Autologous Bone Marrow Transplantation for Non-M3 Acute Myeloid Leukemia (AML) in First Remission in Patients </=60 Years of Age Using Busulfan/Fractionated Total Body Irradiation (FTBI) and VP16 as the Preparative Regimen
Phase: PHASE2
Conditions: Leukemia
Sponsor: City of Hope Medical Center

IRB #99040 
 
04/20/2004 
Packet: 12 
CITY OF HOPE NATIONAL MEDICAL CENTER 
1500 E. DUARTE ROAD 
DUARTE, CA 91010 
 
DIVISION OF HEMATOLOGY AND HEMATOPOIETIC CELL TRANSPLANTATION  
 
TITLE:  
Autologous Stem Cell Transplantation for Non-M3 Acute Myeloid Leukemia (AML) in First Remission in 
Patients < 60 Years of Age Using Busulfan/Fractionated Total Body Irradiation (FTBI) and VP16 as the 
Preparative Regimen 
 
CITY OF HOPE PROTOCOL NUMBER/VERSION: 
IRB # 
99040  
PROTOCOL DATED: 04/20/2004  
 
DATE(S)/ OF AMENDMENT(S)/REVISION(S):                      
 
Amendment 01   
 
 
 
 
 
8/7/00  
 
 
 
 
 
 
Version: 01 
Amendment 02   
 
 
 
 
 
1/30/01  
 
 
 
 
 
 
Version 02  
Amendment 03   
 
 
 
5/4/01  
 
 
 
 
 
Version 03 
Amendment 04   
 
 
 
11/7/01             
 
 
 
 
Version 04 
Amendment 05   
 
 
 
2/22/02  
 
 
 
 
 
Version 05 
Amendment 06   
 
 
 
3/11/02 (Consent form chge 11/15/02)   
 
Version 06 
Amendment 07   
 
 
 
11/18/02 
 
 
 
 
 
Version 07 
Amendment 08   
 
 
 
5/6/03  
 
 
 
 
 
Version 08 
Amendment 09   
 
 
 
(administrative change dated 4/20/04) 
 
 
Version 09 
Amendment 10   
 
 
 
(Title Page dated 4/07/14) 
 
 
 
Version 10 
Amendment 11 at Continuation  
 
Protocol Dated 04/20/04 (TP) 
 
 
 
Packet 11 
Amendment 12 at Continuation  
 
Protocol Dated 04/20/04 (TP) 
 
 
 
Packet 12 
 
 
SITE:  
Hematological  
 
 
 
 
STAGE:  
Acute Myeloid Leukemia 
 
 
 
MODALITY: 
Autologous BMT 
 
 
 
 
TYPE:  
Phase 2 
 
 
 
 
 
 
PRINCIPAL INVESTIGATOR:  
 
 
Anthony Stein, M.D. 
COLLABORATING INVESTIGATOR(S): 
 
Stephen J. Forman, M.D. 
 
 
 
 
 
 
 
Joyce Niland, Ph.D. 
PARTICIPATING CLINICIANS: 
 
 
Ravi Bhatia, M.D. 
Amrita Krishnan, M.D. 
 
 
 
 
 
 
 
Auayporn Nademanee, M.D. 
Ryotaro Nakamura, M.D. 
Leslie Popplewell, M.D. 
Department of Medical Oncology 
 
 
George Somlo, M.D. 
 
 
 
 
 
 
 
Tim Synold, Ph.D. 
Department of Radiation Oncology 
 
 
Nayana Vora, M.D. 
Firoozeh Sahebi, M.D. 
Ricardo Spielberger,  M.D. 
Division of Pediatrics 
 
 
 
 
Joseph Rosenthal, M.D. 
 
 
City of Hope Samaritan Bone Marrow 
 
 
Joseph C. Alvarnas, M.D. 
 
 

SCHEMA 
 
AML 1st Remission 
 
  
 
 
 
 
 
 
  
 
  
 
        Prior HD Ara-c or  
 
 
 
 
 
 
 
 
 
 
 
 
   Anthracycline consolidation 
 
 
No prior consolidation 
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3
 
Consolidation Chemotherapy with HD Ara-C/Idarubicin 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
           Consolidation to be  
 
  
 
    Determined by prior treatment 
 
 
GCSF 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
    GCSF 
 
 
 
 
Primed Peripheral Stem Cells 
 
≥ 3 x 106  CD34+ PSCs/kg 
 
 
 
 
-17   -14 -13   -11 -10  -9 
-8    -7     -6   -5       -4      -3 
 -2 
 -1 
 0 
 
                                           Dilantin x 13 days   
 
 
  
  
             
          
 
Busulfan                             FTBI 
          VP-16         PSC/BMT 
Rev. 11/7/01 
 
 
 
 
 
22mg/m2/dose 
 
  1200 cGy             30mg/kg  
 
 
 
         (120cGyx10) 
 
 
 
 
      or 
 
 
 
         (150cGy x 8) 
 
IL-2 
 
 
 
 
 
 
 
Induction: 
 
 
 
 
 
 
 
 
IL-2, 9mIU/m2/d c.i.v.i. x 96 hours (days 1-4) 
 
 
 
 
 
 
 
 
Days 5-8 Rest 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Maintenance 
IL-2, 1.6 mIU/m2/d c.i.v.i. x 240 hours (days 9-18)

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4
TABLE OF CONTENTS 
 
 
1.0 
Objectives 
 
 
 
 
 
 
 
 
5 
2.0 
Background  
 
 
 
 
 
 
 
5 
3.0 
Institutional Experience and Rationale for Proposal 
 
 
6 
4.0 
Drug Information 
 
 
 
 
 
 
 
8 
5.0 
Patient Eligibility 
 
 
 
 
 
 
 
13 
6.0 
Plan of Treatment  
 
 
 
 
 
 
13 
7.0 
Complications of Therapy  
 
 
 
 
 
29 
8.0 
Statistical Considerations  
 
 
 
 
 
29 
9.0 
Woman and Minorities Guidelines 
 
 
 
 
31 
10.0 Registration Guidelines 
 
 
 
 
 
 
31 
11.0 Data Submission Schedule 
 
 
 
 
 
32 
12.0 Ethical and Regulatory Considerations  
 
 
 
32 
13.0 Toxicities 
 
 
 
 
 
 
 
 
32 
14.0 References  
 
 
 
 
 
 
 
33 
 
 
 
 
 
 
Appendices 
Appendix 1 IV Busulfan Kinetics Form  
 
 
 
 
 
 
 
Appendix 2 COH Schema 
 
 
 
 
 
 
 
Appendix 2a University of Wisconsin Hospital & Clinical TBI Schema 
 
Appendix 3 Consolidation therapy 
 
 
 
 
 
 
Appendix 4 HD Therapy/Transplant therapy  
 
 
 
 
Appendix 5 Post BMT Therapy/IL-2 therapy  
 
 
 
 
Appendix 6  Common Toxicity Criteria  
 
 
 
 
     
Appendix 7 Adverse Event Reporting Requirements for Clinical Trials 
 
Appendix 8 Time points to grade toxicities and collect data  
 
     
Appendix 9 Eligibility checklist  
 
 
 
 
 
     
Appendix 10 Laboratory blood tests 
Appendix 11  Hematopoietic Cell Transplant Intake Module 
 

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5
1.0 
OBJECTIVES 
 
a. 
To evaluate the efficacy and toxicity of fractionated total body irradiation (FTBI) 
in combination with busulfan (BU) dosage targeted to AUC 700-900 and VP-16 
followed by post-BMT interleukin-2 (IL-2) as a preparative regimen for 
autologous BMT for patients with AML in 1st CR. 
 
b. 
To estimate the long term disease free survival for patients < 60 years of age 
with AML in first remission receiving an autologous BMT utilizing primed 
peripheral stem cells following consolidation therapy with high dose ara-c and 
Idarubicin or high dose Ara-c alone.   
 
c. 
To further evaluate the effect of prognostic factors e.g. cytogenetics, WBC at 
presentation, number of courses of induction therapy to enter remission on the 
outcome of autologous BMT and AUC of Busulfan.   
 
2.0 
BACKGROUND 
 
Currently between 60-80% of adults with AML who are under 60 years of age achieved 
complete remission (CR) with intensive chemotherapy.  However, only a fraction of 
these patients enjoy long term disease-free survival and are cured of the disease.  A 
number of studies involving large groups of patients have demonstrated that 
approximately 20% of patients who had attained CR will remain free of disease 
following treatment with “standard” post remission chemotherapy. (1-4) More recent 
studies suggest that if post remission chemotherapy is intensified, as many as 30% of 
remission patients may remain free of disease.  It has been suggested that the use of 
high dose ara-c in post remission chemotherapy may increase long-term disease free 
survival to as much as 40%.(5,6)  The major obstacle for long term survival in patients 
treated with chemotherapy is leukemic relapse which affects between 60-75% of 
patients.   
 
The results of allogeneic bone marrow transplantation for AML in remission 
demonstrates that the risk of leukemic relapse can be substantially reduced when bone 
marrow rescue allows escalation of the dose of chemoradiotherapy.  Adults receiving 
allogeneic transplant for AML in first complete remission have long term disease free 
survival rates of approximately 45-70% in a large number of studies.(3,7-11)  Most studies 
show a leukemic relapse rate of approximately 10-20%.  However, allogeneic bone 
marrow transplantation has limitations, and because of high morbidity of therapy, 
allogeneic transplantation is restricted to adults under the age of 50.  Furthermore, only 
approximately 1/3 of potentially eligible patients in this age group have histocompatible 
donors.  Thus, less than ¼ of adults under the age of 50 will be candidates for 
allogeneic transplantation.  Furthermore, the success of allogeneic transplantation has 
been hindered by an early mortality rate due to treatment related complications, 
particularly 
graft 
versus 
host 
disease 
(GVHD) 
and 
interstitial 
pneumonia.  
Approximately 15-30% of adults die within the first 3 months of transplantation because 
of such complications.  Progress in the prevention and treatment of GVHD may reduce 
this high early mortality rate. 
 
Autologous bone marrow transplantation is attractive because two of the major 
problems with allogeneic transplantation are avoided.  There is no need to find a 

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6
matched donor, and the absence of immunosuppressive therapy and GVHD decreases 
the morbidity and mortality rate.  However, there are several theoretical problems in 
autologous transplantation as therapy for acute leukemia.  One potential problem is the 
absence of graft versus leukemia (GVL) effect.  Analysis of results in Seattle for 
patients without GVHD compared with GVHD showed relapse rates of 65% versus 
35% suggesting that GVHD is accompanied by beneficial GVL effect.(12)  Further 
support for the GVL concept comes from the analysis of relatively a small group of 
patients treated in remission with marrow transplantation utilizing identical twin donor 
(who cannot have GVHD) who have a 50% relapse rate.(13)  Thus, without an improved 
anti-leukemic effectiveness of the preparative regimen one would expect a leukemic 
relapse rate of approximately 50% from auto transplants drawing on the analogy to 
syngeneic transplantation.  Furthermore, one must deal with the risk of infusing viable 
clonogenic leukemic cells even if marrow morphologically demonstrating remission.  
Not only may a small contaminating leukemic cell population be missed but a report 
suggests that even morphological normal cells may be derived from a malignant 
clone.(14)   If leukemic cells were infused during auto transplant the relapse rate would 
be expected to be even higher than 50%.   
 
Studies utilizing autologous BMT for AML in first remission have reported disease free 
survivals of 34-80% (with varying follow-up intervals).(15-20)  Although each trial 
demonstrates the potential efficacy of this approach chosen, many of the studies have 
been criticized because of selection bias.  Results of the MRC AML 10 trial show that 
the addition of autologous BMT to intensive chemotherapy substantially reduced the 
risk of relapse when compared to chemotherapy alone.(21)   
 
Relapse is the major cause of failure of ABMT.  The lowest relapse rates in AML occur 
in allogeneic BMT compared to syngeneic BMT, demonstrating the role of graft versus 
leukemia effect in preventing relapse.  Since relapses after autologous hematopoeitic 
cell transplant tend to occur early, and since IL-2 responsive lymphocytes have been 
detected in circulation within 2-3 weeks after transplantation of autologous marrow or 
peripheral blood stem cells, IL-2 has been administered early, after the patients have 
recovered from transplant related toxicities, at a time when tumor burden is still minimal 
but before relapses are likely to occur.  Several phase I studies have identified a 
maximum tolerated dose of IL-2 which can be administered after autologous stem cell 
transplant and documented its immunomodulatory effects.  Patients usually exhibit 
transient early lymphopenia followed by a rebound lymphocytosis after stopping IL-2.  
This rise reflects increases in the number of cells expressing CD8 + T cells and CD16 
+ and CD56 + activated natural killer cells, with concomitant enhanced ability to lyse 
tumor.(22-25) 
 
 
3.0 
Institutional Experience and Rationale for Proposal 
 
From January 1987 through July of 1998, nine patients underwent autologous bone 
marrow transplant for AML in first remission using the conditioning regimen consisting 
of busulfan and VP-16.  Four of these nine patients are in remission now for more than 
10 years, one patient died a toxic death during the neutropenic phase, there were no 
other unexpected toxicities.   
 

Between March of 1989 and November 1993, the conditioning regimen was changed 
to FTBI 1200cGy/VP-16 60mg/kg and Cyclophosphamide 75mg/kg.  We intended to 
transplant 60 adult patients with AML in first remission.  All 60 patients underwent 
consolidation chemotherapy with high dose Ara-C (HD Ara-C) 3 gm/m2 8-12 doses.  
Following 
this 
consolidation 
treatment, 
bone 
marrow 
was 
harvested 
and 
cryopreserved.  Ten patients relapsed prior to being transplanted.  44 patients 
underwent ABMT with a median follow-up time of 37 months.  The cumulative 
probability of disease free survival at 24 months in the intent to treat group, is 49 
percent and in those actually undergoing ABMT was 61%.  The probability of relapse 
was 44% and 33% for the intent to treat and autologous BMT patients, respectively.   
 
In an effort to try and improve on these results Idarubicin was added to high dose ara-c 
as part of the consolidation regimen and interleukin-2 was added to post BMT therapy 
to try and decrease the relapse rate.  From August 1994 to the present time 58 patients 
have been evaluated with the intent to proceeding to an autologous stem cell 
transplant.  For the intent to treat group the cumulative probability of disease free 
survival at three years is 67% and relapse rate 31%.  For the 50 patients actually 
undergoing autologous stem cell transplant the cumulative probability of disease free 
survival at three years is 72% and their relapse probability is 27%.   
 
Patients with good risk cytogenetics t (8;21) or INV 16 or t (16;16) have been shown to 
have improved DFS when treated with repeated cycles of high dose Ara-C alone.31,32   
At City of Hope fifty six patients were treated with high dose Ara-C/idarubicin 
consolidation treatment with hematological recovery as follows:   
 
ANC >500/µl median of 26 days [range 17,62]  
ANC >1000/µl median of 27 days [range 18,65] 
Untransfused platelets >20,000/µl median of 37 days [range 19,62] 
 
Due to the long hematological recovery and no literature evidence for adding idarubicin 
to the consolidation treatment, the protocol will be amended to omit idarubicin for 
patients with good risk cytogenetics.   
 
At City of Hope between 8/92 and 10/98 61 patients were entered on a phase I study of 
escalating doses of busulfan in combination with TBI and VP-16 in patients with 
advanced hematological malignancies in an effort to try and improve the outcome of 
allogeneic bone marrow transplant in these poor risk patients.  The MTD was defined 
at 11 mg/kg of busulfan in  combination with FTBI 1200 cGy and VP-16 60mg/kg. The 
median AUC was 892µM*min (460-1267) for this group of patients.  With a median 
follow up of 11.5 months, the disease free survival is 32%, and the probability of 
relapse is 40%.  The only variable predictive of an improved disease free survival + 
relapse was Busulfan dose of 7-8mg/kg.  An AUC of 700-950µM*min demonstrated a 
trend to a decreased relapse rate and improved DFS.   
 
Allogeneic and autologous BMT studies performed in approximately 100 patients the 
I/V formulation has been shown to have more predictable pharmacokinetic properties 
than the oral preparation resulting in a better toxicity profile.(26-28)   
 
Rev 5/15/01 
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7

Relapse is still the major reason for failure for BMT.  In an attempt to try and decrease 
the relapse rate post autologous stem cell transplant we plan to substitute intravenous 
busulfan for cyclophosphamide in the conditioning regimen.   
 
4.0 Drug Information 
 
4.1  
Cytosine Arabinoside (cytarabine, Ara-C, cytosar) NSC #63878 
 
 
 
4.11 Source of Pharmacology: Deoxycytidine analogue which is metabolized to 
Ara CTP, a substance which inhibits DNA polymerase.  It is S-phase-specific, 
and thus affects DNA synthesis.  It has an initial half-life of about 15 minutes, 
with a secondary phase of about two hours.  Rapidly catabolized by hepatic 
cytidine deaminases to Ara-U.  Intrathecally administered doses are 
catabolized and eliminated more slowly with a half-life of 1-11 hours. 
 
4.12 Formulation and Stability: A freeze-dried powder available in 100 mg and 500 
mg vials with diluent which contains 0.9% benzyl alcohol in water.  The 
unreconstituted form of the drug is stable at room temperature for at least two 
years.  Reconstitute with 5 ml of diluent to 100 mg vial and 10 ml to the 500 
mg vial.  Also available in 1g and 2g vials without diluent.  Reconstitute with 
10 ml and 20 ml sterile water or bacteriostatic water.  The reconstituted 
solution is stable at room temperature for 48 hours.  Solutions that develop a 
slight haze should be discarded.  Infusion solutions containing up to 500 µg 
(0.5 mg) of cytarabine per ml are stable at room temperature for seven days. 
 
4.13 Supplier: Commercially available and approved by the FDA for the             
 
purposes indicated. 
Revised 3/11/02 
 
4.14 Toxicity: Acute DLT - severe leukopenia and thrombocytopenia.  Nausea and 
vomiting may be dose-limiting at higher doses. Other adverse reactions 
include immunosuppression, anorexia, stomatitis, mild oral ulcerations, flu-
like syndrome with fever, and alopecia.  Diarrhea, fever, somnolence, 
conjunctivitis, ataxia, encephalopathy, or veno-occlusive disease can also 
develop.  Chronic administration may cause mild gonadal dysfunction.  IT 
Administration: Fever, headache, vomiting, and pleocytosis.  On rare 
occasions meningismus, convulsions, paresis, and cardiac arrest have been 
reported. 
 
4.15 Route of Administration: IV infusion, IT.  When given in high doses, 
antiemetics and dexamethasone eye drops are indicated.  Intrathecal 
Administration: IT cytarabine should be reconstituted in physiologically 
buffered diluents (lactated Ringer's) or patient's own CSF. The diluent 
provided should not be used for IT administration. 
 
4.2  
Idarubicin (4-demethoxydaunorubicin, Idamycin) NSC #256439 
 
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8
4.21 Source of Pharmacology: Idarubicin is an analogue of the anthracycline 
daunorubicin. It binds to DNA in a similar manner to daunorubicin and also 
inhibits nucleic acid polymerase.  It has similar activity to daunorubicin in 
inhibiting DNA synthesis, but is more active in inhibiting RNA synthesis.  

Idarubicin is more lipophilic than daunorubicin and has an extensive tissue 
distribution of approximately 1000 L/M2.  It is metabolized to idarubicinol, 
which also has antileukemic activity.  The clearance and consequently the 
half-life show marked inter-individual variability and average 679 ml/min/M2 
and 17.6 hours for that parent drug with a terminal half-life of 56.8 hours for 
idarubicinol.  The excretion is via hepatic (biliary) route.  Renal excretion of 
Idarubicin is minor, therefore renal dysfunction would be expected to have 
little effect on its disposition.  The magnitude of hepatic function and/or blood 
flow could potentially influence the disposition of Idarubicin. 
 
4.22 Formulation and Stability: Idarubicin is supplied in vials of 5 and 10 mg as a 
sterile lyophilized powder for injection.  Its shelf-life at room temperature is 36 
months for the 5 mg vial and 24 months for the 10 mg vial. 
 
Solution Preparation: Idarubicin 5 mg and 10 mg vials should be 
reconstituted with 5 ml and 10 ml respectively of 0.9% sodium chloride for 
injection or sterile water for injection to give a final concentration of 1 mg/ml.  
Bacteriostatic diluents are not recommended. 
 
Revised 3/11/02 
4.23 Supplier: Commercially available and approved by the FDA for the purposes 
indicated. 
 
Stability: Constitution of the vials as recommended results in a solution which 
is chemically stable for 72 hours at room temperature.  Further dilution of the 
constituted solution (0.01 mg/ml) results in a solution which is mildly light 
sensitive and should be protected from light if being administered more than 
six hours after its preparation. 
 
4.24 Compatibility/Incompatibility: 0.9% Sodium chloride injection = compatible; 
5% dextrose = compatible; Ringer's lactate = unknown; dextrose/saline 
mixture = compatible; heparin - incompatible. 
 
4.25 Toxicity: Acute toxicity includes myelosuppression, especially leukopenia and 
thrombocytopenia.  Non-hematologic toxicities include nausea, vomiting, 
alopecia, diarrhea, fatigue, stomatitis, fever, and anorexia.  These non-
hematologic toxicities are rarely severe.  Transaminase elevation has also 
been seen.  Renal toxicity is rare.  Idarubicin shares the cardiac toxicity of 
other anthracyclines, and has caused clinical congestive heart failure, most 
commonly in patients who have received other anthracyclines. 
 
4.26 Route of Administration/Precautions: **IV or PO.  Idarubicin should be 
administered by IV slowly (over 5-15 minutes) into the tubing of a freely-
running IV infusion of compatible fluids. 
 
**Avoid extravasation.  If extravasation occurs: It is recommended that 
intermittent ice packs (1/2 hour immediately, then 1/2 hour 4x/day for 3 days) 
be placed over the area of extravasation and that the affected extremity be 
elevated. 
 
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9

**Monitoring of cardiac function is recommended before each additional 
course of treatment in patients who have received a total of 120 mg/M2 of 
Idarubicin. 
 
4.3 
Busulfan 
 
4.31 Busulfan is a bifunctional alkylating agent.  In aqueous media, busulfan 
hyrolyses to produce reactive carbonum ions that can alkylate DNA. 
 
4.32 Formulation and stability:  Busulfan injection is a sterile, pyrogen-free 
solution provided in a mixture of dimethylacetamide (DMA) and 
polyethlyeneglycol 400 (PEG 400) .  It is supplied in 10-ml single use 
ampules at a concentration of 6-mg Busulfan per ml.  Each ampule contains 
60mg of Busulfan in 3.3 ml of DMA and 6.7 ml of PEG 400.  When diluted in 
normal saline or D5W to a concentration of 0.5mg/ml, the resulting solution 
must be administered within eight (8) hours of preparation, including the 2 
hours of infusion of the drug.   
 
Stable at 4ºC for at least twelve months.  Ampules should be stored 
refrigerated at 2-8ºC.  Do not freeze.  Ampules may be stored for up to seven 
days at room temperature.   
 
Solution preparation:  Prepare the Busulfan solution as follows:  Use sterile, 
non-pyrogenic, disposable containers, syringes, needles, stopcocks, and 
transfer tubing, etc.  Calculate the amount of drug to be administrated based 
on the dosage and the patient’s body weight.   
 
Prepare a solution of 0.9% sodium chloride injection USP (normal saline) 
calculated Busulfan dose in ml from the step above. 
 
Break off the top of the ampule and remove the calculated volume of 
Busulfan from the container by using a syringe fitted with a filter needle or 
equivalent.  Transfer the contents of the syringe into the calculated amount 
of either normal saline or D5W making sure that the drug flows into and 
through the solution.  Mix by inverting the bag. 
 
   
4.33 Administration:  Each dose of the drug will be given by slow central 
intravenous infusion over 2 hours.  Caution:  Do not administer as an 
intravenous push or bolus. 
 
4.34 Supplier:  This drug is commercially available manufactured by Orphan 
Medical Inc.  It is not approved by the FDA for the purposes indicated. 
 
Revised 3/11/02 
4.35 Toxicity:  Toxicity from busulfan includes: 
 
a). Severe bone marrow hypoplasia, which would be fatal without 
administration of bone marrow, stem cells. 
 
b). Nausea and vomiting which can be decreased by the use of sedation and 
anti-emetics. 
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11
 
c). Stomatitis and diarrhea which can be treated symptomatically with fluid 
replacement and atropine or diphenoxylate HC1. 
 
d). Pulmonary fibrosis characterized by delayed onset of cough, shortness of 
breath and low-grade fever. 
 
e). Hepatic damage, which can occur in combination with cytoxan or as a 
single agent and can result in significant hepatic toxicity which, can be 
fatal. 
 
f). Temporary hyperpigmentation of the skin and nail bed changes. 
 
g). Grand mal seizures which can be prevented by the prophylactic 
administration of Dilantin. 
 
4.4 
Interleukin-2 (IL-2) NSC #373364 (Chiron Corporation, Cetus Oncology Unit, 
Emeryville,California) 
 
 
4.41 Drug Formulation and Procurement:  The recombinant mutein IL-2 to be used 
in this trial is commercially available.  It was produced in E. coli transfected 
with the gene for IL-2 isolated from the Jurkat cell line.  The IL-2 has been 
purified to homogeneity and its biological characteristics and in vivo effects in 
animal models have been well studied. 
 
 
 
 
 
Less than 0.04 mg of endotoxin are present per 1x106 units of lyophilized 
IL-2 in the vial along with 5% mannitol and approximately 50µg of SDS.  
The biological activity of IL-2 is to defined as 18 million International Units 
(IU)/mg protein. 
 
 
 
4.42 Drug Toxicity:  IL-2 toxicities may include: fever, chills, nausea, vomiting, 
fatigue, headache, myalgia, arthralgia, weight gain hepatic toxicity, rash, 
depression of myocardial function, arrhythmias, thrombocytopenia, anemia, 
hypotension, renal toxicity, diarrhea and transient confusion or psychosis. 
 
4.43 Drug Storage, Reconstitution and Stability 
 
4.43.1 
Stability Studies: Potency data indicates that lyophilized, 
recombinant IL-2 is stable at 2-8˚ C for two years.  After 
reconstitution in 1.2 ml of sterile water for injection, it is stable for 
at least 24 hours at room temperature. 
 
4.43.2 
Reconstitution: Recombinant IL-2 is supplied as a lyophilized 
cake in vials. Reconstitute each vial as follows: 
 
 
 
 
 
 
 
 
Remove flip-top plastic cap and swab the target area of the 
stopper with antiseptic. 
 
 
 
 
 
 
 
 
 
Antiseptically inject an appropriate volume of sterile water for 
injection into vial to dissolve the lyophilized cake.  Since contents 
of vial are under vacuum, the diluent should be directed against 
the side of vial to avoid excess foaming. 
 

 
 
 
 
 
 
 
 
Mass units indicated on the vial label represent the amount of IL-
2 that can be recovered from the vial when reconstituted, as 
shown below. 
 
 
 
 
 
 
 
 
Vial Label 
 
Volume 
 
Mass units/ml 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
1mg  
 
1.2ml  
 
1.0mg/ml 
 
 
4.43.3 
Dilution Procedure:  Recombinant IL-2 can be diluted in D5W for 
intravenous infusion.  Dilutions in other solutions or mixture with 
other drugs should be avoided.  Each day’s dose will be prepared 
in a 50-ml cassette for delivery at a continuous infusion rate of 
2ml/hour, using the Pharmacia Deltec CADD infusion pump. 
 
4.43.4 
It is not approved by the FDA for the purposes indicated. 
 
Revised 3/11/02 
4.5 
VP-16 
(epipodophyllotoxin, 
etoposide, 
4'-demethyl-9 
(4,6-o-β) 
d-
ethylideneglycopyranoside).  VP-16 is not approved by the FDA for the purposes 
indicated.  It has been commonly used in leukemia transplant conditioning regimens for 
at least 10 years. 
Revised 3/11/02 
 
4.51 Drug Formulation and Procurement:  VP-16 is supplied by Bristol 
Laboratories in a 100 mg ampule in 5 cc of a solution containing citric acid, 
10 mg; benzyl alcohol, 150 mg; polysorbate 80, purified, 250 mg; 
polyethylene glycol 300, 3.75 gm; absolute alcohol q s., 5 cc. 
 
4.52 Drug Toxicity: Myelosuppression, primarily granulocytopenia, is the dose-
limiting toxicity.  Gastrointestinal toxicity at high doses includes nausea, 
emesis and mucositis.  Reversible hepatotoxicity may occur at very high 
doses.  The acute side effects of occasional bronchospasm and hypotension 
are avoided by slow intravenous administration. 
 
4.53 Drug Storage, Reconstitution and Stability:  The contents of the ampule are 
diluted with 50 volumes of NaCl solution for injection, USP, and administered 
by slow intravenous infusion.  Patients will receive the drug through a central 
venous catheter at a rate of 30 mg/kg/4 hours. 
Revised 3/11/02 
 
5.0 PATIENT ELIGIBILITY 
 
Each of the criteria in the following section must be met in order for a patient to be 
considered eligible for consolidation therapy and autologous stem cell transplantation. 
 
a). 
Patients age > or equal to 16 and patients should have not reached their 61st  
birthday (physiological age 60).   
b). 
Patients in first remission who are treated for acute myelogenous leukemia 
AML, FAB types, M0-M7.  M3 will be excluded. 
Rev. 11/7/01 
Revised 8/7/00 
 
c). 
A marrow aspiration and biopsy demonstrating a complete hematological 
remission. Patients need to have a normal platelet count within five days of 
starting consolidation chemotherapy. 
Revised 11/19/02 
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12
 
d). 
No cytogenetic abnormalities in the remission marrow. 

 
e). 
Patients who are in first complete remission of acute myelogenous leukemia 
who have received consolidation therapy prior to coming to transplant center will 
be eligible for the protocol but will evaluated separately. 
Revised 3/
/02 
11
 
f). 
Patients must be in complete remission for less than 6 months.  Patients in 
remission for longer than 6 months may be placed on the study after review by 
P.I. and will be evaluated separately. 
 
 
Exclusion Criteria: 
1. Prior myeloproliferative disorder such as CML, myelofibrosis, essential 
thrombocytosis, or polycythemia vera. 
 
2. Prior myelodysplasia or secondary leukemia. 
 
 
3. Any severe chronic medical or psychological illness as in the judgment of the 
physician would jeopardize the ability of the patient to tolerate aggressive 
chemotherapy.  Patients must have FEV1, >60% + DLCO >50% a cardiac ejection 
fraction > 50% and creatinine clearance of >60ml/min. 
Revised 3/11/02 
 
4. HIV positive  
 
 
5.   Pregnancy 
 
Revised 8/7/00 
6.0 PLAN OF TREATMENT 
 
6.1 Pre-Consolidation Evaluation: Will be performed 4 weeks prior to treatment except 
for the following:  1). Bone marrow aspirate and biopsy + cytogenetics within 14 
days of starting treatment.  2).  CBC, differential, platelets, comprehensive 
metabolic panel within 5 days of starting treatment. 
 
a). 
Prior to admission patient will have a complete history and physical 
examination performed.  Special attention should be given to prior 
chemotherapy, height, weight, and body surface area should also be 
noted. 
 
Revised 8/7/00 
Revised 3/11/02 
 
b). 
Patients will have the following lab tests performed; CBC, differential, 
platelet count, comprehensive metabolic panel, pregnancy test, 24 urine 
for creatinine clearance, hepatitis panel, HIV antibody. 
Revised 8/7/00 
Rev. 11/7/01 
 
 
 
 
c). 
Lumbar puncture will be performed in patients with FAB M4, M4eo + M5, 
patients with WBC at diagnosis > 50,000 and patients with cutaneous 
involvement. 12 mg of intrathecal methotrexate should be given at the 
time of the lumbar puncture.  This can be done as an inpatient at time of 
consolidation treatment. 
Rev. 11/7/01 
 
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13
 
 
 
 
d).  
Pulmonary function tests. 
 
 
e).  
Echocardiogram or MUGA scan. 
 
 
f).  
Bone marrow studies 1). aspirate and biopsies for morphology and 2). 
Cytogenetic analysis. 
 

 
g).  
CT scan of chest, abdomen and pelvis. 
 
The following pre-study tests should be obtained within 28 days of starting 
treatment in accordance with good medical practice.  Results of these tests do not 
determine eligibility and minor deviations would be acceptable if they do not impact 
on patient safety in the clinical judgement of the treating physician.  The Study 
Coordinator must be contacted if there are significant deviations in the values of 
these tests. 
 
Uric acid, LDH, phosphorous, cholesterol, magnesium, urine analysis, herpes 
simplex titer, CMV titer, immunoglobulin levels, thyroid panel (free T4 and TSH), 
chest x-ray and EKG, HLA typing of patient and siblings. 
 
  
Rev. 11/7/01 
6.2 Consolidation Chemotherapy 
 
6.21 Patients who have received consolidation treatment prior to coming to 
City of Hope will be evaluated to determine how many doses of HD Ara-c 
and anthracycline they have received.  Patients who have received more 
than 200mg/m2 of anthracycline will not receive idarubicin.  Patients who 
have received 8 or more doses of HD Ara-c will have GCSF primed cells 
collected.  Patients who have had < 8 doses of HD Ara-C will receive 
additional HD Ara-C not to exceed 12 doses [36grams/m2].   
 
Rev. 05/06/03 
6.22 Patients who have received no consolidation treatment will follow the 
following treatment plan:   
 
 
 
a). Beginning 4 hours prior to starting Ara-C all patients will be 
adequately hydrated.  All patients will require anti-emetics to control 
nausea and vomiting. Patients will undergo a neurological 
assessment prior to each dose of Ara-C for evaluation of cerebellar 
symptoms. 
 
 
 
b) Patients will receive Ara-C 3 gm/m2 IV over 3 hours every 12 hours 
for a total of 8 doses. (Day 1-4).  Patients age 55 to 60 will receive 
2gm/m2  of Ara-C.   
 
 
 
c) Idarubicin 12 mg/m2 will be given by slow intravenous infusion (5-10 
minutes) after Ara-C dose 1, 3, 5.  (Day 1-3).   Patients with good 
risk cytogenetics (t 8;21) or inv 16 or (t 16;16) will not receive the 
idarubicin. 
Revised 8/7/00 
Revised 8/7/00 
Revised 5/4/01 
                         
 
 
d) GCSF 10 µg/kg IV or subcutaneously in 2 divided doses will be 
started 7 days after Ara-C completed and continued until peripheral 
stem cell collections are completed. 
Revised 3/11/02 
 
 
 
e) Once patients' WBC >5000/µl peripheral stem cells will be collected 
with the goal collecting 3 x 106/kg CD34 cells (target 3-5 x 106/kg).  If 
stem cell collections are poor the stem cell collection should then be 
delayed until the platelet count recovers to > 50,000.  The G-CSF 
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dose can be increased to 16 mcg/kg/day subcutaneously in 2 divided 
doses [or I/V depending on transplant center standard protocol. 
 
f) CBC, platelet count daily, (differentials per MD discretion), 
comprehensive metabolic panel plus uric acid, LDH, phosphorous and 
cholesterol, Mg++ are drawn daily during chemotherapy then every 
Monday, Wednesday, Friday during consolidation therapy. 
 
Revised 8/7/00 
Revised 1/30/01 
6.3 Dose Adjustments 
 
a) Idarubicin 
 
 
 
Total Bilirubin 
Dose Reduction 
 
< 2.5 
0 
 
> 2.5 <5 
50% 
 
>5 
100% 
b) Ara-C 
 
 
 
Creatinine 
Dose Reduction 
 
< 1.3 
0 
 
1.3 – 1.4 
33% 
 
1.5 – 2.0 
66% 
 
> 2.0 
Hold Dose 
 
 
 
 
 
For any dose adjustment reduction an attempt will be made to give 
a total Ara-C dose of 24 gm/m2, i.e. give difference on day 5 and 6.  
No dose should exceed 3gm/m2. 
 
 
6.31 Supportive Care: 
 
 
a) Decadron eye drops are given throughout the treatment with Ara-C 
and should be continued for four days following the completion of Ara-
C. 
 
 
b) All patients will have a right atrial catheter inserted prior to beginning 
or during the consolidation chemotherapy. 
 
 
c) All patients will receive systemic fungal prophylaxis with Amphotericin 
B (0.15 mg/kg/d), liposomal Amphotericin B or Itraconazole 200 mg 
b.i.d. following completion of chemotherapy until normalization of 
ANC's. 
Revised 8/7/00 
 
 
d) All patients will receive filtered and irradiated (2500 cGy) blood 
products. Platelet and red cell transfusions will be given as clinically 
indicated. 
 
e) All patients should receive hyper alimentation until oral caloric intake 
is adequate to meet the patients nutritional needs. 
 
 
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6.4 Cryopreservation of Peripheral Blood Stem Cells 
 
At least 3 x 106 CD34 positive cells/kg will be collected with a target range of 3 
to 5 x 106 CD34+ cells/kg.  Enriched mononuclear cells/CD34 preparation is 

obtained by peripheral blood apheresis.  Cells are cryopreserved according to 
participating site institutional standard operating procedure after review and 
approval of the P.I. (Anthony Stein, M.D.) and the City of Hope Stem Cell lab 
director (Andrew Walton, telephone: (626) 359-8111 Ext. 62695, fax number: 
(626) 930-5472). 
 
6.5 High Dose Therapy Treatment 
 
6.51 Pre-Transplant Evaluation:  Within 4 weeks of starting busulfan. 
 
 
 
a) Prior to admission patient will have a complete history and physical 
examination performed.  Special attention will be given to prior 
chemotherapy, height, weight, and body surface area should also be 
noted. 
 
Revised 8/7/00 
Rev. 11/7/01 
b) CBC with differential, platelet  count, comprehensive metabolic panel.  
 
Revised 8/7/00 
c) Chest x-ray  
 
Revised 3/11/02 
 
 
d) MUGA scan or 2D-Echocardiogram. 
 
 
 
e). Bone marrow aspirate and biopsy, and cytogenetics needs to be done 
within four weeks of starting busulfan. 
 
The following pre-study tests should be obtained within 4 weeks of starting 
treatment in accordance with good medical practice.  Results of these tests do not 
determine eligibility and minor deviations are acceptable if they do not impact on 
patient safety in the clinical judgement of the treating physician.  The Study 
Coordinator must be contacted if there are significant deviations in the values of 
these tests. 
 
Revised 8/7/00 
Rev. 11/7/01 
 
 
 
 
 
f). Uric acid, LDH, phosphorous, cholesterol, magnesium, urine analysis, 
herpes simplex titer, CMV titer, immunoglobulin levels, thyroid panel 
(free T4 and TSH), chest x-ray and EKG, HLA typing of patient and 
siblings. 
 
 
 
 
 
 
g). PFT’s as indicated. 
 
 
 
Patients who are evaluated at transplant center after already receiving 
consolidation therapy are required to have the same tests performed pre 
consolidation treatment. (6.1 a-g) 
 
 
 
*If patients tests are performed and the transplant is delayed due to non medical 
causes [e.g. insurance] and patient receives no further treatment then 
echocardiogram, PFT’s, chest x-ray and antibody titres do not need to be repeated 
within 3 months. 
 
6.52 Preparative Chemotherapy Regimen: 
 
Rev. 11/7/01 
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Friday/Day –17 
 
Begin Dilantin 300mg p.o. t.i.d. x 1 day , then 300mg 
p.o./I/V daily x 13 days. 
 
 
 
Tuesday/Day –13 
 
Admission or outpatient, dilantin blood levels will be 
checked and dose adjusted as needed to meet 
therapeutic range.  Further adjustments if clinically 
indicated.  Busulfan test dose administered over 2 
hours as a single dose.  The I/V dose is calculated as 
follows: 
Revised 3/11/02 
 
 
 
 
1. 
Body surface area (BSA) is calculated by the 
equation: 
 
BSA= (Actual body wt.(kg) x height (cm) 
 
 
 
 
 
 
 
                                3600 
 
2. 
Dose of IV busulfan that is equivalent to a total 
dose of 11mg/kg of the oral dose is: 22 mg/m2 
per dose.  Blood levels will be obtained with 
the first dose as per appendix 1.  Busulfan 
levels will be performed at COH (Dr. David 
Senitzer, City of Hope National Medical 
Center, 1500 E. Duarte Road, Duarte, 
California 91010 and will only be sent to Quest 
Diagnostics as a back-up.  Call Gary (626) 
256-8621 24hrs before shipping samples.
 
 
 
 
Wednesday/Day –12 
Busulfan AUC will be calculated by standard 
methods available in the City of Hope Analytical 
Pharmacology Core Facility (APCF).  The resulting 
AUC will be used to determine the dose required to 
achieve an AUC of 800 µM* min according to the 
following formula: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
    800µMx min 
Adj dose = Current dose x  
 
 
 
 
    test dose AUC 
 
 
 
 
 
The maximum dose given will not exceed 32 mg/m2. 
There is no limit on dose reduction Busulfan dose will 
only be adjusted for AUC’s <700 or >900 µM*min. 
 
Thursday/Day –11 
If the adjusted dose of busulfan is indicated, the 
adjusted dose will be given and blood levels will be 
repeated.  Further dose adjustments will be 
performed if AUC>1000. 
Revised 8/7/00 
 
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Friday/Day –10 
Patient admitted to BMT or outpatient department to 
receive further doses of Busulfan.  Resume busulfan 
once PK results are known. 
 
 
 
 
 
 
 
 
Busulfan dose is resumed and is repeated every 6 
hours for a total of 16 doses (including test dose(s). 
Last dose is given at midnight on day –7. 
Revised 8/7/00 
 
 
 
Tuesday/Day-6 
Fractionated TBI will be given at 120 cGy per fraction 
for a total of 4 days [day –6, -5, -4, -3] for a total of 10 
fractions for a total dose of 1200cGy. Or FTBI will be 
given at 150cGy per fraction x 8 fractions for a total 
of 4 days (-6,-5, -4,-3) total dose 1200 cGy Appendix 
IIa. 
 
Saturday/Day –2 
VP-16 30mg/kg based on adjusted ideal body weight 
will be administered. 
 
CALCULATIONS OF IDEAL BODY WEIGHT 
 
 
1. Male       IBW = 50kg + 2.3 kg(height [in] - 60) 
2. Female     IBW = 45.5 kg + 2.3kg (height [in] - 60) 
 
Sunday/Day –1 
Rest 
 
 
 
 
Monday/Day 0 
 
The frozen peripheral blood cells will be transported 
to the transplant unit and thawed in a water bath 
outside the patient's room.  Each bag will be infused 
undiluted rapidly through standard IV tubing without 
a filter. *Premeds for stem cell infusion will be given 
as per the standard operating procedure of the 
respective transplant center.  A recommended 
regimen 
is 
hydrocortisone 
and 
25mg 
of 
diphenhydramine and Mannitol 12.5gm per MD 
discretion.  Those patients who have > 3x106 CD34 
cells/kg PSC's will receive PSC's only.  All other 
patients will receive both primed PSC's and bone 
marrow.  
Revised 3/11/02 
 
 
Saturday/Day +5 
 
Start GCSF 5µg/kg IV or subcutaneously. 
 
 
 
6.53 Central Nervous System Therapy
 
In general, no specific CNS therapy will be administered.  Patients with CNS 
disease at initial diagnosis will receive five weekly doses of intrathecal 
methotrexate (12 mg) both before and after autologous bone marrow 
transplantation.  These patients will then receive monthly doses of intrathecal 
methotrexate (12 mg) during the first year of remission. 
 
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6.54 Supportive Care During Transplant: 

 
 
On day –6 menstruating females will start provera 10 mg p.o. daily and 
Nystatin vaginal suppositories 1 b.i.d.. Prophylactic antibiotics: Levofloxacin 
500 mg p.o or IV qd until ANC >500,  Bactrim DS 1 tablet p.o. b.i.d. will be 
started at start of conditioning regimen and continued until day - 2. 
 
 
 
 
 
Prophylaxis for herpes simplex: Patients with positive ab titres for herpes 
simplex will receive acyclovir 250mg/m2 starting day –1 + continue until Day 
+20 or resolution of mucositis. 
 
 
 
 
 
Hyperalimentation will be given while patient is unable to eat. 
 
 
 
 
 
 
 
Prophylaxis for veno occlusive disease: Heparin 100 units/kg/day continuous 
infusion from start of conditioning until ANC >500. 
 
 
Platelet transfusions will be given to maintain the platelet count > 15,000/ L at 
all times.  Single donor platelets will be used with an attempt to use family 
members when possible.  All platelets will be filtered to remove contaminated 
leukocytes which may harbor cytomegalovirus (CMV).  Packed RBC 
transfusions will be used to keep the hemoglobin level >8.5 gm/dl.  All blood 
products will be irradiated with 2500 cGy prior to transfusion. 
Revised 8/7/00 
 
 
The greatest risk for autologous BMT is infection.  The management of 
infections in these immunocompromised patients must by necessity be 
individualized, but the following general approach will be utilized: If a specific 
infection is documented, patients will be placed on specific antimicrobial 
agents to treat that infection.  For temperatures > 38.5 C without an obvious 
source in patients with less than 1000 granulocytes/1 cultures of blood and 
urine will be obtained.  Following this, a third generation Cephalosporin will 
be used as initial empiric antibiotic coverage.  For persistent or recurrent 
fevers an amino glycoside and/or Ancef will be added.  Prophylactic 
intravenous Amphotericin B will be used and the dose can be increased as 
clinically indicated.  If a specific organism or site of infection is identified after 
starting empiric antibiotic coverage, therapy will be changed as needed. 
 
 
While hospitalized, patients will have a daily CBC with platelet count, and 
basic metabolic panel.  Comprehensive metabolic panel plus uric acid, LDH, 
phosphorous determinations will be performed on Monday, Wednesday, and 
Friday.  
Revised 8/7/00 
 
 
During the first year the patient should be seen monthly and have CBC, Diff., 
platelets, liver function tests and other tests that are clinically indicated.  
Bone marrow should be performed at day +100 and then yearly for the first 
two years after the transplant or when clinically indicated. 
 
6.6 
Post Transplant Therapy 
 
 
 
After PSCT patients will receive Interleukin-2 once the following criteria are met: 
 
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A. The patient is less than or equal to 100 days after PSCT and meets 
the following criteria for peripheral blood. 
 
i. The patient has an absolute neutrophil count > 500/mm3 for three 
days, and 
 
ii. The patient has a platelet count that can be supported to > 
20,000/mm3 with < one platelet transfusion/day for three days. 
 
B. Patients must have received no growth factors, corticosteroids, 
pentoxifylline, or amphotericin-B for at least 72 hours. 
 
C. Patients must be afebrile and free of active bacterial, viral or fungal 
infection. 
 
D. Patients must not be receiving antibacterial, antiviral, or antifungal 
therapy for fever or a documented infection.  Prophylactic antibiotics 
are allowed. 
 
E. Patients must have a total bilirubin, SGOT, alkaline phosphatase and 
creatinine < 1.5 x IULN.  These tests must be completed within seven 
days prior to starting treatment. 
 
F. Cardiac:  EKG with no evidence of active cardiac disease. 
 
 
 
 
 
 
G. Pulmonary: chest x-ray without signs of active pulmonary disease. 
 
These tests must be completed within seven days prior to starting 
treatment. 
 
H. Patients must have a KPS of > 70%. 
 
I. Patients must not have mucosal toxicity; not requiring TPN. 
 
 
6.61 Interleukin-2 (IL-2) Therapy
 
 
 
 
a). Initiation of IL-2 Therapy 
 
 
 
Patients who meet eligibility criteria should begin therapy within three days. 
Some patients, however, will fail to maintain all eligibility criteria to the 
initiation of IL-2 therapy.  In such cases: 
 
 
i) IL-2 therapy should be delayed until the patient again meets all of the 
criteria for IL-2 therapy at which time IL-2 therapy should begin 
immediately. 
 
 
 
 
 
ii). Patients who have documented relapse of leukemia as determined by 
peripheral blood or bone marrow findings will be removed from study and 
not be treated with IL-2. 
Revised 3/11/02 
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21
 
 
 
b). Plan of Treatment 
 
 
 
 
 
 
i). IL-2 Preparation 
 
 
 
 
 
 
 
 
Recombinant human IL-2 (Proleukin) manufactured and provided by 
Chiron-Cetus Corporation will be used in this study.  IL-2 activity  will be 
expressed in International Units (IU). 
 
ii). Outline of IL-2 Treatment Regimen 
 
Treatment 
Phase  
 
Dose 
Route 
Days 
Notes 
Course 1 
(IL-2 induction) 
9.0x106 
IU/m2/24hr
Continuous 
Infusion 
1-4 (total 
96hrs) 
Requires hospitalization.  
Begin in AM on Day 1, 
end in AM on Day 5. 
Rest 
N/A 
 
5-8 
Patient discharged when 
clinically stable 
Course 2 
(IL-2 
Maintenance) 
1.6 x 106 
IU/m2/24hr
Continuous 
Infusion 
9-18 
Begin in AM on Day 9, 
ending in AM on Day 19.  
Administer as outpatient 
unless hospitalization is 
clinically indicated. 
 
c) IL-2 Administration 
 
 
 
i) IL-2 is administered by continuous intravenous infusion (CIV) 
through a central venous catheter.  Interruptions of the infusion 
should be limited to no more than 20 minutes per 24 hours. 
 
 
 
ii) Induction IL-2 is mixed in 500 cc D5W/day containing 0.1% human 
serum albumin (HSA) and should be flushed with D5W.  The 
actual volume of each bag containing IL-2 should be determined 
by the pharmacy in order to calculate the rate to infuse this volume 
over exactly 24 hours.  Failure to do so may result in IL-2 
administered for significantly more/less than 96 hours due to 
overfill/underfill of bags. 
 
iii) Maintenance IL-2 will be administered by CIV via an ambulatory 
infusion pump, mixed in D5W containing 0.1% HSA, total volume 
dependent on the particular pump.  During maintenance, the IL-2 
solution should be changed mid-course. 
 
Formulation/Reconstitution/Storage 
 
IL-2 (Chiron) is supplied as Glyophilized powder.  Each 5 cc vial 
labeled 1 mg, actually contains 1.3 mg of powder.  The vial is 
reconstituted with 1.2 ml of sterile water for injection producing a 
final concentration of 18 million International Units/mL (18x106 
I.V./ml).  Diluent should be directed against the side of vial to avoid 
excess foaming swirl contents gently completely dissolved.  Do not 

shake.  Since vials contain no preservative, reconstituted solution 
should be used within 8 hours. 
 
Intact vials are stored in the refrigerator (2-8°C) with protection 
from light. Each vial bears an expiration date. 
 
6.62 Supportive Care During IL-2 Therapy
 
 
 
a) Intravenous Fluid Administration 
 
During induction IL-2 therapy, patients retain sodium and free 
water and generally exhibit and tolerate weight gain of 5-10% of 
initial body weight. Aggressive sodium and free water restriction 
may result in hypotension whereas aggressive sodium and fluid 
administration may result in pulmonary edema and/or ascites.  IV 
fluid therapy during induction IL-2 should be begun as follows, and 
adjusted according to the patient's subsequent clinical course: 
 
i) 
The patient should receive IV hydration with normal saline 
(NS) at 500 cc/m2/24 hr. 
 
ii) 
The patient's total daily IV intake should be limited to < 1.5 
L/m2/24 hr. 
 
 
 
b) Prophylactic Antibiotics 
 
IL-2 causes a reversible defect in neutrophil function.  Fevers are 
almost universal during induction IL-2 therapy and usually do not 
signify infection. However, gram positive, and rarely gram 
negative, infections occur in 10-25% of patients.  These infections 
can be serious and, therefore, prophylactic antibiotics should be 
administered as follows (choice of antibiotics may be altered due 
to a patient history of sensitivity to these medications).  Patients 
are to receive Levaquin 500mg p.o. q.d. while receiving IL-2. 
Revised 3/11/02 
 
c) Ancillary Medications 
 
To decrease IL-2 toxicity, the following medications are 
recommended during IL-2 therapy.  Alterations may be made 
based on individual patient factors.  NOTE:  One dose of 
acetaminophen, diphenhydramine and naprosyn should be 
administered prior to each dose of IL-2 during the first week.  Then 
for the subsequent weeks acetminophen should be administered 
prior to each dose of IL-2.  Other medications that could be used 
for symptom control or prevention are listed below: 
i)    Acetaminophen: 
650 mg PO 30 minutes before first 
dose of IL-2 is administered and q 4-6 
hr as needed for fever. 
 
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ii)   Diphenhydramine: 
50 mg PO 30 minutes before first dose 
of IL-2 is administered then 25-50 mg 
PO or IV q 4-6 hours prn for nausea, 
pruritis. 
 
iii)  Pepcid:  
 
20 mg PO or I.V. BID. 
 
 
 
 
 
 
 
 
iv)  Meperidine: 
 
25-50 mg IV q 2 hr or 50 to 150mg po 
prn for chills 
 
 
 
 
 
 
 
 
v)   Prochlorperazine: 
10mg IV or PO q 6 hr prn for nausea. 
 
 
 
 
 
 
 
 
vi) Naproxsyn:  
 
375 mg PO 30 minutes prior to IL-2, 
then q 12° for fever/myalgia 
 
 
 
 
 
 
 
 
vii) Contraindicated Medications: See section 6.64 
 
6.63 Supportive Care During Maintenance IL-2 Therapy
 
During IL-2, most patients can be managed on an outpatient basis.  Symptoms 
of malaise, myalgias and anorexia are common and usually peak toward the 
end of the maintenance course.  Fever is uncommon during maintenance (see 
Section 6.63.d.i.) 
 
a) IV Fluid Administration is not required unless dictated by inadequate oral 
intake. 
 
b) Prophylactic Antibiotics: 
 
 
 
i) 
Levofloxacin:  500 mg PO qd, (other antibiotics may be 
substituted based on the individual patient) while taking IL-
2. 
 
c)   Ancillary Medications: 
 
No other ancillary medications to reduce IL-2 toxicity should be routinely 
administered during maintenance IL-2 therapy. 
 
i) 
Tylenol and Indocin should be avoided since they may 
mask signs of infection 
 
ii) 
Antiemetics/antidiarrheals/antipuritic 
agents 
can 
be 
administered as needed on an individual basis. 
 
iii) 
Contraindicated Medications (see Section 6.64) 
 
d)  Toxicity Management: 
 
i) 
Fever is uncommon during maintenance IL-2 and should 
strongly suggest a concomitant infection.  Patients should 

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not be treated with antipyretics alone until the potential for 
infection has been evaluated. 
 
ii) 
Patients who develop other toxicity(ies) during maintenance 
IL-2 should be treated according to the guidelines in Section 
6.66. 
 
6.64 Contraindicated Medications and Procedures During IL-2 Therapy: 
 
a) Contraindicated Medications: 
 
i)   Corticosteroids (including any blood product “pre-meds”). 
ii)  Pentoxifylline 
iii) IV or IT methotrexate 
iv) IV immunoglobulin 
v) Other cytokines or growth factors 
 
b) Radiographic Contrast: 
 
 
 
 
Ten to twenty percent of patients may develop severe 
“anaphylactoid” reactions with fever, chills and severe hypotension 
in response to IV contrast (ionic or non-ionic) administered during 
or within two weeks of completing IL-2 therapy.  IV contrast 
administration (ionic or non-ionic) should, therefore, be avoided 
unless clinically necessary during these times. 
 
6.65 Dose Modification during IL-2 Therapy 
 
a) Treatment with IL-2 is continued until completed or until Grade 3 or 
4 toxicity (or Grade 2 neurologic or cardiac toxicity; Grade 4 
neutrophils 
or 
bilirubin; 
or 
platelets 
< 
10,000/mm3 
with 
transfusions) occurs at which time IL-2 is discontinued until a 
return to Grade 1 toxicity, at which time IL-2 therapy will be 
resumed at 50% of the initial dose.  If Grade 3 or 4 toxicity, or 
Grade 2 neurotoxicity or cardiac toxicity, recurs after resumption of 
the reduced dose of IL-2 then IL-2 is discontinued and not 
restarted. 
 
b) Reduction or discontinuation of IL-2 therapy due to toxicity does 
not alter the IL-2 treatment schema (Section 6.61.b.ii).  If 
temporarily interrupted, IL-2 therapy is resumed according to the 
day of the original schedule.  Any doses missed due to toxicity are 
not administered, and total duration of therapy is not extended 
beyond the original plan at initiation of IL-2 therapy. 
 
6.66 Toxicities of IL-2 Therapy 
 
a) High-dose IL-2 administered by CIV results in dose and time 
dependent toxicities which peak toward the end of the induction 
course.  The most common clinical toxicities seen during induction 

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IL-2 are of a flu-like syndrome with fever, chills, weight gain, 
nausea, diarrhea, and rash. 
 
 
b) Capillary Leak Syndrome (CLS):  The CLS is characterized by 
peripheral of pulmonary interstitial edema and/or ascites, and 
“sepsis-like” 
physiology, 
i.e., 
decreased 
systemic 
vascular 
resistance and increased cardiac output.  Dose modifications are 
made for specific organ system toxicity, as per Section 6.65. 
 
c) Hypotension:  Mild hypotension with systolic blood pressure (SBP) 
10-20% below baseline is common in patients receiving induction 
IL-2. 
 
 
i) 
Asymptomatic patients with SBP > 90 mm Hg should be 
monitored closely. 
 
ii) 
Any symptomatic patient (regardless of the SBP) and all 
patients with SBP < 85 mm/Hg should be treated 
immediately with a fluid bolus of NS, 5-7 ml/kg (STAT  x 1-
2) which may be supplemented with red cell transfusions or 
colloid infusion.  Hypotension which does not respond to 
fluid therapy should be treated with low-dose dopamine or a 
phenylephrine infusion, and IL-2 therapy should be 
interrupted until hypotension resolves. 
 
 
iii) 
Grade 3 hypotension which does not respond to 
crystalloid/colloid therapy requires: 
 
IV pressors, preferably phenylephrine (rather than dopamine). 
 
Discontinuing IL-2 infusion 
 
d) Arrhythmias: 
 
i) Sinus Tachycardia: is common, especially during fever, and is 
not an indication for intervention.  
 
 
 
 
 
 
 
 
ii) Supraventricular Tachycardia: Occurs in < 10% of adult 
patients and is an indication to discontinue IL-2 until SVT 
resolves.  If patient is hemodynamically unstable, this shouldbe 
treated with Digoxin or cardioversion NOT verapamil (which 
may result in severe hypotension) 
 
 
 
 
 
 
 
e) Renal Dysfunction:  Most patients will develop oliguria and some 
elevation of serum creatinine (< 2.0 x baseline) during induction IL-
2 due to decreased renal perfusion, intrinsic renal effects of IL-2 
and indomethacin.  This is usually quickly reversible after induction 
IL-2 is completed. 
 

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26
i) 
The common manifestations of IL-2 induced renal 
dysfunction are:  
 
Weight gain of 1-10% of baseline body weight. 
 
 
 
 
 
 
 
 
Metabolic acidosis (total CO  15-20). 
 
 
 
 
 
 
 
 
Lowering of serum K+, Mg++, Phos+. 
 
ii) 
During induction IL-2 therapy, these guidelines should be 
followed: 
 
a. Allow the patients to gain < 1-1.5%/day of baseline body 
weight. 
 
b.  Reserve diuretic therapy for patients with symptomatic 
interstitial edema (i.e.,pulmonary edema, or ascites).  Overly 
aggressive diuresis for asymptomatic patients with weight 
gain and oliguria will often result in hypotension and 
worsening of renal dysfuntion. 
 
c.  If creatinine increases by < 50% over baseline, reduce 
indomethacin to q 12 hr. 
 
d.  If creatinine increases by > 50% over baseline, discontinue 
indomethacin. 
 
e) 
Hematologic Side Effects – Background: 
 
 IL-2 therapy causes the following hematologic effects. 
 
i) Lymphocytosis as high as 20-50,000/mm3 occurs often 
and is maximal 24 hours after stopping induction IL-2; 
lymphopenia occurs during Days 1-4 of induction IL-2. 
 
ii) Anemia occurs often, due to decreased production and 
destruction RBC’s. Most patients will require RBC 
transfusions during induction IL-2. 
 
iii) Neutrophilia and Eosinohilia occurs often, and is due 
to secondary release of GM-CSF,IL-5 and IL-3. 
 
iv) Thrombocytopenia occurs often.  Platelet counts are 
lowest on Days 4-9 of IL-2 therapy, and most patients 
will require more frequent platelet transfusions during 
this period. 
 
g) 
Infectious Complications: 
 
 
 
 
 
 
 
 
 
 i) All patients should receive prophylactic antibiotics during 
induction IL-2. 
 

Version 09 
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27
ii) Blood cultures should be drawn at least once per day for 
temperature spikes. 
 
 
iii) Any fever that persists more than 24 hours after 
induction IL-2 is completed should suggest a secondary 
infection and NOT be ascribed to IL-2 until infection has 
been ruled out. 
 
h) Gastrointestinal Toxicity: 
 
Nausea, vomiting and diarrhea are common during 
induction IL-2.  Most patients have a limited oral intake 
during this time.  These symptoms usually improve quickly 
once IL-2 is discontinued. 
 
i) 
Hepatic Toxicity: 
 
 
i) Cholestasis 
with 
elevated 
bilirubin 
and 
alkaline 
phosphatase is common, usually peaks on Day 5-7 and 
quickly resolves. 
 
 
 
 
 
 
 
 
 
ii) Drugs which are hepatically metabolized may need 
temporary dose reductions during this period of hepatic 
dysfuntion. 
 
 
 
 
 
 
 
 
j) 
Neurologic Toxicity: 
 
 
 
 
 
 
 
 
 
i) Neurologic 
abnormalities 
such 
as 
lethargy, 
mild 
confusion, subtle personality change and memory 
disturbance occur in some patients receiving narcotics, 
sedatives or antiemetics concomitantly with IL-2. 
Patients with these symptoms should have psychoactive 
drugs reduced or discontinued. 
 
 
 
 
 
 
 
 
 
ii) In any patient who develops > Grade 2 neurologic 
toxicity, IL-2 will be discontinued immediately and 
permanently. 
 
7.0 
COMPLICATIONS OF THERAPY: 
 
Busulfan: Human toxicity from busulfan includes: a) Severe bone marrow hypoplasia 
which could be fatal without administration of bone marrow or peripheral blood stem 
cells. b) Nausea and vomiting which can be decreased by the use of sedation and 
antiemetics. c) Stomatitis and diarrhea which can be treated symptomatically with fluid 
replacement and atropine or diphenoxylate Hcl. d) Pulmonary fibrosis chara-cterized by 
delayed onset of cough, shortness of breath and low grade fever. e) Hepatic damage 
which can occur in combination with melphalan or as a single agent and can result in 
significant hepatic toxicity which can be fatal. f) Temporary hyperpigmentation of the 
skin and nail bed changes. g) Grand mal seizures which can be prevented by the 
prophylactic administration of dilantin. 

Version 09 
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28
 
Total body irradiation: The short term and long term complications of TBI have been 
reviewed by others.  Most patients will experience nausea and vomiting.  This problem 
will be managed symptomatically and usually resolves within 24 hours of ending 
therapy.  Oral mucositis is expected in virtually all patients.  Mouth care will be 
performed with hydrogen peroxide ad clotrimazole.  Only toothbrushes will be allowed.  
Pain will be managed with morphine or dilaudid.  All patients should expect permanent 
sterility.  It is probable that most patients will be infertile from previous therapy, but 
male patients will be offered the option of semen storage before therapy.  Temporary 
alopecia will also be expected in all patients.  Long term survivors may develop 
cataracts within a few years following BMT.  These can be managed successfully in the 
same way as cataracts, unrelated to radiation.  Solid tumors have been seen following 
TBI.  Radiation fibrosis of the lung and hypothyroidism are also potential but unlikely 
complications. 
 
Autologous PSC Reinfusion: Side effects from the bone marrow and peripheral stem 
cell infusion should be minimal. Volume overload may be seen, but can be managed 
with diuretics. Fevers and chills may occasionally be encountered. At the University of 
Nebraska at least two patients developed acute abdominal pain of unknown cause 
during their marrow infusions. The pain was managed with narcotic analgesics and 
resolved spontaneously. The lysis of frozen erythrocytes may be associated with 
hemoglobinuria. Patients will have positive tests for blood in the urine, but no 
erythrocytes will be found in the sediment. At the University of Nebraska three patients 
developed acute renal failure after autologous bone marrow infusion.  This problem 
was presumed to be due to hemoglobinuria and was no longer seen after red blood 
cells were removed from the marrow prior to cryopreservation. This is not expected to 
be a problem since we will also be removing the red cells with Ficoll-Hypaque. DMSO 
will be infused along with the bone marrow. It is excreted through the lungs and its 
characteristic odor may be noticeable for a few days after marrow infusion. 
 
8.0 
STATISTICAL CONSIDERATIONS: 
 
8.1 Primary and Secondary Endpoints: The primary endpoints of this Phase II study 
are to evaluate the toxicity and efficacy of FTBI/VP-16 and targeted Busulfan dosage 
for AUC 700-900 as a preparative regimen for autologous BMT with primed peripheral 
stem cells following consolidation therapy with high dose Ara-c and idarubicin or high 
dose Ara-c alone in patients with AML in first complete remission (CR).  Complete 
remission will be defined as neutrophils >1500/ml and platelets >100,000.   Efficacy will 
be estimated as 2 and 5 year disease-free survival (DFS).  The role of IL-2 following 
autologous BMT will also be evaluated based on feasibility of administration and ability 
to tolerate IL-2.  The effect of cytogenetics, WBC at presentation, AUC of Busulfan and 
number of courses of induction therapy to achieve remission will be evaluated as 
possible prognostic factors for relapse, DFS, and overall survival.  
 
8.2 Sample Size Estimation and Length of Accrual:  A total of 50 patients with AML in 
first CR and less than < 60 years old will be accrued to this trial, so that in estimating 
the engraftment and relapse rates the maximum standard error will be 0.07.  We 
expect to accrue approximately 10-12 patients per year so that this trial will require 4-5 
years for completion. 
 

8.3 Statistical Analyses: 
The rate of engraftment and median time to engraftment will 
be estimated, defined as time to ANC>500 and platelets > 20,000. 
 
The Kaplan-Meier method will be used to estimate time to relapse, DFS, and overall 
survival, and 95% confidence intervals will be calculated using Greenwold’s variance.  
All patients receiving HD Ara-c and Idarubicin consolidation will be included in the 
analysis for intent-to-treat with autologous BMT.  For overall survival, failure time will 
be calculated from the day of first consolidation treatment to the day of death due to 
any cause for those patients who fail.  For DFS, the failure time will be calculated from 
the day of first treatment to the day of disease relapse or death due to any cause.  For 
patients who remain alive and well at the time of analysis, the survival time will be 
censored as of the date of last contact.   
 
A further analysis of time to relapse, DFS and overall survival will be carried out for the 
subset of patients who go on to autologous BMT, with survival estimates calculated 
from the day of transplant.  The Cox proportional hazard regression model will be used 
to analyze possible prognostic factors for relapse, DFS and overall survival. 
 
8.4 Early Stopping Rules: If at any time the severe treatment related complication rate 
(e.g. severe VOD, interstitial pneumonia, neurotoxicity at day 100 post ABMT), 
exceeds 10%, with a high probability (i.e. 95%) then further accrual to the trial will be 
terminated.  Similarly if with a high probability (95%) the regimen related mortality at 
day 100 post ABMT exceeds 10% the trial will be terminated.  This would occur if the 
following numbers of events have been observed, monitoring after every set of 10 
patients it accrued:  
 
 
Number of Patients 
Accrued 
Number of Adverse Events 
Leading to Early Termination 
10 
4 
20 
5 
30 
7 
40 
8 
 
 
 
We will stop accrual of good risk cytogenetic patients on the study if the good risk 
cytogenetic patients demonstrate excess relapse.  Based on previous COH 
experience, good risk cytogenetic patients have a relapse rate of 13%. The study will 
close if the lower bound of an estimate of the true rate of relapse exceeds 15% for the 
subgroup.  Evidence of relapse will be taken as the lower limit associated with an exact 
95% one-sided confidence interval for proportions.  Table 1 below shows the critical 
points for early stopping of accrual.   
Rev. 5/7/01 
 
 
Table 1: Critical points for early stopping for relapse 
 
 
Critical points for early stopping 
95% one-sided CI 
Cumulative enrollment of good risk 
cytogenetic patients 
Conclude omitting idarubicin poses a safety 
threat in >15% of pts if N experiencing 
relapse is at least: 
5 
3 
10 
4 
15 
6 
20 
7 
Version 09 
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29

25 
8 
30 
9 
35 
10 
 
 
9.0 
WOMAN AND MINORITIES GUIDELINES
 
All eligible patients from both genders and from all racial/ethnic groups will be recruited 
equally into this trial, with the only exclusionary criteria being those stated in Section 
5.0. Based on our patient population and previous experience with bone marrow 
transplantation for AML in first remission, the anticipated rates of entry into this study 
by gender and race/ethnicity are as follows: 
 
 
Gender/Race/Ethnicity Table for Acute Myelogenous Leukemia Patients in First 
Complete Remission Transplanted at City of Hope National Medical Center 
 
 
American 
Indian or 
Alaskan 
Native 
Asian or 
Pacific 
Islander 
Black, not of 
Hispanic 
Origin 
Hispanic White, 
not 
of Hispanic 
Origin 
Other 
or 
Unknown 
Female 
0% 
12% 
2% 
16% 
70% 
0% 
Male 
0% 
8% 
2% 
22% 
65% 
3% 
Total 
0% 
10% 
2% 
19% 
65% 
2% 
 
10.0 REGISTRATION GUIDELINES: 
 
 
 
Once signed, informed consent has been obtained and all pretreatment 
evaluations have been performed, patients will be entered on study, after review 
of patient eligibility criteria by the assigned Clinical Research Associate (CRA) 
from City of Hope Department of Biostatistics.  Patients may be screened for 
registration by calling the Department of Biostatistics, ext. 63811.  Eligibility 
checklists are attached.  (Appendix IX).  Patients will be taken off study at time 
of death.   
Revised 3/11/02 
 
11.0 DATA SUBMISSION SCHEDULE: 
 
 
 
All primary data will be maintained by the assigned CRA from the Department of 
Biostatistics.  Data will be collected by the CRA at the time of each patient 
evaluation. Records will be stored in a secure location within the Biostatistics 
Department. 
 
 
 
See Appendix VIII for time points for grading toxicities. 
 
Rev. 3/11/02 
12.0 ETHICAL AND REGULATORY CONSIDERATIONS: 
 
 
 
This study is to be approved by the Institutional Review Board according to City 
of Hope ethical and regulatory guidelines.  All patients will have signed an 
informed consent for participation in research activities, and will have been 
given a copy of the Experimental Subject's Bill of Rights. 
Version 09 
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30

Version 09 
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31
 
 
 
When results of this study are reported in medical journals or at meeting, 
identification of those taking part will be withheld.  Medical Records of patients 
will be maintained in strictest confidence, according to current legal 
requirements.  However, they will be made available for review, as required by 
the Food and Drug Administration (FDA) or other authorized users such as the 
National Cancer Institute (NCI), under the guidelines established by the Federal 
Privacy Act. 
 
13.0 Data & Safety Monitoring Plan (See Appendix VII) 
 
Toxicities will be graded using the Common Toxicity Criteria 2.0 published date April 30, 
1999, Appendix VI [special attention to BMT section]. 
 
Frequency for grading and recording toxicities, see Appendix VIII. 
 
i. 
The COH IRB and the Clinical Protocol Review Monitoring Committee (CPRMC) and 
Data Safety Monitoring Board (DSMB) will have the data monitoring oversight 
responsibilities.  The COH has an NCI approved clinical monitoring plan.  The CPRMC 
is an NCI approved clinical trials monitoring committee.  The COH IRB meets twice 
monthly and reviews protocols annually.  The CPRMC meets twice per month.  
Monitoring accrual and SAE’s will be performed by that committee.  Adverse events will 
be reported to the COH IRB and CPRMC [DSMB].\ 
 
ii. 
Guidelines for reporting AE’s and ADRS – See Appendix VII. 

Version 09 
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32
14.0 REFERENCES
 
1. 
Keating MJ, McCredie KB, Bodey GP, Smith TL, Gehan E, Freireich EJ.  Improved 
prospects for long term survival in adults with acute myelogenous leukemia.  JAMA 
8:2481-2486, 1982. 
 
2. 
Rai KR, Holland JF, Glidewell OJ, et al.  Treatment of acute myelocytic leukemia: A 
study by cancer and leukemia group B.  BLOOD 58:1203-1212, 1981. 
 
3. 
Applebaum FR, Dahlberg S, Thomas ED, et al.  Bone marrow transplantation or 
chemotherapy after remission induction for adults with acute non-lymphoblastic 
leukemia: A prospective comparison.  Annals Int. Med 101:581-588, 1984. 
 
4. 
Berman E, Heller G, Santorsa J, et al: Results of a randomized trial comparing 
idarubicin and cytosine arabinoside with daunorubicin and cytosine arabinoside in adult 
patients with newly diagnosed acute myelogenous leukemia.  BLOOD 77:1666, 1991. 
 
5. 
Phillips GL, Reece DE, Shepherd JD, et al: High-dose cytarabine and daunorubicin 
induction and post remission chemotherapy for the treatment of acute myelogenous 
leukemia in adults.  BLOOD 77:1429, 1991. 
 
6. 
Mayer RJ, Davis RB, Schiffer et al.  Intensive post remission chemotherapy in adults 
with acute myeloid leukemia: N Engl J Med 1994; 331:896-903 
 
7. 
Forman SJ, Spruce WE, Farbstein MJ, et al. Bone marrow ablation followed by 
allogeneic marrow grafting during first complete remission of acute non-lymphocytic 
leukemia.  BLOOD 61:439-442, 1983. 
 
8. 
Santos GW, Tutschka PJ, Brookmeyer R, et al.  Marrow transplantation for acute non-
lymphocytic leukemia after treatment with busulfan and cyclophosphamide.  New 
England Journal of Medicine 309:1347-1352, 1983. 
 
9. 
Dicke KA.  Current status of bone marrow transplantation for acute myelogenous 
leukemia.  Proc Amer Soc Clin Onc 5:167, 1986. 
 
10. 
Snyder DS, Chao NJ, Amylon MD, et al: Fractionated total body irradiation high-dose 
etoposide as a preparatory regimen for bone marrow transplantation for 99 patients 
with acute leukemia in first complete remission.  BLOOD 82:2920, 1993. 
 
11. 
McClave PB, Haake RJ, Bostrom BC, et al: Allogeneic bone marrow transplantation for 
acute non-lymphocytic leukemia in first remission.  BLOOD 72:1512, 1988. 
 
12. 
Weiden PL, Sullivan KM, Flournoy N, Storb R, Thomas ED.  Anti-leukemic effect of 
chronic graft versus host disease: Contribution to improved survival after allogeneic 
marrow transplantation.  New England Journal of Medicine 304:1529-1533, 1981. 
 
13. 
Fefer A, Cheever MA, Greenberg PD, et al.  Bone marrow transplantation for acute 
leukemia in patients with identical twins: Improved results with BMT in complete 
remission.  Proc Amer Soc Clin Onc 1:182, 1983. 
 

Version 09 
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33
14. 
Fearon ER, Burke PJ, Schiffer CA, Zehnbauer BA, Vogelstein P.  Differentiation of 
leukemia cells to polymorphonuclear leukocytes in patients with acute non-lymphocytic 
leukemia.  New England Journal Medicine 315:15-24, 1986. 
 
15. 
Stewart B, Buckner CD, Besinger W, et al.  Autologous marrow transplantation in 
patients with acute non-lymphocytic leukemia in first remission.  Exp Heme 13:267-
272, 1985. 
 
16. 
Burnett AK, McKinnon S.  Autologous bone marrow transplantation in first remission 
AML using non-purged marrow: Update.  Clinics in Hematology 15:211-220, 1986. 
 
17. 
Stein AS, O’Donnell MR, Chai A, et al.  In vivo purging with high dose cytarabine 
followed by high dose chemoradiotherapy and reinfusion of unpurged bone marrow for 
adult acute myelogenous leukemia in first complete remission.  J Clin Oncol 
1996;14:2206-2214. 
 
18. 
Linker CA, Ries CA , Damon LE, Rugo HS, Wolff JL. Autologous bone marrow 
transplantation for acute myeloid leukemia using busulfan plus etoposide as a 
preparative regimen.  Blood 1993;81:311-318 
 
19. 
Chao NJ, Stein AS, Long GD, et al.  Busulfan/Etoposide – Initial experience with a new 
preparatory regimen for autologous bone marrow transplantation in patients with acute 
non-lymphoblastic leukemia. Blood 1993;81:319-323. 
 
20. 
Körbling M, Hunstein W. Fliedner TM et al.  Disease-free survival after autologous 
bone marrow transplantation in patients with acute myelogenous leukemia.  Blood 
1989;74: 1898-1904. 
 
21. 
Burnett AK, Goldstone AH, Stevens RMF, et al.  Randomized comparison of addition of 
autologous bone-marrow transplantation to intensive chemotherapy for acute myeloid 
leukemia in first remission: Results of MRC AML 10 trial.  The Lancet 1998; 351;700-
708. 
 
22. 
Heslop HE, Gottlieb OJ, Bianchi ACM et al:  In vivo induction of gamma interferon and 
tumor necrosis factor by Interleukin-2 infusion following intensive chemotherapy or 
autologous bone marrow transplantation.  Blood 74: 1374-1380, 1989 
 
23. 
Heslop NE, Duncombe AS, Teittie JE, et al: Interleukin-2 infusion induces 
haematopoietic growth factors and modifies marrow regeneration after chemotherapy 
or autologous marrow transplantation.  Br J Haemat 77: 237-244, 1991 
 
24. 
Falkenburg JHF, Schaafsma MR, Smit WM, et al:  Treatment with low dose IL-2 after 
autologous bone marrow transplantation (ABMT) for acute myeloid leukemia (AML) 
Blood, 86: 566a, 1995 
 
25. 
Fefer A, Robinson N, Benyunes MC, et al.  Interleukin-2 therapy after bone marrow or 
stem cell transplantation for hematological malignancies.  Devita Jr VT, Hellman S., 
Rosenberg SA eds.  The Cancer Journal for Scientific American, Vol. 2, Suppl 1, 
Seattle, Washington, 1997;S48-S53. 
 

Version 09 
4/20/04 
34
26. 
Kashyap, S.J. Forman, P. Cagnoni, H. Fernandez, W. Hu, V. Gian, J. Wingard, S. 
Tarantolo, B.S. Andersson. (1998) Intravenous Busulfan (Busulfex™)/Cytoxan (CY) 
Preparative Regimen for Allogeneic (ALLO) and Autologous (AUTO) Hematopoietic 
Stem Cell Transplantation (BMT) is well Tolerated by Patients Over 50 Years of Age. 
ASH, December 1998, Miami Beach 
 
27. 
W.P. Vaughan, P. Cagnoni, H. Fernandez, W. Hu, A. Kashyap, V. Gian*, J. Wingard, 
S. Tarantolo, B.S. Andersson (1998) Decreased Incidence of and Risk Factors for 
Hepatic Veno-Occlusive Disease with an Intravenous Busulfan (BU) Containing 
Preparative Regimen for  Hematopoietic Stem Cell  Transplantation (HSCT). ASH, 
December 1998, Miami Beach 
 
28. 
B.S. Andersson, K. McWilliams, H. Tran, H. Fernandez, P. Cagnoni, R. Jones, V. Gian, 
S. Tarantolo, A. Kashyap, S.J. Forman, WW Hu, KG Blume, R.E. Champlin (1998) IV 
Busulfan, Cyclosphosphamide (Bu/Cy) and Allogeneic Hemopoietic Stem Cells (BMT) 
for Chronic Myeloid Leukemia (CML), ASH, December 1998, Miami Beach 
 
29. 
Cryopreservation References: 
 
 
Procedure Manual and Instrumentation Instruction, Gordinier Electronics, Inc., 
Cryogenic Design, CRYOPAK software, 1990. 
 
 
Gee AP: Bone marrow processing and purging, a practical guide, CRC Press, Boca 
Raton, FL, 1991. (modified) 
 
 
AABB, Marrow Transplantation: Practical and technical aspects of stem cell 
reconstitution, 1992. 
 
30. 
Vaughan WP, Soony S, Cagnoni P, Fernandez, et al. Body Surface area (BSA) Dosing 
using actual body weight (ABW) yields less variation in area under the concentration X 
time curve (AUC) for high dose IV busulfan (BU) than BSA dosing using ideal body 
weight (IBW), adjusted ideal body weight (AIBW) or dosing using ABW, IBW, or AIBW 
directly.  ASCO May 1999, Atlanta, Georgia 
 
31. 
Bloomfield CD, Lawrence D, Byrd JC, Carroll A, Pettenati MJ, Tantravahi R, Patil SR, 
Davey FR, Berg DT, Schiffer CA, Arthur DC, Mayer RJ. Frequency of prolonged 
remission duration after high dose cytarabine intensification in acute myeloid leukemia 
varies by cytogenetic subtype.  Cancer Res 1998; 58: 4173-4179. 
 
32. 
Mayer RJ, Davis RB, Schiffer CA, Berg DT, Powell BL, Schulman P, Omura GA, Moore 
JO, McIntyre OR, Frei E and the Cancer and Leukemia Group B.  Intensive 
postremission chemotherapy in adults with acute myeloid leukemia.  New Engl J Med 
1994; 331:  896-903.  

Appendix I 
IV BUSULFAN KINETICS FORM  
IRB#:  ______________________ 
 
 
DATE: ______________________   
PATIENT ___________________  
 
 
DOSE #_____________________   Actual Body Weight ________ 
Medical Record #_____________ 
 
 
Start time: ___________________   Stop time: ________________ 
Date of birth:  ________________ 
DOSE: _____________mg 
Social Security#: _____________ 
MD/Pager#: _________________ Coordinator/Pager #__________ 
 
INFUSION TO RUN OVER 2 HOURS 
Tube # 
Collection Schedule 
Proposed Collection Time 
Actual Collection Time 
1 
Immediately prior to beginning of infusion 
APPROX. 0555 
 
2 
Immediately prior to end of infusion 
APPROX. 0755 
 
3 
15 minutes post infusion 
APPROX. 0815 
 
4 
30 minutes post infusion 
APPROX. 0830 
 
5 
60 minutes post infusion (1 hour) 
APPROX. 0900 
 
6 
180 minutes post infusion (3 hours) 
APPROX. 1100 
 
7 
240 minutes post infusion (4 hours) 
APPROX. 1200 
 
 
 
 
 
** ALL samples to be obtained in 7cc green top tubes (Sodium Heparin) and kept on ice at Nurses Station. 
Then send to Clinical Pathology. 
RN SIGNATURE _________________________________ 
Ship on 5kg dry ice. 
Results will be reported to the attending physician page by 4 p.m. Pacific time. 
Results will also be faxed. 
Revised 3/11/02 
 
35

 
36
Appendix II 
COH Schema 
Session 
Day 
Time 
Beam Direction 
Energy  
(MeV) 
Dose  
(cGy) 
Notes 
 
1 
–6 
0730 
AP 
8/10X 
120 
TLD 
 
2 
–6 
1230 
PA 
8/10X 
120 
 
3 
–6 
1730 
AP 
8/10X 
120 
 
 
 
4 
 
 
–5  
 
 
0730 
 
 
PA 
8/10X 
 
e¯ boost 
120x 
 
300e¯ 
 
 
5 
 
 
–5 
 
 
1230 
 
 
AP 
8/10X 
 
e⎯ boost 
120x 
 
300e¯ 
 
 
6 
 
 
–5 
 
 
1730 
 
 
PA 
8/10X 
 
e¯ boost 
120X 
 
300e¯ 
 
 
7 
 
 
–4 
 
 
0730 
 
 
AP 
8/10X 
 
e¯ boost 
120X 
 
300e¯ 
 
Chest-wall 
boost 
need not  
be given 
in successive 
fractions 
 
8 
 
–4 
 
1230 
 
PA 
 
8/10X 
 
120 
 
9 
–4  
1730 
AP 
8/10X 
120 
 
 
10 
–3  
0730 
PA 
8/10X 
120 
 
 
 
 
 

 
37
Appendix IIa 
 
University of Wisconsin Hospital and Clinical TBI Schema 
BMT 2001-403 UWHC 
IRB# 99040 
 
Session 
Day 
Time 
Beam  
Direction 
Energy  
(MeV) 
Dose (cGy) 
Notes 
 
1 
–6 
0730 
AP 
8/10X 
150X 
TLD 
 
2 
–6 
1700 
PA 
8/10X 
150X 
 
3 
–5 
0730 
AP 
 
8/10X 
e¯ boost  
150X, 300 e¯ 
 
4 
–5  
1700 
PA 
 
8/10X 
e¯ boost 
150X, 300 e¯ 
5 
–4 
0730 
AP 
 
8/10X 
e¯ boost 
150X, 300 e¯ 
6 
–4 
1700 
PA 
8/10X 
e¯ boost 
 
150X, 300 e¯ 
7 
–3 
0730 
AP 
8/10X 
150X 
 
8 
–3 
1700 
PA 
8/10X 
150X 
 
Electron beam set so the 90% PDD fails at the pleura. 
 
2/26/02 written by Bruce Thomadsen, Physicist 
Department of Radiation Oncology 
University of Wisconsin Hospital and Clinics 

Revised 8/7/00 
Rev. 1/30/01 
Rev. 3/19/02 
Appendix III 
Consolidation therapy  (All testing to be completed no more than 4 weeks prior to starting treatment) 
Required studies 
Pre 
study 
Day 1 
Day 2 
Day 
 3 
Day 
4 
Day  
5 
Day  
6 
Day 
7 
Day 
8 
Day 
9 
Day 10 
Day 
11 
Day 
12 
Day  
15 
Until PBSC 
BM asp, biopsy 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cytogenetics 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X
HIV 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CBC,Diff, PLT ** 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X
X
X
X
X
X
X
X
X
X
X
X
X
X
CMP, uric acid, 
phosphorous, LDH ++ 
X 
 
 
 
 
 
 
 
 
 
 
 
 
X
X
X
X
X
Magnesium ++
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X
X
X
X
X
X
X
UA 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
24hr Crea cl
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X
Hepititis panel 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X
Herpes simplex titer 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X
CMV titer 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Immunogloblobulin levels 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X
Thyroid panel 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CXR 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
LP* 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ECHO or MUGA 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X
CT scan Chest, ABD, 
Pelvis 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
PFT 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
HLA Typing of patient and 
sibling 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pregnancy 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X
Cholesterol 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TREATMENT 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consolidation 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
HD ARA-C 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X
X
X
X
Idarubicin*** 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X
X
X
GCSF# 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X
X
X
*Lumbar Puncture will be performed in patients with FAB M4, M4eo, M5, and patients with WBC at diagnosis >50,000 and patients with cutaneous 
 involvement  12 mg of intrathecal methotrexate should be given at the time of the LP. 
# GCSF will be given until stem cells are collected 
++ Comprehensive Metabolic Panel plus uric acid, phosphorous and LDH every Monday, Wednesday, Friday during consolidation 
** CBC, Diff, PLT should be done until ANC >1500 and PLTs >150.  Diff. to be done on admission and then when WBC recovers to >500. 
***Give Idarubicin dose after Ara-C dose 1,3 and 5. 
See section 6.1 for exceptions. 
++Comprehensive Metabolic Panel [See appendix X for tests included].
 
38

Appendix IV 
Revised 8/7/00  
Rev. 11/7/01 
HD Therapy/Transplant therapy  
Required studies 
 
 
Pre 
treatment 
Day 
-17 
Day 
-13 
Day 
 -12 
Day 
-11+ 
Day  
-10 
Day 
–9 
Day 
–8 
Day 
–7 
Day 
-6 
Day 
–5 
Day 
–4 
Day 
–3 
Day 
-2 
Day 
0 
Day 
1 
Day 
2 
Day 
3 
Day 
4 
Day  
100 
Yearly 
X 2 years 
Busulfan PK 
 
 
X 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X
CBC,Diff, PLT* 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Basic MP $  
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
CMP++ 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X
X
X
X
X
X
X
MG ++ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X
X
X
X
PT,PTT 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
UA 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
24hr Crea cl * 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
PFT * 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EKG 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CXR   
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CT Scan  Chest, 
ABD 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ECHO or MUGA 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
BM asp, bx, 
cytogenetics 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
Dilantin level 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X
X
Busulfan blood  
Shipment 
 
 
X 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TREATMENT 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Dilantin +++ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X
X
X
X
X
X
X
X
X
X
Busulfan 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X
X
X
X
X
X
TBI 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X
X
X
X
VP-16 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
 
 
 
 
 
CNS Disease 
patients   see section 
6.53 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
*As clinically indicated 
++ Every Monday, Wednesday, Friday during hospitalization 
** CBC, Diff, PLT should be done daily until ANC >1000 and PLTs >50 and then at physicians discretion 
See section 6.1 for exceptions 
+++Dilantin given day –17 to Day –4 
+ Day –11 labs done only if 2nd test dose of Busulfan given. 
***Busulfan pharmokinetics done on day –13. 
      Busulfan pharmokinetics done on day –11 only if dose adjustment needed. 
     Busulfan pharmokinetics done on day –10 only if dose adjusted. 
$   Basic MP see Appendix X
 
39

Appendix V 
Post BMT Therapy/ IL2 therapy  (All testing to be completed no more than 7 days prior to starting treatment) 
 
Required studies 
Pre IL-2 
Day 
1 
Day 
2 
Day 
 3 
Day 
4 
Day 
5 
Day 
6 
Day 
7 
Day 
8 
Day 
9 
Day 
14 
Day  
19 
Annually 
X 2 years 
CBC,Diff, PLT 
 
 
 
 
 
 
 
 
 
 
 
 
X
X
X
X
X
X
X
X
X
X 
CMP 
X 
 
 
 
 
 
 
X 
X 
X 
 
X
X
X
X
Magnesium ++ 
 
 
 
 
 
 
 
 
 
 
 
 
 
X
X
X
X
X
X
EKG 
X 
 
 
 
 
 
 
 
 
 
 
 
 
CXR 
 
 
 
 
 
 
 
 
 
 
 
 
 
X
BM asp,bx 
cytogenetics 
 
 
 
 
 
 
 
 
 
 
 
 
X 
TREATMENT 
 
 
 
 
 
 
 
 
 
 
 
 
 
Course 1* 
 IL2 Induction 
 
 
 
 
 
X
X
X
X
X
 
 
 
 
 
 
 
REST 
 
 
 
 
 
 
 
 
 
 
 
 
 
X
X
X
X
Course 2** 
IL2 maintenance 
 
 
 
 
 
 
 
 
 
 
 
 
 
X
thru
X
Toxicity notation 
 
 
 
 
 
 
 
 
 
 
 
 
 
X
X
X
X
X
X
X
X
X
X
X
 
*IL-2 96 hr infusion 
** IL-2 maintenance 10 day infusion. 
 
 Revised 1/30/01 
Revised 11/7/01
 
 
40