Targeting Cross-presentation With Peginterferon Alfa-2a to Enhance Anti-leukemic Responses After Allogeneic Transplantation in High Risk Acute Myeloid Leukemia
Phase: PHASE1
Conditions: Acute Myeloid Leukemia
Sponsor: University of Michigan Rogel Cancer Center

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Targeting Cross-presentation with Peginterferon alfa-2a to Enhance       
Anti-leukemic Responses after Allogeneic Transplantation in High Risk Acute 
Myeloid Leukemia 
Version 5.0 
Blood and Marrow Transplantation Program 
University of Michigan Comprehensive Cancer Center 
Principal Investigator: 
John Magenau, MD 
Co-Investigators: 
Pavan Reddy, MD 
Thomas Braun, PhD 
Sung Choi, MD 
Brian Parkin, MD 
Attaphol Pawarode, MD 
Mary Riwes, DO 
Dale Bixby, MD, PhD 
Gregory Yanik, MD 
Muneesh Tewari, MD, PhD 
Gary Luker, MD 
Brian Ross, MD 
Sarah Anand, MD 
Monalisa Ghosh, MD 
NCT02328755
August 17, 2018

August 2018 
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Thomas Chenevert, MD 
Benjamin Hoff, PhD 
Mark Vander Lugt, MD 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TABLE OF CONTENTS 

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Section  
Page 
1.0 
OVERVIEW……………………………………………………………….... 
5 
 
2.0 
STUDY OBJECTIVES…………………………………………………….. 
6 
 
3.0 
BACKGROUND AND RATIONALE……………………………………… 
 
3.1 Allogeneic HCT for AML not in remission 
3.2 Approach to AML relapse: Conditioning 
3.3 Timing of relapse and post HCT interventions 
3.4 Increasing GVL to limit relapse 
3.5 Clinical use of Type I Interferons in AML and HCT 
3.6 Pegylated IFN-alpha-2a (peg-IFN-α) 
3.7 Rationale  
 
7 
 
4.0 
STUDY POPULATION……………………………………………………. 
12 
 
 
4.1 Inclusion Criteria 
 
 
4.2 Exclusion Criteria 
 
 
5.0 
STUDY DESIGN…………………………………………………………… 
 
14 
 
5.1 Patient Evaluations 
5.2 peg-IFN-α Dosing 
5.3 Allogeneic Stem Cell Collection and Donor Mobilization 
5.4 Conditioning Regimen 
5.5 Seizure Prophylaxis 
5.6 Graft versus Host Disease (GVHD) Prophylaxis 
5.7 Post-transplant Supportive Care 
 
 
6.0 
MANAGING ACUTE GVHD………………………………………………. 
 
6.1 Assessment and treatment 
6.2 Dose modifications of peg-IFN-α 
 
17 
7.0 
ASSESSMENT AND MANAGING AML RELAPSE……………………. 
 
7.1 Scheduled disease assessments 
7.2 Definitions 
7.3 Dosing of peg-IFN-α after relapse 
 
18 
8.0 
DOSE MODIFICATIONS BASED ON LABORATORY VALUES…… 
 
8.1 Hematologic parameters 
8.2 Renal function 
19 

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8.3 Hepatic function 
8.4 Fevers and infection 
 
9.0 
REQUIRED OBSERVATIONS (STUDY CALANDER)………………… 
 
 
20 
10.0 
RESEARCH SAMPLES…………………………………………………… 
 
10.1 Research blood and urine samples 
10.2 Correlative studies 
10.3 Additional research samples 
 
21 
11.0 
DRUG INFORMATION……………………………………………………. 
 
11.1 peg-IFN-α (Peginterferon alfa-2a, PEGASYS®) 
11.2 Methotrexate 
11.3 Mycophenolate (CellCept) 
11.4 Tacrolimus (Prograf, FK506) 
 
23 
12.0 
STUDY DEFINITIONS…………………………………………………….. 
 
12.1 Screening 
12.2 Enrolled 
12.3 Treatment period 
12.4 Follow up period 
12.5 On study 
12.6 Off study 
12.7 Definition of an “evaluable” patient 
12.8 Definition of engraftment and delayed engraftment 
 
30 
13.0 
ADVERSE EVENTS AND REPORTING CRITERIA…………………. 
 
32 
14.0 
DATA SAFETY MONITORING PLAN (DSMP)………………………… 
 
14.1 Trained and Certified Personnel 
14.2 Storage and Dissemination of Reports 
14.3 Clinical Monitoring Procedures 
14.4 Quality Assurance and Audits 
 
35 
15.0 
REMOVAL FROM STUDY……………………………………………….. 
 
38 
16.0 
STATISTICAL CONSIDERATIONS……………………………………... 
 
 
16.1 Study Endpoints 
38 

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16.2 Study Design and Sample Size Justification 
16.3 Stopping Rules 
16.4 Data Analysis Methods 
16.5 Projected Accrual 
REFERENCES 
APPENDIX A: KARNOFSKY PERFORMANCE SCALE 
APPENDIX B: ACUTE GVHD ASSESSMENT 
APPENDIX C: INSTRUCTIONS FOR COLLECTION A URINE 
SAMPLE 
1.0 OVERVIEW 

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This protocol is an open label, single arm, non-randomized, phase I / II clinical trial 
investigating the use of commercially available pegylated interferon alpha-2a (peg-IFN-α, 
Pegasys®, Genentech) for prevention of relapse in acute myeloid leukemia (AML) at very 
high risk for relapse or not in remission at the time of allogeneic hematopoietic stem cell 
transplantation (HCT). The inability to attain remission status following induction therapy 
for AML remains a significant problem and is associated with poor outcomes. While HCT 
remains a curative option, its effectiveness in the setting of relapsed or primary refractory 
AML is significantly diminished due to high rates of relapse. 
The anti-leukemic properties of HCT are primarily attributed to the combined effects of 1) 
pre – transplant chemotherapy (termed conditioning) and 2) the immunologic effects of 
donor cells (termed graft-versus-leukemia or GVL). While increasing the intensity of 
conditioning reduces relapse, this strategy has historically been associated with greater 
toxicity. Alternatively, improving GVL without added toxicity (particularly graft-versus-host 
disease) represents an alternative strategy for limiting relapse and improving outcomes, 
which is the primary aim of this protocol. 
IFN-α, FDA approved for viral hepatitis, has demonstrated anti-tumor activity in several 
hematologic malignancies including myeloproliferative diseases and CML.. IFN-α has 
also shown feasibility in the treatment of post HCT relapse by eliciting durable clinical 
responses, without significant toxicity. Recent insights from pre-clinical studies in HCT 
have now identified a central role of IFN-α in enhancing tumor cell antigen presentation, 
thereby promoting leukemia specific T cell responses (GVL) without GVHD. In this 
protocol, we propose to administer peg-IFN-α to prevent relapse by increasing GVL 
responses in patients with relapsed and refractory AML not in remission at the time of 
HCT. 
2.0 STUDY OBJECTIVES 

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2.1 Primary Clinical Objectives: 
Phase I: To determine a phase II dose of peg-IFN-α in patients with AML not in remission 
at HCT. 
Phase II: To determine the incidence of relapse at six months post HCT for patients 
receiving the phase II dose of peg-IFN-α. 
2.2 Secondary Clinical Objectives: 
To estimate the rate of primary engraftment by day +28 post HCT. 
To estimate the cumulative incidence of non-relapse mortality.  
To estimate the cumulative incidence of relapse.  
To estimate overall and disease free survival.  
To estimate the incidence of viral infection. 
To estimate the cumulative incidence of acute GVHD at six months 
To estimate the cumulative incidence of chronic GVHD. 
2.3 Biologic/Exploratory Objectives: 
To analyze numbers of leukemia antigen specific T cells in donors and patients during 
and after peg-IFN-α. 
To analyze numbers and activation status of BDC3A+ dendritic cells (DCs) in donors and 
patients during and after peg-IFN-α. 
To analyze the pharmacodynamic effects of peg-IFN-α on signaling within the JAK / STAT 
pathway. 
To analyze serum inflammatory markers and cellular immune subsets during and after 
peg-IFN-α. 
To measure in vitro T cells responses during and after peg-IFN-α. 
To characterize genomic and transcriptomic features associated with non-remission AML 
and any subsequent relapse after HCT with peg-IFN-α. 
To measure minimal residual disease by molecular methods during and after peg-IFN-α 
in bone marrow and peripheral blood genomic DNA, plasma cell-free DNA and urinary 
DNA. 

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To measure spatial and temporal dynamics of bone marrow ablation and engraftment 
after HCT using quantitative MRI. 
 
3.0 BACKGROUND 
3.1 Allogeneic HCT for AML not in remission 
Allogeneic hematopoietic stem cell transplantation (HCT) is a curative therapy for many 
high risk hematologic malignancies including acute myeloid leukemia (AML)(1). In recent 
years, the numbers of HCT have increased to greater than 20,000 annually with AML 
representing the most common indication (2, 3). Although outcomes have improved by 
reducing conditioning toxicity, infection, and acute graft-versus-host disease (aGVHD); 
relapse remains the principle cause of treatment failure (2, 4)(FIGURE 1). Relapse rates 
after HCT range from 25 - 65% in patients with AML and is determined by a number of 
factors including conditioning intensity, cytogenetic risk, molecular profile and status of 
disease (5-10). Patients with AML not in remission (e.g. relapsed or refractory to induction 
therapy) consistently have the highest incidence of relapse, exceeding 50% in the first 
year after HCT (8, 11, 12). Likewise, detection of minimal residual disease by  flow 
cytometry or persistence of unfavorable 
clonal 
cytogenetic 
abnormalities 
at 
morphologic remission (< 5% myeloblasts) 
have similarly correlated with high post HCT 
relapse rates and poor survival(13, 14). 
More recently, adverse cytogenetic and / or 
molecular risk by or monosomal karyotype 
have been described as independent 
predictors of poor disease free survival even 
for HCT in remission(15, 16). In these 
settings, 
high 
relapse 
together 
with 
commonly 
encountered 
HCT 
related 
mortality have resulted in disease free 
survivals of approximately 10 – 20% (12, 
17). Furthermore, the median survival is 3 months when relapse occurs after HCT due to 
ineffective therapies (18). Considering 30 - 40% of AML patients do not obtain remission 
after induction therapy, the scope of this problem is significant. Thus, while HCT remains 
the lone curative therapy for relapsed and refractory AML (11), treatment strategies that 
limit relapse after HCT are urgently needed to improve outcomes. 
 
3.2 Approach to relapse for AML not in remission: conditioning therapy 
We have previously approached the problem of relapse after HCT by attempting to 
increase the anti-leukemic properties without adding significant toxicity to myeloablative 
transplant conditioning. Clofarabine, a second generation purine nucleoside analog, had 
FIGURE 1: Causes of Mortality after sibling donor 
allogeneic HCT. CIBMTR Summary Slides, 2013. 

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previously demonstrated potent anti-leukemic properties in treatment of relapsed AML 
(19, 20). Patients with relapsed and refractory hematologic malignancies, predominantly 
AML not in remission at HCT (N = 31), were treated on a phase I/II clinical trial with 
myeloablative clofarabine and busulfan (CloBu4)(21). This regimen demonstrated 
significant early activity in AML with 94% of patients achieving remission post HCT. 
Despite early responses, 44% of patients eventually relapsed after HCT. The two-year 
overall survival (OS) was 35%, which compared favorably to historical outcomes of 
approximately 10 - 15% for AML patients with similar characteristics treated with 
conventional myeloablative conditioning (17). In order to confirm these observations, 
CloBu4 was tested in a multicenter trial of relapsed / refractory AML (22). This trial has 
now completed accrual (N = 74) and again demonstrated a very high day 30 post HCT 
CR rate of 90%, with relatively low toxicity (non-relapse mortality of 20% at one year). 
However, at early follow up the incidence of relapse was higher than in our initial phase I 
/ II experience, estimated to be 50% at six months and 60% at one year (FIGURE 2). 
Therefore, although CloBu4 may be associated with higher CR rates, less toxicity and 
possibly improved overall survival when compared to traditional myeloablative regimens, 
ultimately a pattern of high early relapse is observed (9). This suggests that myeloablative 
conditioning may be effective at inducing initial leukemia free states in patients with 
refractory AML, unfortunately, in many instances these remissions cannot be sustained. 
3.3 
Timing 
of 
relapse 
and 
post 
HCT 
interventions 
In AML not in remission, relapse is an early event, 
predominately occurring within the first six 
months post HCT. In our combined experience 
using CloBu4 conditioning (N = 105), 60% of all 
relapses occurred within 100 days post HCT, and 
82% by six months, and 91% by one year post 
HCT. Therefore, although late events occur, 
estimating early relapse (e.g. six months) 
appears to be a good predictor of overall rates. 
Furthermore, 
considering 
these 
kinetics, 
therapeutic strategies aimed at preventing 
relapse might ideally have the greatest impact if administered 
very early after HCT. 
 
 
3.4 Increasing the graft-versus-leukemia (GVL) effects of HCT to limit relapse 
3.4.1 Biology of GVL 
The clinical observation of high remission rates after myeloablative conditioning coupled 
with subsequent relapse suggests the occurrence of a transient minimal residual disease 
FIGURE 2: Cumulative incidence of relapse 
of AML after myeloablative conditioning with 
CloBu4.

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state that may be amenable to further immune based strategies. Since the anti-leukemic 
properties of HCT result from conditioning and GVL, enhancing GVL effects might also 
prevent relapse. GVL reflects a complex immunologic process that is primarily mediated 
by immune effectors such as T and NK cells from the donor graft. In order to effectively 
mount anti-tumor responses, however, donor T cells must recognize both tumor specific 
antigens (TSAs) and alloantigens (23). However, naïve donor T cells initially administered 
in the HCT inoculum are not activated (or primed) against TSAs and are easily rendered 
tolerant (24, 25). Although tumor cells themselves may illicit immune responses, we have 
shown that antigen presenting cells (APCs) play a pivotal role in orchestrating effective T 
cell specific responses against tumor cells, Reddy, Nat Med. 2005 Nov;11(11):1244-9 
and Toubai, Blood. 2013 May 16;121(20):4231-41 (23, 26). 
3.4.2 Cross-presentation in GVL 
Both host and donor APCs play important roles in mediating GVHD (27, 28), but APCs of 
host origin are particularly implicated in GVL (23, 26, 28). These interactions facilitate 
potent CD8+ T cell responses that can be directed at both allo-antigens and TSAs (23, 
29). Specifically, a subset of host APCs, CD8α+ DCs, are amongst the most specialized 
at presenting exogenous antigens in the context of class I major histocompatibility 
complex (MHC class I), a process termed cross-priming or cross-presentation that is 
crucial for inducing cytotoxic T cell responses (30). Due to their similar specialization in 
cross-presentation of soluble and cell associated antigens to CD8+ T cells, human blood 
DC antigen 3 (BDCA3+) DCs or CD141+ DCs are putative human homologs to murine 
CD8α+ DCs (31, 32). 
Host DCs persist early after HCT, but are 
eventually replaced by donor cells in the first 
several weeks after HCT (33-35). Experimental 
models of donor lymphocyte infusion indicate 
that GVL responses are optimized in the mixed 
host / donor chimeric state; presumably due to 
DC presentation of recipient allo-antigens and 
TSAs (36). This suggests that in addition to the 
rapid pace of relapse, there is a biologic basis for 
early post HCT interventions that promote GVL 
through DC cross-presentation. Although ex vivo 
activation of T cells to TSAs may circumvent the 
requirement for host DCs and generate effective 
GVL, significant cost and infrastructure are 
needed for clinical translation (37). There also 
remains limited knowledge as to whether ex vivo approaches will mimic the robust 
memory responses observed with in vivo activation. 
3.4.3 Methods to enhance cross presentation: Polyl:C and Type I Interferon. 
We have shown that host CD8α+ DCs play a critical role in mediating murine GVL (26). 
In multiple models of HCT, allogeneic mice deficient in CD8α+ DCs (Batf3-/-) consistently 
Figure 3: Absence of GVL CD8+ DCs 
mitigates GVL responses. Syngeneic animals 
(circles), allogeneic animals (triangles), and 
squares allogeneic Batf3-/- mice (squares). 

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demonstrated significantly impaired tumor clearance compared to allogeneic and 
syngeneic controls, despite developing GVHD at severities equivalent to wild-type 
animals (FIGURE 3). Thus, CD8α+ DCs appear necessary for generating effective GVL 
responses, but distinct from the generalized alloreactivity of HCT. Likewise, we have 
shown in subsequent experiments that loss of CD8α+ DCs coincided with a concomitant 
decline in tumor specific CD8+ T cells. Additional signals acting upon DCs can 
significantly influence whether cross presentation results in T cell responses or 
inactivation (tolerance). Toll-like receptor 3 (TLR3), expressed predominantly on CD8α+ 
DCs, represents one signal that has been shown to greatly amplify the cross-presentation 
of exogenous viral antigens and promote cytotoxic CD8+ T cell responses (38). We 
treated HCT recipient animals with the immune adjuvant polyinosinic:polycytidylic acid 
(polyI:C), a Toll-like receptor 3 (TLR3) agonist, to increase DC cross presentation. In 
these models of GVL we observed a significant increase in GVL effects without 
aggravating GVHD (FIGURE 4). Importantly, anti-tumor effects were optimized in the 
context of simultaneous alloantigen responses and were not observed in the 
syngeneic controls. Collectively, these results confirm the relevance of cross-
presentation by host CD8α+ DCs for mediating experimental GVL, in the context of 
allogeneic HCT.  
Multiple lines of evidence suggest type I 
interferons (e.g. IFN-α/β), long available 
clinically, mediate their anti-tumor effects in 
part through cross-presentation by CD8 α+ 
DCs and subsequent antigen specific CD8+ 
T cell responses (39). Type I IFNs released 
by virally infected cells directly act upon and 
are secreted by DCs  promoting activation, 
differentiation, 
co-stimulatory 
molecule 
expression and cross-presentation (40, 41). 
Notably, PolyI:C itself is a potent inducer of 
type I IFN secretion by DCs (42). Likewise, 
type I IFN signaling is necessary for DC 
activation following PolyI:C (43). In the 
absence of type I IFN signaling, CD8α+ DC 
priming of T cells and anti-tumor responses 
are 
markedly 
impaired. 
This 
was 
demonstrated in experiments using conditional knockouts of the IFN receptor (IFNAR1), 
where the absence of IFN- α/β signaling in CD8 α + DCs resulted in loss of anti-tumor 
activity and cross-presentation to CD8+ T cells (44). Furthermore, in murine HCT models 
similar interruption of IFN signaling unexpectedly increased GVHD, but as expected, 
abrogated anti-tumor immunity. In contrast, administration of exogenous type I IFN 
lessened GVHD and enhanced cytotoxic CD8+ T cell responses (45). Taken together, 
these results suggest that signaling by type I IFN is critical for CD8α+ DC cross-
presentation. Therefore, careful administration of exogenous type I IFN early after 
allogeneic HCT in patients with AML not in remission might enhance GVL effects 
by increasing cross-presentation by DCs. 
Figure 4: Use of TLR3 agonist PolyI:C increases 
GVL responses. Allogeneic animals with PolyI:C 
(Triangle / hatched line) and without PolyI:C 
(Triangle / solid line). Treatment had no effect on 
GVL in syngeneic animals (circles) or TLR3 (-/-) 
animals (squares) 

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3.5 Clinical use of Type I Interferons in AML and HCT. 
IFN-α is a type I interferon that is FDA approved for chronic hepatitis B and C and has 
been used in the treatment of several solid and hematologic malignancies including 
chronic myeloid leukemia, myeloproliferative neoplasms and AML (46-49). In AML, IFN-
α has been used primary alone or in combination for remission induction or maintenance 
after remission. IFN-α has also been studied in a limited fashion as treatment for post 
HCT relapse in AML, with several reports of patients achieving durable remissions (50). 
To date, experiences in AML after HCT have been exclusively with unmodified IFN 
preparations which possess a very short biologic half-life. Because patients with post HCT 
relapse often harbor a large burden of disease, it is postulated that immune interventions 
that promote GVT may be best optimized in minimal residual disease states; such as the 
early post HCT period. To our knowledge, only two examples of IFN-α prophylaxis exist 
after HCT, but none specifically for enhancement of GVL. In one study, leukocyte IFN 
was administered after engraftment to patients with acute lymphoblastic leukemia (ALL) 
to prevent CMV reactivation (51). While CMV rates were similar between groups, relapse 
in IFN treated patients was lower. In another study, eleven patients (two with AML) 
received IFN-α at various doses in the context of T cell depleted HCT (52). Importantly, 
and consistent with pre-clinical evidence, neither study reported an increased risk for 
GVHD. Thus, while clinical experience with IFN-α for relapse prevention after HCT is 
limited, these studies suggest feasibility. 
3.6 Pegylated IFN-α 
Despite responses in advanced AML, the efficacy of IFN-α has yet to be clearly 
demonstrated. To date, the large heterogeneity of treatments, small patient numbers and 
diverse preparations have contributed to varied results (50). IFN-α dose and duration of 
activity may be relevant for optimizing in vivo activity (either direct or immunologic). For 
example, higher serum levels of IFN-α (>3000 IU/ml) may correlate with clinical response 
in AML (53). More recently, in vivo models of AML show prolonged IFN-α exposure 
improved activity but the underlying mechanisms of these effects are yet to be described 
(54). At approved doses, modern polyethylene glycol-conjugated (pegylated) 
formulations now used clinically provide reliable and evenly sustained IFN-α exposure at 
serum levels known to exert anti-leukemic activity (55). In the clinic, there is now 
considerable experience with peg-IFN-α formulations for treatment of advanced 
myeloproliferative neoplasms. In one report of AML arising from antecedent 
myelofibrosis, peg-IFN-α (without chemotherapy) induced a durable remission lasting > 
18 months (56). These observations suggest a potential benefit in anti-tumor activity with 
use of peg-IFN-α and suggest modern long-acting formulations may be optimal for 
enhancing GVL after HCT. 
In general, due to their improved efficacy, ease of administration and tolerability at 
approved dosages commercially available peg-IFN-α preparations (peginterferon alfa-2a; 
PEGASYS®, Genentech, Inc. and peginterferon alfa-2a; PEGINTRON®, Merck & Co, 
Inc.) have largely replaced short acting preparations in the clinic.  In studies of patients 
with viral hepatitis and myeloproliferative neoplasms, adverse events are typically 

August 2018 
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constitutional in nature, mild to moderate in severity, and do not result in discontinuation 
(48, 49, 57). Pertinent for HCT, bone marrow suppression did occur but was uncommon, 
and predominantly affected neutrophils. Serious adverse events were reported in 10% of 
chronic hepatitis C patients receiving long term therapy, but only 3% of patients receiving 
short term administration (24 weeks). The proposed duration of treatment for the current 
study is 6 weeks.  
3.7 Rationale and use of pegylated IFN-α in AML not in remission at HCT 
We propose administering commercially available pegylated IFN-α2a or PEGASYS® 
(herein referred to as peg-IFN-α) as a strategy to prevent relapse after HCT. AML not in 
remission is the population to be studied, which is a frequently encountered clinical 
problem associated with very poor outcomes, primarily due to high rates of relapse. While 
HCT is the only known curative therapy, additional strategies that improve disease control 
in this setting are urgently needed. New insights into the underlying immune biology of 
HCT suggest sustained exogenous administration of IFN-α will promote cross 
presentation by DCs, thereby increasing GVL. We hypothesize that peg-IFN-α will limit 
early relapse after HCT for AML not in remission. Peg-IFN-α, administered at approved 
dosages over short durations has been associated with good safety, tolerability, and the 
sustained bioavailibility necessary to best assess IFN mediated DC cross-presentation 
and prevention of relapse. 
Thusfar, in this clinical trial IFN-α, has been escalated to and remains at the maximum 
planed dosage (180mcg), with ongoing assessments for DLT by mTPI design (section 
16.2). During an interim analysis for safety (section 16.3) at 24 patients, no stopping rules 
were met for excessive engraftment failure, non-relapse mortality or acute GVHD.   
 
3.8. Magnetic resonance imaging (MRI) of bone marrow with parametric response 
mapping (PRM).  
MRI is sensitive to the fat and water composition of bone marrow using quantitative 
methods such as multi-echo Dixon sequences that separate signals from fat and water 
with relaxation correction. These methods allow computational analyses for percentages 
and volumes of fat and water within each volume element of an image. Normal 
hematopoietic bone marrow in adults is composed primarily of fat signal as detected by 
MRI with the remainder being hematopoietic and stromal cells (water signal). Increases 
in percent fat indicate a loss of cellularity and vice versa. We propose that quantitative 
changes in bone marrow fat can measure spatial and temporal dynamics of bone marrow 
ablation and repopulation after HCT for AML.  
 
MRI also provides quantitative measurements of mobility of water (diffusion) and 
heterogeneity of tissue composition (susceptibility and cross relaxation transfer 
techniques). Mobility of water in living tissue is affected by factors including cell 
membranes, intercellular interactions, cell size, and extracellular matrix. Our group and 
others have shown that quantitative changes in mobility of water in a tissue or tumor 

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predict response to treatments similar to conditioning regimens used prior to HCT (58-
60). Susceptibility and cross relaxation transfer methods for MRI, such as susceptibility 
weighted imaging, T2* decay, and chemical exchange saturation transfer, detect 
heterogeneity of anatomic environments. As examples, these MRI methods have been 
used to measure trabecular bone structure and extracellular matrix, which we propose 
will provide a non-invasive assessment of the bone marrow microenvironment in AML 
and HCT.  
MRI data typically are analyzed based on mean values for an entire tissue of interest, 
such as bone marrow within an entire bone.  While simple to implement, these whole 
tissue analyses inherently lose information about heterogeneous composition of tissues 
and non-uniform responses to treatment.  To capture the spatial localization of disease 
extent and treatment responses, we will use an image analysis technique, parametric 
response mapping (PRM) that precisely maps each imaging volume element (voxel) to 
the same site over sequential imaging studies (61).  By co-registering identical voxels 
from MRI studies performed before and during therapy, we can determine changes in 
imaging parameters, such as diffusion and proton density fat fraction (PDFF), with much 
finer spatial and temporal resolution.  In the context of cancer therapy, this voxel-wise 
image analysis method substantially improves accuracy for identifying response to 
therapy early in the course of treatment.  We propose that this voxel-wise image analysis 
technique also will improve the ability to use MRI to quantify the extent of bone marrow 
ablation after pre-HCT conditioning, dynamics of bone marrow engraftment and 
repopulation after HCT, and potentially relapse of AML. 
4.0 STUDY POPULATION 
4.1 INCLUSION CRITERIA 
4.1.1 Disease criteria and status: 
To be eligible for this protocol the patient must have AML not in remission or at very high 
risk for post HCT relapse. This will generally be defined as greater than ≥ 5% myeloblasts 
by aspirate morphology as determined by a bone marrow aspirate and biopsy obtained 
within 2 weeks of study registration. The following scenarios indicate exceptions to the 
requirement for ≥ 5% myeloblasts: 
a) In the event induction treatment results in a hypoplastic bone marrow status (< 
10% cellularity), precluding accurate enumeration of blast percentages, the patient 
is still eligible if the preceding bone marrow aspirate contained ≥ 5% myeloblasts. 
To meet this condition, prior induction therapy must have been completed a 
minimum of 21 days prior to this result. 
b) In the event < 5% myeloblasts by aspirate are enumerated but persistence of 
low level AML can be documented the patient is eligible. This can be defined as 
clear (probable or definite) flow cytometric persistence of the leukemia associated 
clone defined at time of diagnosis. Alternatively, persistence of cytogenetic 
abnormalities by karyotype satisfies this requirement. 

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c) The patient has evidence at diagnosis of poor cytogenetic or molecular risk 
associated with very high risk for relapse after HCT. Adverse cytogenetic risk is 
defined as complex karyotype with ≥ 4 clonal abnormalities, inv(3) / t(3;3), and 
t(6;9). Monosomal karyotype is defined as  the presence of two or more autosomal 
chromosome monosomies or one single autosomal monosomy in the presence of 
one or more structural chromosomal abnormalities, excluding marker and ring 
chromosomes. Poor molecular risk is defined as the presence of FLT3-ITD 
mutation.  
4.1.2 Prior Treatment (one of the following scenarios): To be eligible the patient must 
have received previous therapy in one of the following scenarios:    
1) Primary refractory: for newly diagnosed AML, patients must have achieved two 
consecutive induction attempts without achieving complete remission. 
 
2) Relapsed / refractory: for patients initially in complete remission whose AML 
relapses > 6 months after preceding remission, one re-induction must be 
attempted to be eligible 
 
3) Relapsed / untreated: for AML patients with early relapse, in whom the preceding 
remission is shorter than 6 months duration, no re-induction regimen is necessary 
to be eligible. 
 
4) Patients with antecedent MDS (or CMML) who progress to AML: may have 
therapies rendered during both phases counted towards these requirements. For 
example, a patient with MDS (RAEB-II) receives hypomethylating agent or other 
induction therapy that progresses to AML. In such cases regimens administered 
prior to transformation can be counted. 
5)  
6) Patients with poor cytogenetic or molecular risk: associated with very high risk 
for relapse after HCT  (Section 4.1.1 C) may proceed without provisions for prior 
treatment as listed above. However, they must have received at least one induction 
attempt.  Note: Hypoplastic bone marrow status (section 4.1.1 A) and persistence 
of low level AML (section 4.1.1 B) do not constitute achieving complete remission.  
 
4.1.3 Donors and Stem Cell Source:  
1) Availability of an 8/8 matched related or unrelated donor at A, B, C, and DR loci. Note: 
Mismatchs at HLA DQ and/or HLA DPB1 are permissible.  
2) Availability of a HLA-haploidentical donor from a first degree relative (parents, children 
or sibling). In this context, HLA matching at only one haplotype is acceptable according 
to usual BMT program practice guildelines.    
3) Peripheral blood or bone marrow stem cells are acceptable. 

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4.1.4 Age: Patients must be ≥ 18 years of age and considered a candidate for HCT. There 
is no defined upper age limit so long as patient meets institutional criteria for 
myeloablative HCT (see exception of haplo-identical donors in section 5.4). 
4.1.5 Performance status: Karnofsky ≥ 70% (see APPENDIX A) 
4.1.6 Organ function: Patients must meet acceptable organ function criteria for 
allogeneic transplant per institutional guidelines. A summary of these guidelines are 
shown in Table 1 below and may also be found at the following URL: 
http://www.med.umich.edu/i/cancer/guidelines/bmtsoc.htm  
 
 
 
TABLE 1. ORGAN FUNCTION CRITERIA FOR PROCEEDING ON STUDY 
Total bilirubin 
≤2.5 mg% (unless from Gilbert’s disease or 
disease-related) 
AST(SGOT)/ALT(SGPT) 
<5.0 X institutional upper limit of normal 
Estimated or actual GFR* 
>40 mL/min/1.73 m2 for patients with creatinine 
levels above institutional normal 
*GFR should be corrected for BSA 
Pulmonary Function Tests 
DLCO, FEV1, FVC > 50% 
DLCO should be corrected for hemoglobin 
Ejection Fraction 
>50% 
 
4.1.7 Consent: All patients must be informed of the investigational nature of this study 
and given written informed consent in accordance with institutional and federal guidelines.  
4.1.8 The effects of Peg-IFN-α on the developing human fetus are unknown. For this 
reason and because other therapeutic agents used in this trial (e.g., tacrolimus and 
methotrexate) are known to be teratogenic, women and men of child-bearing potential 
must agree to use adequate contraception (hormonal or barrier method of birth control; 
abstinence) prior to study entry and for the duration of study participation. Should a 
woman become pregnant or suspect she is pregnant while she or her partner is 
participating in this study, she should inform her treating physician immediately. Men 
treated or enrolled on this protocol must also agree to use adequate contraception prior 

August 2018 
17 
 
 
to the study, for the duration of study participation, and 3 months after completion of Peg-
IFN-α. 
 
4.2 EXCLUSION CRITERIA 
 
4.2.1 Prior chemotherapy treatment for AML within 21 days from the initiation of HCT 
conditioning. Note, use of hydroxyurea or other low intensity treatment not intended to 
induce remission but rather stabilize disease are acceptable. 
4.2.2 Patients may NOT have evidence or symptoms of CNS disease at the time of 
enrollment. 
4.2.3 HIV or HTLV1 / HTLV2 (seropositivity and/or PCR positivity) 
4.2.4 Patients less than 18 years of age. 
4.2.5 Pregnant and nursing mothers are excluded from this study 
4.2.5 Patients with untreated or uncontrolled neuropsychiatric illness.  
4.2.6 Any physical or psychological condition that, in the opinion of the investigator, would 
pose unacceptable risk to the patient. 
4.2.7 Uncontrolled infections. Patients still under therapy for presumed or proven infection 
are eligible provided there is clear evidence (radiologic, clinical and/or culture) that the 
infection is well controlled. 
4.2.8 Unrelated donor with HLA mismatch at A, B, C, and DR loci. 
5.0 STUDY DESIGN 
This is a prospective, non-randomized, phase I/II study of commercially available peg-
IFN-α (peginterferon alfa-2a; PEGASYS®, Genentech, Inc.) for prevention of relapse in 
AML patients not in remission undergoing HCT. The pre transplant chemotherapy will 
consist of myeloablative conditioning per investigator. HCT will be administered on day 
0. GVHD prophylaxis will consist of calcineurin inhibitor plus methotrexate per institutional 
guidelines. An overview of the study is shown below in FIGURE 5. 

August 2018 
18 
 
 
 
Figure 5: Study schema for peg-IFN-α in prevention of relapse for AML not in remission at HCT 
5.1 Patient Evaluations 
An IRB-approved informed consent must be obtained from patients (or legal guardians) 
prior to the initiation of treatment on this protocol. Patient demographics, including 
underlying disease, donor type, and eligibility criteria will be recorded at entry into the 
study. All screening evaluations will be completed as part of the standard work up for 
HCT. 
5.2 peg-IFN-α: Is the study agent and will be administered prior to HCT (donor stem cell 
infusion) and at three subsequent time points post HCT.  (Maximum of 4 doses) 
5.2.1 Timing of dosing: peg-IFN-α will be administered by subcutaneous injection 
every 14 days as shown in Table 2. 
 
           TABLE 2. SCHEDULE OF ADMINISTRATION FOR PEG-IFN-α 
Dose 
Day of administration 
Last day to administer (if delay) 
1 
                -1 (Pre HCT) 
+6 
2 
+14 
+21 
3 
+28 
+35 
4 
+42 
+49 
 
A maximum of four doses will be administered. If dosing is postponed for any 
reason on its scheduled day of administration, it can be given for up to 7 days. 
Subsequent doses should be administered as per the above schedule. There 
should always be a minimum of 7 days between doses. No doses will be 
administered beyond day + 49. 

August 2018 
19 
 
 
5.2.2 Determination of dose level: The first patient will be assigned to dose level 
1 (90 mcg) and subsequent dose assignments for future patients will be 
determined using the modified toxicity probability interval (mTPI), based on the 
occurrence of dose limiting toxicities (DLTs). Briefly, if minimal toxicity is 
encountered, dose level 2 will be employed (180mcg), which is the FDA approved 
starting dose of peg-IFN-α. If excessive toxicity, we will de-escalate dose level -1 
(45mcg). If excessive toxicity occurs at dose level -1, the study will be halted to 
determine if the trial should be amended or closed. The study is also subject to 
termination according to stopping rules listed in section 16. Finally, the study 
principle investigator with input from BMT data safety monitoring board may elect 
to defer dose escalation or continue at lower dosage if deemed to be in the best 
interest of patient safety. Note, specifics of this design and dose assignment are 
described in the statistical section of this protocol (section 16). 
 
 
5.3 Allogeneic Stem Cell Collection and Donor Mobilization 
Stem cells are to be collected and infused on day 0 as per the institutional Clinical Practice 
Guidelines. Recommended stem cell dosages are per clinical practice guidelines.  
5.4 Conditioning Regimen 
Eligible patients will receive a myeloablative conditioning regimen considered suitable for 
patients undergoing an allogeneic HCT according to the current institutional BMT program 
clinical practice guidelines. The specific agents used for myeloablative conditioning will 
not be mandated, and will be determined by the patient’s primary physician and BMT 
team at weekly clinical consensus meetings. Reduced intensity conditioning regimens 
are prohibited with the exception of recipients of haplo-identical donor HCT. In 
haplo-identical contexts, conditioning intensity and regimen will be selected the 
patient’s investigator.   5.5 Seizure Prophylaxis  
Seizure prophylaxis per institutional guidelines is recommended for recipients of busulfan 
containing preparative regimens. 
5.6 Graft versus Host Disease (GVHD) Prophylaxis 
Eligible patients will receive a standard GVHD prevention regimen according to the 
current institutional BMT program clinical practice guidelines. This will include a 
calcineurin-inhibitor (tacrolimus or cyclosporine) based regimen. Calcineurin-inhibitor will 
typically be combined with mini-dose methotrexate (MTX). Combination with 
mycophenolate mofetil (MMF) is an alternative option. The preferred calcineurin-inhibitor 
is tacrolimus, but cyclosporine can be substituted if patients cannot tolerate tacrolimus. 
In patients who are unable to tolerate tacrolimus or cyclosporine, sirolimus may be 
substituted. 
 

August 2018 
20 
 
 
5.6.1 Tacrolimus 
Tacrolimus begins on day -3 and is dosed IV or orally according to BMT program 
clinical practice guidelines, with a desired trough level of 5-15 ng/ml. When 
cyclosporine is substituted for tacrolimus a desired trough level is 200-300 ng/ml. 
It is suggested that tacrolimus be tapered below therapeutic range starting around 
day 90 post-transplant, per current institutional practice, provided the patient has 
no evidence of GVHD. The recommended taper is approximately 20% of the daily 
tacrolimus dose at the time of initiating taper. In the absence of GVHD, tapers are 
suggested every 14 - 28 days with goal of stopping tacrolimus at day + 180. 
5.6.2 Methotrexate 
If methotrexate is administered as part of GVHD prophylaxis it will be given as an 
intravenous infusion at 5-15 mg/m2 on day +1, and 5-10mg/m2 +3, + 6, and + 11 
post transplant. Standard criteria for administration will be followed as outlined in 
the institutional BMT program clinical practice guidelines. 
5.6.3 Mycophenolate mofetil (MMF or CellCept) 
If mycophenolate is administered as part of GVHD prophylaxis it will be given as 1 
gram PO every eight hours starting on day 1 and ending on day 28 post HCT. 
Mycophenolate can also be given intravenously at a dose of 10 mg/kg/dose 
maximum 1 gram/dose), administered every 8 hours if the patient is unable to 
tolerate oral medications. The conversion is 100% of the oral dose. 
 
5.7 Post-transplant Supportive Care 
Post-transplant supportive care, including infection prophylaxis will generally be 
conducted as per the BMT program Clinical Practice Guidelines. 
Micafungin 50 mg IV once daily is recommended for fungal prophylaxis from admission 
until day +5 post transplant to minimize potential interaction with hepatic function, 
especially if using clofarabine x busulfan based conditioning (ie. CloBu4). Anti-fungal 
coverage with mold activity (Voriconazole or Pozaconazole) are recommended starting 
at day + 5.  
Granulocyte colony stimulating factor (G-CSF, Neupogen) will be administered post -
transplant per institutional Clinical Practice Guidelines. 
 
6.0 MANAGING ACUTE GVHD 
6.1 Assessment and treatment: The absence or presence of clinical Acute GVHD 
(aGVHD), including severity, should be clinically evaluated within 72 hrs of study drug 
administration. aGVHD will be diagnosed, treated, and recorded by using the standard 

August 2018 
21 
 
 
BMT program clinical practice guidelines, which including clinical grading once weekly. 
aGVHD severity will be determined clinically (see APPENDIX B). Biopsies of affected 
organs are strongly encouraged whenever possible. 
6.2 Dose modification of peg-IFN-α: Although pre-clinical and clinical data suggest peg-
IFN-α will not significantly increase aGVHD, this remains a potential risk of enhancing 
post HCT immune responses. Thus, the parameters in Table 3 are designed to enable 
patients with very high risk for relapse to remain on study therapy, but without excessive 
exposure to risk. 
 
TABLE 3: DOSE MODIFICATION ACCORDING TO  ACUTE GVHD 
GVHD Grade 
Dose Modification of peg-IFN-α 
Grade I 
continue without modification 
Grade II 
Hold further doses (1) 
Grade III – IV  
Stop further doses (2) 
 
(1) Grade II aGVHD: peg-IFN-α should be temporally held pending observation 
of clinical response. If the patient is responding well to GVHD directed therapy, 
has been tapered to a corticosteroid dose of ≤ 0.5 mg/kg, and remains within 
the study treatment period (e.g. < 50 days post HCT), peg-IFN-α can be 
resumed at discretion of primary BMT physician. For example, a patient 
develops grade II aGVHD of the skin with 60% body surface area (BSA) 
involvement, and after two weeks of treatment has < 25% BSA involvement. 
Co-enrollment on acute GVHD treatment trials is permitted. 
 
(2) Grade III-IV aGVHD: no further doses of peg-IFN-α will be administered, 
The patient will be removed from further study treatment. In cases of grade III-
IV or steroid refractory GVHD, in addition to treatment with standard of care, 
co-enrollment on acute GVHD treatment trials is permitted. 
 
7.0 ASSESSMENT AND MANAGING AML RELAPSE 
7.1 Scheduled disease assessments: are per standard BMT clinical practice guidelines 
for AML not in remission. Bone marrow biopsy and aspirate will be obtained pre-transplant 
(within 14 days of study registration) and post-transplant on day 28 (±7), day 100 (± 14), 
and day 180 (± 28). Additional assessments of relapse can be performed at any time 
there is clinical suspicion for relapse. 
7.2 Definitions: 
7.2.1 Remission: 
For the purposes of this study, we define remission as achieving a morphologic 
leukemia free state by achieving all of the following criteria: bone marrow 

August 2018 
22 
 
 
myeloblasts < 5% by morphologic assessment; AND absence of circulating blasts 
with phenotypic or morphologic features of leukemia (e.g. Auer rods) AND no 
evidence of extramedulary disease (62). Note, since these assessments are 
occurring in the early post HCT period where numerous factors can affect blood 
counts, full hematologic recovery is not a required component for remission. 
7.2.2 Relapse or Progression: 
We define relapse by meeting one of following criteria: Bone marrow myeloblasts 
≥ 5% by morphologic assessment not attributed to other causes (e.g., bone 
marrow regeneration, G-CSF administration within previous 7 days) OR 
reappearance or persistence of circulating blasts with phenotypic or morphologic 
features of leukemia OR the development or persistence of extramedullary 
leukemia. Note, due to the large leukemic burden of patients at time of HCT, 
suspicion for low level disease or minimal residual disease (MRD) by cytogenetics, 
flow cytometric abberency, or molecular methods will not be counted as a relapse 
event, but will be recorded. The presence of these features will be later correlated 
with occurrence of hematologic relapse. 
7.3 Dosing of peg-IFN-α after relapse: 
Patients with documented relapse or disease persistence as defined in section 7.2.2 may 
continue to receive peg-IFN-α at the discretion of their primary BMT attending. Rapid 
tapering and / or withdrawal of immunosuppression to illicit aGVHD is a standard practice 
in the setting of relapse and is allowed. However, if additional leukemia directed treatment 
is initiated (e.g. re-induction chemotherapy, donor lymphocyte infusion, or clinical trial) 
the patient will be removed from this study. 
 
8.0 DOSE MODIFICATIONS BASED ON LABORATORY VALUES 
8.1 Hematologic parameters 
The following hematologic dose modifications pertains to post – engraftment doses of 
peg-IFN-α (i.e. doses administered on or after day + 28)  
If platelet < 20,000 will hold dose, may resume once platelet >20,000 without transfusion 
in the preceding 72 hrs.   
If ANC < 0.5 ul / mm2 will hold dose, may resume when ANC > 0.5 ul / mm2. Use of G-
CSF is allowed.  
8.2 Renal function 
If GFR is less than 30 mL/min and patient is assigned to dose level 2 (180 mcg), the 
patient should have their dose reduced to 90 mcg 
8.3 Hepatic function 

August 2018 
23 
 
 
Patients receiving HCT with active AML and myeloablative conditioning may have 
transient elevations in LFTs and total bilirubin. Peg-IFN-α has been safely administered 
to patients with active hepatitis and cirrhosis. However, if ALT or AST is greater than 10 
times above the upper limit of normal OR total bilirubin ≥ 8 mg/dl, treatment will be 
temporarily suspended. If ALT or AST fall to  < 5 x ULN and total bilirubin < 8 mg/dl, 
peg-IFN-α can be resumed.  
 
8.4 Fevers and infection 
Fevers are expected after HCT and are commonly encountered during interferon 
therapy. Infectious causes of high or persistent fever must be ruled out, particularly in 
patients with neutropenia. There are no specific dose modifications for fever.  
9.0 REQUIRED OBSERVATIONS (STUDY CALANDER): 
In general pre and post HCT care will follow BMT program clinical practice guidelines. 
For example, routine history, physical, organ function testing (PFT, Echocardogram), and 
laboratory evaluations (including serologic and/or PCR based viral studies) will follow 
institutional practice guidelines.The following studies will be obtained pre-therapy and 
post-therapy (TABLE 4). These studies will be collected as required observations for 
study. 
TABLE 4: STUDY CALANDER 
Pre 
Treatment 
Follow-up 
Observation Period (day) 
-28 to -7 
-1 
+14 
+28 
+42 
+56 
+100 + 180 
Relapse 
   Informed Consent 
x 
 
   Pregnancy test   
x 
 
   KPS (Karnofsky) 
x 
 
   Medical examination 
x 
x 
x 
x 
x 
 
   Laboratory testing 1 
x 
x 
x 
x 
x 
 
   peg-IFN-α 2 (study agent) 
x 
x 
x 
x 
 
   Acute GVHD assessment 
3 
 
 
x 
x 
x 
 
 
 
 
   BM aspirate & biopsy4 
x 
x 
x 
x 
x 
   Research samples 
x 
x 
x 
x 
x 
x 
   MRI 
X 
X 
 
X 
 
 
 
 
 
 
1 Includes CBC, serum chemistries, and standard viral pcr screening in pre-HCT period 
as part of institution practice guidelines (CPG). CBC with differential, serum creatinine, 
AST, ALT, and total bilirubin should be measured within 3 days of peg-IFN-α 
administration. 
2 Per protocol, peg-IFN-α may be administered for up to 7 days after treatment date 
indicated above (see section 5.2.1). In such instances, exam, labs, and aGVHD 
assessments can be deferred to the new treatment day. 

August 2018 
24 
 
 
3 Per institution practice guidelines (CPG) including assessments for chronic GVHD. 
4 Pre - HCT marrow aspirate must be within two weeks of study registration. 
NOTE: required observations: Patient’s medical condition and scheduling issues may 
impact the timing and acquisition of post-HCT observations. The acceptable time frame 
for completing these observations is ± 10 days for observations prior to day 56 and ± 14 
days for observations including and after day + 56. Failure to obtain research blood 
collections or MRI in accordance with the above schedule will not be considered a 
protocol deviation. The day -1 MRI, if delayed, must occur before infusion of donor cells 
on day 0 or will be omitted.   
 
10.0 RESEARCH SAMPLES 
10.1 Research blood samples 
We will obtain peripheral blood samples in 5 heparinized tubes (green top), 1 Cell-Free 
DNA BCT® (“Streck”) tubes, and 1 EDTA tube (purple top) (approximately 50 mL 
total)from each patient at 5 planned timepoints during the course of the study. Samples 
will be collected coincident with routine blood draws on the patients. An additional 5 mL 
of the bone marrow aspirate will be procured at the same time as pre-HCT and post HCT 
bone marrow examinations. Finally, one heparinized blood sample (approximately 2-3ml 
mL) will be taken from the donor stem cell grafts prior to patient administration. Note: 
Donors must sign and additional separate consent for this donor stem cell research 
specimens to be collected. Subjects participation in the collection of research samples is 
optional. 
Samples will be obtained at baseline (day -7) prior to conditioning, study drug, and stem 
cell infusion and then on day 28 (after 2 doses of peg-IFN-α), day + 56 (after 4 doses 
peg-IFN-α), day + 100 and day +180. PBMCs and serum will be isolated and frozen for 
future analysis. All blood samples will be processed, frozen, and banked in the 
Immunology Core Lab at the University of Michigan with the exception of the Streck tube 
and EDTA tube, which will be processed, frozen, and banked in the laboratory of Dr. Brian 
Parkin, respectively. All urine samples will be processed, frozen, and stored in the 
laboratory of Dr. Muneesh Tewari. 
10.1.1 Research urine samples 
Recent studies have demonstrated that nucleic acid and other analytes in urine may 
serve as markers for systemic (i.e. non-urinary tract) disease status. This includes 
microRNA, cell-free (cf) trans-renal DNA fragments, potentially other diverse species of 
RNA, and other biomarker types. In this study, we plan to study blood and urine cfDNA 
and microRNA as potential biomarkers for GVHD in AML patients undergoing HCT, and 
to compare the concordance of biomarkers between blood and urine. 

August 2018 
25 
 
 
We will obtain urine specimens in a urine hat or urinal using the Simple Urine Collection 
subject instructions. (Please see Appendix A below for Subject Instructions for urine 
collection.) Ideally within 30 minutes of urination, the urine will be transferred to a 
collection container with EDTA solution. Samples will be collected coincident with 
routine blood draws or other routine patient care. 
 
10.2 Correlative studies 
The primary aim of the correlative studies is to assess DC mediated cross presentation 
by serial measurement of AML specific immune responses. Generation of T cells directed 
towards tumor associated antigens (TAA) commonly overexpressed by myeloid 
leukemias, such as WT1, Pr3, NE, MAGE-A3, PRAME, will be measured by responses 
to peptide libraries and HLA class I tetramer staining. T cells specific for TAA will be 
measured before HCT (donor cell graft) and serially after HCT following exposure to AML 
antigens. Tetramer staining will be restricted to HLA-A*0201 positive patients. 
Experiments involving peptide libraries and tetramer staining using de-identified patient 
samples will be directed by the laboratory of Dr. Pavan Reddy (Univ. of Michigan) but in 
collaboration with Dr. John Barrett (National Institute of Heath) and / or Dr. Katayoun 
Rezvani (MD Anderson Cancer Center) who have extensive expertise in these methods. 
Any human samples sent for such analysis by external collaborators will be deidentified 
to protect subject personal health information. All other experiments will be performed 
solely at the University of Michigan in the laboratory of Pavan Reddy. These experiments 
will include phenotyping of key immune subsets including numbers and activation status 
of BDC3A+ DCs, functional assays, pharmacodynamic assessment of IFNα signaling, 
and cytokine profiles.  
Furthermore, the secondary aim of the correlative studies is to determine the dynamics 
of molecular minimal residual disease (MRD) during and after treatment and to 
characterize genomic and transcriptomic features of non-remission AML and any 
subsequent relapses after the experimental treatment.  MRD will be measured in bone 
marrow and peripheral blood cell-based genomic DNA as well as plasma-based cell-free 
DNA using a combination of droplet digital PCR and third-generation DNA sequencing to 
detect mutations previously identified in the pretreatment specimen.  Genomic and 
transcriptomic profiling of pre-treatment and post-relapse specimens will include whole 
exome sequencing, total mRNA sequencing, and determination of DNA copy 
number/LOH with genome-wide SNP arrays. These experiments will be performed at the 
University of Michigan in the laboratory of Drs. Sami Malek and Dr. Brian Parkin. 
Pharmacodynamic (PD) targets of peg-IFN-α signaling will be assessed including, but not 
limited to, components of JAK, Tyk2, and STAT pathways. Serum measurements of 
inflammatory cytokines will be analyzed. Finally, the laboratory will perform in vitro assays 
to evaluate DC, tumor and viral specific T cell responses (proliferation, Elispot for cytokine 
production). 

August 2018 
26 
 
 
10.3 Correlative imaging studies.  
Subjects in this study may opt to participate in MRI of bone marrow in the lumbar spine 
and pelvis with PRM analysis to quantify spatial and temporal dynamics of bone marrow 
ablation and repopulation prior to and following HCT, respectively. Subjects may withdraw 
from the MRI component of the protocol without withdrawing from the remainder of the 
protocol. Additional eligibility criteria for a subject to participate in the correlative MRI 
studies are: 1) no contraindications to MRI, such as a pacemaker; and 2) able to undergo 
MRI without general anesthesia and 3) medical condition sufficiently stable in the opinion 
of the treating physician to enable transportation and completion of the MRI sequences . 
This is particularly relevant to plan imaging on Day -1  
MRI examinations of the spine, pelvis, and proximal femora will be performed with a 6-
channel torso coil, body coil, or dedicated surface coil as determined by size of the patient. 
Survey scans will be performed for patient positioning and defining anatomic sites for 
subsequent scans. We will perform MRI sequences for quantitative fat and water imaging, 
cross relaxation transfer, T2* decay, susceptibility, and mobility of water. Specific 
sequence parameters will be adjusted within FDA-approved safety parameters for 
individual patients. No intravenous contrast material will be used. Anticipated duration of 
each MRI study is approximately 40 minutes.10.4 Additional research samples 
Additional samples will be collected whenever a possible new diagnosis of suspected 
relapse is made. Attempts will be made to obtain samples in a timely fashion before 
treatment is initiated. However, treatment will not be delayed while awaiting sample 
procurement. Obtaining samples for research purposes are secondary, not primary 
objective of this study. As such, failure to have a research sample drawn at any time point 
will not be considered a protocol violation. 
11.0 DRUG INFORMATION 
11.1 Peginterferon alfa-2a (peg-IFN-α, PEGASYS®) 
11.1.1 Formulation 
The chemical structure for peg-IFN-α is made by conjugating a single branched 
polyethylene glycol chain (PEG) of approximate molecular weight of 40 kilodaltons (kD) 
to interferon alfa-2a (20 kD) via a stable amide bond. The combination of PEG and 
interferon alfa-2a forms an intact active molecule known as peginterferon alfa-2a, having 
an approximate molecular weight of 60 kD. Chemically, it is a bis-(N-
monomethoxypolyethylene-glycol-urethanyl) lysyl interferon alfa-2a. 
 
11.1.2 Availability 
Peg-IFN-α is a sterile ready-to-use solution for subcutaneous injection. It is available as 
autoinjectors in two strengths, 135 mcg/0.5 mL and 180 mcg/0.5 mL, as prefilled syringes 
containing 180 mcg/0.5 mL, or as single-use vials containing 180 mcg/1.0 mL, per 
institutional standard. The solution is clear and colorless to light yellow. The strength of 

August 2018 
27 
 
 
peg-IFN-α is expressed as the amount of interferon alfa-2a, with excipients sodium 
chloride, benzyl alcohol, sodium acetate, acetic acid, polysorbate 80 and water for 
injections. 
 
11.1.3 Storage and stability 
The samples will be stored per the manufacturer’s recommendation. 
 
11.1.4 Pharmacokinetics 
Time to Peak Concentration: The absorption of peg-IFN-α is sustained with peak serum 
concentrations reached 72 – 96 h after dosing. Serum concentrations are measurable 
within 3 – 6 h of a single subcutaneous injection of peg-IFN-α 180 mcg. Within 24 h, about 
80% of the peak serum concentration is reached. The absolute bioavailability of peg-IFN-
α is 84% and is similar to that seen with interferon alfa-2a 
Peak Concentration: The peak concentrations (Cmax) after single administration of 180 
mcg dose of peginterferon alfa-2a, was 14 ± 5 ng/ml. 
 
Elimination half-life: A mean elimination half-life of 160 h (84 – 353 h) at primary 
elimination phase was observed in patients after subcutaneous (SC) administration of 
peg-IFN-α. The elimination half-life determined after SC administration may not only 
reflect the elimination phase of the compound, but may also reflect the sustained 
absorption of peg-IFN-α. 
Distribution: Peg-IFN-α is found predominately in the bloodstream and extracellular fluid 
as seen by the volume of distribution at steady-state (Vss) of 6 – 14 L after intravenous 
(IV) dosing in humans. Based on studies in rats, peg-IFN-α is distributed to the liver, 
kidney, and bone marrow in addition to being highly concentrated in the blood. 
Area Under the Curve: The mean area under the curve (AUC), after single 
administration of 180 mcg dose of peg-IFN-α, was 92 hrs ± 27. 
 
Metabolism: The metabolic profile of peg-IFN-α is not fully characterized. 
 
11.1.5 Administration 
Peg-IFN-alpha-2a will be administered subcutaneously every two weeks to begin on day 
-1 for a maximum of 4 doses. 
11.1.6 Adverse events 

August 2018 
28 
 
 
Use in hepatitis C and B: The principal adverse reactions listed below are primarily from 
clinical studies in patients who received peg-IFN-α at 180mcg once weekly for 24 - 48 
weeks for treatment of chronic hepatitis B or C with or without evidence of compensated 
cirrhosis. (adapted per PEGYSUS package insert, 2013 Genentech, Inc.) 
In general, the most common adverse reactions (incidence greater than 40%) are 
fatigue/asthenia, pyrexia, myalgia, and headache. The most common life-threatening or 
fatal events induced or aggravated by PEGASYS include depression, suicide, relapse of 
drug abuse/overdose, and bacterial infections, each occurring at a frequency of less than 
1%. Hepatic decompensation occurred in 2% (10/574) of CHC/HIV subjects. 
The most common serious adverse reactions (3% in CHC and 5% in CHC/HIV) was 
bacterial infection (e.g., sepsis, osteomyelitis, endocarditis, pyelonephritis, pneumonia). 
Other SAEs occurred at a frequency of less than 1% and included: suicide, suicidal 
ideation, aggression, anxiety, drug abuse and drug overdose, angina, hepatic 
dysfunction, fatty liver, cholangitis, arrhythmia, diabetes mellitus, autoimmune 
phenomena (e.g., hyperthyroidism, hypothyroidism, sarcoidosis, systemic lupus 
erythematosus, rheumatoid arthritis), peripheral neuropathy, aplastic anemia, peptic 
ulcer, gastrointestinal bleeding, pancreatitis, colitis, corneal ulcer, pulmonary embolism, 
coma, myositis, cerebral hemorrhage, thrombotic thrombocytopenic purpura, psychotic 
disorder, and hallucination. 
 
In clinical trials, 98 to 99 percent of subjects experienced one or more adverse reactions. 
For hepatitis C subjects, the most commonly reported adverse reactions were psychiatric 
reactions, including depression (18%), insomnia (19%), irritability (19%), and flu-like 
symptoms such as fatigue (56%), pyrexia (37%), myalgia (37%), headache (54%), and 
rigors (35%). Other common reactions were anorexia (17%), nausea and vomiting (24%), 
diarrhea (16%), arthralgia (28%), injection site reactions (22%), alopecia (23%), and 
pruritus (12%). 
 
Chronic hepatitis C monoinfected subjects treated for 24 weeks with PEGASYS and 800 
mg COPEGUS (PEGASYS + Ribaviron) were observed to have lower incidence of 
serious adverse reactions (3% vs. 10%), Hgb less than 10 g/dL (3% vs.15%), dose 
modification of PEGASYS (30% vs. 36%) and of withdrawal from treatment (5% vs. 15%) 
compared to subjects treated for 48 weeks. The most common reasons for dose 
modification of PEGASYS in CHC and CHC/HIV subjects was for neutropenia (20%) and 
thrombocytopenia (4%). 
 
The following serious conditions, some of which may become life threatening, have been 
reported have been observed in patients treated with PEGASYS. Hypertension, 
supraventricular arrhythmias, chest pain, and myocardial infarction. Development or 
exacerbation of autoimmune disorders including myositis, hepatitis, thrombotic 
thrombocytopenic purpura, idiopathic thrombocytopenic purpura, psoriasis, rheumatoid 
arthritis, interstitial nephritis, thyroiditis, and systemic lupus erythematosus have been 
reported in patients receiving alpha interferon. PEGASYS causes or aggravates 
hypothyroidism and hyperthyroidism. Hyperglycemia, hypoglycemia, and diabetes 

August 2018 
29 
 
 
mellitus have been observed to develop in patients treated with PEGASYS. Acute 
hypersensitivity reactions (e.g., urticaria, angioedema, bronchoconstriction, and 
anaphylaxis) have been observed during alpha interferon. Pancreatitis, sometimes fatal, 
has occurred during alpha interferon. Dyspnea, pulmonary infiltrates, pneumonia, 
bronchiolitis obliterans, interstitial pneumonitis, pulmonary hypertension and sarcoidosis, 
some resulting in respiratory failure and/or patient deaths, may be induced or aggravated 
by alpha interferon therapy 
 
Use in myeloproliferative neoplasms: A phase II study of weekly PEGASYS in 79 
patients was conducted in patients with advanced essential thrombosis or polycythemia 
vera exploring dosages ranging from 45mcg to 450mcg (48). Patients received therapy 
indefinitely as long as they deriving clinical benefit. At a median follow up was 22 months 
79% of patients remained on therapy. Ninety-six percent of patients developed some 
toxicity, generally grade 1 or 2. The most frequent grade 3 or 4 toxicity was neutropenia, 
which occurred in 20%, others included elevated LFTs (6%), fatigue (4%), pain (3%), 
depression (3%). The toxicity profile of peg-IFN-α was significantly more benign in the 28 
patients who started at 90mcg weekly. The 90mcg weekly schedule resulted in no grade 
4 toxicities and a low rate of grade 3 toxicities, including neutropenia in two patients (7%) 
and infection, diarrhea, depression, and elevated liver function tests in one patient (4%) 
each. 
Use of IFN after HCT in AML. Data in the post HCT setting is limited to multiple case 
series and reports of short acting IFN preparations for treatment of post – HCT relapse 
(63-67). IFN has been administered in combination with complete cessation of 
immunosuppression together with either chemotherapy, DLI, or additional cytokines 
therapies (e.g. IL-2) to illicit GVHD. All reports suggest that the use of IFN was feasible 
and tolerable, but assessment of adverse events are limited by confounding variables 
and progressive AML. Under these conditions aGVHD occurred in approximately 60% of 
patients. The use of IFN was not associated with more severe aGVHD or death. While 
the presence of GVHD may be associated with increased likelihood of achieving durable 
remission. In a small randomized study of acute lymphoblastic leukemia (ALL), human 
leukocyte IFN was administered prophylactically after HCT to prevent CMV reactivation. 
Compared to control patients CMV rates were similar, but relapse was lower in the IFN 
treated patients and there was no difference in the probability or severity of aGVHD (51). 
 
11.2 Methotrexate 
11.2.1 Formulation 
Chemically methotrexate is N - [4 - [[(2, 4 – diamino – 6 – pteridinyl) methyl] 
methylaminolbenzoyl] – L - glutamic acid. Methotrexate is an antimetabolite used in the 
treatment of certain neoplastic diseases, severe psoriasis, adult rheumatoid arthritis, and 
prevention of acute GVHD. Methotrexate inhibits dihydrofolic acid reductase. 
Dihydrofolates must be reduced to tetrahydrofolates by this enzyme before they can be 
utilized as carriers of one-carbon groups in the synthesis of purine nucleotides and 

August 2018 
30 
 
 
thymidylate. Therefore, methotrexate interferes with DNA synthesis, repair, and cellular 
replication. 
11.2.2 Availability and administration 
Methotrexate sodium for injection is available in 25mg/ml solution. The appropriate 
amount is drawn into a syringe for administration.  Store at controlled room temperature, 
20°-25° C (68°-77° F); excursions permitted to 15°-30° C (59°-86° F). Protect from light. 
 
11.2.3 Potential Side Effects 
The most frequently reported adverse reactions associated with methotrexate use as 
GVHD prophylaxis include ulcerative stomatitis, leucopenia and suppressed 
hematopoiesis, nausea, and abdominal distress. Other frequently reported adverse 
effects are malaise, undue fatigue, chills and fever, dizziness and decreased resistance 
to infection. Methotrexate may be associated with increased rates of pulmonary 
complications after transplantation. The risk of infections is due to the suppression of 
hematopoiesis after transplantation. 
11.2.4 Potential Drug Interactions 
Methotrexate is partially bound to serum albumin, and toxicity may be increased because 
of displacement by certain drugs, such as salicylates, phenylbutazone, phenytoin, and 
sulfonamides. Renal tubular transport is also diminished by probenecid; use of 
methotrexate with this drug should be carefully monitored. Oral antibiotics such as 
tetracycline, chloramphenicol, and nonabsorbable broad-spectrum antibiotics, may 
decrease intestinal absorption of methotrexate or interfere with the enterohepatic 
circulation by inhibiting bowel flora and suppressing metabolism of the drug by bacteria. 
Penicillins may reduce the renal clearance of methotrexate; increased serum 
concentrations of methotrexate with concomitant hematologic and gastrointestinal toxicity 
have been observed with high and low dose methotrexate. Use of methotrexate with 
penicillins should be carefully monitored. 
 
 
11.3 Mycophenolate (CellCept) 
11.3.1 Formulation and mechanism of action 
Mycophenolate mofetil is the 2-morpholinoethyl ester of mycophenolic acid (MPA), 
animmunosuppressive agent; inosine monophosphate dehydrogenase (IMPDH) inhibitor. 
Mycophenolate mofetil is rapidly absorbed following oral administration and hydrolyzed 
to formMPA, which is the active metabolite. MPA is a potent, selective, uncompetitive, 
and reversible inhibitor of inosine monophosphate dehydrogenase (IMPDH), and 
therefore inhibits the de novo pathway of guanosine nucleotide synthesis without 

August 2018 
31 
 
 
incorporation into DNA. Because T- and Blymphocytes are critically dependent for their 
proliferation on de novo synthesis of purines, whereas other cell types can utilize salvage 
pathways, MPA has potent cytostatic effects on lymphocytes. MPA inhibits proliferative 
responses of T- and B-lymphocytes to both mitogenic and allospecific stimulation. 
Addition of guanosine or deoxyguanosine reverses the cytostatic effects of MPA on 
lymphocytes. MPA also suppresses antibody formation by B-lymphocytes. MPA prevents 
the glycosylation of lymphocyte and monocyte glycoproteins that are involved in 
intercellular adhesion to endothelial cells and may inhibit recruitment of leukocytes into 
sites of inflammation and graft rejection. Mycophenolate mofetil did not inhibit early events 
in the activation of human peripheral blood mononuclear cells, such as the production of 
interleukin-1 and interleukin-2, but did block the coupling of these events to DNA 
synthesis and proliferation. 
11.3.2 Availability 
CellCept is available for intravenous or oral administration as capsules containing 250 mg 
of mycophenolate mofetil, tablets containing 500 mg of mycophenolate mofetil, and as a 
powder for oral suspension, which when constituted contains 200 mg/mL mycophenolate 
mofetil. CellCept Intravenous is the hydrochloride salt of mycophenolate mofetil. CellCept 
Intravenous is available as a sterile white to off-white lyophilized powder in vials 
containing mycophenolate mofetil hydrochloride for administration by intravenous 
infusion only. Each vial of CellCept Intravenous contains the equivalent of 500 mg 
mycophenolate mofetil as the hydrochloride salt. The inactive ingredients are polysorbate 
80, 25 mg, and citric acid, 5 mg. Sodium hydroxide may have been used in the 
manufacture of CellCept Intravenous to adjust the pH. Reconstitution and dilution with 
5% dextrose injection USP yields a slightly yellow solution of mycophenolate mofetil, 
6mg/mL. 
11.3.3 Administration 
The dosing for oral and intravenous mycophenolate are the same. For oral dosing, doses 
should be rounded to the nearest 250 mg. The oral solution (200 mg/ml) may be 
substituted for capsules or tablets at patient preference or physician discretion, in which 
case, the dose should be rounded to the nearest 100 mg (0.5 ml). 
 
11.3.4 Adverse events 
The principal adverse reactions associated with the administration of CellCept include 
diarrhea, leukopenia, sepsis, vomiting, and a higher frequency of infections, including 
opportunistic infection. The adverse event profile is similar regardless of the form 
administered. 
11.4 Tacrolimus (Prograf, FK506) 
11.4.1 Formulation 

August 2018 
32 
 
 
Tacrolimus, previously known as FK506, is the active ingredient in Prograf. Tacrolimus is 
a macrolide immunosuppressant produced by Streptomyces Tsukubaensis. Tacrolimus 
appears as white crystals or crystalline powder. It is practically insoluble in water, freely 
soluble in ethanol, and very soluble in methanol and chloroform. Tacrolimus inhibits T-
lymphocyte activation, although the exact mechanism of action is not known. 
Experimental evidence suggests that tacrolimus binds to an intracellular protein, FKBP-
12. A complex of tacrolimus-FKBP-12, calcium, calmodulin, and calcineurin is then 
formed and the phosphatase activity of calcineurin inhibited. This effect may prevent the 
generation of nuclear factor of activated T-cells (NF-AT), a nuclear component thought to 
initiate gene transcription for the formation of lymphokines (interleukin-2, gamma 
interferon). The net result is the inhibition of T-lymphocyte activation (i.e., 
immunosuppression). 
11.4.2 Availability and administration 
Prograf is available for oral administration as capsules (tacrolimus capsules) containing 
the equivalent of 0.5 mg, 1 mg or 5 mg of anhydrous tacrolimus. Inactive ingredients 
include lactose, hydroxypropyl methylcellulose, croscarmellose sodium, and magnesium 
stearate. The 1-mg capsule shell contains gelatin and titanium dioxide, and the 0.5 mg 
and 5-mg capsules shell contains gelatin, titanium dioxide and ferric oxide. Prograf is also 
available as a sterile solution (tacrolimus injection) containing the equivalent of 5 mg 
anhydrous tacrolimus in 1 mL for administration by intravenous infusion only. Each mL 
contains polyoxyl 60 hydrogenated castor oil (HCO-60), 200 mg, and dehydrated alcohol, 
USP, 80.0% v/v. Prograf injection must be diluted with 0.9% sodium chloride injection or 
5% dextrose injection before use. Intravenous administration will be given by continuous 
infusion. Oral preparation will be administered on empty stomach every 12 hours. 
11.4.3 Potential Side Effects 
a. Increased susceptibility to infection and the possible development of lymphoma may 
result from immunosuppression. 
b. Nephrotoxicity has been noted in 40% and 33% of liver transplantation patients 
receiving Prograf in the U.S. and European randomized trials, respectively. The risk 
appears to be related to the intensity and duration of immunosuppression rather than to 
the use of any specific agent. A lymphoproliferative disorder (LPD) related to Epstein - 
Barr virus (EBV) infection has been reported in immunosuppressed organ transplant 
recipients. The risk of LPD appears greatest in young children who are at risk for primary 
EBV infection while immunosuppressed or who are switched to Prograf following long-
term immunosuppression therapy. 
c. Mild to severe hyperkalemia has been noted in 44% and 10% of liver transplant 
recipients treated with Prograf in the U.S. and European randomized trials and may 
require treatment. 
d. Neurotoxicity, including tremor, headache, and other changes in motor function, mental 
status, and sensory function were reported in approximately 55% of liver transplant 

August 2018 
33 
 
 
recipients in the two randomized studies. Tremor and headache have been associated 
with high whole-blood concentrations of tacrolimus and may respond to dosage 
adjustment. Seizures have occurred in adult and pediatric patients receiving Prograf. 
Coma and delirium also have been associated with high plasma concentrations of 
tacrolimus. 
e. Hypertension is a common adverse effect of Prograf therapy. Mild or moderate 
hypertension is more frequently reported than severe hypertension. Antihypertensive 
therapy may be required; the control of blood pressure can be accomplished with any of 
the common antihypertensive agents. Since tacrolimus can cause hyperkalemia, 
potassium-sparing diuretics should be avoided. While calcium-channel blocking agents 
can be effective in treating Prograf-associated hypertension, care should be taken since 
interference with tacrolimus metabolism may require a dosage reduction. 
f. Hyperglycemia was associated with the use of Prograf in 47% and 29% of liver 
transplant recipients in the U.S. and European randomized studies, respectively and may 
require treatment. 
11.5 MRI of bone marrow 
Participation in this study exposes subjects to three separate MRI examinations, each of 
which may last up to 60 minutes. The MRI sequences are entirely non-invasive and do 
not require intravenous contrast. MRI does not use ionizing radiation. MRI without 
intravenous contrast has an outstanding safety record, so the overall risk to each subject 
is very minimal.   
12.0 STUDY DEFINITIONS 
12.1 Definition of “screening”: A patient is considered to be in the screening period 
from the time they signed consent until the date their eligibility criteria have been 
determined as either “eligible” or “ineligible (screen fail). 
12.2 Definition of “Enrolled”: A patient is considered to be enrolled onto the study once 
they have signed consent and have successfully met all screening criteria, as 
documented by the inclusion/exclusion document., and the eligibility criteria has been 
reviewed and accepted by either the P.I. or a Co-I. The date of enrollment will be 
documented as the date the P.I. or Co-I. has reviewed and approved eligibility. 
12.3 Treatment Period: The study treatment period is defined as the first day of treatment 
with peg-IFN-α through the last day of treatment with peg-IFN-α. This period is expected 
to last from day -1 through day 56 (or two weeks after last dosage of peg-IFN-α, whichever 
occurs later). Thus, this period may be extended, due to a postponement of the patient’s 
BMT procedure or peg-IFN-α dosing, without constituting a deviation. Patients who 
develop stage III-IV acute GVHD will be considered “off treatment” (see Section 6.2). 
12.4 Follow Up Period: A patient is considered to be in the “follow up period” from the 
14 days after they no longer receive peg-IFN-α therapy (~ day 56) through day +180 post 

August 2018 
34 
 
 
transplant (primary endpoint). After day 180 there are no additional study required 
protocol observations (sec. 9.0), and subjects will be only be monitored for routine clinical 
endpoints of GVHD, relapse, and survival for at least one year or until the study is 
terminated. More detailed outcome information after day 180 may be collected from 
clinical databases on other BMT research studies (HUM00043287, HUM00048885, if the 
subject has consented to these ancillary studies, and may be analyzed in relation to 
patients participating in this study (e.g for determination of long-term outcomes).  
12.5 On Study: Patients are considered “On Study” from the time they are enrolled until 
they meet one of the “Off Study” criteria listed below. 
12.6 Off Study: Patients are considered “Off study” if they meet one or more of the 
following criteria: 
• Death 
• Lost to follow up 
• Entry onto a competing trial (e.g. AML therapeutic trial) 
• Withdrawal of consent by patient or investigator for any further treatment and follow 
up observations 
• Relapse of underlying malignancy and receiving AML directed therapy other than 
peg-IFN-α-2a 
• Development of new malignancy 
• Unacceptable or dose limiting toxicity or complication 
Patients off study (who do not withdrawal consent)will still be followed for routine HCT 
clinical endpoints (e.g. GVHD, Relapse) and survival. Patients who develop AML relapse 
or GVHD may have collection of planned research samples.  Patients have the right to 
withdraw from the study or refuse research samples at any time for any reason. The 
investigator also has the right to withdraw patients from the study in the event of illness, 
adverse events, treatment failure, protocol violation, or other reasons. Should a patient 
decide to withdraw, all efforts will be made to complete and report the observations as 
thoroughly as possible. A complete final evaluation should be made at the time of the 
patient’s withdrawal with an explanation of why the patient is withdrawing and every effort 
should be made to perform follow-up evaluations. The assessment and reporting period 
for all adverse events, reportable under this protocol, will occur from the first day the 
treatment with peg-IFN-α is administered until day +56 post transplant or until 14 days 
after the last dose of peg-IFN-α is administered, whichever comes last.  
12.7 Definition of an “evaluable” patient: Patients removed from study who receive 
peg-IFN-α for at least one dose will be considered fully evaluable for toxicity. The number 
of patients removed from study prior to being fully evaluable will be monitored regularly 
by the study’s DSMB in order to identify and address problems that may develop with 
respect to patient accrual. We estimate that < 5 subjects may need to be replaced. 
 
12.8 Definition of engraftment and delayed engraftment: 

August 2018 
35 
 
 
12.8.1 Engraftment: Engraftment for neutrophils is defined as the first of three 
consecutive days in which the absolute neutrophil count (ANC) is > 500/uL. 
Engraftment for platelets is defined as the first of three consecutive days in which 
the platelet count is > 20,000/uL, without transfusion support. 
12.8.2 Engraftment failure: will be defined as ongoing ANC <500/uL. Patients 
who engraft prior to day 28 and later have low ANC or platelet transfusion 
requirements, as frequently occurs in HCT patients due to infection and other 
complications will not be considered to have delayed engraftment. 
 
13.0 ADVERSE EVENTS AND REPORTING CRITERIA 
 
An adverse event (AE) is any untoward medical occurrence in a subject participating in 
an investigational study or protocol regardless of causality assessment. An adverse event 
can be an unfavorable and unintended sign (including an abnormal laboratory finding), 
symptom, syndrome or disease associated with or occurring during the use of an 
investigational product whether or not considered related to the investigational product. 
As such, the AEs will be followed and reported after the study subjects have been started 
on the investigational drug. 
 
These events may be: 
• Definitely related: clearly associated with study drug/treatment 
• Probably related: likely associated with study drug/treatment 
• Possibly related: may be associated with study drug or other treatment 
• Unlikely to be related, or 
• Definitely not related to the study drug/treatment 
 
For reporting purposes, an AE should be regarded as definitely or probably related to the 
regimen if the investigator believes that at least one of following criteria are met: 
• There is a clinically plausible time sequence between onset of the AE and the 
administration of the study drug or treatment. 
• There is a biologically plausible mechanism for the study drug or treatment causing 
or contributing to the AE. 
• The AE cannot be attributed solely to concurrent/underlying illness, other drugs, or 
procedures. 
• A potential alternative cause does not exist. 
 
Serious Adverse Drug Experience: Any adverse drug experience occurring at any dose 
that results in any of the following outcomes: 
• Death, 
• a life-threatening adverse drug experience, 
• inpatient hospitalization or prolongation of existing hospitalization, 
• a persistent or significant disability/incapacity, 
• or a congenital anomaly/birth defect. 

August 2018 
36 
 
 
 
Important medical events that may not result in death, be life-threatening, or require 
hospitalization may be considered a serious adverse drug experience when, based upon 
appropriate medical judgment, they may jeopardize the patient or subject and may require 
medical or surgical intervention to prevent one of the outcomes listed in this definition. 
 
Expected Event: - An event that is expected in that it has been addressed or described 
in one or more of the following: Informed consent document(s) for this study, IRB 
application for this study, grant application or study agreement, protocol or procedures 
for this study, investigators' brochure or equivalent (for FDA regulated drugs or devices), 
DSMB/DSC Reports, published literature, other documentation, or characteristics of the 
study population. 
 
Unexpected adverse events are those that: 
• those that do not fall in to the above criteria 
• are not described in the  package insert as far as peg-IFN-α is concerned. 
• are not anticipated in the study informed consent or the BMT Program clinical 
transplant consent. This includes adverse events for which the specificity or 
severity is not consistent with 
• the description in the informed consent. 
 
The severity or grade of an adverse event may be measured using the following 
definitions: 
 
Mild: Noticeable to the subject, but does not interfere with the subject’s expected daily 
activities, usually does not require additional therapy or intervention, dose reduction, or 
discontinuation of the study. In the transplant setting CTCAE v. 4.0 grades 1 and 2. 
 
Moderate: Interferes with the subject’s expected daily activities, may require some 
additional therapy or intervention but does not require discontinuation of the study. In the 
transplant setting using the CTCAE v. 4.0  some grade 2 and most grade 3. 
 
Severe: Extremely limits the subject’s daily activities and may require discontinuation of 
study therapy, and/or additional treatment or intervention to resolve. In the transplant 
setting using the CTCAE v. 4.0 some grades 3 and all grade 4. 
 
Therapy for hematological malignancies, with or without stem cell transplantation, is 
associated with significant toxicity. These toxicities are generally viewed as an anticipated 
consequence of therapy rather than an adverse event. Therefore, event reporting for HCT 
Protocols can be complicated and confusing to investigators, data managers, and 
regulatory oversight bodies because patients typically develop numerous complications 
such as infections, chemotherapy-related organ damage, medication side effects, etc. as 
part of the typical course of a bone marrow transplant and not related to the study therapy. 
Furthermore, transplant-related complications often occur both simultaneously and in 
series, as one complication leads to a series of additional downstream events, making 

August 2018 
37 
 
 
time-sensitive reporting of events difficult. Therefore, a well-conceived event reporting 
plan will separate complications that might be seen with any transplant, from study-related 
events that are relevant to subject safety. In order to achieve this goal, the DSM plan for 
this study will focus on rapid and specific identification of SAEs as follows: 
 
a. Adverse events with severity grades 1, 2, 3, and all expected grade 4 toxicities will 
not be reported to the IRB, so long as they are expected for patients undergoing 
stem cell transplantation for hematological malignancies. 
b. Grade 4 events which are serious and likely (probably or definitely) related to the 
investigational component of study therapy will be reported to the IRB. 
c. Events occurring at unusual frequency or severity in study subjects compared to 
non-study subjects undergoing similar transplants will be reported to the IRB. 
d. Events resulting in death (other than relapse or GVHD) regardless of attribution. 
 
Therefore, we will not report as SAEs events that are expected and coincident with 
a typical transplant course unless they are either fatal or probably or definitely 
related to the investigational therapy. 
 
Event grading: The NCI Common Terminology Criteria (Version 4.0) will be used to 
grade intensity of adverse events and assist in reporting adverse events. 
 
Events not reported: 
The large majority of patients undergoing unrelated stem cell transplant will frequently 
experience 
hematologic 
events 
(i.e. 
anemia, 
thrombocytopenia, 
leukopenia, 
neutropenia), infections, electrolyte abnormalities, and organ toxicities. Given the 
frequency with which these occur in transplant patients, we will not report events that 
coincide with events that typically occur during the pre-and post transplant related therapy 
regardless of severity unless they otherwise meet the criteria for reporting as detailed 
above and below. An event is regarded as typical if it is specified in the study consent or 
the BMT Program transplant consent and / or it occurs in more than 5% of transplant 
patients. 
 
Events reported as adverse events in tabular format annually: 
Events that are classified as severe (all CTCAE v.4 grade 4) will be reported to the Cancer 
Center DSMB with each routine report (quarterly) and in the annual IRB report so long as 
the events do not meet the criteria for expedited reporting as defined above. Events 
determined to be a CTCAEv4.0 grade 1 or 2 will not be captured as part of this protocol. 
 
 
 
14.0 DATA SAFETY MONITORING PLAN (DSMP) 
 
The following are the procedures for data and safety monitoring of this clinical trial to be 
conducted within the Blood and Marrow Transplant program. This is to insure the safety 
of participants, the validity of research data, and the appropriate termination of studies for 

August 2018 
38 
 
 
which significant benefits or risks have been uncovered or when it appears that the trial 
cannot be concluded successfully. This protocol will conduct a data and safety monitoring 
process as described in the plan below. 
 
14.1 Trained and Certified Personnel 
All of the research protocol personnel who will work with study subjects, study subject 
data or subjects’ research samples have completed training in the protection of human 
research participants per guidelines issued by the U. S. Department of Health and Human 
Services, Office of Human Research Protections. The documentation of completion of the 
certification is maintained in the UMCCC Clinical Trials Office or the Blood and Marrow 
Transplantation Office. The investigator and designated associates have attended an IRB 
sponsored HIPAA research presentation in accordance with the policy of the study site. 
Each participant in this research trial will be listed by study specific numbers, without 
initials or date of birth; however, the date of transplant may be included when 
corresponding with the IRB or outside agencies. 
 
Designation of Responsibilities: The Principal investigator(s) are solely responsible for 
the implementation and conduct of this trial. The principal investigator has however, 
designated associates to assist with the protocol implementation which includes but is not 
limited to the following: 
 
1. BMT Physicians – have been designated to assist with participant education, informed 
consent process, study implementation and compliance, recording of primary source 
documentation, AE assessment and reporting, adherence to all regulations. 
2. BMT Research Nurse(s) - have been designated to assist with participant education, 
informed consent process, study implementation and compliance, recording of primary 
source documentation and adherence to all regulations. 
3. BMT Data Manager(s) - have been designated to assist with patient 
enrollment/eligibility, verification of protocol compliance, all data collection and recording 
from primary source, AE reporting, DSM reports and adherence to all regulations. 
4. BMT Clinical Team - The members of the BMT clinical team that have been designated 
to assist the investigator in any aspect of this protocol will be listed on the protocol specific 
designation log. 
5. The BMT internal Data and Safety Monitoring Committee (DSMC) will meet monthly to 
review the data, safety and monitoring reports and all SAEs that have been filed. The 
report will be submitted to the UMCCC DSMB and to the UM IRB at least monthly. 
Whenever an unanticipated data, safety and monitoring board meeting takes place or 
when a new development occurs the IRB will be notified of the occurrence. 
 
 
14.2 Storage and Dissemination of Reports 
 
The Clinical Trials Office (CTO) is responsible for collating all the Data and safety 
Monitoring Reports and providing the information to Data Safety Monitoring Board. The 
CTO will coordinate the reporting process between the Investigator and the IRBMED and 

August 2018 
39 
 
 
UM DSMB as well as other applicable reporting agencies (FDA, and study sponsors). 
Copies of all related correspondence and reporting documents will be maintained in a 
locked file by the CTO regulatory team and the research data file will be maintained in a 
file by the BMT data management team. 
 
 
14.3 Clinical Monitoring Procedures 
Clinical studies at the University of Michigan must be conducted in accordance with the 
ethical principles that are consistent with Good Clinical Practices and in compliance with 
other applicable regulatory requirements. 
 
This study will be monitored by a CTO representative of the University of Michigan Cancer 
Center. Monitoring visits will be made during the conduct of the study and at study close-
out. 
 
Prior to subject recruitment, a site initiation meeting will be conducted by the CTO. The 
PI and the study staff should make every effort to attend the site initiation meeting. Study-
related questions or issues identified during the site initiation meeting will be followed by 
the appropriate University of Michigan Cancer Center personnel unit they have been 
answered and resolved. 
 
The first annual monitoring visit should occur after the first five study participants are 
enrolled or twelve months after a study opens, whichever occurs first. The initial annual 
visit is not justified unless there is at least one participant enrolled on a study. At a 
minimum, a routine monitoring visit will be done at least once every 12 months, or once 
during the course of the study if the study duration is less than 12 months. The purpose 
is to verify: 
 
a. 
Adherence to the protocol 
b. 
Completeness and accuracy of study data and samples collected 
c. 
Proper storage, dispensing, and inventory of study medication 
d. 
Compliance with regulations 
 
Monitoring may be in the form of a site visit or a review of the documents at the CTO. 
During a monitoring, access to relevant hospital and clinical records must be given by the 
PI to the CTO representative conducting the monitoring visit to verify consistency of data 
collected on the CRFs with the original source data. While most patient cases will be 
selected from patients accrued since the previous monitoring visit, any patient case has 
the potential for review. At least one or more unannounced cases will be reviewed, if the 
total accruals warrant selection of unannounced cases. 
 
The CTO expects the relevant investigational staff to be available to facilitate the conduct 
of the visit, that source documents are available at the time of the visit, and that a suitable 
environment will be provided for review of study-related documents. Any issues identified 

August 2018 
40 
 
 
during these visits will be communicated and are expected to be resolved in a time 
manner. 
 
At close-out upon completion, termination, or cancellation of a study to ensure fulfillment 
of study obligations during the conduct of the study will occur, and the PI will be informed 
of his / her ongoing responsibilities. In general, close-out is conducted during a site visit. 
However, a site close-out can occur without a site visit if all of the following apply: 
 
a. 
No patient has signed the Informed Consent Form 
b. 
Investigational agent (peg-IFN-α) has not been dispensed 
c. 
All investigational agent (agent) and materials have been returned as defined for 
the study or destroyed and accounted for properly. 
 
14.4 Quality Assurance and Audits 
The Quality Assurance Review Committee (QARC) of the UMCCC performs quality 
assurance audits of investigator-initiated clinical trials. Audits provide assurance that trials 
are conducted in compliance with the protocol. Further, they ensure that study data are 
collected, documented and reported in compliance with Good Clinical Practices (GCP) 
Guidelines and regulatory requirements. A QARC audit of each clinical trial is conducted 
annually. Audits occur within the month of the study’s initial IRB approval. All audit findings 
are reported by QARC to the UMCCC DSMB. The DSMB can also request QARC for a 
‘for cause’ audit of the trial if the board identifies a need for a more rigorous evaluation of 
study-related issues. A regulatory authority (e.g. FDA) may also wish to conduct an 
inspection of the study, during its conduct or even after its completion. If an inspection 
has been requested by a regulatory authority, the site investigator must immediately 
inform the Clinical Trials Office that such a request has been made. 
 
 
 
15.0 REMOVAL FROM STUDY 
Patients have the right to withdraw from the study at any time for any reason. The PI also 
has the right to withdraw patients from the study in the event of intercurrent illness, 
adverse events, treatment failure, protocol violation, or other reasons. Should a patient 
(or a patient’s legally authorized guardian or representative) decide to withdraw, all efforts 
will be made to complete and report the observations as thoroughly as possible. A 
complete final evaluation should be made at the time of the patient’s withdrawal with an 
explanation of why the patient is withdrawing and every effort should be made to perform 
follow-up evaluations. Patients may be removed from the study treatment if one or more 
of the following events occur: 
• Significant protocol violation or noncompliance, either on the part of the patient or 
the PI. 
• Refusal of the patient to continue treatment and / or observations. 
• Unacceptable or dose-limiting toxicity 
• Decision by the PI that removal from the study is in the patient’s medical interest. 
• Unrelated medical illness or complication. 

August 2018 
41 
 
 
• Lost to follow-up. 
• Disease relapse or progression. 
 
Patients removed from the study who have received one or  no doses of peg-IFN-α  will 
be evaluable for toxicity only and will therefore be replaced. The number of patients 
removed from the study prior to being fully evaluable will be monitored regularly by the 
study’s DSMB in order to identify and address problems that may develop with respect to 
patient accrual. We estimate that <10% of subjects may need to be replaced because 
they encounter toxicity from relapsed AML prior to HCT or during conditioning therapy. 
Patients who die before day +14 will be counted toward the endpoints but additional 
patients will be enrolled to make up for the very short follow up on such patients. 
 
16.0 STATISTICAL CONSIDERATIONS 
 
16.1 Study Endpoints 
 
16.1.1 Phase I: The primary endpoint of phase I is to determine a tolerable dose of peg-
IFN-α for phase II study in patients with AML not in remission at HCT. 
 
16.1.2 Phase II: The primary endpoint is to determine the cumulative incidence of relapse 
at six months post-HCT in patients receiving the phase II dose of peg-IFN-α. All patients 
who have persistent AML or relapse between day 0 and day 180 will be counted towards 
this endpoint. 
 
 
16.2 Study Design and Sample Size Justification 
 
16.2.1 Phase I: The aim of the dose finding portion of this study is to determine the 
maximum tolerated dose (MTD) of peg-IFN-α among two dose levels: 90 mcg and 180 
mcg.  Our targeted DLT rate is 0.30.  The first patient will be assigned to 90 mcg and the 
dose assignment of each future patient will be determined using the modified toxicity 
probability interval (mTPI) design (68). If 90 mcg proves to be overly toxic, a lower dose 
of 45 mcg will be included as a “fall-back” dose and be assigned to the next patient to 
avoid closure of the study.  If 45 mcg also proves to be overly toxic, the study will be 
halted and subject to either closure or amendment following DSMB review.  At the end of 
the study, the dose assigned to the most patients will be selected as the MTD. 
 
16.2.2 Definitions of dose limiting toxicity (DLT). The following events with be 
considered DLTs: 
• Unexpected Grade 4 CTCAE v. 4, non-hematologic toxicity, considered probably 
or definitely related to the study drug. 
• Any death not related to relapse of AML or GVHD. 
• Graft failure defined as ANC < 500 by day + 28, not related to persistent AML. 

August 2018 
42 
 
 
Only DLTs encountered  during the treatment period, prior to day 56 post HCT (or 14 
days after final treatment, whichever comes later), will be counted. DLTs after the 
treatment period will be counted only if they reflect an ongoing toxicity that initiated in the 
treatment period. 
16.2.3 Dose Assignment: Dose assignments for the mTPI are outlined in FIGURE 6.  
For example, if the first patient (who is assigned to 90 mcg) does not experience DLT, the 
next patient will be assigned to 180 mcg.  However, if the first patient experiences DLT, 
the next patient will be assigned to 45 mcg. 
 
Based upon simulations, with a sample size of 35 patients, if the true DLT rates of the 
three doses are 0.10, 0.30, and 0.50 (90 mcg is the MTD), we have a probability of 50% 
of selecting 90 mcg as the MTD and 50% of patients will be assigned to 90 mcg on 
average.  If the true DLT rates of the three doses are 0.10, 0.20, and 0.30 (180 mcg is 
the MTD), we have a probability of 80% of selecting 180 mcg as the MTD and over 90% 
of patients will be assigned to 180 mcg on average. 
 
16.2.4 Phase II 
 
We will enroll a maximum of 35 patients to this study.  This sample size was selected to 
have high probability that at least 30 patients would be assigned to 180 mcg during the 
study if 180 mcg is the MTD.  We want to have 30 patients receiving the same dose 
because we will have 80% power, assuming a Type I error rate of 0.05, to show a 
difference between a promising six month relapse rate of 40% versus a relapse rate of 
60%, which is the primary aim of the phase II portion of this study. 
 
 
 
 
 

August 2018 
43 
 
 
 
 
Figure 6: Dose assignment grid for mTPI design 
 
 
16.3 Stopping Rules 
 
16.3.1 Stopping Rules for acute GVHD and Non-Relapse mortality: 
Once 12 patients have been enrolled and have started treatment we will evaluate for 
stopping criteria once this 12th patient has completed 100 days of follow-up. At this point, 
the study will stop if 6 or more patients have developed Grades III-IV aGVHD that is 
refractory to corticosteroid therapy (methylprednisone 2mg/kg or equivalent) before day 
100 post HCT (GVHD100). Independent from the occurrence of GVHD100, the study will 
also stop if 6 or more patients have died from causes other than relapse before day 100 
post HCT (NRM100).  
Although our stopping rules require 100 days of follow-up for each subject, we will not 
halt accrual to wait for full follow-up of previously-enrolled subjects unless there is  
potential for an ‘early stopping’ condition. For example, we will enroll the 13th subject as 

August 2018 
44 
 
 
soon as they are eligible, regardless of whether the first 12 subjects have all been followed 
for 100 days, unless 5 or more patients have already experienced GVHD100 or NRM100 
event. As a result, there is a possibility of enrolling additional subjects on this study before 
we discover the ‘stopping rule’/halt on accrual condition has been met. 
If less than 6 patients have either these events, 12 more patients will be enrolled, for a 
total of 24 patients.  At this point, the study will stop if 12 or more patients (out of 24) have 
developed GVHD100 or NRM100. If less than 12 out of 24 patients have either of these 
events, the study will continue to enroll the remaining subjects. (See TABLE 5) If the true 
rate of grades III-IV acute GVHD or non-relapse mortality within 100 days of transplant is 
40%, 50%, 60%, or 70%, the study will stop with probability of 0.13, 0.44, 0.80, or 0.97, 
respectively. 
16.3.2 Stopping Rule for Graft Failure 
At the same time evaluation for possible stopping for excessive severe acute GVHD and 
non-relapse mortality, we will also assess for possible stopping due to excessive graft 
failure. The study will stop if 2 of the first 12 or 3 of the first 24 patients experience graft 
failure within 28 days of transplant (EF28).  If the true rate of graft failure within 28 days 
of transplant is 5%, 10%, or 15%, the study will stop with probability of 0.17, 0.50, or 0.75, 
respectively. 
TABLE 5 Stopping Rules for GVHD, Non-relapse mortality, and engraftment failure. 
 
Number of 
Evaluable 
Patients 
Number of Patients 
with GVHD100 
Number of 
Patients with 
NRM100 
Number of 
Patients with 
EF28 
12 
6 
6 
2 
24 
12 
12 
3 
 
16.4 Data Analysis Methods 
16.4.1 Primary Outcome: 
The cumulative incidence for relapse will be estimated using proportional hazard model 
for the competing risk of non-relapse mortality (NRM)(69). 
16.4.2 Secondary Outcomes: 
The cumulative incidence of NRM and GVHD will be calculated using proportional hazard 
models methods. Overall survival (OS) will be calculated from the day of transplantation 
(day 0) until death. Event free survival (DFS) will calculated from the day of transplantation 
until death or post HCT detection of relapsed or persistent AML. OS and DFS will be 
estimated using Kaplan-Meier methods. 
 
 

August 2018 
45 
 
 
16.4.3 Biologic Outcomes: 
 
The frequency and absolute numbers of tumor antigen specific T cells (peptide 
responsive or Tetramer + cells), BDC3A+ DCs, ex vivo PBMC responses and other 
cellular immune subsets measured serially will be used to generate kinetic curves that 
will be correlated with pharmacodynamic markers, serum inflammatory markers, and the 
primary clinical endpoint of relapse. These secondary endpoint analyses are 
descriptive (e.g. means and standard errors) and preclude formal hypothesis 
testing. Due to the small sample size, they will be used primarily for hypothesis 
generation and design of future studies. 
 
The optional MRI component of the proposal is a pilot study to measure changes in bone 
marrow composition and environment during HCT for AML. As this is a pilot study, no 
formal sample size or power calculations will be performed, and there will be no formal 
testing of statistical hypotheses.  We will compute summary statistics of data for groups 
of patients including PRM scatterplots, image overlays of PRM data, mean values, 
medians, range, quartiles and standard deviations. These data will be used primarily to 
generate hypotheses and design future studies. 
16.5 Projected Accrual:   
Based upon review of our programs clinical database over the past 10 years, we estimate 
approximately 10-12 patients will be enrolled per year and completion of the trial in 3 
years. Previous protocols for AML not in remission at University of Michigan have accrued 
similar numbers in this timeframe (UMCC 2007.055). We will monitor enrollment rates 
closely in the first six months and make adjustments to eligibility as necessary including 
expansion to other centers. There are currently no competing protocols. 
 
 
 
 
 
 
 
 
 
 
 

August 2018 
46 
 
 
 
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64. 
Mehta J, Powles R, Singhal S, Tait D, Swansbury J, Treleaven J. Cytokine-mediated immunotherapy 
with or without donor leukocytes for poor-risk acute myeloid leukemia relapsing after allogeneic bone 
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65. 
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APPENDIX A: KARNOFSKY PERFORMANCE SCALE 
 
% 
Description 

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52 
 
 
100  
Normal, no complaints, no evidence of disease  
90  
Able to carry on normal activity, minor symptoms of disease  
80  
Normal activity with effort, some signs of symptoms of disease  
70  
Cares for self (consistent with age), unable to carry on normal activity or do active 
work/school/play  
60  
Requires occasional assistance (beyond age-appropriate care), but is able to care for 
most of their needs  
50  
Requires considerable assistance and frequent medical care  
40  
Disabled, requires special care and assistance  
30  
Severely disabled, hospitalization is indicated although death is not imminent  
20  
Hospitalization is necessary, very sick, active support treatment is necessary  
10  
Moribund, fatal processes progressing rapidly 
 
 
 
 
 
 
 
 
 
 
 
 
 
APPENDIX B: ACUTE GVHD ASSESSMENT 

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54 
 
 
APPENDIX C: INSTRUCTIONS FOR COLLECTING A URINE SAMPLE 
1. Read the instructions carefully, and follow each of the steps to ensure you collect the 
correct specimen for the study.  
 
2. Use the urine hat or urinal provided to you for collection.  
 
3. Lift toilet seat and place hat on top of the toilet rim, then lower toilet seat.  Make sure 
the hat is in the correct orientation to collect urine, not stool.  Urinate into the hat.  If 
you need to have a bowel movement, collect the urine separately.  
 
 
 
 
 
 
 
 
 
 
 
Important: 
Do not allow bowel movement to fall into the hat. 
Do not place toilet paper into the hat. 
 
A study team member will receive the urine sample from you and provide additional instructions 
if needed.