A Prospective Study of Tocilizumab for the Prevention of Graft Failure and Graft-versus-Host Disease in Haplo-Cord Transplantation
Phase: PHASE2
Conditions: Hematologic Malignancy, Bone Marrow Transplant
Sponsor: Weill Medical College of Cornell University

Title: A Prospective Study of Tocilizumab for the Prevention of Graft Failure and Graft-versus-Host 
Disease in Haplo-Cord Transplantation 
 
NCT 04395222 
Initial IRB Approval Date: 4/28/2020 
 
Amendment History 
• 
Original Protocol Date: 06APR2020 
• 
Amendment #1: 10SEP2020 
• 
Amendment #2: 21JUN2022 

 
 
  
Page # i 
 
TITLE:   
A Prospective Study of Tocilizumab for the Prevention of Graft Failure and Graft-
versus-Host Disease in Haplo-Cord Transplantation 
 
IRB Protocol #: 19-08020738 
Version Date: 21 June 2022 
 
Principal Investigator: 
 
Alexandra Gomez Arteaga, MD 
520 East 70th Street, Starr 3 
New York, NY 10021 
Tel: 646-962-7950 
Fax: 212-746-6678 
alg9117@med.cornell.edu 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
  
Page # i 
 
Table of Contents 
Statement of Compliance ....................................................................................................................... iv 
Confidentiality Statement ...................................................................................................................... v 
List of Abbreviations .............................................................................................................................. vi 
1.0 Protocol Summary ............................................................................................................................ 1 
1.1 
Schema .................................................................................................................................. 4 
1.2 
Study Objectives .................................................................................................................... 7 
1.2.1  
Primary Objectives ............................................................................................................... 7 
1.2.2  
Secondary Objectives ........................................................................................................... 7 
1.2.3  
Exploratory Objectives ......................................................................................................... 7 
2. Background ........................................................................................................................................ 7 
2.1 
Histocompatibility in Hematopoietic Stem Cell Transplantation ............................................. 7 
2.2 
Umbilical Cord Blood as a Hematopoietic Stem Cell Source .................................................... 8 
2.3 
Haplo-Cord Transplantation ................................................................................................... 9 
2.4 
Cord Blood Transplantation and the Graft versus Tumor effect ............................................ 10 
2.5 
ATG in Cord Blood Transplantation ...................................................................................... 12 
2.6 
ATG in Haplo-Cord Transplantation ...................................................................................... 13 
2.7 
Acute Graft versus Host Disease .......................................................................................... 14 
2.8  
IL-6 Biology .......................................................................................................................... 14 
2.9 
Tocilizumab ......................................................................................................................... 15 
2.10 
Tocilizumab in the Treatment and Prevention of GVHD ....................................................... 16 
2.11  
Rationale ............................................................................................................................. 17 
2.12 
Correlative Studies Background ........................................................................................... 18 
3. Study Design .................................................................................................................................... 19 
3.1 
Overall Design ..................................................................................................................... 19 
3.2 
Scientific Rationale for Study Design .................................................................................... 20 
3.3 
Justification for Dose ........................................................................................................... 20 
3.4 
End of Study Definition ........................................................................................................ 20 
4. Subject Selection .............................................................................................................................. 21 
4.1 
Study Population ................................................................................................................. 21 
4.2 
Inclusion Criteria .................................................................................................................. 21 
4.3 
Exclusion Criteria ................................................................................................................. 22 
4.4 
Screen Failures ..................................................................................................................... 22 
5. Registration Procedures ................................................................................................................... 22 
5.1 
Subject Registration ............................................................................................................. 22 
6. Study Procedures ............................................................................................................................. 22 
6.1 
Schedule of Assessments ..................................................................................................... 22 
6.1.1 
Pre-Transplant Evaluation ...................................................................................................... 24 
6.1.2 
Post-Transplant Evaluation .................................................................................................... 25 
6.1.3 
Follow-up Phase ...................................................................................................................... 26 
7. Study Intervention ........................................................................................................................... 26 
7.1 
Stem Cell Source and Cell Dose ............................................................................................ 26 

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7.1.1 
Umbilical Cord Blood Unit .................................................................................................... 26 
7.1.2 
Haplo-identical Donor .......................................................................................................... 26 
7.1.3 
Infusion of Cells ................................................................................................................... 27 
7.2 
Treatment Plan .................................................................................................................... 27 
7.2.1 
Conditioning Regimen .......................................................................................................... 27 
7.2.2 Post-Transplant Course (GVHD Prophylaxis) ............................................................................ 29 
7.2.3 
Supportive Care ................................................................................................................... 29 
8. Study Intervention Discontinuation and Participant Discontinuation/Withdrawal ............................ 30 
8.1 
Discontinuation of Study Intervention ................................................................................. 30 
8.1.1 
Disease Progression or Disease Persistence ......................................................................... 31 
8.1.2 
Extraordinary Medical Circumstances .................................................................................. 31 
8.2 
Participant Discontinuation/Withdrawal from the Study ..................................................... 31 
9.  Criteria for Study Evaluation ............................................................................................................ 31 
10. Data Reporting / Regulatory Considerations ................................................................................... 32 
10.1 Data Collection ......................................................................................................................... 32 
10.1.1 REDCap ...................................................................................................................................... 32 
10.2 Regulatory Considerations ........................................................................................................ 32 
10.2.1 Institutional Review Board/Ethics Committee Approval ........................................................ 32 
10.2.2 Ethical Conduct of the Study .................................................................................................... 33 
10.2.3 Informed Consent ..................................................................................................................... 33 
10.2.4 Compliance with Trial Registration and Results Posting Requirements ................................. 34 
10.2.5 Record Retention ...................................................................................................................... 34 
11 
 Statistical Considerations ............................................................................................................ 34 
11.1 Study Design/Endpoints ........................................................................................................... 34 
11.2 
Sample Size/Accrual Rate .................................................................................................... 34 
11.3 
Analysis of Endpoints ........................................................................................................... 36 
11.3.1 
Analysis of Primary Endpoints ........................................................................................... 36 
11.3.2 
Analysis of Secondary Endpoints ....................................................................................... 36 
11.4 
Reporting and Exclusions ..................................................................................................... 37 
11.4.1 
Evaluation of Toxicity ......................................................................................................... 37 
11.4.2 
Evaluation of Response ...................................................................................................... 37 
12. Adverse Event Reporting Requirements ......................................................................................... 37 
12.1 Adverse Event Definition .......................................................................................................... 37 
12.1.1 
Investigational Agent or Device Risks (Expected Adverse Events) ................................... 37 
12.2.2 
Adverse Event Characteristics and Related Attributions .................................................. 37 
12.1.4 
Reporting of AE to WCM IRB .............................................................................................. 38 
12.1.5 
Events of Special Interest ................................................................................................... 38 
12.2 Definition of SAE ...................................................................................................................... 38 
12.2.1 
Reporting of SAE to IRB ...................................................................................................... 39 
12.2.2 
Reporting of SAE to FDA ..................................................................................................... 39 
12.3 AE/SAE Follow Up ..................................................................................................................... 39 
13. Unanticipated Problems Involving Risks to Subjects or Others ........................................................ 39 
13.1 Definition of Unanticipated Problems Involving Risks to Subjects or Others (UPIRTSO) ............. 40 
13.1.2 
Unanticipated Problem Reporting ..................................................................................... 40 

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14. Data and Safety Monitoring Plan (DSMP) ....................................................................................... 40 
References ........................................................................................................................................... 40 
Appendix A: Performance Status Criteria ............................................................................................. 46 
Appendix B: Background Drug Information .......................................................................................... 47 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Statement of Compliance 
 
 
The trial will be carried out in accordance with International Conference on Harmonisation Good 
Clinical Practice (ICH GCP) and the following:  
 
• 
United States (US) Code of Federal Regulations (CFR) applicable to clinical studies (45 CFR Part 
46, 21 CFR Part 50, 21 CFR Part 56, 21 CFR Part 312, and/or 21 CFR Part 812)  
 
National Institutes of Health (NIH)-funded investigators and clinical trial site staff who are 
responsible for the conduct, management, or oversight of NIH-funded clinical trials have completed 
Human Subjects Protection and ICH GCP Training. 
 
The protocol, informed consent form(s), recruitment materials, and all participant materials will be 
submitted to the Institutional Review Board (IRB) for review and approval.  Approval of both the 
protocol and the consent form must be obtained before any participant is enrolled.  Any 
amendment to the protocol will require review and approval by the IRB before the changes are 
implemented to the study.  In addition, all changes to the consent form will be IRB-approved; a 
determination will be made regarding whether a new consent needs to be obtained from 
participants who provided consent, using a previously approved consent form. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Confidentiality Statement 
 
This document is confidential and is to be distributed for review only to investigators, potential 
investigators, consultants, study staff, and applicable independent ethics committees or institutional review 
boards. The contents of this document shall not be disclosed to others without written authorization from 
WCM. 
 
 
 

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List of Abbreviations 
 
AE 
Adverse Event 
ALL 
Acute Lymphoblastic Leukemia 
ALT 
Alanine Aminotransferase 
ANC 
Absolute Neutrophil Count 
APC 
Antigen-Presenting Cell 
AST 
Aspartate Aminotransferase 
B-HCG 
Beta-Human Chorionic Gonadotropin 
CAR-T 
Chimeric Antigen Receptor T-Cell 
CBT 
Cord Blood Transplantation 
CFR 
Code of Federal Regulations 
CI 
Continuous Infusion 
CIBMTR 
Center for International Blood and Marrow Transplant Research 
CMV 
Cytomegalovirus 
CONSORT 
Consolidated Standards of Reporting Trials 
CRF 
Case Report Form 
CRS 
Cytokine Release Syndrome 
CT 
Computed Tomography 
CTSC 
Clinical Translational Science Center  
Cy 
Cyclophosphamide 
CyTOF 
Mass Cytometry by Time of Flight 
DAMPS 
Danger-Associated Molecular Patterns 
DFS 
Disease-Free Survival 
DSMB 
Data Safety Monitoring Board 
DSMP 
Data Safety Monitoring Plan 
EBV 
Epstein-Barr Virus 
eGFR 
Estimated Glomerular Filtration Rate 
FDA 
Food and Drug Administration 
Flu 
Fludarabine 
GCP 
Good Clinical Practice 
G-CSF 
Granulocyte Colony-Stimulating Factor 
GFRS 
GVHD-Free/Relapse-Free Survival 
GI 
Gastrointestinal 
GVHD 
Graft-versus-Host Disease 
GVL 
Graft-versus-Leukemia 
GVT 
Graft-versus-Tumor 

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Gy 
Gray 
HIPAA 
Health Insurance Portability and Accountability Act of 1996 
HIV 
Human Immunodeficiency Virus 
HLA 
Human Leukocyte Antigen 
HRBFA 
Human Research Billing Analysis Form 
HSCT 
Hematopoietic Stem Cell Transplantation 
HUD 
Humanitarian Use Device  
ICF 
Informed Consent Form 
IDE 
Investigational Device Exemption  
IFN-y 
Interferon gamma 
IL 
Interleukin 
IND 
Investigational New Drug 
IPA 
Inherited Paternal Antigen 
IQR 
Interquartile Range 
IRB 
Institutional Review Board 
IV 
Intravenously 
JAK 
Janus Kinase 
KPS 
Karnofsky Performance Status 
LVEF 
Left Ventricular Ejection Fraction 
MDRD 
Modification of Diet in Renal Disease Study 
Mel 
Melphalan 
MHC 
Major Histocompatibility Complex 
MMF 
Mycophenolate Mofetil 
MNC 
Mononuclear Cell 
MRD 
Measurable Residual Disease 
MSKCC 
Memorial Sloan Kettering Cancer Center 
MUD 
Matched Unrelated Donor 
NIMA 
Non-Inherited Maternal Antigen 
NMDP 
National Marrow Donor Program 
OS 
Overall Survival 
PAMPS 
Pathogen-Associated Molecular Patterns 
PB 
Peripheral Blood 
PBSC 
Peripheral Blood Stem Cell 
PCR 
Polymerase Chain Reaction 
PET 
Positron Emission Tomography 
PFS 
Progression-Free Survival 

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PHI 
Protected Health Information 
PI 
Principal Investigator 
PO 
Per os 
PTCy 
Post-Transplant Cyclophosphamide 
PTLD 
Post-Transplant Lymphoproliferative Disease 
rATG 
Rabbit Antithymocyte Globulin 
REDCap 
Research Electronic Data Capture 
SAE 
Serious Adverse Event 
SGPT 
Serum Glutamate-Pyruvate Transaminase 
SNP 
Single Nucleotide Polymorphisms 
SR 
Steroid-Refractory 
SUSAR 
Suspected Unexpected Serious Adverse Reaction  
TBI 
Total Body Irradiation 
TBV 
Total Blood Volume 
TNC 
Total Nucleated Cell 
TNFa 
Tumor Necrosis Factor alpha 
Tregs 
Regulatory T-cells 
TRM 
Transplant-Related Mortality 
UCB 
Umbilical Cord Blood 
UIRTSO 
Unanticipated Problem Involving Risks to Subjects or Others 
WCM 
Weill Cornell Medicine 
WRG-CT 
Weill Research Gateway – Clinical Trials 
 
 

Protocol # 19-08020738-01 
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Page # 1 
 
1.0 Protocol Summary 
 
Full Title: 
 
 
 
 
A Prospective Study of Tocilizumab for the Prevention of Graft Failure 
and Graft-versus-Host Disease in Haplo-Cord Transplantation     
 
Short Title:  
 
 
 
Tocilizumab in Haplo-Cord Transplant  
 
Clinical Phase:  
 
 
Phase II 
 
Principal Investigator:  
 
Alexandra Gomez Arteaga, MD 
 
Study Description:  
 
Haplo-Cord transplantation – the co-infusion of a single umbilical cord 
blood graft with CD34-selected cells from a haplo-identical adult donor, 
provides an alternate source of stem cells for patients with high-risk 
hematologic malignancy in need of an allogeneic transplant but lacking a 
suitable HLA-matched donor. Traditionally, anti-thymocyte globulin 
(ATG) is administered prior to haplo-cord transplantation to reduce the 
incidence of graft failure, graft-versus-host disease (GVHD) and graft 
versus graft reactions. However, excessive ATG-mediation of cord 
lymphocytes may compromise immune reconstitution leading to 
increased infections, viral reactivations and relapse – due to impaired 
graft versus tumor (GVT) effects. Tocilizumab is an IL-6 receptor antibody 
with demonstrated efficacy in the prevention of GVHD. In this 
prospective investigator-initiated study, we will assess the safety of 
reducing and ultimately eliminating ATG from our haplo-cord preparative 
regimen while using tocilizumab as an alternative immunomodulatory 
agent. We hypothesize that this will improve immune reconstitution 
while preserving the low rates of graft failure and GVHD that we currently 
enjoy. 
 
Study Population: 
 
Adult patients with hematologic malignancy in need of an alternate 
donor transplant 
 
Sample Size: 
 
The smallest sample size for the trial is 10 subjects and the largest is 70 
evaluable subjects. Four successive subject cohorts will accrue up to 10 
subjects. The final group will be expanded to a total subject size of 40 
(See statistical plan section 11.2) 
 
Enrollment: 
 
Subjects who undergo study treatment but are not evaluable for the 
primary endpoint due to death prior to day +21 will be replaced. 
Assuming that no more than 5% of subjects are non-evaluable, the largest 
accrual would be 74 subjects (=70 x 1.05) (See statistical plan section 
11.2) 

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2 
 
Enrollment Period: 
 
Two years (projected) 
 
Study Design: 
 
In this prospective study, all subjects will receive haplo-cord 
transplantation, conditioned with fludarabine, melphalan and total body 
irradiation (TBI), followed by a single dose of tocilizumab 8 mg/kg on day 
-1 of their regimen. Subjects will be recruited on to four successive 
cohorts – with subjects initially receiving our current standard 3 doses of 
ATG 1.5 mg/kg (total dose 4.5 mg/kg). In the absence of safety signals, 
we will drop one dose of ATG in successive cohorts until the drug 
ultimately has been eliminated entirely.  
 
 
 
We use a single arm, Bayesian study design. Each dose group will accrue 
up to 10 subjects. If there are 4 or fewer successes, that dose group will 
be deemed unacceptable and the next higher ATG dose for which there 
were 5 or more successes will be expanded. In other words, there will be 
10 subjects initially enrolled in the first group (total ATG dose of 4.5 
mg/kg). At the point of 5 or more successes are observed, subjects will 
be enrolled at dose group II (even if less than 10 subjects were accrued 
to group I). This will continue until there is a point where there are 4 or 
fewer successes out of 10 subjects. At this point, the next lower group 
(higher dose) will be expanded to a total of 40 subjects with interim 
analyses done after each 10 subjects for futility. An expansion cohort 
sample size of 40 has 80.9% power of declaring the regimen active if the 
true success probability is 80%. 
 
 
 
Planned correlative studies are outlined in section 2.12 
 
Study Duration: 
 
Projected end date for enrollment January 2022. Final data analysis to be 
completed one year after the last subject accrual – projected January 
2023. 
 
Participant Duration: 
 
Following discharge from the in-patient transplant service, regular study 
visits will take place until 12 months post-transplant. After this time, 
subjects will continue to be followed for long-term outcomes at a 
frequency determined b the primary transplant physician for up to 5 
years. 
 
Study Agent/Device Name  
Tocilizumab 
 
Intervention Description: 
Tocilizumab 8 mg/kg IV administered as a single dose on Day -1 of 
transplant conditioning regimen 
 

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Primary Objective: 
 
To assess the safety and efficacy of tocilizumab in preventing early failure 
of the haplo-identical graft in haplo-graft transplantation 
 
Primary Endpoint: 
 
The primary endpoint is the percentage of successful haplo-derived 
neutrophil engraftment as defined by: 
• 
An absolute neutrophil count (ANC) of ?500 cells/microL for 
three consecutive days with the first on or prior to Day +21 post-
transplant 
• 
Absence of a second nadir, i.e. – a drop in the ANC to <0.3 
cells/microL for 5 consecutive days occurring after initial 
engraftment within the first 3 weeks post-transplant 
 
Secondary Objectives:  
To evaluate transplant outcomes in subjects undergoing haplo-cord 
transplantation using tocilizumab as an alternative to ATG – including 
overall survival, progression-free survival, relapse, transplant-related 
mortality, GVHD, toxicities, platelet engraftment, infections, post-
transplant lymphoproliferative disorders and viral reactivations (See 
section 9 for definitions and section 11.3.2 for analysis) 
 
Exploratory Objectives:  
To characterize the effects of tocilizumab used as an alternative to ATG 
in haplo-cord transplantation on immune reconstitution, serum cytokine 
profiles, novel predictive biomarkers of GVHD and on measurable 
residual disease (MRD) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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1.1 Schema 
 
INCLUSION/EXCLUSION: See Section 4. 
 
ENROLLMENT: All potential participants will have complete human leukocyte antigen (HLA) 
typing and determination of HLA antibodies.   
 
TREATMENT PLAN: 
 
Conditioning Regimen: Age <60yrs 
 
 
Day -7 
Day -6 
Day -5 
Day -4 
Day -3 
Day -2 
Day -1 
Day 0 
Day 1 
or day 0 
Fludarabine 
 
30 
mg/m2 
30 mg/m2 
30 mg/m2 
30 
mg/m2 
30 
mg/m2 
 
 Haplo 
Infusion 
UCB Infusion 
Melphalan 
 
 
 
 
140 mg/m2 
 
 
 
Tocilizumab 
 
 
 
 
 
8 mg/kg 
 
 
 
TBI 
 
2Gray 
2Gray 
 
 
 
ATG Group I 
 
1.5 mg/kg 
 1.5 
mg/kg 
 
1.5 
mg/kg 
 
 
ATG Group II 
 
1.5 mg/kg 
 1.5 
mg/kg 
 
_ 
 
 
ATG Group III 
 
1.5 mg/kg 
 _ 
 
_ 
 
 
ATG Group IV 
 
_ 
 _ 
 
_ 
 
 
 
 
Conditioning Regimen: Age >60yrs 
 
 
Day -5 
Day -4 
Day -3 
Day -2 
Day -1 
Day 0 
Day 1 
or day 0 
Fludarabine 
 
30 mg/m2 
30 
mg/m2 
30 
mg/m2 
 
 Haplo 
Infusion 
UCB Infusion 
Melphalan 
 
 
 
 
140 mg/m2 
 
 
 
Tocilizumab 
 
 
 
 
 
8 mg/kg 
 
 
 
TBI 
 
2Gray 
2Gray 
 
 
 
ATG Group I 
 
1.5 mg/kg 
 1.5 
mg/kg 
 
1.5 
mg/kg 
 
 
ATG Group II 
 
1.5 mg/kg 
 1.5 
mg/kg 
 
_ 
 
 
ATG Group III 
 
1.5 mg/kg 
 _ 
 
_ 
 
 
ATG Group IV 
 
_ 
 _ 
 
_ 
 
 
 
 
 

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Fludarabine:  
Age <60yrs: 30 mg/m2/day IV x 5 days (Total dose 150 mg/m2). 
Age >60yrs: 30 mg/m2/day IV x 3 days (Total dose 90 mg/m2).  
Fludarabine will be dosed according to actual body weight.  
 
Melphalan: 140 mg/m2/day IV x 1 day for all patients. Melphalan will be dosed according to actual body 
weight. Cryotherapy with ice chips will be administered to prevent mucositis.  
 
Tocilizumab: 8 mg/kg/day IV x 1 day. Tocilizumab will be dosed according to actual body weight. Patients 
>100kg will receive a capped maximum dose of 800 mg.  
 
TBI: Conditioning will be intensified with 2 doses of TBI (4 Gy) for all patients. This serves to decrease graft 
rejection and reduce the risk of relapse of malignant disease. 
 
Rabbit ATG (rATG)*: In the absence of safety signals, dosing will be reduced as the study proceeds as 
follows – 
 
• Cohort I: 1.5 mg/kg/day IV x 3 days (Total dose 4.5 mg/kg) on days -5, -3 and -1. 
• Cohort II: 1.5 mg/kg/day IV x 2 days (Total dose 3 mg/kg) on days -5 and -3.  
• Cohort III: 1.5mg/kg/day IV x 1 day (Total dose 1.5 mg/kg) on day -5 only.  
• Cohort IV: No rATG to be administered.  
 
ATG will be dosed according to actual body weight. The first dose will be infused over at least six hours, 
and any subsequent doses over at least 4 hours.  Pre-medications include acetaminophen 650 mg PO, 
diphenhydramine 25-50 mg PO/IV, and methylprednisolone 2 mg/kg (1 mg/ kg at the initiation and 1 
mg/kg half-way through anti-thymocyte globulin administration). 
Circumstances may require minor changes in scheduling of chemotherapy. Variations of up to 24 hours in 
scheduling will be acceptable. 
 
GVHD Prophylaxis: 
Tacrolimus: 0.03 mg/kg/day IV continuous infusion (CI) over 24 hr from 4 PM Day -2 until engraftment or 
when subject is able to take PO, then tacrolimus approximately 0.09 mg/kg PO in 2 divided doses.   
Tacrolimus should be given at full dose to maintain levels of 5-15 ng/mL through day 180, tapered by 20% 
every week thereafter. PO tacrolimus can be used when IV access for CI tacrolimus is unavailable.  
 
Cyclosporine: May be used as an alternative to Tacrolimus. 3 mg/kg/day IV over 24 hr from 9 PM Day -2 
until engraftment or when subject is able to take PO, then cyclosporine 3.5 mg/kg PO twice a day. 
Cyclosporine should be given at full dose to maintain levels of 150-400 ng/mL through day 180 and 
tapered by 20% every week thereafter. PO cyclosporine can be used when IV access for infusion is 
unavailable. 
 
Infection, toxicity or other clinical circumstances may prompt earlier discontinuation or adjustment of 
tacrolimus/cyclosporine doses. In the presence of GVHD, a clinical decision by the attending physician will 
determine if tacrolimus/cyclosporine can be tapered or should be continued. 
 
Mycophenolate Mofetil (MMF): will be started on day -2 and given at a dose of 1000 mg q8 hours until 
day 28. MMF can be given PO or IV. Infection, toxicity, very low patient weight (<50kg) may prompt earlier 
discontinuation or adjustment of doses. 

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Note: Patient specific circumstances may mandate minor variations in conditioning regimen and/or GVHD 
prophylaxis, such as reduction of some of the doses of medications, changes in schedule or – rarely - 
substitution of a particular drug. These changes will be noted and justified, but will not require IRB 
approval. 
 
Stem Cell infusion:  
The infusion of UCB and the haplo-identical units will be separated by at least 2 hours and preferably they 
will occur on successive days (Day 0 and Day 1).  The order of infusion is not specified.  
 
Supportive care: 
• CMV Prophylaxis 
• 
Prophylaxis will follow institutional unit policy and will be guided by the recipient and donor CMV 
serostatus tested during pre-transplant screening.  
 
• Cytomegalovirus (CMV) monitoring: 
• 
CMV viral load monitoring by PCR at least weekly until Day 100 and at least monthly until Day 210, 
regardless of donor/recipient CMV status.  
• 
Pre-emptive CMV treatment should be strongly considered for any positive result on by DNA 
testing (i.e, viral load) within the first 100 days of transplant. 
 
• PTLD Prophylaxis 
• 
Rituximab: All patients with prior EBV exposure not previously exposed to rituximab or who have 
not received rituximab in the six months prior to transplant, will receive one dose of rituximab 
375 mg/m2 prior to or upon admission.  
 
• Epstein-Barr virus (EBV) monitoring: 
 
• 
EBV viral load monitoring by PCR at least weekly until Day 100 and at least monthly until Day 365 
is strongly recommended. 
• 
Rising EBV titers should warrant investigation for EBV post-transplant lymphoproliferative 
disorder (PTLD) including CT imaging and PET scanning for positive CT findings. A bone marrow 
evaluation is recommended if any evidence of PTLD is found on imaging or peripheral blood 
analysis. 
• 
Evidence of PTLD or consecutive increases in EBV PCR should lead to treatment with rituximab at 
a dose and schedule per institutional policy. 
 
• 
A prophylactic broad-spectrum antifungal with anti-mold activity is strongly recommended.  
• 
Other infection prophylaxis and supportive care will be as per institutional unit policy. 
• 
In some cases, a drug called filgrastim (G-CSF) may be administered to hasten the recovery of blood 
counts.1-3 Generic formulations of filgrastim may be utilized as required by insurance or pharmacy.  
• 
Blood transfusion policy should follow institutional policy.  
 
 

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1.2 Study Objectives 
 
 
1.2.1  Primary Objectives  
 
• 
To assess the safety and efficacy of the humanized anti-IL6 receptor monoclonal antibody 
tocilizumab, used as an alternative to ATG, in preventing early failure of the haplo graft in haplo-cord 
hematopoietic cell transplantation. 
 
1.2.2  Secondary Objectives  
• 
To assess the safety and efficacy of tocilizumab, used as an alternative to ATG, in preventing 
graft versus host disease after haplo-cord transplantation.  
 
• 
To evaluate transplant outcomes in subjects undergoing haplo-cord transplantation using 
tocilizumab as an alternative to ATG - including overall survival (OS), progression-free survival 
(PFS), relapse incidence, transplant-related mortality (TRM), GVHD, organ toxicities, 
infections, PTLD and viral reactivations.  
 
• 
To characterize the effects of tocilizumab used as an alternative to ATG on immune 
reconstitution, serum cytokine profiles and on detectable measurable residual disease (MRD) 
after haplo-cord transplantation in the presence and absence of ATG. 
1.2.3  Exploratory Objectives  
• 
To characterize the effects of tocilizumab used as an alternative to ATG in haplo-cord 
transplantation on immune reconstitution, serum cytokine profiles, novel predictive 
biomarkers of GVHD and on measurable residual disease (MRD).  
  
2. Background 
 
2.1 Histocompatibility in Hematopoietic Stem Cell Transplantation 
 
Allogeneic hematopoietic stem cell transplantation (HSCT) remains the most definitive and best-
established curative strategy for high-risk hematologic malignancy. The success of this therapy relies 
on the immunologic effects of a donor-derived hematopoietic system on residual tumor cells – a so-
called ‘graft versus tumor’ (GVT) effect.   
 
Initial attempts at HSCT in the 1950s and 1960s were undertaken without any understanding of 
histocompatibility and as a result were invariably unsuccessful due to disease relapse or severe 
immunologic reactions in the host.4 Studies initially in mice5 and later in dogs6 led to the discovery of 
the human leukocyte antigen (HLA) system that we now recognize as the greatest barrier to successful 
HSCT.7 HLA molecules are proteins expressed on the surface of cells, encoded by a series of over 250 
highly polymorphic genes on chromosome 6 that form the major histocompatibility complex (MHC).7 
They are broadly divided into three categories with differences in structure and function - class I, class 

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II and class III. For transplant purposes, the most important molecules are HLA-A, HLA-B and HLA-C 
from Class I and HLA-DR, HLA-DQ and HLA-DP from Class II. Class I molecules are expressed on the 
surface of all nucleated cells and interact with CD8+ T lymphocytes to activate their cytotoxic or 
cytokine effector function. Class II molecules are expressed on antigen-presenting cells and their 
expression can be either up- or down-regulated by cytokines. These molecules interact with CD4+ T 
lymphocytes to activate cytokine-mediated helper or regulatory function.7 
 
An individual’s HLA type determines their immunologic identity and enables the distinction of self 
from non-self - thus governing the reciprocal immune reactions that occur when HSCs from one 
individual are transplanted into another. Alloreactive T cells in transplant recipients may interact with 
donor HLA molecules to cause graft rejection. The interaction of donor T-lymphocytes with recipient 
HLA molecules mediates the desired GVT effect but also the major transplant complication graft 
versus host disease (GVHD).  
 
HLA genes are co-dominantly expressed and inherited in a Mendelian fashion such that there is a 25% 
probability of any two siblings being HLA-identical. According to the National Marrow Donor Program 
(NMDP), only roughly 30% of patients will have an HLA-matched sibling eligible to donate. Our 
national volunteer registry now contains over 19 million potential domestic unrelated donors and 
through international partnerships provides access to over 30 million. An optimal unrelated donor will 
match the recipient for each allele at least at HLA A, B, C and DRB1 – an 8/8 match. For every allelic 
mismatch at these loci, transplant survival probability decreases by 10%.8 The probability of 
identifying a suitable 8/8 HLA-matched unrelated donor varies widely according to patient ethnicity. 
Whites of European descent have the highest likelihood at 75%, while blacks of South or Central 
American descent have only a 16% chance.9 In our experience treating a uniquely diverse population, 
30% of patients requiring HSCT will be unable to find a fully matched donor and will be in need of an 
alternate stem cell source.  
 
2.2 Umbilical Cord Blood as a Hematopoietic Stem Cell Source 
 
Umbilical cord blood (UCB) is rich in hematopoietic stem cells and has been used in HSCT since the 
1980s. Cord stem cells are highly proliferative and are capable of securely engrafting despite the 
average graft containing 1-log fewer progenitor cells than an adult donation. They have the added 
advantage of being rapidly available, avoiding unnecessary delays in time to transplant for patients 
with high-risk malignancy. 
 
HLA-matching requirements are less stringent for cord blood transplantation (CBT) than they are for 
adult unrelated donor transplants. Even in the mismatched setting, CBT is associated with low 
incidences of acute and chronic GVHD.10 Traditionally matching has been limited to the examination 
of 6 HLA loci – HLA-A and HLA-B at intermediate resolution and HLA-DRB1 at high resolution, with 4-
6/6 matched units being acceptable. HLA-C has generally been ignored. These criteria extend the 
option of transplant to minority patients with no readily available adult donor. In 2014, a registry study 
of 1568 patients reported progressively increasing TRM with increasing 8-allele mismatches. While 
mismatches at 1 or 2 HLA alleles were still better tolerated than they are in adult unrelated donor 
transplants, the study gives cause to consider more rigorous matching criteria.11 This however would 
restrict the availability of cord units for minority populations and at present is only adopted when 
multiple cord units are available for a particular patient.  
 

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The major limitation of CBT is delayed engraftment, with a median time to neutrophil recovery of 16 
to 24 days reported across most series. This prolonged cytopenia translates into increased hospital 
stays, greater transfusion requirements, increased rates of opportunistic infection and ultimately - 
increased early transplant-related mortality (TRM). The total nucleated cell (TNC) dose per kilogram 
of recipient weight is a predictor of hematopoietic recovery after CBT with minimum doses of 2.5 x 
107 TNC/kg being standard practice and even higher doses of 3 x 107 TNC/kg being more recently 
recommended.11 Higher TNC doses again may be required to compensate for increasing degrees of 
HLA mismatching.11,12 The cord blood unit CD34+ count per kilogram of recipient weight measured at 
cryopreservation is an emerging factor guiding unit selection and may be a better predictor of post-
thaw CD34+ dose and hematopoietic recovery than TNC.13 A minimum count of 1.5 x 105 CD34+ 
cells/kg is considered preferable in most centers performing single unit CBT. 
 
Using a minimum cell dose of 2.5 x 107 TNC/kg, the likelihood of identifying a 6/6 or 5/6 HLA-matched 
cord unit for a patient over 20 years of age is highest at 66% for whites of European descent but only 
24% for the African American population with other ethnic groups falling within this range.9 A recently 
published analysis of 126,341 cord blood units in the US inventory showed that adding to this a CD34+ 
cell dose requirement of 1.5 x 105 CD34+ cells/kg, only 4% of stored cord units would qualify for use 
as single-unit grafts for 70-kg patients.14 Thus stringent implementation of these dosing requirements 
precludes the majority of adult minority patients from single unit CBT.  
 
2.3 Haplo-Cord Transplantation 
 
Disappointed with the delayed engraftment after single unit CBT, several groups have tried to enhance 
recovery by in vitro expansion of cords, the infusion of multiple cords or the combination of CBT with 
cells from other origins.15 Our favored approach is a technique originally pioneered in Spain known as 
haplo-cord transplantation - the co-infusion of a single cord blood graft with CD34-selected cells from 
a haploidentical related or unrelated donor.16 In this scenario the T-cell depleted haploidentical graft 
acts as a myeloid bridge until its eventual replacement by durable cord hematopoiesis.  
 
In 2011, we published our initial experience using this technique after reduced intensity conditioning 
in 45 patients with hematologic malignancy. The median age of the cohort was 50 years, the median 
weight 80kg and 58% of the patients had active disease at the time of transplantation.17 Cords were 
matched at a minimum of 4/6 HLA loci and the minimum cell dose was lowered to 1 x 107 TNC/kg. At 
this lower dose, suitable cord blood units could be more easily identified for overweight patients and 
for those of minority descent. Haplo-donations were T-depleted and capped at 3 x 106 CD34+ cells/kg. 
Neutrophil engraftment occurred at 11 days (Interquartile range (IQR), 9 -15) and platelet 
engraftment at 19 days (IQR, 15-33). In the majority of subjects, early haplo-engraftment was replaced 
by durable engraftment of umbilical cord blood by 100 days, with regular persistence of minor cell 
populations of host- and/or haplo-hematopoiesis. Higher haplo-chimerism at Day 100 correlated with 
greater haplo-CD34 dose (p=0.003). The cumulative incidence of acute GVHD was 25% and chronic 
GVHD was 5%.  Actuarial survival at one year was 55%, progression-free survival was 42%, non-relapse 
mortality was 28% and relapse was 30%.  The reduced UCB cell dose had no impact on time to 
hematopoietic recovery. We concluded that reduced intensity conditioning and haplo-cord transplant 
result in fast engraftment of neutrophils and platelets, low incidences of acute and chronic GVHD, low 
frequency of delayed opportunistic infections and promising long-term outcomes.17 We have 
established a minimum UCB cell dose of 1.2 x 107 TNC/kg. Using this threshold, we can identify at least 
5/8 HLA-matched cord units for over 95% of our transplant candidates.  
 

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We have continued to offer haplo-cord transplantation to patients lacking sibling or fully matched 
unrelated donors and now have considerable experience in this technique. In older adults (median 
age 63) with acute myeloid leukemia and myelodysplastic syndrome, we report the 3-year probability 
of overall survival at 45%, progression free survival at 30.2%, non-relapse mortality at 35.1% and 
relapse incidence at 34.7%. These outcomes are comparative to outcomes after matched unrelated 
donor transplantation.18 Our experience in treating high-risk lymphoma and chronic lymphocytic 
leukemia has been similarly encouraging – in a heterogeneous but for the most part heavily pre-
treated patient cohort, we report a 3-year overall survival of 65% and progression-free survival of 
62%. The 1-year cumulative incidence of relapse was 19% and of non-relapse mortality was 19%.19 In 
both of these studies, the rate of chronic GVHD after haplo-cord transplantation was low – 4.9% and 
8% respectively.  
 
Haplo-identical HSCT with post-transplant cyclophosphamide is a competing approach to haplo-cord 
transplantation in situations where fully HLA-matched donors are unavailable. We recently compared 
our haplo-cord outcomes with the outcomes of haplo-identical transplants performed at the MD 
Anderson Cancer Center.20 All patients studied were under 60 years of age and all received reduced-
intensity conditioning with fludarabine and melphalan with or without total body irradiation (TBI). 
GVHD prophylaxis consisted of cyclophosphamide, tacrolimus and mycophenolate for haplo-identical 
transplantation and ATG, tacrolimus and mycophenolate for haplo-cord recipients. Bone marrow was 
used as the preferred graft source in haploidentical transplants whereas for haplo-cord transplants 
peripheral blood stem cells were used. Despite haplo-cord patients being older and having more 
advanced disease, transplant outcomes were similar, with no significant difference in 4-year overall 
survival (Haplo 50% vs. Haplo-cord 49%), 1-year progression free survival (Haplo 45% vs. Haplo-cord 
40%), 1-year relapse incidence (Haplo 27% vs. Haplo-cord 27%) or non-relapse mortality (Haplo 19% 
vs. Haplo-cord 18%). However, haplo-cord transplantation was associated with earlier neutrophil 
recovery (11 vs. 18 days, p=0.001), earlier platelet recovery (22 vs. 25 days, p=0.03) and lower rates 
of grade II-IV acute GVHD by day 100 (16% vs. 33%, p<0.0001) and a lower incidence of chronic GVHD 
at one year (4% vs. 16%, p<0.0001) (Figure 1).20 
 
Figure 1: Comparison of outcomes between HC and haplo transplant over time in days. (A) Neutrophil 
recovery, (B) Acute GVHD Grade 2-4 and (C) Chronic GVHD.20 
 
 
 
2.4 Cord Blood Transplantation and the Graft versus Tumor effect 
 
In retrospective analyses, similar rates of disease-free survival (DFS) are seen when comparing 
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pediatric setting.21-24 Umbilical cord blood appears to mount a robust graft versus tumor (GVT) effect 
that may be superior to that seen from other graft sources and may compensate for the complications 
of delayed engraftment.  
 
Kwon et. al. conducted a comparison of haplo-cord transplantation and haploidentical transplantation 
with post-transplant cyclophosphamide (PTCY-haplo) in patients with AML following myelo-ablative 
conditioning. Similar rates of relapse and survival were observed between the groups despite the 
haplo-cord cohort having a higher proportion of patients with a high disease risk index – suggesting a 
more powerful GVT effect from the cord graft.25 In keeping with this, we have demonstrated that UCB 
chimerism after haplo-cord transplantation directly correlates with relapse incidence. At 2 months 
post-transplant, UCB chimerism levels under 20% in the CD33 lineage were associated with increased 
disease recurrence (54% versus 11%, p<0.0001). Less than 100% UCB chimerism in the CD3 lineage 
also associated with increased recurrence (46% versus 12%, p=0.007)26 
 
A retrospective study from the Fred Hutchinson Cancer Research Center published in the New England 
Journal of Medicine showed that in patients with acute leukemia or myelodysplastic syndrome who 
entered transplant with minimal residual disease, the risk of relapse was higher after MUD than CBT 
(Hazard ratio 2.92, p=0.0007).27 These observations are supported by experiments using a mouse 
model of B-cell lymphoma, which demonstrate that cord blood T-cells mediate stronger antitumor 
responses than adult peripheral blood T cells administered at equal numbers.28    
 
The mechanisms behind the superior GVT effect of UCB are under continued investigation. Cord blood 
T-cells have unique immunologic properties – the majority have a naïve phenotype and are antigen 
inexperienced but once stimulated, they transform more quickly than adult T cells into central 
memory T-cells. CBT recipients also demonstrate faster B-cell and NK-cell reconstitution than other 
cell sources.29  
 
UCB may contain a substantial number of lymphocytes of maternal origin that are primed against the 
paternal HLA-haplotype of the fetus – the inherited paternal antigen or IPA. These lymphocytes are 
protected from immune mediated destruction by the presence of a very high number of fetal T-
regulatory cells. In the large majority of cases, the IPA HLA haplotype is not present in these maternal 
cells and are recognized as foreign. Van Rood et. al. speculated that the IPA-primed maternal cells 
were responsible for the graft versus leukemia (GVL) activity of UCB and that a similar mechanism 
explained why haplo-identical transplant from a mother to her child is associated with less relapse 
than that from a father.  In an elegant retrospective study, they demonstrated that patients with acute 
leukemia who shared on or more HLA-A, -B or DRB1 antigens with their UCB donor’s IPAs had a 
reduced incidence of relapse compared to patients with no shared IPA (Hazard ratio 0.38, p <0.001). 
Relapse risk was lower when the CB came from a second or subsequently born child than from 
firstborn children, perhaps correlating with maternal lymphocyte memory from prior priming.30  
 
Post-transplant disease recurrence can occur if tumor cells develop a means to evade immune 
recognition. In the case of haplo-identical transplantation, disease control depends on donor T-cells 
recognizing a fully mismatched haplotype as foreign. Loss of genomic heterozygosity through acquired 
uniparental disomy can eliminate mismatched HLA alleles from tumor cells and render them invisible 
to immune surveillance. This phenomenon of ‘HLA loss’ accounts for a third of relapses after 
haploidentical HSCT.31 A HLA loss collaborative study group is currently examining data from a global 
cohort of post-transplant relapses across 20 transplant centers – to date no events have been 
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commonly performed across multiple HLA incompatibilities potentiating a GVT effect – however these 
are less likely to be in cis on the same chromosome. Even with loss of one haplotype, HLA mismatches 
will likely persist, that allow tumor cell immune recognition and elimination. 
 
2.5 ATG in Cord Blood Transplantation 
 
The established standard of GVHD prophylaxis is the combination of a calcineurin inhibitor – 
tacrolimus or cyclosporine, with an anti-proliferative agent – methotrexate or mycophenolate mofetil 
(MMF). The addition of anti-thymocyte globulin (ATG) to this standard regimen has been shown in 
randomized trials to reduce both acute and chronic GVHD.33 In addition, ATG suppresses the recipient 
immune system to reduce the odds of graft rejection. ATG is a polyclonal product developed in rabbits 
with IgG activity against many immune cells but with a greatest affinity for naïve T-lymphocytes. The 
beneficial effects of this therapy are tempered by its adverse effects on immune reconstitution. Excess 
toxicity to incoming donor T-lymphocytes is associated with an increased probability of infection and 
viral reactivation, higher relapse rates in malignant disease and poorer overall survival.34,35 
 
The pharmacokinetics of ATG display substantial interpatient variability and with standard weight-
based dosing, a half-life of up to 6 weeks is seen in some patients.36 Recent work in pediatric cohorts 
has shown that T-cell reconstitution in the presence of post-transplant residual ATG is more 
suppressed in cord blood transplantation (CBT) than it is in either bone marrow or peripheral blood 
HSCT.34 In the absence of ATG however, cord blood immune reconstitution can be surprisingly fast 
despite the low T-cell dose infused, with restoration of adaptive immunity within 2 months after 
transplant.37,38 A striking early recovery of CD4 counts is observed, which seems to occur via thymic-
independent peripheral expansion and may be more robust than the recovery seen after adult donor 
transplantation. Improved CD4+ immune reconstitution directly correlates with event-free and overall 
survival.39 
 
Several retrospective studies have demonstrated improved outcomes of CBT when ATG is omitted 
from conditioning regimens. Pascal et. al. examined adult patients with hematologic malignancy 
undergoing CBT after reduced intensity conditioning with cyclophosphamide, fludarabine and total 
body irradiation with 200cGy (Cy/Flu/TBI200) with or without ATG. ATG-treated patients had a higher 
non-relapse mortality (HR 1.68, p=0.0009) and a reduced overall survival (HR 1.69, p=0.03).40 
Wakamatsu et. al. recently compared transplant outcomes in a large series of patients with acute 
leukemia who underwent HSCT from various graft sources with or without ATG. In CBT, the use of 
ATG significantly increased NRM and while it reduced the incidence of acute GVHD, it had an overall 
detrimental effect on GVHD free/Relapse free survival (GRFS) and on overall survival.41 In each of 
these studies, the incidence of acute GVHD increased in the absence of ATG but no statistically 
significant increase in chronic GVHD was observed and neutrophil engraftment was unaffected.40,41 In 
a pediatric analysis of myelo-ablative CBTs, Zheng et. al. demonstrated higher incidences of CMV 
infection in children who received ATG compared with those who did not. A higher 5-year cumulative 
incidence of relapse was seen in the ATG cohort (30.7% vs. 15.4%, p=0.009), which translated into 
poorer leukemia-free survival (37.7% vs. 56.6%, p=0.015). In this study, no significant change in acute 
or chronic GVHD was observed with the omission of ATG and engraftment was unchanged.42 
 
There is thus accumulating evidence to favor the elimination of ATG from CBT protocols with no 
apparent detriment to cord engraftment and no increase in the debilitating toxicity of chronic GVHD.  

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2.6 ATG in Haplo-Cord Transplantation 
 
The success of haplo-cord transplantation depends on early haplo-donor engraftment that serves as 
a myeloid bridge until durable cord blood engraftment can take place. We have to date used ATG as 
part of our conditioning regimen for haplo-cord transplantation as is common practice in centers using 
this transplant platform. In addition to protecting against graft rejection and GVHD, in this unique 
scenario where two competing grafts are infused, ATG may also serve to support the transient 
engraftment of CD34+ selected haplo-identical stem cells by preventing their rapid destruction by 
cord lymphocytes – a ‘graft versus graft’ effect. In our experience, its use leads to robust haplo-donor-
derived neutrophil and platelet engraftment occurring at a median of 11 days and 19 days post-
transplant respectively.  
 
In an effort to improve immune reconstitution, two groups have examined the effects of removing 
ATG from haplo-cord conditioning protocols. Lindemans et. al. reported on 5 patients at their center 
in Utrecht who received haplo-cord transplants without ATG – 1 pediatric patient with MDS and an 
active aspergillus infection whose haplo-graft was CD34-selected and 4 adult patients with poor risk 
malignant disease, whose haplo-products were CD19/ αβ-T-Cell depleted.43 None of the 5 patients 
had a successful haplo-myeloid engraftment. This group was compared to 14 patients who underwent 
haplo-cord transplantation using ATG with CD34-selection of the haplo-donation. Early myeloid 
engraftment was seen in 8 of these 14 patients. ATG exposure appeared to be the only predictor of 
successful engraftment. 87% of haplo-graft failures went on to ultimately lose their cord graft also 
and as a result transplant related mortality was correlated to haplo-engraftment (70% +/- 16% with 
no myeloid bridge versus 12% +/-12% with successful bridge).43  
 
A group from Memorial Sloan Kettering Cancer Center (MSKCC) reported on a series of patients who 
received double cord blood transplants combined with CD34+ selected haplo-identical peripheral 
blood stem cells. After myeloablative conditioning, patients received cyclosporine and 
mycophenolate mofetil but no ATG. In this cohort, 51% of patients had a successful haplo-myeloid 
bridge to durable cord engraftment with neutrophil recovery occurring at a median of 12 days post-
transplant and no recurrent neutropenia. A further 14% had transient early haplo-derived neutrophil 
recovery but with a second leucocyte nadir prior to cord engraftment. 32% had no haplo-
engraftment.44 Of note, 77% of patients in this study developed a pre-engraftment syndrome at a 
median onset of post-transplant day 10, characterized by fever not attributable to infection, rash and 
capillary leak. This was seen in 61% of patients who had a robust myeloid bridge but observed in 94% 
of patients with rapid haplo-rejection.44   
 
 
 
 
 

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2.7 Acute Graft versus Host Disease 
 
Graft versus host disease (GVHD) occurs as a result immunocompetent donor-derived T cells 
recognizing recipient tissues as foreign or ‘non-self’. Occurring to some degree in up to 50% of 
allogeneic HSCT recipients, it remains a major cause of morbidity and transplant-related mortality. 
GVHD can be divided into two phases – acute and chronic, distinguishable by their timing of onset and 
clinic-pathologic manifestations.  
 
Acute GVHD typically affects the skin, GI tract and liver with clinical signs including a maculopapular 
rash, hyperbilirubinemia with jaundice, nausea, vomiting, anorexia and watery diarrhea with crampy 
abdominal pain. By classic definition, this develops within the first 100 days post-transplant. The 
severity can be graded according to the extent of organ involvement – Grade 1 being considered mild, 
Grade 2 moderate, Grade 3 severe and Grade 4 very severe.45  
 
Inflammatory triggers released as a consequence of conditioning chemotherapy or infection initiate 
the early phase of acute GVHD. Damage associated molecular pattern (DAMP) molecules released 
into the extracellular space from dying cells and pathogen associated molecular pattern (PAMP) 
molecules derived from invading intestinal micro-organisms, stimulate the innate immune system - 
setting off a cascade of cytokine and chemokine signaling events that attract and prime donor T-cells 
for activation and expansion.45 Key cytokines released by this tissue damage include pro-inflammatory 
IL-6, TNFa, IFN-y and IL-1 (Figure 2). 
 
Specific T helper cell subsets are stimulated that mediate later cytotoxic tissue damage. Th1 cells 
release IFN-y, which may be important for the development of gut GVHD.46 Th2 cells secrete the anti-
inflammatory cytokines IL-4, IL-10 and IL-13 but may polarize macrophages towards a pro-
inflammatory IL-6 secreting phenotype.47 Some studies have suggested an association between Th2 
polarization and pulmonary and skin GVHD.48 Th17 cells secrete IL-17, thought to mediate GVHD 
severity.49 Conversely, regulatory T cells (Tregs) - which secrete anti-inflammatory IL-10, TGF-B and IL-
35, are suppressed during acute GVHD.50  
  
Ultimately, cytotoxic CD8+ T cells attracted into this inflammatory milieu mediate tissue damage 
through FAS-ligand signaling and the secretion of perforin and granzyme. Tissue damage is further 
augmented by macrophages releasing inflammatory cytokines IL-6 and TNF that have a directly toxic 
effect.51  
  
 
Figure 2. A brief overview of acute GVHD pathogenesis. GVHD, graft-versus-host disease; DAMPS, 
danger-associated molecular patterns; PAMPS, pathogen-associated molecular patterns; APC, 
antigen-presenting cell; MΦ: macrophage.50 
 
 
2.8  IL-6 Biology 
 
In murine studies, systemic IL-6 levels increase after allogeneic HSCT and gradually return to baseline. 
Chen et. al. showed that levels remain high in mice that develop GVHD, with increased expression 
particularly noted in the gut and liver. Selective knockout of IL-6 in either recipient or donor cells was 
able to protect from GVHD development.52 A separate study showed that selective IL-6 knockout in 
donor T cells led to a reduction in severe GVHD and prolonged survival.53 In humans, IL-6 levels 

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increase after chemotherapy, reaching a peak within 2 weeks and then falling toward baseline. Single 
nucleotide polymorphisms (SNPs) in the IL-6 gene or the gene encoding the IL-6 receptor (IL6R) can 
result in higher serum levels of these proteins. Patients who receive grafts from donors that are either 
hetero- or homozygous for a particular SNP - 174 G<C in the IL-6 promoter region, are at significantly 
increased risk of developing acute GVHD (Odds ratio 3.3).54  
 
Interleukin-6 is a cytokine with complex effects. It is involved in both acute and chronic inflammation 
but also has anti-inflammatory effects important for immunoregulation and tissue regeneration. IL-6 
is present at baseline concentrations in healthy human plasma at under 14 pg/mL. Levels can 
dramatically increase during inflammation. A variety of cells can secrete IL-6 including fibroblasts, 
myocytes and endothelial cells. During acute inflammation however, monocytes and macrophages 
appear to be the primary source. A large proportion of CD4+ and CD8+ T cells circulating in the early 
post-HSCT period release high quantities of IL-6.50  
 
IL-6 signaling takes place through at least two distinct mechanisms. Classical signaling takes place 
through the membrane-bound IL-6 receptor (IL6R). This receptor is expressed on limited cell types, 
including hepatocyteJAKs, intestinal epithelial cells, neutrophils, macrophages and naïve T-cells. It has 
a short intracellular domain and so complexes with another cell membrane protein to exert its 
intracellular signaling effects – the ubiquitously expressed gp130. Classic IL6R signaling is linked to 
tissue regeneration and repair – particularly in the liver, gastro-intestinal system and muscle tissue.50 
The membrane-bound IL6R can be cleaved to a soluble form by a disintegrin and metalloproteinase 
(ADAM) proteases. The soluble IL6R can complex with circulating IL-6 and subsequently bind to gp130 
on cells that do not usually express the membrane-bound IL6R. This is known as ‘trans-signaling’ and 
may be the critical mediator of the pro-inflammatory effects of IL-6.50 Upon complexing with IL-6 and 
IL6R, the intracellular domain of gp130 prompts the auto-phosphorylation of the janus kinases (JAK). 
This allows the phosphorylation and activation of STAT3 which translocates to the nucleus to act as a 
transcription factor for target genes. Most IL-6 effects appear to be STAT3-mediated but signaling also 
can occur through RAS/MAPK/ERK and PI3K/AKT channels.55 IL-6 is a primary driver of the acute phase 
response – the increase in serum proteins C-reactive protein, serum amyloid P, ferritin and fibrinogen 
due to their increased production and release from the liver. Elevation of these parameters in cancer 
is partially attributable to IL6 release from tumor cells. 
 
The overall effect of IL-6 on immunocompetent cells is to promote the polarization of pro-
inflammatory Th2 and Th17 T-cell subsets while suppressing Tregs. It also regulates the survival and 
maturation of B-lymphocytes and their differentiation into plasma cells.  
 
2.9 Tocilizumab 
 
Tocilizumab is a humanized monoclonal IL-6 receptor antibody that is currently FDA approved for the 
treatment of rheumatoid arthritis, juvenile arthritis, giant cell arteritis and cytokine release syndrome 
(CRS). Activity has also been reported in multicentric Castleman’s disease and inflammatory bowel 
disease. It inhibits membrane-bound and soluble forms of the IL-6 receptor, therefore inhibiting both 
classical and trans-signaling pathways. Pharmacokinetic studies report a long half-life of 6 to over 9 
days after a single dose of the drug. Clearance may be faster in the setting of active CRS.56  
 
The bulk of experience with tocilizumab comes from the rheumatology sphere – where the standard 
dosing schedule is 8 mg/kg administered intravenously (IV) over 60 minutes every 2-4 weeks. There is 
also a subcutaneous formulation available for selected indications. Treatment in this setting is 

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generally well tolerated, with low rates of discontinuation and overall low rates of adverse events. 
The common side effects reported with continued use are skin and soft tissue infections, dyslipidemia, 
increased liver transaminases and transient cytopenias.57 Gastro-intestinal perforations, primarily in 
patients with diverticulitis, were reported at a rate of 0.26 events per 100 patient-years of intravenous 
tocilizumab therapy. Most of these patients were using concomitant non-steroidal anti-inflammatory 
therapy, steroids or methotrexate and the relative contribution of these concomitant medications 
versus tocilizumab is unknown. Genentech has advised caution in administering tocilizumab to 
patients with a history of diverticulitis or bowel perforation.  
 
In treating CRS, tocilizumab is administered at a stat dose of 8 mg/kg IV. If no clinical improvement is 
observed, this dose can be repeated every 8 hours to a maximum of four doses. The FDA approval for 
this indication was based on a retrospective analysis of patients treated with tocilizumab for severe 
or life-threatening CRS after treatment with CTL019 or KTE-C19 chimeric antigen receptor T-cell (CAR-
T) products on prospective trials. In treating 60 patients with a median of 1-2 doses of tocilizumab, no 
adverse events attributable to the drug were observed.56  
 
2.10 
Tocilizumab in the Treatment and Prevention of GVHD 
 
The identification of IL-6 as an inflammatory mediator of GVHD has led investigators to test the use 
of tocilizumab in treating steroid-refractory (SR) GVHD. The first case was reported by our center in 
2010. A 22 year old male with severe acute gut GVHD that was refractory to steroid and multiple 
secondary agents was treated with tocilizumab 8 mg/kg fortnightly for 8 doses. Clinical improvement 
was noted after the first dose and continued with successive treatments. Eight months after 
completing his course of therapy he remained free of diarrhea and abdominal cramping.58 Following 
on from this, four small studies have reported on the use of tocilizumab in SR GVHD with complete 
responses ranging between 40 – 62.5%.59-62 Treatment has maximal benefit in gut and skin GVHD but 
has no activity against liver GVHD. Responses may be more durable if tocilizumab is administered as 
first-line therapy after steroid failure.60,62 
 
Two published studies to date have examined the use of tocilizumab in addition to tacrolimus and 
methotrexate as a prophylactic strategy for acute GVHD. Kennedy et. al. administered a single dose 
of tocilizumab at a dose of 8mg/kg on transplant day -1 with either myelo-ablative or reduced intensity 
conditioning to patients receiving HLA-matched sibling or unrelated grafts.63 The cumulative incidence 
of grade II-IV acute GVHD at day 100 was 12%, with only 3% of patients suffering grade III-IV disease. 
Combined upper and lower gut GVHD occurred in 8% of patients.63 Using the same GVHD prophylactic 
regimen and administration schedule, Drobyski et. al. studied outcomes in an older patient cohort 
(median age of 66 versus 48 in the Kennedy cohort) receiving matched related or unrelated grafts 
after myelo-ablative or reduced intensity busulfan-containing conditioning.64 The day 100 cumulative 
incidence of grade II-IV and III-IV acute GVHD in this study were 14% and 3% respectively. Strikingly, 
no lower gut GVHD was observed in the first 100 days post-transplant.64 The authors of both studies 
showed that IL-6 signaling blockade did not impede immune reconstitution.63,64 In both studies, 
tocilizumab was found to be safe, with adverse events largely confined to transient elevations in liver 
enzymes and infections that occurred at similar rates in patients receiving standard prophylactic 
regimens.63,64 
 
Tocilizumab has also been used as GVHD prophylaxis in place of ATG serotherapy for pediatric patients 
undergoing haplo-identical HSCT for chemorefractory acute myeloid leukemia following treosulfan-
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8mg/kg on day -1, patients received bortezomib with or without abatacept as additional GVHD 
prophylaxis.65 Patients achieving a complete remission after transplant received CD45RA-depleted 
donor lymphocyte infusions with or without hypomethylation therapy. The cumulative incidence of 
grade II-IV acute GVHD was 18%. While there were several non-conventional elements to this study, 
the authors concluded that the substitution of tocilizumab for ATG was not associated with increased 
graft failure or severe GVHD.65  
 
Finally, two further studies evaluating tocilizumab as GVHD prophylaxis are currently recruiting 
patients – NCT03434730 at MSKCC is treating patients undergoing double cord blood transplantation 
with tocilizumab 8 mg/kg on transplant day -1 in addition to standard GVHD prophylaxis. 
NCT03699631 at the Medical College of Wisconsin is treating HSCT patients with tocilizumab 8 mg/kg 
on transplant day -1 to prevent acute GVHD and with a repeated dose on day +100 as chronic GVHD 
prophylaxis.  
 
2.11  
Rationale 
 
Given the concern for an adverse effect of ATG on cord blood immune reconstitution, we wish 
to minimize and ultimately eliminate its use in our haplo-cord transplant platform. In doing this, 
we aim to reduce the incidences of infection, viral reactivation and relapse of malignant disease 
while minimizing the risk of graft rejection and preserving the low rates of GVHD we currently 
enjoy.  
 
The co-infusion of a T-cell replete cord blood unit with a T-cell depleted haplo-identical graft 
however presents the added potential immune complication of graft versus graft rejection – 
where haplo-progenitors suffer early destruction before they can engraft and provide the 
transient myeloid bridge to the more durable but delayed cord engraftment. Previous efforts at 
haplo-cord transplantation without ATG have been limited by this complication. Rejection of 
the haplo-graft appears to be heralded by a ‘pre-engraftment syndrome’, occurring between 
day +7 and day +14. This syndrome is characterized by fever and capillary leak bearing much 
similarity to clinical CRS and may in part be driven by IL-6.  
 
The IL-6 receptor antibody tocilizumab is approved for the treatment of CRS occurring after CAR 
T-cell therapy. In addition, there is growing evidence supporting its efficacy in the treatment 
and prophylaxis of GVHD in adult hematopoietic stem cell transplantation. It has proven to date 
to be safe and has no negative impact on immune reconstitution after transplant or on T-cell 
proliferation after CAR T-cell therapy.  
  
We plan to administer a single dose of tocilizumab at day -1 to patients receiving haplo-cord 
transplantation for hematologic malignancy. We hypothesize that the inhibition of IL-6 signaling 
for the first 3-4 weeks post-transplant will facilitate the transient engraftment of the haplo-
graft without a prolonged neutropenia or second nadir prior to cord engraftment. Used as an 
adjunct to tacrolimus and mycophenolate mofetil, it will also act as prophylaxis for acute GVHD. 
To ensure patient safety, we will initially treat patient with 3 doses of ATG 1.5 mg/kg as per our 
established protocol. In the absence of safety signals, we will gradually remove 1 dose of ATG in 
sequential patient cohorts until it has been fully eliminated.  

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Weill Cornell is one of the leading centers internationally for haplo-cord transplantation and our 
experience can be extremely useful to the transplant community. 
 
2.12 
Correlative Studies Background 
 
Our collaborator Prof. Boelens at MSKCC has developed and validated a pharmacokinetic model to 
measure ATG exposure. We will collect and freeze EDTA plasma on days 0, +7, +14, +21 and +28, from 
patients in study groups I – III receiving ATG. These samples will be analyzed at MSKCC to calculate 
individual patient’s ATG exposure for correlation with clinical outcomes. 
  
Paralleling our clinical study, we will evaluate patterns of immune reconstitution and changes in the 
cytokine milieu after haplo-cord transplantation utilizing the established expertise of the Guzman 
laboratory.  
  
Peripheral blood (PB) will be collected from all patients at 1,2,3,6 and 12 month post-transplant in 
two separate tubes - one in a Transfix tube (contains a fixative that stabilizes cell surface antigens and 
prevents cellular degradation for up to 14 days) allowing the analysis of unperturbed cells after 
collection, and another heparinized sample which will processed by ficoll gradient and mononuclear 
cells will be cryopreserved for future studies. The cellular immune-profile will be assessed in real time 
on cells collected in the Transfix tubes using flow cytometry. Two multi-parameter antibody panels 
designed to broadly screen for changes in PB leukocyte compartments will be initially utilized, allowing 
us to track the progressive recovery of monocytes, NK cells, DCs, B-lymphocytes and T-lymphocytes 
(which include cytotoxic, helper and regulatory T cells). A portion of the fixed cells will also be 
preserved for the later examination of specific cell populations or intracellular signaling pathways as 
guided by our initial survey. We expect that the gradual reduction of ATG in our successive patient 
cohorts will hasten CB CD4+ T-lymphocyte recovery and hypothesize that suppression of IL-6 signaling 
with tocilizumab will increase the development of Tregs while suppressing Th2 and Th17 effector 
phenotypes. 
  
Pro-inflammatory cytokines invoked by pre-transplant conditioning chemotherapy are known to 
mediate acute GVHD. They are likely also to drive the peri-engraftment syndrome previously reported 
between days 7 and 14 in unsuccessful haplo-cord transplants performed without ATG. As we modify 
our preparative regimen to substitute tocilizumab for ATG, we will be particularly interested in 
observing changes in the cytokine milieu. To this end, serum will be collected and stored prior to the 
start of conditioning chemotherapy and then at days 0, +7, +14, +21 and +28; weeks 6,8 and 10; and 
at months 3,6 and 12. Samples will be tested using a bead-based multiplex immunoassay that will 
assess 13 cytokines simultaneously including IL-6 as well as IFNy, IL4, IL17 and TGFb - cytokines 
secreted by Th1, Th2, Th17 and Treg helper T-phenotypes respectively. We predict that serum IL-6 
levels will increase in the 4 weeks following tocilizumab administration due to delayed clearance, 
while we expect a decrease in other pro-inflammatory cytokines mirroring the lymphocyte changes 
described above. In addition, bone marrow aspirate will be collected at 1,3,6 and 12 months and cell 
compartments analyzed using flow cytometry in a similar fashion to PB. MNCs will be also 
cryopreserved for later study and separated serum stored for cytokine/proteomic analysis. We 
acknowledge that with flow cytometry we are unable to determine the contribution of each graft to 
blood and marrow compartments, however we will be able to infer from chimerism analyses. Data 
can be later validated using single cell RNA seq in sex-mismatched grafts. 

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19 
 
  
This initial study will provide us with a global understanding of immune and cytokine profiles after 
haplo-cord transplantation. Building from this, with future funding we will use our bio-banked 
material to avail of advanced research technologies available at Weill Cornell to characterize post-
transplant immune reconstitution at a deeper level and try to unravel which and whose cells are 
responsible for desired graft versus tumor effect. We expect that by reducing ATG we will reduce the 
incidence of relapse and thus we will investigate the effects of our modification on BM MRD using 
NGS technology. Mass Cytometry by Time of Flight (CyTOF) would facilitate immune-monitoring at 
high-resolution that may be of particular interest in select groups of patients developing transplant 
complications such as disease relapse, GVHD or viral reactivations. Given the size and success of our 
haplo-cord program at Weill Cornell and our established academic core, we are uniquely placed to 
answer these exciting questions that will make a significant impact in transplant medicine. 
3. Study Design 
 
3.1 Overall Design 
 
This study is a prospective phase II non-inferiority study investigating tocilizumab as a potential alternative 
to ATG in haplo-cord transplantation. It is a single-center study based at Weill Cornell Medicine/New York 
Presbyterian Hospital.  
 
Our hypothesis is that tocilizumab is a safe and effective alternative to ATG in haplo-cord transplantation, 
facilitating transient engraftment of the haplo-identical stem cell graft without prolonged neutropenia or 
second nadir prior to durable cord engraftment while also preventing GVHD.   
 
This study plans to enroll patients with hematologic malignancies in need of alternate donor transplant. 
All subjects will be conditioned with fludarabine, melphalan and TBI, followed by a single dose of 
tocilizumab 8 mg/kg on day -1. We will enroll patients into 4 successive cohorts, initially administering our 
current standard 3 doses of ATG 1.5 mg/kg (Total dose 4.5 mg/kg). In the absence of safety signals, we 
will drop one dose of ATG in successive cohorts until the drug ultimately has been eliminated (See Section 
7.2 for further detail on treatment plan).  
 
The primary endpoint of the study is successful haplo-derived neutrophil engraftment. Treatment will only 
be of interest if there is evidence that this rate is greater than 60%.  We use a single arm, Bayesian study 
design. Each dose group will accrue up to 10 subjects. If there are 4 or fewer successes, that dose group 
will be deemed unacceptable and the next higher ATG dose for which there were 5 or more successes will 
be expanded. In other words, there will be 10 subjects initially enrolled in the first group (total ATG dose 
of 4.5 mg/kg). At the point of 5 or more successes are observed, subjects will be enrolled at dose group II 
(even if less than 10 subjects were accrued to group I). This will continue until there is a point where there 
are 4 or fewer successes out of 10 subjects. At this point, the next lower group (higher dose) will be 
expanded to a total of 40 subjects with interim analyses done after each 10 subjects for futility. An 
expansion cohort sample size of 40 has 80.9% power of declaring the regimen active if the true success 
probability is 80% (See Section 12.1 for further detail on statistical plan). 
 
Paralleling our clinical study, extensive correlative study is planned to evaluate patterns of immune 
reconstitution and changes in the cytokine milieu after haplo-cord transplantation. (See Section 2.5 for 
further information on planned correlative studies).  
 

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3.2 Scientific Rationale for Study Design 
 
Given concern for an adverse effect of ATG on cord blood immune reconstitution, we wish to 
minimize and ultimately eliminate its use in our haplo-cord transplant platform. In doing this we 
aim to reduce the incidences of infection, viral reactivation and relapse of malignant disease 
while minimizing the risk of graft rejection and preserving the low rates of GVHD we currently 
enjoy.  
 
However, the co-infusion of a T-cell replete cord blood unit with a T-cell depleted haplo-identical 
graft presents the potential immune complication of graft versus graft rejection – where haplo-
progenitors suffer early destruction before they can engraft and provide the transient myeloid 
bridge to the more durable but delayed cord engraftment. Previous efforts at haplo-cord 
transplantation without ATG have been limited by this complication. Rejection of the haplo-graft 
appears to be heralded by a ‘pre-engraftment syndrome’, occurring between day +7 and day +14. 
This syndrome is characterized by fever and capillary leak bearing much similarity to clinical CRS 
and may in part be driven by IL-6.  
 
The IL-6 receptor antibody tocilizumab is approved for the treatment of CRS occurring after CAR 
T-cell therapy. In addition, there is growing evidence supporting its efficacy in the treatment and 
prophylaxis of GVHD in adult hematopoietic stem cell transplantation. It has proven to date to 
be safe and has no negative impact on immune reconstitution after transplant or on T-cell 
proliferation after CAR T-cell therapy.  
  
We hypothesize that the inhibition of IL-6 signaling for the first 3-4 weeks post-transplant will 
facilitate the transient engraftment of the haplo-graft. Used as an adjunct to tacrolimus and 
mycophenolate mofetil, it should also act as prophylaxis for acute GVHD. The study incorporates 
a staged reduction of ATG to ensure patient safety. In the absence of safety signals, we will 
gradually remove 1 dose of ATG in sequential patient cohorts until it has been fully eliminated.  
 
Extensive background and rationale for the study is provided in section 2.  
 
 
3.3 Justification for Dose  
 
Tocilizumab will be administered as a single dose of 8 mg/kg intravenously on day -1 of the haplo-cord 
transplant conditioning regimen. Patients over 100kg receive a capped dose of 800 mg. This is the 
recommended intravenous dose of tocilizumab for treatment of its licensed indications, including cytokine 
release syndrome (CRS). Prior studies evaluating tocilizumab as GVHD prophylaxis in stem cell 
transplantation also used this dose and administration schedule.  
 
3.4 End of Study Definition 
 
A participant is considered to have completed the study if he or she has completed all phases of the study 
including the last study visit and last scheduled procedure in the Schedule of Assessments (SOA), Section 
6.1. This final assessment takes place at 1 year post-transplant. The end of the study is defined as 

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completion of the last visit or procedure shown in the SOA in the trial globally. Upon completion of the 
study, subjects will continue to be followed for long-term outcomes including survival, disease 
progression, chronic GVHD and secondary malignancy.  
 
 
4. Subject Selection 
 
4.1 Study Population 
 
 
Subjects will be eligible for this study if they have a malignant hematological disease that can be  
 
potentially cured with allogeneic stem cell transplantation. 
 
4.2 Inclusion Criteria 
1. Subject must have a confirmed diagnosis of one of the following: 
a. Relapsed or refractory acute leukemia (myeloid or lymphoid) 
b. Acute leukemia in first remission at high-risk for recurrence 
c. Chronic myelogenous leukemia in chronic, accelerated phase or blast-crisis 
d. Myelodysplastic syndromes 
e. Chronic myeloproliferative disease 
f. 
Recurrent, refractory or high-risk malignant lymphoma 
g. Chronic lymphocytic leukemia, relapsed or with poor prognostic features 
h. Multiple myeloma 
i. 
Other hematological disorder in need of allogeneic transplant (e.g. blastoid dendritic cell 
neoplasm) 
2. Age ≥ 18 years. 
3. Likely to benefit from allogeneic transplant in the opinion of the transplant physician. 
4. An HLA-identical related or unrelated donor cannot be identified within an appropriate time 
frame. 
5. Karnofsky Performance Status (KPS) of ≥ 70%. 
6. Acceptable organ function as defined below: 
a. Serum bilirubin: <2.0 mg/dL 
b. ALT (SGPT) <3x upper limit of normal (ULN) 
c. Creatinine Clearance: >50 mL/min/1.73m2 (eGFR as estimated by the modified MDRD 
equation) 
d. Left ventricular ejection fraction >40% 
e. Pulmonary diffusion capacity >40% predicted 
 
Note: Patients whose organ function or KPS do not fulfill these criteria may still be enrolled if 
considered appropriate transplant candidates and after discussion in transplant conference. 
 
7. Ability to understand and the willingness to sign a written informed consent document. 
 

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22 
 
 
4.3 Exclusion Criteria  
 
1. Life expectancy is severely limited by concomitant illness or uncontrolled infection. 
2. Evidence of chronic active hepatitis or cirrhosis 
3. Uncontrolled HIV disease. 
4. Pregnancy or lactation 
5. History of complicated diverticulitis, including fistulae, abscess formation or gastrointestinal 
perforation. 
6. History of allergic reactions attributed to compounds of similar chemical or biologic composition 
as tocilizumab, including known allergies to Chinese hamster ovary cell products or other 
recombinant human or humanized antibodies. 
4.4 Screen Failures  
 
Screen failures are defined as participants who consent to participate in the clinical trial but are not 
subsequently randomly assigned to the study intervention or entered in the study. A minimal set of 
screen failure information is required to ensure transparent reporting of screen failure participants, 
to meet the Consolidated Standards of Reporting Trials (CONSORT) publishing requirements and to 
respond to queries from regulatory authorities. Minimal information includes demography, screen 
failure details, eligibility criteria, and any serious adverse event (SAE). 
 
Individuals who do not meet the criteria for participation in this trial (screen failure) because of 
inadequate organ function may be rescreened. Rescreened participants should be assigned the same 
participant number as for the initial screening. 
 
 
5. Registration Procedures 
 
5.1 Subject Registration 
 
Subjects will be registered within the WRG-CT as per the standard operating procedure for Subject 
Registration.  
 
 
 
 
 
6. Study Procedures 
 
6.1 Schedule of Assessments 
See Table 1 on page 24. 
 
 
 
 
 
 
 

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23 
 
 
Table 1. Schedule of Assessments 
 
Baseline 
0 
3 
7 
14 
21 
28 
42 
56 
70 
100 
180 
365 
Informed Consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Physical exam, height, weight, and KPS  
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
GVHD and other morbidity assessments 
 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Toxicity assessments 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Infectious disease titers4 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Chest CT or x-ray 
X 
 
 
 
 
 
 
 
 
 
 
 
 
LVEF, or shortening fraction 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Pulmonary Function Test 
X 
 
 
 
 
 
 
 
 
 
 
 
 
HLA typing5 
X 
 
 
 
 
 
 
 
 
 
 
 
 
B-HCG serum pregnancy test9 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Dental/Social Work review 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Hematology1, blood chemistries2 and 
inflammatory markers3 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Fasting lipids 
X 
 
 
 
 
 
 
 
 
 
X 
 
X 
Disease restaging  
X 
 
 
 
 
 
 
 
 
 
X 
X 
X 
Bone marrow examination 
X 
 
 
 
 
X8 
 
 
 
X7 
X7 
X7 
Lumbar Puncture10 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Chimerism 
X 
 
 
X 
 
X 
 
X 
 
X 
X 
X 
Lymphocyte Subsets & Ig levels 
X 
 
 
 
X 
 
X 
 
X 
 
X 
X 
X 
Pneumococcal antibody levels 
X 
 
 
 
 
 
 
 
 
 
 
X 
X 
HLA Antibodies 
X 
 
 
 
 
 
X7 
 
 
 
X7 
 
X7 
Sample for correlative assays6,7 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 

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24 
 
Notes: 
1. Hematology includes CBC with differential and platelet count. CBC performed at least three times a week 
from Day 0 until ANC >500 cells/microL for three days after nadir. CBC performed twice weekly until Day 
28. CBC performed approximately weekly after Day 28 until 12 weeks post-transplant. 
2. Blood chemistries include: serum creatinine, bilirubin, alkaline phosphatase, AST, and ALT, LDH, sodium, 
magnesium, potassium, chloride, and thyroid panel (where standard of care should be according to 
institutional guidelines). Blood chemistries performed twice weekly if possible until Day 28. Blood 
chemistries performed weekly if possible after Day 28 until day 100 post-transplant. 
3. Inflammatory markers include C-reactive protein, ferritin and fibrinogen. 
4. Infectious disease titers to be done as per institutional guidelines. 
5. If not already performed. 
6. Correlative assays may include pharmacokinetic assays of tocilizumab and rATG, measurement of novel 
biomarkers of graft versus host disease, assessment of minimal residual disease (MRD), cytokine analysis 
and assays of immune reconstitution.  
7. Recommended, not required.  
8. Bone Marrow aspirate and biopsy for pathology post-transplant will be performed as per the treating 
physician’s medical-related recommendation. Cytogenetic and molecular analysis as directed by clinical 
team.  
9. Females of childbearing potential only; to be performed within 4 weeks of conditioning regimen. 
10. As clinically indicated. 
 
 
6.1.1 
Pre-Transplant Evaluation 
 
(See also Table 1, page 24) 
Subjects will be admitted to the hospital for a period of three to six weeks, sometimes more. In 
the first week, subjects will receive the conditioning regimen.  
The following observations are considered standard evaluations for transplant eligibility and 
should be determined as close to conditioning as possible and at a reasonable interval from 
transplant usually < 12 weeks before initiation of conditioning therapy. More remote tests may 
be utilized upon approval of the patient’s physician.  
 
These tests may be adjusted as warranted by clinical circumstances and evolving transplant policy. 
Please also refer to institutional transplant work up guidelines.  
 
1. Medical history, physical examination, vital signs, height and weight. 
2. KPS (Karnofsky Performance Score)  
3. Complete blood count (CBC) with differential and platelet count, serum creatinine, bilirubin, 
alkaline phosphatase, ALT, and AST. 
4. Serum c-reactive protein, ferritin and fibrinogen 
5. Fasting lipid profile including serum cholesterol and triglyceride levels 
6. Infectious disease titers, as per institutional guidelines. 
7. Immunoglobulin levels 
8. Beta -HCG serum pregnancy test for females of childbearing potential within 4 weeks of 
conditioning. 
9. High resolution HLA typing, if not already performed. 
10. Pre-transplant chimerism testing.  

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25 
 
11. Left ventricular ejection fraction (LVEF) or shortening fraction. 
12. Pulmonary Function Test 
13. Chest CT or chest x-ray as clinically indicated. 
14. Dental / Social Work review. 
15. Bone marrow evaluation with aspirate and/or biopsy. Cytogenetic and molecular analysis as 
clinically indicated.  
16. Diagnostic lumbar puncture as clinically indicated (particularly ALL and High-grade 
lymphoma). 
 
 
 
 
6.1.2 
Post-Transplant Evaluation 
 
 
 
 
 
The follow-up schedule for scheduled study visits is outlined in Table 2 below. The study visit 
assessments are outlined in Table 1.  
 
These tests may be adjusted as warranted by clinical circumstances and evolving transplant policy. 
Please also refer to institutional transplant work up guidelines.  
 
The exact day of the tests is approximate. Tests can be scheduled several days before or after. The 
window is up to five days before and after in the first four weeks, up to seven days before and 
after until day +100 and up to one month before and after at subsequent time points. 
 
 
 
 
 
Table 2: Follow-up schedule for scheduled study visits. 
Study Visit 
Target Day Post-Transplant 
1 week 
7 + 2 days 
2 weeks 
14 + 5 days 
3 weeks 
21 + 5 days 
4 weeks 
28 + 5 days 
6 weeks  
42+ 7 days 
8 weeks 
56 + 7 days 
10 weeks 
70 + 7 days 
100 day 
100 + 7 days 
6 months 
180 + 28 days 
12 months 
365 + 28 days 

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26 
 
 
6.1.3 
Follow-up Phase 
 
 After 1 year, subjects will be followed for up to 5 years for long-term outcomes including: 
survival, disease relapse, chronic GVHD and secondary malignancy. The frequency of 
follow-up will be at the discretion of the treating physician. 
 
7. Study Intervention 
 
7.1 Stem Cell Source and Cell Dose 
 
7.1.1 
Umbilical Cord Blood Unit 
 
The umbilical cord blood (UCB) unit must supply a minimum cell dose of 1.2 x 107 total nucleated 
cells per kilogram of recipient weight (TNC/kg).  
 
The unit must match with the recipient at a minimum of 4 of 6 at HLA-A, -B, -DRB1 loci. This may 
include 0-2 antigen mismatches at each A or B (at the antigen level) or DRB1 (at the allele level) 
loci. The best-matched unit fulfilling the cell dose requirements should be utilized. All typing will 
be done using molecular typing. Though molecular level typing will be available, a match is defined 
at intermediate resolution for HLA-A and –B and at high resolution for –DRB1.  
 
All recipients will be tested for class I and class II HLA antibodies. This should be done within 100 
days of the planned transplant. If antibodies are present UCB should be chosen that are not 
targeted. This may require DQ and DP testing of the umbilical cord blood.  
 
When available, the cord blood and maternal HLA types will be reviewed by WCMC or the Cord 
Blood Bank to identify units with shared IPA targets with the recipient, or HLA-mismatched but 
non-inherited maternal antigen (NIMA) matched units. These cord blood units will be preferred 
as grafts for the present study assuming a similar HLA match. 
HLA-C matching at the antigen level will also be considered after the above selection criteria. Thus, 
for units equal on all other accounts, an HLA-C match will be considered.  
 
One back-up unit will also be identified per subject following similar selection criteria. 
 
7.1.2 
Haplo-identical Donor 
 
The preferred 3rd party donor will be a young HLA haplo-identical relative. The use of pediatric 
donors is restricted to donors who are over the age of 14 and weigh more than 50 kg.  
 
After appropriate evaluation as per transplant program criteria, the donor will receive G-CSF 
(filgrastim) 5 mcg/kg SQ BID or 10 mcg/kg SQ daily for four consecutive days (doses rounded to 
the nearest vial size). Apheresis will start on the morning of the fifth day and proceed until 
sufficient cells have been collected. If a second day of collection is required, G-CSF will be 
administered on day 5 after collection. 
 
The apheresis procedure will be conducted as per transplant program policy. Typically, four total 
blood volumes (TBV) will be collected or less if a high CD34 yield is expected based on a high 

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number of circulating CD34+ cells in the blood sample drawn immediately prior to apheresis.  
 
After collection and prior to cryopreservation, cells will be T-cell depleted using the Miltenyi 
Clinimax® depletion device. This procedure will be performed, if possible, in the WCMC stem cell 
laboratory. We also have obtained FDA approval to use contract services provided by progenitor 
cell tech (Hackensack, NJ). The target will be to obtain a product containing less than 1x104 CD3+ 
cells per kg of recipient body weight and approximately 3x106/kg CD34 positive cells.  
 
If donor-specific HLA-antibodies are present in the recipient an effort should be made to choose 
a third-party donor who is not targeted. This may require DQ and DP testing of the third-party 
donor.  
 
Occasionally the use of an unrelated haplo-identical CD34-selected peripheral blood stem cell 
(PBSC) graft will be permissible, such as in cases where no haplo-identical relative can be 
identified, or when the recipient has donor specific antibodies directed against all haplo-identical 
relatives. 
 
7.1.3 
Infusion of Cells 
 
The infusion of UCB and the haplo-identical units will be separated by at least 2 hours and 
preferably they will occur on successive days (Day 0 and Day 1).  The order of infusion is not 
specified.  
 
Several lines of evidence indicate that post-thaw cord viability affects engraftment. If an umbilical 
cord blood product turns out to have less than 70% CD34 cell viability upon thawing, a second 
UCB product will be rapidly ordered and infused as soon as possible. 
 
7.2 Treatment Plan 
 
7.2.1 
Conditioning Regimen 
 
 
 
Conditioning Regimen: Age <60yrs 
 
 
Day -7 
Day -6 
Day -5 
Day -4 
Day -3 
Day -2 
Day -1 
Day 0 
Day 1 
or day 0 
Fludarabine 
 
30 
mg/m2 
30 mg/m2 
30 mg/m2 
30 
mg/m2 
30 
mg/m2 
 
 Haplo 
Infusion 
UCB Infusion 
Melphalan 
 
 
 
 
140 mg/m2 
 
 
 
Tocilizumab 
 
 
 
 
 
8 mg/kg 
 
 
 
TBI 
 
2Gray 
2Gray 
 
 
 
ATG Group I 
 
1.5 mg/kg 
 1.5 
mg/kg 
 
1.5 
mg/kg 
 
 
ATG Group II 
 
1.5 mg/kg 
 1.5 
mg/kg 
 
_ 
 
 
ATG Group III 
 
1.5 mg/kg 
 _ 
 
_ 
 
 
ATG Group IV 
 
_ 
 _ 
 
_ 
 
 
 

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Conditioning Regimen: Age >60yrs 
 
Fludarabine:  
Age <60yrs: 30 mg/m2/day IV x 5 days (Day -7 to Day -3) to a total dose of 150 mg/m2. 
Age >60yrs: 30 mg/m2/day IV x 3 days (Day -5 to Day -3) to a total dose of 90 mg/m2.  
Fludarabine will be dosed according to actual body weight.  
 
Melphalan: 140 mg/m2 intravenously x 1 day on Day -2 for all patients.  
Melphalan will be dosed according to actual body weight. Cryotherapy with ice chips will be 
administered to prevent mucositis.  
 
Tocilizumab: 8 mg/kg/day IV x 1 day on Day -1 for all patients. 
Tocilizumab will be dosed according to actual body weight. Patients >100kg will receive a capped 
maximum dose of 800 mg.  
 
TBI: Conditioning will be intensified with 2 doses of TBI (4 Gy) for all patients. This serves to 
decrease graft rejection and reduce the risk of relapse of malignant disease. 
 
Rabbit ATG (rATG)*: In the absence of safety signals, dosing will be reduced as the study proceeds 
as follows – 
 
• 
Cohort I: 1.5 mg/kg/day IV x 3 days on Days -5, -3 and -1 (Total dose 4.5 mg/kg). 
• 
Cohort II: 1.5 mg/kg/day IV x 2 days on Days -5 and -3 (Total dose 3 mg/kg).  
• 
Cohort III: 1.5mg/kg/day IV x 1 day on Day -5 only (Total dose 1.5 mg/kg).  
• 
Cohort IV: No rATG to be administered.  
 
ATG will be dosed according to actual body weight. The first dose will be infused over at least six 
hours, and any subsequent doses over at least 4 hours. Pre-medications include acetaminophen 
650 mg PO, diphenhydramine 25-50 mg PO/IV, and methylprednisolone 2 mg/kg (1 mg/ kg at the 
initiation and 1 mg/kg half-way through ATG administration). Circumstances may require minor 
changes in scheduling of chemotherapy. Variations of up to 24 hours in scheduling will be 
acceptable. 
 
 
Day -5 
Day -4 
Day -3 
Day -2 
Day -1 
Day 0 
Day 1 
or day 0 
Fludarabine 
 
30 mg/m2 
30 
mg/m2 
30 
mg/m2 
 
 Haplo 
Infusion 
UCB Infusion 
Melphalan 
 
 
 
 
140 mg/m2 
 
 
 
Tocilizumab 
 
 
 
 
 
8 mg/kg 
 
 
 
TBI 
 
2Gray 
2Gray 
 
 
 
ATG Group I 
 
1.5 mg/kg 
 1.5 
mg/kg 
 
1.5 
mg/kg 
 
 
ATG Group II 
 
1.5 mg/kg 
 1.5 
mg/kg 
 
_ 
 
 
ATG Group III 
 
1.5 mg/kg 
 _ 
 
_ 
 
 
ATG Group IV 
 
_ 
 _ 
 
_ 
 
 

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7.2.2 Post-Transplant Course (GVHD Prophylaxis) 
 
Subjects will receive either tacrolimus (Prograf ®) or cyclosporine (Neoral ®, Gengraf ®) and 
another immunosuppressant - mycophenolate mofetil (Cellcept ®), starting before transplant to 
reduce the risks of GVHD  and to promote the growth of the graft.   
 
Tacrolimus: 0.03 mg/kg/day IV continuous infusion (CI) over 24 hr from 4 PM Day -2 until 
engraftment or when subject is able to take PO, then tacrolimus approximately 0.09 mg/kg PO in 
2 divided doses.   Tacrolimus should be given at full dose to maintain levels of 5-15 ng/mL through 
day 180, tapered by 20% every week thereafter. PO tacrolimus can be used when IV access for CI 
tacrolimus is unavailable.  
 
Cyclosporine: May be used as an alternative to Tacrolimus. 3 mg/kg/day IV over 24 hr from 9 PM 
Day -2 until engraftment or when subject is able to take PO, then cyclosporine 3.5 mg/kg PO twice 
a day. Cyclosporine should be given at full dose to maintain levels of 150-400 ng/mL through day 
180 and tapered by 20% every week thereafter. PO cyclosporine can be used when IV access for 
infusion is unavailable. 
 
Infection, toxicity or other clinical circumstances may prompt earlier discontinuation or 
adjustment of tacrolimus/cyclosporine doses. In the presence of GVHD, a clinical decision by the 
attending physician will determine if tacrolimus/cyclosporine can be tapered or should be 
continued. 
 
Mycophenolate Mofetil (MMF): will be started on Day -2 and given at a dose of 1000 mg every 8 
hours until day 28. MMF can be given PO or IV. Infection, toxicity, very low patient weight (<50kg) 
may prompt earlier discontinuation or adjustment of doses. 
 
Note: Patient specific circumstances may mandate minor variations in conditioning medications 
and/or GVHD prophylaxis, such as reduction of some of the doses of medications, changes in 
schedule or – rarely - substitution of a particular drug. These changes will be noted and justified, 
but will not require IRB approval. 
 
 
7.2.3 
Supportive Care 
 
CMV Prophylaxis 
• 
Prophylaxis will follow institutional unit policy and will be guided by the recipient and donor 
CMV serostatus tested during pre-transplant screening.  
 
Cytomegalovirus (CMV) monitoring: 
• 
CMV viral load monitoring by PCR at least weekly until Day 100 and at least monthly until Day 
210, regardless of donor/recipient CMV status.  
• 
Pre-emptive CMV treatment should be strongly considered for any positive result on by DNA 
testing (i.e, viral load) within the first 100 days of transplant. 

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PTLD Prophylaxis 
• 
Rituximab: All patients with prior EBV exposure not previously exposed to rituximab or who 
have not received rituximab in the six months prior to transplant, will receive one dose of 
rituximab 375 mg/m2 prior to or upon admission.  
 
Epstein-Barr virus (EBV) monitoring: 
• 
EBV viral load monitoring by PCR at least weekly until Day 100 and at least monthly until Day 
365 is strongly recommended. 
• 
Rising EBV titers should warrant investigation for EBV post-transplant lymphoproliferative 
disorder (PTLD) - including CT imaging and PET scanning for positive CT findings. A bone 
marrow evaluation is recommended if any evidence of PTLD is found on imaging or peripheral 
blood analysis.  
• 
Evidence of PTLD or consecutive increases in EBV PCR should lead to treatment with rituximab 
at a dose and schedule per institutional policy.   
 
A prophylactic broad-spectrum antifungal with anti-mold activity is strongly recommended.  
 
Other infection prophylaxis and supportive care will be as per institutional unit policy. 
 
In some cases, a drug called filgrastim (G-CSF) may be administered to hasten the recovery of 
blood counts.1-3 Administration will follow institutional guidelines. Generic formulations of 
filgrastim may be utilized as required by insurance or pharmacy.  
 
Blood transfusion policy should follow institutional policy. 
 
 
8. Study Intervention Discontinuation and Participant Discontinuation/Withdrawal 
 
8.1 Discontinuation of Study Intervention 
 
Tocilizumab administration and subsequent transplantation are one-time treatments. There is no 
indication for subjects to be taken off treatment except those mentioned below. Even if the subject 
suffers near fatal toxicity, it would not affect his/her ability to stay active on the study. 
 
A subject’s follow-up in the study will end after one of the following applies: 
 
o 
Disease progression, 
o 
Subject decides to withdraw from the study, or 
o Subject lost to follow-up 
o Subject death 
o  General or specific changes in the subject’s condition render the subject unacceptable for 
further treatment in the judgment of the investigator. 

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8.1.1 
Disease Progression or Disease Persistence 
 
 
Relapsing subjects (i.e. those with pathologically proven disease progression) will be removed 
from protocol therapy and followed for survival and secondary malignancy. 
 
8.1.2 
Extraordinary Medical Circumstances 
 
 
If, at any time, the constraints of this protocol are detrimental to the subject’s health and/or the 
subject no longer wishes to continue protocol therapy, protocol therapy shall be discontinued. In 
this event: 
 
o 
Notify the Study Chair. 
o 
Document the reason(s) for discontinuation of therapy in subject records. 
o Follow the subject for survival, progression, relapse, and secondary malignancies. 
 
 
8.2 Participant Discontinuation/Withdrawal from the Study 
 
The reason for participant discontinuation or withdrawal from the study will be recorded in the 
subject medical record. The study chair will be notified. Subjects will continue to be followed for 
survival, progression and secondary malignancy. 
Subjects who sign the informed consent form but do not undergo transplantation may be replaced. 
Subject who sign the informed consent form, receive a haplo-cord transplant and die before 
evaluation of the primary study endpoint at Day +21 may be replaced. Subjects who sign the informed 
consent form, receive transplantation, and subsequently withdraw, or are withdrawn or discontinued 
from the study, will not be replaced. 
 
9.  Criteria for Study Evaluation 
 
Neutrophil engraftment 
Neutrophil engraftment will be defined as the first day in which the ANC is > 500 cells/microL for three 
consecutive days.  Chimerism studies will be used to determine the percentage cord vs. haplo-
identical donor engraftment. 
 
Platelet engraftment 
Platelet engraftment will be defined as the first day the platelet count is > 20,000/microL without 
transfusion support for seven consecutive days. Chimerism studies will be used to determine the 
percentage cord vs. haplo-identical donor engraftment. 
 
Failure of the haplo-graft 
Failure of the haplo-graft will be defined as the absence of neutrophil engraftment by Day +21 or a 
drop in the ANC to < 0.3 cells/microL for five consecutive days occurring after initial neutrophil 
engraftment within the first 3 weeks post-transplantation (second nadir) 
 

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Progression Free Survival 
Relapse will be recorded by the day of initial detection of malignant cells if these cells were on 
subsequent testing confirmed to be increasing in number or by unequivocal radiological progression. 
The molecular detection of matched related donor will not be taken into account for the definition of 
clinical recurrence. The diagnosis of disease recurrence will be based on clinical and pathological 
criteria. 
 
Treatment Related Mortality 
Treatment related mortality is considered any death that cannot be explained by persistence, relapse 
or progression of the underlying malignancy once the preparative regimen starts.  
 
Acute GVHD 
Acute GVHD will be scored according to the Glucksberg system and the IBMTR Severity Index.66 
Whenever possible, histologic biopsies will be taken to confirm diagnosis of GVHD.  
 
Chronic GVHD 
Chronic GVHD will be scored according to the NIH Consensus Development Project on Criteria for 
Clinical Trials in Chronic Graft-versus-Host Disease:  I. The 2014 Diagnosis and Staging Working 
Report.67 Whenever possible, histologic biopsies will be taken to confirm diagnosis of GVHD. 
 
10. Data Reporting / Regulatory Considerations 
 
10.1 Data Collection 
 
The data collection plan for this study is to utilize REDCap to capture all treatment, toxicity, efficacy, 
and adverse event data for all enrolled subjects.  
 
10.1.1 REDCap 
 
REDCap (Research Electronic Data Capture) is a free data management software system that is 
fully supported by the Weill-Cornell Medical Center CTSC.  It is a tool for the creation of 
customized, secure data management systems that include Web-based data-entry forms, 
reporting tools, and a full array of security features including user and group-based privileges, 
authentication using institution LDAP system, with a full audit trail of data manipulation and 
export procedures.  REDCap is maintained on CTSC-owned servers that are backed up nightly and 
support encrypted (SSL-based) connections.  Nationally, the software is developed, enhanced and 
supported through a multi-institutional consortium led by the Vanderbilt University CTSA. 
 
10.2 Regulatory Considerations 
 
10.2.1 Institutional Review Board/Ethics Committee Approval  
 
As required by local regulations, the Investigator will ensure all legal aspects are covered, and 
approval of the appropriate regulatory bodies obtained, before study initiation.  
Before initiation of the study at each study center, the protocol, the ICF, other written material 
given to the patients, and any other relevant study documentation will be submitted to the 
appropriate Ethics Committee. Written approval of the study and all relevant study information 

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must be obtained before the study center can be initiated or the IP is released to the Investigator. 
Any necessary extensions or renewals of IRB approval must be obtained for changes to the study, 
such as amendments to the protocol, the ICF, or other study documentation. The written approval 
of the IRB together with the approved ICF must be filed in the study files.  
The Investigator will report promptly to the IRB any new information that may adversely affect 
the safety of the patients or the conduct of the study. The Investigator will submit written 
summaries of the study status to the IRB as required. On completion of the study, the IRB will be 
notified that the study has ended.  
 
All agreed protocol amendments will be clearly recorded on a protocol amendment form and will 
be signed and dated by the original protocol approving signatories. All protocol amendments will 
be submitted to the relevant institutional IRB for approval before implementation, as required by 
local regulations. The only exception will be when the amendment is necessary to eliminate an 
immediate hazard to the trial participants. In this case, the necessary action will be taken first, 
with the relevant protocol amendment following shortly thereafter.  
Once protocol amendments or consent form modifications are implemented at the lead site, Weill 
Cornell Medicine, updated documents will be provided to participating sites, as applicable. Weill 
Cornell Medicine must approve all consent form changes prior to local IRB submission.  
Relevant study documentation will be submitted to the regulatory authorities of the participating 
countries, according to local/national requirements, for review and approval before the beginning 
of the study. On completion of the study, the regulatory authorities will be notified that the study 
has ended.  
 
10.2.2 Ethical Conduct of the Study  
The Investigators and all parties involved should conduct this study in adherence to the ethical 
principles based on the Declaration of Helsinki, GCP, ICH guidelines and the applicable national 
and local laws and regulatory requirements.  
 
This study will be conducted under a protocol reviewed and approved by the applicable ethics 
committees and investigations will be undertaken by scientifically and medically qualified 
persons, where the benefits of the study are in proportion to the risks. 
 
10.2.3 Informed Consent 
 
The investigator or qualified designee must obtain documented consent according to ICH-GCP 
and local regulations, as applicable, from each potential subject or each subject’s legally 
authorized representative prior to participating in the research study. Subjects who agree to 
participate will sign the approved informed consent form and will be provided a copy of the signed 
document.   
 
The initial ICF, any subsequent revised written ICF and any written information provided to the 
subject must approved by IRB prior to use. The ICF will adhere to IRB requirements, applicable 
laws and regulations. 
 

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10.2.4 Compliance with Trial Registration and Results Posting Requirements  
 
Under the terms of the Food and Drug Administration Modernization Act (FDAMA) and the Food 
and Drug Administration Amendments Act (FDAAA), the Sponsor-Investigator of the trial is solely 
responsible for determining whether the trial and its results are subject to the requirements for 
submission to http://www.clinicaltrials.gov. Information posted will allow subjects to identify 
potentially appropriate trials for their disease conditions and pursue participation by calling a 
central contact number for further information on appropriate trial locations and trial site contact 
information. 
 
10.2.5 Record Retention 
 
Essential documents are those documents that individually and collectively permit evaluation of 
the study and quality of the data produced.  After completion of the study, all documents and 
data relating to the study will be kept in an orderly manner by the Investigator in a secure study 
file.  Essential documents should be retained for 2 years after the final marketing approval in an 
ICH region or for at least 2 years since the discontinuation of clinical development of the IP. In 
addition, all subjects medical records and other source documentation will be kept for the 
maximum time permitted by the hospital, institution, or medical practice.   
 
11 
 Statistical Considerations 
 
11.1 Study Design/Endpoints 
 
Primary endpoint:  The primary endpoint is the percentage of successful haplo-derived neutrophil 
engraftment. This is defined as (1) an ANC of >500 cells/microL for three consecutive days with the 
first on or before Day+21, AND (2) absence of a second nadir—a drop in the ANC to < 0.3 cells/microL 
for five consecutive days occurring after initial neutrophil engraftment within the first 3 weeks post-
transplantation. 
 
There will be up to four different ATG doses tested: 
 
Study Group# 
Total ATG Dose 
1 
4.5 mg/kg 
2 
3 mg/kg 
3 
1.5 mg/kg 
4 
0 mg/kg 
 
We will define the lowest tolerated dose of ATG as the lowest dose that has no evidence that 
successful haplo-derived neutrophil engraftment at Day +21 is less than 60% of subjects. An analysis 
of a historic cohort demonstrates success haplo-engraftment in 80% of subjects and this treatment 
would not be of interest if there is evidence at this time that the rate is below 60%. 
 
11.2 
Sample Size/Accrual Rate 
 
Sample size/ power: We will enroll 10 evaluable subjects in each study group consecutively starting 
with #1. Accrual will continue at the same ATG dose level until at least 10 subjects are evaluable or if 

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futility is established before 10 patients have been enrolled. Subjects who die or relapse before the 
Day +21 assessment are not considered evaluable, and will be replaced. Assuming that there will be 
no more than 5% non-evaluable patients, the smallest sample size for the trial is 10 patients if the first 
dose level is deemed unacceptable due to the first futility analysis and the largest would be 70 
evaluable patients for a possible accrual of 74 (= 70 x 1.05) if the last dose group fully accrues. It is 
anticipated that approximately 35 patients will be accrued per year.  
 
We use a single arm, Bayesian design. Each dose group will accrue up to 10 patients. If there are 4 or 
fewer successes, that dose group will be deemed unacceptable and the next higher dose for which 
there were 5 or more successes will be expanded. In other words, there will be 10 patients initially 
enrolled in the first group (total ATG dose of 4.5 mg/kg). At the point 5 or more successes are 
observed, patients will be enrolled at dose group #2 (even if less than 10 patients were accrued to 
group #1). This will continue until there is a point where there are 4 or fewer successes out of 10 
patients. At this point, the next lower group (higher dose) will be expanded to a total of 40 patients 
with interim analyses done after each 10 patients for futility. The interim analyses will be performed 
after each cohort of 10 subjects have passed the Day +21 mark and accrual will not be suspended for 
the interim analyses during the expansion phase. The interim analysis is for futility only. If futility is 
reached prior to accruing 40 total patients in the expansion phase, consideration will be given to 
expanding the next higher dose level.  
 
Trial criteria: Initially, cohort sizes will be of 10 until futility is met. The primary endpoint is the 
successful haplo-derived neutrophil engraftment. It is assumed that the treatment will only be of 
interest if there is evidence that this rate is greater than 60%. 
 
 
 
Evidence of futility: Pr[Pr(RR > 60%) ≥ 0.90] < 0.05 
 
We will stop a dose level for futility when the probability that the success rate is greater than 60% 
being 0.90 or greater is less than 0.05. For the initial cohorts of 10, futility will be indicated if there are 
4 or fewer successes. If there are five successes observed, accrual will proceed on the next dose group, 
even if less than 10 patients were accrued in the current group. Once futility is met at a dose level (or 
the last dose level is reached without any prior level indicating futility), the previous dose group tested 
(next higher dose level) without hitting futility will be expanded to 40 total patients (or the last dose 
level if it was reached). For the expansion cohort, interim analyses will be performed after every 10 
patients have been followed for the endpoint. Accrual will not stop for the completion of an interim 
analysis. The trial futility stopping rules for the expanded cohort are below: 
 
Trial stopping rules: 
 
# patients 
Stop for futility 
10 
≤ 4 successes 
20 
≤ 11 successes 
30 
≤ 18 successes 
40 (maximum sample size) 
≤ 27 successes 
 
Trial operating characteristics for expansion cohort: A sample size of 40 has a type I error of 
approximately 0.12, meaning that there is a 0.12 chance of declaring the regimen is acceptable when 
the true success proportion is 0.60. This sample size has 80.9% power of declaring the regimen active 
if the true success probability is 80%. 

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Early stopping criteria: Trial accrual will be suspended for evaluation of subject safety if: 
• 
Grade III-IV acute GVHD exceeds 25% after 20 total patients have been accrued.  
• 
Liver toxicity > Grade 2 as per CTCAE v. 5.0 within the first 40 days of transplant unrelated to 
known GVHD, infection, VOD or clearly-defined drug effects in 20% or more patients after 15 or 
more total patients have been accrued.  
 
If there is unacceptable toxicity as described above, the study team will evaluate the adverse event 
profile and decide, in conjunction with the DSMB, to terminate the trial, modify the treatment 
protocol, or reopen it for accrual. 
 
 11.3 
Analysis of Endpoints 
 
11.3.1 Analysis of Primary Endpoints 
 
The trial will go through each dose level sequentially. For each dose level, we will report the 
proportion of success using a binomial point estimate and corresponding 95% exact binomial 
confidence interval. 
 
11.3.2 Analysis of Secondary Endpoints 
 
Secondary endpoints: The secondary endpoints include progression-free survival, overall survival, 
transplant-related mortality, proportion of platelet engraftment success, proportion of failure of 
the haplo-graft, proportion of acute GVHD, and proportion of chronic GVHD.  These are defined 
in Section 10.  
 
Analysis of secondary endpoints: All proportions will be estimated with a binomial point estimate 
and corresponding 95% exact binomial confidence interval.  This will be done separately for each 
dose group and for all dose groups combined. The time to event endpoints will be summarized 
with a Kaplan-Meier estimator. We will generate the corresponding survival curves with 95% 
confidence intervals. Again, this will be done for each dose group and all groups combined. In 
addition, we will generate the median values with the corresponding 95% confidence interval for 
each dose group and all patient combined. 
 
Additional secondary analyses will be a competing risk cumulative incidence analysis. The 
endpoints of interest are: acute GVHD, chronic GVHD, liver toxicity, infection, viral reactivation, 
and PTLD. For each endpoint, the competing risk will be all other endpoints and death. Analysis 
will be done for each dose group as well as all dose groups combined. 
 
Finally, we will also model the data. For time to event endpoints, we will use a Cox proportional 
hazards model that will include the dose group as an explanatory variable. For binomial endpoints, 
we will use logistic regression with dose group as an explanatory variable. 
 
 
 
 
 
 

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 11.4 
Reporting and Exclusions 
 
11.4.1 Evaluation of Toxicity 
 
Subjects are evaluable for toxicity from the start of their transplant conditioning regimen until they 
reach post-transplant Day +100. 
 
11.4.2 Evaluation of Response 
 
Subjects who die or relapse before the Day +21 assessment are not considered evaluable for the 
primary study endpoint and will be replaced. 
 
12. Adverse Event Reporting Requirements  
 
Adverse event (AE) monitoring and reporting is a routine part of every clinical trial.  The investigator will 
be required to provide appropriate information concerning any findings that suggest significant hazards, 
contraindications, side effects, or precautions pertinent to the safe use of the drug or device under 
investigation.  Safety will be monitored by evaluation of adverse events reported by subjects or observed 
by investigators or research staff, as well as by other investigations such as clinical laboratory tests, x-rays, 
electrocardiographs, etc. 
 
12.1 Adverse Event Definition 
 
An adverse event (also referred to as an adverse experience) can be any unfavorable and unintended sign 
(e.g., an abnormal laboratory finding), symptom, or disease temporally associated with the use of a drug, 
and does not imply any judgment about causality. An adverse event can arise with any use of the drug 
(e.g., off-label use, use in combination with another drug) and with any route of administration, 
formulation, or dose, including an overdose.  
 
 
12.1.1 Investigational Agent or Device Risks (Expected Adverse Events) 
Stem cell transplant is a complex procedure with prolonged initial admission and numerous 
immediate and delayed complications as well as frequent readmission. Expected adverse events 
are those listed in the consent form and include regimen-related toxicities, myelosuppression, 
opportunistic infections and GVHD.  
12.2.2 Adverse Event Characteristics and Related Attributions 
 
CTCAE term (AE description) and grade:  The descriptions and grading scales found in the revised 
NCI Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 will be utilized for AE 
reporting.  A copy of the CTCAE version 5.0 can be downloaded from the CTEP web site 
(http://ctep.cancer.gov). 
 
• 
Attribution of the AE: 
- Definite – The AE is clearly related to the study treatment. 
- Probable – The AE is likely related to the study treatment. 
- Possible – The AE may be related to the study treatment. 
- Unlikely – The AE is doubtfully related to the study treatment. 
- Unrelated – The AE is clearly NOT related to the study treatment. 

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12.1.3 
Recording of Adverse Events 
 
• 
Stem cell transplant is a complex procedure with prolonged initial admission and 
numerous immediate and delayed complications as well as frequent readmissions. 
 
• 
Expected adverse events are those listed in the consent form and include regimen-related 
toxicities, myelosuppression, opportunistic infections and GVHD. Most expected adverse 
events of Grade III and higher CTCAE severity will be captured in the transplant database 
and reported to the IRB upon continuing review. 
 
• 
Adverse events that are judged to be unexpected and at least possibly related to the 
investigational procedure will be reported to the study chairman within 48 hours. Such 
events will be reported to the local IRB within the institution’s prescribed time period. 
 
• 
All fatal adverse events will also be reported to the study chairman within 48 hours and 
reported to the local IRB within the institution’s prescribed time period.    
 
 
12.1.4 Reporting of AE to WCM IRB 
 
All AEs occurring on this study will be reported to the IRB according to the IRB policy, which can 
be accessed via the following link:  
http://researchintegrity.weill.cornell.edu/forms_and_policies/forms/Immediate_Reporting_Poli
cy.pdf.  
 
12.1.5 Events of Special Interest 
Non-fatal gastro-intestinal (GI) perforation has been reported in subjects treated with tocilizumab 
on randomized control studies for rheumatoid arthritis. In these trials tocilizumab was 
administered either intravenously or subcutaneously as a regular therapy every 4 weeks. The 
overall rate of GI perforation was 0.26 events per 100 patient years. These events were primarily 
reported as complications of diverticulitis. Most patients who developed this complication were 
taking 
concomitant 
non-steroidal 
anti-inflammatory 
medications, 
corticosteroids 
or 
methotrexate. In comparison, the GI perforation rate in rheumatoid arthritis patients treated with 
corticosteroid alone is 039 per 100 patient years. 
In published case series where tocilizumab has been used as prevention or treatment of GVHD, 
no episodes of GI perforation were observed. Subjects with a past history of complicated 
diverticulitis, including fistulae, abscess formation or perforation are excluded from this study. 
Any events of GI perforation will be reported immediately to the study PI, the IRB and the DSMB. 
 
 
12.2 Definition of SAE 
 

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SAEs include death, life threatening adverse experiences, hospitalization or prolongation of 
hospitalization, disability or incapacitation, overdose, congenital anomalies and any other 
serious events that may jeopardize the subject or require medical or surgical intervention to 
prevent one of the outcomes listed in this definition.  
 
12.2.1 Reporting of SAE to IRB 
 
All SAEs occurring on this study will be reported to the IRB according to the IRB policy, which can 
be accessed via the following link:   
http://researchintegrity.weill.cornell.edu/forms_and_policies/forms/Immediate_Reporting_Poli
cy.pdf.  
 
12.2.2 Reporting of SAE to FDA 
 
IND application sponsor must report any suspected adverse reaction or adverse reaction to study 
treatment that is both serious and unexpected. Unexpected fatal or life-threatening suspected 
adverse reactions represent especially important safety information and must be reported to FDA 
as soon as possible but no later than 7 calendar days following the sponsor’s initial receipt of the 
information. 
i. death, 
ii. a life-threatening adverse event,   
iii. in-patient hospitalization or prolongation of existing hospitalization, 
iv. a persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions, or   
v. a congenital anomaly or birth defect 
 
Important medical events that may not result in death, be life-threatening, or require 
hospitalization may be considered serious when, based upon appropriate medical judgment, they 
may jeopardize the patient or research subject and may require medical or surgical intervention 
to prevent one of the outcomes listed as serious 
CDER-only Biologic INDs:  
Food and Drug Administration  
Center for Drug Evaluation and Research  
Therapeutic Biologic Products Document Room  
5901-B Ammendale Road  
Beltsville, MD 20705-1266  
 
 
12.3 AE/SAE Follow Up 
 
All SAEs and AEs reported during this study will be followed until resolution or until the investigator 
confirms that the AE/SAE has stabilized and no more follow-up is required. This requirement indicates 
that follow-up may be required for some events after the subject discontinues participation from the 
study.  
13. Unanticipated Problems Involving Risks to Subjects or Others 
 

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13.1 Definition of Unanticipated Problems Involving Risks to Subjects or Others (UPIRTSO) 
 
The Office for Human Research Protections (OHRP) considers unanticipated problems involving risks 
to participants or others to include, in general, any incident, experience, or outcome that meets all of 
the following criteria: 
 
• 
Unexpected in terms of nature, severity, or frequency given (a) the research procedures that 
are described in the protocol-related documents, such as the Institutional Review Board (IRB)-
approved research protocol and informed consent document; and (b) the characteristics of 
the participant population being studied; 
• 
Related or possibly related to participation in the research (“possibly related” means there is 
a reasonable possibility that the incident, experience, or outcome may have been caused by 
the procedures involved in the research); and 
• 
Suggests that the research places participants or others at a greater risk of harm (including 
physical, psychological, economic, or social harm) than was previously known or recognized. 
 
13.1.2 Unanticipated Problem Reporting 
The investigator will report unanticipated problems (UPIRTSOs) to the reviewing Institutional Review 
Board (IRB). The UPIRTSO report will include the following information: 
 
• 
Protocol identifying information: protocol title and number, PI’s name, and the IRB project 
number; 
• 
A detailed description of the event, incident, experience, or outcome;  
• 
An explanation of the basis for determining that the event, incident, experience, or outcome 
represents an UPIRTSO;  
• 
A description of any changes to the protocol or other corrective actions that have been taken 
or are proposed in response to the UPIRTSO. 
To satisfy the requirement for prompt reporting, UPIRTSOs will be reported using the following 
timeline:   
• 
UPIRTSOs that are serious adverse events (SAEs) will be reported to the IRB within 24 hours 
of the investigator becoming aware of the event.  
• 
Any other UPIRTSO will be reported to the IRB within 7 days of the investigator becoming 
aware of the problem.  
• 
All UPs should be reported to appropriate institutional officials (as required by an institution’s 
written reporting procedures), the supporting agency head (or designee), Food and Drug 
Administration (FDA), and the Office for Human Research Protections (OHRP) within 7 days 
of the IRB’s receipt of the report of the problem from the investigator.  
 
14. Data and Safety Monitoring Plan (DSMP) 
The Weill Cornell Medical College Data Safety Monitoring Board (DSMB) is being requested to review 
safety data and to make recommendations regarding continuation, termination, or modification to the 
study. The study will be reviewed by the DSMB on a semi-annual basis. 
References 
 
1. 
Crawford J, Becker PS, Armitage JO, et al. Myeloid Growth Factors, Version 2.2017, NCCN 

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41 
 
Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2017;15:1520-41. 
2. 
Smith TJ, Bohlke K, Lyman GH, et al. Recommendations for the Use of WBC Growth 
Factors: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol 
2015;33:3199-212. 
3. 
Crawford J, Caserta C, Roila F, Group EGW. Hematopoietic growth factors: ESMO Clinical 
Practice Guidelines for the applications. Ann Oncol 2010;21 Suppl 5:v248-51. 
4. 
Bortin MM. A compendium of reported human bone marrow transplants. Transplantation 
1970;9:571-87. 
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Snell GD. The Nobel Lectures in Immunology. Lecture for the Nobel Prize for Physiology 
or Medicine, 1980: Studies in histocompatibility. Scand J Immunol 1992;36:513-26. 
6. 
Epstein RB, Storb R, Ragde H, Thomas ED. Cytotoxic typing antisera for marrow grafting 
in littermate dogs. Transplantation 1968;6:45-58. 
7. 
Tumer G, Roberts TK. Genetics, Human Major Histocompatibility Complex (MHC).  
StatPearls. Treasure Island (FL)2019. 
8. 
Lee SJ, Klein J, Haagenson M, et al. High-resolution donor-recipient HLA matching 
contributes to the success of unrelated donor marrow transplantation. Blood 2007;110:4576-83. 
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Gragert L, Eapen M, Williams E, et al. HLA match likelihoods for hematopoietic stem-cell 
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Jagasia MH, Greinix HT, Arora M, et al. National Institutes of Health Consensus 

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Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease: I. The 
2014 Diagnosis and Staging Working Group report. Biol Blood Marrow Transplant 2015;21:389-
401 e1. 
 

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Appendix A: Performance Status Criteria 
 
 
 
ECOG Performance Status Scale 
 
 
Karnofsky Performance Scale 
Grade 
Descriptions 
Percent 
Description 
0 
Normal activity.  Fully active, able 
to 
carry 
on 
all 
pre-disease 
performance without restriction. 
100 
Normal, no complaints, no evidence 
of disease. 
90 
Able to carry on normal activity; 
minor signs or symptoms of disease. 
1 
Symptoms, 
but 
ambulatory.  
Restricted in physically strenuous 
activity, but ambulatory and able 
to carry out work of a light or 
sedentary 
nature 
(e.g., 
light 
housework, office work). 
80 
Normal activity with effort; some 
signs or symptoms of disease. 
70 
Cares for self, unable to carry on 
normal activity or to do active work. 
2 
In 
bed 
<50% 
of 
the 
time.  
Ambulatory and capable of all self-
care, but unable to carry out any 
work activities.  Up and about 
more than 50% of waking hours. 
60 
Requires occasional assistance, but 
is able to care for most of his/her 
needs. 
50 
Requires considerable assistance 
and frequent medical care. 
3 
In bed >50% of the time.  Capable 
of only limited self-care, confined 
to bed or chair more than 50% of 
waking hours. 
40 
Disabled, requires special care and 
assistance. 
30 
Severely disabled, hospitalization 
indicated.  Death not imminent. 
4 
100% bedridden.  Completely 
disabled.  Cannot carry on any self-
care.  Totally confined to bed or 
chair. 
20 
Very sick, hospitalization indicated. 
Death not imminent. 
10 
Moribund, 
fatal 
processes 
progressing rapidly. 
5 
Dead. 
0 
Dead. 
 
 
 
 
 
 
 
 
 
 

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Appendix B: Background Drug Information 
 
CYCLOSPORINE (Neoral ®, Gengraf ®, Sandimmune ®) 
 
AVAILABILITY 
There are two formulations of cyclosporine. Modified cyclosporine (Neoral ®, Gengraf ®) has increased 
bioavailability compared with non-modified cyclosporine (Sandimmune ®). The modified and non-
modified formulations are not bioequivalent. The only formulation available for intravenous use is 
unmodified and is commercially available in solution at 50 mg/mL concentration (5 mL). Modified 
cyclosporine is available for oral use as capsules (25 mg, 50mg, 100 mg) or solution (100 mg/mL).  
 
STORAGE & STABILITY  
Cyclosporine solution for intravenous use should be stored below 30 oC /86 oF and protected from light. 
Infusions should be prepared in glass containers. If PVC bags are used, the solution must be used 
immediately to minimize patient exposure to di(2-ethylhexyl)phthalate (DEHP) which is leached into 
cyclosporine solutions. Cyclosporine capsules and oral solutions should be stored at 20-25 oC /68-77 oF. 
Liquid must not be administered from Styrofoam cups. Not suitable for freezing.  
 
PREPARATION FOR IV USE 
Dilute the concentrate for injection by adding 1 mL (50 mg) of cyclosporine to 20—100 mL of 0.9% Sodium 
Chloride injection or 5% Dextrose injection. 
 
ADMINISTRATION 
Oral therapy should be started as soon as possible as per protocol and 8 to 12 hours after stopping 
intravenous therapy. The conversion from IV to oral therapy should use a 1:3 ratio with dose rounding to 
the nearest 25 mg and administered as a divided dose every 12 hours. Concomitant medications (such as 
azoles) should be taken into account.  
 
TOXICITY 
The most frequent adverse events reported with cyclosporine use are:   
• 
Cardiovascular – hypertension (8-53%), edema (5-14%) 
• 
Central nervous system – headache (2-25%), paresthesia (1-11%), confusion, posterior 
reversible encephalopathy syndrome (PRES) 
• 
Dermatologic – hypertrichosis (5-19%) 
• 
Endocrine/metabolic – hirsutism (21-45%), hypertriglyceridemia (15%), hyperglycemia, 
hypomagnesemia, hyperkalemia, hyperuricemia  
• 
Gastrointestinal – nausea (2-23%), diarrhea (3-13%), gingival hyperplasia (2-16%), 
abdominal distress (<1%-15%), dyspepsia (2-12%), hepatotoxicity 
• 
Infection – increased susceptibility to infection (3-25%) 
• 
Neuromuscular/skeletal – tremor (7-55%), leg cramps (2-12%) 
• 
Renal – increased serum creatinine (16-≥50%), renal insufficiency (10-38%), thrombotic 
microangiopathy (TMA) 

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DRUG INTERACTIONS 
Cyclosporine is extensively metabolized by CYP 3A isoenzymes, in particular CYP3A4, and is a substrate of 
the multidrug efflux transporter P-glycoprotein. Agents that induce or inhibit these proteins may alter 
plasma concentrations of cyclosporine. Of particular importance are azole antifungals (increase 
cyclosporine levels), letermovir (May increase the serum concentration of cyclosporine; decrease dose of 
letermovir to 240 mg PO once daily), mycophenolate mofetil (cyclosporine may decrease the serum 
concentration of mycophenolate) and statins (avoid the use of atorvastatin, lovastatin, pitavastatin, and 
simvastatin in combination with cyclosporine. Rosuvastatin (max dose 5 mg/day) and pravastatin (max 
dose 20 mg/day) are preferred.) 
 
 
FILGRASTIM  (G-CSF:  Granulocyte Colony Stimulating Factor, Neupogen®)   
 
AVAILABILITY 
G-CSF is commercially available in 1.0 and 1.6 mL vials containing 300 mcg and 480 mcg G-CSF, and in 
prefilled syringes containing 300 mcg/0.5 mL and 480 mcg/0.8 mL. 
 
 
STORAGE & STABILITY 
Intact vials and prefilled syringes should be stored under refrigeration.  Do not allow the drug to freeze.  
 
ADMINISTRATION 
The daily dose of G-CSF should be injected subcutaneously in one or two sites.  The dose following 
peripheral blood stem cell infusion is 5 mcg/kg/day.  The dose of G-CSF may be rounded up to the nearest 
vial size. 
 
TOXICITY 
The most common side effect associated with G-CSF is bone pain.  Bone pain is usually reported as mild 
or moderate and, if necessary, may be treated with non-opioid or opioid analgesics. 
 
 
FLUDARABINE (Fludara®) 
 
 
AVAILABILITY 
Fludarabine is commercially available as a white, lyophilized powder.  Each vial contains 50 mg of 
fludarabine, 50 mg of mannitol and sodium hydroxide to adjust pH. 
 
STORAGE & STABILITY 
Intact vials should be stored under refrigeration.  Reconstituted vials are stable for 16 days at room 
temperature or under refrigeration.  Solutions diluted in D5W or NS are stable for 48 hours at room 
temperature or under refrigeration. 
 
PREPARATION 
Fludarabine should be reconstituted with Sterile Water for Injection, USP or normal saline per institutional 
pharmacy guidelines.   
 
ADMINISTRATION 
Fludarabine will be administered as an IV infusion over 30 minutes. 

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TOXICITY 
Myelosuppression, (dose-limiting toxicity), fever, mild nausea and/or vomiting, diarrhea, stomatitis, skin 
rashes, myalgia, headache, agitation, hearing loss, transient episodes of somnolence and fatigue, 
autoimmune hemolytic anemia (may be life-threatening), peripheral neuropathy, and pulmonary toxicity.  
(Both pneumonia and hypersensitivity reactions have been reported.  Fatal pulmonary toxicity has been 
described, especially when fludarabine was used in combination with pentostatin.  Severe, fatal CNS 
toxicity presenting with loss of vision and progressive deterioration of mental status was encountered 
almost exclusively after very high doses of fludarabine.  Such toxicity has only been rarely demonstrated 
at the 25-30 mg /m2 dosage of fludarabine.  Very rarely described complications include transfusion-
associated graft versus host disease.  Tumor lysis syndrome has been observed, especially in patients with 
advanced bulky disease.  Opportunistic infections (protozoan, viral, fungal, and bacterial) have been 
observed.     
 
 
MELPHALAN (Alkeran®) 
 
AVAILABILITY 
Melphalan for IV use is commercially available in sterile 50 mg vials.  The product is a lyophilized powder 
with 20 mg povidone per vial.  Also provided is 10 mL of special diluent for use in reconstituting the 
product.  The special diluent has 0.20 g sodium citrate, 6 mL propylene glycol, 0.5 mL 95% ethanol, and 
sterile water. 
 
 
STORAGE & STABILITY 
Intact vials should be stored at room temperature (15oC-30oC) and protected from light.  Reconstituted 
solutions are chemically and physically stable for at least 90 minutes at room temperature.  Solutions 
further diluted in 0.9% sodium chloride to a concentration of 0.1 mg/mL to 0.45 mg/mL are stable for at 
least 60 minutes.  Solutions diluted to 1 mg/mL are reported to be physically stable for at least 4 hours at 
room temperature-chemical stability of this dilution is not known.  Because of the relative instability of 
melphalan solutions, it is recommended that administration of the diluted solution be completed within 
60 minutes of reconstitution.  Reconstituted solutions should not be refrigerated. 
 
PREPARATION 
Melphalan should be prepared immediately before intended use.  Each vial is reconstituted with 10 mL of 
the special diluent to yield a concentration of 5 mg/mL.  The reconstituted solution may be diluted with 
0.9% sodium chloride to a concentration of 0.1 mg/mL to 0.45 mg/mL. 
 
ADMINISTRATION 
The total dose of melphalan will be administered by short IV infusion over 30-60 minutes, as per 
institutional pharmacy guidelines. 
 
TOXICITY 
The major toxicity of melphalan is bone marrow suppression, usually lasting four to eight weeks.  Other 
toxicities include nausea, vomiting, diarrhea, and mucositis.  Less common toxicities include pulmonary 
fibrosis, interstitial pneumonitis, vasculitis, alopecia, hemolytic anemia, and allergic reactions.  Transient 
rises in BUN and creatinine have occurred with high dose melphalan and also acute renal failure. Tissue 
necrosis may result if infiltration occurs.    
 

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MYCOPHENOLATE MOFETIL (Cellcept®; Myfortic®; MMF) 
 
 
AVAILABILITY 
Mycophenolate mofetil is available as a Capsule, as mofetil:  CellCept®: 250 mg;  
as Injection, powder for reconstitution, as mofetil hydrochloride:  CellCept®: 500 mg [contains polysorbate 
80]; as Powder for oral suspension, as mofetil: CellCept®: 200 mg/mL (225 mL) [provides 175 mL 
suspension following reconstitution; contains phenylalanine 0.56 mg/mL; mixed fruit flavor]; as a Tablet, 
as mofetil: CellCept®: 500 mg [may contain ethyl alcohol]; and as a Tablet, delayed release, as 
mycophenolic acid: Myfortic®: 180 mg, 360 mg [formulated as a sodium salt]. 
 
STORAGE & STABILITY 
Intact vials should be stored at room temperature 15ºC to 30ºC (59ºF to 86ºF).  Store solutions at 15ºC to 
30ºC (59ºF to 86ºF) and begin infusion within 4 hours of reconstitution.  Store capsules at room 
temperature of 15ºC to 39ºC (59ºF to 86ºF).  Tablets should be stored at room temperature of 15ºC to 
39ºC (59ºF to 86ºF) and protected from light.  Store powder for oral suspension at room temperature of 
15ºC to 39ºC (59ºF to 86ºF).  Once reconstituted, the oral solution may be stored at room temperature 
or under refrigeration. Do not freeze. The mixed suspension is stable for 60 days. 
 
PREPARATION 
Mycophenolate mofetil is stable in D5W should be reconstituted per institutional pharmacy guidelines.  
 
ADMINISTRATION 
Intravenous solutions of mycophenolate mofetil should be administered over at least 2 hours (either 
peripheral or central vein); do not administer intravenous solution by rapid or bolus injection.  Oral dosage 
formulations (tablet, capsule, suspension) should be administered on an empty stomach to avoid 
variability in MPA absorption. The oral solution may be administered via a nasogastric tube (minimum 8 
French, 1.7 mm interior diameter); oral suspension should not be mixed with other medications. Delayed 
release tablets should not be crushed, cut, or chewed. 
 
TOXICITY 
Pain, abdominal pain, fever, headache, infection, sepsis, asthenia, chest pain, back pain, hypertension, 
tremor, insomnia, dizziness, acne, rash, diarrhea, constipation, mild N/V, oral monoliasis, anemia, 
leukopenia, 
thrombocytopenia, 
hypochromic 
anemia, 
leukocytosis, 
peripheral 
edema, 
hypercholesterolemia, hypophosphatemia, edema, hypo or hyperkalemia, hyperglycemia, infection, 
dyspnea, cough increase, pharyngitis, bronchitis, pneumonia, UTI, hematuria, kidney tubular necrosis, 
urinary tract disorder. 
 
 
 
 
 
 
 
 
RABBIT ANTITHYMOCYTE GLOBULIN (Thymoglobulin®, rATG) 

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AVAILABILITY 
Antithymocyte globulin is commercially available.  Each package contains two vials:  the first vial contains 
25 mg antithymocyte globulin, and the second vial contains > 5 mL SWFI diluent. 
 
 
STORAGE & STABILITY 
Ampules must be refrigerated (2oC-8oC/ 36oF-46oF),).  Do not freeze.   
 
PREPARATION 
Reconstitute 25 mg vial with diluent provided by manufacturer (SWFI > 5 mL).  Roll vial gently to dissolve 
powder.  Use contents of vial within 4 hours of reconstitution.  Dilute dosage to a final concentration of 
0.5 mg/mL in 0.9% sodium chloride injection or 5% dextrose injection.  Gently invert admixture 1-2 times 
to mix solution.  Use admixture solution immediately.  Final concentration must be 0.5 mg/mL. 
 
ADMINISTRATION 
Infuse the first dose over at least six hours, and subsequent doses over at least 4 hours.  Infuse through a 
0.22 micron in-line filter into a high-flow vein.  Premedications include acetaminophen 650 mg PO, 
diphenhydramine 25-50 mg PO/IV, and methylprednisolone 1 mg/kg (at the initiation and half-way 
through antithymocyte globulin administration). 
 
TOXICITY 
Infusion-related toxicities, including fevers, chills, rash, dyspnea, cardiovascular (hypo- or hypertension, 
tachycardia, edema, chest pain).  In rare cases, anaphylaxis has been reported in which case the infusion 
should be terminated immediately, and emergency treatment with epinephrine and other resuscitative 
measures should be instituted.  rATG should not be administered again to this patient.  
Immunosuppression is a common feature of rATG and can result in severe infections including sepsis, 
CMV, and urinary tract infections.  Serum sickness, neutropenia (57%), thrombocytopenia (37%), 
leucopenia (57%), pain (46%), headache (40%), nausea and diarrhea (37%), peripheral edema (34%), 
systemic infection, malaise, pain, stomatitis, GI bleed, swelling or redness at injection site, myalgia, back 
pain, development of human anti-rabbit antibodies (HARA).  
 
 
TACROLIMUS (Prograf®, FK506) 
 
AVAILABILITY 
Tacrolimus is commercially available as an injection (5 mg/mL; 1 mL ampules) and as oral capsules (0.5 
mg, 1 mg, and 5 mg). 
 
 
STORAGE & STABILITY 
Store tacrolimus capsules and injection at controlled room temperature, 15oC-30oC (59oF-86oF). 
 
 
PREPARATION – FOR IV USE 
Tacrolimus injection must be diluted prior to IV infusion with 0.9% sodium chloride or 5% dextrose 
injection to a concentration of 4-20 mcg/mL.  Solutions should be prepared in non-PVC plastic or glass.  
Tacrolimus injection and diluted solutions of the drug should be inspected visually for particulate matter 
and discoloration prior to administration whenever solution and container permit. 
 

Protocol # 19-08020738 
Version Date 21JUN2022 
 
52 
 
ADMINISTRATION 
Oral therapy should be started as soon as possible as per protocol and 8 to 12 hours after stopping 
intravenous therapy.  Oral doses will be administered twice a day.  The conversion from IV to oral therapy 
should take into account concomitant medications (such as voriconazole). 
 
TOXICITY 
In patients receiving tacrolimus, 5% to 47% experienced anemia, 8% to 32% experienced leukocytosis, and 
14% to 24% experienced thrombocytopenia.  Rare cases of microangiopathic hemolytic anemia have been 
reported.  Chest pain was reported in 19%.  Mild to moderate hypertension is a common adverse effect 
associated with tacrolimus therapy.  Antihypertensive therapy may be required.  The most common 
adverse effects of tacrolimus have involved the central nervous system, and include headache (37% to 
64%), tremors (48% to 56%), insomnia (32% to 64%), paresthesia (17% to 40%), and dizziness (19%).  
Tremor and headache may respond to dosage reduction.  Visual changes, agitation, anxiety, confusion, 
seizures, depression, hallucinations, myoclonus, neuropathy, psychosis, incoordination, and abnormal 
dreams have been reported in 3% to 15%.  Hyperkalemia (13% to 45%), hypokalemia (13% to 29%) 
hypophosphatemia (49%) and hypomagnesemia (16% to 48%) have been associated with tacrolimus 
therapy.  Hyperuricemia has been reported in >3%.  Gastrointestinal adverse effects included nausea (32% 
to 46%), vomiting (14% to 29%), anorexia (7% to 34%), constipation (23% to 35%), and diarrhea (37% to 
72%).  Nephrotoxicity was reported in 38% to 52% of liver and kidney transplant patients, respectively.  
Hematuria has been reported in greater than 3%.  Abnormal liver function tests have been reported in 6% 
to 36% of patients; ascites in 7% to 27%.   
 
Other effects reported in clinical trials include pain, fever, asthenia, back pain, and peripheral edema.  The 
incidence of hyperglycemia was 17% and may require therapy with insulin.  Other less frequently 
occurring effects include abscess, chills, peritonitis, and photosensitivity reactions.  Anaphylaxis has been 
reported in a few patients receiving intravenous tacrolimus.  Tacrolimus injection contains cremophor 
which in other drugs has been associated with anaphylaxis.  Because tacrolimus is an immunosuppressant, 
the risk of opportunistic infections is increased. 
 
DRUG INTERACTIONS   
Tacrolimus is metabolized by cytochrome P450 3A4.  Drugs that are inhibitors (e.g. itraconazole) of 
inducers (e.g. phenytoin) of 3A4 might be expected to increase or decrease tacrolimus concentrations, 
respectively, possibly resulting in increased or decreased effects.  
 
 
 
TOCILIZUMAB (Actemra®) 
 
AVAILABILITY 
Tocilizumab is commercially available in single-dose vials for further dilution prior to intravenous infusion 
(20 mg/mL in 4 mL, 10 mL and 20 mL ampules) and for subcutaneous injection in a single-dose prefilled 
syringe or single-dose prefilled autoinjector (162 mg/0.9 mL).  
 
STORAGE & STABILITY 
Tocilizumab must be refrigerated at 2 oC to 8 oC (36 oF to 46 oF) and cannot be frozen. Vials, syringes and 
autoinjectors must be protected from light by storage in the original package until time of use.  
 
PREPARATION 

Protocol # 19-08020738 
Version Date 21JUN2022 
 
53 
 
For patients over 30 kg dilute tocilizumab to 100 mL in 0.9% or 0.45% Sodium Chloride Injection, USP for 
intravenous infusion using aseptic technique. For patients less than 30 kg dilute tocilizumab to 50 mL in 
0.9% or 0.45% Sodium Chloride Injection, USP using aseptic technique. 
 
ADMINISTRATION 
Administer as a single intravenous drip infusion over 1 hour. Tocilizumab is not to be given as a bolus or 
push.  
 
TOXICITY 
Toxicity data has been gathered from the use of tocilizumab on a continuous basis for rheumatologic 
indications, where many patients were also taking steroid therapy or other biologic agents such as 
methotrexate. The most common serious adverse reactions were infections including pneumonia, urinary 
tract infection, cellulitis, herpes zoster, gastroenteritis, sepsis and bacterial arthritis. Events of 
gastrointestinal perforation have been reported in clinical trials, primarily as complications of 
diverticulitis. Therapy is associated with increases in total cholesterol, triglycerides, LDL, and/or HDL in 
20% of subjects. Monitoring should be implemented. Increased serum alanine aminotransferase is seen 
in up to 36% of patients and increased serum aspartate aminotransferase in up to 22%. These elevations 
did not result in permanent of clinically evident hepatic injury in clinical trials. Treatment can lead to 
neutropenia and thrombocytopenia. Infusion related reactions have been noted in 4-20%. Anaphylactic 
was reported in 0.1%. Headache, hypertension, dizziness and rash have been reported in <10% of patients.  
 
DRUG INTERACTIONS 
Cytochrome P450s in the liver are down-regulated by infection and inflammation stimuli including the 
cytokine IL-6. Inhibition of IL-6 signaling may restore CYP450 activities to higher levels than those see in 
the absence of tocilizumab leading to increased metabolism of drugs that are CYP450 substrates. In vitro 
studies showed that tocilizumab has the potential to affect expression of multiple CYP enzymes including 
CYP1A2, CYP2B6, CYP2C9, CYP2C19, CYP2D6 and CYP3A4. Caution advised when administering 
tocilizumab with CYP3A4 substrate drugs where a decrease in effectiveness is undesirable. Therapeutic 
monitoring of effect or drug concentration may be required.