A Phase II Trial of Transplants From HLA-Compatible Related or Unrelated Donors With CD34+ Enriched, T-cell Depleted Peripheral Blood Stem Cells Isolated by the CliniMACS System in the Treatment of Patients With Hematologic Malignancies and Other Lethal Hematologic Disorders
Phase: PHASE2
Conditions: Acute Lymphoblastic Leukemia, Acute Myelogenous Leukemia, Myelodysplastic Syndrome, Multiple Myeloma
Sponsor: Memorial Sloan Kettering Cancer Center

Memorial Sloan Kettering Cancer Center 
IRB Number: 10-050 A(26) 
Approval date: 05-Jul-2019 
Administrative Update 1 : 21-Jul-2021 
Page 1 of 56 
 
 
 
A Phase II Trial of Transplants from HLA-Compatible Related or Unrelated Donors with CD34+  Enriched, 
T-cell Depleted Peripheral Blood Stem Cells Isolated by the CliniMACS System in the Treatment of 
Patients with Hematologic Malignancies  and other lethal hematologic  disorders 
 
MSKCC THERAPEUTIC/DIAGNOSTIC PROTOCOL 
 
 
Principal  Investigator/Department: 
Richard J. O’Reilly,  M.D. 
Pediatrics, BMT 
Co-Principal  Investigator(s)/Department: 
Sergio Giralt, M.D. 
Medicine, BMT 
Investigator(s)/Department: 
Jaap Jan Boelens, M.D., Ph.D. 
Maria Cancio, M.D. 
Kevin Curran, M.D. 
Andrew Kung, M.D., Ph.D. 
Barbara Spitzer, M.D. 
Nancy Kernan, MD 
Susan Prockop, M.D. 
Andromachi Scaradavou, M.D. 
Juliet Barker, M.B.B.S. 
Christina Cho, M.D. 
David J. Chung, M.D., Ph.D. 
Boglarka Gyurkocza, M.D, 
Katharine Hsu, M.D., Ph.D. 
Ann Jakubowski, M.D., Ph.D. 
Scott James, M.D. Ph.D. 
Parastoo Dahi, M.D. 
Heather Landau, M.D. 
Oscar Lahoud, M.D. 
Esperanza Papadopoulos,  M.D 
Jonathan Peled, M.D. 
Miguel-Angel  Perales, M.D. 
Ioannis Politikos,  M.D. 
Doris Ponce, M.D. 
Craig Sauter, M.D. 
Michael Scordo, M.D. 
Brian Shaffer, M.D. 
Gunjan Shah, M.D. 
Melody Smith, M.D. 
Roni Tamari, M.D. 
Marcel R.M. van den Brink, M.D., Ph.D 
James Young, M.D 
Alan M. Hanash, M.D. 
Glenn Heller, Ph.D. 
Pediatrics, BMT 
Pediatrics, BMT 
Pediatrics, BMT 
Pediatrics, BMT 
Pediatrics, BMT 
Pediatrics, BMT 
Pediatrics, BMT 
Pediatrics, BMT 
Pediatrics, BMT 
Medicine, BMT 
Medicine, BMT 
Medicine, BMT 
Medicine, BMT 
Medicine, BMT 
Medicine, BMT 
Medicine, BMT 
Medicine, BMT 
Medicine, BMT 
Medicine, BMT 
Medicine, BMT 
Medicine, BMT 
Medicine, BMT 
Medicine, BMT 
Medicine, BMT 
Medicine, BMT 
Medicine, BMT 
Medicine, BMT 
Medicine, BMT 
Medicine, BMT 
Medicine, BMT 
Medicine, BMT 
Medicine, BMT 
Epidemiology  and 
Biostatistics 
Consenting  Professional(s)/Department: 
Jaap Jan Boelens, M.D., Ph.D. 
Marica Cancio, M.D. 
Kevin Curran, M.D. 
Barbara Spitzer, M.D. 
Andrew Kung, M.D., Ph.D 
Nancy A. Kernan, M.D. 
Richard J. O’Reilly,  M.D. 
Susan Prockop, M.D. 
Andromachi Scaradavou, M.D. 
Pediatrics, BMT 
Pediatrics, BMT 
Pediatrics, BMT 
Pediatrics, BMT 
Pediatrics, BMT 
Pediatrics, BMT 
Pediatrics, BMT 
Pediatrics, BMT 

Memorial Sloan Kettering Cancer Center 
IRB Number: 10-050 A(26) 
Approval date: 05-Jul-2019 
Administrative Update 1 : 21-Jul-2021 
Page 2 of 56 
 
 
 
 
Juliet Barker, M.B.B.S. 
Pediatrics, BMT 
Christina Cho, M.D. 
Medicine, BMT 
David J. Chung, M.D., Ph.D. 
Medicine, BMT 
Sergio Giralt,  M.D. 
Medicine, BMT 
Boglarka Gyurkocza, M.D, 
Medicine, BMT 
Katharine Hsu, M.D., Ph.D. 
Medicine, BMT 
Ann Jakubowski, M.D., Ph.D. 
Medicine, BMT 
Scott James, M.D., Ph.D. 
Medicine, BMT 
Parastoo Dahi, M.D. 
Medicine, BMT 
Heather Landau, M.D. 
Medicine, BMT 
Oscar Lahoud, M.D. 
Medicine, BMT 
Esperanza Papadopoulos,  M.D. 
Medicine, BMT 
Jonathan Peled, M.D. 
Medicine, BMT 
Miguel-Angel  Perales, M.D. 
Medicine, BMT 
Ioannis Politikos,  M.D. 
Medicine, BMT 
Doris Ponce, M.D. 
Medicine, BMT 
Craig Sauter, M.D. 
Medicine, BMT 
Michael Scordo, M.D. 
Medicine, BMT 
Brian Shaffer, M.D. 
Medicine, BMT 
Gunjan Shah, M.D. 
Medicine, BMT 
Melody Smith, M.D. 
Medicine, BMT 
Roni Tamari, M.D. 
Medicine, BMT 
Marcel R.M. van den Brink, M.D., Ph.D. 
Medicine, BMT 
James Young, M.D. 
Medicine, BMT 
Alan Hanash, M.D. 
Medicine, BMT 
Medicine, BMT 
 
 
Please Note: A Consenting Professional must have completed the mandatory Human Subjects 
Education and Certification Program. 
 
 
 
 
 
 
Memorial Sloan-Kettering Cancer Center 
1275 York Avenue 
New York, New York 10065 

Memorial Sloan Kettering Cancer Center 
IRB Number: 10-050 A(26) 
Approval date: 05-Jul-2019 
Administrative Update 1 : 21-Jul-2021 
Page 3 of 56 
 
 
 
Table of Contents 
1.0 
PROTOCOL SUMMARY AND/OR SCHEMA ..................................................................................... 3 
2.0 
OBJECTIVES AND SCIENTIFIC AIMS ........................................................................................ 5 
3.0 
BACKGROUND AND RATIONALE ................................................................................................... 6 
4.0 
OVERVIEW OF STUDY DESIGN/INTERVENTION ...................................................................... 10 
4.1 Design .................................................................................................................................................... 10 
4.2 Intervention ............................................................................................................................................ 10 
5.0 
THERAPEUTIC/DIAGNOSTIC  AGENTS ........................................................................................... 12 
6.0 
CRITERIA FOR SUBJECT ELIGIBILITY ..................................................................................... 19 
6.1 Subject Inclusion Criteria ................................................................................................................ 19 
6.2 Subject Exclusion Criteria ............................................................................................................... 21 
7.0 
RECRUITMENT PLAN ............................................................................................................................. 21 
8.0 
PRETREATMENT  EVALUATION ........................................................................................................ 21 
9.0 
TREATMENT/INTERVENTION  PLAN............................................................................................... 21 
10.0 
EVALUATION  DURING TREATMENT/INTERVENTION........................................................... 35 
11.0 
TOXICITIES/SIDE EFFECTS ............................................................................................................ 35 
12.0 
CRITERIA FOR THERAPEUTIC RESPONSE/OUTCOME ASSESSMENT ........................... 41 
13.0 
CRITERIA FOR REMOVAL FROM STUDY.............................................................................. 48 
14.0 
BIOSTATISTICS .................................................................................................................................... 43 
15.0 
RESEARCH PARTICIPANT REGISTRATION AND RANDOMIZATION PROCEDURES 48 
15.1 Research Participant Registration ............................................................................................................ 48 
15.2 
Randomization....................................................................................................................................... 48 
16.0 
DATA MANAGEMENT ISSUES ........................................................................................................ 48 
16.1 Quality Assurance ........................................................................................................................... 48 
16.2 Data and Safety Monitoring ...................................................................................................................... 48 
17.0 
PROTECTION OF HUMAN SUBJECTS ............................................................................................. 49 
17.1 Privacy ................................................................................................................................................... 50 
17.2 Serious Adverse Event (SAE) Reporting................................................................................................. 50 
17.2.1 SAE/IND Reporting ................................................................................................................................ 51 
18.0 
INFORMED CONSENT PROCEDURES ............................................................................................. 49 
19.0 
REFERENCES ........................................................................................................................................ 52 
20.0 
APPENDICES ......................................................................................................................................... 56 
1.0 
PROTOCOL SUMMARY AND/OR SCHEMA 

Memorial Sloan Kettering Cancer Center 
IRB Number: 10-050 A(26) 
Approval date: 05-Jul-2019 
Administrative Update 1 : 21-Jul-2021 
Page 4 of 56 
 
 
 
This is a Phase II trial testing 4 disease-specific myeloablative  conditioning  regimens for preparatory 
cytoreduction of patients receiving allogeneic  HLA-compatible related or unrelated transplants of 
GCSF-mobilized  peripheral blood stem cells (PBSC) depleted of T-cells by positive  selection of 
CD34+  progenitor cells using the CliniMACS  system. The CliniMACS Fractionation system is an 
experimental method requiring an IND that positively  selects CD34+  progenitor cells from PBSC by 
immunoadsorption  of cells binding  on anti CD34 monoclonal antibody to paramagnetic beads which 
can then be isolated by passage through a magnetized column and released by agitation of beads. Two 
of the four conditioning  regimens have been used successfully with an alternative similar  system, 
Isolex, which is no longer being manufactured. Although an IND is required, the CliniMACS system 
has been used extensively in Europe and under several INDs in the United States including  IRB 
Protocol 06-005 at MSKCC. 
The primary objectives of the trial are 1) to assess whether or not each of these cytoreductive regimens 
is sufficiently  immuno  ablative to permit consistent engraftment and hematopoietic  reconstitution 
following  allogeneic  PBSC transplants depleted of T-cells by fractionation on the CliniMACS  device; 
2) to confirm the capacity of these transplants to reduce or prevent the development of clinically 
significant  acute GVHD and chronic GVHD, 3) to assess the incidence of transplant-related mortality 
associated with such transplants when administered after each conditioning  regimen at approximately 
day 100, 6, 12 and 24 months post transplant,  and 4) to assess overall and disease free survival (DFS) 
at 6 months, and yearly through at least 5 years and thereafter as clinically  indicated post transplant. 
For this trial, patients will be stratified to receive one of four myeloablative  conditioning  regimens, 
based on their disease, stage of disease, and dose of radiation accumulated in the course of treatment. 
The  four myeloablative  conditioning  regimens are: 1) Hyperfractionated total body irradiation  to a 
dose of 1375 cGy-1500cGy (with lung shielding  to a dose of 800cGy) administered in 125cGy 
fractions at 4-6 hour intervals three times a day for a total of 11 or 12 doses depending on age and 
disease risk (or, if general anesthesia is required,  150 cGy q12h x 8 doses to a total dose of  1375 cGy 
may be given), followed by Thiotepa 5mg/kg/day x 2 (or 10mg/kg/day x 1 ) and cyclophosphamide 
60mg/kg/day x 2 (or fludarabine 25mg/m2   x 5 if cyclophosphamide  is contraindicated); 2) Busulfan 
0.8mg/kg/dose q 6h x 10- 12 doses (depending on disease), Melphalan 70mg/m2/day x 2, and 
fludarabine 25mg/m2/day x 5;  3) Clofarabine 20mg/m2/day x 5 ( or, for children < 18yrs of age, 
30mg/m2/day x 5 if deemed suitable  and with PI approval), Melphalan 70mg/m2/day x 2, and Thiotepa 
5mg/kg/day x 2 (or 10mg/kg/day x 1) or 4) Melphalan 70mg/m2/day x 2, Fludarabine  25 mg/m2/day x 
5, and Thiotepa 5mg/kg/day x 2 (or 10mg/kg/day x 1 day). Patients will also receive anti-thymocyte 
globulin  to eradicate host T-cells that could contribute to graft rejection. 
Approximately  twenty-four to forty-eight hours after completion of each conditioning  regimen, 
patients will receive a transplant of a CD34+  progenitor cell-enriched, T-cell depleted fraction of 
GCSF-mobilized  PBSC after fractionation on the CliniMACS device, from his/her HLA compatible 
donor. 
Each transplant will be derived from a healthy, consenting HLA compatible  related or unrelated donor. 
The donor will receive mobilization  therapy with GCSF  administered as per standard practice. 
Leukapheresis will be performed on a continuous  flow cell separator according to institutional 
standards commencing on approximately Day 5 of GCSF treatment.  Daily leukapheresis of the donor 
with subsequent CD34+  cell selection using the Miltenyi  CliniMACS device will continue until a post- 
selection target of >5.0 x 106  CD34+  cells/kg recipient body weight and < 1.0 x 105  CD3+ cells/kg 

Memorial Sloan Kettering Cancer Center 
IRB Number: 10-050 A(26) 
Approval date: 05-Jul-2019 
Administrative Update 1 : 21-Jul-2021 
Page 5 of 56 
 
 
 
recipient body weight is reached following  at least two but not more than three leukapheresis 
procedures.  There is no limit  to the number of CD34+ progenitors that can be administered. 
No additional GVHD prophylaxis  will be administered. Due to stringent T-cell depletion,  no 
significant  GVHD is anticipated.  Should  GVHD occur, standard treatment will be initiated-  per The 
Pediatric and Internal Medicine Transplant Service guidelines. 
The sample size is as follows: 
 
Regimen A: TBI/Thiotepa/Cyclophosphamide:    110 patients 
Regimen B: Busulfan/Melphalan/Fludarabine:  200 patients 
Regimen C: Clofarabine/Melphalan/Thiotepa:  60 patients 
Regimen D: Melphalan/Fludarabine/Thiotepa:  30 patients 
It is anticipated that the accrual will last  six years. 
 
Patients will be followed for two years following  transplantation. 
 
2.1 
OBJECTIVES AND SCIENTIFIC AIMS 
 
Primary: 
 
1. To assess the incidence of durable hematopoietic engraftment for T-cell depleted transplants 
fractionated by the CliniMACS system administered after each of the four disease targeted 
cytoreduction regimens. 
2. To assess the incidence and severity of acute and chronic GVHD following  T-cell depleted, 
CD34+  progenitor  cell enriched transplants fractionated by the CliniMACS system. 
3. To assess the incidence of non-relapse mortality (transplant-related mortality)  following  each 
cytoreduction regimen and a transplant fractionated by the CliniMACS  system. 
4. To estimate the probability  of survival and disease-free survival (DFS) at 6 months, and yearly 
through at least 5 years and thereafter as clinically  indicated post transplant for life for each 
disease-targeted cytoreduction regimen when used with a T-cell depleted graft fractionated by the 
CliniMACS  system. 
 
Secondary: 
 
1. To determine the proportion  of patients receiving optimal CD34+  (> 5x106/kg) and CD3+ 
(<1x105/kg) cell doses the proportion  recurring suboptimal doses (< 2x106/kg) CD34+  cells; and 
the proportion of patients receiving CD3+ T-cell doses > 1x105/kg. 
2. To correlate doses of CD34+  progenitors and CD3+  T cells with engraftment, graft vs. host disease 
and non-relapse mortality. 
3.0 
BACKGROUND AND RATIONALE 
 
Allogeneic  hematopoietic  cell transplantation (HSCT) is an accepted therapy for the treatment of acute 
lymphoblastic  (ALL) and myeloblastic  (AML) leukemia, and recognized as the curative treatment of 
choice for patients who fail to sustain an initial  remission (1-4). Such transplants are also a recognized 
as a potentially  curative treatment for myelodysplastic  syndromes, advanced non-Hodgkins  lymphoma 

Memorial Sloan Kettering Cancer Center 
IRB Number: 10-050 A(26) 
Approval date: 05-Jul-2019 
Administrative Update 1 : 21-Jul-2021 
Page 6 of 56 
 
 
 
and multiple  myeloma  (5-9). For adults with high risk AML in 1oCR or 2oCR, unmodified  HLA- 
matched related HSCTs have led to sustained DFS rates of 45-60% and 40-53% respectively; for 
patients with high risk ALL in 1o CR or 2o CR, the extended DFS rates are 45-75% and 35-40% 
respectively (3,4,10,11).While   comparative trials of transplants vs chemotherapy in adults with high 
risk acute AML in first remission have consistently recorded higher DFS rates for HSCT recipients, 
the differences have been significant  only in a minority  of studies (12-15).  In these studies, the 
decreased risk of relapse observed following  an allogeneic  HSCT has been offset by the increased 
non-leukemic  mortality  resulting from Graft vs Host disease and its treatment. 
For patients lacking an HLA-matched sibling,  the prospects of transplantation have greatly improved 
over the last 10 years, reflecting improvements both in the selection and the rapid mobilization  of 
HLA compatible  donors through the National Marrow Donor Program (NMDP) and the computerized 
worldwide network of donor centers that now includes over 12 million  volunteer donors.  Currently, 
results from single  centers suggest survival rates for HLA-matched unrelated transplants administered 
to patients with AML and ALL in early remission are comparable to those recorded for matched 
sibling  grafts (16, 17).  Strikingly,  relapse rates following  unrelated grafts are lower. However, this 
advantage has been neutralized by the higher incidences of acute and chronic GVHD and the  
morbidity  and mortality  associated with their treatment. 
Thus, the early morbidity  and mortality associated with acute GVHD is a major factor limiting  the 
success of transplantation as is the long-term morbidity  associated with chronic GVHD. The risk of 
acute GVHD following  allogeneic  bone marrow transplantation (BMT) from HLA-matched siblings  is 
20-60% despite the use of immunosuppressive  agents like  cyclosporine  A (CSA), tacrolimus (FK506), 
methotrexate (MTX), antithymocyte  globulin  (ATG) and corticosteroids, alone or in combination  (18- 
21). Grades II-IV (moderate to severe) acute GVHD are associated with an increased risk of 
transplant-related mortality  (21, 22). Mortality rates among patients who develop GVHD can be as 
high as 75% when that disease is unresponsive to therapy (22). 
Over the last 35 years, several combinations  of immunosuppressive  drugs have been evaluated for  
their potential to prevent acute and chronic forms of GVHD when administered from immediately  
prior to until 6-12 months post transplant.  However, despite prophylaxis  with any of these regimens, 
18-40% of patients receiving HLA-matched related grafts will develop grade II-IV acute GVHD, and 
24-58% of those who survive over 3 months will develop chronic GVHD (18-21). In these trials,  
lower incidences of acute HVHD have also been invariably  counter balanced by higher incidences and 
sensitivities  of chronic GVHD. Higher rates of acute and chronic GVHD are observed following 
matched unrelated HSCT.  Furthermore, rates of GVHD continue to be prohibitive  following  HLA- 
non-identical grafts (23, 24).  Thus, immunosuppressive  agents are only partially effective in reducing 
the incidence and severity of acute GVHD and have to date failed to decrease the incidence of chronic 
GVHD. Despite immunosuppressive  therapy, engrafted donor T-lymphocytes derived from the 
hematopoietic cell graft can respond to alloantigens  on the cell surface of host cells, initiating  the 
pathologic  process leading to GVHD (25). 
Over the past twenty years, several techniques for T-cell depletion (TCD) of donor grafts have been 
introduced and evaluated for their capacity to prevent acute and chronic GVHD. These include 
techniques involving  physical adsorption of T-cells to protein ligands such as lectins, elutriation,  and 
immunoadsorption  or immuno  deletion with T-cell or lymphocyte-specific  monoclonal antibodies  (26- 
30).  Comparative analyses have demonstrated that these techniques vary widely in their capacity to 

Memorial Sloan Kettering Cancer Center 
IRB Number: 10-050 A(26) 
Approval date: 05-Jul-2019 
Administrative Update 1 : 21-Jul-2021 
Page 7 of 56 
 
 
 
deplete T-cells (1.5-3.5 log10  depletion)  (31). The relationship  between the T-cell dose transplanted 
and the risk of acute GVHD is complex and varies depending upon the degree of MHC-compatibility, 
graft source (bone marrow versus peripheral blood),  type of GVHD prophylaxis  (pharmacological 
versus T-cell depletion), method of T-cell depletion, conditioning  regimen, use of in vivo depleting 
antibodies  (33-36), as well as patient and donor characteristics including  underlying  disease, age, 
gender and parity (37-39).  Our studies in more than 200 patients have suggested that the threshold 
dose of T-cells required to induce grade II-IV acute GVHD after HLA-matched sibling transplants is 
105  clonable T-cells/kg (31). A 2.8-3.0 log10  reduction in marrow grafts or a 4.0-4.5 log10  reduction in 
peripheral blood stem cell (PBSC) grafts is required if this threshold is not to be exceeded. This likely 
explains  the variable reductions in GVHD and inconsistent reductions in chronic GVHD observed 
with several techniques despite the concomitant use of CSA and MTX prophylaxis. 
Certain methods of T-cell depletion are effective in reducing or preventing acute GVHD in both HLA- 
matched and HLA-disparate transplant recipients without co-administration  of CSA and/or MTX. The 
first is: T-cell depletion of a marrow allograft by soybean lectin agglutination  and E-rosette depletion 
(SBA), an approach reported by Memorial Sloan-Kettering Cancer Center (MSKCC) (26,40) and the 
University of Perugia (41) to be associated with a 0-5% incidence of acute GVHD in HLA-matched 
transplant recipients and a 0-8% incidence in HLA haplotype transplant recipients. The second is: 
depletion of T-cells by positive  selection of CD34+  hematopoietic  cells from GCSF mobilized 
peripheral blood leukocytes (PBSC) and transplantation of these CD34+ cell-enriched, T-cell depleted 
cell fractions (43, 44). 
Two methods of positive  selection of CD34+  progenitors have thus far been found to yield populations 
of CD34+  progenitor cells adequate to secure engraftment that are also sufficiently  depleted of T-cells 
to prevent GVHD. One approach, extensively studied at MSKCC, requires two steps: a) initial  
isolation  of CD34+  cells on the Isolex device which treats the cells with a murine CD34-specific 
MoAb and subsequently adsorbs the antibody-coated cells to anti-mouse IGG coated paramagnetic 
beads. Following  separation of the cells adsorbed to the beads, the cells are eluted from the beads. 
Thereafter, residual T-cells are depleted by removal of cells forming sheep red cell rosettes. This 
procedure yields  a progenitor-enriched cell fraction that provides CD34+ cell doses of 0.7-29.6 (median 
6.6) x 106/kg and CD3+  T-cell doses of 0.2-4.1 (median 1.4) x 103/kg. Such transplants,      
administered after total body irradiation,  Thiotepa and either cyclophosphamide  or fludarabine have 
provided consistent engraftment with rates of grade II-IV acute GVHD of 8% and 9% in recipients of 
HLA-matched related or unrelated donors respectively, and rates of extensive chronic GVHD of 6% 
and 11% respectively (44). However, this method, while effective, will no longer be available as of 
April 1 2010, because Baxter is terminating the manufacturing of their Isolex system and its 
reagents. 
 
The other technique, which has been extensively employed in Europe (43, 45) but has only recently 
been studied in the United States, is the CliniMACS  system (Miltenyi Biotec). In this system, GCSF- 
mobilized  PBSC are introduced into the closed device, which treats the cells with anti CD34 MoAB 
coated paramagnetic beads. The CD34+  progenitor cells are then separated from other cells by passage 
through an electromagnetic field, and then washed and eluted. In the large Perugia series, recipients of 
HLA haplotype disparate CD34+  PBSC isolated on the CliniMACS device had only a 10% probability 
of developing  acute or chronic GVHD (42). In a multicenter trial conducted by the BMT Clinical  
Trials Network under an FDA IND, for which Dr. O’Reilly was principal investigator,  this method 
yielded a progenitor-enriched cell fraction that provided doses of progenitor cells ranging from 2.4 – 

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IRB Number: 10-050 A(26) 
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Administrative Update 1 : 21-Jul-2021 
Page 8 of 56 
 
 
 
31.3 (med 7.9) x 106  CD34+  cells kg and T-cell doses of 1.1-84.9 (median 6.6) x 103  CD3+  cells/kg. 
HLA matched related HSCT fractionated by this approach were administered after cytoreduction with 
our protocol of hyperfractionated TBI, thiotepa and cyclophosphamide.   These transplants provided 
consistent engraftment (1 late graft failure in 44 patients transplanted), and were associated with 
incidences of 20.5% grade 2-4 acute GVHD and 7.6% extensive chronic GVHD.  Overall survival for 
patients with AML transplanted in 1o and 2o  remission was 74% (46). Overall risk of relapse for 
patients is 1° or 2° CR was 18%, which compares favorably with results of unmodified  transplants for 
these disease indications. 
The highly  favorable results of the BMT CTN trial, which were presented at ASH, December 2009, 
have now been submitted for publication  and form the basis for an application  to the FDA for 
licensure as a device to prevent GVHD in patients transplanted for AML.  As we are waiting for 
approval, trials of T-cell depleted CD34+ PBSC transplants fractionated on the CliniMACS 
device will continue to require an IND. 
As noted above, over the last 9 years our transplantation program has accrued extensive experience 
with CD34+E- T cell depleted PBSC transplants isolated by positive  selection of CD34+  progenitors on 
the FDA approved Isolex device followed by E. rosette depletion.  Under IRB #01-070, 108 patients 
received transplants of HLA-matched related or HLA compatible  unrelated CD34+E-  PBSC transplants 
fractionated by this approach after cytoreduction with TBI/THIO/Fludarabine only 2 patients had late 
graft failure (1.7%) (44).  The incidence of acute grade 2-4 GVHD was 9% for recipients of HLA- 
matched related grafts and 16% for recipients of unrelated or HLA disparate transplants.  Chronic 
GVHD of any severity developed in only 8% of the matched related and 21% of the matched or non- 
identical unrelated recipients.  Of the patients transplanted for acute leukemias in 1o and 2o remission, 
over 65% are surviving  disease-free at up to 9 years of follow-up. 
In a separate protocol (IRB 01-055), we also evaluated T cell depleted CD34+E-  PBSC transplants 
fractionated on the Isolex device administered after a chemotherapeutic myeloablative  cytoreduction 
regimen consisting of Busulfan, 0.8mg/kg/dose, every 6 hours x 10 doses, melphalan 70 mg/m2/day x 
2 and Fludarabine 25 mg/m2/day x 5.  The patients enrolled had advanced AML, ALL, MDS or NHL. 
They received transplants from matched related (N=23) and unrelated (N=34) donors or HLA non- 
identical related or unrelated (N=35).  Of 91 patients evaluable, 88 (97%) achieved durable 
engraftment (graft failure rate=3%).  Acute grade II-IV acute GVHD was observed in 8%; chronic 
GVHD in 7%.  The non-relapse mortality  in this heavily pre-treated patient population  was 20% at 2 
years.  DFS at 2 years was 55%, a result which compares very favorably with published  results of 
unmodified  grafts applied to patients in similarly  advanced stages of leukemia  and MDS. This regimen 
was particularly promising  for patients transplanted for advanced MDS and secondary AML, and 
forms the basis of a trial being conducted by Dr. Castro-Malaspina for patients with these disease 
indications  (IRB 08-008). This trial also demonstrated for the first time, that engraftment of  
extensively T-cell depleted hematopoietic progenitor cells could be consistently achieved, both in 
HLA-matched and HLA disparate patients, after a myeloablative  cytoreduction regimen that did not 
include  total body irradiation. 
 
While  modifications  of these protocols were planned for subsequent trials, such as the adjunctive use 
of KGF to reduce radiation and chemotherapy-induced injury to the thymus and thereby foster earlier 
immune  reconstitution,  the decision of Baxter Bioscience to terminate manufacture of the Isolex 
device and the reagents required for positive  selection of CD34+  progenitor cells has temporarily 

Memorial Sloan Kettering Cancer Center 
IRB Number: 10-050 A(26) 
Approval date: 05-Jul-2019 
Administrative Update 1 : 21-Jul-2021 
Page 9 of 56 
 
 
 
closed these options,  and created the urgent need to further evaluate the CliniMACS  system in our 
trials of T-cell depleted HSCT. 
As a first and needed step, we propose this trial which will evaluate the potential of T-cell depleted 
HSCT fractionated by the CliniMACS system, when administered after each of  four, disease targeted 
cytoreductive regimens, to secure consistent engraftment and hematopoietic reconstitution  in HLA- 
compatible  related or unrelated hosts, and to prevent or abrogate acute and chronic forms of GVHD. 
We also seek to validate that these pre-transplant conditioning  regimens, when administered with a 
CD34+  progenitor cell enriched, T-cell depleted graft, fractionated in the CliniMACs  system, will be 
associated with an acceptably low incidence of non-leukemic  mortality. 
 
The  four cytoreduction regimens to be tested in this trial are: 
 
1) The combination  of 1375cGy (adults) or 1400-1500 cGy (Pediatrics) hyperfractionated total 
body irradiation  followed by thiotepa (5 mg/kg/day x 2 or 10 mg/kg/day x 1) and cyclophosphamide 
(60 mg/kg/day x 2) (or fludarabine  25mg/m2/day x 5 if Cyclophosphamide  is contraindicated), which 
we have previously  evaluated with SBA-E-  T-cell depleted marrow grafts (IRB 89-119 and 01-070), 
and which has been associated with consistent engraftment, a low incidence of acute and chronic 
GVHD, and incidences of post transplant relapse in patients transplanted for ALL and AML that are 
equal to or lower than those reported following  unmodified  grafts in patients with the same diseases 
and stages of disease (40).  We have also tested this cytoreduction regime together with CliniMACS 
fractionated T-cell depleted PBSC transplants in HLA-matched related patients with AML in 1o  or 2o 
remission, as part of the multicenter BMT CTN trial (IRB 06-005). As previously  noted, the results of 
this trial are among the best reported (44, 46).  However, this regimen has not yet been evaluated with 
HLA-compatible unrelated T-cell depleted grafts fractionated by the CliniMACS  system. 
2) The combination  of Busulfan 0.8- 1.0mg/Kg/dose q 6 hours x 10- 12 doses (with doses 
adjusted based on Busulfan pharmacokinetics), melphalan 70 mg/m2/day x 2 and Fludarabine  25 
mg/m2/day x 5. We have previously  studied this regimen in combination  with Isolex separated T-cell 
depleted grafts (IRB 01-055) from both related and unrelated donors.  This regimen is applicable  to 
patients with MDS, AML and multiple  myeloma and particularly to patients with advanced myeloid 
malignancies or non-malignant  disorders of hematopoiesis who, by virtue of young age or prior 
radiation therapy, cannot receive a cytoreductive regimen containing  total body irradiation. 
 
3) The combination  of clofarabine 20 mg/m2/day x 5 ( or, for children < 18 yrs of age, 
30mg/m2/day x 5 if deemed suitable  and with PI approval), melphalan 70 mg/m2/day x 2 and thiotepa 
5 mg/kg/day x 2 (or 10mg/kg/day x 1). This regimen is myeloablative  and immunoablative.   This 
regimen used with unmodified  HLA compatible  related or unrelated HSCT, has shown particular 
promise in the treatment of patients with high risk and advanced staged ALL (IRB 06-125). We have 
transplanted a series of 19 evaluable patients after cytoreduction with this regimen, of whom 12 had 
ALL in 2o  or greater remission or relapse.  All patients achieved full engraftment.  Of the 19 patients, 
15 are alive, 14 disease-free at a median follow-up  of 10 months.  We will continue to give priority  to 
IRB 06-125 for patients with advanced ALL. However, graft vs. host disease has been a significant 
cause of morbidity;  five patients developed grade II-IV acute GVHD, which was lethal in 1 case; 3 
patients have chronic GVHD.  To address this complication,  we now propose to evaluate this regimen 
for preparatory cytoreduction of patients with lymphoid  malignancies  who will then receive a T-cell 
depleted HLA compatible  related or unrelated HSCT fractionated by the CliniMACS system. 

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4) The combination  of fludarabine  25mg/m2/day x 5, melphalan 70 mg/m2/day x 2 and 
thiotepa 5 mg/kg/day x 2 (or 10mg/kg/day x 1). This reduced intensity, myeloablative  regimen was 
employed as preparative conditioning  for 7 CD34+ T cell depleted Isolex transplants and, under single 
patient use INDs, 3 T cell depleted CD34+ (CliniMACS) PBSC transplants to treat 10 patients: 
refractory leukemia (n=2), aplastic anemia, (n=3), PNH or refractory autoimmune  cytopenia (n=2), 
lethal congenital immune  deficiencies (n=3). The regimen induced only moderate GI toxicity. 
However, in each of 9 evaluable patients, we observed rapid reconstitution with full donor chimerism 
and without GVHD. This regimen is proposed for use in (1) patients heavily  sensitized by 
transfusions for whom busulfan, melphalan and fludarabine  may not be adequate to ensure 
engraftment, (2) patients who, because of prior hepatic and/or pulmonary  injury are at high risk of 
severe and life threatening toxicity if treated with regimen A, B and C and, (3) patients with life 
threatening nonmalignant  acquired and genetic disorders of hematopoiesis  and immunity. 
 
4.1 
OVERVIEW OF STUDY DESIGN/INTERVENTION 
 
4.2 
Design 
 
This is a four-armed phase II trial designed to evaluate the potential of an HLA compatible related or 
unrelated GCSF-mobilized  peripheral blood progenitor cell (PBSC) transplants depleted of T-cells by 
positive  selection of CD34+ progenitors, using the CliniMACS  system to secure consistent 
engraftment, a low rate of acute and chronic GVHD with an acceptably low incidence  of non-relapse 
mortality when administered after one of four disease-targeted myeloablative  conditioning  regimens. 
4.3 
Intervention 
 
Patients with high risk forms of acute leukemia, CML, multiple  myeloma, myelodysplastic  syndrome 
(MDS) or other lethal disorders of hematopoiesis who fulfill  eligibility  requirements and consent to 
treatment, will be stratified to receive one of  four myeloablative  conditioning  regimens, based on their 
disease and/or stage of disease, and clinical parameters including  age, prior history of radiation  
therapy, prior exposure to specific chemotherapies or the presence of comorbidities  that could increase 
risk of severe toxicity or disease relapse in the post transplant period. 
 
The four cytoreduction regimens to be evaluated are: 
A. TBI/Thiotepa/Cyclophosphamide: 
a. Hyperfractionated total body irradiation  to a dose of 1375-1500 cGy (depending on 
age, stage of disease and requirement of general anesthesia) with lung shielding) 
b. Thiotepa (5 mg/kg/day x 2 or 10 mg/kg/day x 1) 
c. Cyclophosphamide  (60 mg/ kg/day x 2) (or fludarabine 25mg/m2  x 5 if 
cyclophosphamide  is contraindicated). 
B. Busulfan/Melphalan/Fludarabine: 
a. Busulfan (0.8 mg/kg every 6 hours x 10 or 12 doses), (depending on disease) with 
dose modified according to pharmacokinetics 
b. Melphalan (70mg/m2/day x 2 ) 
c. Fludarabine  (25mg/m2/ day x 5) 
C. Clofarabine/Melphalan/Thiotepa: 
a. Clofarabine (20mg/m2/ day x 5) (or, for children <18 years of age, 30mg/m2/day x 5 if 
deemed suitable  and with PI approval), 
b. Melphalan (70 mg/m2/day x 2) 

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c. Thiotepa (5 mg/kg/day x 2 or 10mg/kg/day x1) 
D. Melphalan/Fludarabine/Thiotepa 
a. Melphalan (70 mg/m2/day x 2) 
b. Fludarabine (25mg/m2/ day x 5 ) 
c. Thiotepa (5 mg/kg/day x 2 or 10mg/kg/day x1) 
 
All patients (with the exception of patients ≤ 18 who receive transplants from HLA-matched related 
siblings  in Arm A) will also receive antithymocyte globulin  (ATG) (thymoglobulin  2.5 mg/kg/day x 
2 or equine ATG 15 mg/kg/day x 2 or 30mg/kg/day x 1 if thymoglobulin  is not tolerated) during 
pre-transplant conditioning  to deplete radiation or chemotherapy resistant host T-cells that could 
hamper engraftment. Recipients of HLA-non-identical transplants will receive an additional dose of 
ATG. If patient is receiving a second transplant from the same donor, ATG administration  will be at 
the discretion of the physician. 
 
Following  preparative cytoreduction, all patients will receive a GCSF mobilized  PBSC transplant 
depleted of T-cells by positive  selection of CD34+ progenitor cells with the CliniMACS system. 
The targeted dose progenitor cells will be > 5 x 106  CD34+  cells/kg with the dose of T-cells limited 
to < 1.0 x 105CD3+  cells/kg. 
 
Following  transplantation,  the patients will receive transfusions and supportive  care according to the 
guideline  of the Transplant Service in Pediatrics and Medicine. These guidelines  will also be 
invoked for prophylaxis  and treatment of infectious  complications. 
 
The patients will then be evaluated sequentially for toxicities,  engraftment, acute and/or chronic 
GVHD, the kinetics  and quality  of hematopoietic  and immune  reconstitution,  and both relapse-free 
survival and overall survival. 
 
Historically,  under the multicenter BMTCTN trial 0303 (IRB 06-005 ) which employed the 
CliniMACS  device, GCSF mobilized  PBSC, after washing, were suspended in buffered saline only 
and then incubated with antiCD34 coated paramagnetic beads prior to separation of the CD34+  cells 
bound to the beads by adherence to an electromagnet in the CliniMACS device. A provision 
recommended as an adjunct but not required or known to be necessary was that the diluent in which 
the washed GCSF-mobilized  PBMC were incubated with the antiCD34 coated beads also include 
30% autologous plasma or intravenous gamma globulin  at a concentration of 1.5 mg/ml. This 
provision  was not used by the centers participating in the BMTCTN trial, including  our own. That 
trial, as initially  noted in the Background for Protocol 10-050 recorded an incidence of acute grade 
II-IV GVHD of 20.5% and a 7.6% incidence of extensive GVHD. While  these findings were 
significantly  better than any results recorded with drug prophylaxis  or methods of T-cell depletion 
developed at other centers, the incidence of acute GVHD was higher than what we had published 
using SBA-E-  T-cell depleted marrow or CD34+  (ISOLEX) E- T-cell depleted PBSC. Since we did 
not see significant GVHD in the small number of patients that we contributed to the trial, I ascribed 
the higher incidence to limited  experiences with the CliniMACS  device and to recent changes in the 
grading system used for acute GVHD. Accordingly, no change in procedures were made to protocol 
10-050. 

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However, as accrual to 10-050 proceeded, we also saw acute GVHD in up to 19% of HLA-matched 
cases, and severe acute GVHD in some patients who received partially  HLA-matched transplants. 
Again, the data were not different from the BMT CTN trial results. However, the rate of acute 
GVHD was higher than that reported by 2 European groups using the CliniMACS device for HLA 
disparate grafts. We subsequently learned that the largest of these centers, Perugia U., did 
incorporate IVIG in the incubation step. 
 
Considering the possibility  that in the absence of plasma or IVIG, cells can non-specifically  adsorb 
to paramagnetic beads, the cytotherapy laboratory validated separation of CD34+  cells on the 
CliniMACS  in the presence or absence of IVIG in the incubation  period, demonstrating comparable 
yields of CD34+  cells and similar levels of T-cell depletion. Thereafter, on 7/25/12, the procedure 
was modified to include  the IVIG. In February 2013, we evaluated the incidence of acute grade II- 
IV GVHD and chronic GVHD in 19 patients treated since then. The incidence of acute grade II-IV 
GVHD has been 5% in the whole group and 0% in HLA matched recipients. Because of the size of 
the group, this reduction in GVH incidence does not reach significance. 
 
 
In order to be able to meaningfully  compare the incidence of acute GVHD in patients receiving 
transplants fractionated in the presence or absence of IVIG, we wish to continue to enroll patients to 
all four arms.  To insure appropriate representation of patients conditioned  on Arm B, we request 
that enrollment on Arm B continue for an additional 20 patients. Enrollment  to Arm B is nearly 
complete. In order to further evaluate the efficacy of patients treated on Arm B, an additional120 
patients will be enrolled onto Arm B, 60 in the poor risk group and 60 in the standard risk group. In 
order to have comparative numbers for Arms B and C,  an additional 30 patients will also be 
enrolled onto the standard risk group of Arm A. 
 
 
 
5.0 
THERAPEUTIC/DIAGNOSTIC  AGENTS 
5.1 Hyperfractionated total body irradiation, cyclophosphamide, thiotepa, Busulfan, Melphalan, 
fludarabine and clofarabine are standard antineoplastic agents that will be employed in the four 
cytoreductive regimens as detailed in the treatment plan. 
 
5.1.1. Total Body Irradiation 
 
Hyperfractioned TBI is administered by a linear accelerator at a dose rate of < 20 cGy/minute.   Doses 
of 125 cGy/fraction are administered at a minimum  interval of 4 hours between fractions, three 
times/day for a total of 11 or 12 doses (1375 or 1500 cGy) over 4 days (Day -9, -8, -7, and -6).  If 
general anesthesia is required, 150 cGy q12h x 8 doses to a total dose of 1375 cGy may be given. 
Sequential doses are administered in an anterior/posterior or lateral orientation.   Compensators and 
lung blocks are used to shield the lung, so that the lung receives 800 cGy.  The blocked areas of the 
chest will be boosted with high-energy electrons so that the cumulative  chest wall dose is 
approximately 1500 cGy. This insures that marrow sites in the ribs are adequately treated. 
 
 
5.1.2. Thiotepa (Thioplex®) 
Formulation:  15 mg vial lyophilized  powder; must be diluted prior to infusion. 

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Re constitution: Add 1.5 ml of Sterile Water for injection  to 15mg vial to yield 10mg/ml.   Solutions 
which are grossly opaque or contain a precipitate, should not be used.  In order to eliminate haze, 
solutions  should be filtered through a 0.22-mcron filter prior to administration. 
 
Storage and Stability: 
1. Store vials in refrigerator and protect from light. 
2. Refrigerated: Prepare Infusion in NSS; stable for 14 days. 
3. Room temperature: Prepare Infusion in NSS; stable for 7 days. 
 
Pre paration: 
1. Standard IV fluid: NSS 
2. Final concentration range up to: 5mg/ml. 
3. IV piggyback volume: 500 cc. 
4. Spike infusion  bag with IMED 2200 tubing, primed with non-chemo containing  fluid (i.e. 
NSS). 
Clinical Cons iderations:  
Hydration: NA 
Eme tic Potential: High 
 
Incompatibilitie s : Cisplatin, filgrastim  (G-CSF), vinorelbine. 
 
5.1.3 Cyclophosphamide (Cytoxan®, Neosar®) 
Supplie d As : 200 mg, 500 mg, 2000 mg vials 
 
Re constitution Dire ctions: Add Sterile Water for injection  to yield a final concentration of 
20 mg/ml. 
 
Storage and Stability: 
1. Store vials at room temperature. 
2. Refrigerated: Prepare infusion in D5W, stable for 28 days. 
3. Room Temperature: Prepare infusion in D5W; stable for 48 hours. 
 
Pre paration: 
1. Standard IV fluid: D5W. 
2. Final concentration range up to: 20mg/ml. 
3.IV piggyback volume: For doses <1200mg/m2,  infuse in 25cc D5W; for doses >1200mg,  infuse 
as straight drug. 
 
Clinical Cons iderations: 
1. Hydration: As per MSKCC guidelines. 
2. Emetic Potential: High and Delayed. 
3. Supportive  Medications: None. 
 
Incompatibilitie s : Do not administer with other drugs. 
 
5.1.4 Busulfan (busulfex®) 
 

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a. Source and Pharmacology: Supplier:  Orphan Medical Company; Busulfan is a 
bifunctional  alkylating  agent known chemically as 1,4-butanediol,  dimethanesulfonate.  BUSULFEX® 
(busulfan). This is an agent in which two labile  methanesulfonate groups are attached to opposite  ends 
of a four carbon alkyl chain. In aqueous media, busulfan hydrolyzes  to release the methanesulfonate 
groups. This produces reactive carbonium ions that can alkylate DNA. DNA damage is thought to be 
responsible  for much of the cytotoxicity  of busulfan. 
 
b. Formulation and Stability:  It is supplied  as a clear, colorless, sterile, solution  in 
10 mL single  use ampoules. Each ampoule of BUSULFEX contains 60 mg (6 mg/mL) of busulfan, the 
active ingredient,  a white crystalline  powder with a molecular  formula of CH3SO2O(CH2)4OSO2CH3 
and a molecular weight of 246 g/mole. Busulfan is dissolved in N,N-dimethylacetamide  (DMA) 33% 
wt/wt and polyethylene glycol 400, 67% wt/wt. Busulfan’s solubility  in water is 0.1 g/L and the pH of 
a >0.5% solution  in 0.9% Sodium Chloride Injection, USP or 5% Dextrose Injection, USP as 
recommended for infusion reflects the pH of the diluent used and ranges from 3.4 to 3.9. 
 
c. Solution Preparation: BUSULFEX is supplied  as a sterile solution  in 10 mL single-use clear glass 
ampoules each containing 60 mg of busulfan at a concentration of 6 mg/mL for intravenous use. 
BUSULFEX must be diluted  prior to use with either 0.9% Sodium  Chloride  Injection, USP (normal 
saline) or 5% Dextrose Injection, USP (D5W). The diluent quantity should be 10 times the volume  of 
BUSULFEX, ensuring that the final concentration of busulfan is approximately  0.5 mg/mL. 
 
d. Storage and Stability:  Unopened ampules of BUSULFEX must be stored under refrigerated 
conditions  between 2° -8° C (36° -46° F). 
 
e. Administration:  Intravenous, over 2 hours. 
 
5.1.5 Melphalan (Alkeran®) 
 
a. Source and Pharmacology: Supplier:  Glaxo Wellcome. A derivative of nitrogen mustard, 
an analog of mustard gas.  It is a polyfunctional  alkylating  agent that causes miscoding, 
cross-linkage of DNA, and single-strand breakage of DNA.  It inhibits  cellular glycolysis, 
respiration, and protein synthesis.  It is cell cycle-phase non-specific. 
 
b. Formulation and Stability: A lyophilized  powder of 50 mg melphalan and 20 mg 
povidone per vial.  Also provided is 10 ml of sterile diluent  for use in reconstituting the 
product and 
a 0.45 micron filter. 
The special diluent has the following  composition: 
Sodium citrate 0.2 g, 
Propylene glycol 6.0 ml, Ethanol (95%) 0.5 ml, and sterile water 10 ml. 
 
c. Solution Preparation:  Vial/50 mg: Reconstitute by rapidly  injecting  10 ml of the supplied diluent into   
the vial to yield a final concentration of 5 mg/ml. Shake vigorously  until the solution  is clear.  Immediately 
dilute the dose to be administered in 0.9% Sodium Chloride, USP, to a concentration no greater than 0.45 
mg/ml 
d. Storage and Stability:  The intact packages should be stored at room temperature (15-30°C) protected 
from light. Shelf-life surveillance of the intact dosage form is ongoing.   Constitution  with the special 
diluent as directed results in a solution  that retains at least 90% potency for about three hours at 30°C. 
Storage at 5°C results in precipitation. 

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e. Administration:  Intravenous, over 30 minutes. Complete infusion within  60 minutes of preparation. 
 
5.1.6 Fludarabine (FLUDARA®) 
 
a. Source and Pharmacology: Supplier:  Berlex Laboratories, Inc. FLUDARA FOR INJECTION contains 
fludarabine phosphate, a fluorinated  nucleotide analog of the antiviral agent vidarabine, 9-ß-D- 
arabinofuranosyladenine  (ara-A) that is relatively resistant to deamination  by adenosine deaminase. The 
chemical name for fludarabine phosphate is 9H-Purin-6-amine, 2-fluoro-9-(5-O-phosphono-ß-D- 
arabinofuranosyl).  Fludarabine phosphate is rapidly  dephosphorylated to 2-fluoro-ara-A and then 
phosphorylated intracellularly  by deoxycytidine  kinase to the active triphosphate, 2-fluoro-ara-ATP. This 
metabolite  appears to act by inhibiting  DNA polymerase alpha, ribonucleotide  reductase and DNA 
primase, thus inhibiting  DNA synthesis. The mechanism of action of this antimetabolite  is not completely 
characterized and may be multi-faceted. 
 
b. Formulation and Stability: Each vial of sterile lyophilized  solid  cake contains 50 mg of the active 
ingredient fludarabine phosphate, 50 mg of mannitol,  and sodium hydroxide  to adjust pH to 7.7. The pH 
range for the final product is 7.2-8.2. Reconstitution with 2 mL of Sterile Water for Injection USP results  
in a solution  containing  25 mg/mL of fludarabine phosphate intended for intravenous administration. 
FLUDARA FOR INJECTION is supplied in a clear glass single  dose vial (6 mL capacity) and packaged in 
a single dose vial carton in a shelf pack of five 
 
c. Solution Preparation: FLUDARA should be prepared for parenteral use by aseptically adding Sterile 
Water for Injection USP. When reconstituted with 2 mL of Sterile Water for Injection, USP, the solid cake 
should fully dissolve in 15 seconds or less; 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 7.7. The pH range for 
the final product is 7.2-8.2. In clinical studies, the product has been diluted in 100 cc or 125 cc of 5% 
Dextrose Injection USP or 0.9% Sodium  Chloride  USP 
 
d. Storage and Stability: FLUDARA is supplied as a white, lyophilized  solid cake. Each vial contains 50 
mg of fludarabine phosphate, 50 mg of mannitol and sodium hydroxide to adjust pH to 7.7. The pH range 
for the final product is 7.2-8.2. Store under refrigeration, between 2°-8° C (36°-46° F). 
 
e. Administration: Intravenous, over thirty  minutes. 
 
 
5.1.7 C lofar abine (C lolar ™)  
 
a. Formulation and Stability: 
 
Clofarabine is formulated at a concentration of 1 mg/mL in sodium chloride (9 mg/mL), United States 
Pharmacopeia (USP) and water for injection, USP, qs to 1 mL. Clofarabine is supplied in a 1 mg/ml, 20 mL 
vial. The pH range of the solution is 4.0 to 7.0. The solution is clear with color ranging from colorless to 
yellow and is free from visible particulate matter.  Genzyme will be supplying  the drug for this study. 
 
Vials containing undiluted Clofarabine for injection should be stored at controlled room temperature (15 to 
30°C). Shelf-life studies of intact vials are currently ongoing. Clofarabine for injection should  be filtered 
through a sterile 0.2 µm syringe filter and then further diluted with 5% dextrose injection  USP or European 

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Pharmacopoeia (EP) (D5W) or 0.9% sodium chloride injection USP or EP (normal saline [NS]) prior to IV 
infusion. The resulting admixture may be stored at room temperature, but must be used within 24 hours of 
preparation. 
 
b. Administration: 
Clofarabine will be administered by IV infusion over 2 hours daily for 5 consecutive days. To prevent drug 
incompatibilities,  no other medications should be administered through the same IV line. 
 
5.2 Anti-Thymocyte Globulin (Rabbit) (Thymoglobulin®) 
 
 
a. Source and pharmacology: Supplier:  Sangstat, The Transplant Company®. 
Thymoglobulin®     [Anti-thymocyte  Globulin  (Rabbit)] is a purified,  pasteurized, gamma 
immune 
globulin,  obtained by immunization  of rabbits with human thymocytes. This   immunosuppressive  product 
contains cytotoxic antibodies  directed against antigens 
expressed on human T-lymphocytes. 
 
b. Formulation and stability: Thymoglobulin  is a sterile, freeze-dried product for intravenous 
administration  after reconstitution with sterile Water for Injection, USP (WFI).  Each package contains 
two 7 mL vials: Vial 1: Freeze-Dried Thymoglobulin  Formulation  Active ingredient: Anti-thymocyte 
Globulin  (Rabbit) 25 mg - Inactive ingredients: Glycine (50 mg), mannitol (50 mg), sodium chloride (10 
mg); Vial 2: Diluent Sterile Water for Injection,  USP 5 mL. The reconstituted preparation contains 
approximately 5 mg/mL of Thymoglobulin,  of which >90% is rabbit gamma immune globulin  (IgG). The 
reconstituted solution  has a pH of 7.0± 0.4. Human red blood cells are used in the manufacturing process 
to deplete cross-reactive antibodies to non-T-cell antigens. The manufacturing process is validated to 
remove or inactivate potential exogenous viruses. All human red blood cells are from US registered or 
FDA licensed blood banks. A viral inactivation  step (pasteurization, i.e., heat treatment of active  
ingredient at 60°C/10 hr) is performed for each lot. Each Thymoglobulin  lot is released following  potency 
testing (lymphocytotoxicity  and E-rosette inhibition  assays), and cross-reactive antibody testing 
(hemagglutination,  platelet agglutination,  anti-human serum protein antibody, antiglomerular  basement 
membrane antibody, and fibroblast toxicity  assays on every 5th lot). 
 
c. Solution preparation: Each reconstituted vial contains 25 mg or 5 mg/mL of 
Thymoglobulin.  Transfer the contents of the calculated number of Thymoglobulin  vials into 
the 
bag of infusion  solution (saline or dextrose). Recommended volume: per one vial of    Thymoglobulin  use 
50 mL of infusion  solution  (total volume usually between 50 to 500   mL). Mix the solution  by inverting 
the bag gently only once or twice. 
 
d. Storage and stability: Store in refrigerator between +2° C to +8° C (36° F to 46° F).   Protect from 
light. Do not freeze. Do not use after the expiration date indicated on the label. Reconstituted vials of 
Thymoglobulin  should be used within 4 hours. Infusion 
 
solutions of Thymoglobulin must be 
used immediately.  Any unused drug remaining after 
infusion  must be discarded. 
 
e. Administration: Infuse through a 0.22-micron filter. 
 
5.3 The CliniMACS System for Positive Selection of CD34+ Progenitor Cells and 
Depletion of T-Cells. 
The CliniMACS  System (Miltenyi Biotec, Auburn, CA) including  the CliniMACSplus   Instrument, 

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a CliniMACS Tubing Set, the CliniMACS CD34 Reagent and the CliniMACS PBS/EDTA Buffer  is 
intended for the selection and enrichment of human CD34 positive hematopoietic progenitor cells from a 
leukapheresis  product. 
 
The CD34 antigen is a cell membrane glycoprotein expressed by early hematopoietic stem and progenitor 
cells. The CD34 positive cell separation process may be useful in several areas of clinical stem cell 
transplantation, including purging of tumor cells, T-cell depletion, ex vivo cell expansion and gene therapy. 
When re-infused after myeloablative chemotherapy, CD34 positive peripheral blood progenitor cells have 
been shown to reconstitute all hematologic lineages and exhibit both short and long term repopulating 
capacities. 
 
The CliniMACS System uses selective CD34 monoclonal antibodies conjugated to super-paramagnetic 
particles.  The CD34 positive  target cells are selected in an automated continuous  flow separation system. 
 
The CD34 positive cells are specifically labeled for selection by incubation with the CliniMACS CD34 
Reagent. After unbound reagent is washed from the suspension, the cells are ready for the automated 
separation process. The CliniMACS System passes the antibody-labeled suspension, the cells are ready for 
the automated separation process. The CliniMACS  System passes the antibody-labeled suspension through 
a column in which strong magnetic gradients are generated. The Selection Column retains the magnetically 
labeled CD34 positive cells, while unwanted cells flow through the Selection Column and are collected in 
the Negative Fraction Bag. The system performs several washing steps, disposing most of the liquid into 
the Buffer Waste Bag. The Separated CD34 positive cells are released from the column by removing the 
column from the magnetic field and cluting  the cells into the Cell Collection  Bag. 
 
The components of the CliniMACS System include: 
 
5.3.1 The CliniMACS Instrument 
 
The CliniMACS Instrument is a bench-top instrument consisting of a supporting structure to hold the 
column/tubing assembly and various bags, a series of valves through which the tubing set is fitted, a magnet 
between the poles of which the separation column is placed, a peristaltic pump through which a section of 
tubing is placed, software to control the instrument and user interface and a computer touchpad with a 
display window. The instrument is operated at ambient temperature and it is intended to be multi-use  item. 
 
The software for the CliniMACS Instrument controls the function of the electromechanical components of 
the instrument and the user interface. Two separate computers, one a micro-controller located on a control 
board of the CliniMACS Instrument and the second a PC compatible computer which operates the user 
interface are incorporated with the instrument. Software Version 2.31, the current version of software is 
directly traceable to the version of software utilized in pre-clinical testing and European Safety trials, and 
has been inspected and approved by TÜV product services with the CE Mark. 
 
5.3.2. CliniMACS Tubing Set 
 
The CliniMACS Tubing Set consists of a tubing element combined with a pair of proprietary cell selection 
columns. These form a closed, sterile system for processing the cells. The separation column is a 
proprietary   component   of  the   CliniMACS   System  consisting   of  a  plastic   column   housing   with 

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polypropylene frits in eachend. The interior of the column housing is filled with a matrix of sub-millimeter 
iron beads coated with a heat-cured biocompatible  resin.  The columns are placed at appropriate locations 
in the CliniMACS  Tubing Set to facilitate the cell selection process.  The first column serves as a device 
to remove components that bind non-specifically  to the column.  The second column which is placed within 
a magnetic field performs the actual cell selection. The columns are incorporated sterile as part of the 
tubing set and are intended for single use only. 
 
The tubing element consists of a series of tubes, connectors, spikes, Luer locks, and collection bags. The 
tubing of the tubing element is comprised of materials that have been qualified for use in this application 
by testing to ISO 10993. The principal constituents are polyvinyl chloride (PVC) and silicone. The 
connectors are made of various polymers (e.g., ABS and PVC) suitable for use in a blood contact 
environment. They are solvent bonded to the PVC tubing. The silicone pump tubing is softened with 
petroleum ether for manufacturing and mechanically fixed to connectors. The cell wash bags are composed 
of PVC. 
The CliniMACS Tubing  Set is packaged in a thermoformed tray and heat sealed with a Tyvek® lid. The 
CliniMACS Tubing Set is sterilized by ethylene oxide gas in a validated sterilization  cycle and supplied as 
a single-use component for the CliniMACS Instrument. 
 
5.3.2. CliniMACS CD34 Reagent 
The CliniMACS CD34 Reagent is a dark amber, nonviscous, colloidal solution containing the antibody 
conjugate in buffer. The conjugate consists of a monoclonal antibody towards the human CD34 antigen. 
The murine monoclonal IgG1 antibody is covalently linked to dextran beads having an  iron 
oxide/hydroxide core. The concentration of the conjugate is equivalent to 20 micrograms (µg) per mL of 
antibody protein, 800 µg/mL of dextran and 800 µg/mL of iron. The colloid is buffered in a phosphate- 
buffered saline (PBS) containing ethylenediaminetetraacetic acid (EDTA) and Poloxamer 188.  The 
nominal concentrations of its components are 0.0095 M phosphate, 0.004 M potassium, 0.163 M sodium, 
0.139 M chloride, 0.005 M EDTA and 0.03 % (w/v) Poloxamer 188.  The pH is 7.4 - 7.7. Poloxamer 188 
is added to the CliniMACS CD34 Reagent to stabilize it during shipping, handling and storage. The 
CliniMACS CD34 Reagent is supplied sterile and pyrogen-free in glass vials containing 7.5 mL and is 
intended for single use and in vitro use only. 
 
5.4. The CliniMACS  PBS/EDTA Buffer 
 
The CliniMACS PBS/EDTA Buffer is an isotonic  and isohydric  buffer solution with a pH-value of 7.2 and 
osmolarity of 290 mosmol/L.    Its formulation  is shown in the following  table. 
 
Table 1  Formulations  of the CliniMACS  PBS/EDTA Buffer 
 
Ingredient 
Compendial 
Amount 
NaCl 
Ph. Eur. 
8.0   g/L 
KCl 
Ph. Eur. 
0.19  g/L 
Na2HPO4  anhy. 
Ph. Eur. 
1.15  g/L 
KH2PO4 
Ph. Eur. 
0.19  g/L 

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Na2EDTA 
Ph. Eur. 
0.37  g/L 
Water for Injection 
Ph. Eur. 
ad 1L 
 
 
The CliniMACS PBS/EDTA Buffer is used as external wash and transport fluid for the in vitro preparation 
of human heterogeneous cell populations intended to be separated with the CliniMACS Cell Selection 
System. Prior to and during incubation of the antiCD34 beads with the mobilized PBSC, intravenous 
gammaglobulin  is added to the incubation fluid  at a concentration of 1.5 mg IVIG/ml. 
 
 
6.1 
CRITERIA FOR SUBJECT ELIGIBILITY 
 
6.2 
Subject Inclusion Criteria 
 
Malignant conditions  or other life threatening disorders correctable by transplant for which CD34+ 
selected, T-cell depleted allogeneic  hematopoietic stem cell transplantation is indicated such as: 
1) 
AML in 1st remission - for patients whose AML does not have ‘good risk’ cytogenetic features 
(i.e. t 8;21, t15;17, inv 16). 
 
2) 
Secondary AML in 1st  remission 
 
3) 
AML in 1st relapse or > 2nd  remission 
 
4) 
ALL/CLL in 1st  remission clinical or molecular features indicating  a high risk for relapse; or 
ALL/CLL  > 2nd remission 
 
5) 
CML failing  to respond to or not tolerating Imatinib or dasatinib in first chronic phase of disease; 
CML in accelerated phase, second chronic phase, or in CR after accelerated phase or blast crisis. 
 
6) 
Non-Hodgkins lymphoma  with chemoresponsive disease in any of the following  categories: 
 
 
a) 
intermediate or high grade lymphomas who have failed to achieve a first CR or have 
relapsed following  a 1st  remission who are not candidates for autologous  transplants. 
 
b) 
any NHL in remission which is considered not curable with chemotherapy alone and 
not eligible/appropriate  for autologous  transplant. 
 
7) Myelodysplastic  syndrome (MDS): RA/RARS/RCMD with high risk cytogenetic features or 
transfusion dependence, as well as RAEB-1 and RAEB-2 and Acute myelogenous  leukemia 
(AML) evolved from MDS who are not eligible  for transplantation and/or unable to enroll onto 
protocol IRB 08-008. 
 
8) Chronic myelomonocytic  leukemia:  CMML-1 and CMML-2. 
 
9) Multiple  Myeloma with disease in the following  categories: 
 
a) Patients with relapsed multiple  myeloma following  autologous  stem cell transplantation who 
have achieved at least partial response following  additional chemotherapy. 

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b) Patients with high risk cytogenetics at diagnosis must have achieved at least a partial response 
following  autologous  stem cell transplantation.  Patients must have complex karyotype,   
del17p, t4;14 and/or t14;16 by FISH and/or del13 by karyotyping. 
 
10) Other rare lethal disorders of Hematopoiesis and Lymphopoiesis  for which a T-cell 
depleted transplant is indicated  (e.g. hemophagocytic lymphohistiocytosis;  refractory aplastic 
anemia or congenital cytopenias; non-SCID lethal genetic immunodeficiencies  such as Wiskott 
Aldrich Syndrome, CD40 ligand deficiency or, ALPS, as well as refractory autoimmune 
cytopenias, PNH, metabolic storage diseases or heavily transfused congenital 
hemoglobinopathies.) 
 
Accrual to each treatment arm will include  standard risk and poor risk patients, except for 
Regimen D.  All patients on Arm D will be poor risk by virtue of risks of relapse and/or 
transplant related mortality. 
 
Standard risk patients will include  eligible  patients, as defined above, who are receiving 
transplants as treatment for MDS in RA/RCMD,RARS, AML in 1st or 2nd remission,  ALL in 1st 
CR, NHL in 1st remission, MM in 1st  remission, Very Good Partial Response, or 1st Partial 
Response or CML in the first chronic phase or 1st remission. 
 
All other patients, including  those with treatment related malignancies  and/or those who have 
AML derived from MDS, will have received extensive prior chemo/radiotherapy and, therefore, 
will be considered to be at poor risk of conditioning  and transplant related morbidities,  and 
potentially  transplant related mortality.  Patients with life threatening non-malignant  genetic and 
acquired disorders will also, by virtue of their history of, optional transfusions and/or infection be 
considered poor risk. Stopping  rules for non-relapse related mortality  in these heavily treated 
patients are, therefore, slightly  less stringent than patients in the poor risk transplant groups. 
Stopping  rules for the principal endpoints of graft failure and GvHD are the same for all groups. 
 
The following  inclusion  criteria are also required: 
• Patient’s age includes from birth on to < 70 years old. 
• Patients may be of either gender or any ethnic background. 
• Patients must have a Karnofsky (adult) or Lansky (pediatric) Performance Status > 70% 
• Patients must have adequate organ function measured by: 
Cardiac: asymptomatic or if symptomatic then LVEF at rest must be > 50% and must 
improve  with exercise. 
Hepatic:  < 3x ULN AST and < 1.5 total serum bilirubin,  unless there is congenital benign 
hyperbilirubinemia  or if the hyperbilirubinemia  is directly caused by the disease in which the 
patient is receiving a transplant (e.g. AML Chloroma obstructing the biliary  tree). Patients 
with higher bilirubin  levels due to causes other than active liver disease are also eligible  with 
PI approval e.g. patients with PNH, Gilbert’s disease or other hemolytic  disorders. 
Renal:  serum creatinine <1.2 mg/dl or if serum creatinine is outside the normal range, then 
CrCl > 40 ml/min  (measured or calculated/estimated). 
Pulmonary:  asymptomatic or if symptomatic, DLCO > 50% of predicted (corrected for 
hemoglobin). 
Each patient must be willing  to participate as a research subject and must sign an informed consent 
form. 

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6.3 
Subject Exclusion Criteria 
 
• 
Female patients who are pregnant or breast-feeding 
• 
Active viral, bacterial or fungal infection 
• 
Patient seropositive  for HIV-I/II; HTLV -I/II 
• 
Presence of leukemia in the CNS. 
 
 
6.3 Donor Inclusion Criteria 
• 
Each donor must meet criteria outlined  by institutional  guidelines 
• 
Donor should agree to undergo general anesthesia and bone marrow harvest collection  if PBSC 
yield is inadequate or otherwise not transplantable for whatever reason. 
 
6.4 
Donor Exclusion Criteria 
 
• 
If donors do not meet institutional  guidelines, exclusion will be considered. 
 
7.1 
RECRUITMENT PLAN 
 
Patients who fulfill  the eligibility  criteria as listed in Section 6.0 will be recruited for this study by an 
Attending Physician of the Allogeneic  BMT services in Medicine or Pediatrics.  This protocol will take due 
notice of NIH/ADAMHA policies concerning inclusion  of women and minorities  in clinical research 
populations. 
 
8.0 
PRETREATMENT EVALUATION 
 
8.1. 
Pretreatment evaluation of the patient 
 
The  patient  will  receive an extensive  medical  evaluation  within  approximately 
45 days  prior  to starting 
preparatory cytoreduction. This evaluation may include  the below tests: 
- 
Complete physical exam and medical history 
- 
Dental evaluation (may be completed outside of 30 day window). 
- 
CBC 
- 
PT/PTT/INR (if clinically  indicated) 
- 
Blood Type and screen 
- 
Serum chemistries including  BUN, creatinine, electrolytes, glucose,  total protein,  albumin,  liver  function 
tests (AST, ALT, bilirubin,  alkaline  phosphatase). 
- 
Infectious disease markers will be performed as per each department’s guidelines or at the discretion of the 
treating attending. 
- 
Pregnancy test for women of childbearing  age 
- 
Disease Evaluation (including  bone marrow aspirate and/or biopsy,  when indicated) 
- 
Urinalysis  (if clinically  indicated) 
- 
Electrocardiogram, echocardiogram or a gated pool scan, if clinically  indicated 
- 
Pulmonary function test for patients older than 7 years, if clinically  indicated 
- 
Chest X-ray and/or other types of scans (CT scan and PET scan, if needed) 
- 
Samples  of  bone  marrow and/or  peripheral  blood  cells  will  be  obtained  to  define  donor/host  genetic 
differences and to determine engraftment of donor cells (may be completed outside of 45 day window). 
 
 
9.1 
TREATMENT/INTERVENTION  PLAN 

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9.2 Selection of Cytoreduction Regimen 
 
Patients eligible  for this protocol include individuals  with ALL, AML, CML, multiple  myeloma, MDS 
or other lethal disorders of hematopoiesis  or immunity  who fulfill  eligibility  requirements and consent 
to treatment.  Stratification of patients to one of the four disease-targeted cytoreductive regimens will 
be based on the patient’s disease and stage of disease as well as clinical parameters that could increase 
risk of severe toxicity or disease relapse in the post transplant period.  Examples of disease indications 
for each of the  four cytoreductive regimen are summarized in Table _1_. The basis for selection of a 
specific regimen can be briefly described. 
 
 
Table 1: Examples of Disease Indications for Each Cytoreductive Regimen (NOT EXCLUSIVE) 
 
 
 
 
DISEASE 
INDICATION 
REGIMEN A 
TBI/THIOTEPA/CTX 
REGIMEN B 
BU/MEL/FLU 
REGIMEN C 
CLO/MEL/THIO 
REGIMEN D 
MEL/THIO/FLU 
ALL 1°CR 
+ 
- 
+ 
+ 
ALL 2°CR 
+ 
- 
+ 
+ 
ALL>CR2 
- 
- 
+ 
+ 
AML CR1 
+ 
+ 
+ (infant 
- 
AML) 
AML CR2 
+ 
+ 
+ 
- 
AML>CR2 
- 
+ 
+ 
+ 
MDS RA/CR 
- 
+ 
+ 
- 
MDS>RA/CR 
- 
+ 
+ 
+ 
MULTIPLE 
- 
+ 
+ 
MYELOMA 
- 

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DLBCL  > 2° CR 
OTHER  (E.G 
HLH,  ALPS) 
+ 
+ 
- 
+ 
+ 
- 
+ 
+ 
Regimen A which combines total body irradiation,  thiotepa and cyclophosphamide  (TBI/THIO/CTX) 
is the standard cytoreduction regimen employed for patients with high risk ALL or AML in 1° or 2° 
CR.  It is also the standard preparation used for patients with diffuse large B cell lymphoma in 2° CR 
or greater as well as for patients with rare malignant  disorders such as hemophagocytic 
lymphohistiocytosis  (HLH) treated with a T-cell depleted graft.  Selection of an alternate 
cytoreduction regimen for these disease indications  will be based on clinical parameters which 
preclude TBI or suggest that this conditioning  would be too toxic or less likely  to induce durable 
remissions. 
Regimen B which combines busulfan, melphalan and fludarabine, is a regimen that has been tested 
with T-cell depleted grafts fractionated on the Isolex device (IRB 01-055). It is a chemotherapeutic 
regimen that secures consistent engraftment and has been particularly effective for patients with AML 
and MDS as well as patients with multiple  myeloma.   It  should be the cytoreduction regimen of 
choice for multiple  myeloma and for AML > 2° CR and for MDS, including  patients with advanced 
MDS who are not eligible  for transplantation under protocol 08-008.  It  should also be the regimen 
employed for those patients who, by virtue of very young or advanced age, prior radiation exposure, or 
prior cardiac, renal or gastrointestinal disorders cannot receive total body irradiation  or 
cyclophosphamide. 
Regimen C, which combines clofarabine, melphalan and thiotepa  has been tested with unmodified 
HLA-compatible transplants (IRB 06-125) and has shown particular promise in the treatment of high 
risk and advanced forms of ALL, including  infant ALL.  It  should be the regimen of choice for 
patients with ALL referred after a first relapse, for infants and young children with high risk ALL in 
1° CR or others with ALL or DLBCL who are at undue risk of early and/or late toxicities associated 
with TBI or cyclophosphamide. 
Regimen D, which combines fludarabine, melphalan and thiotepa  has been employed successfully for 
cytoreduction of heavily transfused patients with congenital acquired cytopenias, aplastic anemia, 
genetic immune  deficiencies, and acquired auto immune  disorders resulting in severe autoimmune 
cytopenias and lymphoproliferative  disease and refractory leukemia. The immunosuppressive  activity 
of thiotepa and fludarabine, coupled with the myeloablation  induced by melphalan and thiotepa, has 
generated consistent full engraftment with only moderate gastrointestinal  toxicities. 
Please note: patients weighing  < 10 kg may have medications calculated per kg instead of per m2, 
when indicated. 
9.3 Admission for Transplantation 

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IRB Number: 10-050 A(26) 
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Patients will be treated as inpatient on the Memorial Hospital Allogeneic  Transplant Services in 
Pediatrics or Medicine. All orders will be administered upon admission  as per institutional  standard of 
practice. 
 
9.4 Cytoreduction Regimens in Preparation for Transplantation 
 
Please note: prior to transplant, an additional day of rest may be added to the treatment 
schedule, due to unforeseen scheduling issues. 
9.4.1. Regimen A: Hyperfractioned Total Body Irradiation, Thiotepa and Cyclophosphamide. 
 
Hyperfractionated TBI is administered at a dose rate of < 20 cGy/minute. Doses of 125 cGy/fraction 
are administered at a minimum interval of 4 hours between fractions, three times/day for a total of 11 
or 12 doses (1375 or 1500 cGy) over 4 days (Day -9, -8, -7 and -6). 
1500 cGy will be administered to children ≤ 18 years of age with  ALL > 1CR, since the higher dose 
has greater anti-leukemic activity and is well tolerated. Older patients, but ≤ 21 years of age, with ALL 
types seen predominantly  in children and adolescents (e.g. T-cell leukemia/lymphoma  syndrome) may 
also receive a dose of 1500cGy TBI, if the attending physician considers it appropriate and likely  to be 
well tolerated. Sequential doses are administered in an anterior/posterior or lateral orientation.  Lung 
blocks will be used to reduce the lung dose to 800 cGy.  The blocked chest wall areas will be boosted 
with high-energy electrons so that the cumulative  chest wall dose is approximately 1500 cGy, so as to 
insure that marrow sites in the ribs are adequately treated. 
In addition, male patients receiving transplants for ALL or AML will receive an additional  dose of 400 
cGy to the testes to reduce the risk of relapse from leukemia cells in this privileged  site. 
If general anesthesia is required for TBI administration  (e.g. young children), a dose of 150 cGy q12h 
x 8 doses to a total dose of 1375  cGy may be given. 
9.4.1.b Thiotepa 
 
Thiotepa: 5mg/kg/day IV over approximately 4 hr  daily x 2 (Day-5 and Day -4). If scheduling of 
transplant harvests requires, the dose of Thiotepa may be administered as a single dose of 10mg/ kg/ 
day x 1. On days when Thiotepa and ATG are both administered, Thiotepa will be administered first, 
followed by ATG. In select cases in which the peripheral blood stem cells must be harvested a day 
later than requested due to a scheduling issue with the donor or Stem Cell Processing Laboratory, 
there may be a day of rest between the last day of radiation and the first day of thiotepa (Donor can 
only donate on Friday). Alternatively, if the peripheral blood stem cells must be handled a day earlier 
than requested, the doses of Thiotepa may be given approximately 12 hours apart on Day -4/-5. 
Thiotepa dosing will be adjusted if patient is > 125% of ideal body weight and will be calculated based 
on adjusted ideal body weight, as per MSKCC standard of care guidelines. 
9.4.1.c Cyclophosphamide 
Cyclophosphamide:  60 mg/kg/day IV over approximately 30 min daily x 2 days (d –3 and –2).  On 
days when Cyclophosphamide  and ATG are both administered, Cyclophosphamide  will be 
administered first, followed by ATG. If a patient cannot receive cyclophosphamide  due to a prior 
history of hemorrhagic cystitis or exposure to high doses of cyclophosphamide  or ifosfamide, the 
patient may receive fludarabine 25mg/m2/day x 5 days. Cyclophosphamide  dosing will be adjusted if 
patient is > 125% of ideal body weight and will be calculated based on adjusted ideal body weight, as 

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Administrative Update 1 : 21-Jul-2021 
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per MSKCC standard of care guidelines. If Fludarabine is given, dose may be adjusted in the case of 
renal toxicity. 
9.3.1d Rabbit antithymocyte globulin (thymoglobulin) and Methylprednisolone (MPD) 
Rabbit ATG will be given to all transplant recipients > 18 years old. Rabbit ATG will also be given to 
patients ≤ 18 years of age who receive transplants from donors other than HLA-matched related 
siblings  on this arm. Rabbit antithymocyte globulin  (Genzyme) will be administered on day -4 and -3 
at a dose of 2.5 mg/kg/day.  If the patient has a history of allergy or intolerance to rabbit ATG, equine 
antithymocyte globulin  at a dose of 15 mg/kg x 2 or 30 mg/kg x 1 may be used.  If the clinical 
condition  of the patient requires it, ATG may be administered on days -3 and -2.  Furthermore, if 
severe reaction is encountered after the first dose of ATG, the second dose can be delayed until day 
+5. Methylprednisolone  1 mg/kg will be given as premedication.  Additional  medications to prevent or 
treat reactions will be administered as indicated according to institutional  guidelines.  Patients receiving 
transplants from HLA-mismatched donors should receive an additional  dose of ATG on day 
-2 or -1, depending on when the doses are administered. If patient is receiving a second transplant 
from the same donor, ATG administration  will be at the discretion of the physician. ATG dosing will 
be adjusted if patient is > 125% of ideal body weight and will be calculated based on adjusted ideal 
body weight, as per MSKCC standard of care guidelines. 
Because Acetaminophen depletes glutathione  and the alkylators  require glutathione  transferase for 
their metabolism, Acetaminophen administration  is discouraged during the course of cytoreduction. 
 
9.3.1 e Schema of conditioning regimen 
 
EXAMPLE OF ROAD MAP OF PREPARATION  FOR TRANSPLANT 
 
SUNDAY 
MONDAY 
TUESDAY 
WEDNESDAY 
THURSDAY 
FRIDAY 
SATURDAY 
-13 
-12 
-11 
-10 
-9 
TBI 
TBI 
-8 
-7 
TBI 
TBI 
-6 
-5 
Thiotepa 
5 mg/kg/day 
IV X 1 
-4 
Thi otepa 
5 mg/kg/day 
IV X 1 
Rabbit ATG* 
2.5 mg/Kg/d 
-3 
Cyclophosphami 
de 
60 mg/kg/day 
IV X 1 
Rabbit ATG 
2.5 mg/Kg/d 
-2 
Cyclophosphami 
de 
60 mg/kg/day 
IV X 1 
Rabbit ATG** 
2.5 mg/Kg/d 
For HLA- 
mismatched 
SCTs only 
-1 
0 
T-ce ll depleted 
Stem cell 
transplant 
+ 1 
+2 
+3 
+4 
+5 
+6 
+7 
Start G-CSF 
 
* If the clinical  condition of the patient requires it, ATG may be administered  on days -3 and -2. 
** Patients receiving transplants from HLA-mismatched donors will receive an additional dose of ATG 
on day -2 or -1, depending on when the doses are administered. 

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9.4.2. Regimen B Busulfan, Melphalan and Fludarabine 
9.3.2a Busulfan 
For patients with hematologic  malignancies other than multiple  myeloma: 
 
Busulfan*  0.8 mg/Kg/dose Q6H X 12 doses/3 days IV  If > 4 years of age over 2 hours 
 
(Busulfex®) 1.0 mg/Kg/dose Q6H X 12 doses/3 days IV  If < 4 years of age over 2 hours 
 
For patients with multiple  myeloma: only .8 mg/Kg/dose Q6H X 10 doses/3 days IV will be 
administered. 
busulfan dosing and administration: 
 
Patients will have busulfan levels drawn whenever possible  after the first dose on day 1, with 
adjustments in dosing based on the pharmacokinetics of the first dose according to institutional 
standard clinical practice, as indicated. The doses administered on days -9 and -8 should be adjusted if 
patient is > 125% ideal body weight and should be calculated on adjusted ideal body weight per 
MSKCC standard of care guidelines.  Once pharmacokinetics are available, subsequent dosing will be 
adjusted as per  institutional  guidelines. 
Keppra (Levetiracetam) will be administered as per institutional  guidelines  to all research participants 
prior to starting busulfex for the prevention of busulfan-associated seizures. In case of allergic 
reactions to Levetiracetam, alternative anti-seizure medications will be used as clinically  indicated. 
9.4.2.b Melphalan 
 
Melphalan 
70 mg/m2/day 
x 2 days 
IV 
over 30 minutes 
 
melphalan dosing and administration: 
Dose should be adjusted if patient is > 125% ideal body weight and should be calculated on adjusted 
ideal body weight per MSKCC standard of care guidelines. Melphalan will be administered on Days - 
7 and -6 for multiple  myeloma patients. 
 
9.3.2 c Fludarabine 
 
Fludarabine 
25 mg/m2/day 
x 5 days 
IV 
over 30 minutes 
 
fludarabine dosing and administration: 
Fludarabine  may be adjusted in the case of renal toxicity. 
 
 
In select cases in which the peripheral blood stem cells must be harvested a day later than requested 
due to a scheduling issue with the donor or Stem Cell Processing Laboratory, there may be a day of 
rest between the last day of busulfan and the first day of melphalan and fludarabine. 
 
9.3.2.d Rabbit Anti-thymocyte Globulin (Thymoglobulin®) and Methylprednisolone (MPD) 

Memorial Sloan Kettering Cancer Center 
IRB Number: 10-050 A(26) 
Approval date: 05-Jul-2019 
Administrative Update 1 : 21-Jul-2021 
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Rabbit ATG will be administered in the pre-transplant period for all research participants on this arm. 
Research participants will receive rabbit ATG (Thymoglobulin®)  at 2.5 mg/Kg/day x 2 days on days - 
3 and -2. If the patient has a history of allergy or intolerance to rabbit ATG, equine antithymocyte 
globulin  at a dose of 15 mg/kg x 2 or 30 mg/kg x 1 may be used. If severe reaction is encountered after 
the first dose of ATG, the second dose can be delayed until day +5.  Methylprednisolone  will be given 
at 1 mg/Kg/day x 2 days with the ATG administration  and will be discontinued  thereafter. Patients 
receiving transplants from HLA-mismatched donors should receive an additional  dose of ATG on day 
-1. If patient is receiving a second transplant from the same donor, ATG administration  will be at the 
discretion of the physician. ATG dosing will be adjusted if patient is > 125% of ideal body weight and 
will be calculated based on adjusted ideal body weight, as per MSKCC standard of care guidelines. 
Because Acetaminophen depletes glutathione  and the alkylators  require glutathione  transferase for 
their metabolism, Acetaminophen administration  is discouraged during the course of cytoreduction. 
9.3.2.e SCHEMA  OF CYTOREDUCTION  AND PREPARATION  FOR  ALLOGENEIC   PBSCT 
 
 
EXAMPLE OF ROAD MAP OF PREPARATION  FOR TRANSPLANT 
 
SUNDAY 
MONDAY 
TUESDAY 
WEDNESDAY 
THURSDAY 
FRIDAY 
SATURDAY 
-13 
-12 
-11 
-10 
Levetiracetam 
-9 
Busulfan IV 
0.8-1.0 
mg/Kg/dose 
IV Q 6H X4 
Levetiracetam 
-8 
Busulfan IV 
0.8-1.0 
mg/Kg/dose 
IV Q 6H X4 
Busulfan dose 
will be adjusted 
per institutional 
guidelines 
Levetiracetam 
-7 
Busulfan IV 
dose per PK 
IV Q 6H X2 
Busulfan IV 
dose per PK 
IV Q 6H X2 
Levetiracetam 
-6 
Fludarabine 
25 mg/m2/day 
IV X 1 
Melphalan 
70 mg/m2/day 
IV X 1 
Levetiracetam 
-5 
Fludarabine 
25 mg/m2/day 
IV X 1 
Melphalan 
70 mg/m2/day 
IV X 1 
-4 
Fludarabine 
25 mg/m2/day 
IV X 1 
-3 
Fludarabine 
25 mg/m2/day 
IV X 1 
Rabbit ATG 
2.5 mg/Kg/d 
-2 
Fludarabine 
25 mg/m2/day 
IV X 1 
Rabbit ATG 
2.5 mg/Kg/d 
-1 
Rabbit ATG 
2.5 mg/Kg/d 
For HLA- 
mismatched SCTs 
only 
0 
T-ce ll depleted 
Stem cell 
transplant 
+ 1 
+2 
+3 
+4 
+5 
+6 
+7 
Start G-CSF 
 
9.3.3 Regimen C: Clofarabine, Thiotepa, Melphalan 
9.3.3a Clofarabine 
Clofarabine will be administered via approximately a 2 hour intravenous infusion  at a dose of 
20mg/m2/day for 5 doses (days -9, -8, -7, -6. -5). Patients < 18 years of age deemed suitable may 
receive Clofarabine at 30mg/m2/day with PI approval. 

Memorial Sloan Kettering Cancer Center 
IRB Number: 10-050 A(26) 
Approval date: 05-Jul-2019 
Administrative Update 1 : 21-Jul-2021 
Page 28 of 56 
 
 
 
Clofarabine will be administered after premedication with hydrocortisone.  Hydrocortisone was added 
to the amended protocol in an attempt to prevent hepatic inflammation  and elevation of transaminases. 
The timing  of conditioning  may be lengthened by 2 days based if deemed clinically  necessary and 
approved by the PI. 
 
Hydrocortisone will be dosed at 50 mg/m2 dose IV once daily pre-clofarabine (maximum 100 mg). 
 
9.3.3b Thiotepa 
 
Thiotepa will be administered via approximately a 4 hour intravenous infusion  at a dose of 
10mg/kg/day for 1 dose (day –4). Thiotepa may also be administered at 5mg/kg/day IV over 
approximately 4 hr daily x 2 days (Day-5 and Day -4), depending on scheduling of transplant harvests. 
In select cases in which the peripheral blood stem cells must be harvested a day later than requested 
due to a scheduling issue with the donor or Stem Cell Processing Laboratory, there may be a day of 
rest between the last day of clofarabine and the first day of thiotepa. Thiotepa dosing will be adjusted  
if patient is > 125% of ideal body weight and will be calculated based on adjusted ideal body weight,  
as per MSKCC standard of care guidelines. 
 
9.3.3c Melphalan 
 
Melphalan will be administered via approximately  a 30 minutes infusion at a dose of 70mg/m2/day for 
2 doses (days -3, and -2). Melphalan dosing will be adjusted if patient is > 125% of ideal body weight 
and will be calculated based on adjusted ideal body weight, as per MSKCC standard of care  
guidelines. 
 
9.3.3d Rabbit Anti-thymocyte Globulin* (Thymoglobulin®) and Methylprednisolone (MPD) 
Rabbit ATG will be administered in the pre-transplant period for all research participants on this arm. 
Research participants will receive rabbit ATG (Thymoglobulin®)  at 2.5 mg/Kg/day x 2 days on days - 
3 and -2. If the patient has a history of allergy or intolerance to rabbit ATG, equine antithymocyte 
globulin  at a dose of 15 mg/kg x 2 or 30 mg/kg x 1 may be used. If severe reaction is encountered after 
the first dose of ATG, the second dose can be delayed until day +5.  Methylprednisolone  will be given 
at 1 mg/Kg/day x 2 days with the ATG administration  and will be discontinued  thereafter. Patients 
receiving transplants from HLA-mismatched donors should receive an additional  dose of ATG on day 
-1. If patient is receiving a second transplant from the same donor, ATG administration  will be at the 
discretion of the physician. ATG dosing will be adjusted if patient is > 125% of ideal body weight and 
will be calculated based on adjusted ideal body weight, as per MSKCC standard of care guidelines. 
Because Acetaminophen depletes glutathione  and the alkylators  require glutathione  transferase for 
their metabolism, Acetaminophen administration  is discouraged during the course of cytoreduction. 

Memorial Sloan Kettering Cancer Center 
IRB Number: 10-050 A(26) 
Approval date: 05-Jul-2019 
Administrative Update 1 : 21-Jul-2021 
Page 29 of 56 
 
 
 
 
9.3.3 
e Approximate Schema for Regimen C 
 
EXAMPLE OF ROAD MAP OF PREPARATION  FOR TRANSPLANT 
 
SUNDAY 
MONDAY 
TUESDAY 
WEDNESDAY 
THURSDAY 
FRIDAY 
SATURDAY 
-13 
-12 
-11 
-10 
-9 
Clofarabine 
20 mg/m2/day 
IV X 1 
-8 
Clofarabine 
20 mg/m2/day 
IV X 1 
-7 
Clofarabine 
20 mg/m2/day 
IV X 1 
-6 
Clofarabine 
20 mg/m2/day 
IV X 1 
-5 
Clofarabine 
20 mg/m2/day 
IV X 1 
-4 
Thi otepa 
10 mg/kg/day 
IV X 1 
-3 
Melphalan 
70 mg/m2/day 
IV X 1 
Rabbit ATG 
2.5 mg/Kg/d 
-2 
Melphalan 
70 mg/m2/day 
IV X 1 
Rabbit ATG 
2.5 mg/Kg/d 
-1 
Rabbit ATG 
2.5 mg/Kg/d 
For HLA- 
mismatched SCTs 
only 
0 
T-ce ll depleted 
Stem cell 
transplant 
+ 1 
+2 
+3 
+4 
+5 
+6 
+7 
Start G-CSF 
 
9.3.4 Regimen D: Fludarabine, Thiotepa, Melphalan 
9.3.4a Fludarabine 
Fludarabine will be administered via approximately a 30 minute infusion  at a dose of 25 mg/m2/day 
for 5 days (day -6 through day -2). Fludarabine may be adjusted in the case of renal toxicity. 
 
9.3.4b Melphalan 
 
Melphalan will be administered via approximately  a 30 minute infusion  at a dose of 70mg/m2/day for 
2 doses (days -8, and -7). Melphalan dosing will be adjusted if patient is > 125% of ideal body weight 
and will be calculated based on adjusted ideal body weight, as per MSKCC standard of care 
guidelines. 
 
9.3.4c Thiotepa 
Thiotepa will be administered via approximately a 4 hour intravenous infusion  at a dose of 
5mg/kg/day IV over approximately 4 hr daily x 2 days (Day-6 and Day -5). Thiotepa may also be 
administered at 10mg/kg/day for 1 dose (day –5) depending on scheduling  of transplant harvests. 
Thiotepa dosing will be adjusted if patient is > 125% of ideal body weight and will be calculated based 
on adjusted ideal body weight, as per MSKCC standard of care guidelines. 
In select cases in which the peripheral blood stem cells must be harvested a day later than requested 
due to a scheduling issue with the donor or Stem Cell Processing Laboratory, there may be a day of 
rest between the last day of melphalan and the first day of fludarabine  and thiotepa. 

Memorial Sloan Kettering Cancer Center 
IRB Number: 10-050 A(26) 
Approval date: 05-Jul-2019 
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9.3.4d Rabbit Anti-thymocyte Globulin (Thymoglobulin®) and Methylprednisolone (MPD) 
 
Rabbit ATG will be administered in the pre-transplant period for all research participants on this arm. 
Research participants will receive rabbit ATG (Thymoglobulin®)  at 2.5 mg/Kg/day x 2 days on days - 
3 and -2. If the patient has a history of allergy or intolerance to rabbit ATG, equine antithymocyte 
globulin  at a dose of 15 mg/kg x 2 or 30 mg/kg x 1 may be used. If severe reaction is encountered after 
the first dose of ATG, the second dose can be delayed until day +5.  Methylprednisolone  will be given 
at 1 mg/Kg/day x 2 days with the ATG administration  and will be discontinued  thereafter. Patients 
receiving transplants from HLA-mismatched donors should receive an additional  dose of ATG on day 
-1. If patient is receiving a second transplant from the same donor, ATG administration  will be at the 
discretion of the physician. ATG dosing will be adjusted if patient is > 125% of ideal body weight and 
will be calculated based on adjusted ideal body weight, as per MSKCC standard of care guidelines. 
Because Acetaminophen depletes glutathione  and the alkylators  require glutathione  transferase for 
their metabolism, Acetaminophen administration  is discouraged during the course of cytoreduction. 
 
9.3.4e Approximate Schema for Regimen D 
 
EXAMPLE OF ROAD MAP OF PREPARATION  FOR TRANSPLANT 
 
SUNDAY 
MONDAY 
TUESDAY 
WEDNESDAY 
THURSDAY 
FRIDAY 
SATURDAY 
-13 
-12 
-11 
-10 
-9 
-8 
Melphalan 
70 mg/m2/day 
IV X 1 
-7 
Melphalan 
70 mg/m2/day 
IV X 1 
-6 
Fludarabine 
25mg/m2/day 
IV X 1 
Thi otepa 
5 mg/kg/day 
IV X 1 
-5 
Fludarabine 
25 mg/m2/day 
IV X 1 
Thi otepa 
5 mg/kg/day 
IV X 1 
-4 
Fludarabine 
25 mg/m2/day 
IV X 1 
-3 
Fludarabine 
25 mg/m2/day 
IV X 1 
Rabbit ATG 
2.5 mg/Kg/d 
-2 
Fludarabine 
25 mg/m2/day 
IV X 1 
Rabbit ATG 
2.5 mg/Kg/d 
-1 
Rabbit ATG 
2.5 mg/Kg/d 
For HLA- 
mismatched SCTs 
only 
0 
T-ce ll depleted 
Stem cell 
transplant 
+ 1 
+2 
+3 
+4 
+5 
+6 
+7 
Start G-CSF 
 
 
9.4 Prophylaxis agains t acute graft-versus-host disease 
 
No GvHD prophylaxis  will be administered other than the CliniMACS  fractionated T-cell depleted 
transplant. 
9.5. Stem Cell Transplantation 

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IRB Number: 10-050 A(26) 
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9.5.1.    PBSCT 
Donor peripheral blood progenitor cells: stimulation,  harvesting, isolation  and T-cell depletion.  For 
related donors, GCSF will be administered according to MSKCC standard of care. For unrelated 
donors, the G-CSF will be administered and the leukapheresis obtained according to the National 
Marrow Donor Program protocol and IND. Mononuclear cell fractions collected on the fourth and 
fifth days will be pooled. 
 
HLA-compatible donors (9/10 or 10/10 HLA-matched), whenever possible, will be further prioritized 
based on KIR/HLA genotype combinations between the donor and recipient. Donors who are 
KIR3DS1 (40% of the population)  are prioritized  in order to improve transplant-related mortality  and 
to prevent viral reactivation61. For patients with AML/MDS/blastic CML, two donor populations are 
desired: 1) donors who exhibit the HLA-C1 class I KIR ligand group and who are KIR2DS1-positive 
(34% of all donors) 62, and 2) donors who are negative for KIR2DL3 and homozygous for KIR2DL2 
(cenBB compound haplotype, 17% of all donors) 63. In addition, allele level typing for inhibitory 
KIR3DL1 may be incorporated into donor selection, where donors with KIR3DL1 alleles with low 
affinity will be selected over donors with high affinity for the patients HLA-Bw4 allele64. For 
AML/MDS/blastic CML patients whose HLA-C alleles belong to the HLA-C2 class KIR ligand group 
(HLA-C2C2) and who are at higher risk of relapse65-67, consideration may be given to choosing an 
HLA-C1C2 donor.  In this situation, the donor will, by definition,  be mismatched for one HLA-C locus 
in order to capture donor NK alloreactivity due to “missing  self.” 
 
 
Isolation of CD34+ hematopoietic progenitor cells with the CliniMACS TM System, Miltenyi 
Biotec. 
The apheresis product is collected from a blood-related or matched unrelated donor. Aliquots of the 
apheresis product are collected and then tested and screened as per blood banking guidelines.  The 
apheresis product is then prepped for the CliniMACS  Cell Selection System. After washing the GCSF 
mobilized  PBSC, the cells are suspended in CliniMACS  PBS/EDTA buffer to which is added sterile 
human intravenous Immune Globulin  at a concentration of 1.5mg IVIG/ml. This fluid  is then used 
during incubation  of the PBSC with the antiCD34 antibody coated paramagnetic beads. 
The mechanism of action of the CliniMACS Cell Selection System is based on magnetic-activated cell 
sorting, which can select or remove specific cell types depending on the cell-specific immunomagnetic 
label used. The apheresis product is first co-incubated with the CliniMacs  CD34 reagent (antibody- 
coated paramagnetic particles). After magnetic labeling  and washing, the cells are passed through a 
high-gradient  magnetic separation column in the CliniMACS  clinical cell selection device. 
Magnetically labeled CD34+ cells are retained in the magnetized column,  and CD34-negative cells flow 
through as the effluent fraction and discarded. The CD34+positive cells retained in the column are eluted 
by removing the magnetic field from the column, then washing the cells through the column and 
collecting  them. The final CD34+ cell enriched product is concentrated by centrifugation and tested 
before final release for administration.  Before infusion, the CD34+ cells will be washed in normal 
saline for intravenous infusion  containing 1% human serum albumin, and suspended in a volume of 
25-50 ml. for intravenous administration. 
Throughout the process, critical control points and associated assays are identified and performed on 
each cellular therapy product. Aliquots  of the same product sample are taken for in-process and final 
product testing. After each step (apheresis, platelet washing, CD34 labeling  and washing, enrichment), 
QC testing includes; Sterility.  Endotoxin,  gram stain, Total nucleated cells (TNC), flow cytometry 
phenotype/analysis  of CD45, CD34, and CD3, and viability  assessed by 7-AAD is assessed. To ensure 
sterility, 14-day sterility tests are performed for in-process sterility testing and a gram stain is 
performed on the final product prior to release. 

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IRB Number: 10-050 A(26) 
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Administrative Update 1 : 21-Jul-2021 
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9.5.2 Transplantation of the T-cell depleted stem cells. 
 
The CD34+T-cell depleted peripheral blood progenitor cells or the SBA-E- fraction of the bone 
marrow, suspended in a volume  of approximately 20-50 ml will be infused intravenously  over 
approximately 15 minutes with monitoring  of vital signs. 
9.6. 
Supportive Care 
 
a. Prophylaxis against infections 
 
Standard of care guidelines will be followed for prophylaxis  against post transplant infections by 
opportunistic  organisms, including  Pneumocystis jiroveci,  fungal organisms, DNA herpesviruses and 
more specifically CMV. 
 
b. Prophylaxis against menorrhagia 
 
All post-pubertal females will receive prophylaxis  against menorrhagia according to our standard of 
care guidelines. 
c. Transfusions 
 
Following  initiation  of the pre-transplant cytoreduction, all blood products for transfusion, with the 
exception of the peripheral blood stem cell, will be irradiated to 3,000 cGy to inactivate lymphocytes 
capable of initiating  lethal GvHD. Blood products are irradiated in the blood bank, using a cesium 
gamma emitter. Platelets will be administered for clinical evidence of active hemorrhage. Platelets will 
be administered at the discretion of the treating attending and as per standard of care. 
 
d. Nutritional support 
 
Nutritional status will be carefully monitored by the physician, and high-calorie  parenteral 
alimentation  will be introduced as needed. Vitamin supplements will be as clinically  indicated. 
 
 
 
e. CNS le ukemia Prophylaxis 
 
Patients with ALL, those with M4/M5, and those transplants with AML in bone marrow relapse may 
receive intrathecal infusions of cytarabine at monthly intervals, beginning approximately 2 months 
posttransplant, and thereafter on a monthly basis for a total of 5 doses. Patients with a prior history of 
CNS leukemia may receive 11 doses of IT cytarabine from approximately 2 until 12 months post- 
transplant. Intrathecal Cytarabine will be dosed according to age as per institutional  guidelines. 
 
 
10.0 
EVALUATION  DURING TREATMENT/INTERVENTION 
 
10.1 Post-trans plant e valuation 
 
The chart below shows the approximate dates for tests and procedures performed after transplant. Certain tests 
may be held or repeated at the discretion of the treating physician if deemed in the best clinical interest of the 
patient. 

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X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
1. This should apply to patients with malignant  disease in which the BM was previously involved. BM Chimerism 
should also be assessed whenever possible. BMA may  be delayed if patient is clinically  unstable. 
2. May be done more  frequently if clinically  indicated. Tests need not be done if patient has a low number of 
peripheral white cells. 
3. PBL phenotyping should be performed  until CD34  counts is >200  or if  patient is being immunized. 
4. Should be performed  until normal or reached plateau 
 
Patients will be followed for life by telephone assessments conducted once a year to assess overall and disease 
free (DFS) survival. 
 
 
11.0 
TOXICITIES/SIDE  EFFECTS 
 
Patients recruited to this transplantation trial are individuals  who are either referred by physicians or self- 
referred for peripheral blood stem cell transplantation as a potentially  curative treatment for their malignancy 
or other life threatening disorders. Prior to consideration for transplant, all patients undergo a series of 1-3 
hour consultations discussing the risks and potential benefits of an allogeneic  stem cell transplantation and the 
Activity 
Transplant   to 
Discharge 
DISCHARG 
E TO DAY 
Day 100 
100 
6 
Months 
12 
months 
M
24 
onths 
Blood counts and 
chemistry  (CBC, 
Comprehensive 
Metabolic Panel) 
CBC:  Daily 
CMP: 2xs  a 
week 
CBC/CMP: 
Weekly , 2x a 
week or 2-3 
Every 
weeks 
2-4 weeks 
X 
Physical exam 
for GVHD 
evaluation 
Monitored 
routinely as 
per inpatient 
transplant 
service 
guidelines 
Weekly 
Every 2-4 weeks 
X 
Disease 
evaluation 
BMA 1, 2 
30 - 100  days after transplant, if clinically 
indicated 
X 
X 
T-cell 
chimerism2 
NA 
30 days after 
X 
transplant 
X 
X 
X 
Peripheral blood 
lymphocyte 
(PBL) 
phenotyping3 
NA 
NA 
X 
X 
X 
X 
In vitro response 
of PBL to 
standard panel of 
mitogens 2,4 
NA 
NA 
NA 
X 
X 
X 

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IRB Number: 10-050 A(26) 
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different procedures which will be a normal part of the transplant course. The risks and potential benefits of 
the transplant procedure, as well as the participation  in any given research, experimental, or therapeutic 
protocol are also discussed. 
 
 
11.1 
Toxicities/Side effects of conditioning regimens 
 
The risks of short-term treatment with G-CSF are likely negligible.  However, administration  of GCSF is 
frequently associated with low grade fever and low back pain which usually resolves within one day following 
cessation of GCSF treatment. Furthermore, there has now been one recorded patient who developed acute 
splenomegaly and splenic rupture in response to high dose GCSF. The bone pain may require treatment with 
analgesics. The risks of a leukapheresis are negligible,  involving  an occasional vasovagal response to 
venipuncture and the minimal hemodynamic  alterations associated with single unit phlebotomies.  To protect 
against these risks, leukapheresis are conducted in the Blood Bank Donor Room with full medical and nursing 
supervision and support systems to address adverse events. 
 
11.1.1 Total Body Irradiation 
Likely 
• 
Nausea and vomiting  - virtually  all patients will experience nausea and vomiting  after irradiation. 
This can be diminished  somewhat with mild  anti-emetics. Strong sedatives or phenothiazine 
derivatives should be avoided just before radiation treatment, as they frequently cause excessive 
drowsiness and/or symptomatic  orthostasis, which prevent delivery of TBI done in the standing 
position. 
 
• 
Myelosuppression is the major dose-limiting  toxicity. 
 
• 
Hyperpigmentation  - most patients will get some degree of hyperpigmentation  within 2-3 weeks of 
transplantation. 
 
• 
Increased risk of infection 
 
• 
Mucositis - most patients will develop moderate to severe mucositis of the oral and GI tracts, which 
will be managed with aggressive nursing mouth care, analgesics and prophylactic  antifungal and 
antiviral  agents. 
 
• 
Late effects - there is the possibility  of cataract formation. Although mild  cataracts may occur in up to 
70% of cases with single  dose TBI, we have seen cataracts in < 30% of patients treated with 
hyperfractionated TBI. 
 
• 
Sterility  is extremely common following  total body irradiation  and administration  of alkylating 
chemotherapy; the risk increases with the number of years since puberty. 
 
Less Likely 
• 
Parotitis - some patients will experience symptomatic parotitis within the first 24 hours post radiation. 
This resolves spontaneously over several days. 
 
• 
Diarrhea - most patients develop some diarrhea in the first week post irradiation.  This can be treated 
symptomatically. 
 
• 
Fever – low grade fever [greater than 38°C] may occur for 24 hr post irradiation.  This can be treated 
symptomatically. 

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• 
Erythema - this may occur in patients within 24 hours and resolves in 2-3 days. 
 
• 
Hypothyroidism  has been reported in small numbers of adult patients following  TBI plus alkylating 
chemotherapy, and this will be routinely  monitored post transplant with hormonal replacement as 
indicated. 
 
• 
There is a possibility  that secondary malignancies may develop, particularly due to the combined 
effects of radiation and an alkylating  agent [cyclophosphamide].  The age-adjusted incidence of 
secondary cancer in transplant patients after radiation and chemotherapy has recently been estimated 
to be 6.7 times higher than that of first cancers in the general population;  and most of these were non- 
Hodgkin's  lymphomas. 
 
• 
veno-occlusive disease of the liver (VOD) 
 
11.1.2 Thiotepa 
Likely 
• 
Myelosuppression is the major dose-limiting  toxicity,  occurring regularly at doses >405mg/m2.  Other 
non-fatal toxicities  have been observed almost exclusively  after administration  of thiotepa at doses 
greater than 1000mg/m2. 
 
• 
Increased risk of infection. 
 
• 
Cutaneous erythema and bronzing  is seen in most patients given  900mg/m2. Erythema develops 4- 
14d after the first dose and may last up to 3wks. Bronzing  may persist for months. 
 
Less Likely 
 
• 
Nausea, vomiting,  diarrhea - occasional, rarely severe. 
 
Rare but Serious 
 
• 
CNS toxicity  manifested by mild  cognitive  dysfunction,  disorientation,  confusion, irritability,  bizarre 
behavior, is usually not observed at doses <1000mg/m2. 
 
• 
Interstitial pneumonia 
 
• 
Renal failure 
 
• 
Transient hepatic transaminase elevations  are occasionally seen, but rarely severe. 
 
11.1.3 Cyclophosphamide 
Likely 
• 
Myelosuppression 
 
• 
Increased risk of infection 
 
• 
Edema and weight gain secondary to inappropriate  ADH secretion can occur in some patients, but 
can usually be corrected with medical management 
 
• 
Gastrointestinal:  anorexia, nausea, vomiting,  and diarrhea occur commonly,  but are reversible. 

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• 
Elevated transaminases are usually transient 
 
• 
Alopecia, amenorrhea, azoospermia would be expected to occur. 
 
Less Likely 
 
• 
Hemorrhagic cystitis can be severe and in few cases, life threatening. 
 
Rare but Serious 
 
• 
Cardiotoxicity  can be severe and in few cases, life threatening. 
 
11.1.4 Busulfan 
Likely 
• 
Myelosuppression 
 
• 
Fatigue 
 
• 
Anorexia 
 
• 
Nausea and Vomiting 
 
• 
Mucositis 
 
• 
Diarrhea 
 
• 
Edema 
 
• 
Alopecia 
 
• 
Increased risk of infection 
 
• 
Sterility 
 
Less Likely 
 
• 
Cataracts 
 
• 
Under-activity of the thyroid gland 
Rare but Serious 
• 
Seizures 
 
• 
veno-occlusive disease of the liver (VOD) 
 
 
 
11.1.5 Melphalan 
Likely 

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• 
nausea and vomiting  - Diarrhea 
 
• 
mucositis 
 
• 
myelosuppression  and pancytopenia 
 
• 
elevated liver function tests 
 
• 
sterility 
 
• 
alopecia 
 
• 
fever 
 
Less Likely 
 
• 
Syndrome of Inappropriate anti-diuretic  hormone (SIADH) 
 
• 
Interstitial  pneumonitis 
 
• 
Pulmonary fibrosis 
 
Rare but serious 
 
• 
secondary leukemia 
 
• 
anaphylaxis 
 
• 
seizures 
 
• 
kidney failure 
 
• 
veno-occlusive disease of the liver (VOD) 
 
11.1.6 Fludarabine 
Likely 
• 
Nausea, vomiting,  mouth sores, stomach cramps and diarrhea, jaundice, and elevations of liver enzymes. 
 
• 
Scaling and redness of the skin, which is usually  of short duration. 
 
• 
Transient but significant myelosuppression  at the doses called for in this protocol.  Fludarabine  is also 
profoundly  immunosuppressive.   These toxicities place the patient at increased risk for infections  for 
periods of 1-2 months. 
 
 
 
Rare but Serious 
 
• 
Effects on the nervous system are not usually seen at the fludarabine dose used in this protocol, but, when 
they occur, can include cerebellar dysfunction with loss of balance and trouble walking, blurring of vision 
or, in extremely rare cases, blindness, and mental agitation or confusion. 

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11.1.7 Clofarabine 
Likely 
• 
Reversible hepatotoxicity  is the major dose-limiting  toxicity.   This is most commonly  demonstrated by a 
transient elevation of transaminases.  Hyperbilirubinemia  was less common. 
• 
Dermatitis and pruritus 
• 
nausea, vomiting  , diarrhea, abdominal pain 
• 
myelosuppression  and pancytopenia 
• 
headache 
• 
fever - chills  or rigors 
 
Less Likely 
 
• 
acrodermatitis 
• 
anorexia, weight loss myalgias, arthralgias 
• 
headache, fatigue, dizziness,  somnolence,  tremor 
• 
shortness of breath 
• 
infections 
 
 
Rare but serious 
 
• 
Capillary leak syndrome 
• 
Systemic inflammatory  response syndrome 
 
 
11.1.8 Rabbit Antithymocyte Globulin (Thymoglobulin) 
 
The ATG to be used in this trial is a purified preparation of rabbit gamma globulin containing high 
concentrations of antibodies against human lymphocytes. The preparation may contain low levels of 
antibody that cross-react with human platelets, white cells or red cells. The potential side effects of ATG 
are: 
 
Likely 
 
• 
Fever, shaking, chills  and lowered blood pressure: These are regularly observed, particularly during initial 
infusions of the rabbit globulin.   They probably result from a breakdown of cells binding  the antibody. 
 
• 
Skin rash and itching: A frequent complication which is probably due to minor allergic reactions to rabbit 
globulin. These symptoms will usually be prevented by or controlled with anti-histamines as well as with 
concomitant administration  of corticosteroids. 
 
• 
Platelet and white cell count depression: These are frequently observed and are probably caused by the 
binding of the rabbit antibody to human blood elements. Platelet transfusions will be administered to reduce 
the chance of bleeding or life threatening hemorrhage. 
 
 
Less Likely 
 
• 
Serum sickness:  Approximately  30% of patients treated with rabbit globulin  will develop a late immune 
reaction to the globulin  resulting  in serum sickness 3-10 days after the administration.    This may lead to 

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severe skin rashes, mouth and vaginal sores, pain and swelling  of the joints,  or kidney damage.  Serum 
sickness is transient and its damage reversible but it may require prolonged treatment with corticosteroids. 
 
Rare, but potentially serious 
 
• 
Anaphylaxis: A rare but severe allergic reaction which may cause a life threatening drop in blood pressure, 
wheezing and difficulty breathing and severe hives. This complication  can be treated with anti-histamines 
and steroids. 
 
 
11.2 Toxicities/Side effects of the transplant and the combined effects of the conditioning regimen 
and transplant 
 
In addition to tracking patients for survival and relapse, all participants may also be monitored for post- 
transplant toxicities. 
 
Grade 3-4 toxicities which occur within 30 days following a transplant AND are also possibly, probably, or 
definitely attributable to the CliniMACS device will be graded and attributed. Additional toxicities will be 
reviewed and graded/attributed at the discretion of the PI. 
 
Toxicities which are attributable to underlying  malignancy  and/or expected toxicities  from the transplant will 
not be tracked. 
 
The grading for monitoring  transplant related toxicities will be based on the CTCAE 4.0 (57). 
 
11.2.1 
Potential Sensitization to Murine Proteins 
 
Mouse protein antibodies are used in the CliniMACS processing procedures. If the recipient has a pre-existing 
allergy, he or she may be at risk for allergic reactions during infusion of the processedcells, although the residual 
amount of murine protein in the final product is very low (estimated maximum dose for a 50 kg patient would 
be 30 µg). To date, no allergic reactions are reported in patients receiving cells processed with the CliniMACS 
System.  Epinephrine  and antihistamines  will be available  at the recipient's bedside during the PBSC infusion. 
 
 
11.2.2 
PBSC Infusion 
 
Symptoms may include changes in heart rate and/or rhythm, changes in blood pressure, fever, chills, sweats, 
nausea, vomiting, diarrhea, abdominal cramping, hemoglobinuria, acute renal failure, allergic reactions, 
respiratory dysfunction,  or headache. 
 
11.2.3 
Infections 
 
Transplantation puts the patient at higher risk for bacterial, viral, or fungal infections, which are potentially life 
threatening. These risks are potentially higher with TCD transplants.  Prophylaxis will be initiated  and patients 
will be closely monitored for signs of infections and will receive early and appropriate treatment. 
 
11.2.4 
Microbial Contamination of PBSC 
 
There is a potential that processing the leukapheresis product will inadvertently introduce microorganisms that 
could cause infection in the recipient after the cells are infused. All precautions to maintain sterility will be 
taken. Cultures of the leukapheresis product and the selected product will be obtained to monitor for 
contamination. 

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11.2.5 
Graft  Failure / Poor Marrow Function 
 
T cell depletion of donor cells is associated with an increased incidence of graft failure in allogeneic transplant 
recipients. After allogeneic transplantation, the recipient's marrow function may be poor and leukopenia, 
anemia, or thrombocytopenia may result from many causes including graft rejection induced by surviving host 
immune T-cells, or ongoing suppression of engrafted donor blood-forming cells by GVHD, infection or marrow 
suppression or immunosuppressive  drugs and other medications.  Graft failure may result in death if not reversed. 
In patients with immune rejection second transplants can be administered with immunosuppressive therapy, 
including non-myeloablative conditioning regimens. For patients who are engrafted with donor cells but have 
severe cytopenia  affecting one or more blood cell lineages, secondary transplants of CliniMACS fractionated 
CD34+ T-cell depleted PBSCs may be administered to booster and replenish donor hematopoietic cells without 
conditioning  or after treatment with anti- thymocyte globulin. 
 
 
11.2.6 
Graft-versus-host Disease 
 
Acute or chronic GVHD may develop after allogeneic  transplantation that can be disabling  and can lead to 
death.  GVHD is thought to be initiated  by T cells contained in the PBSC graft.  CD34+ selection and CD3+ 
depletion reduces the number of T cells in the PBSC but GVHD can occur after TCD transplants. Acute and/or 
chronic GVHD will be treated with immunosuppressive  drugs as per the transplant service guidelines. 
 
11.2.7 Veno-occlusive Disease (VOD) of the Liver 
VOD is a manifestation of damage to the liver by the conditioning  regimen that usually develops within two 
weeks after allogeneic transplant and is characterized by at least two of the following: 
• 
Hyperbilirubinemia  (total bilirubin  > 2 mg/dL) 
• 
Hepatomegaly or right upper quadrant pain, or 
• 
Rapid weight gain (> 5% above baseline) 
 
Recipients developing VOD will be monitored closely and will receive appropriate supportive  care and careful 
fluid management.  TCD is not expected to affect the risk of VOD. 
11.2.8 End Organ Damage 
 
End organ damage of all or any of the major organs, including  the brain, may occur as a result of cumulative 
toxicity from anti-neoplastic  therapy, reactions to other drugs, and as a result of destructive processes (e.g., 
infection, GVHD, etc.) and may have a fatal outcome.  Toxicities may occur in any individual  patient due to 
multiple  events and cumulative effects that may involve  any and all organs, including  the brain.  Brain damage 
can result in severe loss of cognitive or neurologic  function.  Data from previous studies do not suggest that  
the risk of end organ damage is appreciably affected by TCD or the preparative regimens to be used in this 
study. 
 
11.2.9 Disease Relapse 
 
Allogeneic  transplantation using T cell depleted peripheral blood stem cells has, in some cases, been 
associated with an increased incidence of leukemic  relapse in patients with chronic myelogenous leukemia, 
compared to recipients who receive unmanipulated  donor cells. The risk of relapse has not been increased in 
patients with acute leukemias. Nevertheless, despite cytoreduction and a transplant, relapse may occur. 
 
11.2.10 Lymphoproliferative  Syndrome 

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Recipients of TCD allogeneic grafts have an increased risk of developing  lymphoproliferative  syndromes 
caused by EBV infection (47, 48).  This syndrome should be included in the differential diagnosis of recipients 
with unexplained symptoms such as fever, diarrhea, hepatomegaly or lymphadenopathy.   Biopsy evaluation is 
required to make the diagnosis.  EBV PTLD may rapidly  progress and can be fatal if not treated.  Management 
of suspected EBV PTLD should be discussed with one of the Protocol P.I.s.  EBV PTLD can be treated with 
rituximab  and/or infusion  of 106  T cells/kg from the donor.  Rituximab has been shown to induce regression in 
50 - 70% of cases (49).  However, Rituximab does not enter the CNS and is not effective in treating CNS 
disease.  Donor lymphocyte infusions  may induce regression in > 90% of cases of EBV PTLD and are 
effective in CNS disease but may cause GVHD (50). EBV-immune cells are experimental, but can also induce 
regression of EBV PTLD without risk of graft vs host disease (51, 52). 
 
11.2.11 Death 
 
There is an approximately 5-10% risk of treatment related mortality  within the first month of transplant due to 
the risk of severe regimen related toxicity, hemorrhage, opportunistic  infection, or other complications.   It is 
not expected that the regimens to be used in this protocol will increase this risk. 
12.0 
CRITERIA FOR THERAPEUTIC  RESPONSE/OUTCOME  ASSESSMENT 
 
 De finition of e ve nts in the post-trans plant course important for analys is and tre atme nt 
 
12.1 
Engraftment and Chimerism 
 
Engraftment will be documented by analysis of blood cells, T cells and bone marrow cells for chimerism by 
standard cytogenetic studies at about 1 month, 100 days, 6 months, 12 months, and 24 months posttransplant 
or as needed thereafter. 
 
12.2 
Graft  failure or rejection 
 
Primary non-engraftment is diagnosed when the patient fails to achieve an ANC 500/l at any time in the first 
28 days post-transplant. If the patient's leukemia recurs during this interval, the patient is scored as having 
refractory leukemia. In such a situation, the absence of donor hematopoiesis is not evaluable for graft failure or 
rejection. If host T-cells capable of specifically inhibiting  donor hematopoietic  progenitor growth in vitro are 
concurrently detected during graft failure, a presumptive diagnosis of immune mediated rejection is made (53, 
54). If (1) after achievement of an ANC 500/mm3, the ANC declines to <500/mm3   for more than 3 
consecutive days in the absence of relapse, or, (2) there is absence of donor cells in the marrow and/or blood  as 
demonstrated by chimerism assay in the absence of relapse, a diagnosis of secondary graft failure is made. If, 
however, recurrence of host leukemia  is detected concurrently, the patient is not evaluable for graft failure or 
rejection. 
Patients with evidence of graft failure without evidence of recurrence of host leukemia  may have additional 
studies drawn to ascertain cause and define relevant histoincompatibilities.   These analyses may include  (1) 
Evaluation of bone marrow aspirates and biopsies  for residual or recurrent leukemia, when indicated, (2) 
Culture and/or molecular analyses of marrow and blood for viral pathogens potentially  causing graft failure 
including  CMV, HHV6 and parvovirus B 19, (3) Immunophenotypic  and genetic analysis of circulating T- 
cells and NK cells to ascertain their origin  and potential function, (4) Analysis of the functional activity of 
residual circulating  lymphocytes to determine whether and to what degree they exhibit  cytotoxic or cyto- 
inhibitory  activity against donor host or third party PHA-stimulated blasts or clonogenic  hematopoietic 
progenitor cells. If donor-specific  reactivity is identified,  attempts will be made to identify targeted 
specificities  (HLA or minor  alloantigens)  whenever possible. 

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Patients who suffer graft failure may be considered for a secondary transplant. The need for additional 
immunosuppression  or treatment for viral infection prior to the secondary transplant will be determined by the 
results obtained from chimeric and viral studies. 
 
12.3. Graft-versus-host disease 
 
Standard BMT-CTN and IBMTR systems clinical criteria as defined by Rowlings, et al (55) will be used to 
establish and grade acute GvHD. 
To determine the severity of acute GvHD, data will be collected approximately weekly to characterize the 
severity of symptoms and signs caused by GvHD and to evaluate possible  confounding  factors. Real time data 
collection  will include  descriptive characteristics of rash and estimated body surface area involved, extent of 
dermal/epidermal separation, identification  of concomitant causes of increased bilirubin  other than GvHD, 
presence or absence of nausea, vomiting  or anorexia persistent after engraftment, peak diarrhea volume with 
annotations concerning the presence after engraftment, peak diarrhea volume with annotations concerning the 
presence or absence of urinary mixing  and estimates of true diarrhea volume,  presence or absence of 
abdominal cramps, presence or absence of frank stool blood or melena, concomitant causes of GI symptoms 
other than GvHD, biopsy results, identification  of any agents used for treatment and autopsy results. 
Patients will be observed for acute and/or chronic GvHD as long as they have not received donor derived 
leukocytes infusion  (DLI). If at any time, a patient receives DLI, that time will represent the end-time for 
evaluation of GvHD. Graft-versus-host disease occurring after DLI infusions  will be analyzed separately. 
Patients with moderate to severe acute GvHD (grade II-IV) will be treated in standard fashion with high-dose 
I.V. methylprednisolone  (2-20mg/kg/day)  or in combination  with other immunosuppressants  as per ongoing 
trials on GvHD and at the discretion of the treating attending. Patients failing  to respond to steroids will be 
considered for treatment with experimental treatments available  at the time of diagnosis  of GvHD. 
Chronic GvHD will be diagnosed and graded according to the criteria of Sullivan (56) treated with standard or 
experimental immunosuppressive  therapy. Treatment will consist of corticosteroids, cyclosporin A or 
azathioprine,  or combinations of these agents. Other novel treatments could be used if available, i.e. 
thalidomide  and psoralen/ultraviolet  A phototherapy (PUVA). 
 
12.4. 
Transplant related mortality 
Transplant-related mortality (TRM) includes  fatal complications  resulting from the allogenic  transplant and/ 
or treatment regimens such as graft failure, GvHD, hemorrhages, and infections. 
12.5. Infections 
 
The occurrence of life-threatening opportunistic  infections  will be evaluated according to the criteria 
established by BMT CTN and will correlate this with the level of immune  recovery. The infection-related 
mortality will be also determined. Patients will be considered to have died from infection if death is attributed 
to a recent severe infection and/or infection was identified at autopsy. Patients with relapsed disease or GVHD 
before death will be excluded from the above definition,  even if an infection was the final cause of death. 
 
12.6. Disease relapse and recurrence 
 
Relapse of MDS, ALL and AML will be defined by an increasing number of leukemic  blasts in the marrow 
over 5%, by the presence of circulating peripheral blasts, or by the presence of blasts in any extramedullary 

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site. Cytogenetic and/or Molecular analysis of the marrow and/or peripheral blood  will also be obtained for the 
diagnosis  of relapse. 
Relapse of myeloma and lymphoma  will be diagnosed by clinical and radiological  findings coupled with 
biopsy of affected tissue. A sustained risk in the serum concentration of myeloma paraprotein will also be 
considered evidence of relapse. 
Disease recurrence 
 
In non-neoplastic  diseases, disease recurrence would be considered if engraftment of donor hemopoietic  cells 
have not been achieved and function or phenotypic  abnormalities  of hemopoietic  or lymphoid  lineages 
affected, occur. 
 
12.7 
Disease-free Survival 
 
DFS is defined as the minimum  time interval of times to relapse/recurrence, to death or to the last follow-up, 
from the time of transplant. 
 
12.8 
Overall Survival 
 
Overall survival is defined as time from transplant to death or last follow-up. 
 
12.9 
CD34+ and CD3+ Cell Doses 
 
Total CD34+  and CD3+  cell doses will be calculated based on results of flow cytometric analysis. 
 
 
13.0 
CRITERIA FOR REMOVAL FROM STUDY 
 
Research participants may be removed from the study if requested by the research participant. Management 
will depend on where they are in their treatment course. Such research participants will receive appropriate 
supportive  care. Patients may also be removed from the study at any point deemed appropriate by the principle 
investigator. 
 
Patients may be removed from study, and not followed further, if one or more of the following  events occur: 
 
- Significant  noncompliance  on the part of the patient 
- Refusal of the patient to continue treatment or observations 
- Progressive disease or relapse 
- Decision by the investigator that termination is in the patient’s best medical interest 
- Unrelated medical illness  or complication 
- Lost to follow-up 
 
 
 
 
14.0 
BIOSTATISTICS 
 
The intent of this phase 2 trial is to determine if the introduction of the CliniMACS  system, as a method of T- 
cell depletion, maintains or reduces the current rates of graft failure, graft versus host disease, and non-relapse 
mortality in patients with hematologic disease that require a stem cell transplant. The patient population for this 
study will  be divided  into three groups based on the cytoreduction regimen administered.  Because patients at 

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later stages of disease may be more susceptible to toxicities induced by the three conditioning  regimens, accrual 
to the three groups will also be stratified according to transplant risk as standard risk or poor risk. Cytoreduction 
regimens are detailed in section 4.2. Risk strata are detailed in Section 6.1. 
Each of the six treatment strata will accrue 30 patients, and to insure patient safety, will be monitored for graft 
failure, graft versus host disease, and non-relapse mortality. The same stopping boundaries for excessive graft 
failure, acute GvHD, and the corresponding power calculations will be used for each stratum. The boundary for 
100 day non-relapse mortality in the poor risk transplant patients is 20% in each treatment group and 15% for 
standard risk transplant patients in each treatment group. This is because patients in the poor risk transplant 
group have been repeatedly shown to have a higher treatment related mortality than patients in earlier stages of 
ALL, AML, and CML, who constitute the standard risk group. In the event that the stopping boundary is crossed 
for one treatment stratum, the study will continue accrual in the other treatment groups. The power calculations 
are computed for each of the three failure endpoints  separately. 
 
Table of Stopping boundaries – poor risk group 
 
# of failures needed  
Failure  rate  
Probability  boundary 
Failure Endpoint 
to stop the arm 
in the population 
is crossed 
Graft failure 
2 in the first 26 patients 
3 within 30 patients 
0.02 
0.10 
0.15 
0.93 
Acute GvHD at d100 
(Grades 3-4) 
3 in the first 16 patients 
4 in the first 26 patients 
5 within 30 patients 
0.06 
0.10 
0.23 
0.91 
Non-relapse mortality 
by d100 
3 in the first 11 patients 
4 in the first 19 patients 
5 in the first 27 patients 
6 within 30 patients 
0.08 
0.10 
0.25 
0.88 
Table of Stopping boundaries – standard risk group 
 
# of failures needed  
Failure  rate  
Probability  boundary 
Failure Endpoint 
to stop the arm 
in the population 
is crossed 
 
Graft failure 
2 in the first 26 patients 
3 within 30 patients 
0.02 
0.10 
0.15 
0.93 
Acute GvHD at d100 
(Grades 3-4) 
3 in the first 16 patients 
4 in the first 26 patients 
5 within 30 patients 
0.06 
0.10 
0.23 
0.91 
3 in the first 20 patients 
0.02 
0.10 

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Non-relapse mortality 
by d100 
4 within 30 patients 
0.15 
0.93 
 
 
We have modified  the eligibility  criteria to include individuals  under the age of 70. In addition, patients with 
mismatched donors will receive an additional  dose of ATG. 
Given the modification  in the patient population,  treatment, and the classification of risk used for patient 
evaluation, we proposed amendment 3 to the protocol to accrue an additional 30 patients to each of the  six 
strata, determined by the two risk groups and the three cytoreductive regimens (section 4.2). The stopping 
rules below will be used to monitor  the additional 30 patients for excessive graft failure, day 100 graft versus 
host disease, and day 100 non-relapse related mortality. 
An analysis of the initial  set of patients on this protocol indicated that the day 100 acute graft versus host 
disease occurred more frequently in patients with a mismatched donor and that the ratio of matched to 
mismatched donors was approximately 3:1. As a result, for the additional 30 patients, the projected 
unacceptable failure rate for day 100 acute graft versus host disease has been updated to reflect the differential 
failure and accrual rates. The updated stopping  boundaries for graft failure, day 100 acute graft versus host 
disease, and day 100 non-relapse related mortality are the same for each cytoreduction regimen but may differ 
with respect to patient risk. 
 
As a result of the changes (detailed above) to the study design, accrual for the study re started from zero 
as of the Amendment 3 approval on 5/31/11. 
An additional treatment regimen, consisting  of Melphalan, Fludarabine, and Thiotepa, will be administered to 
the poor risk patients on this protocol as defined in the Eligibility Criteria section. This regimen was added to 
the protocol with the approval of Amendment 7 on 12/4/2012. Thirty (30) poor risk patients will receive this 
fourth conditioning regimen will be monitored for safety according to the stopping boundaries provided in the 
Table below: 
 
Table of Stopping boundaries for the poor risk group 
 
# of failures needed  
Failure  rate  
Probability  boundary 
Failure Endpoint 
to stop the arm 
in the population 
is crossed 
 
Graft failure 
2 in the first 26 patients 
3 within 30 patients 
0.02 
0.10 
0.15 
0.93 
Acute GvHD at d100 
(Grades 3-4) 
3 in the first 16 patients 
4 in the first 26 patients 
5 within 30 patients 
0.06 
0.10 
0.23 
0.91 
Non-relapse mortality 
by d100 
3 in the first 11 patients 
4 in the first 19 patients 
5 in the first 27 patients 
6 within 30 patients 
0.08 
0.10 
0.25 
0.88 

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Amendment 9 was approved on 5/28/2013.  Accrual adjustments for arm B and the updated stopping 
rules are detailed below: 
In addition, recent data at MSKCC suggests that the addition  of immune gammaglobulin  (IVIG) added to the 
incubation  fluid at a concentration of 1.5 mg IVIG/ml during incubation  of the antiCD34 beads with the 
mobilized  PBSC results in a reduction in the rate of grade 2-4 acute graft versus host disease (GVHD).  For 
HLA-matched transplant patients treated on this protocol,  19/98 patients without the addition  of IVIG patients 
have experienced grade 2-4 acute GVHD, whereas there are no reports of acute GVHD in 15 patients treated 
with immune gammaglobulin  exposed products with a minimum  follow up of 100 days.  We plan to continue 
the exploration of the IVIG effect in this protocol; however, accrual for cohort B in this study is near 
completion. As a result, we will expand this cohort and accrue an additional 20 patients. In order to ensure 
patient safety in this additional  cohort, if at any time during accrual 2 patients experience grade 3-4 acute graft 
versus host disease  at day 100 or 2 patients experience graft failure, accrual will stop. The stopping 
boundaries for the other patient cohorts remain in effect. 
 
As result of the increased accrual proposed in Amendment 15, accrual adjustments for arm A and the 
updated stopping rules are detailed below: 
In order to further evaluate the efficacy of standard risk patients treated on arm A, accrual for this cohort/risk 
group was increased by an additional  20 patients.  For these additional 20 patients, in order to ensure patient 
safety in this additional cohort, if at any time during accrual 2 patients experience grade 3-4 acute graft versus 
host disease at day 100 or 2 patients experience graft failure, accrual will stop in Arm A. 
Patient accrual for the poor risk and standard risk groups treated with the Arm B regimen is nearly complete. 
As a result, after accrual of the additional 20 patients added with amendment 9 is complete, and the 
stopping boundaries have not been exceeded, we propose to accrue an additional 60 patients to each risk 
group on this arm with Amendment 15.  These additional patients will provide a more precise estimate of  
the disease-free and overall survival in this patient population.  The stopping rules below will be used to  
monitor the additional 120 patients for excessive graft failure, graft versus host disease, and non-relapse 
mortality. 
At the conclusion of the study, Kaplan-Meier estimates of overall and disease-free survival will be computed 
over time. In addition, the probability of graft failure, non-relapse mortality, and acute and chronic graft-versus- 
host disease will be calculated using the cumulative incidence function. The proportion of patients receiving 
optimal CD34+, CD3+, and CD3+ T-cell doses will be computed. A logistic regression model and a Cox 
proportional hazards model will be used to correlate the dose of CD34+ progenitors and CD3+ T cells with 
engraftment, GvHD, and non-relapse mortality. 
 
As a result of four treatment related deaths within the first nineteen patients in the poor risk group of 
Arm C have been observed, accrual adjustments for the poor risk group of Arm C are detailed below: 
Although the stopping boundary for this risk group has been crossed, accrual will continue. The number of 
treatment related deaths in this group will continue to be monitored and if the observed proportion exceeds 30% 
at any time during the study, accrual will be suspended. 

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Table of stopping boundaries poor risk group 
 
 
 
 
Failure endpoint 
 
# of failures needed to 
Failure rate 
Probability  boundary 
stop accrual within group 
in the population 
 is crossed 
Graft failure 
4 in the first 30 patients 
0.05 
0.09 
5 in the first 40 patients 
0.15 
0.88 
6 in the first 50 patients 
7 within 60 patients 
Acute GvHD at d100 
5 in the first 20 patients 
0.10 
0.10 
7 in the first 30 patients 
0.25 
0.95 
(Grades 3-4) 
8 in the first 40 patients 
9 in the first 50 patients 
11 within  60 patients 
Non-relapse mortality 
5 in the first 20 patients 
7 in the first 30 patients 
0.10 
0.10 
at d100 
8 in the first 40 patients 
0.25 
0.95 
9 in the first 50 patients 
11 within  60 patients 
 
 
 
 
Table of stopping boundaries – standard risk group 
 
 
 
Failure endpoint 
# of failures needed to 
Failure rate 
Probability  boundary 
stop accrual within group 
in the population 
 is crossed 
 
Graft failure 
4 in the first 30 patients 
0.05 
0.09 
5 in the first 40 patients 
6 in the first 50 patients 
0.15 
0.88 
7 within 60 patients 
Acute GvHD at d100 
5 in the first 20 patients 
0.10 
0.10 
7 in the first 30 patients 
(Grades 3-4) 
8 in the first 40 patients 
0.25 
0.95 
9 in the first 50 patients 
11 within  60 patients 
Non-relapse mortality 
4 in the first 30 patients 
0.05 
0.09 
5 in the first 40 patients 
at d100 
6 in the first 50 patients 
0.15 
0.88 
7 within 60 patients 

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15.1 
RESEARCH PARTICIPANT REGISTRATION AND RANDOMIZATION PROCEDURES 
 
15.2 
Research Participant Registration 
 
 
Confirm  eligibility  as defined  in the section entitled  Inclusion/Exclusion  Criteria. Obtain  informed 
consent, by following  procedures defined  in section entitled  Informed  Consent Procedures. 
During  the registration  process registering  individuals  will  be required  to complete  a protocol 
specific  Eligibility  Checklist.  The individual  signing  the Eligibility  Checklist  is confirming 
whether or not the participant  is eligible  to enroll  in the study. Study staff are responsible  for 
ensuring  that all institutional  requirements  necessary to enroll  a participant  to the study have been 
completed.  See related Clinical  Research Policy  and Procedure #401 (Protocol Participant 
Registration).   15.2 
Randomization 
This research study does not require a randomization. 
 
16.1 
DATA MANAGEMENT ISSUES 
 
A Clinical Research Coordinator (CRC) will be assigned to the study and will be responsible  for both 
pediatric and adult accruals. The responsibilities  of the CRC and principal investigator include  project 
compliance, data collection,  abstraction and entry, data reporting, regulatory monitoring,  problem 
resolution and prioritization,  and coordinate the activities of the protocol study team.  The data 
collected for this study will be entered into The Clinical Research Data Base (CRDB), a secure 
database.  Source documentation will be available to support the computerized patient record. 
Dr. Guenther Koehne at Miami Cancer Institute will assist with data analysis.  Identifiable  data will 
not leave MSKCC, and only de-identified  data will be shared over secured email.  Dr. Koehne has 
cared for some of these patients and has familiarity  with this clinical entity in his capacity as a 
clinician  who was previously the Co-Principal Investigator for this study at MSKCC. 
 
16.2 
Quality Assurance 
 
Weekly registration reports will be generated to monitor patient accruals and completeness of 
registration data.  Routine data quality  reports will be generated to assess missing data and 
inconsistencies.   Accrual rates and extent and accuracy of evaluations and follow-up will be monitored 
periodically  throughout the study period and potential problems will be brought to the attention of the 
study team for discussion and action. 
Random-sample data quality and protocol compliance audits will be conducted by the study team, at a 
minimum  of two times per year, more frequently if indicated. 
 
16.3 
Data and Safety Monitoring 
The Data and Safety Monitoring  (DSM) Plans at Memorial Sloan-Kettering Cancer Center were 
approved by the National Cancer Institute in September 2001.  The plans address the new policies set 
forth by the NCI in the document entitled “Policy of the National Cancer Institute for Data and Safety 
Monitoring  of Clinical  Trials” which can be found at: 
http://cancertrials.nci.nih.gov/researchers/dsm/index.html. 
The DSM Plans at MSKCC were 

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established and are monitored by the Office of Clinical Research.  The MSKCC Data and Safety 
Monitoring  Plans can be found on the MSKCC Intranet at: http://mskweb2.mskcc.org/irb/index.htm 
There are several different mechanisms by which clinical trials are monitored for data, safety and 
quality.   There are institutional  processes in place for quality  assurance (e.g., protocol monitoring, 
compliance and data verification  audits, therapeutic response, and staff education on clinical research 
QA) and departmental procedures for quality control, plus there are two institutional  committees that 
are responsible for monitoring  the activities of our clinical trials programs.  The committees: Data and 
Safety Monitoring  Committee (DSMC) for Phase I and II clinical trials, and the Data and Safety 
Monitoring  Board (DSMB) for Phase III clinical trials, report to the Center’s Research Council and 
Institutional  Review Board. 
During the protocol development and review process, each protocol will be assessed for its level of 
risk and degree of monitoring  required.  Every type of protocol (e.g., NIH sponsored, in-house 
sponsored, industrial sponsored, NCI cooperative group, etc.) Will be addressed and the monitoring 
procedures will be established at the time of protocol activation. 
 
17.1 
PROTECTION OF HUMAN SUBJECTS 
The risks associated with a T-cell depleted transplant after cytoreduction by any of the  four 
conditioning  regimens under study are those associated with the toxicities  of the conditioning 
regimens, as detailed in Section 11.0, as well as the risks of an allogeneic  transplant, particularly graft 
failure, or graft vs. host disease, as also detailed in Section 11.0. 
To protect against the toxicities  of the cytoreductive regimens, the patient will be transplanted in a 
single  room, HEPA filtered environment.  Organ toxicities  such as mucositis, enteritis and hepatic 
dysfunction as well as infectious complications  will be treated by standard procedures developed for 
transplantation to support our patients.  Blood and platelet counts will be supported by transfusion. 
Graft failure might necessitate a second transplant, after additional conditioning.    Approaches to the 
diagnosis  and treatment of graft failure that secure consistent engraftment have been developed by the 
Transplantation Services.  Similarly,  advanced treatments will be instituted  in the event the patient 
develops graft vs. host disease. 
Despite a transplant, the patient’s disease may recur.  In this case, standard and/or experimental 
therapies, such as phase I/II drugs, antibodies or cell therapies, will be available to the patient for 
consideration  as treatment options. 
 
B e nefits : 
 
A transplant is administered with curative intent.  The approaches being evaluated may achieve this 
goal and may also be effective in preventing acute and chronic graft vs. host disease. 
The results of this study will also define risks and benefits of T-cell depleted grafts fractionated on the 
CliniMACS  device, when administered after each of the cytoreduction regimen proposed for study. 
This may greatly accelerate further development of transplantation approaches employing  this 
approach to T-cell depletion. 
Consent Process: Participation in this study is voluntary. All patients will be required to sign a 
statement of informed consent which must conform to MSKCC IRB guidelines. 

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Approval date: 05-Jul-2019 
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Alternatives:  Enrollment  in this study is voluntary. Alternative treatment options will be presented to 
the patient prior to taking part in this study. Alternative treatment options may include getting a 
transplant from a volunteer unrelated donor, if one is available; getting treatment for the cancer with 
either chemotherapy or a transplant without being on a study; taking part in another study; or getting 
no treatment. 
 
 
Costs: The patient’s health plan/insurance company will need to pay for all of the costs of treatment in 
this study. The patient will be responsible  for the costs of standard medical care, all hospitalizations 
and any transplant complications.  Pre-authorization for the transplant will be cleared with the health 
plan/insurance company prior to admission. Patients will not be paid for taking part in this study. 
Research tests will be done at no cost to the patient. 
 
Confidentiality:  Every effort will be made to maintain patient confidentiality.  Research and hospital 
records are confidential. 
17.2 
Privacy 
 
MSKCC’s Privacy Office may allow the use and disclosure of protected health information  pursuant 
to a completed and signed Research Authorization form. The use and disclosure of protected health 
information  will be limited  to the individuals  described in the Research Authorization form. A 
Research Authorization form must be completed by the Principal Investigator and approved by the 
IRB and Privacy Board (IRB/PB). 
 
The consent indicates that individualized  de identified information  collected for the purposes of this 
study may be shared with other qualified  researchers. Only researchers who have received approval 
from MSK will be allowed to access this information  which will not include  protected health 
information,  such as the participant’s name, except for dates. It is also stated in the Research 
Authorization  that their research data may be shared with other qualified  researchers. 
 
 
 
17.3 
Serious Adverse Event (SAE) Reporting 
 
 
An adverse event is considered serious if it results in ANY of the following  outcomes: 
• Death 
• A life-threatening adverse event 
• An adverse event that results in inpatient hospitalization  or prolongation  of existing hospitalization 
• A persistent or significant incapacity or substantial disruption  of the ability  to conduct normal life functions 
• A congenital anomaly/birth  defect 
• Important Medical Events (IME) that may not result in death, be life threatening, or require hospitalization 
may be considered serious when, based upon medical judgment,  they may jeopardize  the patient or participant 
and may require medical or surgical intervention  to prevent one of the outcomes listed in this definition 
 
Note: Hospital admission for a planned procedure/disease treatment is not considered an SAE. 
SAE reporting is required as soon as the participant starts investigational  treatment/intervention. SAE 
reporting is required for 30-days after the participant’s last investigational  treatment/intervention. Any event 

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Page 51 of 56 
 
 
 
that occur after the 30-day period that is unexpected and at least possibly  related to protocol treatment must be 
reported. 
Please note: Any SAE that occurs prior to the start of investigational  treatment/intervention and is related to a 
screening test or procedure (i.e., a screening biopsy) must be reported. 
All SAEs must be submitted in PIMS. If an SAE requires submission to the HRPP office per IRB SOP RR-408 
‘Reporting of Serious Adverse Events’, the SAE report must be submitted within 5 calendar days of the event. 
All other SAEs must be submitted within 30 calendar days of the event. 
The report should contain the following  information: 
• The date the adverse event occurred 
• The adverse event 
• The grade of the event 
• Relationship  of the adverse event to the treatment(s) 
• If the AE was expected 
• Detailed text that includes the following 
o An explanation of how the AE was handled 
o A description of the participant’s condition 
o Indication if the participant remains on the study 
 
• If an amendment will need to be made to the protocol and/or consent form 
• If the SAE is an Unanticipated Problem 
 
For IND/IDE protocols: The SAE report should be completed as per above instructions.  If appropriate, the 
report will be forwarded to the FDA by the IND Office. 
 
17.2.1 
This protocol has an IND, therefore, the SAE will also be reported to the FDA through the IND Office 
and the report will include  the FDA assigned IND number and name. 
17.2.2 Definition of SAE 
 
An SAE is an undesirable experience that meets one of the following  criteria: 
 
• 
Is fatal or life-threatening 
• 
Is disabling 
• 
Results in a congenital anomaly or occurrence of malignancy 
• 
Important medical event that jeopardizes the participant AND requires medical or surgical 
intervention  to prevent one of the outcomes above 
Note: Hospital admission for a planned procedure/disease treatment is not considered an SAE. 
 
Attribution: 
 
• 
Unrelated: The AE is clearly NOT related to the  device 
• 
Unlikely:  The AE is doubtfully related to the  device 
• 
Possible: The AE may be related to the  device 
• 
Probable: The AE is likely related to the  device 
• 
Definite: The AE is clearly related to the  device 
 
 
Expected and Unexpected Event: 

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• 
Expected: Any experience previously reported (in nature, severity, or incidence) in the current 
Investigator’s Brochure for the CliniMACS  device or general investigational  plan 
• 
Unexpected: Any experience not previously reported (in nature, severity, or incidence) in the 
current Investigator’s Brochure for the CliniMACS  device or general investigational  plan 
 
 
REPORTABLE  EVENTS: 
 
• 
Grades 1-2: Adverse Event Reporting NOT required. 
• 
Grades 3-4: Possible, Probable or Definitely  attributed to the CliniMACS  device, (as detailed  as 
11.2.1), will be reported *. 
• 
Grades 5: Regardless of Attribution  will be reported*. 
*Reportable events are those which occur within 30 days of the last dose of treatment on protocol. Events 
beyond 30 days will be reported at the discretion of the PI. 
 
 
18.1 
INFORMED CONSENT PROCEDURES 
 
Before protocol-specified procedures are carried out, consenting professionals will explain full details 
of the protocol and study procedures as well as the risks involved  to participants prior to their  
inclusion  in the study. Participants will also be informed that they are free to withdraw from the study 
at any time. All participants must sign an IRB/PB-approved consent form indicating  their consent to 
participate. This consent form meets the requirements of the Code of Federal Regulations  and the 
Institutional  Review Board/Privacy Board of this Center. The consent form will include  the following: 
1. The nature and objectives, potential risks and benefits of the intended study. 
2. The length of study and the likely  follow-up required. 
3. Alternatives to the proposed study. (This will include  available standard and investigational 
therapies. In addition,  patients will be offered an option  of supportive care for therapeutic 
studies.) 
4. The name of the investigator(s) responsible for the protocol. 
5. The right of the participant to accept or refuse study interventions/interactions  and to withdraw 
from participation  at any time. 
Before any protocol-specific  procedures can be carried out, the consenting professional will fully 
explain the aspects of patient privacy concerning research specific information.   In addition to signing 
the IRB Informed Consent, all patients must agree to the Research Authorization component of the 
informed consent form. 
Each participant and consenting professional will sign the consent form. The participant must receive 
a copy of the signed informed consent form. 
 
 
19.0 
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64. Giglio  F, Venstrom J, Gallagher M, et al. KIR3DL1/S1 and HLA-B alleles combine to influence 
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2012;[Abstract]. 
65. Cook MA, Milligan  DW, Fegan CD, et al. The impact of donor KIR and patient HLA-C genotypes on 
outcome following  HLA-identical sibling  hematopoietic  stem cell transplantation for myeloid 
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66. Giebel S, Locatelli F, Wojnar J, et al. Homozygosity  for human leucocyte antigen-C ligands of 
KIR2DL1 is associated with increased risk of relapse after human leucocyte antigen-C-matched 
unrelated donor haematopoietic stem cell transplantation. Br J Haematol. 2005;131:483-486. 
67. Gagne K, Busson M, Bignon J, et al. Donor KIR3DL1/3DS1 gene and recipient Bw4 KIR ligand as 
prognostic  markers for outcome in unrelated hematopoietic  stem cell transplantation. Biol Blood Marr 
Transpl.  2009;15:1366-1375. 
 
 
20.0 
APPENDICES 
 
There are no appendices with this protocol.