Haploidentical Allogeneic Peripheral Blood Transplantation: Clinical Trial and Laboratory Correlates Examining Checkpoint Immune Regulators' Expression
Phase: PHASE3
Conditions: Acute Myeloid Leukemia, Chronic Lymphocytic Leukemia, Chronic Myeloid Leukemia, Myelodysplasia, Myeloproliferative Disorder, Myelofibrosis, Lymphoma, Lymphoma, Non-Hodgkin, Plasma Cell Disorder
Sponsor: Dartmouth-Hitchcock Medical Center

Official Title:
Haploidentical Allogeneic Peripheral Blood
Transplantation: Clinical Trial and Laboratory Correlates
Examining Checkpoint Immune Regulators’ Expression
NCT number:
NCT03480360
Document Type:
Study Protocol
Date of the
Document:
March 4, 2019

Meehan, Hill; Haploidentical - 1
Rev#2: March 4, 2019
Haploidentical Allogeneic Peripheral Blood 
Transplantation: Clinical Trial and Laboratory Correlates 
Examining Checkpoint Immune Regulators’ Expression 
Principal Investigator:
Kenneth R. Meehan, M.D.
Co - Investigators:
John M. Hill, M.D.
Rodwell Mabaera M.D.
Randy Noelle Ph.D.
Christi Hayes M.D.
Christopher Lowrey M.D.
Zbigniew Szczepiorkowski M.D., Ph.D.
Kate Wilcox R.N.
Lynn Root R.N.
Division of Biostatistics
Jiang Gui Ph.D.
Clinical Research Associate 
and Data Management
Dorie McKenna M.S.
Clinical Research Associate 
TBD
Blood and Marrow Transplant Program
Division of Hematology/Oncology
Dartmouth-Hitchcock Medical Center
Norris Cotton Cancer Center
1 Medical Center Drive
Lebanon, NH  03756-0001
Phone:  603-650-4628
Fax:  603-650-7791

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Treatment Schema
Adapted from BMT 2008, 42:523
Cyclophosphamide (Cy): 14.5 mg/kg for 2 days (days -6, -5) and then 50 mg/kg for two days 
(days 3, 4)
Fludarabine:  30 mg/m2 daily for 5 days
Total Body Irradiation (TBI): 200 cGy for one day (day -1)
Immune suppression: will begin on day 5, 24 hours after the completion of the last dose of 
cyclophosphamide
Tacrolimus: 1 mg IV daily, (or the oral equivalent) adjusted to achieve a level between 5 
and 15 ng/ml. If there is no evidence of GVHD, discontinue Tacrolimus by Day 180.
MMF (Cellcept): dose at 15 mg/kg po TID (maximum dose of 3 grams/day). Stop 
Cellcept at Day 35 following transplantation.
G-CSF (or biosimilar): 5 mcg/kg/d starting day 5 and continue until ANC > 1000/mcL for 3 
days.
Day 0 = day of transplant; cell dose goal: < 5 x 106 CD34+ cells/kg recipient weight

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TABLE OF CONTENTS
1.0
INTRODUCTION
 
4
2.0
OBJECTIVES
 
8
3.0
ELIGIBILITY CRITERIA 
 
9
4.0
REGISTRATION AND DATA SUBMISSION
10
5.0
GENERAL WORKUP AND DIAGNOSTIC PROCEDURES
10
6.0
TREATMENT PLAN
11
7.0
POTENTIAL TOXICITES and DOSE MODIFICATIONS 
14
8.0
DRUG FORMULATION, AVAILABILITY AND TOXICITY
16
9.0
REQUIRED DATA AND CORRELATIVE  LABORATORY STUDIES
18
10.0
CRITERIA FOR RESPONSE AND TREATMENT ENDPOINTS         
21
11.0
REMOVAL OF PATIENTS FROM PROTOCOL AND STOPPING RULES
22
12.0
REPORTING OF SERIOUS ADVERSE EVENTS AND 
UNANTICIPATED PROBLEMS
23
13.0
STATISTICAL CONSIDERATIONS
25
14.0
STUDY MONITORING, AUDITING AND INSPECTION
26
15.0
HUMAN SUBJECTS
27
16.0
BIBLIOGRAPHY
          
28
APPENDICES 
a) DHMC SOP –Pre Transplant Evaluation for Allogeneic Recipients
b) DHMC SOP - Donor Evaluation
c) CIBMTR guidelines for assessing disease status and response to therapy 
(www/cibmtr.org/manuals)
d) DHMC - Flu/Bu/ATG Order Set
e) DHMC SOP - Mobilization of Allogeneic Donors
f) DHMC SOP - Grading and Treatment of GVHD

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SECTION 1.0
INTRODUCTION
Background
The types of allogenic hematopoietic stem cell transplantations have evolved over the 
past 30 years. With the improved understanding of the mechanisms of graft versus host disease 
(GVHD), what initially began using only related donors, has expanded to unrelated donors. Over 
the ensuing years, if neither a related nor unrelated donor was available, then further options 
developed to include cord blood transplantations or mismatched donor transplantations. With the 
limited supply of cord blood available and the inferior outcomes of mismatched donors, the use 
of a haplotype-matched donor, also called haploidentical transplant, was examined. Since 
patients share a haplotype with one of their parents or one of their children, donors can be 
identified for most, if not all patients. A major advantage of using a haplotype-identical donor is 
that almost all patients will have a readily available donor. 
How do the outcomes of haploidentical transplants compare with other types of transplants?
Several large clinical trials of haploidentical trials demonstrate that haploidentical 
transplant for patients with hematologic malignancies result in similar outcomes, when compared 
with age-matched controls for HLA-matched related and unrelated donors (1,2) (Table 1). A 
large multicenter study confirmed these findings in AML patients and showed that the 3-year 
overall survival for haploidentical recipients was 45%, compared with 50% for matched 
unrelated donors and 44% for reduced intensity recipients using unrelated donors (3).
Table 1
Bashey et al
Haplo (n=53)
MRD (n=117)
MUD (n=101)
TRM at day 100
20%
19%
30%
OS at 2 years
64%
76%
67%
DFS at 2 years
60%
53%
53%
Acute GVHD (grade 3-4)
11%
8%
11%
Chronic GVHD (grade 3-4)
38%
54%
54%
TRM = treatment related mortality; MRD=matched related donor; MUD=matched unrelated 
donor
Johns Hopkins University has pioneered the efforts into haploidentical transplants and 
they have the largest experience to date. Their regimen, the regimen we propose to use, uses pre-
transplant cyclophosphamide with fludarabine and one day of low dose total body irradiation. 
Post-transplant immune suppression is accomplished using high dose cyclophosphamide, 
tacrolimus and mycophenolate (Cellcept). Donor bone marrow is used as the source of stem 
cells. The Hopkins group identified a very low non-relapsed mortality, measuring 4% at 1 year 
and 15% at 2 years. These low rates were due to the low incidence of GVHD and the low rate of 

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infections. The addition of mycophenolate (Cellcept) at an increased dose for haploidentical 
transplants has also contributed to the lower incidence of GVHD. The graft rejection rate was 
13% and the incidence of GVHD was 34% (4). These incidences of graft rejection and GVHD 
are similar to HLA-matched sibling donor transplant rates (5,6). It is interesting to note that there 
is a low incidence of infections (< 15%) in this patient population (4). Due to the administration 
of post-transplant cyclophosphamide, engraftment of neutrophils and platelets occur a little later 
than in other types of allogeneic transplants, at approximately Day 15 and Day 24, respectively 
(4). As with all types of transplants, relapse was the major reason for failure in this high-risk 
group of patients. 
In summary, a review of the literature notes overall survival rates at 1 year ranging from 
31% to 78% and at 2 years, 28-64%. Treatment-related mortality at Day 100 ranges from 4 % to 
20% and at 2 years, from 10 to 42% (Table 2).
Table 2
Reference
Number of 
patients
TRM at day 
100
Survival at 1 
year
DFS at 1 
year
Ciurea Blood 2015
n = 192
12%
61%
38%
Luznik BBMT 2008
n = 67
4%
52%
50%
Bashey JCO 2013
n = 53
20%
78% (approx.)
64%
Solomon BBMT 2012
n = 20
10%
69%
50%
TRM=treatment-related mortality; DFS=disease-free survival
Controversial areas of haploidentical transplantation
It is difficult to compare clinical outcomes for recipients of haploidentical 
transplantations since this is a new and evolving field. Many centers are using various treatment 
regimens that may or may not include TBI and may include a myeloablative, rather than reduced 
intensity chemotherapy regimen. Other centers are using various immune suppression regimens 
and other centers are using marrow, peripheral blood progenitor cells or a combination of both. 
Some of the early trials transplanted patients after failing numerus regimens while other centers 
transplanted patients in first remission. This area is thoroughly reviewed in many review articles 
(3, 7 - 9). We have summarized 4 of the most prominent studies to date below (Table 2).
The process of haploidentical transplantation continues to evolve. To date, the major 
source of cells has been donor marrow. Recently, a large study indicated that donor peripheral 
blood progenitor cells provide an alternative source without a marked increase in the incidence 
of GVHD and with similar outcomes (1). Unlike the Hopkins’ regimen, we propose to use donor 
–derived peripheral blood progenitor cells, instead of marrow.
The ideal chemotherapy regimen is also unknown, as is the optimal immune suppression 
during the transplant. In addition, the regimen that was first proposed and developed by Hopkins 
is developing into a standard regimen, and this will be the regimen we will use, including the 
same chemotherapy and immune suppression. Finally, the best characteristics of the optimal 
donor is still uncertain (see below for details).

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The role of post-transplant cyclophosphamide
In preparation for a haploidentical transplantation, a non-myeloablative chemotherapy or 
chemotherapy with irradiation regimen is used. Due to the HLA disparity between the patient 
and the HLA-haploidentical donor, the initial major concern was the potential for a high 
incidence of GVHD, as well as graft rejection. It was determined that the administration of 
POST-transplant immune suppression using cyclophosphamide markedly reduced graft rejection 
and GVHD (10). Cyclophosphamide was selected due to its potent immune suppressive effects. 
To prevent GVHD, two large doses of cyclophosphamide (50 mg/kg) are administered following 
transplant, on Days 3 and 4.  Additional immune suppression is used, including Tacrolimus and 
CellCept to assist in suppressing GVHD.
The timing of administering post-transplant cyclophosphamide was found to be critical to 
prevent GVHD. Cyclophosphamide needs to be administered soon after the transplant and 
BEFORE starting any other immune suppression. It is hypothesized that cyclophosphamide 
induces T cell tolerance, by targeting alloreactive T cells, specifically in the allogeneic T cells 
that have been recently infused and activated. Since calcineurin inhibitors (i.e. tacrolimus) block 
cyclophosphamide-induced tolerance, tacrolimus started AFTER cyclophosphamide has been 
administered.
Selection of the appropriate donor
Patients undergoing haploidentical HSCT will often have more than one potential donor, 
and consideration for the optimal donor-recipient match should be addressed along a hierarchy of 
factors. However, in the haplo- identical setting, some of these factors remain controversial. 
These donor-recipient factors and the donor selection is crucial to the success of the 
transplant. As with any type of allogeneic stem cell donor selection, the donor selected affects 
the donor cell yield, the risk for graft rejection, the incidence of  GVHD (both acute and 
chronic), the transplant-related mortality, the graft-versus-tumor effect, relapse and overall 
survival.  
The hierarchy of factors for algorithmic consideration for a potential donor includes the 
following:
odonor-specific antibodies 
oABO matched donor-recipient status preferred (based on anticipated cell loss if 
cell processing is needed in the major ABO-mismatched setting)
odonor age (younger age donor preferred, to optimize cell yield and immuno-
genicity; donor < 30 years is the optimal,  donor ages 31-45 years is intermediate 
and donors > 46 years are the least optimal)
ogender (male donor preferred to avoid issues of increased allo-immunization, 
especially with multiparous female donors, including responses directed against 
the H-Y antigen in male recipients)
ocytomegalovirus serology (CMV serostatus match preferred). 
Controversial factors demonstrating uncertain impact at this time on transplant outcome 
include the number of HLA mismatches, natural killer (NK) cell alloreactivity via killer 

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immunoglobulin-like receptor (KIR-KIR) ligand donor-recipient mismatching, and the presence 
of non-inherited maternal HLA antigens (NMAs).                
Immune reconstitution following an haploidentical transplant
Research examining immune reconstitution following a haploidentical transplant remains 
in its infancy. As with all types of allogeneic transplantations, within the first 6 months following 
a haploidentical transplant, CD4+T cells, CD8+ naïve T cells and memory T Cells remain low in 
number and demonstrate depressed cellular function. (11). An extensive review of this topic 
states that future studies are critically needed to address this area so that we will better 
understand the mechanisms of immune reconstitution (12).
Laboratory Correlates: The role of Immune Check point regulators in transplantation
An active area of research is exploring ways to maximize the beneficial graft-versus-
tumor (GVT) effect while minimizing GVHD. Murine models, and limited clinical case series in 
acute GVHD, demonstrate that immune checkpoint regulators, such as CTLA4 (cytotoxic T-
lymphocyte-associated protein 4) and PD-L1 (programmed death-ligand 1) determine donor T-
cell responses against minor HLA-antigens, on both normal host tissues in GVHD and tumor 
cells, in GVT (13-15). The expression of CTLA4 and PD1 ligand (PD-L1) on donor T cells 
protect against GVHD. For example, treatment of mice with a CTLA4 fusion protein (CTLA4-
Ig) prevents acute GVHD without inhibiting the GVT (16-17).  Both the prevalence of these 
Immune Checkpoint Regulators and the cell types that express them following allogeneic stem 
cell transplant are currently unknown.
Dr. Randy Noelle’s lab has recently identified a new immune checkpoint regulator called 
VISTA (V-domain Ig Suppressor of T-cell Activation). VISTA plays a role in tumor immune 
surveillance and peripheral tolerance (18-20). VISTA’s expression is restricted to hematopoietic 
cells. We recently showed that VISTA is expressed on myeloid-derived suppressor cells 
(MDSCs) and its expression enhances the function of MDSCs in several tumor models (21). 
Based on these findings, we postulate that through its expression on MDSCs, VISTA modulates 
GVHD and GVT effects. 
In addition to immune checkpoint regulators, MDSC are known to suppress alloreactive 
T cells following allogeneic stem cell transplantation. In mouse models, the administration of 
donor-derived MDSCs at the time of transplantation prevented acute GVHD (22,23). This effect 
did not negate the beneficial GVT effect. The role of MDSCs in the setting of chronic GVHD is 
suggested by a study demonstrating that patients’ GVHD improved as the number of MDSCs 
increased in response to extracorporeal photopheresis (24). These results suggest that MDSCs 
are a potential therapeutic target in GVHD.  
To date, there are no studies evaluating the incidence, prevalence or function of immune 
checkpoint regulators following haploidentical stem cell transplantation or in the setting of 
GVHD. We hypothesize that VISTA may play a role in suppressing GVHD in through its 
expression on MDSCs. It is unknown which cell subsets express these immune checkpoint 
regulators and the prevalence of these regulators following allogeneic stem cell transplantation.  

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Summary
We plan to use the standard Johns Hopkins’ regimen, with the use of donor peripheral 
blood stem cells, rather than marrow. We will define clinical outcomes while focusing our efforts 
on immune reconstitution focusing on immune checkpoint regulators after a related 
haploidentical stem cell transplant. 
2.0
OBJECTIVES
We propose a clinical trial to define clinical endpoints, including engraftment, 100-day 
survival and one year survival (Objective #1). We will characterize the incidence, prevalence 
and function of immune checkpoint regulators in patients’ blood and bone marrow following 
transplantation (Objective #2). We will correlate these laboratory results with clinical outcomes 
and the incidence of GVHD. As an exploratory aim, in those patients experiencing GVHD and 
requiring treatment, we will define the frequency/expression of checkpoint regulator expression 
and correlate these results with the patient’s response to GVHD therapy.
2.1 Objective #1: The primary objective of this trial is to define the 100-day survival of 
patients being treated on this regimen.
Secondary objectives include: To define clinical endpoints using this myeloablative 
haploidentical transplant regimen, including:
2.1.1Time to marrow engraftment (defined as absolute neutrophil count > 
500/mm3 and platelets > 20,000/mcl for three consecutive days (count first 
day as engraftment) 
2.1.2Response to treatment at 100 days
2.1.3Response to treatment at one year
2.1.4One year survival
2.1.5Treatment-related mortality in the first 100 days
2.1.6Toxicities associated with this treatment regimen
2.1.7Incidence of acute and chronic GVHD
2.1.8Donor-recipient chimerism following transplant at Days 30, 60 and 90.
2.2 Objective #2: To characterize the incidence, prevalence and function of immune 
checkpoint regulators (VISTA, CTLA-4, PD-1) during early immune recovery 
following an allogeneic stem cell transplant.
Since the presence of MDSCs may correlate with engraftment, the response to 
treatment, and the risk of developing GVHD, we will define MDSCs frequency and 
immune checkpoint regulators expression on MDSCs and on peripheral blood and 
bone marrow in allogeneic transplant recipients following transplantation.
We will correlate these laboratory results with clinical outcomes (described 
above) and the incidence of GVHD.
2.3 Exploratory aim # 2a) In those patients experiencing GVHD, we will define the 
MDSCs frequency and checkpoint regulator expression on MDSCs, peripheral blood 

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mononuclear cells and myeloid subsets. Blood samples will be drawn at the time of 
diagnosis and weekly for four weeks to evaluate changes in response to treatment.
3.0 ELIGIBILITY CRITERIA
3.1 Age:  < 75 years
3.2 The patient must be approved for transplant by the treating transplant physician. This 
includes completion of their pre-transplant workup, as directed by standard DHMC 
SOPs (DHMC SOP – Pre-transplant Evaluation of allogeneic recipient 
(Appendix). 
3.3 The patient must have a disease (listed below) with treatment-responsiveness that the 
treating transplant physician believes will benefit from an allogeneic stem cell 
transplant. The diseases include:  
3.3.1
Acute leukemia – AML, ALL
3.3.2
Chronic leukemia – CML, CLL 
3.3.3
Myelodysplasia
3.3.4
Myeloproliferative disorder
3.3.5
Myelofibrosis
3.3.6
Lymphoma – NHL or  Hodgkin’s disease
3.3.7
Plasma 
cell 
disorder, 
including 
myeloma, 
Waldenstrom’s 
Macroglobulinemia
3.4 Donor availability- the patient must have an identified RELATED haplo-identical 
donor 
3.5 No HIV infection or active hepatitis B or C 
3.6 ECOG performance status: 0-2   
3.7 DLCO 40% predicted
3.8 Left ventricular ejection fraction  40%
3.9 Serum bilirubin < 2x upper limit of normal; transaminases < 3x normal at the time of 
transplant
3.10
No active or uncontrollable infection
3.11
In female, a negative pregnancy test if experiencing menstrual periods
3.12
No major organ dysfunction precluding transplantation
3.13
No evidence of an active malignancy that would limit the patient’s survival to less 
than 2 years. (If there is any question, the PI can make a decision).
3.2
 EXCLUSION CRITERIA 
3.2.1   Psychiatric disorder or a mental deficiency of the patient that is sufficiently severe 
to make compliance with the treatment unlikely, and making informed consent 
impossible.
3.2.2    Major anticipated illness or organ failure incompatible with survival from BMT.
3.2.3
History of refractory systemic infection 
3.3 Donor eligibility 
3.3.1 HLA haplo-identical matched related.
3.3.2
The donor must be healthy and must be willing to serve as a donor, based 
on standard NMDP guidelines and DHMC SOP – Donor Evaluation 
(Appendix)

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3.3.3
The donor must have no significant co-morbidities that would put the 
donor at marked increased risk
3.3.4
There is no age restriction for the donor
3.3.5
Informed consent must be signed by donor
3.4 Donor Exclusion Criteria
3.4.1
The NMDP guidelines for exclusion criteria will be used (Appendix). In 
addition, the following donors are NOT eligible:
3.4.2
Pregnant or lactating donor
3.4.3
HIV or active Hep B or C in the donor
3.4.4
Donor unfit to receive G-CSF and undergo apheresis 
3.4.5
A donor with a psychiatric disorder or mental deficiency that makes 
compliance with the procedure unlikely and informed consent impossible
4.0       REGISTRATION AND DATA SUBMISSION
This is a non- randomized trial with laboratory correlates.  To enter eligible patients or to 
discuss a patient’s eligibility, please contact Dr. Kenneth R. Meehan (or any of the 
Transplant physicians) at 603-650-4628 or the Clinical Research Associate (TBD at 603-650-
4035). Informed consent must be signed prior to the initiation of treatment. 
5.0     GENERAL WORKUP AND DIAGNOSTIC PROCEDURES
The Pre-study evaluation will follow the DHMC SOP - Pre-transplant 
evaluation of allogeneic recipient (Appendix).
5.1
It is recommended that the pre-transplant evaluation be done within a 
reasonable amount of time prior to transplant, this time frame will vary, but 
it is recommended to be within 8 weeks of admission for transplantation. 
Exceptions are noted below.
5.1.1
HLA typing – HLA typing can be performed at any time prior to 
transplant
5.1.2
At some point during patient’s treatment, a biopsy of the involved site or 
bone marrow biopsy is needed to document the malignant diagnosis. This 
could also include cytogenetics, molecular analysis and/or flow cytometry.
5.1.3
Disease remission status at the time of transplant (varies by disease – 
CIBMTR definitions will be used)
5.1.4
Serologic testing:  CMV, EBV, HSV, VZV
5.1.5
Bone marrow aspirate and biopsy (within 8 weeks)
5.1.6
Antibody screen for HBV, HCV, HIV, HTLV I/II, CMV, EBV,  
toxoplasmosis, syphilis
5.1.7
Bloodwork: CBC, Comprehensive metabolic panel, TSH
5.1.8
Serum pregnancy test, if female with child-bearing potential
5.1.9
PSA is recommended in males > 50 years of age (done within one year)
5.1.10 Pulmonary function tests with DLCO
5.1.11 Cardiac function tests to include an EKG and ECHO
5.1.12 Chest x-ray
5.1.13 Urinalysis
5.1.14 Dental Exam (as indicated - done within one year)
5.1.15 GYN exam w/ PAP smear (as indicated- done within one year)

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5.1.16 Mammogram (as indicated- done within one year)
5.1.17 Informed written consent must be obtained. Patients must be able to give 
informed consent as a prerequisite to this procedure. The Informed 
Consent form will become part of the permanent record and a copy will be 
given to the patient.
6.0
TREATMENT PLAN
Adapted from BMT 2008, 42:523
Cyclophosphamide (Cy): 14.5 mg/kg for 2 days (days -6, -5) and then 50 mg/kg for two days 
(days 3, 4)
Fludarabine:  30 mg/m2 daily for 5 days
Total Body Irradiation (TBI): 200 cGy for one day (day -1)
Immune suppression: will begin on day 5, 24 hours after the completion of the last dose of 
cyclophosphamide
Tacrolimus: 1 mg IV daily, (or the oral equivalent) adjusted to achieve a level between 5 
and 15 ng/ml. If there is no evidence of GVHD, discontinue Tacrolimus by Day 180.
MMF (Cellcept): dose at 15 mg/kg po TID (maximum dose of 3 grams/day). Stop 
Cellcept at Day 35 following transplantation.
G-CSF (or biosimilar): 5 mcg/kg/d starting day 5 and continue until ANC > 1000/mcL for 3 
days.
Day 0 = day of transplant; cell dose goal: < 5 x 106 CD34+ cells/kg recipient weight
6.1 Details of the treatment regimen:
6.1.2 For each medication, actual body weight will be used. 
6.2 Cyclophosphamide (Cy): 14.5 mg/kg IV for 2 days (days -6, -5); Following 
transplant, cyclophosphamide will be administer at 50 mg/kg IV over 90 mins 
for two days (days 3, 4). Cyclophosphamide will be administered with Mesna 
(80% dose of cyclophosphamide in 4 divided doses over 8 hours).
6.3 Fludarabine:  30 mg/m2 IV daily for 5 days, on days -6 to day -2.

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6.4 Total Body Irradiation (TBI): 200 cGy to be administered for one day (day -
1).
6.5 Immune suppression: Will start on day 5, 24 hours after the completion of 
the last dose of cyclophosphamide. 
6.6 Tacrolimus: initiated at a dose of 1 mg IV daily, adjusted to achieve a level 
between 5 and 15 ng/ml. This can be started as an oral medication at the 
appropriate dose or converted to oral form once the patient is clinically stable. 
If there was no evidence of GVHD, discontinue Tacrolimus by Day 180. 
6.7 MMF (Cellcept): dose Cellcept at 15 mg/kg po TID (maximum dose of 3 
grams/day). Discontinue Cellcept on day 35 following transplantation 
(without a taper).
6.8 Mesna
6.8.1Pre-transplant: On Days – 6 and – 5, Mesna (3 mg/kg) 
will be administered intravenously over 15 minutes prior to 
each dose of cyclophosphamide and repeated at 4 hours and 
8 hours after the start of each cyclophosphamide dose.
6.8.2Post-transplant: On Day + 3, Mesna (10 mg/kg) will be 
administered intravenously prior to the first dose of 
cyclophosphamide. Mesna (30 mg/kg every 12 hours) will 
then be administered as a continuous infusion every 12 
hours x 4 doses (total of 48 hour infusion).
6.5.1 Further modifications of tacrolimus doses will be based on tacrolimus trough 
concentrations (target trough of 5-10 ng/mL; not to exceed 15 ng/mL).
6.5.2
Tacrolimus taper should begin approximately between Day 90 and 120 with a 
goal of stopping by Day 180.
6.10 Supportive Care Recommendations
6.10.1Infectious prophylaxis will include Fluconazole, Acyclovir and Levaquin 
(Recommendations from DHMC SOP addressing antimicrobial prophylaxis, and adapted 
from BBMT 2009;15:1143-1238). The following are recommended:
Fluconazole:  400 mg PO daily beginning on day 0. 
Levofloxacin:  750 mg PO daily from day 0 until ANC is greater than 500/mm3 post-
engraftment or broad spectrum antibiotics are started. 
Acyclovir:  800 mg PO twice daily beginning on admission. 
Sulfamethoxazole 800 mg/trimethoprim 160 mg (Bactrim DS) one tablet PO once daily 
from admission until and including day - 2. Discontinue after day - 2 dose given. As an 
alternative, Pentamidine (300 mg inhalation) can be used once on admission. 
At day 30, PJP prophylaxis will resume using sulfamethoxazole 800mg / 
trimethoprim 160mg using one of the various recommended regimens. IF ANC is less 
than 500 and/or platelets are less than 20,000 without transfusion on day +30 do NOT 
restart sulfamethoxazole/trimethoprim, instead consider atovaquone, dapsone or 
pentamidine.
6.11 CMV monitoring- using standard guidelines and the DHMC SOP addressing 
monitoring of CMV, it is recommended that CMV PCR be tested once every 1-2 weeks, 

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starting approximately day 28 until day 100. CMV testing could continue after this time 
point if the patient remains on immunosuppression. Treatment for a positive result will be 
done according to standard guidelines as outlined in the DHMC SOP.
6.12 EBV monitoring- using standard guidelines and the DHMC SOP addressing 
monitoring of EBV, it is recommended that EBV PCR be tested approximately every 2-3 
weeks after transplant starting approximately day 30 until day 100. EBV testing could be 
checked periodically after this time point if the patient remains on immunosuppression. 
Treatment for a positive result will be done according to standard guidelines as outlined 
in the DHMC SOP.
6.13 Veno-Occlusive Disease (VOD) Prophylaxis: Day -7 until discharge or through 
Day +30: 
For those patients believed to be at increased risk for the development of VOD, 
one of the following regimens may be used until the time of discharge or up until day 
+30, based on the treating physician’s level of concern:
6.13.1 Regimen #1: Ongoing Enoxaparin with platelet transfusion
Enoxaparin: 40 mg subcutaneous daily. Maintain platelet count > 10 x103/mcL.
Ursodiol: 300 mg PO twice daily for body weight < 90 kg 
OR
Ursodiol : 300 mg PO every AM and 600 mg PO every PM for body weight > 90 
kg 
6.13.2 Regimen #2 Discontinue Enoxaparin once platelets decrease
Enoxaparin: 40 mg subcutaneous daily. Discontinue once platelet count 
decreases to 20 x103/mcL.
Ursodiol: 300 mg PO twice daily for body weight < 90 kg 
OR
Ursodiol : 300 mg PO every AM and 600 mg PO every PM for body weight > 90 
kg 
6.15  Filgrastim or the generic equivalent (G-CSF): G-CSF will be administered once 
daily beginning on day +7 and continue until ANC > 1000/mcL for 3 days. NMDP 
guidelines will define the final dose, as listed below (based on patient’s actual weight): 
6.15.1 G-CSF Doses:
Patient’s weight (kilograms)
Daily G-CSF dose (mcg/day)
< 60
300
61 - 99
480
100 - 130
600
>130
780
6.16 Collection of Allogeneic Stem Cells from Donors
6.16.1 Haplo-identical donors
Donors will be relatives (parent, child, sibling etc.). Donors will be mobilized 
following NMDP and institutional guidelines (DHMC SOP Mobilization of allogeneic 
donor – Appendix).  G-CSF (or the generic equivalent) will be administered daily as a 

Meehan, Hill; Haploidentical - 14
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subcutaneous injection. The final dose used will be based on NMDP guidelines, as noted 
below (using the donor’s actual weight). The collected cells may be stored frozen or 
collected fresh and infused.
Donor weight (kilograms)
Daily G-CSF dose (mcg/day)
45 - 60
600
61 - 78
780
79 - 90
900
91 - 96
960
97 - 108
1080
>109
1200
6.16.2 Target CD34+ cell doses will be based on DHMC guidelines. A minimum of 2 x 
106 CD34+ cells/kg of recipient weight will be infused.
6.17 Allogenic stem cells – Infusion into recipients
On day 0 of treatment, a minimum of 2 x 106 CD34+ cells/kg of recipient weight 
will be infused. Standard infusion procedure will be followed using DHMC SOP.
Based on the above considerations, the hierarchy of factors for algorithmic consideration 
for a potential donor includes the following:
odonor-specific antibodies 
oABO matched donor-recipient status preferred (based on anticipated cell loss if 
cell processing is needed in the major ABO-mismatched setting)
odonor age (younger age donor preferred, to optimize cell yield and immuno-
genicity; donor < 30 years is the optimal,  donor ages 31-45 years is intermediate 
and donors > 46 years are the least optimal)
ogender (male donor preferred to avoid issues of increased allo-immunization, 
especially with multiparous female donors, including responses directed against 
the H-Y antigen in male recipients)
ocytomegalovirus serology (CMV serostatus match preferred). 
7.0
POTENTIAL TOXICITIES AND DOSE MODIFICATIONS
7.1Evaluation of toxicities (other than Hematologic) will be graded using NCI 
Common Toxicity Criteria, specifically CTC AE 4.0.  Life-threatening toxicities 
must be reported to the principal investigator, the clinical research assistant and 
the IRB.   The following laboratory test abnormalities and adverse events should 
be captured on the non-serious AE CRF page or SAE Report Form (paper or 
electronic) as appropriate:
Any laboratory test result/adverse reaction that is ≥ Grade 4 or meets the 
definition of an SAE
Any laboratory test result/adverse reaction abnormality that required the 
subject to have study drug discontinued or interrupted

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Any laboratory test result/adverse reaction abnormality that required the 
subject to receive specific corrective therapy.
Any laboratory test result/adverse reaction deemed related to the treatment that 
required medical intervention, either by requiring an office/infusion room visit, 
treatment (ranging from medication administration, hydration or transfusion).
7.2
 Monitoring of Toxicities after discharge from the hospital
        Monitoring of all acute toxicities will occur until the time of discharge. 
After discharge (approximately day 17-20 following transplant), transplant 
patients often experience a number of medical issues. As a result, after 
discharge until day 100, only serious toxicities (> grade 4) will be recorded. Of 
course, should any life threatening event possibly be linked to the study at any 
time, the investigator shall use his/her discretion is reporting the event to the 
appropriate committees.
7.3 Fludarabine
Consider 20% dose reduction of fludarabine for patients with a creatinine 
clearance < 70 ml/min.
7.4 Tacrolimus
The dose of tacrolimus will be adjusted to achieve levels between 5 – 10 ng/ml.
7.6 GVHD
The diagnosis of GVHD is based on clinical signs (known as “clinical GVHD”) 
and/or a tissue biopsy (“pathologic GVHD”). The clinical signs and symptoms include 
rash, diarrhea, increased liver function tests (LFTs), or nausea/vomiting. If a tissue biopsy 
is obtained (skin, GI tract, Liver), this provides additional histopathologic evidence for 
the diagnosis of GVHD.
The treatment of GVHD varies greatly, and it is recommended to follow the 
DHMC SOP for treatment of GVHD (DHMC SOP – Grading and Treatment of 
GVHD – Appendix). For reporting purposes, the following tables should be used.
TABLE 2 Clinical grading of acute GVHD

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TABLE 3
 Overall grading of acute GVHD
Typically, acute GVHD occurs until day 100. GVHD occurring after day 100 is 
considered chronic GVHD.
Clinical grade of acute GVHD
Skin
GI Tract
Liver
I
1 – 2
None
None
II
3
1
1
III
NA
2 - 4
2 – 3
IV
4
NA
4
Abbreviations: NA = not applicable
7.9 Clinical grading of chronic GVHD
7.9.1 GVHD occurring after Day 100 is considered chronic GVHD. Chronic GVHD will 
be defined as “limited” or “extensive”.
7.9.2 Limited Chronic GVHD
1. localized skin
AND/OR
2. Liver dysfunction due to chronic GVHD
7.9.3 Extensive Chronic GVHD
1. generalized skin involvement
OR
2.Localized skin and/or liver dysfunction due to GVHD
AND
1. Involvement of eye – clinically
2. Involvement of oral mucosa or salivary glands
3. Involvement of any other target organs
8.0
DRUG FORMULATION, AVAILABILITY AND TOXICITY
8.1Fludarabine Monophosphate
8.1.1 Availability: Fludarabine is c o m m e r c i a l l y available.
8.1.2 Administration: Fludarabine is administered as an IV infusion over 30 
minutes.
8.1.3 Toxicities: The dose -limiting toxicity is myelosuppression. Additional 
toxicities include, fever, mild nausea and/or vomiting, skin rashes,  
myalgia, fatigue, autoimmune hemolytic anemia  (may  be life-threatening), 
peripheral  neuropathy and pulmonary toxicity (both pneumonia and 
pulmonary hypersensitivity reactions have  been reported; fatal pulmonary 
toxicity has  been described, especially when fludarabine was  used in 
combination with  pentostatin). Severe or fatal CNS toxicity presenting with 
loss of vision and progressive deterioration of mental status has been 
described primarily after high doses of fludarabine. 
8.1.4 Rare complications - include transfusion-associated graft versus host 
disease, thrombotic thrombocytopenia purpura and l i v e r  failure. Tumor 

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Rev#2: March 4, 2019
lysis syndrome has been observed, especially in patients with   advanced 
bulky disease. Opportunistic infections (protozoan, viral, fungal, and 
bacterial) have been observed. 
8.2Cyclophosphamide  
8.1Mechanism of action: Cyclophosphamide is a pro drug that requires activation. 
Following hepatic and cellular activation, phosphoramide mustard and acrolein are 
formed. Phosphoramide mustard is the alkylating agent that demonstrates cytotoxic 
effects. Acrolein binds to proteins but does not contribute to the anti-tumor effects. 
8.2Toxicities: Potential toxicities include: fever and/or chills, nausea and vomiting, 
anemia, oliguria/anuria, diarrhea, mental status changes, sinus tachycardia, elevated 
bilirubin, thrombocytopenia, BUN elevation, serum creatinine elevation, elevated 
transaminase, 
elevated 
alkaline 
phosphatase, 
pulmonary 
congestion, 
fatigue/weakness/malaise, 
dyspnea, 
pruritus, 
edema, 
erythema 
leukopenia, 
stomatitis, anorexia, rash, infection, weight gain 
(>10%), 
arrhythmias, 
hypomagnesemia, acidosis, hypocalcemia, dizziness, dry skin, exfoliative dermatitis, 
GI bleeding, sensory dysfunction, jaundice, pulmonary edema, proteinuria, 
hypophosphatemia, headache, coagulation disorders. In addition, heart problems can 
occur including a heart attack, the development of fluid around the heart or 
inflammation of the heart or the tissue surrounding the heart. Acrolein is toxic to the 
bladder and is associated with the development of hemorrhagic cystitis.
8.3How supplied: cyclophosphamide is commercially available  
8.5 Tacrolimus
8.5.1 Availability: Tacrolimus is commercially available as an injection (5 
mg/mL) and as oral capsules. 
8.5.2 Administration: Oral therapy will b e    administered twice   a day.   
Intravenous tacrolimus may be administered in divided doses every 12 
hours.
8.5.3 Toxicities: Most   of t h e  adverse event information described 
comes from   studies of tacrolimus in solid organ transplantation. Patients 
can experience anemia, leukocytosis, thrombocytopenia, mild to moderate 
hypertension, chest p a i n . Antihypertensive therapy may be required.  The  
most  common  adverse  effects   of tacrolimus have  involved  the  central 
nervous system, and include headache,  tremors,  insomnia,  paresthesias  
and dizziness. Less common side effects include agitation, anxiety, confusion, 
seizures, depression, hallucinations, myoclonus, neuropathy, psychosis, 
incoordination, and abnormal dreams. Metabolic abnormalities include 
hyperkalemia, hypokalemia, hypophosphatemia and hypomagnesaemia. In 
addition, hirsutism occurs only rarely. Gastrointestinal adverse effects   
include nausea, vomiting, anorexia, constipation and diarrhea.  Overt 
n ep h ro t o x i cit y is usually seen early after transplantation and is  
characterized by an increased serum creatinine and a decrease in 
urine output. Hematuria has been reported in greater than 3% o f  
tacrolimus-treated patients.  Abnormal liver f u n c t i o n  tests have been 
reported in 6% to 36% of patients; ascites was reported in 7-27% of these 

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Rev#2: March 4, 2019
patients. Other miscellaneous effects that have occurred in clinical trials 
include pain, fever, b a c k  pain, peripheral edema and hyperglycemia. 
Other rare effects include peritonitis, photosensitivity and very rarely 
anaphylaxis.
8.5.4 Drug Interactions: Tacrolimus is metabolized by cytochrome P450. 
Drugs that are inhibitors (e.g., Iitraconazole) o r    inducers (e.g.,   
phenytoin) o f    3A4   might increase o r    decrease tacrolimus 
concentrations respectively. This could result in increased or decreased 
effect of tacrolimus. Tacrolimus dose will be adjusted based on blood levels.
8.7 G-CSF or Filgrastim (or biosimilar)
8.7.1 Availability: G-CSF is commercially available.
8.7.2 Administration: The dose for recipients is 5 mcg/kg/ day as a 
subcutaneous injection. The dose for donor stem cell collection is 10 
mcg/kg/day given subcutaneously. We will be using doses based on NMDP 
guidelines (as listed within the protocol).
8.7.3 Toxicities: Toxicities can include chills, nausea,   anorexia, 
m y a l g i a s , bone p a i n , local injection site pain or inflammation, abnormal 
liver function tests, thinning of hair, and enlargement of the spleen.  Rarely 
fluid   retention and pericardial effusions occur. All of these are   generally 
reversible when the drug is discontinued.
9.0 
REQUIRED DATA and CORRELATIVE LABORATORY STUDIES
9.1The “Treatment Evaluation” required for this trial is listed in Section 5.0, “General 
Workup and Diagnostic Procedures”.
9.1.1During the inpatient hospital stay for the transplant, toxicity will be 
monitored (Section 7.0, “Potential Toxicities and Dose Modifications”).
9.1.2We will identify the following clinical endpoints:
9.1.1 Time to Marrow engraftment: Standard definitions of engraftment 
are being used. Engraftment of each cell line will be defined as an absolute 
neutrophil count (ANC) of > 500/mm3 for three days (count first day) and 
a platelet count of 20,000/mm3  untransfused (count first day). 
9.1.2
Response to treatment at 100 days – using standard international 
response criteria, based on CIBMTR definitions.
9.1.3
Response to treatment at one year – using standard international 
response criteria, based on CIBMTR definitions.
9.1.4
100 day survival
9.1.5
One year survival
9.1.6
Treatment-related mortality in the first 100 days
9.1.7
Toxicities associated with this treatment regimen during the 
inpatient stay
9.1.8
Incidence of acute and chronic GVHD
9.1.9
Donor-recipient chimerism following transplant at Days 30, 60 and 
90.

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9.1
Transplant Evaluation –during the in-patient hospital course
Daily:  During the inpatient hospital course, the patient will be evaluated daily 
using physical exam and lab work as needed.
9.2 Out-Patient Evaluation – Post-Transplant
Patients will be seen in clinic by the treating transplant attending.  The 
recommended follow-up is weekly for 4 weeks.  Evaluation during each clinic 
visit should include pertinent history and physical, CBC with diff and platelets, 
comprehensive metabolic profile panel.  Other labs can be requested at the 
discretion of treating physician. Of course, extensive follow-up is required for 
each patient. The follow-up clinic schedule will be directed by the treating 
transplant physician. 
9.3 Re-staging Evaluations
Tumor restaging will include bone marrow aspirate and biopsy on the following 
days:
Day 30
Day 60 (not mandatory)
Day 90-100
One year
The biopsy can be done within 21 days of designated dates, based on patient’s 
clinical course, toxicities, and side effects. 
It is possible that the patient may not require blood or marrow assessment at these 
time points, if their clinical course deems this not necessary. For example, in the setting 
of relapsed disease, ongoing treatment, the presence of GVHD or concurrent treatment of 
a co-morbid condition, the performance of a marrow biopsy may be contraindicated OR 
the results of the marrow may have no clinical significance, In these cases, a marrow 
(and/or blood work) is not necessary.
When a biopsy is done, it is recommended to check marrow for chimerism.
9.4 Since GVHD can be diagnosed clinically, if the treating physician believes a biopsy 
of a specific organ is needed to confirm a diagnosis, this may be done.
9.5 Response to treatment 
Response to treatment will be assessed at approximately Day 100 (+/- 21 days) 
and at approximately one year (+/- 21 days) (as required by Foundation for the 
Accreditation of Cellular Therapy and the Center for International Blood and Marrow 
Transplant Research). Standard International Criteria for responses for each disease will 
be used, based on CIBMTR criteria. After one year, each patient will only be followed 
for survival or the development of GVHD.
9.6 Patient Samples
Objective #2 focuses on the correlative laboratory evaluations. The goal is to 
demonstrate in vivo changes with this regimen. The following research specimens will be 
needed:

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9.7 Blood and marrow patient samples
Per the protocol design, each patient will have blood and marrow assessments at 
Days 30, 60 (not mandatory), and day 90 - 100 (+/- 21 days). For each patient, at the time 
of a blood draw approximately an additional 8 cc will be obtained for research purposes. 
For each patient, at the time of a bone marrow aspirate approximately, an additional 5-6 
cc will be obtained for research purposes. Baseline blood samples should be obtained 
within 14-21 days of admission.
It is possible that the patient may not require blood or marrow assessment at these 
time points, if their clinical course deems this not necessary. For example, in the setting 
of relapsed disease, ongoing treatment, the presence of GVHD or concurrent treatment of 
a co-morbid condition, the performance of a marrow biopsy may be contraindicated OR 
the results of the marrow may have no clinical significance, In these cases, a marrow 
(and/or blood work) is not necessary.
SAMPLES
Time of 
engraftment
Day 30
Day 60
(not mandatory)
Day 90
Blood
X
X
X
X
Bone Marrow
X
X
X
9.8 Processing of patient samples
 
Patients’ blood and marrow samples will be processed and analyzed by the 
Immune Monitoring Laboratory or by Dr. Mabaera. Each sample will be labeled with the 
trial number and provided with a unique patient number (UPN). No individual patient 
samples will be identifiable. The laboratory tests will be conducted by the Immune 
Monitoring Lab or by Dr. Mabaera (within Dr. Randy Noelle’s laboratory). A copy of the 
results will remain in the laboratory and with the PI.  The PI will be the only individual 
with access to the UPN and patient identity, so that lab results can be correlated with 
clinical outcomes. 
Because early marrow recovery is associated with release of immature cells into 
the peripheral blood, including increased numbers of MDSCs, we plan to evaluate the 
frequency and phenotype of MDSCs during bone marrow recovery. Blood samples will 
be obtained at the time of neutrophil engraftment, approximately between days 12 – 18 
following transplant. A sample will be obtained on day 21 if criteria for neutrophil 
engraftment are not met. Because MDSC frequency and activity are likely to be 
important predictors during early immune recovery, we will evaluate MDSC and immune 
checkpoint regulator expression on blood and marrow samples on approximately days 30, 
60 and 90-100 following transplant, since patients undergo these evaluations as part of 
their routine care at these time intervals.
9.9 Use of patient samples
The patient samples will be used as outlined below:
9.5.1 To characterize incidence, prevalence and function of MDSCs and 
immune checkpoint regulators (VISTA, CTLA-4, PD-L1) during early 
immune recovery following an allogeneic stem cell transplant.
Since the presence of MDSCs may correlate with engraftment, the 
response to treatment, and the risk of developing GVHD, we will define MDSCs 

Meehan, Hill; Haploidentical - 21
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frequency and immune checkpoint regulators expression on MDSCs and on 
peripheral blood and bone marrow in allogeneic transplant recipients following 
transplantation.
We will correlate these laboratory results with clinical outcomes and the 
incidence of GVHD.
9.5.2 Exploratory aim # 2a) In those patients experiencing GVHD, we will 
define the MDSCs frequency and checkpoint regulator expression on MDSCs, 
peripheral blood mononuclear cells and myeloid subsets. Blood samples will be 
drawn at time of diagnosis and weekly for four weeks to evaluate changes in 
response to treatment.
9.10 Flow Cytometry for MDSCs and VISTA expression
We will define the two human subsets of MDSCs using the following antibodies: 
CD11b+, CD33+ (subset), HLA-DR-/low; with two subsets of granulocytic (CD15+) and 
monocytes (CD14+). In the limited studies available that have examined MDSCs 
following transplant, suppressive function has been associated with arginase-1 (Arg1) 
and indoleamine 2,3-dioxygenase-1 (IDO1) expression. 
To evaluate MDSC subsets and immune checkpoint regulators, a portion of the 
sample will undergo red blood cell lysis and then be directly labeled for 8-color flow 
cytometry using the following antibodies: anti-CD15-BV421, anti-HLA-DR-BV510, 
anti-CD11b-FITC, anti-CD33-PE, anti-CTLA4-PerCP-Cy5.5, anti-CD14-PE-Cy7, anti-
VISTA-APC, and anti-PD-L1-APC-Cy7. To determine MDSC mediators of MDSC 
suppressive activity, a second panel with anti-IDO1-AF647, anti-Arg1-APC, CellROX 
(reactive oxygen species) will be used in place of anti-CTLA4, anti-VISTA, and anti-PD-
L1. 
To evaluate immune checkpoint regulators’ expression in T cells, blood will be 
run on ficoll-gradient and then stained with the following antibodies: anti-CD3, anti-
CD4, anti-CD8, anti-CD11b, anti-FoxP3, anti-CTLA4, antiPD-L1 and anti-VISTA. All 
flow cytometry will be performed with appropriate staining (CD-Chex plus) and isotype 
controls. The data will be analyzed using FlowJo software.
9.11 Correlating the lab results to the clinical results 
Potential correlation between lab findings and clinical parameters will be evaluated using 
descriptive methods. 
10.0
CRITERIA FOR RESPONSE AND TREATMENT ENDPOINTS
10.1Objective #1 is to define clinical endpoints using this haploidentical 
transplant regimen, including:
10.1Time to Marrow engraftment (defined as absolute neutrophil count > 500/mm3 
and platelets > 20,000/mcl for three consecutive days (count first day as 
engraftment) 
10.2
Response to treatment at 100 days
10.2.1
Response to treatment at one year
10.2.2
100 day survival
10.2.3
One year survival

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10.2.4
Treatment-related mortality in the first 100 days
10.2.5
Toxicities associated with this treatment regimen
10.2.6
Incidence of acute and chronic GVHD
10.2.7
Donor-recipient chimerism following transplant at Days 30, 60 and 90-
100.
10.2
Response Criteria
At day 100 and at one year (+/- 21 days at each time point), the patient will be evaluated 
for response using standard CIBMTR criteria for each disease. See “Response to 
Treatment” for additional details.
10.3 Monitoring of Toxicities after discharge from the hospital
        Monitoring of all acute toxicities ( > grade 3) will occur until the time of 
discharge. After discharge (approximately day 15-17 following transplant), transplant 
patients often experience a number of medical issues. As a result, after discharge until 
day 100, only serious toxicities ( > grade 4) will be recorded. Of course, should any life 
threatening event possibly be linked to the study at any time, the investigator shall use 
his/her discretion is reporting the event to the appropriate committees.
10.3
Defining  “Off Therapy”
Patients will be considered “off therapy” at day 100 following transplant. After 
day 100, patients are far enough out from transplantation that any toxicity is not related 
to the transplant process. After day 100, patients will be followed for survival and the 
development of GVHD.
10.4
Defining “Off Study”
10.4.1 Three year time point: Since three-year post-transplant remission is felt to 
predict for an extended disease-free survival, patients will be considered “off 
study” three years from the date of their transplant.
10.4.2 Relapsed or progressive disease: If the patient progresses or relapses at any 
time, the patient will be removed from study, since any intervening treatment will 
influence the endpoints and objectives of the study. The patient will be monitored 
for overall survival.
10.4.3 Development of a new malignancy: If the patient develops a new 
malignancy, the patient will be removed from study. The patient will be 
monitored for overall survival.
11.0
REMOVAL OF PATIENTS FROM PROTOCOL and STOPPING RULES
11.1Any patient may request removal from the trial at any time. In addition, the 
treating physician may remove a patient from the trial at any time during treatment. If a 
patient requests withdrawal, the patient’s samples will not be used for analyses. 
11.2
Monitoring of Toxicities after discharge from the hospital
        Monitoring of all toxicities will occur until the time of discharge. After discharge, 
transplant patients often experience a number of medical issues. As a result, after 
discharge, only serious toxicities (> grade 4) will be recorded. Of course, should any life 

Meehan, Hill; Haploidentical - 23
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threatening event possibly linked to the study at any time, the investigator shall use 
his/her discretion is reporting the event to the appropriate committees.
11.3 Stopping Rules
All high dose chemotherapy regimens will cause significant toxicity.  Thus, 
toxicity will be monitored closely.  The Stopping rules for this protocol will address five 
areas, including:
oPatient’s death before Day 100
oEngraftment
oPersistent > Grade 4 toxicities
oRejection of transplanted marrow
oIncidence of GVHD
11.4 Patient’s death before Day 100
Given the high-risk nature of this treatment and the often poor prognosis of these 
diseases, there is an expected 4 - 20% mortality rate until day 100. As a result, the trial 
will be suspended if > 25% of patients die due to treatment-related toxicities before day 
100. If a patient dies before day 100, the trial will be suspended until the PI and the 
required committees have had an opportunity to review the patient’s clinical course and 
medical records to determine if the trial should continue. 
11.5.2. Engraftment
In this cohort of patients, we anticipate a 10 - 13 % of patients could experience 
failure to engraft. As a result, the trial will be suspended if > 20% patients fail to engraft. 
Engraftment will be defined as an absolute neutrophil count of < 500 cells/mcl by day 60 
or platelet transfusion-dependence (to keep count > 20,000/mm3) by day 60.  
Of note, marrow engraftment following a haploidentical transplant is typically 
delayed when compared to a myeloablative related transplant. For example, the absolute 
neutrophil counts typically recovers on day 15 for haploidentical transplants compared 
with day 11-13 for a matched related donor. In addition, platelets engraft around day 24 
for haploidentical recipients compared with day 12-15 for a matched related donor 
undergoing a myeloablative transplant.
11.5.3 Persistent > Grade 4 toxicities
Due to the high-risk nature of this therapy and the anticipated side effects and 
toxicities, if similar grade 4 or greater toxicities occur in a consistent fashion, the PI and 
responsible committee members will review the patients’ records and clinical course to 
determine if the clinical trial should continue.
11.5.4 Rejection of transplanted marrow
Following an allogeneic transplant, some patients engraft their donor cells, but 
lose their graft three or more months out from transplant. Based on the literature review 
of this trial and similar trials, the marrow rejection rate is 13 %. If 20 % or more of 
patients reject the marrow, the PI and the responsible committees will review the 
patient’s medical records and clinical course to determine if the clinical trial should 
continue.

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11.5.4 Incidence of GVHD
In general, the incidence of acute GHVD (grade 2-4) is 25-50% for recipients of a 
related donor transplant. The incidence of chronic GVHD is 30-50% for patients who 
received a related donor. If the incidence of acute GVHD is > 60% for related donors, the 
PI and the responsible committees will review the patient’s medical records and clinical 
course to determine if the clinical trial should continue. If the incidence of chronic 
GVHD is > 80%, the PI and the responsible committees will review the patient’s medical 
records and clinical course to determine if the clinical trial should continue.
12.0
REPORTING of SERIOUS ADVERSE EVENTS and UNANTICIPATED 
PROBLEMS
12.1
Any adverse event is any undesirable event occurring with the use of these study 
procedures.  Adverse events will be graded according to the NCI Common Toxicity 
Criteria Version 4.0.  A copy of the CTC version 4.0 can be downloaded from the CTEP 
home page (http://ctep.info.nih.gov).  All appropriate treatment areas should have access 
to a copy of the CTC version 4.0. Adverse events and unanticipated problems will be 
reported to The Dartmouth Committee for the Protection of Human Subjects (CPHS) as 
per their statement found at http://www.dartmouth.edu/~cphs/docs/aedsmmemo.pdf using 
their Serious Adverse Event (SAE) Reporting Form or their Reporting Form for An 
Unanticipated Problem Involving Risks to Subjects or Others (UPR)for Clinical Trials 
found at http://www.dartmouth.edu/~cphs/tosubmit/forms/. 
Adverse events to be reported to the CPHS are: any adverse experience, defined 
as any untoward or unfavorable medical occurrence in a human subject, including any 
abnormal sign (for example, abnormal physical exam or laboratory finding), symptom, or 
disease, temporally associated with the subject’s participation in research, whether or not 
considered related to the subject’s participation in the research), that is considered:
–
Serious: 
Death; 
a 
life-threatening 
adverse 
drug 
experience; 
inpatient 
hospitalization or prolongation of existing hospitalization; a persistent or significant 
disability or incapacity; or a congenital anomaly or birth defect; and
–
Unexpected:  Any adverse experience, the specificity or severity of which is not 
consistent with the current investigator brochure or consent form; and
–
Possibly related:  There is a reasonable possibility that the incident, experience, or 
outcome may have been associated with the procedures involved in the research; and 
is experienced by a participant in a trial open at a site subject to review by the CPHS. 
 
The following definitions will be used to assess causality:
No:
The clinical adverse event is definitely unrelated to study procedures (e.g., 
does not follow a reasonable temporal sequence from study procedure, present prior 
to procedure, etc.)
Unlikely: The study procedures do not have any reasonable association with the 
observed experience; however, relationship cannot be definitely excluded.
Possibly:
The connection with study procedures appears feasible, but cannot be 
excluded with certainty (e.g., follows a reasonable temporal sequence from 
procedure, but may also be related to other known factors).

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Probably: The clinical experience appears related to the study procedures with a high 
degree of certainty (e.g., follows a reasonable temporal sequence from procedure  and 
abates upon termination of the procedure, cannot be reasonably explained by known 
characteristics of the patient’s clinical state or other modes of therapy administered to 
the patient, etc.)
An unanticipated problem involving risks to subjects or others is defined as any 
incident, experience, or outcome that meets each of the following criteria:
•
Unanticipated in terms of nature, severity, or frequency given: (a) the research 
procedures that are described in the protocol-related documents, such as the IRB-
approved research protocol and consent document; and (b) the characteristics of the 
subject population being studied; and
•
Possibly related to participation in the research means there is a reasonable 
possibility that the incident, experience, or outcome may have been associated with 
research participation; and
•
The problem suggests that the research places subjects or others at a greater risk 
of harm (including physical, psychological, emotional, economic, legal, or social harms) 
than was previously known or recognized.
•
Copies of each report and documentation of IRB notification and receipt will be 
kept in the Clinical Investigator’s study file.
13.0
STATISTICAL CONSIDERATIONS 
The primary objective of this clinical trial is to define clinical endpoints for the proposed 
haploidentical transplant regimen, including engraftment, 100-day survival and one year 
survival. Time to event data will be summarized with Kaplan-Meir curves for censored data 
along with confidence intervals (Objective #1). 
13.1 
Sample size. The patient sample size is based on determining the 100 day 
survival for patients treated on this trial. The trial proposes that 20 evaluable 
patients will be needed to define the 100 day survival rate. The analysis for 
the primary objective of 100 day survival rate will be based on the Intent to 
Treat population, so that all patients will be evaluable for this objective. 
Based on haploidentical transplant clinical trials (see Introduction), the 
100-day overall survival in these trials ranged from 80% to 96%. We estimate the 
100-day survival for this clinical trial will be > 70%.  Based on exact confidence 
intervals for binomial proportions, we expect the half width of our confidence 
intervals to be approximately 20 % for 100-day survival.
 
13.2
Survival analysis. All patients will be followed for 100 day survival, one 
year survival and overall survival.  The trial proposes that 20 evaluable patients 
will be needed to define the 100 day survival rate.  The analysis for the primary 
objective of 100 day survival rate will be based on the Intent to Treat 
population, so that all patients will be evaluable for this objective. With a 
projected accrual rate of 10-12 patients per year, we estimate that the study will 
be completed in approximately 24 months. Each patient will be followed for at 
least one year. After one year, each patient will be followed only for survival and 
the development of GVHD. Duration of response and survival will be analyzed 

Meehan, Hill; Haploidentical - 26
Rev#2: March 4, 2019
using the product-limit method for censored time to event data to estimate the 
primary outcomes of 100 day and one year survival.
13.3  Engraftment will be evaluated in all treated patients. The rate of 
engraftment will be determined as the ratio of the number of patients with 
successful engraftment to the total number of patients treated.  An exact 
95% confidence interval will be computed based on the binomial 
distribution.  
13.4 Toxicity will be tabulated according to type and grade. Rates of toxicity 
will be determined as the ratio of the number of patients experiencing the 
toxicity to the total number of patients receiving any treatment.  Toxicity 
rates will be computed according to type and grade.  In addition, the rate of 
any grade 3 or worse toxicity that occurs during the transplant hospital 
course or any grade 4 or greater toxicity that occurs out until day 100 will 
be computed.  
13.5 Laboratory analysis.  Statistical analysis will focus on the results of 
myeloid-derived suppressor cells (MDSCs) and the presence and function 
of Immune Checkpoint Regulators. Since minimal information is known 
about the presence of MDSCs following allogeneic stem cell 
transplantation, we will define their presence or absence within one patient 
over time. We will also compare the results between patients. It is 
impossible to compare the results to “baseline” results, since MDSC cell 
subsets are dynamic and change over time. In addition, the patient’s or 
donor’s baseline MDSCs will not be representative of the MDSCs identified 
following myeloablative chemotherapy and immune suppressive therapy. 
13.6 Immune Checkpoint Regulators. We will identify their presence or 
absence on MDSCs. These results will be monitored over time in individual 
patients and results will also be compared between patients. Appropriate 
descriptive summary statistics (e.g., means and standard errors, medians) 
and graphical displays will be generated for each measure at baseline and 
during treatment and follow-up. Graphical displays will show changes over 
time for continuous endpoints both in terms of the absolute measures as 
well as percent change from baseline.  We will use Wilcoxon signed-rank 
tests to evaluate changes from baseline (absolute change and percent 
change).  
13.7 Correlation analysis. We will evaluate the correlation between biological 
endpoints and clinical outcomes using appropriate techniques. We will 
examine the presence/absence of MDSCs in each patient and compare time 
to bone marrow engraftment, 100 day survival, one year survival and 
incidence of GVHD using log rank tests for censored time-to-event data and 
Chi-square test for dichotomous outcomes.  These methods will also be 
used to determine if a correlation exists between the presence/absence of 
GVHD or Immune Checkpoint Regulators on survival. Where necessary, 

Meehan, Hill; Haploidentical - 27
Rev#2: March 4, 2019
we will use transformations (e.g., logarithm and square root) to adjust for 
skewed distributions for lab measurements. Associations among lab results 
will be evaluated using Pearson or Spearman correlation analysis. In 
particular, we will construct a correlation matrix for the immune 
parameters. We will use 2-dimensional scatter plots to examine the 
distributions of the measures.
13.8 Stopping Rules.   (See above section “REMOVAL OF PATIENTS 
FROM PROTOCOL and STOPPING RULES”.  
The Transplant Program performs a monthly Quality Assurance Meeting with 
presentation of all data on Transplant Inpatients and completed transplants. 
14.0
STUDY MONITORING, AUDITING AND INSPECTION
14.1 Safety and Data Monitoring
This study will be monitored by the Data Safety Monitoring and Accrual 
Committee (DSMAC) of the Norris Cotton Cancer Center. The Committee meets 
quarterly to review accrual rates and information of all studies that have accrued 
participants. The Clinical Cancer Review Committee (CCRC) determines the frequency 
of DSMAC review. The DSMAC has the authority to suspend or to recommend 
termination to the CCRC of all research activities that fall within its jurisdiction.  In the 
event that a study is suspended or terminated by the DSMAC, that information will be 
forwarded to the CPHS (Dartmouth IRB) office.
The DSMAC will monitor this trial. In particular, areas that will be monitored include 
accrual to the trial, toxicity associated with the treatment and patient outcomes (the 
“Objectives”). We will closely monitor for any side effects or toxicities.  Stopping rules 
will be followed, as outlined in Section 11. 
14.2 On-site monitoring
Clinical research monitoring for regulatory compliance and data integrity will be 
conducted according to the NCI-approved NCCC Data and Safety Monitoring Plan. 
Internal monitoring is conducted by appropriately trained staff of the NCCC Office of 
Clinical Research and Dartmouth-Hitchcock Medical Center Clinical Trials Office who 
are not involved in the study. This monitoring will include periodic assessment of the 
regulatory compliance, data quality, pharmacy records and study integrity. Study records 
will be reviewed and directly compared to source documents and the conduct of the study 
will be discussed with the investigator. Monitors may request access to all regulatory 
documents, source documents, CRFs, and other study documentation for on-site 
inspection. Direct access to these documents is guaranteed by the investigator, who must 
provide support at all times for these activities.
14.3
Auditing and Inspection
Participation as an investigator in this study implies acceptance of potential 
inspection by government regulatory authorities and applicable Dartmouth research 
compliance and quality assurance offices. The investigator will permit study protocol 
related audits and inspections by the Dartmouth CPHS, government regulatory bodies, 
and the Dartmouth compliance and quality assurance groups of all study related 
documents (e.g., source documents, regulatory documents, data collection instruments, 

Meehan, Hill; Haploidentical - 28
Rev#2: March 4, 2019
study data etc.). The investigator will ensure the capability for inspections of applicable 
study-related facilities (e.g., pharmacy, diagnostic laboratory, etc.).
14.4 Record Retention
Following closure of the study, the investigator will maintain all site study records 
in a safe and secure location.  The records are maintained to allow easy and timely 
retrieval when needed (e.g., audit or inspection) and, whenever feasible, to allow any 
subsequent review of data in conjunction with assessment of the facility, supporting 
systems, and staff.  Upon completion of study analysis, research information is stored in 
Dartmouth College Records Management off-site storage located at 6218 Etna Road, 
Hanover, NH  03755.  Documents are shredded on site after 50 years of storage.
Electronic case report forms, participant, and study information will be kept in the 
Velos eResearch password-protected database (or equivalent) indefinitely.
15.0
HUMAN SUBJECTS
15.1This is a non-randomized study.  To enter eligible patients or discuss a patient’s 
eligibility, please contact Dr. Kenneth R. Meehan or the Clinical Research Associate 
(TBD at 603-650-4035). No patients shall be entered on study without consultation with 
the Principal Investigator or CRA.
15.2Patient care and status will be monitored by a Transplant/Hematology Physician 
and a designated Data Manager. All data will be maintained on a closed database with 
each subject identified by a unique patient number (UPN) with access to patient names 
only for those involved in clinical care.  All patients will provide informed consent prior 
to study entry.  Necessary information will be forwarded to the Center for International 
Blood and Marrow Transplant Registry (CIBMTR). Each patient will be fully informed 
concerning this study, including pertinent adverse reactions.  All institutional or other 
Federal regulations and guidelines concerning informed consent will be fulfilled.
15.3Gender and Minority Inclusion for Research Involving Human Subjects: The 
clinical trial is open to all patients with the hematologic malignancies as outlined within 
the “Eligibility Criteria” of the trial. All races and both genders are eligible. Given the 
geographic location of Dartmouth-Hitchcock Medical Center and the Norris Cotton 
Cancer Center, we anticipate the majority of patients will be Caucasian with an equal 
distribution of males and females.
15.4
Participation of Children: Stem cell transplants in pediatric patients are not 
performed at Dartmouth.
16.0
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