilization:  Filgrastim 10 mcg/kg/day SC, 
beginning 4 days prior to collection. 
b) Collection:  Peripheral blood apheresis. 
c) Minimum dose:  ≥ 3 x 106 CD34+ cells/kg 
(recipient weight) 
Day +1:  GVHD Prophylaxis (Methotrexate) 
 
Methotrexate 5 mg/m2 IV, days +1, +3, +6, and +11. 
Day 0:  Allogeneic Stem Cell Infusion 
 
Filgrastim 10 µg/kg/day SC, starting day 0. 
Continues until ANC > 5000 for 3 consecutive days. 

27 
3.2 
Stem Cell Mobilization and Collection: 
3.2.1 Donors will receive filgrastim for stem cell mobilization, at a dose of 10 
µg/kg/day by subcutaneous injection. The filgrastim will be given at 
approximately 7:00 am each day. 
3.2.2 Apheresis will start on the fifth day of filgrastim administration.  15-25 
liters will be processed daily.  Apheresis and filgrastim administration will 
continue daily for up to 3 consecutive days until the target cell dose of > 4 
x 106 CD34+ cells/kg-recipient weight is obtained.  If the minimum cell 
dose of 3 x 106 CD34+ cells/kg-recipient weight is obtained during the 
first mobilization cycle, no further collection will be scheduled, and the 
patient will be eligible for transplantation.  Donors who do not reach the 
minimum number of 3 x 106 CD34+ cells/kg-recipient weight after three 
collections will discontinue filgrastim for a minimum of three weeks, after 
which the mobilization and collection will be attempted again.  If the 
minimum number of cells has not been reached at this time, the patient 
will be removed from the trial. 
3.2.3 Cells will be processed, cryopreserved, and stored in liquid nitrogen until 
the day of transplant.  If an ABO incompatibility exists between the donor 
and patient, the donor erythrocytes will be removed from the graft in the 
cell processing laboratory, according to standard procedures.  
3.3 
Induction Chemotherapy: 
3.3.1 After enrollment, chemotherapy will be initiated as an outpatient.  
Adequate central venous access is required for all patients undergoing 
transplantation on this protocol. 
3.3.2 EPOCH-Fludarabine/Rituximab (EPOCH-F/R): 
Induction Chemotherapy Regimen 
Drug 
Dose 
Days 
Rituximab 
375 mg/m2 IV infusion via specified rate titration. 
 (patients with CD20+ malignancies only) 
Day 1 only 
Fludarabine 
25 mg/m2 per day IV 
Infusion over 30 minutes, 
Daily for 4 days 
Days 1, 2, 3, 4 
Etoposide 
50 mg/m2 per day continuous IV 
Infusion over 24 hours, 
Daily for 4 days 
Days 1, 2, 3, 4 
Doxorubicin 
10 mg/m2 per day continuous IV 
Infusion over 24 hours, 
Daily for 4 days 
Days 1, 2, 3, 4 
Vincristine 
0.4 mg/m2 per day continuous IV 
Infusion over 24 hours, 
Daily for 4 days 
Days 1, 2, 3, 4 
Cyclophosphamide 
750 mg/m2 IV Infusion over 30 minutes 
Day 5 only 
Prednisone 
60 mg/m2 per day orally, 
daily for 5 days 
Days 1, 2, 3, 4, 5 

28 
a) Only patients with CD20+ B-cell malignancies will receive rituximab 
as part of the induction chemotherapy regimen.  The initial infusion 
should begin at a rate of 50 mg/hr; if no hypersensitivity reaction is 
observed after the first 30 minutes, the infusion rate may be escalated 
in 50 mg/hr increments every 30 minutes, to a maximum rate of 400 
mg/hr.  If a hypersensitivity reaction occurs, the infusion should be 
temporarily slowed or halted, with resumption at half the previous rate 
upon improvement in patient symptoms.  If the first infusion is 
tolerated well, infusions during subsequent cycles of EPOCH-F/R can 
begin at 100 mg/hr and be increased by 100 mg/hr increments at 30-
minute intervals.  However, if the first infusion is not tolerated well, 
then the guidelines for the initial infusion should be followed for 
subsequent administration.  Premedication with acetaminophen 650 
mg PO and diphenhydramine 50 mg IV will be administered 30 to 60 
minutes prior to the beginning of each rituximab infusion.  Rituximab 
should be infused prior to the administration of fludarabine and the 
start of infusional EPOCH chemotherapy on the first day of each 
cycle. 
b) Fludarabine will be given immediately after the rituximab infusion is 
completed on day 1.  If venous access permits, fludarabine may be 
given concurrently with the start of infusional EPOCH chemotherapy 
on days 1 through 4 of each cycle (preferred); otherwise, fludarabine 
will be given before the start of EPOCH infusional agents on days 1-4. 
c) Etoposide, doxorubicin, and vincristine will be prepared and 
administered according to NIH Clinical Center Pharmacy standard 
guidelines (section 8.6).  
d) The total vincristine dose per cycle will not be capped, even if it 
exceeds 2.0 mg over four days. 
e) Cyclophosphamide will be administered on day 5 of each cycle 
immediately after the prior day’s infusion is completed.   Hydration 
with 1 liter of 0.9% sodium chloride is recommended to begin one 
hour prior to cyclophosphamide, infused over two hours. 
f) Because immune depletion with EPOCH-F/R is a secondary endpoint 
of this study, patients should receive a consistent steroid regimen with 
each cycle of induction chemotherapy.  Therefore, steroids will not be 
used as an anti-emetic during EPOCH-F/R chemotherapy. 
g) Filgrastim will be initiated on day 6 at a dose of 10 µg/kg/day; it will 
be continued until the ANC is greater than 1000 cells/µl on two 
consecutive biweekly measurements following the ANC nadir, or 
greater than 5000 cells/µl on 1 biweekly measurement.  Biweekly 
measurements are obtained at least 3 days apart (e.g., Monday and 
Thursday).  Only biweekly CBC values will be used to determine the 
Filgrastim 
10 µg/kg per day subcutaneously 
Daily from day 6 
until ANC > 1000/µl x 2 
following nadir 
(Section 3.3.2.f) 

29 
duration of filgrastim administration during each cycle, even if 
additional CBC’s are obtained. 
3.3.3 Determination of Number of Cycles of Induction Chemotherapy: 
a) Because a major goal of the induction chemotherapy is to establish 
severe host immune T cell depletion prior to the allogeneic HSCT, the 
number of induction chemotherapy cycles administered will be 
determined principally by the level of host T cell depletion achieved. 
b) The CD4 count will be measured by FACS analysis at least 48 hours 
after the cycle’s last dose of filgrastim and within three days before the 
next scheduled cycle (i.e. day 22).  FACS analysis will be performed 
by William Kopp, Ph.D. at FCRF using a CLIA certified flow 
cytometry methodology to determine the percentage of circulating 
CD4+ cells.  A simultaneous CBC will be drawn in order to calculate 
the absolute CD4 number. 
c) If a patient has fewer than 100 CD4 cells/µl of blood on the final CD4 
determination of the induction chemotherapy cycle, then that patient 
will receive the transplant preparative regimen.  If there are > 100 CD4 
cells/µl, an additional cycle of induction chemotherapy will be 
administered.  These criteria may be used for each induction 
chemotherapy cycle.  A minimum of one cycle of induction 
chemotherapy will be administered.  However, a maximum of three 
cycles of induction chemotherapy can be administered. 
d) Patients will receive the second cycle of chemotherapy on day 22 after 
the first cycle was initiated.  However, up to two weeks of additional 
recovery time may be provided if medically indicated before 
administration of the second cycle (e.g., for delay in neutrophil 
recovery to 1000 cells/µl, documented infection or other complication 
resulting from the induction chemotherapy regimen). 
e) If a patient develops neutropenia of less than 500 cells/µl on 4 or more 
consecutive biweekly CBC’s during any cycle of induction 
chemotherapy administered at dose level 1 or lower, the patient will 
receive no further induction chemotherapy.  At that point, the patient 
will receive the transplant preparative regimen, even if the CD4 count 
is > 100 cells/µl.  Only biweekly CBC values (at least 3 days apart, 
e.g. Monday and Thursday) will be used to define the duration of 
neutropenia during each cycle, even if additional CBC’s are obtained. 
f) If the maximum of three cycles of induction chemotherapy has been 
administered, then patients will proceed to the transplant preparative 
regimen, even if the CD4 count is still > 100 cells/µl. 
g) Patients who develop progressive disease during the induction 
chemotherapy cycles will proceed to the transplant preparative 
regimen regardless of the CD4 count (see also Section 3.8.1.d). 
3.3.4 Dose Adjustment for Cycles 2 and 3 (for individual patients) 
a) Dose adjustments above starting dose level (level 1) consist of a 20% 
escalation in the daily doses of etoposide, doxorubicin, and 
cyclophosphamide.   

30 
b) Dose adjustments below starting dose level (level 1) consist of a 20% 
reduction in the cyclophosphamide dose only. 
c) Drug doses are based on the duration of ANC nadir during the 
previous cycle, based upon consecutive biweekly CBC/differential (> 
3 days apart).  Only biweekly CBC values will be used to determine 
dose adjustment, even if additional CBC’s are obtained. 
d) Rules for dose adjustment are summarized in the following table: 
 
3.3.5 Dose Reduction of EPOCH-F/R Induction Chemotherapy (for study 
population) 
a) The following dose reduction rules will apply only to cycles of 
EPOCH-F/R that are administered at dose level 1 or lower (see section 
3.3.4, above). 
b) If three patients experience either: (1) grade IV hematologic toxicity 
(ANC less than 500 cells/µl) lasting for 4 or more consecutive 
biweekly measurements; or (2) any grade IV non-hematologic toxicity 
by the NCI Common Toxicity Criteria, then fludarabine will be 
reduced from four days to three days of administration, without 
changing the daily dose of 25 mg/m2. 
c) If, after such a change in the EPOCH-F/R regimen is made, three 
patients again experience:  (1) grade IV hematologic toxicity (ANC 
less than 500 cells/µl) lasting for 4 or more consecutive biweekly 
measurements; or (2) any grade IV non-hematologic toxicity, then the 
cyclophosphamide will be given on day 5 with a reduction in dose 
from 750 mg/m2 to 600 mg/m2. 
d) If dose reductions in the EPOCH-F/R regimen are made as described 
in Sections 3.3.6.a and 3.3.6.b (above), and three patients again 
experience:  (1) grade IV hematologic toxicity (ANC less than 500 
cells/µl) lasting for 4 or more consecutive biweekly measurements; or 
(2) any grade IV non-hematologic toxicity, then the etoposide, 
doxorubicin, and vincristine will be reduced from four days to three 
days of administration, without a change in daily dose of these drugs.  
In the event of this dose reduction, the cyclophosphamide will be 
given on day 4 of the cycle at a dose of 600 mg/m2, and filgrastim will 
start on day 5.  The dose and schedule of prednisone administration 
will not change. 
If ANC < 500/µl on 1 or fewer measurements 
 Increase 1 dose level above previous 
cycle. 
If ANC < 500/µl on 2 measurements 
 Same dose level as previous cycle. 
If ANC < 500/µl on 3 measurements 
 
 Decrease 1 dose level below previous 
cycle. 
If ANC < 500/µl on 4 or more measurements, 
at dose level 1 or lower 
 Discontinue EPOCH-F/R; proceed to 
transplant conditioning regimen. 

31 
3.4 
Transplant Conditioning Regimen 
3.4.1 The patient may proceed to transplantation only if the minimum number 
of stem cells is collected (Section 3.2.2). 
3.4.2 On day 22 after the start of the last cycle of induction chemotherapy, 
patients will be eligible to start the transplant conditioning regimen.  Non-
hematologic toxicities of induction chemotherapy must resolve to < grade 
2 in order to proceed.  If more than 14 days of additional recovery time is 
required for resolution of toxicity or other medical complications (for 
example, prolonged neutropenia or documented infection), PI approval is 
required prior to initiation of the transplant conditioning regimen. 
3.4.3 Fludarabine/Cyclophosphamide/Mesna: 
Transplant Conditioning Regimen 
Drug 
Dose 
Days 
Fludarabine 
30 mg/m2 per day 
IV infusion over 30 minutes, 
daily for 4 days 
Transplant Days –6, -5, -4, -3 
Mesna 
150 mg/m2 
IV infusion over 3 hours, 
(start 1 hour before cyclophosphamide) 
Transplant Day –6 only 
Cyclophosphamide 
1200 mg/m2 per day 
IV infusion over 2 hours, 
daily for 4 days 
Transplant Days –6, -5, -4, -3 
Mesna 
1200 mg/m2 per day 
Continuous IV infusion, 
daily for 4 days 
Transplant Days –6, -5, -4, -3 
 
 
 

32 
3.4.4 Hydration during the conditioning regimen: 
a) Hydration will be initiated 12 hours prior to cyclophosphamide 
infusion (on day –7 of the transplant), consisting of 0.9% sodium 
chloride supplemented with 10 mEq/liter potassium chloride (KCl) at 
an initial rate of 100 ml/hour.  For patients with poor oral intake, the 
rate of hydration may be increased as clinically indicated to meet fluid 
requirements.  Hydration will continue until 24 hours after the last 
cyclophosphamide dose has been completed. 
b) During hydration, serum potassium level will be monitored every 12 
hours.  If serum potassium is > 4.5 mEq/l, KCl will be removed from 
the saline infusion.  If serum potassium is < 3.0, KCl concentration in 
the saline will be increased to 20 mEq/l. 
c) During hydration, 20 mg of furosemide will be administered daily by 
IV route to maintain diuresis, with additional doses of furosemide to 
be given as needed for weight gain due to fluid retention.  In general, 
furosemide doses should be separated by at least a four-hour 
observation interval. 
d) During hydration, if urine output is < 1.5 ml/kg/hour or if fluid intake 
exceeds urine output by greater than 500 ml during an 8-hour period, 
an additional 20 mg of furosemide will be administered. 
e) Routine hematologic monitoring, cardiac monitoring, and urinalysis 
will be performed as deemed clinically necessary. 
3.5 
Transplant Procedure:  Allogeneic Peripheral Blood Stem Cell Transplantation 
3.5.1 On day 0, the patient will receive cryopreserved PBSC.  The PBSC 
product will be administered intravenously immediately after thawing. 
3.5.2 Diphenhydramine and/or meperidine are preferred for the treatment of 
acute DMSO toxicities (e.g., chills, myalgias); steroids should be avoided. 
3.6 
Graft-Versus-Host Disease Prophylaxis: 
3.6.1 Cyclosporine (CsA) will be initiated on the day –1 before the transplant.  
CsA will be administered by IV infusion at 2 mg/kg/dose every 12 hours; 
infusion will be over a 2-hour period.  Subsequently doses will be adjusted 
according to trough levels monitored biweekly and/or upon symptoms or 
alteration in renal function.  The target range for serum cyclosporine levels 
will be 200–250 µg/ml.  When the patient is able to take oral medications 
(typically two to three weeks after transplantation), cyclosporine will be 
converted to an equivalent oral dose.  The total daily dose will be divided 
into two equal doses, one dose given approximately every 12 hours. 
3.6.2 This dose of CsA will continue until day +100, and then will be tapered as 
long as the severity of GVHD is less than grade 2.  Cyclosporine will be 
tapered by reducing the dose by approximately 10% from the last dose 
administered each week to a dose of 25 mg/day. Cyclosporine will then be 
completely discontinued if there are no signs of GVHD. 
3.6.3 Methotrexate will be given at 5 mg/m2 IV over 15 minutes on days +1, +3, 
+6, and +11.  Each day’s dose of methotrexate will not be administered 
until approved that day by the transplant attending after the transplant 
team has evaluated the patient.  Doses will be withheld for the 

33 
development of grade III or IV mucositis or clinical evidence of veno-
occlusive disease.  Administration of the combination of trimethoprim and 
sulfamethoxazole (i.e., Bactrim) or non-steroidal anti-inflammatory 
drugs is contraindicated during methotrexate administration.  Methotrexate 
administration will be assessed on each planned day of administration, and 
dose adjustments will be based upon the following criteria: 
 
Creatinine 
 
Total Bilirubin 
Methotrexate Dose 
< 1.5 mg/dL  
< 2.0 mg/dL  
100% 
1.6 – 2.0 mg/dL 
2.1 – 3.0 mg/dL 
75% 
2.1-2.5 mg/dL  
3.1 – 4.0 mg/dL 
50% 
> 2.5 mg/dL  
> 4.0 mg/dL  
Hold Dose 
 
3.7 
Treatment of Mixed Chimerism, Bone Marrow Aplasia, or Persistent/Progressive 
Disease Post-Transplant 
3.7.1 Donor Lymphocyte Infusion 
a) Patients with persistent or progressive malignancy post-HSCT, or 
mixed chimerism that does not improve after tapering or discontinuing 
immune suppression, will be eligible to receive donor lymphocytes 
(donor lymphocyte infusion, or “DLI”) as a component of this study.  
DLI may be administered alone or after chemotherapy. 
b) Donor lymphocytes will be collected by apheresis from the patient’s 
stem cell donor, either in steady state (i.e., no donor therapy) or after 
filgrastim administration.  The donor product will be divided into 
aliquots as follows: 
• 1 x 106 CD3+ T cells per kg of recipient weight (1 aliquot only, to 
use for treatment of mixed donor chimerism; not required if 
collection obtained for treatment of malignant disease) 
• 1 x 107 CD3+ T cells per kg of recipient weight (1 aliquot) 
• 5 x 107 CD3+ T cells per kg of recipient weight (remainder of 
collection) 
c) DLI may be sequentially administered, with initial dosing at 1 x 106 
CD3+ T cells per kg of recipient weight for mixed chimerism, up to 1 x 
107 CD3+ T cells per kg for malignant disease.  Subsequent doses may 
be escalated to 1 x 108 CD3+ T cells per kg. 
3.7.2 Secondary Infusion of CD34+ Donor Stem Cells 
a) Certain clinical situations may require additional donor stem cells 
without donor lymphocytes (e.g., bone marrow aplasia with 
established GVHD).  In such cases, consenting donors will undergo 
repeat filgrastim mobilization and stem cell collection according to the 
procedure in section 3.2.  However, the apheresis product will undergo 
positive selection of CD34+ cells to achieve separation of donor stem 
cells and lymphocytes, according to standard DTM procedures using 
an FDA-approved device.  This procedure ordinarily achieves a 4-log 
depletion of CD3+ cells in the CD34+ cell-selected product, relative to 
unmanipulated mobilized donor cells.  The CD34+ cell-selected 

34 
fraction will typically be administered in its entirety to the transplant 
recipient in these cases, with or without initial cryopreservation.  The 
CD3+ cell-enriched fraction may be divided into aliquots and 
cryopreserved for subsequent use if clinically indicated, as described 
in section 3.7.1(c). 
3.7.3 Other Post-Transplant Therapy 
a) In addition to DLI, persistent or progressive disease may be treated 
with any approved therapy thought to be in the best interest of the 
patient, such as chemotherapy, cytokines, or monoclonal antibodies.  
Alternatively, such patients may be offered therapy on other NCI 
protocols. 
3.8 
Interim Evaluation During Induction Chemotherapy: 
3.8.1 The following studies will be obtained in the patient (recipient) at the end 
of each cycle of EPOCH-F/R induction chemotherapy: 
a) Routine chemistry and hematology panels 
b) For patients with lymphoma:  computed tomography scans of 
chest/abdomen/pelvis (and neck, if clinically indicated) 
c) For patients with multiple myeloma:  serum protein electrophoresis; 
serum Ig level; 24h collection of urine for urine protein 
electrophoresis; B2 microglobulin; immunofixation if M protein is 
undetectable; bone marrow biopsy. 
3.9 
Pre-Transplant Evaluation: 
3.9.1 The following studies will be obtained in the patient (recipient) within 28 
days before the initiation of the transplantation conditioning regimen to 
determine disease status: 
a) Routine chemistry and hematology panels 
b) Bone marrow aspiration and biopsy; flow cytometry, cytogenetics, and 
molecular studies as clinically appropriate 
c) For patients with lymphoma or CLL:  computed tomography scans of 
chest/abdomen/pelvis (and neck, if clinically indicated); FDG-PET 
scan. 
d) For patients with multiple myeloma:  serum protein electrophoresis; 
serum Ig level; 24h collection of urine for urine protein 
electrophoresis; B2 microglobulin; immunofixation if M protein is 
undetectable; bone marrow biopsy; skeletal survey. 
3.9.2 The following studies will be obtained in the patient (recipient) within four 
weeks before the initiation of the conditioning regimen: 
a) Pulmonary function testing including DLCO 
b) 2-D echo or MUGA scan 
c) Serum creatinine, hepatic transaminases, total bilirubin 
d) Urine β-HCG for women of childbearing potential. 
3.10 
Evaluation During Transplantation 
3.10.1 The following studies will be obtained in the patient (recipient) during 
hospitalization for transplantation: 
a) CBC twice daily; differential count daily 

35 
b) Acute care and mineral panels twice daily; hepatic panel and LDH 
daily 
c) Type and screen every 3 days 
d) Cyclosporine trough level twice weekly, starting day +1 
3.11 
Off Study Criteria: 
3.11.1 The donor or recipient will be removed from protocol for any of the 
following reasons: 
a) Inadequate stem cell collection (Section 3.2.2); this will result in the 
removal of both the donor and recipient. 
b) Unacceptable toxicity (> grade 3) for the donor. 
c) Irreversible non-hematologic toxicity (> grade 3) for the recipient 
while receiving induction chemotherapy (EPOCH-F/R). 
d) The donor or recipient refuses to continue therapy. 
e) In addition, the patient may at any time be removed from protocol at 
the principal investigator’s discretion, if the PI deems the patient to be 
at unacceptable risk to remain on study.  Reasons for this action may 
include (but are not limited to) disease progression with declining 
organ function/performance status before transplantation; inadequate 
family/caregiver support; noncompliance. 
3.11.2 Authorized physicians must notify ORKAND when a patient is taken off 
study. 
3.12 
Post Study Evaluation: 
3.12.1 After completion of therapy the patient will be followed for potential 
complications related to allogeneic SCT. The patient will be followed at 
least twice weekly in the outpatient setting until at least Day +100 after 
discharge from the hospital. 
3.12.2 The patient (recipient) will seen in follow-up at the Clinical Center to 
evaluate disease status and late problems related to allogeneic HSCT, at 
days +28 and +100; and at 6, 9, 12, 18, and 24 months post-transplant.  At 
these times patients will have the following tests performed to determine 
clinical response: 
a) Routine chemistry and hematologic panels. 
b) Bone marrow aspiration and biopsy with flow cytometry, cytogenetics, 
and molecular studies as clinically appropriate. 
c) For patients with lymphoma:  computed tomography scans of 
chest/abdomen/pelvis (and neck, if clinically indicated).  FDG-PET 
scan will be obtained 28 and 100 days post transplant in all patients 
with lymphoma.  For patients who enter into CR or CRu with negative 
PET, follow-up evaluation will include PET at 6 and 12 months post 
transplant.  Other time points may be included if clinically indicated. 
d) For patients with multiple myeloma:  serum protein electrophoresis 
with M protein; serum Ig level; 24h collection of urine for urinary 
protein excretion, protein electrophoresis and M protein; B2 
microglobulin; immunofixation if M protein is undetectable; skeletal 
survey. 

36 
3.12.3 Repeat pulmonary function testing will be performed at 100 days and 1 
year post transplant.  Repeat 2-D echocardiography or MUGA scan will be 
performed 100 days post transplant. 
3.13 
Immunologic Studies 
3.13.1 Correlation between patient (recipient) T-cell subpopulations, serum IL-7 
and IL-15 levels (Hakim/Gress & Fry laboratories): 
a) Baseline evaluation of donor NK and T cells:  40 ml of heparinized 
whole blood (4 10cc green top tubes) prior to filgrastim mobilization; 
aliquot of donor apheresis product with ~50 x 106 mononuclear cells.  
Performed in Hakim/Gress lab (10/5A07). 
b) Patient lymphocyte subpopulations:  60 ml heparinized whole blood 
(20 ml for FACS, 40 ml for RNA RT-PCR of NK receptors) to 
Hakim/Gress lab (10/5A07).  Baseline before start of EPOCH-F/R 
induction chemotherapy; at end of each cycle of EPOCH-F/R; day 0 
following administration of transplant preparative regimen; days +7, 
+14, +28, +60, +100; 6 months, 9 months, 12 months, 18 months, 24 
months, and annually therafter. 
c) Patient IL-7 and IL-15 levels:  10 ml whole blood (1 10cc red top 
tube), to be sent to Frederick for storage.  IL-7 levels will be 
performed in Fry lab (10/13C210); IL-15 levels will be performed in 
Hakim/Gress lab (10/5A07).  Baseline before start of EPOCH-F/R 
induction chemotherapy; at end of each cycle of EPOCH-F/R; day 0 
following administration of transplant preparative regimen; days +7, 
+14, +28, +60, +100; 6 months, 9 months, 12 months, 18 months, 24 
months, and annually therafter.  Note:  IL-7 levels will not include day 
+60 or time points after day 100. 
d) Lymphocyte subpopulations, IL-7, and IL-15 levels may be obtained 
at other time points of interest (e.g., development of GVHD). 
3.13.2 Correlation of lymphocyte cytokine expression patterns with GVHD in 
patients: 
a) 40 ml of blood will be drawn in heparinized tubes each Thursday, 
starting from the second week post-SCT and extending until day 50 
post-transplant.  Samples will be sent to the Fowler Lab (10/12C210) 
to the attention of Jason Foley, 4-4537.  These samples will be 
Ficolled, cultured overnight in media containing the golgi inhibitor 
monensin, and evaluated for monocyte surface markers and 
intracellular cytokine markers for CD14 monocyte production of IL-1 
alpha, TNF alpha, and IL-15. 
b) 50 ml of blood will be drawn into green top heparinized tubes on day 6 
and day 7 post-transplant.  Samples will be sent to the Fowler Lab 
(10/12C210) to the attention of Jason Foley, 4-4537.  These samples 
will be Ficolled, and evaluated either fresh (day 7 sample) or after 
CD3, CD28 stimulation (day 6 sample) for T cell cytokine secretion 
profile.  This assay will be by cytokine capture flow cytometry, with 
surface markers of CD4 and CD8 evaluated.  Cytokine capture 

37 
staining of these populations will evaluate both T1 (IL-2, IFN-γ) and 
T2 (IL-4, IL-10) cytokine secretion 
3.13.3 Donor/recipient chimerism studies: 
a) Baseline determination in donor and patient (prior to start of induction 
chemotherapy with EPOCH-F/R). 
b) After transplantation in patient: 
• Peripheral blood lymphoid, myeloid, and total chimerism on day 
+14.  Requires 10 ml of whole blood in EDTA. 
• Peripheral blood and bone marrow total chimerism on days +28, 
+100, and 12 months.  Lymphoid & myeloid subset chimerism will 
also be measured at these timepoints if donor chimerism was < 
95% on the previous study. 
• Chimerism may be measured at other timepoints if clinically 
indicated (e.g., to determine effect of manipulating immune 
suppression in order to increase donor chimerism). 
 
4.0 
Supportive Care 
4.1 
Infection Prophylaxis – See Appendix A for detailed description. 
4.1.1 All patients will receive prophylaxis against Pneumocystis carinii 
pneumonia, beginning with the first cycle of EPOCH-F/R induction 
therapy, continuing until transplantation, and resuming at the time of 
platelet recovery.  PCP prophylaxis will continue until day +100 or until 
immunosuppression is discontinued.  Trimethoprim/sulfamethoxazole is 
the preferred regimen.  See Appendix A, Section 9.1.1 for details.   
4.1.2 All patients will receive fluconazole for prophylaxis against yeast 
infections. Because of its interaction with vincristine, fluconazole should 
not be taken concurrently with EPOCH-F/R chemotherapy.  Therefore, 
fluconazole will start on day 6 of the first cycle of pre-transplant induction 
chemotherapy and will be held on days 1 through 5 of each subsequent 
cycle.  Fluconazole will then continue through transplantation until day 
+100 or until immunosuppression is discontinued.  See Appendix A, 
Section 9.1.2 for details. 
4.1.3 Antibiotic therapy for neutropenic patients will be managed in accordance 
with CDC guidelines.  Patients with neutropenia and fever that persists for 
longer than 5 days despite broad-spectrum antibiotics will receive empiric 
antifungal therapy with liposomal amphotericin B or with voriconazole, as 
described in Appendix A, Section 9.1.3. 
4.1.4 All patients will receive valacyclovir for prophylaxis against herpes 
simplex virus and varicella zoster virus infection/reactivation.  This 
therapy will start on day 1 of pre-transplant induction chemotherapy, 
continuing 
through 
transplantation 
until 
day 
+100 
or 
until 
immunosuppression is discontinued.  See Appendix A, Section 9.1.4 for 
details. 
4.1.5 Patients with positive pre-transplant serology for Cytomegalovirus (CMV) 
and/or CMV-seropositive donors will be monitored for CMV reactivation 
by weekly testing for CMV antigenemia and clinical evaluation.  Positive 

38 
antigenemia will be treated according to the schema in Appendix A, 
Section 9.1.5.  Weekly monitoring will continue through day +100 (longer 
for patients at risk – see Appendix A). 
4.1.6 Patients receiving immunosuppression for chronic GVHD will receive 
pencillin V for prophylaxis against bacterial infections.  All patients will 
undergo vaccination against Streptococcus pneumoniae and Haemophilus 
influenzae, beginning 12 months after transplantation.  See Appendix A, 
Section 9.1.6 for details. 
4.2 
Management of Engraftment Syndrome 
4.2.1 Engraftment syndrome may occur at the time of neutrophil recovery.  Its 
clinical manifestations include noninfectious fever, rash, and vascular leak 
causing noncardiogenic pulmonary edema, weight gain, and renal 
insufficiency [73].  Diagnostic criteria and a treatment schema for 
engraftment syndrome are included in Appendix B. 
4.3 
Treatment of Graft-Versus-Host Disease: 
4.3.1 In patients in whom GVHD is suspected, standard clinical criteria and 
biopsy findings (when clinically indicated) will be used to establish the 
diagnosis.  Acute GVHD will be graded by the Glucksberg criteria [74].  
See Appendix C for details concerning the grading and management of 
acute GVHD. 
4.3.2 Patients with clinical Stage 1 or 2 (Grade I) GVHD of the skin without any 
other organ involvement will be treated with a topical corticosteroid 
cream. 
4.3.3 In general, patients with ≥ Grade II acute GVHD will be treated with high-
dose, systemic corticosteroids. 
4.3.4 Patients who fail to respond satisfactorily to corticosteroids will be 
considered for second-line immunosuppressive therapy, e.g., tacrolimus, 
mycophenolic acid, monoclonal antibodies, or other experimental acute 
GVHD protocols, if they are available. 
4.4 
Menses Suppression and Contraception – Pre-menopausal women who have not 
undergone hysterectomy will be placed on medroxyprogesterone acetate 10 
mg/day orally to suppress menses.  This therapy will begin with the first cycle of 
induction therapy and continue until platelet recovery after transplantation. (> 
50,000/mm3 without transfusion).  Female transplant recipients will be advised to 
use contraception for at least 1 year after transplantation and to have their male 
partners use condoms.  Male transplant recipients will be advised to use 
contraception, preferably condoms, for 1 year after transplantation. 
4.5 
Blood Product Support – Patients will receive packed red blood cells and platelets 
as needed to maintain Hb > 8.0 gm/dl, and plts > 10,000/mm3 (or higher, if 
clinically indicated).  All blood products with the exception of the stem cell 
product will be irradiated. 
4.5.1 Leucocyte filters will be utilized for all blood and platelet transfusions to 
decrease sensitization to transfused leukocytes and decrease the risk of 
CMV infection [75]. 
4.6 
Nutritional Support – When mucositis or GVHD prevents adequate PO intake, 
parenteral hyperalimentation will be instituted and discontinued under the 

39 
direction of the dietary service.  Oral intake will resume when clinically 
appropriate under the supervision of the dietary service of the Clinical Center. 
4.7 
Anti-emetics – Anti-emetic usage will follow Clinical Center Guidelines as well 
as recommendations from the Pharmacy service. 
4.8 
Hematopoietic Growth Factor Support – All patients will start G-CSF 
10µg/kg/day on day 0 starting after the stem cell infusion.  The dose will be given 
subcutaneously (SC).  G-CSF will be continued until the absolute neutrophil 
count (ANC) is > 5000/µl for three consecutive days and will be resumed if ANC 
drops below 1000/µl. 
 
5.0 
Data Collection and Evaluation 
5.1 
Data Collection - Data will be prospectively collected and entered into the 
Medical Oncology Clinical Research Unit database. 
5.2 
Response Criteria 
5.2.1 Complete Response (CR): 
a) Non-Hodgkin’s lymphoma or Hodgkin’s lymphoma:  complete 
disappearance of all detectable signs and symptoms of lymphoma for a 
period of at least one month.  All lymph nodes and nodal masses must 
have regressed to normal size (< 1.5 cm in greatest transverse diameter 
for nodes > 1.5 cm before therapy). Previously involved nodes that 
were 1.1 to 1.5 cm in greatest transverse diameter before treatment 
must have decreased to < 1 cm in their greatest transverse diameter 
after treatment or by more than 75% in the sum of the products of the 
greatest diameters (SPD).  The spleen (or any other organ), if 
considered to be enlarged due to involvement by lymphoma before 
therapy and on the basis of a CT scan, must have regressed in size and 
must not be palpable on physical examination.  Any macroscopic 
nodules in any organs detectable on imaging techniques should no 
longer be present.  If bone marrow was involved by lymphoma before 
treatment, the infiltrate must be cleared on repeat bone marrow 
aspirate and biopsy of the same site [40]. 
b) Chronic lymphocytic leukemia:  complete resolution of all detectable 
signs and symptoms for at least 2 months, with peripheral blood 
lymphocytes < 4K/µl, neutrophils > 1.5K/µl, platelets > 100K/µl, 
hemoglobin > 11g/dl (untransfused), bone marrow lymphocytes < 30% 
without lymphoid nodules. 
c) Chronic myelogenous leukemia:  Hematologic CR – normalization of 
peripheral blood counts (WBC < 10K/µl, platelets < 450K/µl), no 
immature 
cells 
on 
peripheral 
smear 
(blasts, 
promyelocytes, 
metamyelocytes).  Cytogenetic CR – hematologic CR, with 
cytogenetic studies negative for Philadelphia chromosome (Ph).  
Molecular CR – hematologic and cytogenetic CR, with PCR studies 
negative for bcr/abl. 
d) Other leukemias, myeloproliferative disorders, or myelodysplastic 
syndrome:  normalization of peripheral blood counts and bone marrow 
morphology, fewer than 5% blasts in bone marrow; absence of specific 

40 
molecular or cytogenetic markers of disease that were previously 
present.  In the case of myeloproliferative disorders, there must be 
absence of bone marrow fibrosis with normal hematologic parameters. 
e) Multiple myeloma:  absence of urine and serum M-components by 
immunofixation 
and 
electopheresis; 
normalization 
of 
immunoglobulins is not required.  Clonal plasma cells in bone marrow  
<1% by PCR or flow cytometry.  Normal serum calcium.  No new 
bone lesions; no enlargement of existing lesions. Vertebral collapse or 
other pathological fracture due to osteoporosis or existing lesion does 
not prevent categorization as CR. 
5.2.2 Complete Response/unconfirmed (CRu): 
a) Non-Hodgkin’s lymphoma or Hodgkin’s lymphoma:  A residual 
lymph node mass > 1.5 cm in greatest transverse diameter will be 
considered CRu if it has regressed by more than 75% in the SPD, does 
not change over at least one month, is negative by PET or gallium, and 
is negative on any biopsies obtained (biopsy not required).  Individual 
nodes that were previously confluent must have regressed by more 
than 75% in their SPD compared with the size of the original mass and 
be stable for at least one month.  Any residual lesions in involved 
organs must have decreased by more than 75% in the SPD or be < 1 
cm, be clinically consistent with residual scarring, and be stable for at 
least one month.  Indeterminate bone marrow, if previously involved 
with lymphoma, will also be considered CRu. 
5.2.3 Partial Response (PR): 
a) Non-Hodgkin’s lymphoma or Hodgkin’s lymphoma:  a 50% or greater 
decrease in SPD of all measured lesions lasting for a period of at least 
one month.  No individual lesion may increase in size, and no new 
lesions may appear [40]. 
b) Chronic lymphocytic leukemia:  a 50% or greater decrease in SPD of 
measured lymph nodes, hepatomegaly, or splenomegaly lasting at least 
2 months, plus one or more of neutrophils > 1.5K/µl, platelets > 
100K/µl, or hemoglobin > 11g/dl (or 50% improvement). 
c) Chronic myelogenous leukemia:  Hematologic PR – as for 
hematologic CR, except for (1) persistence of immature cells, or (2) 
platelets < 50% pretreatment level but > 450K/µl, or (3) persistent 
splenomegaly but > 50% of pretreatment size.  Cytogenetic PR – 
hematologic CR, with 1-34% Ph-positive cells (major response).  
Cytogenetic minor response – hematologic CR, with 35-90% Ph-
positive cells. 
d) Multiple myeloma:  reduction by > 75% in serum myeloma protein 
production, with decrease in Bence-Jones proteinuria by > 90%.  
Clonal marrow plasmacytosis < 5%.  No new lytic bone lesions. 
5.2.4 Stable Disease (SD): 
a) Non-Hodgkin’s lymphoma or Hodgkin’s lymphoma:  tumor 
measurements not meeting the criteria for CR, CRu, PR, or PD. 

41 
b) Chronic lymphocytic leukemia:  response parameters not meeting 
criteria for CR, PR, or PD. 
5.2.5 Relapsed or Progressive Disease (PD): 
a) Non-Hodgkin’s lymphoma or Hodgkin’s lymphoma:  a 25% or greater 
increase in SPD of all measured lesions compared to the smallest 
previous measurements, or appearance of any new lesion(s). 
b) Chronic lymphocytic leukemia:  a 50% or greater increase in SPD of 
all measured lesions compared to the smallest previous measurements, 
or appearance of any new lesion(s); a > 50% increase in circulating 
lymphocytes; Richter’s syndrome. 
c) Chronic myelogenous leukemia:  Increase in the number of 
metaphases demonstrating Ph by cytogenetics or t(9:22) by FISH; 
return to PCR positivity for bcr/abl after previously becoming 
negative. 
d) Other leukemias, myeloproliferative disorders, or myelodysplastic 
syndrome:  bone marrow and peripheral blood morphological features 
consistent with relapse or progression, including rising blast count and 
re-emergence of specific molecular or cytogenetic markers. 
e) Multiple myeloma (requires 2 of the following):  an increase in serum 
M-protein to > 50% above the lowest level or a rise > 2 g/dl; an 
increase in urine light chain excretion to 50% above the lowest value 
(at least 250 mg/24 hours) or an increase > 2 g/24 hours of light chain 
excretion; an increase in soft tissue plasmacytomas by 50% or new or 
increasing lytic bone lesions; the above protein criteria for relapse, 
plus hypercalcemia > 12 mg/dl, anemia with hemoglobin decrease > 2 
g/dl, increased bone marrow plasma cells by 50%, or generalized bone 
pain. 
5.2.6 Refractory Disease: 
c) Disease progression at any time during treatment with EPOCH-F/R 
induction chemotherapy, or failure to achieve CR or PR after EPOCH-
F/R and/or allogeneic HSCT. 
5.3 
Toxicity Criteria 
5.3.1 The NCI Common Toxicity Criteria (Version 2.0, available via NCI web 
site:  http://ctep.info.nih.gov/CTC3/ctc.htm) will be utilized for evaluation 
of toxicity during induction chemotherapy with EPOCH-F/R. 
a) For patients with leukemia or bone marrow infiltrative/myelophthisic 
processes, hematologic toxicities during induction chemotherapy with 
EPOCH-F/R will be graded according to the specified criteria in CTC 
Version 2.0. 
b) After patients begin the transplant preparative regimen (transplant day 
–6), hematologic and other toxicities will be graded where applicable 
according to the criteria specified for bone marrow transplantation 
studies in CTC Version 2.0. 
5.4 
Statistical Section:  
5.4.1 There are no gender or racial/ethnic restrictions on patient selection.  This 
protocol is open to all genders and racial/ethnic groups. 

42 
5.4.2 Statistical Considerations 
5.4.3 The primary objectives of this study are to conduct an allogeneic HSCT 
protocol to identify if a more intensive GVHD prophylaxis regimen can be 
used with good results, and to assess the toxicity of a new induction 
chemotherapy regimen, EPOCH-F/R.  Secondary objectives are to study 
the efficacy of the new induction regimen, to evaluate the fractions of 
patients with complete and mixed chimerism, and to study CD4 
lymphopenia as a surrogate marker for the degree of immunosuppression 
required for engraftment after transplantation, and to determine an 
approximate level of correlation between serum IL-7 and IL-15 levels and 
circulating lymphocyte subpopulations. 
5.4.4 The GVHD prophylaxis will primarily be evaluated in an overall fashion 
(i.e, in all patients enrolled on this trial); for this analysis, patients will not 
be stratified prospectively by induction chemotherapy received (i.e., with 
or without rituximab, actual dose level administered).  This analysis is 
appropriate because the induction regimen is not expected to influence the 
development of GVHD (Section 1.2.7); relevant clinical risk factors for 
acute GVHD include the transplant conditioning and GVHD prophylaxis 
regimens, which are identical for all patients undergoing allogeneic HSCT 
in this study.  A post-hoc analysis will be performed to verify that no 
relationship is observed between rituximab administration with the 
induction regimen and the development of acute GVHD.  Data from CC 
99-C-0143 and elsewhere suggest that 25 to 45% of patients like those 
enrolling in this trial will ordinarily develop grade III or IV GVHD with 
cyclosporine monotherapy for GVHD prophylaxis.  We would like to 
determine if, with the GVHD prophylaxis regimen to be evaluated in this 
trial, we can obtain at least a slightly improved GVHD prophylaxis result 
in a limited number of subjects.  To do so, the protocol will follow a 
standard Simon two-stage optimal design, with alpha=0.10, beta=0.10, 
p0=0.55 (aiming to rule out 55% without grade III or IV GVHD) and 
p1=0.80 (targeting 80% without grade III or IV GVHD).  Stage I will 
initially enroll 8 patients; if no more than 4 of the first 8 patients enrolled 
in the study avoid grade III or IV acute GVHD, then the study will be 
halted.  (In practice, a small number of additional patients may be accrued 
before the proportion of the first 8 patients experiencing grade III or IV 
acute GVHD can be determined.)  If 5 or more of the first 8 patients 
evaluated (62.5% or more) avoid grade III or IV GVHD, then the study 
will continue accrual to a total of 26 patients.  If 5 to 17 of 26 patients in 
the study avoid grade III or IV acute GVHD, this will be considered 
insufficient to conclude that the GVHD prophylaxis regimen is potentially 
better than that used in CC 99-C-0143.  It should be noted, however, that it 
is unlikely that fewer than 14/26 patients will have acceptable GVHD, 
given that at least 5/8 were acceptable from the first accrual stage.  Should 
14-17 of 26 have less than grade III or IV GVHD, then we will use other 
information obtained from this trial and others to evaluate its potential 
utility.  However, if 18 or more of 26 patients avoid grades III-IV acute 

43 
GVHD (69% or more), we will conclude that the GVHD prophylaxis 
regimen is potentially superior to that used in 99-C-0143. 
 
An interim analysis of results through April 2004 suggested that the 
combination GVHD prophylaxis regimen being tested in this trial may 
demonstrate superiority over that used in 99-C-0143.  As of this analysis, 
12 of 17 patients evaluable through 100 days post HSCT had avoided 
grade III or IV acute GVHD (71%).  Based upon these results, the accrual 
ceiling was increased by up to 6 additional patients in May 2004.  
Currently, 16 of 21 patients evaluable through 100 days post HSCT have 
avoided grade III or IV acute GVHD (76%).  In view of these successful 
outcomes, the accrual ceiling will be increased so that up to 8 more 
patients may be enrolled to undergo allogeneic HSCT on CC 03-C-0077.  
The increased accrual target will permit a more precise estimate of the 
incidence of grade III or IV acute GVHD and will enable us to collect 
additional data on the more frequent occurrence of mixed donor-recipient 
chimerism post HSCT that we have observed with this prophylaxis 
regimen.  In addition, the higher accrual capacity will support the 
continued development of our research program by extending this 
protocol’s availability for eligible patients while our next allogeneic 
HSCT protocol is completing the process of regulatory approval. 
5.4.5 The induction chemotherapy regimen will differ for patients with CD20 
positive and CD20 negative malignancies, as described in Section 3.3.  
The main purpose of this study is to determine the effectiveness of the 
GVHD prophylaxis regimen; with respect to the induction regimen, this is 
a pilot study only.  Our study population is expected to include patients 
with a broad range of characteristics, making it difficult to draw reliable 
conclusions by comparing efficacy and toxicity with the results seen in CC 
99-C-0143.  For these reasons, our analyses of efficacy and toxicity will 
be exploratory and will serve as the basis for designing subsequent studies.  
Subject to those provisos, we will determine the overall response rate of 
the induction regimen, with confidence intervals, as our principal 
evaluation of the EPOCH-F/R regimen’s efficacy.  This response rate will 
be compared informally with that observed with the EPOCH-F regimen in 
CC 99-C-0143.  In addition, we will determine the response rate according 
to CD20 status and rituximab therapy, recognizing that the study design 
will not have sufficient statistical power to allow formal comparison of 
response between these subgroups.  Similarly, our analysis of toxicity will 
be predominantly descriptive, as varying patient risk factors will render 
more formal analysis difficult to interpret.  We will determine the worst 
overall toxicity per patient as well as the individual toxicities of each type 
per cycle and report these and other descriptive results; this analysis will 
be conducted primary in an overall fashion.  Although we do not predict 
that rituximab therapy will contribute significantly to toxicity, our analysis 
will be stratified according to the use of rituximab to explore any possible 
relationship. 

44 
5.4.6 For patients with disease progression after transplantation who receive 
additional conventional therapies (chemotherapeutics, cytokines, or 
monoclonal antibodies) and/or donor lymphocyte infusion (DLI), we will 
determine the overall response rate to such therapies, with confidence 
intervals.  Further evaluation of response rates may be performed 
according to the type of salvage therapy received (conventional agents, 
DLI, or both) and according to response to induction chemotherapy, if the 
number of patients receiving salvage therapy is sufficient to permit 
meaningful analysis. 
5.4.7 Based on results in CC 99-C-0143, we anticipate that a high percentage of 
patients will engraft with early conversion to full donor chimerism.  Thus, 
we will compare the results obtained on this trial to those of the previous 
study and other relevant trials. The following stopping rule will be 
employed with regard to graft rejection or failure to engraft: 
 
 
Engraftment Failure or Graft Rejection 
Action 
Cumulative # events observed 
Patients 1 through 10 
> 1 
Suspend accrual 
Patients 11 through 20 
> 2 
Suspend accrual 
Patients 21 through 26 
> 3 
Suspend accrual 
 
The fractions of patients with mixed chimerism and complete chimerism 
will be determined and reported with a 95% confidence interval.  These 
results will also be stratified according to the use of rituximab with 
induction chemotherapy, but will primarily be evaluated in an overall 
fashion.  If graft rejection or mixed chimerism is seen, then CD4, CD8 and 
absolute lymphocyte counts will be compared between patients who 
engrafted or not using a Wilcoxon rank sum test, and we will consider 
using logistic regression to try to identify, in a limited manner given the 
size of this study, which factors are best associated with successful 
engraftment, possibly adjusting for other clinical factors as appropriate.  In 
addition, Spearman correlation will be used to address the association 
between serum IL-7 levels, IL-15 levels, and lymphocyte subpopulations. 
5.4.8 It is expected that accrual to this protocol can be completed in 2 years if 
approximately 1 patient per month is enrolled. 
5.4.9 Kaplan-Meier estimates of overall and progression free survival will be 
determined, but will be interpreted with appropriate cautions given the 
small sample size of the study. 
5.5 
Data and Safety Monitoring Plan 
5.5.1 In accordance with NCI IRB policies, this pilot study will not require 
independent monitors or review by a Data Safety and Monitoring Board. 
5.5.2 The PI and LAI will provide continuous, close monitoring, with prompt 
reporting of serious adverse events to the IRB (Section 7.1).  On a weekly 
basis, the PI, LAI, Protocol Research Nurse, and Transplant Coordinator 
will review clinical and laboratory data from each of the transplant 
recipients.  A complete summary of patient outcomes will be provided 

45 
annually to the IRB.  The Protocol Support Office of the Medical 
Oncology Clinical Research Unit, CCR, NCI will assist with annual 
internal auditing of subject case records.  After accrual of 3 subjects, the 
Protocol Support Office will also perform a protocol activation audit to 
review 
adherence 
to 
informed 
consent 
procedures, 
eligibility 
documentation, and initial treatment. 
5.5.3 The expected heterogeneity of study participants with respect to 
malignancy and risk factors for toxic events renders these parameters 
impractical to evaluate in a statistical manner; accordingly, formal 
stopping rules will not incorporate toxic events but will instead be based 
upon the rate and severity of acute GVHD, as described in Section 5.4. 
 
6.0 
Human Subject Protections 
6.1 
Rationale for Subject Selection: Patients with refractory lymphoid malignancies, 
leukemia, myelodysplasia, and myeloproliferative disorders will be the subjects 
for this study.  Conventional chemotherapy is seldom curative for patients with 
the disorders selected for inclusion in this study (section 2.1.1).  Allogeneic 
HSCT represents a potentially curative treatment for these diseases, which occur 
most frequently in individuals greater than 40 years of age.  However, the 
considerable risk of early treatment-related mortality related to conventional 
preparative regimens increases with patient age.  The use of a reduced-intensity 
preparative regimen in patients with these conditions will potentially reduce 
treatment-related mortality without a reduction in efficacy. 
6.2 
Risks/Benefits Analysis:  There is potential benefit to the transplant recipient, as 
demonstrated by the published literature documenting long-term disease-free 
survival for patients with refractory lymphoid malignancies, leukemias, 
myeloproliferative disorders, and myelodysplasia following allogeneic HSCT.  
The use of a reduced-intensity preparative regimen may permit patients to 
undergo allogeneic HSCT with fewer toxicities than if a conventional preparative 
regimen were used; this potential benefit increases with the age of the transplant 
recipient (see section 6.1).  However, we do not anticipate any direct benefit to 
the other subject covered by this protocol, i.e., the stem cell transplant donor. 
6.2.1 The acute risks to the stem cell donor include those associated with 
venipuncture and apheresis. 
6.2.2 Potential risks to the transplant recipient have also been considered and 
are felt to be potentially less than would otherwise occur in conventional 
allogeneic HSCT.  The risk of both acute and chronic GVHD will be 
present, as discussed previously. 
6.2.3 Children under the age of 12 years will be excluded as potential donors, 
given the uncertain risks in this young population and the low likelihood 
that such potential donors will be encountered. 
6.3 
Consent and Assent Process and Documentation: 
6.3.1 The procedures and treatments involved in this protocol, with their 
attendant risks and discomforts, potential benefits, and potential 
alternative therapies will be carefully explained to the recipient.  Similarly, 
the procedures and treatments involved in this protocol, with their 

46 
attendant risks and discomforts, will be carefully explained to the donor.  
A signed informed consent document will be obtained from both the 
recipient and the donor. 
6.3.2 Consent forms: The original signed informed consent documents will be 
kept with the patient's chart.  The Data Management Section will also 
retain a copy of the informed consent document.  A copy of the informed 
consent documents will also be given to the recipient and the donor. 
6.3.3 The Clinical Coordinator, Data Management Section, will ascertain the 
date of IRB approval before registering the first patient. 
 
7.0 
Data Reporting 
7.1 
Adverse Reactions - Reports of adverse reactions will be made using the Division 
of Cancer Treatment Common Toxicity Criteria (Version 2.0) for reference 
according to the guidelines published by the DCTD, NCI.  A copy of the CTC 
version 2.0 can be obtained from the CTEP home page (http://ctep.info.nih.gov). 
These guidelines are summarized as follows: 
7.1.1 Report by telephone to NCI IRB within 24 hours (301-230-2330): 
a) All life-threatening events (i.e., grade 4, except for myelosuppression), 
which may be due to administration of the study drug(s). 
b) All failures to engraft, or occurrences of graft rejection. 
c) All fatal events (grade 5). 
7.1.2 A written report should follow within 10 working days to: 
NCI Institutional Review Board 
Center for Cancer Research 
National Cancer Institute 
Building 82, Room 117 
Bethesda, MD  20892 
Serious adverse events that occur with commercially available agents will 
also be reported directly to the FDA through the MedWatch system 
(http://www.fda.gov/medwatch/). 
7.2 
Record Keeping 
7.2.1 All patients (donor and recipient) must have signed an Informed Consent, 
and on-study confirmation of eligibility form will be filled out before 
entering on the study. 
 
8.0 
Pharmaceutical Information 
8.1 
CYCLOPHOSPHAMIDE (CTX, Cytoxan, NSC-26271) 
8.1.1 Supply – Cyclophosphamide will be purchased by the NIH Clinical Center 
Pharmacy Department from commercial sources and is supplied as a 
lyophilized powder in various vial sizes. 
8.1.2 Preparation - will be reconstituted with sterile water for injection to yield a 
final concentration of 20 mg/ml as described in the package insert. 
8.1.3 Storage and Stability - The vials are stored at room temperature.  
Following reconstitution as directed, solutions of cyclophosphamide are 
stable for 24 hours at room temperature, or 6 days when refrigerated at 2-
8° C. 

47 
8.1.4 Route of Administration - The cyclophosphamide used in this regimen 
will be mixed in 100 ml normal saline and given as an IVPB over 30 
minutes in the induction regimen (i.e. EPOCH-F/R; Section 3.3.2). In the 
preparative regimen (Section 3.4.4), it is given over two hours.  
8.1.5 Toxicities: 
a) Nausea and vomiting - variable; symptomatically improved with 
standard anti-emetics and/or benzodiazepines [e.g., lorazepam]. 
b) Water retention – cyclophosphamide may rarely provoke the syndrome 
of inappropriate antidiuretic hormone secretion and resultant 
hyponatremia, usually manifested 12-48 hrs after IV administration, 
necessitating frequent accurate assessment [q 1-2 hrs] of intake, urine 
output and urine specific gravity.  This effect can be counteracted by 
furosemide.  Fluid restriction is not feasible during administration of 
high dose cyclophosphamide. 
c) Cardiomyopathy - cyclophosphamide may cause severe, sometimes 
lethal, 
hemorrhagic 
myocardial 
necrosis 
or 
congestive 
cardiomyopathy. 
 
Patients 
may 
present 
with 
congestive 
cardiomyopathy as late as 2 weeks after the last dose of 
cyclophosphamide.  The clinical syndrome has been observed in 
patients receiving the dose of cyclophosphamide used in this protocol.  
In an attempt to minimize this complication, patients with significant 
cardiac dysfunction are excluded from this protocol [see patient 
eligibility].  Congestive failure is managed according to standard 
medical therapeutics. 
d) Hemorrhagic cystitis – this is a serious, potentially life-threatening 
complication related to injury of the bladder epithelium by 
cyclophosphamide metabolites.  Although subclinical hematuria is not 
uncommon at this dose level, clinically significant hematuria or 
serious hemorrhage can usually be avoided by maintaining a high 
urine volume and frequent voidings and the administration of Mesna.  
Diuresis is maintained for 24 hrs after completion of last dose by 
parenteral infusions of normal saline with potassium chloride, as 
specified in section 3.4.4.  Careful monitoring of serum and urine 
electrolytes is mandated.  Furosemide may be required to ensure this 
diuresis.  Continuous bladder irrigation may be used for control of 
significant hematuria. 
e) Sterility 
f) Less common but serious complications include pulmonary fibrosis 
and secondary malignancies. Less common but reversible toxicities 
include alopecia and skin rash. 
8.2 
MESNA (Sodium 2-mercaptoethanesulfonate, Mesnum, Mesnex, NSC-113891) 
8.2.1 Supply – Mesna will be will be purchased by the NIH Clinical Center 
Pharmacy Department from commercial sources and is supplied as a 
100mg/ml solution. 
8.2.2 Preparation – Dilute up to 20 mg Mesna/ml fluid in D5W or normal saline.  
Mesna should be started one hr prior to the cyclophosphamide in the 

48 
preparative regimen (Section 3.6).  Bag #1 of the Mesna will be 150 
mg/m2 IV in 250 ml, given as a 3 hour infusion (thus stopping when 
cyclophosphamide ends).  Then immediately afterward, Mesna will be 
given at 1200 mg/m2 in 500 ml by continuous IV infusion over 24 hour 
infusion for four doses (days -6, -5, -4, and -3). 
8.2.3 Storage and Stability – Intact ampules are stored at room temperature.  
Diluted solutions (1 to 20 mg/dl) are physically and chemically stable for 
at least 24 hours under refrigeration.  Mesna is chemically stable at room 
temperature for 48-72 hours in D5W, 48-72 hour in D5W/0.45% normal 
saline, or 24 hours in normal saline. 
8.2.4 Administration - To be administered intravenously as continuous infusion. 
8.2.5 Toxicities - Nausea, vomiting, diarrhea.  A very rare complication is 
cough, dyspnea and fever with rapid progression to diffuse pulmonary 
fibrosis and death. 
8.3 
FILGRASTIM (G-CSF, Neupogen) 
8.3.1 Supply – Commercially available as filgrastim injection in a concentration 
of 300µg/ml in 1ml (300µg) and 1.6ml (480µg) vials. 
8.3.2 Preparation – For subcutaneous administration, the appropriate prescribed 
dose is drawn up from the vial with no further dilution prior to 
administration.  For intravenous administration, the commercial solution 
for injection should be diluted prior to administration.  It is recommended 
that the prescribed dose be diluted with dextrose 5% in water to a 
concentration greater than 5µg/ml.  Dilution of filgrastim to a final 
concentration of less than 5µg/ml is not recommended at any time.  Do not 
dilute with saline at any time; product may precipitate.  Filgrastim diluted 
to concentrations between 5 and 15µg/ml should be protected from 
absorption to plastic materials by the addition of Albumin (Human) to a 
final concentration of 2mg/ml.  When diluted in 5% dextrose or 5% 
dextrose plus Albumin (Human), filgrastim is compatible with glass 
bottles, PVC and polyolefin IV bags, and polypropylene syringes.  The 
dose may be “rounded down” to within 10% of patient’s calculated dose to 
use the drug cost-effectively. 
8.3.3 Storage and Stability – Filgrastim for injection should be stored in the 
refrigerator at 2o to 8oC (36o to 46oF).  Avoid shaking. 
8.3.4 Administration – Subcutaneous injection is preferred.  If clinically 
indicated, filgrastim may be administered as an intravenous infusion over 
4 or 24 hours. 
8.3.5 Toxicities – Medullary bone or skeletal pain is the most commonly 
reported toxicity.  In addition, reversible elevations in uric acid, lactate 
dehydrogenase, and alkaline phosphatase are common laboratory 
abnormalities.  Four cases of splenic rupture have been reported in healthy 
donors when given filgrastim or other myeloid growth factors for 
peripheral blood stem cell mobilization; 1 of these cases resulted in 
fatality.  Five additional cases of splenic rupture have been reported in 
cancer patients undergoing chemotherapy or peripheral blood stem cell 
mobilization; splenic rupture may have contributed to deaths in 2 of these 

49 
cases.  One additional death due to splenic rupture after filgrastim therapy 
was reported to the manufacturer without additional information.  
According to the manufacturer, the reporting rate for splenic rupture with 
filgrastim is less than 1 in 486,000. 
8.4 
CYCLOSPORINE (Gengraf, Sandimmune, Neoral) 
8.4.1 Supply – Cyclosporine will be obtained by the NIH Clinical Center 
Pharmacy Department from commercial sources and is available in 
capsules (25 mg and 100 mg), USP [MODIFIED], oral solution (100 
mg/ml), USP [MODIFIED], and as a parenteral concentrate for injection 
(50 mg/ml).  When oral capsules are prescribed for this protocol, the 
cyclosporine capsules, USP [NON-MODIFIED] should NOT be used. 
8.4.2 Preparation – For parenteral doses, each milliliter of concentrate 
(50mg/ml) should be diluted in 20 to 100ml of dextrose 5% in water or 
sodium chloride 0.9%.  Parenteral doses of cyclosporine will be prepared 
in non-PVC containers and infused with non-PVC administration 
sets/tubing (see Storage and Stability, section 8.4.2).  Oral cyclosporine 
solution may be mixed in orange juice or other beverages, but not milk. 
8.4.3 Storage and Stability – Capsules, oral solution, and ampules of parenteral 
concentrate bear expiration dates and are stored at room temperature and 
protected from light.  Cyclosporine concentrate for injection that has been 
diluted to a final concentration of approximately 2mg/ml is stable for 24 
hours in 5% dextrose or 0.9% sodium chloride injection in glass, PVC or 
non-PVC plastic containers.  To minimize the potential for sorption to 
PVC plastic bags and tubing as well the leaching of phthalate plasticizer 
(DEHP) into the solution, only non-PVC plastic bags and intravenous 
administration sets should be utilized. 
8.4.4 Administration – Cyclosporine may be given intravenously over 2 hours 
or orally. 
8.4.5 Toxicities – Acute cyclosporine nephrotoxicity is usually manifested by a 
moderate decline in renal excretory function, which is readily reversible 
by a decrease in drug dosage.  Although some degree of transient renal 
dysfunction may occur in patients with therapeutic levels of cyclosporine, 
significant renal toxicity is associated with elevated trough levels.  In 
addition to an increase in BUN and creatinine, hyperkalemic 
hyperchloremic acidosis, low fractional excretion of sodium and the onset 
of hypertension with hypomagnesemia are seen with cyclosporine 
nephrotoxicity.  Hypertension occurs in up to 60% of patients.  
Hypomagnesemia can be associated with neurologic symptoms, including 
seizures, cerebellar ataxia and depression.  Dose-related hepatotoxicity, 
manifested by elevation of serum transaminases and bilirubin, has been 
reported. 
8.5 
FLUDARABINE (Fludara, Berlex Laboratories) 
8.5.1 Supply - Fludarabine monophosphate will be purchased by the NIH 
Clinical Center Pharmacy Department from commercial sources and is 
supplied as a white, lyophilized powder.  Each vial contains 50 mg of 

50 
fludarabine phosphate, 50 mg of mannitol, and sodium hydroxide to adjust 
pH.  Fludara is stored at room temperature. 
8.5.2 Preparation - FLUDARA IV should be prepared for parenteral use by 
aseptically adding Sterile Water for Injection, USP.  When reconstituted 
with 2 ml of Sterile Water for Injection, each ml of the resulting solution 
will contain 25 mg of Fludarabine Phosphate, 25 mg of mannitol, and 
sodium hydroxide to adjust the pH to 7–8.5.  Fludarabine will be diluted in 
100 to 125ml of either 5% dextrose in water or 0.9% sodium chloride, and 
infused IV over 30 minutes. 
8.5.3 Storage and Stability - Reconstituted FLUDARA IV is chemically and 
physically stable for 24 hours at room temperature or for 48 hours if 
refrigerated.  Because reconstituted FLUDARA IV contains no 
antimicrobial preservative, care must be taken to assure the sterility of the 
prepared solution; for this reason, reconstituted FLUDARA IV should be 
used or discarded within 8 hours. 
8.5.4 Administration - Parenteral drug products should be inspected visually for 
particulate matter and discoloration prior to administration.  
8.5.5 Toxicities – Fludarabine toxicities include myelosuppression (dose 
limiting 
toxicity), 
fever, 
nausea, 
vomiting, 
stomatitis, 
diarrhea, 
gastrointestinal bleeding, anorexia, edema, skin rashes, myalgia, headache, 
agitation, hearing loss, transient episodes of somnolence and fatigue, auto-
immune hemolytic anemia, auto-immune thrombocytopenia, paresthesias, 
peripheral neuropathy, renal, and pulmonary toxicity (intersititial 
pneumonitis).  Severe fatal CNS toxicity presenting with loss of vision and 
progressive deterioration of mental status were encountered almost 
exclusively after very high doses of fludarabine monophosphate.  Such 
toxicity has only rarely been demonstrated at the 25-30 mg/m2/day dosage 
of fludarabine.  Very rarely described complications include transfusion-
associated 
graft-versus-host 
disease, 
thrombotic 
thrombocytopenic 
purpura, and liver failure.  Tumor lysis syndrome following fludarabine 
administration has been observed, especially in patients with advanced 
bulky disease.  Opportunistic infections (protozoan, viral, fungal, and 
bacterial) have been observed post-fludarabine, especially in heavily pre-
treated individuals, and in individuals receiving fludarabine combined 
with other agents. 
8.6 
ETOPOSIDE, DOXORUBICIN, and VINCRISTINE (in EPOCH) 
8.6.1 Supply – Etoposide, doxorubicin, and vincristine will be purchased by the 
NIH Clinical Center Pharmacy Department from commercial sources. 
8.6.2 Preparation and Administration - Etoposide, doxorubicin, and vincristine 
will be combined in a single (‘3-in-1’) admixture, diluted in a volume of 
0.9% Sodium Chloride (NS), Injection, USP, that is based on the amount 
of etoposide needed to complete one day of treatment: 
 
Etoposide 
Dose 
Volume of Fluid 
Containing a 
Daily Dose 
Volume of 
Overfill 
(fluid + drug) 
Volume To Infuse 
(over 24 hours) 
Administration 
Rate 
≤150 mg 
528 mL 
25 mL 
528 mL 
22 mL/hour 

51 
≥151 mg 
1056 mL 
25 mL 
1056 mL 
44 mL/hour 
 
All 3-in-1 admixtures dispensed from the Pharmacy will contain a 24-hour 
supply of etoposide, doxorubicin, and vincristine PLUS 25 mL overfill 
(excess) fluid and a proportional amount of drug to compensate for 
volume lost in administration set tubing. 
Before dispensing 3-in-1 admixtures, Pharmacy staff will [1] purge all air 
from the drug product container, [2] attach an administration set 
appropriate for use with a portable pump and the set will be [3] primed 
close to its distal tip and [4] capped with a Luer-locking cap.  Bags will be 
exchanged daily for 4 consecutive days to complete a 96-hour drug 
infusion. 
Portable pumps used to administer etoposide + doxorubicin + vincristine 
admixtures will be programmed to deliver one of two fixed volumes at one 
of two corresponding fixed rates based on the amount of etoposide and 
fluid that is ordered (see table, above).  At the end of an infusion, some 
residual fluid is expected because overfill fluid and drug were added; 
however, nurses are asked to return to the Pharmacy for measurement any 
drug containers that appear to contain a greater amount of residual drug 
than expected. 
8.6.3 Storage and Stability - Studies conducted by the Pharmaceutical 
Development Service, Pharmacy Department, NIH Clinical Center, have 
demonstrated that admixtures of vincristine, doxorubicin, and etoposide in 
0.9% Sodium Chloride for Injection (at concentrations, respectively, of 1, 
25, and 125 mcg/ml; 2, 50, and 250 mcg/ml; and 2.8, 70, and 350 mcg/ml) 
are stable for at least 48 hours at room temperature when protected from 
light [76].   
8.6.4 Toxicities– 
a) Etoposide:  nausea, vomiting, stomatitis, diarrhea, neutropenia, 
thrombocytopenia, and alopecia.  Secondary AML has been associated 
with etoposide.  Bradycardia and hypotension are sometimes observed 
with etoposide administration. 
b) Doxorubicin:  Cardiotoxicity is particularly noted after cumulative 
doses of greater than 550 mg/m2.  Other toxicities include 
myelosuppression, nausea, vomiting, stomatitis, diarrhea, and alopecia.  
Skin infiltration of doxorubicin causes tissue necrosis. 
c) Vincristine causes neurological toxicities such as paresthesias, jaw 
pain, ataxia, foot-drop, cranial nerve palsies, paralytic ileus, 
constipation, abdominal pain, and loss of deep tendon reflexes.  It is 
also 
a 
vesicant, 
and 
occasionally 
causes 
alopecia 
and 
myelosuppression. 
8.7 
PREDNISONE 
8.7.1 Supply – Prednisone will be purchased by the NIH Clinical Center 
Pharmacy Department from commercial sources.  Prednisone is 
commercially available as tablets, in strengths of 1, 2.5, 5, 20, and 50 mg. 

52 
8.7.2 Storage and Stability - Prednisone tablets should be stored in the container 
provided away from heat.  The product labeling bears the manufacturer's 
expiration dating for stability. 
8.7.3 Administration - Prednisone will be administered at a dose of 60 mg/m2 
orally on days 1, 2, 3, 4, and 5 of the induction chemotherapy regimen.  In 
patients unable to tolerate oral medication, methylprednisolone can be 
substituted at an equivalent dosage, diluted in a small volume (e.g. 25-
50ml) of 5% dextrose in water or 0.9% sodium chloride and infused over 
15 minutes.  To reduce gastrointestinal side effects, prednisone should be 
taken with food. 
8.7.4 Toxicities - Prednisone frequently causes gastritis, immunosuppression, 
muscle wasting, fluid retention, and hyperglycemia. 
8.8 
METHOTREXATE (Methotrexate sodium, MTX, NSC-740) 
8.8.1 Supply – Methotrexate will be obtained commercially and is supplied as a 
25 mg/ml preservative-free isotonic solution for injection. 
8.8.2 Preparation – The desired dose will be diluted in 5% dextrose in water or 
0.9% sodium chloride. 
8.8.3 Storage and Stability – Methotrexate should be stored at room temperature 
and protected from light.  Once the prepared dose is diluted for 
administration, the solution is stable for 24 hours refrigerated or at room 
temperature when protected from light. 
8.8.4 Administration – Methotrexate will be given as IV infusion over 15 
minutes. 
8.8.5 Toxicities - The toxicity associated with methotrexate primarily involves 
the gastrointestinal tract.  Severe mucositis can occur, particularly in 
patients who have received an intensive preparative regimen. Other 
gastrointestinal symptoms include nausea, vomiting and diarrhea.  
Transient elevations in serum transaminases have been seen. The 
myelosuppression associated with methotrexate often results in delayed 
engraftment.  Folinic acid can effectively circumvent the enzymatic block 
produced by methotrexate. 
8.9 
RITUXIMAB (Rituxan) 
8.9.1 Supply – Rituximab will be obtained commercially and is supplied as a 10 
mg/ml sterile, preservative-free solution for injection, in vials of 100 mg 
and 500 mg. 
8.9.2 Preparation – The desired dose will be diluted to a final concentration of 1 
to 4 mg/mL in either 0.9% Sodium Chloride or D5W. 
8.9.3 Storage and Stability – Rituximab vials should be stored at 2–8°C (36–
46°F) and should be protected from direct sunlight. 
8.9.4 Administration – First Infusion: The rituximab solution for infusion 
should be administered intravenously at an initial rate of 50 mg/hr. 
Rituximab should not be mixed or diluted with other drugs.  If 
hypersensitivity or infusion reactions do not occur, escalate the infusion 
rate in 50 mg/hr increments every 30 minutes, to a maximum of 400 
mg/hr.  If hypersensitivity (non-IgE-mediated) or an infusion reaction 
develops, the infusion should be temporarily slowed or interrupted. The 

53 
infusion can continue at one-half the previous rate upon improvement of 
patient symptoms.  If the first infusion is tolerated well, infusions during 
subsequent cycles of EPOCH-F/R can begin at a rate of 100 mg/hr and be 
increased by 100 mg/hr increments at 30-minute intervals.  However, if 
the first infusion is not tolerated well, then the guidelines for the initial 
infusion should be followed for subsequent administration.  Premedication 
will routinely be administered 30 to 60 minutes prior to the beginning of 
each rituximab infusion, consisting of acetaminophen 650 mg PO and 
diphenhydramine 50 mg IV. 
8.9.5 Toxicities – The most serious adverse reactions caused by rituximab 
include infusion reactions, tumor lysis syndrome, mucocutaneous 
reactions, hypersensitivity reactions, cardiac arrhythmias and angina, and 
renal failure. 
a) Fatal and Severe Infusion Reactions:  Deaths within 24 hours of 
rituximab infusion have been reported.  Approximately 80% of fatal 
infusion reactions occurred in association with the first infusion.  
Severe reactions typically occurred during the first infusion with time 
to onset of 30 to 120 minutes.  Signs and symptoms of severe infusion 
reactions may include hypotension, angioedema, hypoxia or 
bronchospasm, 
and 
may 
require 
interruption 
of 
rituximab 
administration.  The most severe manifestations and sequelae include 
pulmonary infiltrates, acute respiratory distress syndrome, myocardial 
infarction, ventricular fibrillation, and cardiogenic shock.  In the 
reported cases, the following factors were more frequently associated 
with fatal outcomes:  female gender, pulmonary infiltrates, and chronic 
lymphocytic leukemia or mantle cell lymphoma.  Management of 
severe infusion reactions:  The rituximab infusion should be 
interrupted for severe reactions and supportive care measures instituted 
as medically indicated (e.g., intravenous fluids, vasopressors, oxygen, 
bronchodilators, diphenhydramine, and acetaminophen).  In most 
cases, the infusion can be resumed at a 50% reduction in rate (e.g., 
from 100 mg/hr to 50 mg/hr) when symptoms have completely 
resolved.  Patients requiring close monitoring during first and all 
subsequent infusions include those with pre-existing cardiac and 
pulmonary conditions, those with prior clinically significant 
cardiopulmonary adverse events and those with high numbers of 
circulating malignant cells (= 25,000/mm3) with or without evidence 
of high tumor burden. 
b) Tumor Lysis Syndrome (TLS):  Acute renal failure requiring dialysis 
with instances of fatal outcome has been reported in the setting of TLS 
following treatment with rituximab.  Rapid reduction in tumor volume 
followed by acute renal failure, hyperkalemia, hypocalcemia, 
hyperuricemia, or hyperphosphatasemia, have been reported within 12 
to 24 hours after the first rituximab infusion.  Rare instances of fatal 
outcome have been reported in the setting of TLS following treatment 
with rituximab.  The risks of TLS appear to be greater in patients with 

54 
high numbers of circulating malignant cells (= 25,000/mm3) or high 
tumor burden.  Prophylaxis for TLS should be considered for patients 
at high risk.  Correction of electrolyte abnormalities, monitoring of 
renal function and fluid balance, and administration of supportive care, 
including dialysis, should be initiated as indicated.  Following 
complete resolution of the complications of TLS, rituximab has been 
tolerated when re-administered in conjunction with prophylactic 
therapy for TLS in a limited number of cases. 
c) Severe Mucocutaneous Reactions:  Mucocutaneous reactions, some 
with fatal outcome, have been reported in patients treated with 
rituximab.  These reports include paraneoplastic pemphigus (an 
uncommon disorder which is a manifestation of the patient’s 
underlying 
malignancy), 
Stevens-Johnson 
syndrome, 
lichenoid 
dermatitis, vesiculobullous dermatitis, and toxic epidermal necrolysis.  
The onset of the reaction in the reported cases has varied from 1 to 13 
weeks following rituximab exposure.  Patients experiencing a severe 
mucocutaneous reaction should not receive any further infusions and 
seek prompt medical evaluation.  Skin biopsy may help to distinguish 
among different mucocutaneous reactions and guide subsequent 
treatment.  The safety of readministration of RITUXAN to patients 
with any of these mucocutaneous reactions has not been determined. 
d) Infusion reactions and lymphopenia are the most commonly occurring 
adverse reactions.  Mild to moderate infusion reactions consisting of 
fever and chills/rigors occur in the majority of patients during the first 
rituximab infusion.  Other frequent infusion reaction symptoms 
included nausea, pruritus, angioedema, asthenia, hypotension, 
headache, bronchospasm, throat irritation, rhinitis, urticaria, rash, 
vomiting, myalgia, dizziness, and hypertension.  These reactions 
generally occur within 30 to 120 minutes of beginning the first 
infusion, and resolved with slowing or interruption of the rituximab 
infusion and with supportive care (diphenhydramine, acetaminophen, 
IV saline, and vasopressors).  In an analysis of data from 356 patients 
with relapsed or refractory, low-grade NHL who received 4 (N = 319) 
or 8 (N = 37) weekly infusions of rituximab, the incidence of infusion 
reactions was highest during the first infusion (77%) and decreased 
with each subsequent infusion (30% with fourth infusion and 14% 
with eighth infusion). 
8.10 
DIPHENHYDRAMINE 
8.10.1 Supply – Commercially available.  Diphenhydramine HCl injection is 
available in an injectable solution at a 50mg/ml concentration in single 
dose ampules, syringes and vials as well as multi-dose vials from multiple 
manufacturers. 
8.10.2 Preparation – Diphenhydramine HCl may be given by direct intravenous 
injection without additional dilution.  Alternatively the prescribed dose 
may be diluted in a small volume (e.g. 25-50ml) of 5% dextrose in water 
(D5W) or 0.9% sodium chloride (NS) and infused over 10-15 minutes. 

55 
8.10.3 Storage and Stability – Store commercially available injectable product at 
controlled room temperature. 
8.10.4 Administration – Diphenhydramine HCl injection may be administered by 
direct IV injection (IV push) at a rate generally not exceeding 25mg/min.  
Alternatively, diphenhydramine HCl injection may be diluted and given 
over 10-15 minutes (see Preparation). 
8.10.5 Toxicities – Sedation, sleepiness, dizziness, disturbed coordination, 
epigastric distress, thickening of bronchial secretions.  Diphenhydramine  
can provide additive effects with alcohol or other CNS depressants.  
Diphenhydramine can cause anticholinergic side effects (e.g. dry mouth, 
fixed or dilated pupils, flushing, urinary retention).  Diphenhydramine 
should be used with caution in patients with a history of bronchial asthma, 
increased intraocular pressure, hyperthyroidism, cardiovascular disease or 
hypertension. 
8.11 
ACETAMINOPHEN 
8.11.1 Supply – Commercially available as 325 mg or 500 mg tablets for oral 
administration from multiple manufacturers. 
8.11.2 Storage – Store at controlled room temperature. 
8.11.3 Administration – Oral.  For analgesia and antipyresis, the usual dose is 
650 to 1000 milligrams every 4 to 6 hours, to a maximum of 4 grams/day. 
8.11.4 Toxicities – No toxicities are anticipated to result from single doses of 
acetaminophen administered as premedication for rituximab infusions. 
8.12 
VALACYCLOVIR (Valtrex®) 
8.12.1 Supply – Commercially available as 500mg tablets and 1gm tablets.  Dose 
adjustment is necessary in patients with significant renal impairment (refer 
to the manufacturer's labeling for dose adjustment guidelines.) 
8.12.2 Pharmacology – Valacyclovir is the hydrochloride salt of L-valyl ester of 
the antiviral drug acyclovir. After oral administration, valacyclovir is 
rapidly absorbed from the GI tract and nearly completely converted to 
acyclovir and L-valine by first-pass intestinal or hepatic metabolism. 
8.12.3 Storage and Stability – Oral tablets should be stored at 15o to 25oC (59o to 
77oF). 
8.12.4 Administration – Oral. 
8.12.5 Toxicities – Nausea and/or vomiting, headache, dizziness, abdominal pain, 
dysmenorrhea, arthralgia, acute hypersensitivity reactions, elevations in 
liver enzyme laboratory values (e.g. AST).  Renal failure and CNS 
symptoms have been reported in patients with renal impairment who 
received valacyclovir or acyclovir at greater than the recommended dose. 
Dose reduction is recommended in this patient population (refer to the 
manufacturer's labeling for dose adjustment guidelines). 
8.13 
FLUCONAZOLE (Diflucan®) 
8.13.1 Supply – Commercially available as 50 mg, 100 mg, 150 mg and 200 mg 
tablets, or as a powder for oral suspension for reconstitution at a 
concentration of 10mg/ml or 40 mg/ml.  Parenteral fluconazole is 
available in a solution for injection at a concentration of 2 mg/ml in glass 

56 
bottles and Viaflex® Plus plastic containers containing either 100ml (200 
mg) or 200ml (400 mg). 
8.13.2 Preparation – For parenteral administration, the commercial solution for 
injection is available in its final form for administration (concentration of 
2 mg/ml). 
8.13.3 Storage and Stability – Oral tablets and oral suspension should be stored at 
temperatures below 30oC (86oF).  Store reconstituted oral suspension 
between 5o to 30oC (41o to 86oF) and discard unused portion after 2 weeks.  
Fluconazole for injection in glass bottles should be stored between 5o to 
30oC (41o to 86oF).  Fluconazole for injection in Viaflex® Plus plastic 
containers should be stored between 5o to 25oC (41o to 77oF). 
8.13.4 Administration – Oral and parenteral.  Parenteral doses should be 
administered by an intravenous infusion at a maximum rate of 200mg/hr. 
8.13.5 Toxicities – Nausea, vomiting, headache, skin rash, abdominal pain, 
diarrhea have been reported at an incidence of 1% or greater in clinical 
trials.  In combined clinical trials and marketing experience, there have 
been rare cases of serious hepatic reactions during treatment with 
fluconazole.  The spectrum of these hepatic reactions has ranged from 
mild transient elevation in transaminases to clinical hepatitis, cholestasis 
and fulminant hepatic failure, including fatalities. 
8.13.6 Drug Interactions – Fluconazole is a potent inhibitor of the cytochrome 
P450 3A4 isoenzyme system.  Coadministration of fluconazole with other 
drugs metabolized by the same enzyme system may result in increased 
plasma concentrations of the drugs, which could increase or prolong 
therapeutic and adverse effects.  Refer to the package literature or other 
drug information resources for additional information on identification and 
management of potential drug interactions. 
8.14 
TRIMETHOPRIM/SULFAMETHOXAZOLE 
(TMP/SMX, 
Cotrimoxazole, 
Bactrim, Septra) 
8.14.1 Supply – Commercially available as a single strength tablet  containing 
trimethoprim 80mg and sulfamethoxazole 400mg and a double strength 
(DS) tablet containing trimethoprim 160mg and sulfamethoxaole 800mg.  
It is also available in a oral suspension at a concentration of 40mg of 
trimethoprim and 200mg sulfamethoxazole per 5ml.  Parenteral 
TMP/SMX is available in a solution for injection at a concentration of 
80mg of trimethoprim and 400mg of sulfamethoxazole per 5ml. 
8.14.2 Preparation – For parenteral administration, the commercial solution for 
injection must be diluted prior to administration.  It is recommended that 
each 5ml of the solution for injection be diluted with 100-125 ml or, if 
fluid restriction is required, in 75ml of dextrose 5% in water.  Normal 
saline (0.9% sodium chloride) may be substituted as a diluent but the 
resulting solutions have reduced stability.  Consult with pharmacy for 
questions regarding diluent, volume, and expiration. 
8.14.3 Storage and Stability – Oral tablets and oral suspension should be stored at 
15o to 30oC (59o to 86oF) in a dry place and protected from light.  
TMP/SMX for injection should be stored at room temperature between 15o 

57 
to 30oC (59o to 86oF) and should not be refrigerated.  Stability of 
intravenous doses after final dilution is dependent on concentration and 
diluent.  Consult with pharmacy for questions regarding stability and 
expiration dating. 
8.14.4 Administration – Oral and parenteral.  Parenteral doses should be 
administered by an intravenous infusion over 60 to 90 minutes. 
8.14.5 Toxicities – The most common adverse effects from TMP/SMX are 
gastrointestinal disturbances (nausea, vomiting, anorexia) and allergic skin 
reactions (such as rash and urticaria).  Fatalities associated with the 
administration of sulfonamides, although rare, have occurred due to severe 
reactions, 
including 
Stevens-Johnson 
syndrome, 
toxic 
epidermal 
necrolysis, fulminant hepatic necrosis, agranulocytosis, aplastic anemia 
and other blood dyscrasias.  For TMP/SMX injection, local reaction, pain 
and slight irritationon IV administration are infrequent.  Thrombophlebitis 
has rarely been observed. 
8.15 
MEDROXYPROGESTERONE ACETATE (Provera) 
8.15.1 Supply – Commercially available as 2.5mg, 5mg, and 20mg tablets. 
8.15.2 Storage – Tablets should be stored at controlled room temperature 20o to 
25oC (68o to 77oF). 
8.15.3 Administration – Oral. 
8.15.4 Toxicities – nausea, breast tenderness or galactorrhea, sensitivity reactions 
(urticaria, pruritis, edema, rash), acne, alopecia, hirsutism, fluid retention, 
mental depression, cholestatic jaundice, changes in cervical erosion and 
cervical 
secretions, 
breakthrough 
bleeding 
or 
spotting, 
and 
thromboembolic phenomena. 
8.16 
IMMUNE GLOBULIN INTRAVENOUS (IGIV) 
8.16.1 Supply – Commercially available (multiple sources) in a variety of 
formulations, including solution for injection and powder for injection in a 
variety of vial sizes. 
8.16.2 Preparation – Refer to the manufacturer’s package labeling for guidelines 
in preparation. 
8.16.3 Storage and Stability – Refer to the manufacturer’s package labeling for 
storage and stability information. 
8.16.4 Administration – Intravenous infusion.  Refer to the manufacturer’s 
package labeling for recommendations on rate of administration. 
8.16.5 Toxicities: 
a) Infusion related toxicities may occur.  Symptoms may include 
flushing, feelings of tightness in the chest, chills, fever, dizziness, 
nausea, diaphoresis, backache, leg cramps, urticaria, and hypotension 
or hypertension.  Slowing or stopping the infusion usually allows the 
symptoms to disappear promptly.  Immediate anaphylactic and 
hypersensitivity reactions are a remote possibility.  Patients with IgA 
deficiency who have developed antibodies to IgA have an increased 
risk of anaphylactic reactions when treated with IgA-containing IGIV 
products. 

58 
b) Immune Globulin Intravenous products have been associated with 
renal dysfunction, acute renal failure, osmotic nephrosis, and death.  
Patients predisposed to acute renal failure include patients with any 
degree of pre-existing renal insufficiency, diabetes mellitus, > 65 years 
of age, volume depletion, sepsis, paraproteinemia, or patients receiving 
known nephrotoxic drugs. Especially in such patients, IGIV products 
should be administered at the minimum concentration available and 
the minimum rate of infusion practicable. While these reports of renal 
dysfunction and acute renal failure have been associated with the use 
of many of the licensed IGIV products, those containing sucrose as a 
stabilizer accounted for a disproportionate share of the total number. 
c) Since Immune Globulin Intravenous products are made from human 
plasma, there is the risk of transmitting infectious agents such as 
viruses that can cause disease.  This risk has been reduced by 
screening plasma donors, testing for certain virus infections, and by 
inactivating and/or removing certain viruses. 
d) An aseptic meningitis syndrome has been reported to occur 
infrequently in association with IGIV treatment. 
e) There is also clinical evidence of a possible association between IGIV 
administration and thrombotic events. The exact cause of this is 
unknown; therefore caution should be exercised in the prescribing and 
infusion of IGIV in patients with a history of cardiovascular disease or 
thrombotic episodes. 
 
 

59 
9.0 
Appendices 
 
9.1 
Appendix A:  Prophylaxis and Treatment of Infectious Complications in 
Allogeneic HSCT Recipients 
Note:  The practice guidelines included in this Appendix are based upon the best 
available clinical evidence and may change as additional data become available. 
9.1.1 Pneumocystis carinii pneumonia 
f) At the start of pre-transplant induction chemotherapy, all patients will 
receive trimethoprim 160 mg/sulfamethoxazole 800 mg (TMP/SMX 
160/800), one tablet PO BID on two days per week (e.g., on each 
Saturday and Sunday).  This will continue until completion of 
induction chemotherapy. 
g) Upon admission for the transplant conditioning regimen (day –7), all 
patients will receive TMP/SMX 160/800, one tablet PO BID, 
continuing daily through the evening of day –2. 
h) Prophylaxis is resumed when the absolute neutrophil count is greater 
than 1000/µl and the platelet count is consistently above 50,000/mm3 
for two consecutive days without transfusion.  Note: TMP/SMX 
should not be resumed before the last day of methotrexate 
administration (day +11 – see Section 3.5.3).   The dose for post-
transplant prophylaxis is TMP/SMX 160/800, one tablet PO BID on 
two days per week, continuing for 6 months after transplantation or 
until the patient is off immunosuppression, whichever is longer.  For 
patients allergic to sulfa, see discussion in “Rationale”, below. 
 
FUNGAL PATHOGENS 
9.1.2 Yeast Infections 
Rationale: 
• 
PCP is common (incidence 21 cases per 100 patients/year in the absence of prophylaxis), 
potentially lethal and preventable.  It is not known when it is safe to discontinue prophylaxis, 
but CDC guidelines recommend prophylaxis for 6 months after transplant unless there is 
persistent immunosuppression (i.e., steroids).  In a case series reported in 1996, late PCP 
happened only in patients receiving steroids for GVHD [77]7]. 
• 
The CDC recommends TMP/SMX 160/800 daily OR 80/400 daily OR 160/800 three 
days/week.  The “weekend” regimen has not been shown to be equivalent in RCT, but has been 
used widely in BMT and solid organ transplant. 
• 
Chronic GVHD in the absence of active immunosuppressive treatment probably does not 
require PCP prophylaxis.  A convenient alternative in this setting is TMP/SMX 80/400 daily, 
as this provides prophylaxis for PCP and bacterial infections. 
• 
The alternative regimens for PCP prophylaxis are less effective than TMP/SMX.  Pentamidine 
inhalation 300 mg/4 weeks is felt to be the least effective regimen [78]8].  There is ample 
documentation in the HIV literature that pentamidine 300 mg q 2 weeks is more effective than 
monthly, so this may be considered an option in selected cases [79-81]1].  Dapsone is the 
recommended alternative, but its use is often impractical due to occasional cross-reactivity with 
TMP/SMX. Also, dapsone has known hepatotoxicity, so it may be difficult to use in patients 
with already abnormal liver enzymes.  Atovaquone has been used successfully in liver 
transplantation [82]2], HIV [83, 84]4] and autologous BMT [85]5]. 

60 
a) On day 6 of the first cycle of pre-transplant induction chemotherapy, 
all patients will begin fluconazole 400 mg PO daily.  Because of its 
interaction with vincristine, fluconazole will be discontinued during 
days 1, 2, 3, 4 and 5 of induction chemotherapy.  Fluconazole will then 
be restarted on day 6 of each cycle. 
b) Patients will continue fluconazole 400 mg PO daily throughout the 
transplant conditioning regimen (day –6) until 100 days after 
transplantation or until the patient is off immunosuppression, 
whichever is longer.  Intravenous dosing will be substituted when 
patients are unable to tolerate oral medications. 
Rationale: 
The CDC Guidelines recommend fluconazole until day 30 (or 7 days of ANC > 1000/µl) only.  
However, the long-term follow-up [86] of the Seattle study that showed decreased fungal infections 
and improved survival [87] suggests that fluconazole for 75 days protects from gut GVHD, 
disseminated candidal infections and candidiasis-related death.  For this reason we prefer to continue 
fluconazole administration until day 100 or the end of immunosuppressive treatment, whichever is 
longer.  
 
9.1.3 Mould Infections (including Aspergillus) 
a) During Neutropenia:  Neutropenic patients who are febrile for more 
than 5 days despite broad-spectrum antibiotics and have no clinical 
evidence of invasive fungal disease will receive liposomal 
amphotericin B (Ambisome) 5 mg/kg/day or voriconazole 6 mg/kg 
q12h for two doses and then 4 mg/kg q12h.  This therapy will continue 
until the patient attains an ANC > 500/µl AND is afebrile for 24 hours.  
Fluconazole prophylaxis will be discontinued during this therapy. 
Rationale: 
The empirical use of antifungal therapy during neutropenia is controversial.  Less than 5% of patients 
with persistent fever during neutropenia have a documented fungal infection.  Only one RCT has 
shown decreased fungal infection-related death with the empirical addition of amphotericin B in 
neutropenic fever, and this study actually failed to show an overall survival advantage [88].  The 
relevance of these results to patients with short neutropenia (median = 9 days) who are receiving 
fluconazole prophylaxis is questionable.  The most recent trial of empirical antifungal therapy in 
febrile neutropenic patients showed 19 fungal infections in 837 patients at the time of initiating 
antifungal therapy and another 29 documented “breakthrough” invasive fungal infections during 
follow-up.  In the high-risk subgroup (relapsed leukemia and/or allogeneic bone marrow transplant), 
the prevalence of breakthrough fungal infections was higher (15/289) [89].  Our recommendations are 
based on the following reasoning:  if persistent fever during neutropenia is a manifestation of an occult 
fungal infection in our patients (severely immunosuppressed, with short neutropenia and long-term use 
of fluconazole), then the most likely pathogens (fluconazole-resistant Candida and Aspergillus) are 
probably better treated with high-dose liposomal amphotericin B (at least 5 mg/kg).  As all the 
allogeneic HSCT patients receive cyclosporine after transplantation, liposomal amphotericin B is the 
lipid formulation of choice.  Voriconazole is a valid alternative, and in the mentioned study was 
associated with significantly fewer breakthrough fungal infections than Ambisome [89]. 
 
VIRAL PATHOGENS 

61 
9.1.4 Herpes Simplex Virus (HSV) and Varicella Zoster Virus (VZV) 
a) All patients will receive valacyclovir 500 mg PO QD for suppression 
of HSV and VZV infection/reactivation.  This prophylaxis will begin 
when patients start induction chemotherapy (EPOCH-F/R) and 
continue throughout transplantation.  Valacylovir will continue for 6 
months after transplantation or until the end of immunosuppression, 
whichever is longer.  If a patient cannot take oral medications, 
acyclovir 250 mg/m2 IV q12h will be substituted for valacyclovir. 
Rationale: 
• 
HSV is an important cause of morbidity after high-dose chemotherapy.  Several effective regimens 
are available.  Every patient receives prophylaxis regardless of HSV serology because of the 
possibility of primary infection after the test, and the fact that valacyclovir may also prevent VZV 
reactivation.  There is no compelling reason to try to prevent HSV beyond the period of mucositis, 
but our patients will remain on valacyclovir for a minimum of 6 months. 
• 
VZV reactivates in a significant proportion of allogeneic HSCT recipients once antiviral agents 
are stopped (30-60% in the first year).  The morbidity associated with VZV reactivation is high.  
Hence, prophylaxis with antiviral agents is accepted practice (“...this therapy could be considered 
for use among HSCT recipients with severe, long-term immunodeficiency”[90]).  Low-dose 
acyclovir (400 mg/d) administered until the end of immunosuppressive therapy has been reported 
to significantly decrease the incidence of reactivation [91].  It is not known which antiviral and 
what dose are best to prevent VZV, or for how long to administer it.  The universal experience 
seems to be that reactivation is unusual for as long as patients are on any prophylactic anti-
herpesvirus agent [92, 93].  We prefer valacyclovir because of the convenience of once daily 
dosing, although it is not FDA-approved for this indication. 
 
9.1.5 Cytomegalovirus (CMV) 
a) Preemptive Therapy Before Day +100:  Patients with positive pre-
transplant serologies for CMV, or whose donors have positive 
serologies, will undergo weekly monitoring of CMV antigenemia.  
Antigenemia monitoring will begin at the time of engraftment after 
transplantation and continue through day +100.  If a patient has an 
ANC < 1000/µl, CMV monitoring will be performed via polymerase 
chain reaction (PCR) instead of antigenemia.  If antigenemia becomes 
positive (expressed as the number of positive cells per 400,000 white 
blood cells) before day +100, then patients will be treated with oral 
valganciclovir, IV ganciclovir, or IV foscarnet according to the 
following schema: 
 
 

62 
# Of  
(+) cells 
Rx: 
VALGANCICLOVIR 
Rx: 
IV GANCICLOVIR 
Monitoring 
Reinduction 
Any 
Valganciclovir 
induction: 
900 mg PO q12h 
for 7 days, then 
maintenance: 
900 mg/24h  
until antigenemia is  
negative x 2 weeks* 
Ganciclovir  
induction: 
5 mg/kg IV q12h 
for 7 days, then 
maintenance: 
5 mg/kg/24h 5 days/week 
until antigenemia is 
negative x 2 weeks* 
Weekly 
antigenemia 
1. If antigenemia 
becomes positive 
after being 
negative 
2. For doubling of 
antigenemia 
*I.e., on two consecutive weekly antigenemia tests.  This may include tests performed during the 
two-week period of induction therapy.  
 
NOTES: 
• Valganciclovir and ganciclovir may cause bone marrow suppression.  If ANC < 
1000:  Start filgrastim (G-CSF) 5-10 µg/kg/d 
• Weekly IVIG infusion has no proven benefit in the setting of CMV reactivation 
without established infection.  Therefore, its use will be limited to patients with 
CMV pneumonitis (or other target organ infection, at the investigators’ 
discretion). 
 
Indications for IV ganciclovir:  
• GVHD with diarrhea or clinical suspicion of malabsorption 
Indications for foscarnet: 
• ANC < 500/μl despite G-CSF 
• Platelets < 20,000/mm3 
• Resistance to ganciclovir:  rising antigenemia after 3 weeks with no response to 
ganciclovir reinduction. 
 
Dose Adjustments for Renal Insufficiency 
 
Valganciclovir 
 
Ganciclovir 
Calculated 
CrCl 
Induction 
Maintenance 
 
Calculated 
CrCl 
Induction 
Maintenance 
>60 
900 mg q12h 
900 mg q24h 
 
>70 
5 mg/kg q12h 
5 mg/kg q24h 
40-59 
450 mg q 12h 
450 mg q 24h 
 
>50-69 
2.5 mg/kg q12h 
2.5 mg/kg q24h 
25-39 
450 mg q 24h 
450 mg q 48h 
 
25-49 
2.5 mg/kg/24h 
1.25 mg/kg/24h 
10-24 
450 mg q 48h 
450 mg 2x/week 
 
10-24 
1.25 mg/kg/24h 
0.625 mg/kg/24h 
 
 
 
 
<10 
1.25 mg/kg 3x/wk 
0.625 mg/kg 3x/wk 
 
b) Preemptive Therapy After Day +100:  Patients who remain at risk for 
CMV reactivation after day +100 will continue to have antigenemia 
(or PCR) monitoring performed weekly.  These patients include: 
• Patients with chronic GVHD and systemic steroid therapy 
• Patients undergoing transplantation from unrelated donors 
• Patients receiving T cell-depleted allogeneic HSCT 

63 
Note that pre-emptive therapy after day +100 differs in both threshold 
and duration from that administered before day +100.  The treatment 
schema follows: 
 
# Of  
(+) cells 
Rx: 
VALGANCICLOVIR 
Rx: 
IV GANCICLOVIR 
Monitoring 
Reinduction 
1 cell 
None 
None 
Repeat 
antigenemia 
in 3 days 
 
> 1 cell 
Valganciclovir 
induction: 
900 mg PO q12h 
for 7 days, then 
maintenance: 
900 mg/24h  
until antigenemia is  
negative x 2 weeks* 
Ganciclovir  
induction: 
5 mg/kg IV q12h 
for 7 days, then 
maintenance: 
5 mg/kg/24h 5 days/week 
until antigenemia is 
negative x 2 weeks* 
Weekly 
antigenemia 
1. If antigenemia 
becomes positive 
after being 
negative 
2. For doubling of 
antigenemia 
*I.e., on two consecutive weekly antigenemia tests.  This may include tests performed during the 
two-week period of induction therapy. 
 
Rationale: 
Valganciclovir is has proven similar efficacy to IV ganciclovir in a randomized controlled trial of 
therapy for retinitis in AIDS [94].  Both drugs have NOT been shown to be equivalent in the setting of 
allogeneic HSCT, and the preferred treatment is IV ganciclovir as per the CDC guidelines [95].  In 
particular, when there is a strong concern with drug absorption, ganciclovir is the treatment of choice.  
Others and we have used valganciclovir successfully during the national shortage of ganciclovir, but 
there is still no strong evidence to support its use for this indication. 
 
9.1.6 Bacterial Pathogens 
a) Prophylaxis During Chronic GVHD:  All patients receiving treatment 
for chronic GVHD will receive penicillin V 500 mg PO BID until 
treatment for chronic GVHD is discontinued.  For penicillin-allergic 
patients, TMP/SMX 80/400 PO QD can be used.  For patients allergic 
to both penicillin and sulfa, clarithromycin 500 mg PO QD can be 
used. 
Rationale: 
There is an increased risk of infection caused by encapsulated organisms, particularly Streptococcus 
pneumoniae in patients with chronic GVHD [96].  Functional hyposplenism has been considered, and 
some investigators have attempted to monitor it by ultrasound [97].  Current recommendations support 
the use of antibiotic prophylaxis with penicillin to prevent these infections [90].  TMP/SMX could be 
substituted, but only when administered daily. 
 
b) Vaccination against Streptococcus pneumoniae and Haemophilus 
influenzae:  All patients will receive Streptococcus pneumoniae 23-
valent polysaccharide vaccine (Pneumovax) at 12 and 24 months, and 
Hib vaccine at 12, 14 and 24 months after transplant.  An alternative 

64 
vaccine against Streptococcus pneumoniae may be adopted when it 
becomes available. 
Rationale: 
• 
The Hib vaccine has been shown to induce neutralizing antibodies effectively [98]. 
• 
The pneumococcal vaccine may be effective and is safe. 
 
 

65 
9.2 
Appendix B:  Management of Engraftment Syndrome (ES) 
 
Clinical Definition of Engraftment Syndrome 
 
A constellation of clinical symptoms and signs has been observed during neutrophil recovery 
following HSCT, most commonly termed “engraftment syndrome” (ES), but interchangeably 
termed “capillary leak syndrome” and “autoaggression syndrome”.  Engraftment syndromes 
have been observed after both autologous and allogeneic HSCT; in the latter setting, the clinical 
sequelae of neutrophil recovery were historically attributed to an early, sometimes “hyperacute” 
graft-versus-host reaction.  Our current understanding of ES holds the overproduction of pro-
inflammatory cytokines at the time of neutrophil recovery to be the initiating event.  The study of 
ES has been somewhat hindered by the lack of uniform definition for this clinical entity; 
therefore, the following criteria have been proposed [73]: 
 
Major criteria: 
• Fever > 38.3° with no identifiable infectious etiology 
• Erythrodermatous rash involving more than 25% of body 
surface area and not attributable to a medication 
• Noncardiogenic pulmonary edema, manifested by diffuse 
pulmonary infiltrates and hypoxia 
Minor criteria 
• Hepatic dysfunction with either total bilirubin > 2 mg/dl 
or transaminases levels > two times normal 
• Renal insufficiency (serum creatinine > two times 
baseline) 
• Weight gain > 2.5% of baseline body weight 
• Transient encephalopathy unexplainable by other causes 
 
A diagnosis of ES is established by the presence of all three major criteria, or two major criteria 
and one or more minor criteria; the clinical signs and symptoms should appear within 96 hours of 
neutrophil recovery, according to the above proposed definition. 
 
Treatment of Engraftment Syndrome: 
 
The mainstay of therapy for ES is high-dose corticosteroids.  This approach is derived from the 
literature on diffuse alveolar hemorrhage [99] in the setting of bone marrow transplantation – a 
complication that many investigators now believe to be part of the spectrum of ES.  Our group 
has adopted the following treatment schema for patients diagnosed with ES, with satisfactory 
results: 
 
Day 1:  
Methylprednisolone 250 mg IV Q6 hours x 4 doses 
Day 2:  
Methylprednisolone 250 mg IV Q8 hours x 3 doses 
Day 3:  
Methylprednisolone 250 mg IV Q12 hours x 2 doses 
Day 4:  
Methylprednisolone 125 mg IV Q12 hours x 2 doses 
Day 5:  
Methylprednisolone 60 mg IV Q12 hours x 2 doses 
Day 6:  
Methylprednisolone 30 mg IV Q12 hours x 2 doses 
Days 7-8: 
Prednisone 60 mg PO QD x 2 days 
Days 9-10: 
Prednisone 50 mg PO QD x 2 days 

66 
Days 11-12: 
Prednisone 40 mg PO QD x 2 days 
Days 13-14: 
Prednisone 30 mg PO QD x 2 days 
Days 15-16: 
Prednisone 20 mg PO QD x 2 days 
Days 17-18: 
Prednisone 10 mg PO QD x 2 days 
Day 19: 
Discontinue prednisone 
 
In the event that symptoms or clinical signs of ES recur during the steroid taper, patients should 
be retreated with methylprednisolone at a minimum dose of 60 mg IV QD.  This schema is 
intended to serve as a guideline and to promote consistency in our clinical practice; it may be 
modified for individual patients as clinical circumstances warrant. 
 
 

67 
9.3 
Appendix C:  Grading and Management of Acute Graft-Versus-Host Disease 
 
Clinical Staging of Acute GVHD [74] 
 
Stage 
Skin 
Liver 
Gut 
+ 
Rash < 25% BSA 
Total bilirubin 2-3 mg/dl 
Diarrhea 500-1000ml/d 
++ 
Rash 25-50% BSA 
Total bilirubin 3-6 mg/dl 
Diarrhea 1000-1500ml/d 
+++ 
Generalized erythoderma 
Total bilirubin 6-15 mg/dl 
Diarrhea >1500ml/d 
++++ 
Desquamation and bullae 
Total bilirubin > 15 mg/dl 
Pain +/- ileus 
BSA = body surface area; use “rule of nines” or burn chart to determine extent of rash. 
 
Clinical Grading of Acute GVHD [74] 
 
 
Stage 
Grade 
Skin 
Liver 
Gut 
PS 
0 (none) 
0 
0 
0 
0 
I 
+ to ++ 
0 
0 
0 
II 
+ to +++ 
+ 
+ 
+ 
III 
++ to +++ 
++ to +++ 
++ to +++ 
++ 
IV 
++ to ++++ 
++ to ++++ 
++ to ++++ 
+++ 
 
Treatment of Acute GVHD 
This schema is intended to serve as a guideline and to promote consistency in our clinical 
practice; it may be modified for individual patients as clinical circumstances warrant. 
 
Grade 0-I GVHD:  
1) Topical corticosteroids (usually 0.1% triamcinolone; 1% hydrocortisone to face) applied to 
rash BID. 
 
Grade II-IV GVHD:  
1) Methylprednisolone (MP) 62.5 mg/m2 per dose IV, BID for 4 consecutive days. 
2) If no response after 4 days, continue until response (7-day maximum trial). 
3) If response within 7 days, taper as follows: 
a) 50 mg/m2 per dose IV BID for 2 days. 
b) 37.5 mg/m2 per dose IV BID for 2 days. 
c) 25 mg/m2 per dose IV BID for 2 days. 
d) If clinically appropriate, change MP to oral prednisone 100 mg PO (or oral equivalent 
of IV dose) daily for 2 days.  MP may be converted to prednisone later in the taper at 
the investigators’ discretion. 
e) After this, steroids will be reduced by 10% each week until a dose of 10 mg/day is 
reached.  Subsequent reductions will be made at the investigators’ discretion. 
f) If GVHD worsens during taper, steroids should be increased to previous dose. 
g) During steroid taper, maintain cyclosporine at therapeutic levels (Section 3.5.1). 
4) If no response is observed within 7 days of MP treatment: 
a) Increase Methylprednisolone to 500 mg/m2 per dose IV, BID for 2 days. 

68 
b) If there is no improvement, consideration will be given to using second-line 
immunosuppressive therapy, e.g., tacrolimus, mycophenolic acid, monoclonal 
antibodies, or studies of investigational agents for acute GVHD, if they are available. 
5) Antifungal prophylaxis with agents effective against mould will be started when it is 
anticipated that the patient will be receiving steroids at > 1 mg/kg/d of methylprednisolone 
(or equivalent) for > 2 weeks.  Voriconazole is the agent of choice, but liposomal 
amphotericin B (Ambisome) 5 mg/kg/d or amphotericin B lipid complex (Abelcet) 5 mg/kg/d 
are valid alternatives.  During prophylaxis with any of the above agents, fluconazole should 
be discontinued.  In patients with therapeutic cyclosporine levels at the initiation of 
voriconazole therapy, the cyclosporine dose should be decreased by approximately 50%. 
6) Determination of GVHD treatment response should be made within 96 hours of starting the 
treatment.  The following are criteria to determine definitions of response to GVHD 
treatment: 
a) Complete response:  Complete resolution of all clinical signs and symptoms of acute 
GVHD. 
b) Partial Response: 50% reduction in skin rash, stool volume or frequency, and/or total 
bilirubin.  Maintenance of adequate performance status (Karnofsky Score > 70%). 
c) Non-responder: < 50% reduction in skin rash, stool volume or frequency, and/or total 
bilirubin.  Failure to maintain adequate performance status (Karnofsky Score ≤ 70%). 
d) Progressive disease:  Further progression of signs and symptoms of acute GVHD, 
and/or decline in performance status after the initiation of therapy. 

69 
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