Non-Myeloablative Allogeneic Hematopoietic Peripheral Blood Stem Cell Transplantation for Hematologic Malignancies and Disorders
Phase: PHASE2
Conditions: Chronic Myeloproliferative Disorders, Leukemia, Lymphoma, Multiple Myeloma and Plasma Cell Neoplasm, Myelodysplastic Syndromes, Myelodysplastic/Myeloproliferative Diseases, Fanconi Anemia, Aplastic Anemia
Sponsor: Roswell Park Cancer Institute

Protocol Number: RP 01-05
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Protocol Title:
NON-MYELOABLATIVE ALLOGENEIC HEMATOPOIETIC STEM CELL 
TRANSPLANTATION FOR HEMATOLOGIC MALIGNANCIES AND 
DISORDERS.
Roswell Park Study Number: RP 01-05
VERSION #18
 Principal Investigator:
•
Philip McCarthy, M.D.
Roswell Park Cancer Institute
Elm and Carlton Streets
Buffalo, New York 14263
Confidentiality Statement
Any and all information presented in this document shall be treated as confidential and 
shall remain the exclusive property of the party (ies) mentioned above (Roswell Park 
Cancer Institute Corporation d/b/a Roswell Park Comprehensive Cancer Institute). The 
use of such confidential information must be restricted to the recipient for the agreed 
purpose and must not be disclosed, published, or otherwise communicated to any 
unauthorized persons, for any reason, in any form whatsoever without the prior written 
consent of the party(ies) above.
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Table of Contents
Section
Page No.
1.0
INTRODUCTION
4
2.0
OBJECTIVES
6
3.0
ELIGIBILITY
7
4.0
EXCLUSION CRITERIA
  9
5.0
DONOR ELIGIBILITY CRITERIA / STEM CELL
SOURCE CRITERIA
10
6.0
REGISTRATION AND DATA SUBMISSION
11
7.0
REQUIRED DATA
12
8.0
TREATMENT PLAN
13
9.0
POTENTIAL TOXICITIES, THEIR MANAGEMENT
& DOSE MODIFICATION
22
10.0
DRUG FORMULATION, AVAILABILITY,
AND PREPARATION
26
11.0
RESPONSE CRITERIA
39
12.0
REMOVAL OF PATIENTS FROM PROTOCOL AND
ADVERSE EVENT REPORTING (AER)
43
13.0
STATISTICAL CONSIDERATIONS
44
14.0
REFERENCES
46
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                             Appendices:                                                                 Page No.
I.
Bearman criteria for toxicity grading.
50
II.
Calculation of adjusted ideal body weight.
51
III.
Criteria for acute graft-versus-host disease.
52
IV.
Grading of chronic graft-versus-host disease.
53
V.
Stem Cell infusion.
54
VI.
Karnofsky performance status.
55
VII.
Child-Pugh Classification of Liver Failure.
56
VIII
Required tests and observations
57
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1.0) INTRODUCTION:
1.1)
Conventional allogeneic stem cell transplantation is a valuable approach to therapy 
for many hematologic malignancies.  However, high dose conditioning regimens are 
associated with a high incidence of acute and long-term side effects.  This has 
precluded the use of allografting for older patients and those patients with pre-
existing organ damage.  Thus, an important goal is the development of safer 
allografting procedures that can be extended to those patients who would otherwise 
suffer from a high morbidity and mortality during allogeneic transplant.
Considerable data support the presence of a graft versus leukemia (GvL) effect after 
allogeneic transplants, including the reduced risk of leukemic relapse in patients 
with acute and chronic graft versus host disease (1,2,3).  There is a higher risk of 
leukemia relapse after syngeneic (identical twin) bone marrow transplantation 
(4,5,6) and after T-cell depleted allotransplants due to lack of a graft versus 
leukemia (GvL) effect (1,7).  The most striking and direct evidence supporting the 
existence of the GvL effect is the observation that certain patients who relapse after 
allogeneic transplantation can be re-induced into complete remission by infusing 
additional donor lymphocytes (8,9,10,11,12). 
The data discussed above indicate 
that the graft versus leukemia/lymphoma (GvL) effect alone may cure susceptible 
diseases.  An alternative strategy is to utilize a less intense, non-myeloablative 
conditioning regimen designed not to eradicate the malignancy but to provide 
sufficient immunosuppression to achieve donor engraftment.  This strategy allows 
subsequent development of a graft versus malignancy effect. 
Recent preclinical studies in a canine model have shown that the conditioning 
regimen for allografting can be reduced in intensity yet still achieve the goal of 
engraftment (13).  Other investigators have performed pilot trials to determine 
whether this strategy of non- myeloablative chemotherapy with allogeneic blood 
stem cell transplantation could induce durable engraftment and remission in patients 
with hematologic malignancies.  This approach was studied in patients who were 
ineligible for standard myeloablative conditioning regimen because of advanced age 
or co-morbid illness.
Childs et al at NIH investigated lineage specific chimerism in fifteen patients 
receiving an allogeneic peripheral blood stem cell transplant from an HLA-identical 
(n=14) or a 5/6 HLA antigen matched sibling donor after a preparative regimen of 
cyclophosphamide and fludarabine (14).  Eight patients had hematologic 
malignancies, MDS (n=3), CML chronic phase (n=2), CML second chronic phase 
(n=1)), refractory extramedullary plasmacytoma (n=1), relapsed diffuse large cell 
non-Hodgkin’s lymphoma (n=1).  Seven patients had solid tumors, metastatic 
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melanoma (n=4), metastatic renal cell ca (n=3).  Seven of 14 patients had mixed 
(donor range; 40% to 90%) T-cell chimerism on day +30.  After cyclosporine A 
(CSA) withdrawal, three additional patients became 100% donor T-cell chimeric.  
The four remaining patients with mixed T-cell chimerism, 2-4 weeks after CSA 
withdrawal received 1-3 doses of donor lymphocyte infusions (DLI) given at 30 day 
intervals.  Three achieved 100% donor T-cell chimerism.  One patient, who only 
reached a maximum of 40% donor T-cell chimerism, showed a progressive decrease 
in percentage of donor T-cells despite three doses of donor lymphocyte infusions (2, 
10 and 150 x 106 CD3+ cells/kg) and completely rejected the transplant by day +72.  
Overall, 13 out of 14 patients established 100% donor T-cell chimerism. At day +30 
posttransplant, all 14 surviving patients had  evidence of residual disease.  
Subsequently, ten patients (71.4%) had disease regression, five of whom remain in 
complete remission (CR).  One patient with extensive renal cell cancer and two 
patients with CML remain disease free 13, 12, and 5 months, respectively, post 
transplant. 
Indolent lymphoid malignancies are also affected by graft versus malignancy effects 
(15). Fifteen patients with chronic lymphocytic leukemia (CLL) or lymphoma have 
been treated using a non-myeloablative regimen of fludarabine or 
cyclophosphamide or fludarabine, cytarabine, and cisplatin (16).  All patients had 
failed to respond or had disease after primary chemotherapy.  Nine patients had CLL 
in relapse after a prior fludarabine response, and 6 patients had lymphoma.  All 
patients had active disease at the time of transplantation.  Three had an ECOG 
performance status of 3, two patients had elevated liver function tests, and all had 
received extensive prior therapy.  Eleven of 15 patients had evidence of 
engraftment.  The percentage of donor cells in marrow ranged between 50% and 
100% at one month after transplantation.  One patient had 75% donor cells in his 
marrow at 6 weeks post-transplant and converted to 100% donor cells following 
donor lymphocyte infusion (DLI).  All eleven patients with engraftment had a 
response, and 8 patients achieved complete remission.  Maximal responses are slow 
to develop and occur gradually over a period of several months to a year.
High dose therapy with allogeneic marrow transplantation in multiple myeloma 
carries a high risk of treatment related mortality, up to 70% in some series 
(17,18,19).  The existence of a graft versus myeloma effect is also well established, 
as indicated by the success of DLI in re-inducing remission in selected patients 
relapsing after allogeneic transplant (20,21).  The strategy of a non-myeloablative 
conditioning regimen is of major interest as a potential means of harnessing this 
graft-versus-myeloma effect while reducing regimen related toxicities.
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Fanconi anemia is an autosomal recessive disorder characterized by chromosomal 
fragility, congenital abnormalities, progressive  bone marrow failure and a marked 
propensity to develop malignancies. FA is only cured by hematopoietic stem cell 
transplantation, and is a universally accepted indication for HLA-identical sibling 
allografts (38). FA patients are natural candidates for reduced intensity conditioning 
because of their cellular hypersensitivity to DNA crosslinking agents such as 
cyclophosphamide and radiotherapy (39). Fludarabine based regimens are attractive 
as they are capable of intense T-cell immunosuppression, and have been used 
successfully for nonmalignant diseases, including Fanconi anemia, with minimal 
toxicity and stable, durable engraftment (40, 41).
This transplant approach has advantages over conventional transplant; first, acute 
GVHD is delayed and usually occurs after patients have fully recovered from 
conditioning-related toxicities.  Second, the ability to modify chimerism by 
withdrawing anti-GVHD medications or by DLI allows flexibility in selecting the 
optimum pace of donor immune recovery, with its attendant benefit from graft 
versus tumor effects and its risk of GVHD induction.  While these low intensity 
transplants have a decreased immediate procedural mortality, the long-term efficacy 
must still be determined.  Furthermore, because the preparative regimen does not 
contribute a significant anti-malignancy effect, the risk of disease progression might 
be higher. 
2.0) OBJECTIVES:
2.1) Primary objectives are: 
2.1.1) To determine safety and toxicity of this form of treatment in a patient 
population that is usually not eligible for full myeloablative allogeneic 
transplant
2.2) Secondary objectives:
2.2.1) To evaluate clinical response and overall outcome of non-myeloablative 
allogeneic hematpoietic stem cell transplantation/ cord blood transplantation.
2.2.2) To evaluate the evidence of graft-versus-tumor effect/ graft-versus-host 
disease/ chimerism of non-myeloablative allogeneic stem cell transplantation 
for the treatment of transplantable hematological malignancies and disorders.
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3.0) ELIGIBILITY CRITERIA:
3.1)
Diagnosis of disorders or histologically documented hematologic malignancy 
or transplantable disorder.
3.2)
Patients not eligible for standard myeloablative allogeneic stem cell transplant.
3.3)
Disease Status:
3.3.1) Hematologic Disorders: 
Severe disorders as described in literature (22).  Failed at 
least one cycle of standard immunosuppressive regimen 
with cyclosporine (CSA) and anti-thymocyte globulin 
(ATG).
Life-threatening disorders for which there is no standard 
therapy e.g. congenital bone marrow disorders (including 
congenital dyserythropoiesis, thrombasthenia that could 
lead to life threatening conditions. 
3.3.2) Acute Leukemia:
3.3.2.A)
Resistant or recurrent disease after combination 
chemotherapy with at least one standard regime (23, 24, 
25).
3.3.2.B)
First remission patients at high risk of relapse.
•
AML - antecedent myelodysplastic syndrome, secondary
•
AML, high risk cytogenetic abnormalities (23). 
•
ALL - high-risk cytogenetic abnormalities (25).
3.3.3) Chronic Myeloid Leukemia (CML):
•
Chronic phase (failed Gleevec, failed interferon after at 
least 6 months of treatment with minimum of 21 million 
units of Interferon/ week or unable to tolerate 
Interferon).
•
Accelerated Phase (blasts < 20%).
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3.3.4) Myeloproliferative and myelodysplastic Syndromes:
•
Myelofibrosis (after splenectomy).
•
Refractory anemia.
•
Refractory anemia with excess blasts.
•
Chronic myelomonocytic leukemia.
3.3.5) Lymphoproliferative disease:
•
CLL, Low-grade non-Hodgkin Lymphoma  (recurrent or 
persistent).  Symptomatic disease after first-line 
chemotherapy.
•
Multiple myeloma (progressive disease after autologous 
stem cell transplant). 
•
Waldenstrom's macroglobulinemia (failed one standard 
regimen). 
3.3.6) Non-Hodgkin Lymphoma: intermediate and high grade:
•
Controlled and chemo-sensitive disease.
•
First remission lymphoblastic or small, non-cleaved cell 
lymphoma at high risk of relapse (26,27).
3.3.7) Hodgkin’s disease:
•
Relapsed and chemosensitive disease.
3.3.8) Fanconi anemia:
•
Positive chromosome breakage analysis using 
diepoxybutane (DEB)
3.4)
Identification of suitable donor:
•
Donor eligibility criteria is outlined in section 5.0
3.5)
Age ≥ 4, < 75 years for related and fully matched blood and bone marrow 
unrelated donor transplants and < 60 for unrelated cord blood transplants.
3.6)
No serious concomitant psychiatric illness. 
3.7)
No concomitant malignancy other than non-melanoma skin cancer.
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3.8)
Non-pregnant and non-nursing woman. (women and men of reproductive 
potential should agree to use an effective means of birth control).
3.9)
Patients may have received prior autologous BMT.
3.10
Patients may have received prior allogeneic BMT (at least 6 months have 
elapsed).
3.11) Informed consent.
3.12) ≥ 2 weeks since prior chemotherapy, radiation treatment and/or surgery.
4.0) EXCLUSION CRITERIA: 
4.1)
Uncontrolled CNS disease (for hematologic malignancies).
4.2)
Karnofsky performance status ≤ 50%.
4.3) DLCO less than 40% predicted, corrected for Hb and/or alveolar ventilation.
4.4)
Cardiac ventricular ejection fraction (MUGA scan) less than 35%.
4.5)
Bilirubin, alkaline phosphatase, SGOT/SGPT ≥ 3 x institutional normal.
4.6)
Child’s class B and C  liver failure (see appendix no. VII).
4.7)
Calculated creatinine clearance ≤ 40 cc/min.
4.8)
Uncontrolled diabetes mellitus, cardiovascular disease, active serious infection  
or other disease which in the opinion of treating physician, would make this 
protocol unreasonably hazardous for the patient.
4.9)
HIV antibody positive.
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5.0) DONOR ELIGIBILITY CRITERIA/ STEM CELL SOURCE CRITERIA:
5.1)
HLA matching is important in determining the risk for transplant related 
complications, in particular GVHD.   The HLA loci: A, B, DR and to lesser 
extent C have been identified as regions that are important in determining 
HLA matching.   Full HLA identity is associated with the least risk of GVHD.   
Initially matching was determined at the A, B, DR loci with a total of 6 
possible alleles (3 inherited from each parent).   A single antigen mismatch at 
A, B, or the DR transplant from a family member is associated with a higher 
risk of GVHD but similar survival when compared to full identity at these 3 
regions.  When evaluating patients for unrelated donor transplant, a higher 
degree of matching is preferred due to the higher risk of GVHD.  However, 
recent data from the National Marrow Donor Program has demonstrated that 
single antigen mismatching with a reduced-intensity transplant results in 
acceptable levels of GVHD.
Molecular testing has allowed for more detailed analysis of the HLA locus 
(34).  Multiple alleles have been described in the A, B, DR and C loci.  The 
DR region has been further defined by molecular typing into 2 major regions: 
DRB1 and DQB1. However the clinically relevant antigen for matching is 
DRB1.  In addition, molecular testing has allowed for more accurate 
determination of the C region.  Thus, matching can take place at a more 
stringent level for unrelated donor transplants.
Related donor/recipient pairs must be matched at 6 or 5 HLA antigens (A, B, 
DR).  Volunteer unrelated donor/recipient pairs must be matched at the antigen 
level by molecular analysis at the DRB1 loci for blood and marrow 
transplants.  An antigen mismatch may be considered in patients otherwise 
matched at the other loci.  Patients who do not have an appropriate unrelated 
donor will be considered for cord blood transplant on this protocol.
5.2)
Single antigen mismatch at A, B, or C may participate in this protocol for 
voluntary unrelated donors.  The priority would be C mismatching followed by 
A then B.
5.3)
If a patient has no suitable family donor matched for 5 or 6 HLA antigens (A, 
B, DR) and no suitable unrelated donor is identified, patient can be considered 
a candidate for cord blood transplant, provided a cord blood donor is identified 
either a 4,5 or 6 match with the patient for HLA antigens (A, B, DR).   The 
cord blood product must provide a minimum of 2 x 107 nucleated cells/kg, test 
negative for HIV and Hepatitis A, B and C, and sterility assays have no growth 
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(28,29,30,31,32).  The cord blood products are located through the National 
Marrow Donor Program, the American Registry, or the Bone Marrow Donor 
Worldwide, and may be stored in the N.Y Placental Cord Blood Bank, the St. 
Louis Cord Blood Bank, or any of the established, registered European or 
Canadian blood and marrow banks.
5.4)
The donor must be healthy and must have negative testing for HIV, hepatitis 
and syphilis.  Donors who test positive for hepatitis and/or syphilis must be 
cleared by infectious disease consultation.
5.5)
The donor must have no uncontrolled cardiopulmonary, renal, endocrine, 
hepatic or psychiatric disease.
5.6)
Donor must be able to give informed consent for peripheral blood stem cell 
collection or bone marrow collection.  
5.7)
Syngeneic donors are not eligible.
5.8)
Donors who have no good peripheral venous access, may require central 
venous line placement for stem cell collection.
6.0) REGISTRATION AND DATA SUBMISSION:
6.1)
Contact the BMT coordinator. 
6.2)
Registration requirements:
6.2.1) Informed consent:  Patient must be aware of the neoplastic nature of 
his/her disease and willingly consent after being informed of the 
procedure to be followed, the experimental nature of the therapy, 
alternatives, potential benefits, side-effects, risks, and discomforts. 
Human protection committee approval of this protocol and of its consent 
form is required.
6.2.2) Histological review: Submission of appropriate tissue sample to confirm 
the underlying diagnosis.
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6.2.3) Radiological review:  All patients with lymphoma/ multiple myeloma 
must have appropriate radiographic workup at least 4 weeks prior to 
registration and must be submitted for review.
6.2.4) Registration procedures:  Confirm eligibility criteria (see Sections 4.0 & 
5.0).  Complete the registration worksheet.  When the patient is 
registered, a patient identification number will be generated.  Data 
pertaining to this protocol will be collected by the BMT research nurse, 
and/ or any other persons assigned by the BMT department head.
7.0)
REQUIRED DATA:
7.1)
Protocol Date Definitions:
7.2)
To be completed within 4 weeks before registration. (see appendix VIII)
7.3)
Record on the flow sheets: 
Patient name
Patient identification number
Date of birth
Patient’s gender
Disease type and stage
Treatment start date
Date of signed consent
Patient’s race
•
Important hematologic recovery endpoints;
Day ANC ≥500/μL; Plt ≥20K.
Day of last Platelet transfusion, last RBC transfusion.
•
Day of occurrence of severe toxicity (grade 3) by Bearman criteria.
On-Study
 Date
Start Treatment 
Date
Stop Treatment
Date
Off-Study
Date
Date 
conditioning 
regimen 
started
Date 
conditioning 
regimen 
started
Date infusion of stem cells is 
complete (relevant for 
patients who have more than 
one infusion over 2 or more 
days)
Date of first disease 
progression post-transplant or 
date of death due to any 
cause,date patient failed to 
engraft.or 4 years of follow up
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8.0)
TREATMENT PLAN:
8.1)
Stem cell Collection:
Donors will receive 10 micrograms/ kg GCSF daily sub-cutaneously, starting 
on day -5. Mobilized peripheral blood stem cells (PBSCs) will be collected by 
apheresis on day “-1” and again on day “0” if necessary, to achieve a minimum 
target dose of 2 x 106 CD34+ cells/kg of recipient weight (maximum 8 x 106 
CD34+ cells /kg for related donors, no maximum for unrelated donors) (33, 
34).  PBSCs will be unmanipulated. CD3+ and CD34+ cells as fractions of the 
peripheral mononuclear cells (PMN) will be determined from the established 
PMN cell collection according to institutional flow cytometry.
The preferred method of collection is peripheral blood collection, but if 
peripheral blood collection either cannot  be obtained or this method is 
declined, a bone marrow harvest will be performed.  The target dose for bone 
marrow harvest will be 3 x 108 nucleated cells per kilogram of patient body 
weight.  Bone marrow will be unmanipulated.
The peripheral mononuclear cells will be separated and collected, while all the 
other separated blood components will be returned to the donor.
If donor lives outside of the area or is unable to come back after 
transplantation, donor lymphocytes will be collected by apheresis before the 
GCSF mobilization, aliquotted into CD3+ cell doses as per section 8.6 and 
cryopreserved for subsequent thawing and infusion.  If donor will be 
accessible after transplant, donor lymphocytes will be collected by apheresis 
after transplant.  If the stem cell collection is ≤ 1x106 per kg of body weight 
then bone marrow harvest will be done.
8.2) Preparative regimen:
8.2.1) Preparative regimen for related and unrelated non-cord blood 
transplant;
Day
-5 
-4 
-3
-2
-1
0
Cyclophosphamide 
50mg/kg IV
X
X
Fludarabine 
25 mg/m2 IV
X
X
X
X
X
Stem cell infusion
X
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8.2.1.A)
Cyclophosphamide; 50 mg/kg IV on days –5 and –4. Begin IV 
hydration at 150 ml/m
2/hr.  Cyclophosphamide, 50mg/kg (ideal 
body weight, but if actual body weight is 25% > ideal body 
weight then adjusted ideal body weight will be used. Appendix 
II).  If the actual body weight is less than ideal body weight, the 
actual body weight will be used.  The cyclophosphamide will be 
mixed in 500ml of an appropriate IV solution , is given by 2-hr IV 
infusion (e.g., 1100-1300 hrs) on day –5 and -4 (total dose 100 
mg/kg). Hyperhydration is continued until 24 hrs, after the last 
cyclophosphamide dose.  Lasix, 10-20 mg IV, will be given 2 hrs 
after each cyclophosphamide dose and then every 4 hrs. as needed 
to maintain urine output  ≥ 100ml/hr.
8.2.1.B)
Fludarabine, 25 mg/m2 (actual body weight) IV on days –5, -4, -3, 
-2, and –1. Fludarabine, 25 mg/m2 in 100 ml of appropriate IV 
solution, is given by 30-minute IV infusion (e.g., 0900 – 0930 
hrs.) on days  -5, -4, -3,  -2 and -1 (total dose 125 mg/m2).
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8.2.2)
Preparative regimen for cord blood transplant:
Day
-5 
-4 
-3
-2
-1
0
Cyclophosphamide 
50mg/kg/d IV
X
X
Fludarabine 
25 mg/m2/d IV
X
X
X
X
X
*Anti-thymocyte 
Globulin. (ATG) 
30mg/Kg/d IV
X
X
X
Stem cell infusion
X
*ATG will be given as preparative regimen for cord blood transplant in addition to 
Cyclophosphamide and Fludarabine (as described above).  Start ATG 2 hours after CTX 
completion.  ATG is given at 30mg/Kg IV on day -3, -2 and –1. Acetaminophen  (10mg/Kg or 650 
mg , max), Diphenhydramine  (1.25 mg/Kg IV or 50 mg max), and Methylprednisolone  (2 mg/Kg) 
IV will be given prior to each ATG dose. ATG is infused over 4 hrs.  (Use ideal body weight 
for ATG, but if actual body weight is > 25% ideal body weight, then adjusted 
ideal body weight will be used. Refer to Appendix II.  If the actual body weight 
is less than ideal body weight, the actual body weight will be used.)
8.2.3)  Preparative regimen for patients with Fanconi anemia (matched related, 
matched unrelated, or cord blood transplant)
Day
-6 -5 -4 -3 -2 -1 0
Cyclophosphamide
7.5 mg/kg/d IV
X
X
X
X
Fludarabine
25 mg/m2/d IV
X
X
X
X
X
Anti-thymocyte globulin (ATG)
30 mg/kg/d
X
X
X
Stem cell reinfusion
X
8.2.3A) Cyclophosphamide: 7.5 mg/kg/d on days -6, -5, -4 and -3.  Begin IV 
hydration at 3000 ml/m2/day. Start hydration 12 hours before cyclophosphamide and 
continue for minimum of 24 hours after last dose of cyclophosphamide. Use actual 
body weight, or adjusted ideal body weight if actual > 25% of ideal weight (if actual 
less than ideal use actual weight, see Appendix II). Cyclophosphamide is given as a 2 
hour infusion each day (e.g., 0930-1130). Dilute in an appropriate IV solution and 
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run over 2 hours). Lasix 0.5 mg/kg (no max. dose) IV will be given every 2 hours as 
needed to maintain urine output at minimum of 2 cc/kg/hr.  Recommended max dose 
is 20-40 mg.
8.2.3B) Fludarabine  on days -6, -5, -4, -3, and -2. Base on actual body weight.  
Dilute in 100ml (or 50 ml if < 1m2)of appropriate IV solution  and run over 30 
minutes (eg,  0900-0930).
8.2.3C) ATG is given at 30 mg/kg IV on days -3, -2, and -1. Acetaminophen (10-15 
mg/kg po, max 650 mg),  Diphenhydramine (1-1.25 mg/kg IV, max 50 mg), and 
methylprednisolone (2 mg/kg IV) (ideal body weight, but if actual body weight is 
> 25% of ideal body weight then adjusted ideal body weight will be used. Refer 
to Appendix II.  If the actual body weight is less than ideal body weight, the 
actual body weight will be used)  will be given as premedication 30 minutes before 
each dose of ATG. Continue acetaminophen every 4 hours and diphenyhdramine 
every 6 hours until 24 hours after completing ATG. Infuse ATG over 4 hours.
8.3)
GVHD Prophylaxis:
8.3.1) GVHD prophylaxis for related and unrelated blood and marrow 
transplant (35):
DAY
-1
0
+1
+2
+3
+4
+5
+6
FK506Ψ
X
X
X
X
X
X
X
X
MMFΣ
X
X
X
X
X
X
X
X
MTXΩ
X
X
X
ψ
Tacrolimus (FK506): Dose will be 0.03 mg/kg (ideal body weight) PO BID or IV equivalent, 
from day -1 to day +60 then taper as described in section 8.6.1.  The target level of 
tacrolimus will be 5-15 ng/ml.  In patients who are unable to take oral tacrolimus, the 
intravenous dose is generally 1/3 of the oral dose.  Levels of FK506 will be maintained in 
the therapeutic range.  Use ideal body weight or Actual weight if less than ideal body weight.
Σ
Mycophenolate mofetil (MMF): Dose will be 1 gram by mouth (PO) or IV twice a day 
(37,38).  MMF will be continued from day –1 to day + 60, and then taper as described in 
section 8.6.1. The pediatric dose will be 600mg/m2 BID.  Patients with a BSA of 1.25 to 1.5 
can be started on a dose of 750 mg BID; those with a BSA > 1.5 can be dosed with 1 
GmBID.
Ω
Methotrexate 5 mg/m2 IVPB on days 1, 3 and 6 
8.3.2) GVHD prophylaxis for cord blood transplant: 
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DAY
-1
0
+1
+2
+3
+4
+5
+6
FK506Ψ
X
x
x
x
x
x
x
x
MMFΣ
X
x
x
x
x
x
x
x
Methylpred
nisolone 
(0.5mg/kg 
BID)Θ
X
X
X
X
Methylpred
nisolone (1 
mg/kg BID)
X
X
Ψ
Tacrolimus (FK506); Dose will be 0.03 mg/kg (ideal body weight) PO BID or 
IV equivalent, from day -1 to day +180 then taper as described in section 
8.6.1.  The target level of tacrolimus will be 5-15 ng/ml. In patients who are 
unable to take oral tacrolimus, the intravenous dose is generally 1/3 of the oral 
dose.  Levels of FK506 will be maintained in the therapeutic range.
Σ
Mycophenolate mofetil (MMF); Dose will be 1 gram by mouth (PO) or IV 
twice a day.  MMF will be continued from day –1 to day + 60, and then taper 
as described in section 8.6.1.  Refer to 8.3.1 for dosing in pediatric patients.
Θ
Methylprednisolone (ideal body weight, but if actual body weight is > 25% 
ideal body weight then adjusted ideal body weight will be used.  Refer to 
Appendix II.  If the actual body weight is less than ideal body weight, the 
actual body weight will be used.)will be given at a dose of 1 mg/kg IV (0.5 
mg/kg BID) from day +1 to day +4 and 2 mg/kg (1 mg /kg IV BID) beginning 
on day +5 until day +19 or until the first day ANC reach ≥ 500/mm3.  After 
ANC have reached ≥ 500/mm3, steroids should be tapered by 0.2 mg /kg/week.
8.3.3) GVHD Prophylaxis for Patient with Fanconi’s anemia
8.3.3A) Tacrolimus (FK506): Dose will be 0.03 mg/kg (ideal body weight) PO 
BID or IV equivalent, from day -1 to +100 for related, or 180 days for 
unrelated, cord blood recipients. The target level will be 5-15 ng/ml. In 
patients unable to take oral medication, the IV dose is 1/3 the oral dose. Taper 
if no signs of GVHD by 10% per week.
8.3.3B) Mycophenolate mofetil (MMF): Dose will be 600 mg/m2 po or IV BID 
for patients < 1.25 m2. For patients with BSA 1.25-1.5, dose will be 750 mg 
po or IV BID. For patients with BSA > 1.5 m2, dose will be 1000 mg (1 gm) 
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po or IV. Dosing will start on day -1 and continue until day + 60. Dose will 
then be stopped.
8.4)
Supportive care:
8.4.1) Prior to initiating therapy, placement of a multi-lumen indwelling 
silastic catheter is required. 
8.4.2) Patients will receive full supportive care, including transfusions of 
blood and blood products, erythropoietin, antibiotics, anti-emetics, etc., 
when appropriate.  The reason(s) for treatment, dosage, and the dates of 
treatment should be recorded on the flow sheets.
8.4.3) Use of allopurinol will be at the discretion of the treating physician.
8.4.4) Mucosal evaluation and care:  Mucositis is expected to be very mild 
with this chemotherapy regimen.  Stomatitis and esophagitis due to 
herpes virus may be confused with drug-induced mucositis and viral 
cultures should be obtained frequently.  
Patients should receive 
acyclovir according to the RPCI standard of care for an allogeneic 
transplant patient.
8.4.5) Candida prophylaxis:  
Antifungal prophylaxis should be given 
according to the RPCI standard of care for an allogeneic transplant 
patient.
8.4.6) Pneumocystis Pneumonia (PCP) Prophylaxis:  Anti-PCPl prophylaxis 
should be given according to the RPCI standard of care for an allogeneic 
transplant patient
8.4.7) CMV Infections:  
No prophylaxis for CMV will be initiated. 
Surveillance for CMV using CMV antigenemia is required once weekly 
until day +100 and then PRN (as needed).  Patients with positive CMV 
antigenemia should receive treatment as per the RPCI SOP.  Dosing will 
be adjusted for hematological and renal toxicity.  Maintenance therapy 
will be left up to attending physician’s discretion.  CMV surveillance 
will start no later than day +21 unless patient has not engrafted.
8.5)
Allogeneic stem cell reinfusion:
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8.5.1) On Day 0 a minimum total cell dose of (CD34+ cells) 2 x 106/kg (blood)  
No maximum CD34+ dose for blood.)  An adequate minimum CB dose 
is 2 x 106 nucleated cells/kg.  BM dose is 1 x 108  nucleated cells/kg.
8.5.2) GM-CSF 250 μg/m2 subcutaneously daily beginning on day +7 and 
continuing until ANC ≥ 500/μL for three consecutive days.  If the ANC 
falls to ≤ 500/μL then resume GM-CSF at 250 μg/m2.  G-CSF may be 
substituted if patients are unable to tolerate GM-CSF.
8.6)
Followup;
8.6.1) Immunosuppression: 
After transplant, serial samples of blood and marrow will be analyzed 
for chimerism analysis by polymerase chain reaction (PCR).  Chimerism 
will be analyzed in blood on day 30 - 40, day 60 - 70  and then as  
indicated in section 8.6.3.  Chimerism will be analyzed in bone marrow 
(for leukemia and patients with other malignancies if bone marrow was 
involved previously) on day 30- 40 and day 100 -120 and then as 
indicated in section 8.6.3.
For peripheral blood and bone marrow transplant patients, those  
showing 100% donor T-lymphocyte chimerism by minisatellite analysis 
on day +30 continue FK506 and MMF until day +60; thereafter MMF 
will be stopped.  Cord blood patients will be continued on FK506 until 
day + 180.  All patients will be tapered off FK506 by 25% every 10 days 
and discontinued if no GVHD develops.  Patients not converting to 
100% donor T-cell chimerism by day + 120 and showing signs of 
progression of disease after FK506 and MMF withdrawal, will be 
evaluated for DLI (section 8.6.5).  Pts who receive cord blood will not 
receive DLI.  For Fanconi Anemia, taper FK506 at day 100 (for related 
donor) or day 180 (for unrelated donor).
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8.6.2) Disease measurement:
Patients will be followed according to response criteria as referenced in 
Section 11.4.
8.6. 3) Management of acute graft versus host disease;
Patients with symptomatic grade 1 acute GVHD of the skin will be 
treated with topical steroids.  Grade II or greater acute GVHD will be 
treated with high dose methylprednisolone 1-2 mg/kg daily for 10-14 
days followed by slow tapering in responders.  At 10% weight,continue 
for at least 2 weeks from the disappearance of all symptoms of GVHD.  
FK506/MMF will be maintained or increased during active aGVHD.  
Refractory aGVHD will be treated as per attending physician’s 
discretion.
8.6.4) Donor Lymphocyte Infusion; 
8.6.4.A) Eligibility Criteria for Infusion of Donor Lymphocytes:
•
Patients have either persistent AML/ALL or progressive disease 
(Lymphoma/multiple myeloma).
•
Patients must be off all immunosuppressives for a minimum of 30 days.
•
Patients must show no signs of active GVHD
•
The original donor must be available
8.6.4.B)
Collection of Donor Lymphocytes:
The original  donor will undergo leukapheresis to collect 1.0 x 107 CD3+ 
cells/kg (recipient weight) for use as donor lymphocyte infusions.
8.6.4.C)
Infusion of Donor Lymphocytes: 1 x 107 CD3+ cells/kg from the original  
donor.
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8.6.4.D) 
Prophylaxis for GVHD and post-transplant immunosuppression will not 
be given at this time.
8.6.4.E) 
Patients will be monitored weekly for engraftment and toxicity.  Sample 
submission for chimerism studies should be collected on day +30 after 
DLI.  Samples should be collected prior to an infusion of donor 
lymphocytes.
8.6.5) Second Infusion of Donor Lymphocytes (4 weeks after first DLI).
8.6.5.A) Eligibility Criteria for a Second Infusion of Donor 
Lymphocytes:
•
Patients have either persistent AML/ALL or progressive disease 
(Lymphoma/multiple myeloma).
•
Patients must be off all immunosuppressives for a minimum of 30 days.
•
Patients must show no signs of active GVHD
•
The original donor must be available
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8.6.5.B) 
Collection of Donor Lymphocytes; The original  donor will undergo 
leukapheresis to collect 5 x 107 CD3+ cells/kg (recipient weight).  
Alternatively, cells from the initial stem cell collection may be stored 
and frozen.
8.6.5.C) 
Infusion of Donor Lymphocytes: 5 x 107 CD3+ cells/kg from the original  
donor will be infused over 2 hours.
8.6.5.D) 
Prophylaxis for GVHD and post-transplant immunosuppression will not 
be given at this time.
8.6.5.E) 
Patients will be monitored weekly for engraftment and toxicity with 
chimerism samples collected again on day +30 after DLI.  Samples 
should be collected prior to an infusion of donor lymphocytes.
8.6.6)
Third Infusion of Donor Lymphocytes:  If more than 8 weeks from 
second DLI and all criteria for second DLI in Section 8.6.4.A are met, 
an optional infusion of 5 x 107 CD3+ cells/kg from the original  donor 
may be administered.
9.0)
POTENTIAL TOXICITIES, THEIR MANAGEMENT AND DOSE 
MODIFICATION:
9.1)
REGIMEN RELATED TOXICITY (Bearman Criteria, Appendix 1).
9.1.1) Cardiac: 
The risk of fatal cardiac toxicity with the study regimens is <5%.  
Patients who develop signs of congestive heart failure not attributable  to 
fluid overload should be evaluated for signs of carditis before additional 
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cytoxan is given.  Studies should include ECG (to compare voltage to 
pretreatment ECG), radionuclide ventriculogram, and/or 
echocardiography.  If evidence of pericarditis, pericardial effusion or 
impaired myocardial function (decreased ejection fraction) is found, no 
further chemotherapy will be administered.  In this situation patients 
must be watched carefully for signs of pericardial tamponade; 
pericardiectomy may be required.
9.1.2 Bladder: 
Urinary metabolites of cyclophosphamide can produce hemorrhagic 
cystitis. Microscopic hematuria is common following high dose 
cyclophosphamide regimens and up to 20% of patients may have gross 
hematuria.  Vigorous hydration of patients (3,000 ml/m2/day) prior to 
beginning cyclophosphamide and continuing until 24 hours after the 
final cyclophosphamide dose, produces a dilute urine and reduces the 
likelihood of severe cystitis.  The risk of life-threatening cystitis is 
estimated to be <1%.  For patients with a history of previous 
cyclophosphamide induced hemorrhagic cystitis, MESNA may be used.
9.1.3 Renal: 
All these agents in high doses can produce renal toxicity which can be 
minimized by vigorous hydration and avoidance of concomitant 
exposure to other nephrotoxic agents.  Kidney damage is usually 
reversible, but severe cases may require dialysis.
9.1.4 Pulmonary:  
With the study regimens the risk of fatal idiopathic interstitial 
pneumonitis is felt to be <10%.  Patients with diffuse pulmonary 
infiltrates often present a difficult diagnostic and management problem.   
Whenever possible, histologic confirmation of the diagnosis should be 
attempted by bronchoalveolar lavage, transbronchial or open-lung 
biopsy to exclude infectious causes, including cytomegalovirus.
9.1.5 Hepatic:  
Moderate toxicity is common.   More severe, possibly fatal, liver 
toxicity can occur, usually in the form of veno-occlusive disease.  With 
the study regimens the incidence of fatal liver toxicity should be < 10%.   
Management of liver toxicity is with standard supportive and 
symptomatic measures.  Avoid exposure of patients to other hepatotoxic 
agents whenever possible.
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9.1.6 CNS:
Fludarabine can cause weakness, paresthesias or peripheral 
neuropathies, visual or auditory impairment, and/or mental status 
changes such as confusion, agitation, depression, or coma.  Some 
antibiotics, which may be needed to treat infections during the period of 
low white blood cell counts, can cause VIIIth cranial nerve damage 
resulting in hearing loss (especially high-frequency tones) and dizziness 
which may be permanent.  To minimize this possibility, antibiotic levels 
will be monitored.
9.1.7) Stomatitis/Dysphagia:  
Many patients will experience moderate to severe stomatitis and 
dysphagia.  Adequate pain relief often requires parenteral narcotics.
9.1.8) Gastrointestinal: 
9.1.8.A) Nausea/Vomiting: Many patients will experience moderate to 
severe nausea and vomiting.  All patients should receive 
vigorous antiemetic treatment. 
9.1.8.B) Diarrhea:  
Most patients will experience moderate-severe 
diarrhea, which responds to standard symptomatic therapy.  
Appropriate studies are needed to exclude infectious causes of 
diarrhea, especially C. difficile.
9.2) OTHER TOXICITIES:
9.2.1) Hematologic: 
All blood products will be irradiated (2500 cGy) to prevent graft 
vs host disease. Infection prophylaxis and treatment will be given 
according to standard accepted medical practice.  With 
prophylactic platelet transfusions, the risk of death from 
hemorrhage is <5%. 
9.2.2) Skin:
Generalized erythroderma can occur with painful palms and soles 
and superficial desquamation at sites of mechanical trauma.  
Topical steroid creams may provide symptomatic relief. Severe 
cases may require a brief course (3-5 days) of systemic 
corticosteroids. Long lasting hyperpigmentation may follow 
resolution of the erythroderma.
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9.2.3) Hair:  
Most patients will experience total (reversible) alopecia.
9.2.4) Allergy:  
ATG may be associated with a serum sickness like reaction with 
rash, hives, pruritis, joint aches.  More severe anaphylactic like 
reactions with bronchospasm and shock are uncommon but 
reported.  Prior to administration of ATG, patients will be 
pretreated with Tylenol, Benadryl and Solumedrol.  Epinephrine 
and resuscitation equipment will be available at the bedside 
during administration.
9.2.5) Graft-vs-Host Disease:  
Approximately 80% of patients will exhibit some manifestation of 
GvHD.  Severe acute GvHD (grade II-III) may occur in up to 40% 
of patients with an overall mortality of 20% due to GvHD and its 
complications.  The risk of severe or fatal GvHD is increased for 
older patients and for patients receiving stem cells from partially-
matched donors.  A chronic form of GvHD is expected to occur in 
up to 40% of patients who survive beyond 3 months; 10% of 
patients may experience significant disability due to chronic 
GvHD that persist for months to years post-transplant.  Standard 
measures for prevention and treatment of GvHD will be followed.
9.2.6) Secondary malignancy:  
Exposure to alkylating agents increases the risk of developing 
leukemia or a second cancer. The incidence of leukemia is 
probably approximately 5%. (Vincent T. Devita; Cancer. 
Principles and Practice of Oncology. 6th edition, 2000).
9.2.7) Toxicities of G-CSF: 
Include bone pain, headache and muscle aches.  These can be 
treated with non-narcotic and narcotic analgesics.
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9.2.8) With apheresis the following discomforts may occur:  
Tingling around mouth or in fingers, feeling cold or feeling a 
pressure sensation in  chest due to the blood thinner (citrate) used 
only in the machine method.  Feeling light-headed or fainting any 
time during or at the end of the procedure.  Pain, bruising or 
infection at the point of the needle entry into the skin. Reaction 
(such as a rash) if a drug is given to which the patient is allergic.
Blood loss (seldom more than one pint) because of equipment 
problems which make it impossible to return the blood.  Air 
entering the blood stream causing air to go to body organs (rare 
risk because of safety measures used).
9.2.9) Failure to engraft:  
Autologous count recovery is the most likely outcome.
 
10.0) DRUG FORMULATION, AVAILABILITY AND PREPARATION:
10.1) Cyclophosphamide (Cytoxan®; CTX; CPA; Endoxan®; Neosar®; 
Cytoxan Lyophilized®)
10.1.1) AVAILABILITY:
Commercially available in 100 mg/10 ml, 200 mg/20 ml, 500 mg/30 ml, 
or in a powder for injection in 100 mg, 200 mg, 500 mg, 1 gram, and 2 
gram vials.
10.1.2) PREPARATION;
Reconstitute 100 mg, 200 mg, 500 mg, 1 gram and 2 gram vials with 5, 
10, 25, 50, or 100 ml of SWI or NS to give a final concentration of 20 
mg/ml.  Lyophilized CYTOXAN should be prepared for parenteral use 
by adding Sterile Water for Injection, USP, to the vial and shaking to 
dissolve.  Further dilute in –250-500 ml of D5W or NS for IV infusion.
10.1.3) ADMINISTRATION;
Dissolved in diluent as per pharmacy and will be administered over  2 
hours   Appropriate antiemetic therapy will be used.  Patients must be 
adequately hydrated before, during, and after administration of 
cyclophosphamide.
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10.1.4) STORAGE AND STABILITY;
Solutions reconstituted with SWI or bacteriostatic water are stable for 
24 hours at room temperature and 6 days if refrigerated.
10.1.5) TOXICITY;
Myelosuppression: leukopenia (nadir 8-14 days), thrombocytopenia.  
Acute sterile hemorrhagic cystitis (patients must be well hydrated 
before, during, and after treatment and have adequate renal function).  
Syndrome of inappropriate antidiuretic hormone (SIADH).  Bladder 
carcinomas and cellular dysplasias.  Alopecia (50%).  GI: anorexia, 
nausea, vomiting, diarrhea. Sterile phlebitis.  Rare pulmonary toxicity.  
Gonadal  abnormalities and teratogenicity.  With too rapid IV push, 
oropharyngeal tingling, “metallic” taste, headache, urticaria, and facial 
flushing can occur.  With high doses, cardiac toxicity.
10.2) Fludarabine Monophosphate (Fludara®);
10.2.1) AVAILABILITY:
Fludarabine monophosphate is commercially available as FLUDARA 
IV as a white, lyophilized powder.  Each vial contains 50 mg of 
fludarabine phosphate, 50 mg of mannitol and sodium hydroxide to 
adjust pH.  Store at 15-30°C (59-86°F).
10.2.2) STORAGE & STABILITY:
Reconstituted FLUDARA IV is chemically and physically stable for 24 
hours at room temperature or 48 hours if refrigerated.  In addition, 
reconstituted FLUDARA IV contains no antimicrobial preservative and 
thus care must be taken to assure the sterility of the prepared solutions 
and should be discarded eight hours after initial entry.
10.2.3) PREPARATION:
FLUDARA IV should be prepared for parenteral use only by aseptically 
adding Sterile Water for Injection, USP.  When reconstituted with 2 ml 
of Sterile Water for Injection, USP, 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.  The product may be further 
diluted for intravenous administration to a concentration < 1 mg/ml in 
5% Dextrose for Injection USP or in 0.9% Sodium Chloride, USP.
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10.2.4) ADMINISTRATION:
Parenteral drug products should be inspected visually for particulate 
matter and discoloration prior to administration.  Fludarabine will be 
delivered as a piggy-bag via an ongoing IV line, over a period of 30 
minutes.
10.2.5) TOXICITY:
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, autoimmune hemolytic anemia, autoimmune 
thrombocytopenia, paresthesias, peripheral neuropathy, renal  and 
pulmonary toxicity (interstitial 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 been rarely 
demonstrated at the 25-30 mg dosage of fludarabine monophosphate.  
Very rarely described complications include transfusion-associated graft 
versus host disease, thrombotic thrombocytopenic purpura, and liver 
failure.  Tumor lysis syndrome, complicating fludarabine 
monophosphate therapy has been observed, especially in patients with 
advanced bulky disease.  Opportunistic infections (protozoan, viral, 
fungal, and bacterial) have been observed in both pre-treated patients 
receiving fludarabine and in individuals receiving fludarabine combined 
with other agents (corticosteroids, mitoxantrone, and 
cyclophosphamide).
10.3) LEUKINE (GMCSF): 
10.3.1) Class: hematopoietic. 
10.3.2) Dosage, Adult (usual); 250mcg/m2/day  SC. 
10.3.3) Dosage, Pediatric, (usual); 
•
BMT 250mcg/m2/day IV or SC (use lower doses for first dose) 
•
recovery 3-15mcg/kg/day IV or SC. 
10.3.4) Indications:
•
AML 
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•
peripheral stem cell mobilization 
•
bone marrow transplant 
10.3.5) Contraindications:
•
excess leukemic myeloid blasts 
•
hypersensitivity to GM-CSF products 
•
concomitant chemo- or radiotherapy 
10.3.6) Adverse effects; 
•
arthralgia 
•
chills 
•
rash
•
fever 
10.3.7) Drug Interactions; 
•
lithium 
•
vincristine 
10.3.8) Pregnancy category; C
10.4) Filgrastim (r-met HuG-CSF, G-CSF: Granulocyte Colony-Stimulating Factor, 
Neupogen®):
10.4.1) AVAILABILITY:
r-met HuG-CSF is commercially available in 1.0 and 1.6 ml vials 
containing 300 μg and 480 μg G-CSF, respectively, by Amgen.
10.4.2) STORAGE & STABILITY; 
G-CSF is available as a sterile buffered protein solution and must 
be stored at 2-8°C. DO NOT ALLOW THE DRUG TO FREEZE.
10.4.3) ADMINISTRATION;
Each vial should be entered only once, and the remainder of the 
vial discarded and not re-entered a second time.  The daily dose 
should be injected subcutaneously in one or two sites. Standard 
dosing is 5 μg/kg daily as a subcutaneous injection.  Higher 
dosing (10 μg/kg) will be used for donors in this protocol.
10.4.4) TOXICITY:
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Chills, nausea, anorexia, myalgias, bone pain, local injection site 
pain or inflammation, abnormal liver function tests, thinning of 
hair, and enlargement of the spleen.  Rarely fluid retention and 
pericardial effusion are observed.  All of these are generally 
reversible when the drug is discontinued.
10.5) Tacrolimus (Prograf®);
10.5.1)AVAILABILITY:
Tacrolimus is a commercially available macrolide compound with 
potent immunosuppressant properties. Tacrolimus is available for 
oral administration as capsules, containing the equivalent of 0.5 
mg, 1 mg, or 5 mg of anhydrous tacrolimus.  For IV use, 
tacrolimus is available as a sterile solution in 1mL ampules 
containing the equivalent of 5 mg of anhydrous tacrolimus per ml.
The oral absorption of tacrolimus is erratic and incomplete; 
absolute bio-availability is approximately 25%.  Peak serum 
levels are seen 1 to 3 hours after an oral dose.  Therapeutic trough 
blood concentrations have ranged from 5 to 20 ng/ml.  Tacrolimus 
is extensively metabolized in the liver, with only small amounts 
of unchanged drug (2% or less) being recovered in the urine.  The 
elimination half-life of tacrolimus is approximately 10 hours. 
Tacrolimus suppresses both humoral (antibody) and cell-mediated 
immune responses.  The compound is chemically distinct from 
cyclosporine but both agents elicit similar immunosuppressant 
effects.  The immunosuppressive activity of tacrolimus is, 
however, more marked than that of cyclosporine. 
10.5.2) PREPARATION : FOR IV USE:
Tacrolimus concentrate for injection must be diluted prior to IV 
infusion.  For IV infusion, the concentrate will be prepared as per 
pharmacy standards.  Preparation of the solution in polyethylene 
or glass containers allows storage for 24 hours beyond which 
unused solution should be discarded.  A plasticized polyvinyl 
chloride (PVC) container should not be used because stability of 
the solution is decreased and polyoxyl 60 hydrogenated castor oil 
contained in the formulation may leach phthalates from PVC 
containers.  Tacrolimus concentrate for injection and diluted 
solutions of the drug should be inspected visually for particulate 
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matter and discoloration prior to administration whenever 
solution and container permit.
10.5.3)ADMINISTRATION:
Oral therapy should be started as soon as possible after 
transplantation and 8 to 12 hours after stopping intravenous 
therapy. In patients unable to tolerate oral therapy, the initial 
recommended intravenous dose is 0.03 to 0.05 mg/kg/day 
administered as a continuous infusion. 
10.5.4) STORAGE & STABILITY:
Store tacrolimus capsules at controlled room temperature, 15-
30°C (59-86°F) (Prod Info Prograf®, 1997).  An extemporaneous 
suspension of tacrolimus with a final concentration of 0.5 
milligrams/milliliter was stable for 56 days when it was stored at 
24-26°C in glass or plastic amber prescription bottles.
10.5.5) TOXICITY:
In patients receiving tacrolimus, 5% to 47% experienced anemia, 
8% to 32% experienced leukocytosis, and 14% to 24% 
experienced thrombocytopenia.  Rare cases of microangiopathic 
hemolytic anemia have been reported.  Mild to moderate 
hypertension was reported in 38% to 50% of patients receiving 
tacrolimus.  Mild to moderate hypertension is a common adverse 
effect associated with tacrolimus therapy.  Chest pain was 
reported in 19%.  Antihypertensive therapy may be required.  The 
most common adverse effects of tacrolimus have involved the 
central nervous system, and include headache (37% to 64%), 
tremors (48% to 56%), insomnia (32% to 64%), paresthesia (17% 
to 40%); and dizziness (19%).  Tremor and headache may respond 
to a dosage reduction. Agitation, anxiety, confusion, seizures, 
depression, hallucinations, myoclonus, neuropathy, psychosis, 
incoordination, and abnormal dreams have been reported in 3% to 
15% of tacrolimus-treated patients.  Hyperkalemia (13% to 45%), 
hypokalemia (13% to 29%), hypophosphatemia (49%), and 
hypomagnesemia (16% to 48%) have been associated with 
tacrolimus therapy.  In addition, hirsutism occurs only rarely with 
tacrolimus.  Hyperuricemia has been reported in greater than 3% 
of tacrolimus-treated patients. Gastrointestinal adverse effects of 
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tacrolimus have included nausea (32% to 46%), vomiting (14% to 
29%), anorexia (7% to 34%), constipation (23% to 35%) and 
diarrhea (37% to 72%). Gingival hyperplasia observed in patients 
treated with cyclosporine has not been reported with tacrolimus 
therapy.  Nephrotoxicity was reported in 36% to 40% and 52% of 
liver and kidney transplant patients receiving tacrolimus.  Overt 
nephrotoxicity 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% of 
tacrolimus-treated patients (Prod Info Prograf®, 1997).  Abnormal 
liver function tests have been reported in 6% to 36% of patients 
receiving tacrolimus; ascites was reported in 7% to 27% of these 
patients. 
Other miscellaneous effects that have occurred in clinical trials 
include pain (24% to 63%), fever (19% to 48%), asthenia (11% to 
52%), back pain (17% to 30%), and peripheral edema (12% to 
36%).  The incidence of hyperglycemia is 17% and may require 
therapy with insulin. Other less frequently occurring effects 
(greater than 3%) include abscess, chills, peritonitis, and 
photosensitivity reactions. Anaphylaxis has been reported in a 
few patients receiving intravenous tacrolimus.  Tacrolimus 
contains castor oil which has been associated with anaphylaxis in 
other drugs containing castor oil derivatives. 
10.6) Mycophenolate (CellCept®):
CellCept (mycophenolate mofetil) is the 2-morpholinoethyl ester 
of 
mycophenolic 
acid 
(MPA), 
inosine 
monophosphate 
dehydrogenase (IMPDH) inhibitor. 
10.6.1) Availability and administration:
CellCept is available for oral administration as capsules 
containing 250 mg of mycophenolate mofetil, tablets containing 
500 mg of mycophenolate mofetil, and as a powder for oral 
suspension, which when constituted contains 200 mg/mL 
mycophenolate mofetil.  
Each vial of CellCept Intravenous 
contains the equivalent of 500 mg mycophenolate mofetil as the 
hydrochloride salt.  Reconstitution and dilution with 5% Dextrose 
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Injection USP yields a solution of mycophenolate mofetil, 6 
mg/mL.
10.6.2) Clinical Pharmacology: 
Mechanism of Action:  
Mycophenolate mofetil is rapidly 
absorbed following oral administration and hydrolyzed to form 
MPA, which is the active metabolite.  MPA is a selective and 
uncompetitive, 
inhibitor 
of 
inosine 
monophosphate 
dehydrogenase (IMPDH), and
therefore inhibits the de-novo pathway of guanosine nucleotide 
synthesis without incorporation into DNA.  Because T- and B-
lymphocytes are critically dependent for their proliferation on de- 
novo synthesis of purines, whereas other cell types can utilize 
salvage pathways, MPA has potent cytostatic effects on 
lymphocytes.  MPA inhibits proliferative responses of T- and B-
lymphocytes to both mitogenic and allospecific stimulation. 
10.6.3) Pharmacokinetics:  
Oral absorption of the drug is rapid and essentially complete.  
MPA is metabolized to form the phenolic glucuronide of MPA 
(MPAG) which is not pharmacologically active. 
10.6.4) Metabolism:  
Following oral and intravenous dosing, mycophenolate mofetil 
undergoes complete metabolism to MPA, the active metabolite. 
MPA is metabolized principally by glucuronyl transferase to form 
the phenolic glucuronide of MPA (MPAG) which is not 
pharmacologically active.  In vivo, MPAG is converted to MPA 
via enterohepatic recirculation.  Increased plasma concentrations 
of mycophenolate mofetil metabolites (MPA 50% increase and 
MPAG about a 3-fold to 6-fold increase) are observed in patients 
with renal insufficiency. 
10.6.5) Excretion:  
Orally administered radiolabeled mycophenolate mofetil resulted 
in complete recovery of the administered dose, with 93% of the 
administered dose recovered in the urine and 6% recovered in 
feces.  Most (about 87%) of the administered dose is excreted in 
the urine as MPAG. 
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10.6.6) Contraindications:
Allergic reactions to CellCept have been observed; therefore, 
CellCept is contraindicated in patients with a hypersensitivity to 
mycophenolate mofetil, mycophenolic acid or any component of 
the drug product. CellCept Intravenous is contraindicated in 
patients who are allergic to Polysorbate 80 (TWEEN). 
10.6.7) Adverse effects:
The principal adverse reactions associated with the administration 
of CellCept include diarrhea, leukopenia, sepsis, vomiting, and 
there is evidence of a higher frequency of certain types of 
infections.  
Patients receiving immunosuppressive regimens 
involving combinations of drugs, including CellCept, as part of an 
immunosuppressive regimen are at increased risk of developing 
lymphomas and other malignancies, particularly of the skin.  The 
risk appears to be related to the intensity and duration of 
immunosuppression rather than to the use of any specific agent.  
Oversuppression of the immune system can also increase 
susceptibility to infection, including opportunistic infections, fatal 
infections, and sepsis. 
As usual for patients with increased risk for skin cancer, exposure 
to sunlight and UV light should be limited by wearing protective 
clothing and using a sunscreen.  Lymphoproliferative disease or 
lymphoma developed in 0.4% to 1% of patients receiving 
CellCept (2 g or 3 g) with other immunosuppressive agents in 
controlled clinical trials of renal, cardiac, and hepatic transplant 
patients. 
There are no adequate and well-controlled studies in pregnant 
women.  
However, as CellCept has been shown to have 
teratogenic effects in animals, it may cause fetal harm when 
administered to a pregnant woman.  Therefore, CellCept should 
not be used in pregnant women unless the potential benefit 
justifies the potential risk to the fetus.  It is recommended that 
CellCept therapy should not be initiated by the physician until a 
report of a negative pregnancy test has been obtained. 
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In patients receiving CellCept (2 g or 3 g) in controlled studies for 
prevention 
of renal, cardiac or hepatic rejection, fatal 
infection/sepsis occurred in approximately 2% of renal and 
cardiac patients and in 5% of hepatic patients. 
Severe neutropenia [absolute neutrophil count (ANC) <0.5 × 10 3 
/μL] developed in up to 2.0% of renal, up to 2.8% of cardiac, and 
up to 3.6% of hepatic transplant patients receiving CellCept 3 g 
daily.  If neutropenia develops (ANC <1.3 × 10 3 /μL), dosing 
with CellCept should be interrupted or the dose reduced, 
appropriate diagnostic tests performed, and the patient managed 
appropriately.  
Gastrointestinal 
bleeding 
(requiring 
hospitalization) has been observed in approximately 3% of renal 
transplant patients treated with CellCept 3g daily. Gastrointestinal 
perforations have rarely been observed. 
10.7) Antithymocyte Globulin:
10.7.1) Class; Immune globulin.
10.7.2)Dosage, Adult (usual); 15-30mg/kg IV for a total of 14 
days, however, we will be using 30mg/kg/day IV on days –3, -2, 
and –1. 
10.7.3) The same dose will be used for pediatric and adult 
patients. 
10.7.4) Administration:  Reconstitute: dilute with NS, dextrose 
5% and ¼ normal saline, or dextrose and ½ normal saline.  
Adding ATGAM to dextrose is not recommended due to possible 
precipitation.  In addition, highly acidic solutions can also, over 
time contribute to physical instability. 
10.7.5) The bottle of solution should be inverted so that the 
undiluted drug does not contact the air inside.  The concentration 
should not exceed 4mg/ml.  Do not shake the diluted solution.  
10.7.6) Indications: treatment of rejection in renal transplant 
patients. 
10.7.7) Contraindications;
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•
Weigh benefits to risk in patients with systemic reaction to 
test dose 
•
Continued use contraindicated with severe and unremitting 
thrombocytopenia or leukopenia, or systemic reactions such 
as generalized rash, tachycardia, dyspnea, hypotension, or 
anaphylaxis.
10.7.8) Adverse Effects; 
•
leukopenia 
•
N/V, diarrhea 
•
dizziness 
•
headache 
•
fever, chills
•
chest pain
•
acute renal failure
•
apnea, dyspnea, ARDS
10.8) METHOTREXATE:
10.8.1) General:
Methotrexate is an antimetabolite which binds to 
dihydrofolic acid reductase, thereby preventing the 
reduction of folic acid to tetrahydrofolate.  It interferes with 
DNA synthesis, repair, and cellular replication.  Actively 
proliferating tissues are in general more sensitive to this 
effect.
10.8.2) Administration:
Methotrexate 
LPF® 
Sodium 
(methotrexate 
sodium 
injection), Isotonic Liquid, Preservative Free, for single use 
only, is available in 25 mg/ml, 2 ml, 4 ml, 8 ml, and 10 ml 
vials, containing 50 mg, 100 mg, 200 mg, and 250 mg of 
methotrexate respectively.  If desired, the solution may be 
further diluted immediately prior to use with an appropriate 
sterile, preservative-free medium.
Methotrexate 
Sodium 
for 
Injection, 
Freeze 
Dried, 
Preservative Free, Low Sodium, for single use only, is 
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available in 20 mg, 50 mg, and 1 gram vials, containing 
approximately 0.14, 0.33 and 7 meq of sodium respectively.  
Reconstitute immediately prior to use with an appropriate 
sterile, preservative-free medium.    
Methotrexate 
Sodium 
Injection, 
Isotonic 
Liquid, 
Preservative Protected, is available in 25 mg/ml, 2 ml (50 
mg), and 10 ml (250 mg) vials.  
The preservative 
formulation contains benzyl alcohol and must not be used 
for intrathecal or high dose therapy.  If desired, the solution 
may be further diluted with a compatible medium.
 
10.8.3) Toxicities:
10.8.3.A)
Hematologic: myelosuppression [leukopenia 
(nadir 7 days), thrombocytopenia, anemia]. 
10.8.3.B)
Hepatic:  acute (elevated transaminases) and 
chronic 
(fibrosis 
and 
cirrhosis) 
hepatic 
toxicity.  
Chronic toxicity has generally 
occurred after prolonged use (generally 2 years 
or more) and after a total dose of at least 1.5 
grams.
10.8.3.C)
Urogenital:  
severe nephropathy or renal 
failure, azotemia, cystitis, hematuria; defective 
oogenesis 
or 
spermatogenesis, 
transient 
oligospermia, 
menstrual 
dysfunction 
and 
vaginal discharge; infertility, abortion, fetal 
defects.  
Close attention to renal function 
including adequate hydration, and urine 
alkalinization 
are 
essential 
for 
safe 
administration.  
10.8.3.D)
Gastrointestinal: 
gingivitis, 
pharyngitis, 
stomatitis, 
anorexia, 
nausea, 
vomiting, 
diarrhea, hematemesis, melena, gastrointestinal 
ulceration and bleeding, enteritis.  Should be 
used with extreme caution in the presence of 
peptic ulcer disease or ulcerative colitis.  
Therapy may be discontinued if ulcerative 
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stomatitis or other severe GI adverse reactions 
occur.
10.8.3.E)
Pulmonary:  
interstitial pneumonitis deaths 
have been reported, and chronic interstitial 
obstructive 
pulmonary 
disease 
has 
occasionally occurred.  Pulmonary symptoms 
or 
a 
nonspecific 
pneumonitis 
may 
be 
indicative of a potentially dangerous lesion 
and require interruption of treatment and 
careful investigation; infection needs to be 
excluded.  This lesion can occur at all dosages.
10.8.3.F)
Skin: erythematous rashes, pruritus, urticaria, 
photosensitivity, 
pigmentary 
changes, 
alopecia, ecchymosis, telangiectasia, acne, 
furunculosis.
10.8.3.G)
Central 
Nervous 
System: 
headaches, 
drowsiness, blurred vision.  There have been 
reports of leukoencephalopathy following 
intravenous administration of methotrexate to 
patients who have had craniospinal irradiation.  
Aphasia, hemiparesis, paresis, and convulsions 
have also occurred following administration of 
methotrexate.  
Following 
low 
doses, 
occasional patients have reported transient 
subtle cognitive dysfunction, mood alteration, 
or unusual cranial sensations.
10.8.3.H)
Other: 
opportunistic 
infection, 
arthralgia/myalgia, loss of  libido/impotence, 
diabetes, osteoporosis and sudden death.  A 
few cases of anaphylactoid reactions have 
been reported.
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11.0) RESPONSE CRITERIA: 
11.1) Lymphoma (IBMTR response criteria):
11.1.1)
Complete Response (CR):  Complete disappearance of all known 
disease for ≥ 4 weeks.
11.1.2)
Complete Remission Undetermined (CRU); as above with the 
exception of persistent scan abnormalities of unknown 
significance.
11.1.3) 
Partial Remission (PR); ≥ 50% reductions in greatest diameter of 
all sites of known disease and no new sites.
11.1.4)
No Response/Progressive Diseases; ≤ 50% reduction in greatest 
diameter of all sites of known disease or increase in size of known 
disease or new sites of disease.
11.2) Multiple Myeloma (IBMTR response criteria):
11.2.1)
Complete Response (CR); Requires all of the following:
1. Absence of monoclonal protein in urine and serum by 
electrophoresis and immunofixation for at least 6 weeks.
2.  ≤ 5% plasma cells in marrow trephine biopsy (repeat biopsy in 
6 weeks needed in non-secretory myeloma only).
3. No increase in number or size of lytic bone lesion ; no new 
lesions.
11.2.2)
Partial Response (PR); requires all of the following;
1.
≥ 50% reduction in serum paraprotein levels for at least 6 
weeks.
2.
Reduction of urinary paraprotein to ≤ 200 mg/24hr or  ≥  
90% reduction in paraprotein excretion over 24 hours for at 
least 6 weeks.
3.
No increase in number or size of lytic bone lesions ; no new 
lesion.
4.
≥ 50% reduction in size of soft  tissue plasmacytomas (by 
radiographs or exams).
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5.
For non-secretory myeloma only, ≥ 50% reduction in 
marrow plasma cells by marrow trephine biopsy for at least 
6 weeks.
11.2.3)
Minimal Response: Requires all of the following;
1. 25% –50% reduction in serum paraprotein level for at least 6 
weeks.
2. 50%-90% reduction in urinary paraprotein but still ≥ 200 
mg/24hrs for at least 6 weeks.
3. No increase in size or number of lytic lesions or 
extramedullary plasmacytomas.
4. For non-secretory myeloma only, 25-50% reduction in marrow 
plasma cells by bone marrow trephine biopsy for at least 6 
weeks.
11.2.4) 
No response/Stable Disease (NR/SD); Not meeting criteria of  
either minimal response or progressive disease.
11.2.5)
Progressive Disease: Includes any of the following;
1. ≥ 25% increase in the level of serum monoclonal protein 
which must be an absolute increase of 5 gm/L above baseline 
and must be confirmed by at least 1 repeated evaluation.
2. ≥ 25% increase in 24 hr urinary paraprotein from a minimum 
baseline amount of at least 500 mg/24 hrs on 2 occasions.
3. ≥ 25% increase in bone marrow plasma cells on trephine 
biopsy from minimum baseline of 5% in non-secretory 
myeloma.
4. Increase in number and /or ≥ 25% increase in size of 
extramedullary plasmacytomas.
5. New lytic bone lesions.
6. Development of hypercalcemia.
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11.3) Acute Leukemia:  
Complete Remission (CR):  <5% blasts in bone marrow biopsy, 
ANC>1000/uL and platelets>100,000/uL.
Cri:
<5% blasts in bone marrow biopsy but ANC<1000/ul and/or platelets 
<100,000/ul.
CRc: fulfill definition for CR plus normalization of prior abnormal 
cytogenetics, N/A in patients with normal cytogenetics pre-transplant.
Stable disease:  less than 25% change (+/-) in blast count from pre-transplant 
level.
Progression:  >25% increase in blast count from pre-transplant level.
11.4) Response Criteria for Patients with Chronic Lymphocytic Leukemia & 
Prolymphocytic Leukemia:
11.4.1)Complete Response: requires all of the following for a period of at least 
two months from completion of therapy:
•
Absence of lymphadenopathy on physical exam
•
No hepatomegaly or splenomegaly on physical exam
•
Absence of constitutional symptoms
•
Normal CBC as exhibited by polymorphonuclear leukocytes ≥ 
1,500/μL, 
platelets 
≥ 
100,000/μL, 
hemoglobin 
≥ 
11.0 
g/dL 
(untransfused), lymphocyte count ≤ 5,000/μL.
•
Bone marrow aspirate and biopsy must be normocellular for age with 
≤ 30% of nucleated cells being lymphocytes.  Lymphoid nodules must 
be absent. If the marrow is hypocellular, a repeat determination should 
be performed in 2-3 months.
•
Patients who fulfill the criteria for CR with the exception of a persistent 
cytopenia that is believed to be treatment related will be considered a 
partial response.  Additionally, patients who fulfill the criteria of CR 
with the exception of having bone marrow lymphoid nodules will be 
considered a partial response.
11.4.2)Partial Response: Requires a ≥ 50% decrease in peripheral lymphocyte 
count from pre-treatment value, ≥ 50% reduction in lymphadenopathy, 
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and/or ≥ 50% reduction in splenomegaly/hepatomegaly for a period of at 
least two months from completion of therapy. Additionally, these 
patients must have one of the following:
•
Polymorphonuclear leukocytes ≥ 1,500/μL or 50% improvement 
from pre-treatment value;
•
Platelets ≥ 100,000/μL or 50% improvement from pre-treatment 
value.
•
Hemoglobin ≥ 11.0 g/dL (untransfused) or 50% improvement from 
pre-treatment value.
11.4.3) Progressive Disease: Characterized by any one of the following events:
•
≥ 50% increase in the products of at least two lymph nodes on two 
consecutive determinations two weeks apart (at least one lymph node 
must be ≥ 2 cm); appearance of new palpable lymph nodes.
•
≥ 50% increase in the size of the liver and/or spleen as determined by 
measurement below the respective costal margin; appearance of 
palpable hepatomegaly or splenomegaly, which was not previously 
present.
•
≥ 50% increase in the absolute number of circulating lymphocytes to 
at least 5,000/μL.
•
Transformation to a more aggressive histology (i.e., Richter’s 
syndrome or prolymphocytic leukemia with ≥ 56% prolymphocytes).
•
Patients not fulfilling the above criteria for progressive disease but 
demonstrating a decrease in hemoglobin ≥ 2 g/dL, decrease ≥ 50% in 
platelet or granulocyte count will not be rated as progressive disease 
because these may occur as both a consequence of therapy and of 
underlying CLL.  A bone marrow biopsy in such settings is strongly 
encouraged.
11.4.4)
Stable Disease:  Patients who do not fulfill the criteria for complete 
or partial response as defined above but do not exhibit progressive 
disease will be considered as having stable disease.
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11.5) Aplastic Anemia: 
Response:  
Neutrophils:  ≥ 500 cells/mcl of colony stimulating factors.
Platelets:  ≥ 50K untransfused
≥ 100K untransfused
Hgb:  ≥ 8 untransfused
11.6) Fanconi anemia: Engraftment and negative chromosomal breakage on DEB 
testing will be used to evaluate response for Fanconi’s anemia.
Response:  
Neutrophils:  ≥ 500 cells/mcl of colony stimulating factors.
Platelets:  ≥ 50K untransfused
≥ 100K untransfused
Hgb:         ≥ 8 untransfused
12.0) REMOVAL OF PATIENTS FROM PROTOCOL AND ADVERSE 
EVENT REPORTING (AER):
12.1) Removal from protocol:  
If the constraints of this protocol are detrimental to the patient's health 
and/or the patient no longer wishes to continue protocol therapy, the 
patient will be removed from the protocol.  In this event the reason for 
withdrawal will be documented and the patient will be followed for 
survival. Any patient with rapid disease progression will be removed 
from the protocol. Document details, including tumor measurements on 
flow sheets and follow the patient for survival and secondary 
malignancies.
12.2) Toxicity Reporting:
12.2.1)
Expected toxicity: (recorded in protocol consent form or 
manufacturer's literature).
Within 10 days of occurrence, written reports should be 
submitted to the IRB and the protocol chairman in the 
following circumstances (Bearman toxicity).
•
Any fatal toxicity.
•
Any non-hematologic grade 3 toxicity.
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•
Grade 3-4 acute GvHD.
12.2.2)
Unexpected toxicity:
All instances of Bearman grade 3-
4 toxicity will be reported to the IRB and the protocol 
chairman immediately by telephone and followed by a 
written report. 
•
Failure to engraft (patient alive on day 45 with no ANC 
recovery)
•
Graft Failure (patient had initial ANC recovery but 
subsequently had a decline in ANC that required additional 
stem cell support)
13.0) STATISTICAL CONSIDERATIONS:
13.1) Power Computations
Sample size calculation is based on the primary endpoint: 
toxicity, defined as day 100 treatment related mortality (TRM).  
The null hypothesis is that the TRM is < 25% vs. the alternative 
hypothesis that the TRM is > 40%.
A two-stage study design will be used in which a total of 60 
patients with hematologic malignancies and disorders will be 
accrued.  If more than 20 patients experience TRM, the null 
hypothesis will be rejected and the treatment is not considered 
worthy of further study.   
13.2) Early Stopping Rules  
Assessment of the day 100 TRM rate is significantly higher than 
40%. At stage 1 with accrual of 30 patients, if 13 or more patients 
die of TRM, the study will be closed.  Otherwise accrual will 
continue until the target of 60 patients or if 20 or more patients 
die of TRM.
The decision rules of this study design yield a type I error rate = 
0.0933 and power = 0.8709.
13.3) Secondary End points
The secondary endpoint is disease response rate.  Although 
response rate will be assessed, no statistical comparisons will be 
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performed because we expect too heterogeneous a population of 
diseases to compare.
13.4) October 2003 Amendment
Due to slow accrual, the study design has been changed as follows.  
The null and research hypotheses, denoted 
 and 
, respectively, 
0
H
1
H
continue to be that the day 100 treatment related mortality (TRM) = 
25% versus TRM > 25%.  Let 
 and 
 be the numbers of 
1S
2
S
evaluable patients accrued at stages 1 and 2 who die due to 
treatment.  Then, the following new two-stage design replaces the 
original two-stage design described in Section 13.2.  
At stage 1, accrue 17 evaluable patients.  If 
, the study will be 
1
10
S ≥
closed to accrual and it will concluded that the day 100 TRM 
exceeds 25%.  That is, if 10 or more patients among the first 17 
evaluable patients experience treatment related death on or before 
day 100, it will be concluded that the day 100 TRM exceeds 25%.  
If 
 continue to stage 2.
1
9
S ≤
At stage 2, accrue 16 more evaluable patients.  If 
 12, 
1
2
S
S
+
≥
conclude that the day 100 TRM exceeds 25%.  Otherwise, there is 
insufficient evidence to draw this conclusion.
With this design, the probability is 0.099 of erroneously concluding 
 and the probability is 0.880 that 
 will be correctly concluded if 
1
H
1
H
the true rate is 45%.  That is, the significance level of  the test is 
0.099 and 0.880 is the power of the test when 45% the true rate.
This design is optimal in the following sense.  The stage 1 sample 
size, 17, is as small as possible.  The stage 2 sample size, 16, is as 
small as possible subject to the constraint that it is bounded above by 
the stage 1 sample size.  The significance level of the test is bounded 
above by 0.10, and the power of the test when the day 100 TRM is 
45% is bounded below by 0.88.
Observing disease response rate continues to be a secondary 
objective.  No statistical comparisons among disease-type response 
rates will be made because of the heterogeneity of diseases.
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14.0) REFERENCES:
1. 
Horowitz MM, Gale RP, Sondel PM, et al: Graft versus leukemia reactions after 
bone marrow transplantation. Blood 75:555,1990.
2. 
Sullivan KM, Storb R, Buckner CD et al: Graft versus host disease as adoptive 
immunotherapy in patients with advanced hematologic neoplasms, N Engl. J 
Medicine. 320: 828, 1989.
3. 
Weiden PL, Sullivan KM, Flourony N, et al: for the Seattle marrow transplant team. 
Antileukemic effect of chronic graft versus host disease. Contribution to 
improvement of survival after allogeneic marrow transplantation. N Eng. J Medicine. 
304: 1529, 1981.
4. 
Fefer A, Cheever MA, Greenberg PD: Identical twin (syngeneic) marrow 
transplantation for hematologic cancers. J Natl. Cancer Inst. 76:1269, 1986.
5. 
Gale RP, Champlin RE: How does bone marrow transplantation cure leukemia? 
Lancet 2:28, 1984.
6.
Gale RP, Horowitz MM, Ash RC, et al: Identical twin bone marrow transplants for
 
leukemia. Ann Internal Medicine 120:646, 1994.
7. 
Antin JH. Graft versus leukemia: No longer an epiphenomenon. Blood 82: 2273, 
1993.
8.
Cullis JO, Jiang YZ, Schwarer AP, et al: Donor leukocyte infusions for chronic 
myeloid leukemia in relapse after allogeneic bone marrow transplantation. Blood 
79:1379, 1992.
9.
Drobyski WR, Keever CA, Roth MS, et al: Salvage immunotherapy using donor 
leukocyte infusions as treatment for relapsed chronic myelogenous leukemia after 
allogeneic bone marrow transplantation: Efficacy and toxicity of a defined T-cell 
dose. Blood 82:2310,1993.
10.
Kolb HJ, Schattenberg A, Goldman JM, et al: Graft versus leukemia effect of donor 
lymphocyte transfusions in marrow grafted patients. Blood 86:2041,1995.
11.
Mackinnon S, Papadopoulos EB, Carabasi MH et al. Adoptive immunotherapy 
evaluating escalating doses of donor leukocytes for relapse of chronic myeloid 
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leukemia after bone marrow transplantation: Separation of graft versus leukemia 
responses from graft versus host disease. Blood 86: 1261, 1995.
12.
Van Rhee F, Lin F, Cullis JO et al. Relapse of chronic myeloid leukemia after 
allogeneic bone marrow transplant. The case of giving donor leukocyte transfusion 
before the onset of hematologic relapse. Blood 83: 3377, 1994.
13.
Georges GE, Storb R, Nash RA et al: Adoptive immunotherapy in canine mixed 
chimeras after non-myeloablative hematopoetic cell transplantation. Blood, 95: 3262, 
2000.
14.
Childs R, Clave E et al: Engraftment kinetics after non-myeloablative allogeneic 
peripheral blood stem cell transplantation: Full donor T-cell chimerism precedes 
alloimmune responses. Blood, 94: 3234, 1999.
15.
Giralt S, Estey E, Albitar M, et al. Engraftment of allogeneic hematopoetic 
progenitor
cells with purine analogue containing chemotherapy: Harnessing graft 
versus leukemia  without myeloablative therapy. Blood 89:4531,1997.
16.
Khouri I, Keating M, Korbling M, et al. Transplant Lite: Induction of graft versus 
leukemia using fludarabine-based nonablative chemotherapy and allogeneic blood 
progenitor cell transplantation as treatment for lymphoid malignancies. J Clin Oncol 
16: 2817, 1998.
17.
Bensinger WI, Buckner CD, Anasetti C et al. Allogenic marrow transplantation for 
multiple myeloma: an analysis of risk factors on outcome. Blood 88: 2787: 1996.
18.
Gahrton G, Tura S, Ljungman P, et al. Allogenic bone marrow transplantation in 
multiple myeloma: N Eng J Medicine 325: 1267,1991.
19.
Gahrton G, Tura S, Ljungman P, et al. Prognostic factors in allogeneic bone marrow 
transplantation in multiple myeloma. J Clin Oncol 13: 1312, 1995.
20.
Lokhorst HM, Schattenberg A, Cornellisen JJ et al.  Donor leukocyte infusions are 
effective in relapsed multiple myeloma after allogeneic bone marrow transplantation. 
Blood 90:4206, 1997.
21.
Tricot G, Vesole DH, Jagganath S, et al: Graft versus myeloma effect: Proof of 
Principle. Blood 87: 1196, 1996.
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22.
Camitta BM, Thomas Ed, Nathan DG et al: Severe aplastic anemia: a prospective 
study of the effect of early marrow transplantation on acute mortality. Blood 48: 63, 
1976
23.
Buckner CD, Applebaum Fr, et al. Allogeneic marrow transplantation during
       
untreated first relapse of acute myeloid leukemia. J Clin Oncol 1992, 10: 1723   
24.
Stockerl-Goldstein A, Blume K, Allogeneic hematopoetic cell transplantation for 
adult  patients with acute myeloid leukemia. In: Thomas Ed, Blume K, Forman S.
      
Haematopoetic cell transplantation. 2nd ed. Malden, MA: Blackwell, 1999:823   
25.
SebbanC, Lepage E, Vernant J-p et al. Allogeneic bone marrow transplantation in 
adult acute lymphoblastic leukemia in first complete remission: a comparative study. 
J Clin Oncol. 12: 2580, 1994.
26.
Bouabdallah R. Xerri L. Bardou VJ. Stoppa AM. Blaise D. Sainty D. Maraninchi D.           
Gastaut JA. Role of induction chemotherapy and bone marrow transplantation in 
adult lymphoblastic lymphoma: a report on 62 patients from a single center. Annals 
of Oncology. 9 (6): 619-25, 1998
27.
Van Besien KW. de Lima M. Giralt SA. Moore DF Jr. Khouri IF. Rondon G. Mehra 
R.Andersson BS. Dyer C. Cleary K. Przepiorka D. Gajewski JL. Champlin RE. 
Management of lymphoma recurrence after allogeneic transplantation: the relevance 
of graft-versus-lymphoma effect. Bone Marrow Transplantation. 19(10): 977-82, 
1997.
28.
Kurtzberg J. Laughlin M. Graham ML. Smith C. Olson JF. Halperin EC. Ciocci G. 
Carrier C. Stevens CE. Rubinstein P. Placental blood as a source of hematopoietic 
stem cells for transplantation into unrelated recipients [see comments]. New England 
Journal of Medicine. 335(3): 157-66, 1996
29. 
Wagner JE. Kernan NA. Steinbuch M. Broxmeyer HE. Gluckman E. Allogeneic 
sibling umbilical-cord-blood transplantation in children with malignant and non-
malignant disease [see comments]. Lancet. 346(8969): 214-9, 1995.
30. 
Issaragrisil S. Visuthisakchai S. Suvatte V. Tanphaichitr VS. Chandanayingyong D.
        Schreiner T. Kanokpongsakdi S. Siritanaratkul N. Piankijagum A. Brief report:
        transplantation of cord-blood stem cells into a patient with severe thalassemia [see
        comments]. New England Journal of Medicine. 332(6): 367-9, 1995.
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31. 
Gluckman E. Rocha V. Boyer-Chammard A. Locatelli F. Arcese W. Pasquini R. 
Ortega J. Souillet G. Ferreira E. Laporte JP. Fernandez M. Chastang C. Outcome of 
cord-blood transplantation from related and unrelated donors. Eurocord Transplant 
Group and the European Blood and Marrow Transplantation Group. New England 
Journal of 
Medicine. 
337(6): 373-81, 1997.
32.
Hansen J, Peterdorf E, Martin P, Anasetti C.  Hematopoietic stem cell transplants 
from unrelated donors.  Immunological Reviews 157: 141-151, 1997
33.  
Majolino I, Buscerni, Scime R et al.  G-CSF mobilized PBSC for allogeneic
       
transplantation.  Blood 1994; 84 (Suppl 1): 92a
34.   Laporte JPh, Lesage S, Douay L et al.  Allogeneic transplantation with peripheral 
blood  hematopoietic progenitors mobilized with G- CSF.  Blood 1994; 84
 (Suppl 1):90a
35.  
Nash RA, Antin JH, Ratanatharathorn V et al. Phase 3 study 
       
comparing methotrexate and tacrolimus with methotrexate and cyclosporine for
       
prophylaxis of acute graft versus- host disease after marrow transplantation from
       
unrelated donors. Blood 96 (6): 2062-2068, 2000.
36.  
Gibbs, JP, Gooley, T, Comeau, B, et al. The Impact of Obesity and Disease on 
Busulfan  Oral Clearance in Adults. Blood, Vol 93, No 12:  pp 4436-4440, 1999.
37.
Rubinstein P. Dobrila L. Rosenfield RE. Adamson JW. Migliaccio G. Migliaccio R. 
Taylor PE. Stevens CE. Processing and cryopreservation of placental/umbilical cord 
blood for unrelated bone marrow reconstitution. Proceedings of the National 
Academy of  Sciences of the United States of America. 92 (22): 10119-22, 1995.
38.
Dufour C, Rondelli R, Locatelli F, et al. Stem cell transplantation from HLA-
matched related donor for Fanconi anaemia: a retrospective review of the 
multicentric Italian experience on behalf of Associazone Italiana di Ematologia ed 
Oncologia Pediatrica (AIEOP) – Gruppo Italiano Trapianto di Midollo Osseo 
(GITMO). British Journal of Hematology, vol 112: 796-806, 2001.
39.
Slavin S, Nagler A, Naparstek E, et al. Non-myeloablative stem cell transplantation 
and cell therapy as an alternative to conventional bone marrow transplantation with 
lethal cytoreduction for the treatment of malignanat and non-malignant hematologic 
disease. Blood, Vol 91: 756-763, 1998.
40.
Motwani J, Lawson SE, Darbyshire PJ. Successful HSCT using nonradiotherapy-
based conditioning regimens and alternative donors in patients with fanconi anaemia 
– experience in a single UK centre. Bone Marrow Transplantation. Vol 36, no 5;405-
410, 2005.
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41.
Tan Pl, Wagner JE, Auerbach AD, Defor TE, Slungaard A, Macmillan ML. 
Successful engraftment without radiation after fludarabine-based regimen in Fanconi 
anemia patients undergoing genotypically identical donor hematopoietic cell 
transplantation. Pediatric Blood and Cancer. Online pub Aug 2, 2005.
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Appendix No. I
Bearman* criteria for toxicity grading
Grade I
Grade II
Grade III
Cardiac
Mild EKG abnormality, not requiring 
medical intervention; or noted heart 
enlargement on CXR with no clinical 
symptoms
Moderate EKG abnormalities requiring and 
responding to medical intervention; or 
requiring continuous monitoring without 
treatment; or congestive heart failure 
responsive to digitalis or diuretics
Severe EKG abnormalities with 
no or only partial response to 
medical intervention; or heart 
failure with no or only minor 
response to medical intervention; 
or decrease in voltage by more 
than 50%
Bladder
Macroscopic hematuria after 2 days from 
last chemotherapy dose with no subjective 
symptoms of cystitis and not caused by 
infection
Macroscopic hematuria after 7 days from last 
chemotherapy dose not caused by infection; 
or hematuria after 2 days with subjective 
symptoms of cystitis not caused by infection
Hemorrhagic cystitis with frank 
blood, necessitating invasive 
local intervention with 
installation of sclerosing agents, 
nephrostomy or other surgical 
procedure
Renal
Increase in creatinine up to twice the 
baseline value (usually the last recorded 
before start of conditioning)
Increase in creatinine above twice baseline 
but not requiring dialysis
Requirement of dialysis
Pulmonary
Dyspnea without CXR changes not caused 
by infection or congestive heart failure; or 
CXR showing isolated infiltrate or mild 
interstitial changes without symptoms not 
caused by infection or congestive heart 
failure
CXR with extensive localized infiltrate or 
moderate interstitial changes combined with 
dyspnea and not caused by infection or CHF; 
or decrease of PO2 (>10% from baseline) but 
not requiring mechanical ventilation or > 50% 
O2 on mask and not caused by infection or 
CHF
Interstitial changes requiring 
mechanical ventilatory support or 
>50% oxygen on mask and not 
caused by infection or CHF
Hepatic
Mild hepatic dysfunction with bili > 2.0 
mg% but  < 6.0 mg %; or weight gain > 
2.5 % and 
< 5 % from baseline of noncardiac origin; 
or SGOT increase more than 2-fold but 
less than 5-fold from lowest 
preconditioning
Moderate hepatic dysfunction with bili >6 
mg% < 20 mg %; or SGOT increase with 
> 5-fold from preconditioning; or clinical 
ascites or image documented ascites > 100ml; 
or weight gain > 5% from baseline of 
noncardiac origin
Severe hepatic dysfunction with 
bili 
> 20 mg %; or hepatic 
encephalopathy; or ascites 
compromising respiratory 
function
CNS
Somnolence but the patient easily 
arousable and oriented after arousal
Somnolence with confusion after arousal; or 
other new objective CNS symptoms with no 
loss of consciousness not more easily 
explained by other medication, bleeding, or 
CNS infection
Seizures or coma not explained 
by other medication, CNS 
infection, or bleeding
Stomatitis
Pain and/or ulceration not requiring a 
continuous IV narcotic drug
Pain and/or ulceration requiring a continuous 
IV narcotic drug
Severe ulceration and/or 
mucositis requiring preventive 
intubation; or resulting in 
documented aspiration 
pneumonia with or without 
intubation
GI
Watery stools > 500 ml but < 2,000 ml 
every day not related to infection
Watery stools > 2,000 ml every day not 
related to infection; or macroscopic 
hemorrhagic stools with no effect on 
cardiovascular status not caused by infection; 
or subileus not related to infection
Ileus requiring nasogastric 
suction and/or surgery and not 
related to infection; or 
hemorrhagic enterocolitis 
affecting cardiovascular status 
and requiring transfusion
NOTE:  Grade IV regimen-related toxicity is defined as fatal toxicity
*Bearman Sl et al. Regimen Related Toxicity in Patients Undergoing Bone Marrow Transplantation. JCO 1988, 6(10); 1562-15
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Appendix No.  II 
                  Calculation of adjusted ideal body weight (36)
To calculate ideal body weight for men
50 + [0.91 x (height in cm – 152)]
                 OR
50 + [2.3 x (height in inches – 60)]
To calculate ideal body weight for women;
45 + [0.91 x (height in cm – 152)]
                      OR
45 + [2.3 x (height in inches – 60)]
Adjusted ideal body weight
Ideal body weight + [0.25 x (actual body weight – ideal body weight)]
The calculation of ideal body weight is referenced in the package insert of Busulfex 
(busulfan)
Injection. 
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Appendix No. III
CRITERIA FOR ACUTE GRAFT-VS-HOST DISEASE
Clinical staging of acute graft-vs.-host disease according to organ involvement
STAGE
SKIN
LIVER
INTESTINAL TRACT
0
No rash
Bilirubin
< 2.0 mg/dL
< 34μmol/L
Diarrhea
500 ml/day
+
Maculopapular rash
<25% of body surface
Bilirubin
2-2.9 mg/dL
34-50 μmol/L
Diarrhea
500-1000 ml/day
Peds: >30 ml/kg, < 60ml/kg
++
Maculopapular rash
25-50% of body surface
Bilirubin
3.0-6.0 mg/dL
51-102 μmol/L
Diarrhea
1000-1500 ml/day
Peds: > 60 ml/kg, < 90 ml/kg
+++
> 50% body surface
Bilirubin
6.1-15 mg/dL
103-255 μmol/L
Diarrhea
1500 ml/day
Peds: >90 ml/kg
++++
Generalized erythroderma
with bullous formation
and desquamation
Bilirubin
> 15 mg/dL
> 255 μmol/L
Severe abdominal pain with 
or without ileus
Clinical grading of severity of acute graft-vs-host disease
GRADE
DEGREE OF ORGAN INVOLVEMENT
I
+ to ++skin rash; 
no gut involvement; 
no liver involvement; 
no decrease in clinical performance
II
+ to +++ skin rash;
+ gut involvement or
+ liver involvement (or both);
mild decrease in clinical performance
III
++ to +++ skin rash;
++ to +++ gut involvement or
++ to ++++ liver involvement (or both)
marked decrease in clinical performance
IV
Similar to Grade II with 
++ to ++++ organ involvement and 
extreme decrease in clinical performance
Source:  Thomas et al, N Engl. J Med. 1975; 292, 832
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Appendix No. IV
Clinical Grading of Chronic GVHD
Limited Chronic GVHD:
1.
Localized skin involvement,
and/or
2.
Hepatic dysfunction due to chronic GVHD.
Extensive Chronic GVHD:
1.
Generalized skin involvement, or
2.
Localized skin involvement and/or hepatic dysfunction due to 
chronic GVHD
Plus
3a. Liver histology showing chronic aggressive hepatitis, bridging 
necrosis, or cirrhosis, or 
3b. Involvement of eye (Schirmer’s test with less than 5 mm 
wetting), or
3c. Involvement of minor salivary glands or oral mucosa 
demonstrated on labial biopsy, or
                             3d.  Involvement of any other target organ.
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Appendix No.   V
Stem Cell Infusion:  
Day 0 is the day on which the stem cells are infused. The procedure of infusing stem cell 
products may be performed by the physician or the BMT Coordinator. Stem cells are to 
remain sterile throughout the infusion process.  All patients require continuous pulse 
oximetry monitoring during the procedure, with oxygen equipment available in the patient's 
room.  All patients will have vital signs recorded before the procedure and at timed 
intervals during and after stem cell infusion.  Emergency drugs, such as benadryl, 
epinephrine and corticosteroids will be available for use in appropriate doses.  No other 
blood products should be given on the day of transplant, especially within 8 hours of 
planned infusion time. Stem cells must be infused without the use of a blood filter.  No 
more than 480 ml of stem cells may be infused at one time.  Patients will be pre-medicated 
according to RPCI Standard Operating Procedure for Stem Cell reinfusion.
Cord Blood Stem Cell Preparation and Reinfusion (37).
Cryopreserved units of cord blood stem cells will be shipped to Roswell Park in liquid 
nitrogen in vapor phase and stored in liquid nitrogen prior to patients receiving their 
preparative regimen. Subsequently the unit will be thawed in the laboratory and washed 
with 10 % Dextran 40 and 5% human albumin before infusion. A nucleated cell count, 
CD34+ count, ABO and Rh typing, test of cell viability, bacterial and fungal cultures and 
assay for
hematopoietic progenitors will be performed on a sample from each thawed unit if there are 
more than adequate cells for transplant. If there is a limited amount of cord blood, then 
samples will be sent for bacterial and fungal cultures and cell viability only.  The cord 
blood product is then infused intravenously into the patient. Cord blood units will not be T-
cell depleted, volume reduced or depleted of red cells.                            
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Appendix No.  VI
Karnofsky Performance Status (KPS)
KPS
DEFINITION
100 Normal; no complaints; no evidence of disease
90
Able to carry on normal activity; minor signs or symptoms of disease
80
Normal activity with effort; some sign or symptoms of disease
70
Cares for self; unable to carry on normal activity or do active work
60
Requires occasional assistance, but is able to care for most personal needs
50
Requires considerable assistance and frequent medical care 
40
Disabled; requires special care and assistance
30
Severely disabled; hospitalization is indicated, although death not imminent
20
Very sick; hospitalization necessary; active support treatment  is necessary
10
Moribund; fatal processes progressing rapidly
0
Dead
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Appendix No. VII
Child-Pugh Classification of Liver Failure
Measurement
Points 
Scored  1
Points 
Scored  2
Points 
Scored  3
Encephalopathy
None
1 and 2
3 and 4
Ascites
None
Slight
Moderate
Bilirubin (mg/100 ml)
1.0 – 2.0
2.0 – 3.0
> 3.0
Albumin (gm/ 100 ml)
        3.5
2.8 - 3.5
< 2.8
Prothrombin time 
(sec. prolonged)
1 - 4
4 - 6
>6
For PBC, bilirubin 
(mg/100 ml)
1 - 4
4 - 10
>10
Child - Pugh Classification: 
A = 1 – 6,
B = 7 – 9,
C = 10-15
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Appendix No. VIII
Tests/Observations*
Pre-Rx
Post-Rx
History and physical exam              
x
--
Signed Informed Consent
x
--
Ht/Wt/IBW/BSA
x
--
Ht/Wt/IBW/BSA
x
--
Serology (HIV, Hepatitis, CMV)
x
--
HLA-A, B typing
x
--
Cr Clearance
x
--
PFT's/ DLco
x
--
PFT's/ DLco
x
--
ABG/Exercise Study (if indicated)
x
--
MUGA
x
--
EKG
x
--
Quantitative Immunoglobulins
x
xΩ
BM aspirate, biopsy
day 30-40, day 100-120 and then as indicated in section  8.6.3
Peripheral blood for chimerism      
x
day 30-40, 60-70 and then as indicated in section 8.6.3
Molecular and cytogenetics 
analysis                           
x
day 30-40,100-120 and then as clinically indicated
CBC/Plt
x
q day till PMN≥500, Plt≥20K, and then as clinically 
indicated
Urinalysis
x
--
PT/PTT
x
--
P22, LDH
x
q wk x 4 and then as indicated
Chest X-ray
x
as clinically indicated
CT ScanΨ                                         
x
q wk x 4 and then as clinically indicated
Karnofsky Performance Status
x
q wk x 4 and then as clinically indicated
Toxicity (Bearman)
                 
--
wkly x 4 and then day 100 & then as clinically indicated
Acute GVHD                                   
--
q wk till day +100
Chronic GVHD                               
--
twice a year
*
Day  0 is day of stem cell transplant; studies to be obtained as close to indicated time as possible.  Intervals 
shown are the minimum requirement.
Ω
Post transplant SPEP, IFE, Quantitative immunoglobulins, serum beta-2 microglobulin and Urine protein 
electrophoresis will be done only for patients with multiple myeloma on day 100-120 and then as clinically 
indicated.
Σ    
BM aspirate and biopsy will be performed for patients with leukemias only.  Patients with other 
malignancies will have BM aspirate and biopsy only if bone marrow was involved previously.  Chimerism 
study will be done on each specimen. Cytogenetics will be done if it was abnormal previously.
Φ   
 In pts who receive DLI, a final sample should be collected day + 100 post DLI completion
Ψ   
For patients with lymphoma only.  Also palpable tumor measurement should be recorded for lymphoma 
patients.
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