Phase II Open-Label Trial of Tacrolimus/Methotrexate and Tocilizumab for the Prevention of Acute Graft-Versus-Host Disease After Allogeneic Hematopoietic Stem Cell Transplantation
Phase: PHASE2
Conditions: Hematopoietic Stem Cell Transplantation
Sponsor: William R. Drobyski, MD

 
Protocol and Statistical Analysis Plan 
 
Phase II Open-Label Trial of Tacrolimus/Methotrexate and Tocilizumab for the Prevention of Acute 
Graft-Versus-Host Disease After Allogeneic Hematopoietic Stem Cell Transplantation 
 
NCT02206035 
 
12 NOV 2015 
 

 
 
 
 
 
 
 
 
 
PHASE II OPEN LABEL TRIAL OF TACROLIMUS/METHOTREXATE AND 
TOCILIZUMAB FOR THE PREVENTION OF ACUTE GRAFT VERSUS HOST 
DISEASE AFTER ALLOGENEIC HEMATOPOIETIC STEM CELL 
TRANSPLANTATION 
 
 
Version 8.0 November 12, 2015 
 
Protocol Version Summary 
Original Protocol v. 1.0 June 2, 2014 
Amendment 1 Protocol v. 2.0 June 23, 2014 
Amendment 2 Protocol v. 2.1 July 25, 2014  
Amendment 3 Protocol v. 3.0 November 19, 2014 
Amendment 4 Protocol v. 4.0 January 27, 2015 
Amendment 5 Protocol v. 5.0 April 7, 2015 
Amendment 6 Protocol v. 6.0 May 7, 2015 
Amendment 7 Protocol v7.0 June 9, 2-15 
 
 
Co-Principal Investigators: William R. Drobyski1, MD, Marcelo C. Pasquini1, MD, MS 
 
 
Co-Investigators: 
 
Jennifer Le-Rademacher2, PhD 
Carolyn Keever-Taylor1, PhD 
Anita D’Souza1, MD 
Parameswaran Hari1, MD, MS 
Mehdi Hamadani1, MD    
Mary Eapen1, MD 
J. Douglas Rizzo1, MD, MS 
Wael Saber1, MD, MS 
Mary Horowitz1, MD, MS 
Jennifer Knight, MD 
 
 
 
1Division of Hematology Oncology, Department of Medicine, Medical College of Wisconsin 
2 Division of Biostatistics, Institute for Health and Society, Medical college of Wisconsin 
 
 
 

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Investigators: 
 
William R. Drobyski, MD 
Professor of Medicine 
Phone: 414-456 4941 
Email: wdrobysk@mcw.edu  
 
Marcelo C. Pasquini, MD, MS 
Associate Professor of Medicine 
Phone: 414-805-0700 
Email: mpasquini@mcw.edu 
 
Jennifer Le-Rademacher, PhD 
Assistant Professor of Biostatics 
Phone: 414-955-4849 
Email: jlerade@mcw.edu 
 
Carolyn Keever-Taylor, PhD 
Professor of Medicine 
Phone: 414-805-6145 
Email: ckeever@mcw.edu 
 
Anita D’Souza, MD 
Assistant Professor of Medicine 
Phone: 414-805-0700 
Email: anitadsouza@mcw.edu  
 
Parameswaran Hari, MD, MS 
Arman Quick – William Stapp Professor of 
Hematology 
Phone: 414-805-4600 
Email: phari@mcw.edu 
 
 
 
Mehdi Hamadani, MD 
Associate Professor of Medicine 
Phone: 414-805-0700 
Email: mhamadani@mcw.edu 
 
Mary Eapen, MD 
Professor of Medicine 
Phone: 414-805-0700 
Email: meapen@mcw.edu 
 
J. Douglas Rizzo, MD, MS 
Professor of Medicine 
Phone: 414-805-0700 
Email: drizzo@mcw.edu 
 
Wael Saber, MD, MS 
Assistant Professor of Medicine 
Phone: 414-805-0700 
Email: wsaber@mcw.edu 
 
Mary Horowitz, MD, MS 
Robert A. Uihlein, Jr. Chair in Hematology 
Research 
Professor of Medicine 
Phone: 414-805-0700 
Email: marymh@mcw.edu 
 
Jennifer Knight, MD 
Assistant Professor 
Phone: 414-955-8900 
Email: jmknight@mcw.edu 
 
 
 
 

Tac/Mtx/Toc for GVHD prophylaxis 
 
Protocol v8.0, Dated November 12, 2015 
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PROTOCOL SYNOPSIS 
 
Phase II Study of Tacrolimus Methotrexate and Tocilizumab for the Prevention of Acute 
Graft-versus-Host Disease after Allogeneic Hematopoietic Cell Transplantation 
 
 
Principal Investigator: 
 
William R. Drobyski, MD; Marcelo Pasquini, MD 
 
Study Design: 
This is a phase II open label trial designed to evaluate the 
efficacy of Tacrolimus, Methotrexate and Tocilizumab 
(Tac/MTX/Toc) in preventing graft versus host disease 
(GVHD) compared to a contemporary control from the 
CIBMTR.    
 
Primary Objective: 
The primary end point of the study is to compare grade II-
IV aGVHD-free survival at Day 180 between recipients of 
Tac/MTX/Toc to contemporary CIBMTR controls.  
 
Secondary Objectives:  
Compare, grades II-IV and III-IV aGVHD, chronic GVHD, 
neutrophil and platelet engraftment, transplant related 
mortality 
(TRM), 
disease 
relapse 
or 
progression, 
progression-free and overall survival. Phase 2 specific 
outcomes include incidence of grades ≥3 toxicities 
according to CTACAE v4, incidence of infections, and 
proportion of donor chimerism, immune reconstitution, and 
production of pro-inflammatory cytokines.  
 
Exploratory Objectives: 
Compare depressive symptoms, anxiety, fatigue, sleep, and 
pain 
among 
allogeneic 
HCT 
recipients 
receiving 
tocilizumab to a control group of allogeneic HCT recipients 
who did not receive prophylactic tocilizumab (UW control 
cohort). To describe gene expression and Rap1 prenylation 
among allogeneic HCT recipients receiving prophylactic 
tocilizumab. 
 
 
Eligibility:  
Eligible patients are 18 years and older undergoing HCT 
for treatment of acute leukemia in complete morphologic 
remission; 
chronic 
myelogenous 
leukemia, 
other 
myeloproliferative disorders and myelodysplasia with less 
than 5% blasts in bone marrow; and chemotherapy 
sensitive lymphoproliferative diseases. Patients must 
receive a busulfan-based conditioning regimen and have 
related or unrelated peripheral blood or bone marrow 
donor. Sibling donor must be a 6/6 match for HLA-A, B 
and DRB1 or unrelated donor must be a 8/8 match at HLA-

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A, -B, -C and DRB1. Patients are excluded if they have a 
history of intolerance or allergy to Tocilizumab; or if they 
received rituximab or other monoclonal antibodies as part 
of the conditioning regimen. Eligibility from the control 
cohort includes patients who received their first allogeneic 
transplant at a US center, for the same indications and 
conditioning regimens as listed above, from a HLA match 
related or unrelated donor with bone marrow or peripheral 
blood graft in the years of 2010 to 2013. Controls should 
also receive tacrolimus and methotrexate as the sole GVHD 
prophylaxis. Donor type of the controls will be matched to 
that of patients enrolled in the clinical trial. 
  
Treatment Description: 
Patients enrolled in the clinical trial will receive tacrolimus 
per standard of care at doses to maintain therapeutic levels 
and continued until at least Day 90 post-transplant. 
Methotrexate will be dosed at 15 mg/m2 Day +1 and 
10mg/m2 Days +3, +6 and +11.  Tocilizumab will be 
administered intravenously at a dose of 8 mg/kg at Day -1.   
. 
Accrual Objective: 
 
35 patients will be accrued to the clinical trial and at most 
200 CIBMTR controls will be included in the analysis. 
 
Accrual Period: 
 
The estimated accrual period is 2 years. 
 
Study Duration: 
Patients will be followed for 12 months following initiation 
of therapy. 
 
 
 

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TABLE OF CONTENTS 
1.0 BACKGROUND AND RATIONALE .......................................................................................................................... 1 
1.1 
Acute Graft versus Host Disease ................................................................................................................. 1 
1.2 
Interleukin 6 ................................................................................................................................................ 1 
1.3 
Tocilizumab ................................................................................................................................................. 2 
1.4 
IL-6 blockade in GVHD prophylaxis ............................................................................................................. 2 
1.5 
Rationale..................................................................................................................................................... 3 
2.0 
STUDY DESIGN ................................................................................................................................................. 3 
2.1 
Primary Objective ....................................................................................................................................... 3 
2.2 
Secondary Objectives .................................................................................................................................. 3 
2.3 
Exploratory Objectives ................................................................................................................................ 3 
2.4 
Patient Eligibility ......................................................................................................................................... 4 
2.5 
Donor Selection ........................................................................................................................................... 5 
2.6 
Treatment Plan ........................................................................................................................................... 5 
2.7 
Supportive Care .......................................................................................................................................... 8 
2.8 
Participant Risks ......................................................................................................................................... 9 
2.9 
Study Drug Information ............................................................................................................................ 11 
3.0 
STUDY ENDPOINTS ........................................................................................................................................ 13 
3.1 
Primary Endpoint ...................................................................................................................................... 13 
3.2 
Secondary Endpoints ................................................................................................................................ 13 
4.0 
PATIENT ENROLLMENT AND EVALUATIONS .................................................................................................. 17 
4.1 
Patient evaluation and enrollment ........................................................................................................... 17 
4.2 
Guideline for serious adverse event reporting .......................................................................................... 17 
4.3 
Study monitoring ...................................................................................................................................... 18 
5.0 
STATISTICAL ANALYSIS ................................................................................................................................... 22 
5.1 
Study Design ............................................................................................................................................. 22 
5.2 
Sample Size and Power Calculation .......................................................................................................... 23 
5.3 
Guidelines for Safety Monitoring .............................................................................................................. 23 
5.4 
Demographic and Baseline Characteristics .............................................................................................. 25 
5.5 
Analysis of the Primary Endpoint .............................................................................................................. 25 
5.6 
Analysis of Secondary endpoints .............................................................................................................. 25 
 
LIST OF APPENDICES  
 
APPENDIX A 
GVHD GRADING 
APPENDIX B  
LABORATORY PROCEDURES 
APPENDIX C  
ADVERSE EVENT REPORTING 
APPENDIX D  
REFERENCES 
APPENDIX E  
ANCILLARY STUDY 
 

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1.0 BACKGROUND AND RATIONALE 
1.1 
Acute Graft versus Host Disease 
 
Graft versus host disease (GVHD) is the major complication associated with allogeneic 
hematopoietic cell transplantation (HCT).  A prominent characteristic of GVHD is the presence 
of a proinflammatory milieu that is attributable to conditioning regimen-induced host tissue 
damage as well as secretion of inflammatory cytokines [e.g. interleukin-1 (IL-1), tumor necrosis 
alpha-α (TNF-α), interferon-γ (IFN-γ), interleukin-6 (IL-6)] by alloactivated donor T cells and 
other effector cell populations.1-3 These cytokines perpetuate GVHD through direct cytotoxic 
effects on host tissues,4-6 activation and/or priming of immune effector cells,7 and differentiation 
of proinflammatory T cell populations (i.e. TH1 and TH17 cells) from naïve T cell precursors.8,9  
This inflammatory environment is also promoted by the absence of an effective regulatory T cell 
(Treg) response as both a relative and an absolute decline of Tregs in the peripheral blood and 
target tissues has been demonstrated in a majority of studies.8,10-12 The strong association 
between a proinflammatory milieu and the absence of an effective counter regulatory response 
suggests that the inflammatory environment prevents and/or inhibits Treg reconstitution during 
GVHD.  How this occurs, however, is not well understood.  
 
Up to 30% of the recipients of HCT from HLA-match donors develop at least grade II aGVHD 
despite immunosuppressive prophylaxis.13 The occurrence of moderate (grade II) or severe 
(grade III or IV) aGVHD after HCT results in increased treatment related mortality (TRM), 
which precludes improvement in overall survival.14 T-cells in the graft play a key role in the 
pathogenesis of aGVHD.  During the past 20 years, a combination of a calcineurin inhibitor 
(tacrolimus or cyclosporine (CSA)) and methotrexate (MTX) has been standard therapy for 
prevention of GVHD. However, despite use of these agents, the incidence of grade II-IV GVHD 
is 35-50%15 The risk increases with unrelated or partially HLA-matched donors due to the 
greater genetic disparity between the donor and the host.  Furthermore, acute GVHD incidence 
and severity is augmented in older aged patients who increasingly comprise the majority of adult 
patients that need an allogeneic stem cell transplant for the treatment of their hematological 
malignancy.  Thus, new therapeutic treatment strategies are desperately needed for the 
prevention of acute GVHD.   
 
1.2 
 Interleukin 6 
 
IL-6 is a pleiotrophic cytokine that is produced by a variety of cell types, including T cells, B 
cells, fibroblasts, endothelial cells, monocytes and keratinocytes.16 IL-6 is of particular interest 
with respect to GVHD biology since it occupies a unique position at the crossroads where the 
fate of naïve T cells to become either regulatory cells or proinflammatory T cells is determined.  
In the presence of IL-6 and transforming growth factor-β (TGF-β), naïve T cells differentiate 
into TH17 cells, whereas in its absence these same cells are induced to become Tregs.117,18  
Furthermore, IL-6 produced by dendritic cells after activation through Toll-like receptors is able 
to inhibit the suppressive function of natural Tregs.19,20 Thus, IL-6 appears to have a pivotal role 
in directing the immune response towards an inflammatory phenotype and away from a 
regulatory response. The potential importance of IL-6 in GVHD is also supported by clinical 
studies that have shown that patients with elevated plasma levels of IL-6,21,22 as well as those 
with a recipient or donor IL-6 genotype that results in increased IL-6 production,23,24 have an 
increased incidence and severity of GVHD.   

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Signaling through IL-6 occurs by the binding to a low affinity IL-6 receptor (IL-6R) which 
together induces homodimerization of gp130 and subsequent transduction of the intracellular 
signal.25 This membrane-bound IL-6R, however, is expressed only on hepatocytes and 
hematopoietic cells.  Notably, the IL-6R can also be shed from the membrane generating a 
soluble form of the receptor which can complex with IL-6 and induce an intracellular response in 
cells that lack the membrane-bound IL-6R through a process called trans-signaling.26,27  
Interference with the actions of IL-6 by administration of an IL-6R antibody that prevents 
binding of the cytokine to its receptor has been shown to be effective in the treatment of a variety 
of inflammatory disease such as rheumatoid arthritis,28,29 amyloidosis,30 and colitis.31 
 
1.3 
Tocilizumab 
 
Tocilizumab (Actemra) is a humanized anti-IL-6 receptor antibody that blocks IL-6 signaling 
and has been FDA-approved for the treatment of severe active rheumatoid arthritis.  It has been 
shown to have remission-inducing efficacy in patients with moderate to severe rheumatoid 
arthritis, systemic juvenile idiopathic arthritis, and multicentric Castlemans’ disease.32,33  A pilot 
phase I/II study in patient with active Crohn’s disease also suggested benefit when administered 
on an every two week basis.34 Recent studies in a murine model of GVHD, has shown that 
treatment with an anti-IL-6R antibody is able to significantly reduce GVHD-associated mortality 
and pathological damage.35 One of the mechanisms by which this occurs is through the enhanced 
reconstitution of regulatory T cells that express the transcription factor foxp3.  Reconstitution of 
both natural and induced Tregs has been demonstrated in animals treated with this antibody, 
suggesting that the increase in overall numbers of Tregs is responsible, in part, for the 
attenuation in GVHD severity. A recent case report demonstrated that administration of 
Tocilizumab was effective at significantly reducing the severity of GVHD in the GI tract as 
determined by a marked reduction in the volume of diarrhea.36  Notably, this patient had failed 
multiple prior therapies, including high dose steroids, infliximab, budesonide, photopheresis, 
sirolimus, and mycophenolate mofetil.  Furthermore, Drobyski et al37 published a series of 
patients who received Tocilizumab for steroid refractory acute GVHD.  Responses were 
observed in four of six patients with severe acute GVHD that had failed to respond to first, and 
in most cases, second line therapies.  Collectively, these studies support the premise that 
Tocilizumab has activity in GVHD. 
 
1.4 
IL-6 blockade in GVHD prophylaxis 
 
Whether blockade of IL-6 signaling has efficacy in the prevention of GVHD has not been 
critically examined. In a preliminary unpublished report, Kennedy et al38 analyzed IL-6 levels 
during HCT and demonstrated that levels peaked at day 7 post transplant and only returning to 
pre-transplant level by day 30. This study demonstrated the same pattern of IL-6 levels in the 
related and unrelated HLA matched transplants, myeloablative regimens were associated with 
higher day 7 peaks of IL-6 in the serum compared to reduced intensity conditioning. Kennedy et 
al subsequently used an anti-IL-6 humanized monoclonal antibody with cyclosporine and 
methotrexate as GVHD prophylaxis in 48 recipients of HLA matched HCT. The mAb was 
administered as a single dose day -1 of transplant. The rates of grade II-IV and III-IV acute 

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GVHD were 11.1% and 5.6%, respectively. There were no reports of graft failure in this 
analysis.  
   
 
1.5 
Rationale 
 
The current clinical trial has the objective to compare the combination of tacrolimus, 
methotrexate and tocilizumab (Tac/MTX/Toc) as GVHD prophylaxis to a contemporary control. 
The study will build upon the experience from Kennedy et al, by further exploring IL-6 blockade 
in GVHD prevention.  
 
 
2.0   STUDY DESIGN 
 
This is a phase II open label trial designed to evaluate the efficacy of Tac/MTX/Toc in 
preventing graft versus host disease (GVHD).  Outcomes of patients on this clinical trial will be 
compared to those of contemporary controls from the CIBMTR.    
 
2.1 
 Primary Objective 
 
The primary objective of this study is to compare the probabilities of Grade II-IV acute GVHD-
free survival at Day 180 post-transplant between recipients of Tac/MTX/Toc and contemporary 
controls who received Tac/MTX based GVHD prophylaxis.  
 
2.2 
 Secondary Objectives 
 
Secondary objectives of the study are to compare grades II-IV and III-IV aGVHD, chronic 
GVHD, neutrophil and platelet engraftment, transplant related mortality (TRM), disease relapse 
or progression, progression-free and overall survival between Tac/MTX /Toc and Tac/MTX 
CIBMTR controls. Additionally, secondary objectives include description of incidence of grades 
≥3 toxicities according to CTACAE v4, incidence of infections, and proportion of donor 
chimerism, immune reconstitution, and production of pro-inflammatory cytokines among 
patients who receive Tac/MTX/Toc.  
 
2.3 
Exploratory Objectives 
 
The primary objective of this ancillary study is to compare levels of depressive symptoms, 
anxiety, fatigue, sleep, and pain between allogeneic HCT recipients who received prophylactic 
tocilizumab to a control group of allogeneic HCT recipients who did not receive tocilizumab 
(UW control cohort). Additionally, exploratory objectives include assessing gene expression and 
Rap1 prenylation levels.  
 
 
 
 
 

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2.4 
  Patient Eligibility 
 
2.4.1 Inclusion Criteria (Tocilizumab Arm) 
 
1. Age ≥18years 
2. Patients with acute leukemia, chronic myelogeneous leukemia, myeloproliferative disease 
and myelodysplasia with less than 5% of blasts in the bone marrow.  
3. Patients with chronic lymphocytic leukemia/small lymphocytic lymphoma, Non-Hodgkin 
Lymphoma or Hodgkin Disease with chemosensitive disease at time of transplant.  
4. Planned conditioning regimens including combination of busulfan and fludarabine or 
busulfan and cyclophosphamide. 
5. Transplantation with T-cell-replete grafts 
6. Bone marrow or mobilized peripheral blood cell grafts 
7. Patients must have either a sibling donor (6/6 match at HLA-A, B and DRB1) or a 
unrelated donor (8/8 match at HLA-A, -B, -C and -DRB1). 
8. Cardiac function: Ejection fraction at rest >45% for myeloablative conditioning or >40% 
for reduced intensity conditioning.  
9. Estimated creatinine clearance greater than 50 mL/minute (using the Cockcroft-Gault 
formula and actual body weight) 
10. Pulmonary function: DLCO ≥40% (adjusted for hemoglobin) and FEV1≥50%  
11. Liver function: total bilirubin < 1.5 x the upper limit of normal and ALT/AST < 2.5x the 
upper normal limit.  
12.  Signed informed consent. 
 
2.4.2 Exclusion criteria (Tocilizumab Arm) 
 
1. Prior allogeneic HCT 
2. Karnofsky Performance Score <70% 
3. Patients with uncontrolled bacterial, viral or fungal infections (currently taking 
medication and with progression of infectious disease or no clinical improvement) at time 
of enrollment.  
4. Prior intolerance or allergy to Tocilizumab 
5. Use of rituximab, alemtuzumab, ATG or other monoclonal antibody at time of 
conditioning regimen.  
6. History of diverticulitis, Crohn’s disease or ulcerative colitis 
7. History of demyelinating disorder 
8. Pregnant and lactating women 
9. Patients with a history of rheumatologic disorders who have previously received 
Tocilizumab 
 
 
2.4.3 Eligibility for the Control Arm 
 
Patients in the control arm will be identified from patients reported to the CIBMTR from U.S 
centers.  Control patients will be required to satisfy similar eligibility requirements as patients 

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being enrolled in the clinical trial.  Patients will need to fulfill the same inclusion criteria for the 
clinical trial according to Section 2.3.1, plus the following: 
 
1. Receive Tac/MTX as the sole GVHD prophylaxis approach 
2. Receive the same regimens as specified in Table 2.5 
3. Year of transplant from 2010 to 2013 
 
Exclusion criteria for the controls: 
1. Karnofsky Performance Score < 70% 
 
Data for all eligible patients will be used to constitute the control database for this study. 
 
 
2.5 
  Donor Selection 
 
Donor selection will be done according to the eligibility of this trial following the standard 
operating procedures from MCW BMT program.  
 
 
2.6 
Treatment Plan 
 
It is recommended that adjusted ideal body weight be used when calculating conditioning 
regimen chemotherapy doses. One exception is fludarabine, which uses actual body weight.  
 
Ideal Body Weight (IBW) will be calculated per institutional standards. 
 
 
2.6.1 Conditioning Regimens 
 
Eligible patients will receive either a myeloablative or reduced intensive conditioning according 
to the decision of the treating physician. Regimens allowed in this protocol are outlined in table 
2.5. 
 
TABLE 2.5: CONDITIONING REGIMENS1 
Reduced Intensity Conditioning 
Myeloablative Conditioning 
Fludarabine/Busulfan (Flu/Bu2) 
• Fludarabine (120-180 mg/m2) 
• Busulfan (≤  6.4 mg/kg IV) 
Fludarabine/Busulfana  (Flu/Bu) 
• Busulfan (12.8-16 mg/kg ) 
• Fludarabine (120-180 mg/m2) 
 
Busulfana/Cyclophosphamide (Bu/Cy) 
• Busulfan (12.8 -16 mg/kg ) 
• Cyclophosphamide (120 mg/kg) 
 a Bu = PO doses will be adjusted to maintain BU Css at 900±100 ng/ml. 

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2.6.1.1 Fludarabine and busulfan (Flu/Bu2) 
 
The recommended Flu/Bu regimen is the following:  
• Days -6 to -2: Flu (30 mg/m2/day, total dose of 150 mg/m2) 
• Days -5 to -4:  Busulfan (3.2mg/kg/day IV for 2 days, total dose of 6.4mg/kg, 
respectively) 
 
The sequence of fludarabine and busulfan administration in RIC regimens will be done 
according to MCW BMT standing operating procedures.  
 
 
2.6.1.2 Busulfan and fludarabine (Flu/Bu4) 
 
The recommended Bu/Flu regimen is the following: 
• Days -5 to -2: Busulfan (~3.2 mg/kg/day for 4 days with targeted Bu Css 900±100 
ng/mL) 
• Days -5 to -2: Flu (30 mg/m2/day, total dose of 120 mg/m2) 
 
Busulfan dosing for myeloablative doses will follow pharmacokinetics to target a concentration 
at steady state of 900±100 ng/mL. Busulfan will be administered every 6 hours and starting dose 
may range from 0.8mg/kg to 0.9mg/kg or according to the test dose pharmacokinetics if it is 
done.  
 
2.6.1.3 Busulfan and cyclophosphamide (Bu/Cy) 
 
The recommended Bu/Cy regimen is the following: 
• Days -7 to -4: Busulfan  (~3.2 mg/kg/day for 4 days with targeted Bu Css 900±100 
ng/mL) 
• Days -3 to -2: Cy (60 mg/kg/day, total dose of 120mg/kg). 
 
Busulfan dosing for myeloablative doses will follow pharmacokinetics to target a concentration 
at steady state of 900±100 ng/mL. Busulfan will be administered every 6 hours and starting dose 
may range from 0.8mg/kg to 0.9mg/kg or according to the test dose pharmacokinetics if it is 
done. 
 
2.6.2 Hematopoietic Cell Transplantation 
 
Bone marrow and mobilized peripheral blood progenitor cells are the graft sources in this study.  
 

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2.6.2.1 Peripheral Blood Progenitor Cells PBPC) Mobilization and Collection 
 
PBPC mobilization and collection will be done according to standard operating procedures from 
MCW BMT program.  It is recommended the following mobilization and collection: 
- 
Donors will receive G-CSF (filgrastim, Amgen) at a dose of ~10 mcg/kg/day 
subcutaneously for 5 consecutive days.  Daily dose will not exceed 1200 mcg/day, and 
volume per injection site will not exceed 2.0 mL.  G-CSF should be administered at 
approximately the same time each day.  The fifth dose will be given at least one hour 
prior to apheresis.   
- 
Apheresis will begin on Day 5 of G-CSF administration. The recommended method for 
apheresis is through a continuous-flow apheresis device and ideally bilateral peripheral 
venous access. Donors with insufficient peripheral access will undergo placement of a 
central venous catheter.   
 
Target CD34 cell doses are between 5-10 x 106 per kg recipient body weight.   
 
The transportation of the PBPC product from unrelated donors shall be done in accordance with 
NMDP Standards. 
 
2.6.2.2 Bone marrow collection 
 
Bone marrow donors should undergo harvest on Day 0.  Either general or regional (epidural, 
spinal) anesthesia may be used.  The bone marrow cell dose recommended is approximately 4 x 
108 nucleated cells per kg of recipient body weight.  This dose will be unattainable for many 
recipients because of donor and/or recipient factors, e.g., body size mismatches.  The volume of 
marrow shall not exceed 20 mL per kg donor weight.  The estimated cell dose and a planned 
donor marrow volume shall be agreed upon by the donor and transplant centers for unrelated 
donors and between the transplant physician and cell processing laboratory for related donors 
before initiation of the transplant conditioning regimen. 
 
Processing of bone marrow for reduction of volume, plasma, red blood cells, or fat, will be 
performed by the transplant center cell processing laboratory according to standard operating 
procedures from MCW BMT program. 
 
2.6.2.3 PBPC and Marrow Infusion 
 
PBPC or BM grafts will be infused through an appropriate central catheter, according to standard 
operating procedures from MCW BMT program at Day 0.  For recipients of related donor PBPC, 
whose donors require a third day of collection (Day +1), these cells will be infused separately 
from the Day –1 and Day 0 collections on Day +1.   
 
 
 
 
 
 

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2.6.3 Tacrolimus/Methotrexate/Tocilizumab 
 
Tacrolimus 
 
Tacrolimus will be given per standard operating procedures from MCW BMT program,. 
Subsequent dosing will be based on blood levels. The dose should be adjusted accordingly to 
maintain a suggested level of 5-15 ng/mL. The dose of tacrolimus may be switched to oral at a 
1:4 dose equivalence and rounded to the nearest 0.5 mg at the discretion of the treating 
physician. If patients are on medications which alter the metabolism of tacrolimus (e.g. azoles), 
the initial starting dose and subsequent doses should be altered as per institutional practices. 
Tacrolimus taper can be initiated at a minimum of 90 days post HSCT if there is no evidence of 
active GVHD. The rate of tapering will be done according institutional practices but patients 
should be off tacrolimus by Day 180 post HSCT if there is no evidence of active GVHD.  
 
Methotrexate 
 
Methotrexate will be administered, per institutional practices, at the doses of 15 mg/m2 IV bolus 
on Day +1, and 10 mg/m2 IV bolus on Days +3, +6 and +11 after hematopoietic stem cell 
infusion. Dose reduction of MTX due to worsening creatinine clearance after initiation of 
conditioning regimen, high serum levels or development of oral mucositis is allowed according 
to institutional practices.  
 
Tocilizumab 
 
Tocilizumab will be administered intravenously at a dose of 8 mg/kg (maximum dose of 800mg) 
once on the Day-1 approximately 24 hours prior to the estimated time of the hematopoietic stem 
cell infusion. The infusion will be administered over 60 minutes through a dedicated IV line and 
must not be administered by IV bolus.   
 
2.7 
Supportive Care 
 
All supportive care will be given according to standard operating procedures of the MCW BMT 
program.  
 
2.7.1 Growth Factors 
 
G-CSF or other growth factors will not be used preemptively in patients enrolled in this clinical 
trial. The use of growth factor for treatment of delayed engraftment is allowed according to 
physician preference. 
 
2.7.2 Prophylaxis Against Infections 
 
Patients will receive infection prophylaxis according to standard operating procedures of the 
MCW BMT program. Infection prophylaxis will include, but is not limited to, agents or 
strategies (e.g., PCR screening and preemptive therapy) to reduce the risk of bacterial, herpes 
simplex, CMV, HHV-6, EBV, Pneumocystis jiroveci, and fungal infections: 

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• Antifungal therapy: Prophylaxis with fluconazole or other antifungal agents can be given 
as per standard operating procedures of the MCW BMT program.  Fluconazole, 
voriconazole and other azoles are expected to increase serum tacrolimus levels, therefore, 
dosages of tacrolimus should be adjusted accordingly.   
• CMV: CMV monitoring through nucleic acid amplified testing (NAAT) will be done 
weekly starting Day 21 through Day 63 post-transplant and then at day 100, or at anytime 
if there is clinical suspicion. Any reactivation and/or CMV disease will be captured in 
this study.  
 
2.7.3 Intravenous Immune Globulin (IVIG) 
 
IVIG administration will be according to standard operating procedures of the MCW BMT 
program 
 
2.8 
Participant Risks 
 
2.7.1 Busulfan 
 
Busulfan side effects include: 
• Cardiovascular: Tachycardia (rapid heart rate), High blood pressure, Low blood pressure 
• Neurologic: Dizziness, Headache, Insomnia, Seizures 
• Gastrointestinal: Abdominal discomfort, Constipation, Diarrhea, Heartburn, Nausea and 
vomiting 
• Hematologic: Low blood counts 
• Endocrine and Metabolic: High magnesium and phosphorus levels in the blood, High 
sugar levels in the blood, Irregular or no menstrual cycles, 
• Miscellaneous: Fluid retention, Lack of appetite, Mouth sores, Running nose, Skin 
rashes, Cough, Hepatic Veno-occlusive disease (damage to the liver which can be life-
threatening), Infertility, Cataracts, Lung fibrosis (scarring) 
 
2.7.2 Fludarabine 
 
Fludarabine side effects include: 
• Neurologic:  Sensitivity to light, Numbness or tingling in your fingers or toes 
• Gastrointestinal: Nausea and vomiting, Diarrhea, Loss of appetite 
• Hematologic: Low white blood cell count and increased risk of infection, Low 
platelet count and increased risk of bleeding, Low red blood cell count and increased 
need for red cell transfusions 
• Endocrine and Metabolic: Fatigue 
• Miscellaneous: Trouble seeing or problems with your eyes, Lung failure or 
pneumonia (may be permanent), Shortness of breath, Confusion, Coma 
 
2.7.3 Cyclophosphamide 
 
Cyclophosphamide side effects include: 

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• Gastrointestinal: Diarrhea, Loss of appetite, Nausea, Vomiting 
• Hematologic: Low blood counts, Suppression of the immune system 
• Endocrine and Metabolic: Damage to male (testes) and female (ovaries) sex 
glands, Infertility, Irregular or no menstrual cycles 
• Miscellaneous: Fluid retention, Hair loss, Bleeding and/or irritation in the bladder, 
Inflammation of the heart muscle (heart failure), Shortness of breath, Allergic 
reaction, Lung fibrosis (scarring), Serious skin rashes 
 
2.7.4 Tacrolimus 
 
Tacrolimus side effects include:  
• Cardiovascular: hypertension 
• Neurologic: confusion, dizziness, insomnia, seizures, tremors, changes in how clearly one 
can think, headaches, trouble seeing or problems with your eyes (may be permanent) 
• Gastrointestinal: nausea, vomiting, stomach pain or feeling of indigestion, liver problems  
• Hematologic: microangiopathic hemolytic anemia, thrombocytopenia 
• Endocrine and metabolic: hypomagnesemia, hypokalemia, hypocalcemia, hyperlipidemia 
• Miscellaneous: unwanted hair growth,  renal insufficiency (reversible or permanent), 
infections and post-transplant lymphoproliferative disorders, swelling of the hands or feet 
with a burning sensation , numbness and tingling of the hands or feet, sensitivity to light, 
muscle cramps 
 
2.7.5 Methotrexate 
 
The reported adverse reactions associated with methotrexate use as GVHD prophylaxis include: 
• Neurologic: fever, dizziness, chills, undue fatigue, blurred vision, changes in how clearly 
one can think, headaches 
• Gastrointestinal: ulcerative stomatitis, nausea, vomiting, abdominal distress, diarrhea, 
loss of appetite 
• Hematologic:  leucopenia, anemia, thrombocytopenia and suppressed hematopoiesis 
(leading to infection) 
• Miscellaneous: abnormal liver blood tests, liver damage, kidney failure, mouth sores, 
greater risk of sunburn, allergic inflammation of the lung with fever, cough and feeling 
short of breath, hair loss, skin reactions (rash, itching), Redness of eyes and maybe 
itching but not serious (conjunctivitis) 
 
 
 
 
 
 
2.7.6 Tocilizumab 
 
Tocilizumab side effects include: 

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• Hematologic:  Decreased white blood cells with risk of infections, decreased platelets 
• Respiratory: upper respiratory tract infections, nasopharyngitis, bronchitis 
• Gastrointestinal: mouth ulceration, upper abdominal pain, gastritis, gastrointestinal 
perforations. 
• Hepatic: transaminases elevation 
• Neurologic: headache, dizziness 
• Cardiovascular: hypertension 
• Dermatologic: skin rash, increase in cholesterol 
• Miscellaneous: Hypersensitivity reactions and infusion reactions 
 
2.9 
Study Drug Information 
 
Study Agent: Actemra® (Tocilizumab) 
 
Classification: Immunomodulatory 
 
2.9.1 Clinical Pharmacology 
 
Tocilizumab is a recombinant humanized interleukin-6 receptor inhibiting monoclonal antibody. 
Tocilizumab binds to both soluble and membrane bound IL-6 receptors and results in the 
blockade of interleukin-6 signaling through these receptors. 
 
2.9.1.1 Pharmacokinetics 
 
Pharmacokinetic studies indicate that tocilizumab undergoes biphasic elimination from the 
circulation.  In rheumatoid arthritis patients treated with 4 and 8 mg/kg every 4 weeks, the 
central volume of distribution was 3.5 L and the peripheral volume of distribution was 2.9 L with 
a volume of distribution at steady state of 6.4 L.  Tocilizumab dosed at 8 mg/kg resulted in a 
mean steady state area under the curve (AUC), minimum concentration (Cmin) and a maximum 
concentration (Cmax) of 35 + 15 mg∙hr/ml, 9.74 + 10.5 mcg/ml and 183 + 85.6 mcg/ml 
respectively.  Tocilizumab AUC, Cmin and Cmax increased with increasing body weight with a 
86% higher exposure in patients greater than 100 kg.  As a result, doses exceeding 800 mg (max 
dosing weight 100 kg) per infusion are not recommended. 
 
The total clearance of Tocilizumab is concentration-dependent and is represented by the both the 
linear clearance and the nonlinear clearance.  Upon saturation of the non-linear clearance 
pathway, the main determining factor is linear clearance.  The reported linear clearance in the 
pharmacokinetic studies is estimated to be 12.5 mL/h.  The concentration dependent half-life is 
up to 11 days for the 4 mg/kg dose and up to 13 days for the 8 mg/kg dose every 4 weeks at 
steady state. 

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2.9.2  Special Populations 
 
Pharmacokinetic analysis in adult rheumatoid arthritis patients did not demonstrate a change in 
kinetics based on age, gender or race. The effects of renal and hepatic impairment have not been 
assessed.  
 
2.9.3 Drug Supply and Storage 
 
Tocilizumab is commercially available, but will be paid for by the study. Single use vials 
containing Tocilizumab, preservative free, sterile concentrate solutions (20 mg/ml) for IV 
infusion are available in the following sizes:  80 mg, 200mg, and 400 mg. The solution is 
colorless to pale yellow, with a pH of approximately 6.5. 
 
Vials should be stored under refrigeration at 2°C to 8°C (36°F to 46°F).  Do not freeze.  Protect 
the vials from light by storage in the original package until time of use.  Inspect vials visually for 
particulates and discoloration prior to use and discard if particulates or discoloration is noted. 
 
2.9.4 Preparation 
 
Using aseptic technique, utilize a 100 ml bag of 0.9% sodium chloride injection USP and 
withdraw a volume equal to the volume of the tocilizumab solution required for the dose.  Next, 
withdraw the calculated volume of tocilizumab solution necessary for the dose from the vials and 
slowly inject the tocilizumab to the infusion bag.  The final solution volume should be 100ml.  
Gently invert the IV bag to mix the solution.  Inspect the prepared IV solution for particulates. 
 
2.9.5 Storage of prepared IV solution 
 
The solution may be stored under refrigeration or at room temperature for up to 24 hours and 
should be protected from light. 
 
 
2.9.6 Warning and Precautions 
 
2.9.6.1 Serious Infections 
 
The product information labeling contains a black box warning regarding the risk of serious 
infection. Most patients who developed these infections were taking concomitant 
immunosuppressants such as Methotrexate or corticosteroids.  Serious infections leading to 
hospitalization or death, including tuberculosis, bacterial, invasive fungal, viral and other 
opportunistic infections have occurred in patients receiving tocilizumab. Viral reactivation and 
cases of herpes zoster exacerbation were reported in clinical trials.   It is recommended that 
patients are tested for latent tuberculosis before and during use of tocilizumab.  If a serious 
infection develops, Tocilizumab should be withheld until the infection is controlled. 
 

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2.9.6.2 Gastrointestinal perforations 
 
Events of GI perforation have been reported in clinical trials, primarily as complications of 
diverticulitis.  Patients presenting with new onset abdominal symptoms should be evaluated 
promptly. 
 
2.9.6.3 Laboratory Parameters 
 
Neutropenia, decreases in platelets, transaminase elevations, and increases in lipid parameters 
(total cholesterol, LDL and triglycerides) have been reported in relation to the use of 
tocilizumab. 
 
2.9.6.4 Drug Interactions 
 
Elevated levels of IL-6 and other cytokines have been associated with reduced expression of 
some cytochrome (CYP) P450 enzymes.  Tocilizumab, through IL-6 inhibition, has the potential 
to affect expression of multiple CYP enzymes by restoring their activity to a higher level than 
that in the absence of tocilizumab.  Monitoring of drugs that are metabolized by CYP’s with 
narrow therapeutic index or where the dose is individually adjusted is advised.  Caution should 
be exercised when tocilizumab is coadministered with CYP3A4 substrate drugs where decrease 
in effectiveness is undesirable, e.g., oral contraceptives, atorvastatin etc.  The effect of 
tocilizumab on CYP450 enzymes may occur within approximately 2 weeks of starting therapy 
and persist for several weeks after stopping therapy.  A list of CYP drug interactions can be 
found at this site http://medicine.iupui.edu/clinpharm/ddis/ 
 
3.0 STUDY ENDPOINTS 
 
3.1 
Primary Endpoint 
 
The primary endpoint of this phase II clinical trial is to compare the probabilities of grade II-IV 
acute GVHD-free survival at Day 180 post-transplant between recipients of Tac/MTX/Toc and 
CIBMTR controls who received Tac/MTX alone. Development of grade II-IV acute GVHD or 
death is considered event for this composite endpoint. Patients who are alive without ever 
experiencing grade II-IV acute GVHD will be censored at the last follow-up.   
 
3.2 
Secondary Endpoints 
 
3.2.1 Acute GVHD 
 
Cumulative incidences of grade II-IV and III-IV acute GVHD will be determined.  Acute GVHD 
will be graded according to the Appendix A.  The time of onset of acute grades II-IV and III-IV 
acute GVHD will be recorded, as well as the maximum grade achieved.  This endpoint will be 
evaluated through 180 days post HSCT. Rates of grade II-IV and III-IV will be compared to the 
CIBMTR controls. Within the acute GVHD endpoint, the proportion of patients with visceral 
involvement (liver or gut) will be described.  
 

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3.2.2 Chronic GVHD 
The cumulative incidence of chronic GVHD will be determined.  Assessment of chronic GVHD 
will occur up to one year post HSCT. Rates of chronic GVHD will be compared to the CIBMTR 
controls 
 
3.2.3 Hematologic Recovery  
Hematologic recovery will be assessed according to neutrophil and platelet counts recovery after 
HSCT. Neutrophil recovery is defined as achieving an absolute neutrophil count (ANC)  
≥ 500/mm3 for three consecutive measurements on three different days.  The first of the three 
days will be designated the day of neutrophil recovery.  The competing event is death without 
neutrophil recovery.   
 
Platelet recovery is defined by two different metrics: the first day of a sustained platelet count 
>20,000/mm3 or >50,000/mm3 with no platelet transfusion in the preceding seven days.  The first 
day of sustained platelet count above these thresholds will be designated the day of platelet 
engraftment. 
 
Cumulative incidence of hematologic recovery will be compared with CIBMTR controls.   
 
3.2.4 Transplant Related Mortality 
 
The cumulative incidence of TRM will be estimated at Days 100, 180, and 1 year after HSCT.  
An event for this endpoint is death without evidence of disease progression or recurrence. 
Disease progression or recurrence will be considered competing event. Cumulative incidence of 
TRM will be compared with CIBMTR controls.   
 
3.2.5 Disease Relapse or Progression 
 
Relapse is defined by either morphological or cytogenetic evidence of acute leukemia or MDS 
consistent with pretransplant features, or radiologic evidence of lymphoma, documented or not 
by biopsy.  Progression of disease applies to patients with lymphoproliferative diseases 
(lymphoma or chronic lymphocytic leukemia) not in remission prior to transplantation.  The 
event is defined as increase in size of prior sites of disease or evidence of new sites of disease, 
documented or not by biopsy.  
 
Acute leukemia and MDS – Relapse will be diagnosed when there is: 
- 
Reappearance of leukemia blast cells in the peripheral blood; or, 
- 
>5% blasts in the bone marrow, not attributable to another cause (e.g. bone marrow 
regeneration) 
- 
The appearance of previous or new dysplastic changes (MDS specific) within the bone 
marrow with or without falling donor chimerism; or  
- 
The development of extramedullary leukemia or leukemic cells in the cerebral spinal 
fluid or 
- 
The reappearance of cytogenetic abnormalities present prior to transplantation 

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Lymphoproliferative Diseases – Relapse or progression will be diagnosed when there is: 
- 
Appearance of any new lesion more than 1.5 cm in any axis during or at the end of 
therapy, even if other lesions are decreasing in size.  Increased FDG uptake in a 
previously unaffected site will only be considered relapsed or progressive disease after 
confirmation with other modalities. In patients with no prior history of pulmonary 
lymphoma, new lung nodules identified by CT are mostly benign.  Thus, a therapeutic 
decision should not be made solely on the basis of the PET without histologic 
confirmation. 
- 
At least a 50% increase from nadir in the sum of the product diameters of any previously 
involved nodes, or in a single involved node, or the size of other lesions (e.g., splenic or 
hepatic nodules).  To be considered progressive disease, a lymph node with a diameter of 
the short axis of less than 1.0 cm must increase by ≥ 50% and to a size of 1.5 x 1.5 cm or 
more than 1.5 cm in the long axis.  
 
Lesions should be PET positive if observed in a typical FDG-avid lymphoma or the 
lesion was PET positive before therapy unless the lesion is too small to be detected with 
current PET systems (<1.5 cm in its long axis by CT). 
 
- 
In addition to the criteria above, patients with CLL who present in complete remission 
prior to transplantation may fulfill the relapse definition if there is reappearance of 
circulating malignant cells that are phenotypically characteristic of CLL.  
 
Institution of any therapy to treat persistent, progressive or relapsed disease, including the 
withdrawal of immunosuppressive therapy or donor lymphocyte infusion, will be 
considered evidence of relapse/progression regardless of whether the criteria described 
above were met.  
 
Rates of disease progression or relapse will be compared to CIBMTR controls.  
 
3.2.6 Disease Free Survival 
 
The event for this endpoint is relapse/progression or death.  The time to this event is measured 
from transplant to death or relapse/progression, whichever comes first.  Patients who are alive 
and disease free will be censored at the last follow-up. Disease-free survival will be compared 
with CIBMTR controls. 
 
3.2.7 Overall Survival 
 
The event for this endpoint is death from any cause.  The time to this event is measured from the 
time of transplant to death from any cause or for surviving patients, to last follow-up.  Overall 
survival rates among recipients of Tac/MTX/Toc will be compared to CIBMTR controls.  
 
 
 
 

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3.2.8 Incidence of Infections 
 
The incidence of definite and probable viral, fungal and bacterial infections will be tabulated for 
recipients of Tac/Mtx/Toc.  The cumulative incidence of CMV reactivation by nucleic acid 
amplification test (NAAT) in the first 100 days post HSCT will be described.  All Grade 2 and 3 
infections will be reported.  
 
3.2.9 Toxicities 
 
All grades ≥ 3 toxicities according to CTCAE, version 4 will be tabulated for recipients of 
Tac/Mtx/Toc.  The proportion of patients developing grade ≥ 3 AE will be reported.  
 
 
3.2.10 Donor cell Chimerism 
 
Chimerism will be evaluated using sorted whole blood in CD3 and CD33 fractions.  For the 
purpose of this protocol, mixed chimerism is defined as the presence of donor cells, as a 
proportion of total cells to be < 95% but > 5% in the bone marrow or peripheral blood.  Full 
donor chimerism is defined as ≥ 95% of donor cells. Mixed and full chimerism will be evidence 
of donor cell engraftment.  Donor cells of ≤ 5% will be considered as graft rejection.  The 
proportion of patients with each level of chimerism described above will be described as part of 
this outcome for recipients of Tac/Mtx/Toc.  For sorted blood cell fractions, CD3+ donor cell 
chimerism will be used to define the donor/recipient chimerism status.  
 
3.2.11 Immune Reconstitution 
 
Quantitative assessments of peripheral blood CD3, CD4, CD8, CD19 and CD56 positive 
lymphocytes will be done through flow cytometric analysis at Days 28, 100,180 and 365 after 
transplant. Results will be tabulated according to time from transplant. Detailed immune 
reconstitution assessments are outlined in appendix C. Approximately 30 mL in green top tubes 
(sodium heparin) will be drawn for each assessment.  Study team will notify Dr. Carolyn 
Taylor’s lab prior to study draws. 
 
3.2.12 Levels of Pro-inflammatory Cytokines  
 
Serum will be analyzed for IL-4, IL-6, IL-10, IL-13, IL-17, interferon-gamma, and tumor 
necrosis alpha using a Bio-Plex Human Cytokine Assay Kit (Bio-Rad) at baseline, days +7, +14, 
and +28.  Soluble IL-6 receptor levels will also be assessed at the same time points using an 
ELISA assay. Results will be tabulated according to time from transplant. Approximately 10 mL 
in red top tubes will be drawn for each assessment.  Study team will notify Dr. Carolyn Taylor’s 
lab prior to study draws. 
 
 
 
 

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4.0 PATIENT ENROLLMENT AND EVALUATIONS 
 
4.1 
Patient evaluation and enrollment 
Patients will be approached for this study after the decision to proceed with transplant is made 
and a suitable HLA-matched donor is identified. Transplant physicians will evaluate the patient 
eligibility onto this study. Eligible patients willing to participate in the trial will sign a MCW 
Institutional Review Board approved informed consent form. A Clinical Trials Office clinical 
research coordinator will record the documentation of patient consent and proceed with 
registration procedures.  
All source documents that support eligibility including a signed informed consent/HIPAA and 
signed eligibility checklist, will be available, reviewed and eligibility verified.  
At the point of registration, a member of the study team will register the patient in the electronic 
database, including demographics, consent and on-study information. The patient will be 
assigned a unique sequence number for the study. One of the co-Principal Investigators of the 
study, Drs. Drobyski or Pasquini, will be notified prior to enrollment.  Pharmacy will be notified 
upon patient registration. 
 
4.2 
Guideline for serious adverse event reporting 
 
Please refer to Appendix C for more details on adverse event reporting. 
 
4.2.1 Monitoring the Progress of Trial and the Safety of Participants 
  
This Phase II clinical trial will be monitored by the principal investigators (PI), William R 
Drobyski MD and Marcelo C. Pasquini, MD, MS.  The PIs will review the outcome of the data 
for each individual patient on an ongoing basis. The PIs of the study will have primary 
responsibility for ensuring that the protocol is conducted as approved by the Institutional Review 
Board. The PIs will ensure that the monitoring plan is followed and that all data required for 
oversight of monitoring are accurately reported, that all AEs are reported according to the 
protocol guidelines, and that any AEs reflecting patient safety concerns are appropriately 
reported.  
 
4.2.2 Reporting of Adverse Events 
  
The capture of toxicities and AEs in this protocol will follow the same approach and will be done 
in two levels. First, grades 3-5 AEs will be collected at different time points during the study 
period. Any AE that fulfills this criteria will be capture and the frequency of each organ toxicity 
tabulated. The DSMC and IRB will receive a summary of all the AEs captured in a log form on a 
quarterly to biennial basis depending the schedule of protocol review meetings. Additionally the 
PIs will review the frequency of toxicities in a quarterly basis.  
 
Second, any AE that is unexpected and of grades 3 to 5 will required expedited report to the 
oversight committees (MCW IRB, MCW DSMC and FDA – if applicable for studies under 
IND). The collection grades 3-5 unexpected AEs is event driven and require a more 
comprehensive description of the event. The report for these AEs are termed Individual Case 
Safety Reports (ICSR) and include the following components: 1 summary cover sheet of the 

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event, 2 narrative of the event, 3 associated conditions, medications and diagnostic information, 
source documents with further explanation of the even and an evaluation of the event by one of 
the PIs. The PIs will review all these events and will determine if they require expedited 
reporting. If they are considered grades 3-5 and unexpected the report will be sent to the 
oversight committees within three days from acknowledgement of the event. If the event is not 
considered to fulfill criteria of grades 3-5 unexpected AE, it will be included in the DSMC and 
IRB reports for scheduled protocol reviews and will not require expedited reporting.  
 
Reporting timelines: 
1. Fatal  (grade 5) or Life Threatening events must be reported within 24 hours but not 
later than 3 calendar day of the investigator’s observation or awareness of the event.  
2. All other events grades 3-4 unexpected events (non-fatal/non life-threatening) must be 
reported within 3 to 5 calendar days of the investigator’s observation or awareness of the 
event. 
 
 
This study will be reviewed by the Medical College of Wisconsin Cancer Center Data Safety 
Monitoring Committee (MCW CC DSMC). A summary of the MCW CC DSMC activities are as 
follows: 
 
• Review the clinical trials for data integrity and safety 
• Review all adverse events requiring expedited reporting as defined per protocol 
• Review all DSM reports 
• Submit a summary of any recommendations related to study conduct 
• Terminate the study if deemed unsafe for patients 
 
A copy of the MCW CC Data and Safety Monitoring Plan and membership roster will be 
maintained in the study research file and updated as membership changes. The committee will 
review reports from the study PI twice annually (or more frequently if needed) and provide 
recommendations on trial continuation, suspension or termination as necessary. Any available 
DSMC letters will be submitted to the IRB of record as required. 
 
4.3 
Study monitoring 
The follow-up schedule for scheduled study visits is outlined in Table 4.3a.  
 

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TABLE 4.3a: STUDY VISIT SCHEDULE 
 
Study Visit 
Target Day Post-Transplant* 
Baseline 
≤ 42 days from conditioning 
1 week  
7 ± 6 days 
2 week  
14 ± 6 days 
3 week 
21 ± 6 days 
4 week 
28 ± 6 days 
5 week 
35 ± 6 days 
6 week 
42 ± 6 days 
7 week 
49 ± 6 days 
8 week 
56 ± 6 days 
9 week 
63 ± 6 days 
100 day 
100 ± 10 days 
4 month 
120 ± 10 days 
5 month 
150 ± 10 days 
6 month 
180 ± 14 days 
9 month 
270 ±14 days 
12 month 
365 ± 14 days 
*Research samples (Proinflammatory Cytokines, Immune reconstitution and ancillary samples) will be collected as 
close to the target day ± the window as possible, however, due to the research labs availability to run samples some 
samples may be drawn outside the above specified window. A note to file will document when this situation occurs. 
 
4.3.1 Patient Assessments 
 
Table 4.3b summarizes patient clinical assessments over the course of the study.  

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TABLE 4.6b: PATIENT CLINICAL ASSESSMENTS 
Study Assessments/  
Testing 
Baseline 
-6 
7 
14 
21 
28 
35  
42 
49 
56 
63 
100 
120 
150 
180 
270 
365 
History, physical exam, weight and height* 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Karnofsky performance status and HCT-CI* 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
HLA typing (donor and recipient) * 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
(CBC1, differential1, platelet count1, and CMP2)* 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
X 
X 
X 
Estimated creatinine clearance3* 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Infectious disease titers4* 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EKG* and LVEF* 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DLCO* and FEV1 * 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
X 
Disease evaluation5* 
X 
 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
 
X 
Chest x-ray or chest/abdomen/pelvis CT* 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pregnancy test6* 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
GVHD assessments7* 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Toxicity assessments8 
 
X 
 
 
 
X 
 
 
 
X 
 
X 
 
 
X 
X 
X 
Chimerism9* 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
X 
 
X 
CMV NAAT peripheral blood* 
 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
 
 
Immune reconstitution11 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
X 
 
X 
Proinflammatory Cytokines10, 11 
X 
 
X 
X 
 
X 
 
 
 
 
 
 
 
 
 
 
 
Ancillary Protocol Research (see appendix E) 11 
X 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
X 
 
 
*Indicate evaluations are currently performed as standard of care at the FMLH/MCW BMT program.  1CBC performed three times weekly from Day 0 until 
ANC > 500/mcL for three days and platelet count > 20,000/mcL after nadir, while hospitalized.  CBC then performed weekly through Day 63 post-transplant and every 
other week through Day 100 post-transplant, then at Days 180, 270 and 365 post-transplant. 2Blood chemistries include: serum creatinine, bilirubin, alkaline 
phosphatase, AST and ALT. Blood chemistries performed twice weekly until hospital discharge.  Blood chemistries performed weekly after hospital discharge until Day 
63 post-transplant, then every other week through Day 100 post-transplant, and then at Days 180, 270 and 365 post-transplant. 3Estimated creatinine clearance is 
calculated using the Cockcroft-Gault formula and actual body weight. 4Infectious disease titers include: CMV, Hepatitis panel (HepA Ab, HepB SAb, HepB SAg, HepB 
Core Ab, HepC Ab), herpes simplex virus, syphilis, HIV and HTLV I/II antibody, and varicella zoster. 5Evaluation of the malignant disease: For acute leukemia, CML 
and MDS this includes a bone marrow aspirate and biopsy. For lymphomas this includes imaging studies, which will be done according to institutional practices, or the 
same as prior to transplant, for matter of comparison.  6Pregnancy test must be performed < 30 days before the start of the transplant conditioning regimen. Pregnancy 
test is required for females of child-bearing potential, urine or blood assays are allowed per institutional standards. 7GVHD assessments performed weekly until Day 63 
post-transplant, and then at Days 100, 120, 150, 180, 270, and 365.  The GVHD assessment will include a review of all abnormalities experienced during the entire 
assessment period and the highest grade for each abnormality (whether attributed to GVHD or not) during the assessment period will be recorded on the Acute GVHD 
form and/or the Follow-up GVHD form 8The toxicity assessment will include a review of all toxicities experienced during the entire assessment period and the 
highest grade for each toxicity during the assessment period will be recorded on the Toxicity forms. 9Chimerism in whole blood fractionated as CD3 and CD33. 10 
Cytokine assessments include IL-4, IL-6, IL-10, IL-13, IL-17, interferon-gamma, tumor necrosis factor and soluble IL-6 receptor. 11Research samples will  not be 
collected for patients who have disease relapse, and receive further chemotherapy.

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Pre-transplant evaluations must be completed < 84 days prior to patient enrollment.  
• LVEF (may be performed < 84 days prior to patient enrollment). 
• Pulmonary function tests, including DLCO and FEV1 (may be performed < 84 days prior 
to patient enrollment). 
 
Pre-transplant evaluations must be completed < 42 days prior to patient enrollment.  
 
• 
History, physical examination and weight. 
• Karnofsky performance status and HCT-Specific Comorbidity Index score. 
• CBC with differential and platelet count, serum creatinine, bilirubin, alkaline 
phosphatase, AST and ALT. 
• Estimated creatinine clearance, using the Cockcroft-Gault formula and actual body 
weight. 
• Infectious disease titers to include: CMV antibody, Hepatitis panel (HepA Ab, HepB 
SAb, HepB SAg, HepB Core Ab, HepC Ab), herpes simplex virus, syphilis, HIV and 
HTLV I/II antibody, and varicella zoster. 
• Disease evaluation of the malignant disease: For acute leukemia, CML and MDS this 
includes a bone marrow aspirate and biopsy for pathology and cytogenetics. For 
lymphomas this includes imaging studies, which will be done according to institutional 
practices for matter of comparison post-transplant.  
• Chest X-ray or chest CT. 
• Pre-transplant donor and recipient samples for post-transplant chimerism studies. 
 
Pre-transplant evaluations performed < 30 days before initiation of the transplant 
conditioning regimen. 
• Pre-transplant Proinflammatory cytokine panel  
• Pregnancy test for females of child-bearing potential  
• Assessment for toxicities  
 
Post-transplant evaluations 
 
The following observations will be made according to Table 4.6b: 
• History and physical exam (per institutional standards) 
• Assess GVHD weekly through Day 63 post-transplant, then at Days 100, 120, 150, 180, 
270 and 365 post-transplant.  
• Assessment for toxicities at Days 28, 56, 100, 180, 270 and 365 post-transplant. 

Tac/Mtx/Toc for GVHD prophylaxis 
 
Protocol v8.0, Dated November 12, 2015 
22 
 
• CBC with differential at least three times a week from Day 0 until ANC > 500/μL for 3 
days and platelet count > 20,000/μL for 3 days (while hospitalized only) after nadir is 
reached.    Thereafter, CBC with differential weekly until Day 63 post-transplant, then 
every other week through Day 100 post-transplant, and then at Days 180, 270 and 365 
post-transplant.  
• Serum creatinine, bilirubin, alkaline phosphatase, ALT and AST, twice a week until 
hospital discharge and then weekly until Day 63 post-transplant, then every other week 
through Day 100 post-transplant, and then at Days 180, 270 and 365 post-transplant. 
• Chimerism studies will be performed at Days 28 (+/- 6 days), 100 (+/- 14 days), 180 (+/- 
14 days), and 365 (+/- 14 days) post-transplant. Chimerism will be evaluated in whole 
blood in fractions including CD3 and CD33.  
• Disease evaluation of the malignant disease at Days 100 (+/- 10 days), 180 (+/- 14 days) 
and 365 (+/- 14 days) post-transplant: For acute leukemia, CML and MDS this includes a 
bone marrow aspirate and biopsy for pathology and cytogenetics. For lymphomas this 
includes imaging studies, which will be done according to institutional practices and the 
same as prior to transplant, for matter of comparison. 
• Pulmonary function tests, including DLCO and FEV1 at Days 180 and 365 (+/- 14 days) 
post-transplant. 
• Immune reconstitution panel will be collected at approximately days 28, 100, 180 and 
365.  
• Proinflammatory cytokine panel will be collected on approximately days 7, 14, and 28.  
 
 
5.0 STATISTICAL ANALYSIS 
 
5.1 
Study Design 
 
The study is designed as a Phase II, open label, single center trial to compare a novel GVHD 
prophylaxis regimen, Tac/MTX/Toc with standard Tac/MTX regimens in recipients of 
allogeneic transplant for malignant diseases. The primary endpoint of grades II-IV acute GVHD 
free survival probabilities at Day 180 post-transplant will be compared to a non-randomized 
contemporary Tac/MTX control group collected through the CIBMTR.  The control group of 
patients will satisfy similar eligibility requirements as the patients enrolled in the clinical trial 
and their donor type will be matched to patients enrolled in the phase II trial.   
 
5.1.1 Accrual 
 
It is estimated that 24 months of accrual will be necessary to enroll the targeted sample size.  
Accrual will be reported by race, ethnicity, gender, and age. 
 
5.1.2 Primary Endpoint 
 
The primary endpoint is Day 180 Grade II-IV acute GVHD-free survival (GFS). All patients will 
be followed for the primary endpoint for at least 6 months.  

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Protocol v8.0, Dated November 12, 2015 
23 
 
 
5.2 
Sample Size and Power Calculation 
 
Sample size and power considerations are based on the comparison of the Tac/MTX/Toc arm to 
the CIBMTR controls. We plan to accrue 35 patients to this phase II trial.  We plan to identify 
approximately four controls (35 X 4 = 140) for each patient enrolled in the trial, matched by 
donor type and limit the number of patients in the control group to 200.  The probability of grade 
II-IV aGVHD-free survival at Day 180 with standard Tac/MTX regimen in this patient 
population is expected to be 40%.  The intervention being studied will be considered promising 
if the survival probability increases by 20%.  The test hypothesis being considered in this study 
is H0: p ≤ .40 vs. H1: p ≥ 0.60.  Table 5.2.1 shows the probability of concluding Tac/MTX/Toc 
regimen is promising (the power) when the true Day 180 aGVHD-free survival probability with 
Tac/MTX/Toc regimen is 60% with a total sample size ranging from 175 to 235 using a one-
sided Type I error of 0.10.    
 
Table 5.2.1 Power to detect a 20% improvement in Day 180 Grade II-IV aGVHD-free survival 
Control group sample 
size 
Total sample 
size 
Power 
140 
175 
0.80 
200 
235 
0.82 
 
With 35 patients enrolled in the trial and 140 controls, there is 80% power to detect an 
improvement of 20% in Day 180 aGVHD-free survival and with 200 controls, there is 82% 
power. 
 
5.3 
Guidelines for Safety Monitoring 
 
Monitoring of a key safety endpoint will be conducted on an ongoing basis, and if rates 
significantly exceed pre-set thresholds, the trial may be paused for further review.  The following 
guidelines serve as trigger for additional review and are not formal “stopping rules” that would 
mandate automatic closure of study enrollment. 
 
The key safety endpoint for this study is graft failure at Day 60 post-transplant.  Graft failure will 
be monitored up to 60 days post-transplant.  For this safety endpoint, graft failure is defined as 
lack of engraftment in patients who are alive and disease-free 60 days post-transplant.   
 
The expected graft failure rate at Day 60 is 5%, graft failure rate significantly higher than 5% is 
considered unacceptable.  .  A truncated Sequential Probability Ratio Test (SPRT) based on a 
binomial test of proportions for graft failure will be used as described below.  This sequential 
testing procedure conserves type I error across all of the monitoring looks for graft failure.  The 
SPRT can be represented graphically.  At each interim analysis, the number of patients enrolled 
in the clinical trial is plotted against the number of patients who have experienced graft failure.  
The continuation region of the SPRT is defined by two parallel lines.  Only the upper boundary 
will be used for monitoring to protect against excessive graft failure.  If the graph falls above the 
upper boundary, the SPRT rejects the null hypothesis, and concludes that there are more graft 
failures than predicted by the number of recipients evaluable.  Otherwise, the SPRT continues 
until enrollment reaches the target goal. 

Tac/Mtx/Toc for GVHD prophylaxis 
 
Protocol v8.0, Dated November 12, 2015 
24 
 
 
The usual measures of performance of an SPRT are the error probabilities α and β of rejecting 
H0 when θ = θ0 and of accepting H1 when θ = θ1, respectively, and the expected sample size 
E(N|θi).  Note that since the test uses only the upper boundary, and is truncated by a finite 
sample size, the size of the test will be slightly lower than the nominal level.  The test to be used 
in this protocol was developed from the following SPRT:   
 
• An SPRT contrasting 5% versus 20% graft failure, with nominal type I and II errors of 
7% and 22%, respectively.   
• The slope of the parallel lines for monitoring graft failure is 0.110 and the intercepts 
are –0.925 and 1.547. 
 
The stopping rule is summarized in Table 5.3.1   
 
Table 5.3.1 Stopping guidelines for graft failure at Day 60 among patients enrolled in trial 
 
* Stopping guideline is triggered if ≥ x recipients out of n experience graft failure 
 
    The actual operating characteristics of the truncated test, shown in Table 5.3.2, were 
determined in a simulation study.  The simulation assumed uniform accrual of 35 patients over a 
24-month period.  Graft failure will be monitored in all patients in the Tac/MTX/Toc arm.  The 
SPRT rejects the null hypothesis in favor of the alternative 5% of the time when the true Day 60 
graft failure is 5%, and 84% of the time when the true Day-60 graft failure is 20%.  This 
corresponds to a type I error rate of α = 0.05 and a type II error rate of β = 0.16.  When the true 
Day 60 graft failure rate is 20%, on average, the guideline will be triggered 13.3 months after 
opening, when 3.4 events have been observed in 17 patients.  Note that the SPRT procedure is 
adequately powered to distinguish between a graft failure rate of 5% and 20%. 
 
Table 5.3.2 Operating Characteristics of Sequential Testing Procedure for 60-Day Graft 
Failure from a Simulation Study with 10,000 Replications 
 
Graft Failure 
True 60-day rate 
5% 
10% 
15% 
20% 
Probability reject the null hypothesis 
0.050 
0.289 
0.600 
0.836 
Mean month stopped 
25.2 
22.0 
17.6 
13.3 
Mean # endpoints 
1.7 
2.9 
3.5 
3.4 
Mean recipients with 60 days follow-up 
33.9 
29.4 
23.1 
17.0 
 
 
 
Number of recipients (n) 
Stopping boundary (x) 
2-4 
2 
5-13 
3 
14-22 
4 
23-31 
5 
32-35 
6 

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Protocol v8.0, Dated November 12, 2015 
25 
 
5.4 
Demographic and Baseline Characteristics 
 
Demographics and baseline characteristics will be summarized for all patients.  Characteristics to 
be examined are: age, gender, race/ethnicity, performance status, primary disease, disease 
specific risk categories, hematopoietic cell transplant comorbidity index (HCT CI), donor type 
and HLA matching, donor/recipient CMV status, donor/recipient sex match, donor/recipient 
ABO match, and conditioning regimen.  Comparisons between groups will be performed for 
continuous variables via a Kruskal-Wallis test and for categorical variables, via the chi-square 
test. 
 
5.5 
Analysis of the Primary Endpoint 
The primary outcome of the trial is grade 2 – 4 aGVHD-free survival (GFS) at 180 days after 
transplant.  Day 180 GFS probabilities with 90% confidence intervals will be estimated for the 
treatment group as well as the control using the Kaplan-Meier estimator.  The primary null 
hypothesis of the study is that there is no difference in GFS between the treatment arms at 180 
days post-transplant.  The primary analysis will be performed using the difference in Kaplan-
Meier estimates for GFS at 180 days.  A 90% confidence interval for the difference in GFS at 
180 days will also be constructed.   
 
5.6 
Analysis of Secondary endpoints 
 
5.6.1 Acute GVHD  
 
Incidence of grades 2-4 and 3-4 acute GVHD at Day 100 and Day 180 will be estimated for each 
group using the cumulative incidence function treating death prior to grade 3-4 acute GVHD as 
the competing risk. Cumulative incidence of grade 3 – 4 acute GVHD at Day 100 and Day 180 
will be compared between groups. 
 
5.6.2 Chronic GVHD 
 
Incidence of chronic GVHD at 6 and 12 months will be estimated for each group using the 
cumulative incidence function treating death prior to chronic GVHD as the competing risk. 
Cumulative incidence of chronic GVHD will be compared between groups using Gray’s test. 
 
5.6.3 Hematologic Recovery 
 
Probabilities of achieving an absolute neutrophil count ≥ 500/mm3, and transfusion independent 
platelet count >20,000/mm3 and >50,000/mm3 will be estimated using the cumulative incidence 
function treating death without the event as the competing risk.  Incidence of neutrophil and 
platelet engraftment will be compared between groups.   
 
5.6.4 Treatment-related mortality (TRM) 
 
The event for this endpoint is death due to any cause other than relapse of the underlying 
malignancy. The time to this event is time from transplant to death, relapse, or the last follow-up 
whichever occurs first.  TRM at 6 and 12 months for each treatment group will be estimated 

Tac/Mtx/Toc for GVHD prophylaxis 
 
Protocol v8.0, Dated November 12, 2015 
26 
 
using the cumulative incidence function treating relapse as the competing risk. TRM will be 
compared between the two groups using Gray’s test.  
 
5.6.5 Incidence of disease relapse/progression 
 
The event for this endpoint is relapse of the underlying malignancy. The time to this event is the 
time from transplant to first evidence of laboratory recurrence or progression of primary disease 
according to standard criteria, death, or the last follow-up whichever occurs first.  Incidence of 
relapse/progression at 6 and 12 months for each treatment group will be estimated using the 
cumulative incidence function treating TRM as the competing risk. Incidence of 
relapse/progression will be compared between the two groups using Gray’s test.  
 
5.6.6 Disease-free Survival (DFS) 
 
The event for this endpoint is death or relapse/progression. The time to this event is from the 
time of transplant to death, relapse/progression, or the last follow-up whichever occurs first.  The 
DFS probabilities at 6 and 12 months will be estimated for each group using the Kaplan-Meier 
estimator.  DFS will be compared between the two treatment groups using the log-rank test. 
 
5.6.7 Overall Survival (OS) 
 
The event is death from any cause. The time to this event is from the time of transplant to death 
or the last follow-up whichever occurs first.  The overall survival probabilities at Day 180 will be 
estimated for each group using the Kaplan-Meier estimator.  OS will be compared between the 
two treatment groups using the log-rank test. 
 
5.6.8 End points only applicable for patients receiving Tac/Mtx/Toc 
 
The endpoints below will be assessed only in patients who are receiving the intervention 
(Tac/MTX/Toc) and will not be compared with controls.  
 
5.6.9 Donor Cell Chimerism 
 
The percentage of donor cell chimerism at day 100 post transplantation will be summarized. 
 
5.6.10 Incidence of Toxicities 
 
Incidence of serious adverse events and grade 3-5 CTACAE v4 will be summarized.   
  
5.6.11 Incidence of Infections 
 
The incidence of definite and probable viral, fungal and bacterial infections will be tabulated.  
 

 
 
 
 
 
 
 
 
 
 
 
 
 
APPENDIX A 
GVHD ASSESSMENT 
 

Tac/Mtx/Toc for GVHD prophylaxis 
 
Protocol v8.0, Dated November 12, 2015 
1 
 
 
GVHD GRADING, STUDY DEFINITIONS AND ENDPOINTS 
 
 Staging and Grading of Acute GVHD 
 
Staging* 
 
Stage 0 
Stage 1 
Stage 2 
Stage 3 
Stage 4 
Skin 
No rash 
Rash 
< 
25% 
BSA 
25-50% 
> 
50% 
Generalized 
erythroderma 
Plus bullae and 
desquamation 
Gut 
< 500 mL 
diarrhea/day 
501-1000 
mL/day 
1001–1500 
mL/day 
> 
1500 
mL/day 
Severe 
abdominal pain 
& ileus 
UGI 
 
Severe 
nausea/vomiting 
 
 
 
Liver 
Bilirubin 
≤  2 mg/dl 
2.1-3 mg/dl 
3.1-6mg/dl 
6.1-15mg/dl 
> 15 mg/dl 
 
 
Grading Index of Acute GVHD*  
 
Grade A 
Grade B 
Grade C 
Grade D 
Skin 
1 
2 
3 
4 
Gut 
0 
1-2 
3 
4 
Upper GI 
0 
1 
 
 
Liver 
0 
1-2 
3 
4 
 
 
 
 
 
 
 
 
 

Tac/Mtx/Toc for GVHD prophylaxis 
 
Protocol v8.0, Dated November 12, 2015 
2 
 
Diagnostic Assessment of Chronic GVHD 

Tac/Mtx/Toc for GVHD prophylaxis 
 
Protocol v8.0, Dated November 12, 2015 
3 
 
 
 
Mild chronic GVHD involves only 1 or 2 organs or sites (except the lung: see below), with no clinically 
significant functional impairment (maximum of score 1 in all affected organs or sites). Moderate chronic 
GVHD involves (1) at least 1 organ or site with clinically significant but no major disability (maximum 
score of 2 in any affected organ or site) or (2) 3 or more organs or sites with no clinically significant 
functional impairment (maximum score of 1 in all affected organs or sites). A lung score of 1 will also be 
considered moderate chronic GVHD. Severe chronic GVHD indicates major disability caused by chronic 
GVHD (score of 3 in any organ or site). A lung score of 2 or greater will also be considered severe 
chronic GVHD. 

 
APPENDIX B 
Laboratory Correlatives 

Tac/Mtx/Toc for GVHD prophylaxis 
 
Protocol v8.0, Dated November 12, 2015 
C-1 
 
Laboratory Correlatives 
Laboratory correlative for this clinical trials include evaluation of proinflammatory cytokines 
and immune reconstitution. The schedule of evaluations and blood volume required are listed 
below: 
 
 
 
Baseline 
7 
14 
21 
28 
100 
180 
365 
Immune reconstitution 
 
 
 
 
30mL 
30mL 
30mL 
30mL 
Proinflammatory Cytokines 
10mL 
10mL 
10mL 
 
10mL 
 
 
 
 
 
Proinflammatory Cytokines: 
Tocilizumab blocks the activity of IL-6 and may interfere with further downstream pro 
inflammatory cascade. The clinical trial will evaluate levels of IL-4, IL-6, IL-10, IL-13, IL-17, 
interferon-gamma, tumor necrosis factor and soluble IL-6 receptor early in the study period.  
 
 
Post Transplant Immune Reconstitution 
 
The laboratory studies proposed to measure patient response to Tocilizumab treatment are based 
on the known activity of IL-6 in promoting inflammation and autoimmunity in both T and B 
cells.  While the effects of Tocilizumab on specific immune cell subsets has been described in 
patients with autoimmune disease, GVHD and its treatment have profound effects on the 
immune system.  The additional effect of blocking the action of IL-6 in GVHD is not well 
described.  We will examine a number of immune cell populations to determine whether there is 
any correlation between clinical response and immune parameters in this study.  Testing will be 
performed at approximately the following time points: day 28, day 100, day 180 and day 365.  
The specific immune cell populations to be examined are as follows: 
 
1. B cell effects by assessment of antigen inexperienced B cells, and, transitional B cells, 
memory B cells, and plasma cells.  Specifically we will use multi-parameter flow cytometry 
measuring the level of expression of CD27, CD38, CD5, IgD, and IgM on the surface of 
CD19+ B cells.  Using these antibodies the following subsets can be defined: 
 
Table 1.  CD19+ B Cells 
 
CD19 
CD27 
IgD 
IgM 
CD38 
Subset 
+ 
- 
- 
low 
high 
Pre-B cells 
+ 
- 
- 
Int 
-/low 
Transitional 
+ 
- 
High 
High 
-/low 
Naïve mature 
+ 
-/low 
Int/low 
Int/low 
-/low 
Activated 
+ 
High 
low 
 
 
In Vivo Activated 
+ 
Int 
-/Low 
+/- 
Low/int 
Memory/Post-GC 
int 
High 
- 
- 
high 
Plasamablast/Plasma Pre-GC 
+ 
- 
+ 
? 
high 
Transitional-GVH 
+ 
+ 
+ 
 
Low 
IgD+ memory B 

T ac/ Mtx/ T oc f or G V H D pr o p hyl axis  
 
Pr ot oc ol v 8 . 0, D ate d N ove m ber 1 2 , 2 0 1 5 
C- 2 
 
 
2.   Re g ul at or y  T  cells  ( Tre gs) -   Re g ul at or y  T  cells  defi ne d  as  C D 3 +  C D 4 +  C D 2 5 +  C D 1 2 7 -
F o x P 3 +  are  k n o w n  t o  i n hi bit  t he  ma nifestati o n  of  G V H D.    Gi ve n  t hat  I L -6  ca n  i n hi bit  t he 
e x pa nsi o n  of  Tre gs,  bl o c ka ge  of  t his  effect  ma y  res ult  i n  i ncrease d  n u m bers  i n  patie nts 
res p o n di n g t o T ociiz u ma b t hera p y.  T his p o p ulati o n will be e x presse d as a perce nta ge of all 
C D 4 + cells a n d as a bs ol ute n u m bers at t he vari o us ti me p oi nts teste d. 
 
T a ble 2.  Re g ul at or y T cells 
 
C D 3  
C D 4  
C D 2 5  
C D 1 2 7  
F o x P 3  
S u bset  
+  
+  
Bri g ht  
Ne g  
+  
Tre gs  
+  
+  
+  
+  
+/ - 
Acti vate d C D 4 effect or cells  
 
 
3.    T H 1 7,  T H 1,  T H 2,  T C 1,  T C 2  Cell  P o p ul ati o ns -   Ele vate d  le vels  of  T H -1 7  T  cells  are 
ass ociate d  wit h  G V H D  a n d  ar e  i ncreas e d  i n  t he  prese n ce  of  I L -6.    T heref ore,  t his  s u bset 
mi g ht be re d uce d i n reci pie nts of T ociliz u ma b  res p o n di n g t o treat me nt.  T H-1 7 cells ca n be 
i de ntifie d  b y  t he  pr o d ucti o n  of  I L-1 7  w h e n  acti vate d  a n d  ca n  b e  f o u n d  i n  b ot h  C D 4 +  a n d 
C D 8 +  T  cells  s u bsets.    C D 4 +  T  hel per  a n d  C D 8 +  T  c yt ot o xic  cells  ca n  li ke wise  be 
disti n g uis he d  b y  t he  e x pressi o n  of  cell  s urface  mar kers  a n d  c yt o ki ne  pr o d ucti o n  u p o n 
acti vati o n.    We  will  use  a nti b o dies  t o  C D 3,  C D 4.  C D 8,  C D 2 9 4,    I L 1 7  a n d  I F N -ga m ma  t o 
disti n g uis h t he f oll o wi n g s u bsets. 
 
T a ble 3.  T H 1 7, T H 1, T H 2, T C 1, & T C 2 T cells 
  
C D 3  
C D 4  
C D 8  
C D 2 9 4  
I F N- 
I L-1 7  
S u bset  
+  
+  
- 
 
 
+  
C D 4 + T H 1 7  
+  
- 
+  
 
 
+  
C D 8 + T H 1 7  
+  
+  
- 
 
+  
+  
C D 4 + Tra nsiti o nal T H 1 7  
+  
- 
+  
 
+  
+  
C D 8 + Tra nsiti o nal T H 1 7  
+  
+  
- 
- 
+  
 
T H 1  
+  
+  
- 
+  
- 
 
T H 2  
+  
- 
+  
- 
+  
 
T C 1  
+  
- 
+  
+  
- 
 
T C 2  
 
4.    Acti v ate d  T  Cells - B ot h  G V H D  a n d  a ut oi m m u ne  disease  res ult  i n  T  cell  acti vati o n.  
Res p o nse  t o  T ociliz u ma b  i n  patie nts  treate d  f or  S L E  was  ass oci ate d  wit h  fe wer  circ ulati n g 
acti vate d  T  cells,  a n d  t h e  pres e nce  of  a  u ni q ue  s u bset  of  T C R  al p ha/ bet a  p ositi ve  T  cells 
lac ki n g e x pressi o n of b ot h C D 4 a n d C D 8 t hat are acti vate d a n d f o u n d i n i ncreas e d n u m bers 
i n  patie nts  wit h  a ut oi m m u ne  disease.    T o  detect  acti vate d  T  cells  a n d  T C R  αβ  C D 4 -C D 8 - 
cells  we  will  use  a nti b o dies  t o  C D 3,  T C R  α β ,  C D 4,  C D 8,  C D 2 5,  H L A-D R  a n d  C D 6 9  as 
s h o w n i n ta ble 4. 
 
 
 
T a ble 4.  Acti v ate d T cells 

Tac/Mtx/Toc for GVHD prophylaxis 
 
Protocol v8.0, Dated November 12, 2015 
C-3 
 
 
CD3 
CD4 
CD8 
TCRαβ 
CD25 
HLA-
DR 
CD69 
Subset 
+ 
+ 
- 
+ 
+ 
+ 
+ 
Recently activated CD4 
+ 
+ 
- 
+ 
- 
+ 
- 
Chronically activated CD4 
+ 
- 
+ 
+ 
+ 
+ 
+ 
Recently activated CD8 
+ 
- 
+ 
+ 
- 
+ 
- 
Chronically activated CD8 
+ 
- or + 
- or + 
+ 
- 
- 
- 
Unactivated CD4 or CD8 
+ 
- 
- 
+ 
 
 
 
TCRαβ+ double neg 
+ 
- 
- 
- 
 
 
 
TCRγδ+ T cells 
 
5.   Naive, central memory, and effector CD4 and CD8 subsets, terminal effector CD8+ T 
cells, NK cells and NK-T cells- Similar to B cells, the presence of naïve CD4 or CD8 T cell 
subsets is a marker of immune reconstitution in recipients of HSCT. GVHD and its therapy 
hinder immune reconstitution, and in SLE patients receiving Tocilizumab the presence of 
naïve T cells correlated with therapy response.  In contrast an increased number of effector T 
cells may be an indication that the disease process has not subsided.  In addition while NK 
cells are not typically considered to be a causative agent of GVHD, nor are they likely to be 
affected by Tocilizumab, a subset of NK cells that express CD3 do display suppressor 
activity and may be elevated in patients responsive to Tocilizumab in our study.  To identify 
these subsets the following antibodies in combination are required: CD3, CD4, CD8, CCR7, 
CD45RA, CD45RO, CD56/CD16. 
 
Table 5.  Naïve, central memory, and effector T cells, NK and NK-T cells 
 
CD3 
CD4 
CD8 
CCR7 
CD45 
RA 
CD45 
RO 
CD56+ 
CD16 
Subset 
+ 
+ 
- 
+ 
+ 
- 
- 
Naïve CD4 
+ 
+ 
- 
+ 
- 
+ 
- 
Central memory CD4 
+ 
+ 
- 
- 
- 
+ 
- 
Effector memory CD4 
+ 
- 
+ 
+ 
+ 
- 
- 
Naïve CD8 
+ 
- 
+ 
+ 
- 
+ 
- 
Central memory CD8 
+ 
- 
+ 
- 
- 
+ 
- 
Effector memory CD8 
+ 
- 
+ 
- 
+ 
- 
- 
Terminal Effector memory 
CD8 
- 
 
 
 
 
 
+ 
NK Cells 
+ 
- 
+/- 
 
 
 
+ 
NK-T Cells 
 
 
 
 

Tac/Mtx/Toc for GVHD prophylaxis 
 
Protocol v8.0, Dated November 12, 2015 
C-4 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
APPENDIX C 
ADVERSE EVENT REPORTING 
 
 

Tac/Mtx/Toc for GVHD prophylaxis 
 
Protocol v8.0, Dated November 12, 2015 
C-5 
 
 
Introduction 
 
Clinical trials that assess interventions in the setting of hematopoietic cell transplantation 
is challenging as the number of expected AEs is high. The Blood and Marrow Transplant 
Clinical Trial Network (BMT CTN) establish a capture an AE capture approach specific 
for transplant trials. This approach has the objective of optimizing the capture of AEs, by 
reducing the noise-signal ratio and identifies AEs that are not expected after transplant or 
overlaps with manifestations of common complications, such as GVHD or graft failure.  
 
Definitions 
 
Adverse Event (AE) - Any untoward medical occurrence in a patient or clinical 
investigation subject administered a pharmaceutical product, medical treatment or 
procedure and which does not necessarily have to have a causal relationship with this 
treatment. An AE can considered therefore be any unfavorable and unintended sign 
(including an abnormal laboratory finding, for example), symptom, or disease temporally 
associated with the use of a medicinal product, medical treatment or procedure whether 
or not related to the medicinal product. 
 
Expectedness: An adverse event can be Expected or Unexpected  
• Expected adverse events are those that have been previously identified as 
resulting from administration of the agent. For the purposes of this study, an 
adverse event is considered expected when it appears in the current adverse event 
list, the Investigator’s Brochure, the package insert or is included in the informed 
consent document as a potential risk. 
• Unexpected adverse events are those that vary in nature, intensity or frequency 
from information in the current adverse event list, the Investigator’s Brochure, the 
package insert, or when it is not included in the informed consent document as a 
potential risk. 
 
  
Life-threatening Adverse Event – Any adverse event that places the patient or subject, 
in view of the investigator or treating physician, at immediate risk of death from the 
reaction. Study toxicities are graded using the adapted NCI Common Toxicity Criteria 
(where appropriate use the criteria for transplant patients.)  
  
  
• Serious Adverse Event (SAE) – Any adverse event occurring that results in any of the 
following outcomes: 
• Death – regardless of cause. 
• life-threatening adverse event (see above). 
• persistent or significant disability/incapacity. 
• congenital anomaly. 
• requires intervention to prevent permanent impairment or damage. 
 

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  AE Grading: All AEs that occur in this protocol will be graded according to the NCI 
Common Terminology Criteria for Adverse Event (CTCAE) v 4.0.  
 
AE Reporting: Depending on the type, severity and whether it is expected, each AE will 
need to be reported in an appropriate timeline to MCW IRB, Data Safety and Monitoring 
Committee and FDA (if applicable for studies under an Investigational New Drug [IND] 
protocol).   
 
Adverse Events Reported to the DSMB 
All adverse events that are classified as grades 3 to 5 will be reported to the DSMC. The 
differences are the timing and amount of information associated with each.  
 
The two-tier approach collects adverse events at specific time points during the trial 
(calendar-driven) and event-driven upon knowledge of an event deemed serious (grades 3 
to 5) or unexpected to be seen in a transplant setting.  
 
Grades 3-5 Adverse Events 
For the calendar-driven collection of toxicity, the protocol mandates collection of toxicity 
on a form that captures most of the most important toxicities observed post transplant. 
The forms would capture all the AEs that occur in a preceding period, for example day 28 
toxicity form, collects all the AEs that occurred from enrollment to day 28 and the grade 
of each AE. This first period includes all non-hematologic toxicity, since it is expected 
significant hematologic toxicity will occur immediately post transplant as an effect of the 
transplantation. Hematologic toxicity will be capture when it occurs beyond day 28 post 
transplant.  
 
Unexpected Grades 3-5 
The threshold for collection of adverse events outside the calendar forms is related to the 
grade (grades 3-5) and expectedness related to the transplant procedure or possibly 
related to the study drug. These events are required to be reported to the DSMC in a more 
immediate time frame and also require more information. For any adverse event that 
meets these criteria, the report would require a narrative of the event, associated 
laboratory and imaging information, associated medications and any relevant source 
documents. These reports are uploaded into Oncore and we will notify the DSMC chair 
and MCW IRB within 24 hours or 3 to 5 calendar days depending on the severity of the 
event.  Both the PI and the CTO BMT Section leader will be responsible to review and 
determine if an event meet criteria prior to uploading it in Oncore.   
 
Reporting timelines: 
1. Fatal  (grade 5) or Life Threatening events must be reported within 24 hours 
but not later than 3 calendar day of the investigator’s observation or awareness of 
the event.  
2. All other events grades 3-4 unexpected events (non-fatal/non life-threatening) 
must be reported within 3 to 5 calendar days of the investigator’s observation or 
awareness of the event. 
 

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The proposed method outlined here follows the same requirements from MCW IRB for 
prompt reporting of an event or Unanticipated Problem Involving Risks to Subjects or 
Others (UPIRSO): which is defined as any incident, experience, or outcome that meets 
all of the following criteria: 
1. Unanticipated (in terms of nature, severity , or frequency) given (a) the research 
procedures described in the protocol-related documents, such as the IRB-
approved research protocol and informed consent document, instructions for 
Use/Device Manual and or Investigator’s Brochure; and (b) the characteristics of 
the subject population being studies; 
2. Related or possibly related to participation in the research (in this guidance 
document, possibly related means there is a reasonable possibility that the 
incident, experience, or outcome may have been caused by the procedures 
involved in the research ) or test article; and  
3. Suggests that the research places subjects or others at a greater risk of harm 
(including physical, psychological, economic, or social harm) than was previously 
known or recognized. 
 
DSMC Reporting 
 
The table below summarizes the reporting practices from the study to the DSMC. For the ongoing 
review of an opened trial, the DSMC will receive a report that includes in a tabular form all the 
grades 3 to 5 that occurred in the trial, summarized according to reporting periods: for example 0-
28d, 28-56d, 56 to 100d, 100-180d, 180-270d, 270 to 365d and 0-365d. Additionally the report 
will include all the unexpected grades 3-5 that occurred in trial participants since activation of the 
trial and lastly the number of patients who met the graft failure stopping guidelines.  
 
For the unexpected grades 3 to 5, upon knowledge of the event, this will be discussed with the 
study PI and the CTO BMT section leader. If this fulfills criteria for expedited reporting to the 
DSMC and IRB, a narrative will be uploaded in Oncore and the DSMC will be notified, either 
through its secretary or directly to the Chair.  
 
 
All Grades 3-5 
Unexpected Grades 3-5 
Type of collection 
Calendar-driven 
Event-driven 
Reporting format 
Tabular or graphical 
format 
Narrative with 
supporting documents 
Timing of reporting 
Biennial basis - 
cumulative 
Within 3 to 5 calendar 
days from knowledge of 
the event and cumulative 
in a biennial basis.  
 
 
 

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APPENDIX D 
REFERENCES 
 
 
 
 

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1. Hill GR, Crawford JM, Cooke KR, Brinson YS, Pan L, Ferrara JL. Total body 
irradiation and acute graft versus host disease: the role of gastrointestinal damage and 
inflammatory cytokines. Blood 90: 3204-3213, 1997. 
2. Xun CQ, Thompson JS, Jennings CD, Brown SA, Widmer MB. Effect of total body 
irradiation, busulfan-cyclophosphamide, or cyclophosphamide conditioning on 
inflammatory cytokine release and development of acute and chronic graft versus 
host disease in H-2 incompatible transplanted SCID mice. Blood 83: 2360-2367, 
1994. 
3. Ferrara JL, Reddy P. Pathophysiology of graft versus shot disease. Semin Hematol 
43: 3-10, 2006. 
4. Teshima T, Ordemann R, Reddy P, et al. Acute graft versus host disease does not 
require alloantigen expression on host epithelium. Nat Med 8: 575-581, 2002. 
5. Mowat AC. Antibodies to IFN-γ prevent immunologically mediated intestinal 
damage in murine graft versus host disease. Immunology 68: 18-23, 1989. 
6. Burman AC, Banovic T, Kuns RD, et al. IFNγ differentially controls the development 
of idiopathic pneumonia syndrome and GVHD of the gastrointestinal tract. Blood 
110: 1064-1072, 2007. 
7. Nestel FP, Price KS, Seemayer TA, Lapp WS. Macrophage priming and 
lipopolysaccharide-triggered release of tumor necrosis factor α during graft versus 
host disease. J  Exp Med 175: 405-413, 1992. 
8. Chen X, Vodanovic-Jankovic S, Johnson B, Keller M, Komorowski R, Drobyski WR. 
Absence of regulatory T cell control of TH1 and TH17 cells is responsible for the 
autoimmune-mediated pathology in chronic graft versus host disease. Blood 110: 
3804-3813, 2007. 
9. Carlson MJ, West ML, Coghill JM, Panoskaltsis-Mortari A, Blazar BR, Serody JS. In 
vitro differentiated TH17 cells mediate lethal acute graft versus host disease with 
severe cutaneous and pulmonary pathology. Blood 113: 1365-1374, 2009.   
10. Miura Y, Thoburn CJ, Bright EC, et al. Association of Foxp3 regulatory gene 
expression with graft versus host disease. Blood 104: 2187-2193, 2004. 
11. Zorn E, Kim HT, Lee SJ, et al.  Reduced frequency of Foxp3+ CD4+ CD25+ 
regulatory T cells in patients with chronic graft versus host disease. Blood 106: 2903-
2911, 2005. 
12. Rieger K, Loddenkemper C, Maul J, et al. Mucosal Foxp3+ regulatory T cells are 
numerically deficient in acute and chronic GVHD. Blood 107: 1717-1723, 2006. 
13. Chao NJ, Schmidt GM, Niland JC, et al. Cyclosporine, methotrexate, and prednisone 
compared with cyclosporine and prednisone for prophylaxis of acute graft-versus-
host disease. N Engl J Med. 1993; 329:1225-1230. 
14. Couriel D, Caldera H, Champlin R, Komanduri K. Acute graft-versus-host disease: 
pathophysiology, clinical manifestations, and management. Cancer. 2004; 101:1936-
1946.  
15. Bolanos-Meade J and Vogelsang GB. Acute graft-versus-host disease. Clin Adv 
Hematol Oncol. 2004; 2: 672-682. 
16. Nishimoto N and Kishimoto T. Interleukin 6: from bench to bedside. Nat Clin Pract 
Rheumatol. 2006; 2: 619-626.  

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17. Veldhoen M, Hocking RJ, Atkins CJ, Locksley RM, Stockinger B. TGF in the 
context of an inflammatory cytokine milieu supports de novo differentiation of IL-17-
producing T cells. Immunity 2006; 24: 179-189.  
18. Bettelli E, Carrier Y, Gao W, et al. Reciprocal developmental pathways for the 
generation of pathogenic effector TH17 and regulatory T cells. Nature. 2006; 441: 
235-238. 
19. Pasare C, Medzhitov R. Toll pathway-dependent blockade of CD4+CD25+ T cell-
mediated suppression by dendritic cells. Science 2003; 299: 1033-1036. 
20. Wan S, Xia C, Morel L. IL-6 produced by dendritic cells from lupus-prone mice 
inhibits CD4+ CD25+ T cell regulatory functions. J Immunol 2007; 178: 271-279. 
21. Barak V, Levi-Schaffer F, Nisman B, Nagler A. Cytokine dysregulation in chronic 
graft versus host disease. Leuk Lymphoma 1995; 17: 169-173. 
22. Imamura M, Hashino S, Kobayashi H, et al. Serum cytokine levels in bone marrow 
transplantation: synergistic interaction of interleukin 6, interferon gamma, and tumor 
necrosis factor alpha in graft versus host disease.  Bone Marrow Transplant 1994; 13: 
745-751. 
23. Cavet J, Dickinson AM, Norden J, Taylor PRA, Jackson GH, Middleton PG. 
Interferon γ and interleukin 6 gene polymorphisms associate with graft versus host 
disease in HLA-matched sibling bone marrow transplantation. Blood 2001; 98: 1594-
1600. 
24. Socie G, Loiseau P, Tamouza R, et al. Both genetic and clinical factors predict the 
development of graft versus host disease after allogeneic hematopoietic stem cell 
transplantation. Transplantation 2001; 72: 699-706. 
25. Rose-John S, Scheller J, Elson G, Jones SA. Interleukin-6 biology is coordinated by 
membrane-bound and soluble receptors: role in inflammation and cancer. J Leuk Biol 
2006; 80: 227-236.  
26. Mullberg J, Schooltink H, Stoyan T, et al. The soluble interleukin 6 receptor is 
generated by shedding. Eur J Immunol 1993; 23: 473-480. 
27. Jones SA, Horiuchi S, Topley N, Yamamoto N, Fuller GM. The soluble interleukin-6 
receptor: mechanisms of production and implications in disease. FASEB J 2001; 15: 
43-58. 
28. Takagi N, Mihara M, Moriya Y, et al. Blockage of interleukin 6 receptor ameliorates 
joint disease in murine collagen-induced arthritis. Arthritis Rheum 1998; 41: 2117-
2121. 
29. Nishimoto N, Kishimoto T, Yoshizaki K. Anti-interleukin 6 receptor antibody 
treatment in rheumatic disease. Ann Rheum Dis 2000; 59: i21-i27. 
30. Mihara M, Shiina M, Nishimoto N, Yoshuzaki K, Kishimoto T, Akamatsu K. Anti-
interleukin 6 receptor antibody inhibits murine AA amyloidosis. J Rheumatol 2004; 
31: 1132-1138. 
31. Atreya R, Mudter J, Finotto S, et al. Blockade of interleukin 6 trans signaling 
suppresses T-cell resistance against apoptosis in chronic intestinal inflammation: 
evidence in Crohn’s disease and experimental colitis in vivo. Nat Med 2000; 6: 583-
588.  
32. Nishimoto N, Yoshizaki K, Miyasaka N, et al. Treatment of rheumatoid arthritis with 
humanized anti-interleukin 6 receptor antibody. Arthritis Rheum 2004; 50: 1761-
1769. 

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33. Yokota S, Imagawa T, Mori M, et al. Efficacy and safety of tocilizumab in patients 
with systemic-onset juvenile idiopathic arthritis: a randomized, double-blind, 
placebo-controlled, withdrawal phase III trial. Lancet 2008; 371: 998-1006. 
34. Ito H, Takazoe M, Fukuda Y, et al. A pilot randomized trial of a human anti-IL-6 
receptor monoclonal antibody in active Crohn’s disease. Gastroenterology 126: 989-
996, 2004. 
35. Chen X, Das R, Komorowski R, Beres A, Hessner MJ, Mihara M, Drobyski WR. 
Blockade of interleukin 6 signaling augments regulatory T cell reconstitution and 
attenuates the severity of graft versus host disease. Blood 2009; 114: 891-900.    
36. Gergis U, Arnason J, Yantiss R, Shore T, Wissa U, Feldman E. Effectiveness and 
safety of tocilizumab, an anti-interleukin 6 receptor monoclonal antibody in a patient 
with refractory GI graft versus host disease. J Clin Oncol 2010; 28:e602-4. 
37. Drobyski WR, Pasquini M, Kovatovic K, et al. Tocilizumab for the Treatment of 
Steroid Refractory Graft-versus-Host Disease. Biol Blood Marrow Transplant. 2011; 
17: 1862-1868. 
38. Kennedy GA, Varelias A, Vuckovic S, Zhang P, MacDonald KPA, Leach J, 
Sturgeon E, Avery J, Olver SD, Lor M, Hutchins CJ, Morton JA, Durrant STS, 
Misra A, Subramoniapillai E, Butler JP, Curley C, Tey SK, Hill GR. The addition of 
interleukin 6 inhibition to standard GVHD prophylaxis prevents acute GVHD: 
Interim results of a phase I/II clinical study. American Society of Hematology 
Meeting, New Orleans, LA, December 2013. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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APPENDIX E 
Ancillary Study 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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TOCILIZUMAB FOR THE PREVENTION OF DEPRESSION AND COGNITIVE 
CHANGES AMONG ALLOGENEIC HEMATOPOIETIC STEM CELL 
TRANSPLANTATION RECIPIENTS 
 
An addendum to parent study “PHASE II OPEN LABEL OF 
TACROLIMUS/METHOTREXATE AND TOCILIZUMAB FOR THE PREVENTION 
OF ACUTE GRAFT VERSUS HOST DISEASE AFTER ALLOGENEIC 
HEMATOPOIETIC STEM CELL TRANSPLANTATION” 
Principal Investigator: William R. Drobyski, MD 
 
PRINCIPAL INVESTIGATOR: Jennifer M. Knight, MD 
Co-Investigators: PI and Co-I’s of parent study 
 
1.0 BACKGROUND AND RATIONALE 
 
1.1 Depression, cancer, and inflammation 
 
35-45% of cancer patients have emotional distress,1 with depression being a significant 
predictor of increased mortality among cancer and hematopoietic stem cell transplant 
(HCT) recipients.2, 3 Depression is associated with an elevation in pro-inflammatory 
cytokines, as is graft-versus-host disease (GVHD), a significant source of morbidity and 
mortality for allogeneic HCT recipients.4, 5 It is unknown whether blocking inflammation 
associated with GVHD would also alleviate depressive symptoms in HCT patients.    
 
Pro-inflammatory cytokines associated with infection or other diseases involving 
inflammation (i.e. GVHD) act on the brain to cause sickness behavior, including 
depression.6 Given the cytokine dysregulation involved in GVHD,5 it is mechanistically 
plausible that there may be onset or exacerbation of depressive symptoms in association 
with this disease, and in fact significant deficits in quality of life (QOL) are associated 
with GVHD.7 
 
Specifically, IL-6 is consistently identified as a key cytokine implicated in inflammation-
associated mood dysregulation,8-10 including among cancer patients.11, 12 Studies 
demonstrate that blocking other pro-inflammatory cytokine receptors associated with 
depression (i.e. TNF alpha) reduces depressive symptoms in individuals with high levels 
of inflammation.13 Despite accumulating evidence that inflammation and IL-6 play a role 
in mood alteration and depressive symptomatology, tocilizumab, an IL-6 receptor 
antagonist, has never been evaluated for its possible role in improving mood or 
preventing deterioration of mood in association with pro-inflammatory states. This 
represents a novel approach for targeting depressive symptoms in an immunologically 
compromised population with a high degree of psychiatric morbidity. Though less 
robustly examined in the literature than depression, there is also indication that anxiety,14, 
15 fatigue,16, 17 sleep,17 and pain18 are associated with alterations in IL-6. Therefore, these 
additional cognitive components may also be affected by the administration of 
tocilizumab. 
 

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1.2 Gene expression and inflammation in transplant 
 
Research suggests that ß-adrenergic signaling regulates many cellular processes 
contributing to the initiation and progression of cancer,19 with the downstream effects of 
this signaling pathway reflected in the expression of a discrete grouping of genes 
comprising the conserved transcriptional response to adversity (CTRA) profile. This 
CTRA profile (53 inflammatory, interferon-related, and antibody-related genes) has been 
identified as overexpressed in other populations under conditions of chronic stress or 
adversity and is consistent with the physiology of stress-associated illness.20 We recently 
identified that unrelated donor HCT recipients exposed to the chronic stress of low 
socioeconomic status display significantly increased expression of ß-adrenergic signaling 
pathways as well as increased expression of the CTRA gene expression profile 
(manuscript under review). This increased expression was significantly associated with 
adverse clinical outcomes including increased relapse and decreased overall leukemia-
free survival (manuscript under review). Given the iterative and feedback dynamics 
involved in processes affecting expression of these ß-adrenergically-mediated gene 
expression profiles, affecting peripheral inflammatory stimulation as occurs with 
tocilizumab may alter associated gene expression. 
 
1.3 Rap1 prenylation  
 
Rap1, a small GTPase, plays an important role in cell function by regulating cell 
adhesion.21-26 In this way, Rap1 suppresses metastasis by localizing at the plasma 
membrane of tumor cells through the process of prenylation, the post-translational 
attachment of a lipid tail to Rap1. When Rap1 is localized at the plasma membrane of 
tumor cells, Rap1 promotes adhesion of the tumor cells and inhibits their metastatic 
spread. In contrast, when Rap1 prenylation is inhibited, Rap1 cannot anchor at tumor cell 
membranes, resulting in loss of cell-cell adhesion and increased metastasis of tumor cells. 
Recently, it was discovered that prenylation of Rap1 is regulated by novel signaling 
pathways involving cAMP.27, 28 Both cAMP 29-31 and Rap132, 33 have been found to 
participate in cellular responses to IL-6. These findings support the hypothesis that IL-6-
mediated signaling may affect the prenylation of Rap1 and alter the localization of 
prenylated Rap1 at the cellular plasma membrane. Therefore, tocilizumab may alter Rap1 
prenylation and membrane localization, thereby suppressing the metastatic potential of 
tumor cells. 
 
1.4 Rationale 
 
Given that IL-6 is implicated in depressive symptomatology, the current trial aim is to 
assess whether the immunomodulator and IL-6 antagonist tocilizumab may be effective 
in reducing depressive symptoms among individuals undergoing allogeneic stem cell 
transplantation. Given additional evidence that anxiety, fatigue, sleep, and pain may also 
be associated with IL-6, we will examine the effect of tocilizumab on these symptoms as 
well. Further, given that IL-6 is associated with ß-adrenergic signaling and Rap1 
prenylation, we will explore whether there are changes in gene expression patterns and 
Rap1 prenylation in response to tocilizumab. These additional psychosocial, genetic, and 

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biochemical assessments will leverage findings from the parent study “Phase II open 
label of tacrolimus/methotrexate and tocilizumab for the prevention of acute graft versus 
host disease after allogeneic hematopoietic stem cell transplantation”. 
 
2.0 STUDY DESIGN 
 
This is a non-randomized trial comparing the efficacy of tocilizumab to decrease 
depressive symptoms among a cohort of allogeneic HCT recipients. The intervention 
group is as described in the parent protocol “Phase II open label of 
tacrolimus/methotrexate and tocilizumab for the prevention of acute graft versus host 
disease after allogeneic hematopoietic stem cell transplantation”. Administration of 
tocilizumab will occur through the Medical College of Wisconsin HCT Program. 
Individuals participating in a longitudinal study evaluating the biobehavioral implications 
of allogeneic HCT at the University of Wisconsin-Madison (UW) will serve as controls 
for the psychosocial data. 165 allogeneic transplant participants with follow up QOL 
outcomes have been enrolled to date and none of them have received tocilizumab.  
 
Participants will complete a battery of self-report surveys at the following time points: 
baseline, day 28, day 100, and day 180 post-transplant in conjunction with scheduled data 
collection as part of the parent protocol (Table 1). These additional self-report surveys to 
be completed include: Inventory of Depression and Anxiety Symptoms (IDAS; 
depression and anxiety), Fatigue Symptom Inventory (FSI; fatigue), Pittsburgh Sleep 
Quality Index (PSQI; sleep), and Brief Pain Inventory (BPI; pain). Control participants 
from UW have also completed these surveys at the time points as described above. Blood 
samples will be collected at the above time points. Two tubes of blood will be drawn at 
each time point: a PAXGene RNA tube and an 8.0 mL BD Vacutainer CPT tubes  (Table 
1). These tubes will be used to describe RNA expression34 and prenylation27, 
respectively.  
 
2.1 Primary Objective  
 
The primary objective of this ancillary study is to compare depressive symptoms among 
allogeneic HCT recipients receiving tocilizumab to a control group of allogeneic HCT 
recipients who did not receive tocilizumab. 
 
2.2 Secondary Objectives 
 
Secondary objectives of this ancillary study are: 
 
1) To compare levels of anxiety, fatigue, sleep, and pain between allogeneic HCT 
recipients who received prophylactic tocilizumab vs. allogeneic HCT recipients who did 
not receive tocilizumab (UW control cohort). 
2) To describe gene expression and Rap1 prenylation among allogeneic HCT recipients 
receiving prophylactic tocilizumab. 
 
 

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2.3 Patient Eligibility 
 
2.3.1-2.3.2 Inclusion and exclusion criteria same as parent study. 
 
2.3.3 Eligiblity for the Control Arm 
 
Consistent with eligibility criteria for the control arm study being done at UW, eligible 
participants are adult allogeneic transplant recipients who have been followed for at least 
6 months post-transplant.   
  
2.4 – 2.8 Donor Selection, Treatment Plan, Supportive Care, Participant Risk, Study Drug 
Information same as parent study. 
 
3.0 STUDY ENDPOINTS 
(In addition to those of parent study) 
 
3.1 Primary endpoint 
 
The primary endpoint of this ancillary study is to compare depressive symptoms at day 
28 post-transplant for a group of allogeneic HCT recipients who receive tocilizumab as 
compared to a control group of allogeneic recipients not receiving tocilizumab. This will 
be addressed through the General Depression subscale of the IDAS and includes 20 
questions with a scoring range of 20-100 (mean in community dwelling adult of 44.99 
and standard deviation of 14.75).35  
 
3.2 Secondary endpoints 
 
The secondary endpoints of this ancillary study are 1) to compare depressive symptoms 
at day 100 and day 180 as well as anxiety, fatigue, sleep, and pain at day 28, day 100, and 
day 180 post-transplant for a group of allogeneic HCT recipients who receive tocilizumab 
as compared to a control group of allogeneic recipients not receiving tocilizumab; and 2) 
to describe gene expression and Rap1 prenylation among allogeneic HCT recipients 
receiving prophylactic tocilizumab at baseline, day 28, day 100, and day 180. 
 
QOL outcomes: 
• Depression: As described in section 3.1. 
• Anxiety: Anxiety will be assessed using two subscale items of the IDAS including 
panic (health population mean = 12.58, SD = 5.26) and traumatic intrusions 
(healthy population mean = 7.60, SD = 4.20).35 
• Fatigue: The FSI will be utilized to assess fatigue; a score of 3 or greater on items 
assessing fatigue in the past week (average of items 1-3; FSI Composite) indicates 
clinically meaningful fatigue.36, 37 The FSI can also be evaluated using the average 
rating of the degree to which fatigue interfered with some general activities (0-10; 
FSI Interference); participants’ ratings of the number of days in the past week 
they felt fatigued (0-7; FSI Days); and participants’ rating of what percent of each 
day in the past week, on average, they felt fatigued (0-100; FSI Percent).37 

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Individuals scoring at or above the cutoff also report significantly greater scores 
on these other subscales. 
• Sleep: Sleep will be assessed using the PSQI, with a score of >5 considered 
disturbed sleep as adjusted for cancer populations.38, 39  
• Pain: The BPI assesses pain intensity as well as pain-related interference in 
function40, 41 BPI Pain Severity score ranges from 0-40 (first four items), and the 
BPI Pain Interference score is a mean of the last 7 items (5a-5g) with a range of 0-
10. 
 
Biological outcomes: 
• Gene expression: Description of transcription factor binding motifs and CTRA 
gene expression levels will be described at all study time points. 
• Rap1 prenylation: Western blotting on the cytosolic and membrane fractions of 
isolated PBMCs will determine the distribution of Rap1 in the different fractions 
as well as the status of Rap1 prenylation. 
 
 
4.0 ENROLLMENT PROCEDURES 
 
4.1 Patient enrollment same as parent study. 
 
4.2 Guidelines for serious adverse event reporting same as the parent study. 
Additionally, should patients endorse any thoughts of suicidality or self harm per the 
IDAS, the study PI for this ancillary protocol (Dr. Jennifer Knight) will contact them by 
phone. Should completion of the study surveys prompt participants to want treatment for 
any of the other symptoms, participants will be offered a referral for appropriate care 
through the Quality of Life Center at the Froedtert Cancer Center. 
 
4.3 Study monitoring same as parent study. Psychosocial data and two additional tubes 
of blood will be collected as described above.  
 
4.4 Specimen collection 
 
A clinical research coordinator will collect blood to be stored in two different tubes, a 
PAXGene RNA tube and a 8.0 mL BD Vacutainer CPT tube, at baseline, day 28, day 
100, and day 180 post-transplant. The PAXGene RNA tube will be stored at -80C in the 
Neuroscience Research Center until they are batched and shipped to UCLA for gene 
expression analysis. The 8.0 mL BD Vacutainer CPT tube will be sent to Dr. Carol 
Williams’ laboratory for storage at -80C until Western blot analysis is done to assess 
Rap1 prenylation. 
 
4.5 Psychosocial assessments 
 
Participants will complete assessments to evaluate depression, anxiety, fatigue, sleep and 
pain. The primary endpoint of this ancillary study is to compare depression at baseline 
and day 28, day 100, and day 180 and the secondary endpoints are to compare anxiety, 

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fatigue, sleep, and pain at these same time points. These self-report surveys include: 
Inventory of Depression and Anxiety Symptoms (IDAS; depression and anxiety), Fatigue 
Symptom Inventory (FSI; fatigue), Pittsburgh Sleep Quality Index (PSQI; sleep), and 
Brief Pain Inventory (BPI; pain). Participants will also provide information about income 
and education level at their baseline visit. 
 
4.6 Gene expression profiling 
 
The UCLA Social Genomics Core (Directed by Dr. Steve Cole, Professor, 
Hematology/Oncology, UCLA) will conduct all gene expression profiling on obtained 
blood samples by using Illumina HT-12 human gene expression bead arrays 42. Total 
RNA will be extracted from the whole blood samples stored at MCW, subjected to 
quality assurance assays to test suitable mass (by spectroscopy) and integrity (by Agilent 
Bioanalyzer RNA Integrity Score) for analysis, and subjected to microarray target 
synthesis and hybridization in collaboration with the UCLA Neuroscience Genomics 
Core Laboratory using standard Illumina assay equipment and protocols. The output of 
these analyses is quantification of whole genome RNA production. 
 
4.7 Rap1 prenylation 
 
PBMCs will be isolated from the whole blood samples collected from patients at all time 
points. Members of Dr. Carol Williams’ laboratory (Professor, Pharmacology and 
Toxicology, MCW) will conduct Western blotting on the cytosolic and membrane 
fractions of isolated PBMCs to determine the distribution of Rap1 in the different 
fractions, and the status of Rap1 prenylation in the cells. 
 
5.0 STATISTICAL ANALYSIS 
 
Sample size justification 
The sample sizes of 35 patients treated with tocilizumab and 165 control patients are 
determined by the parent studies. With this sample size, our study will have 80% power 
to detect a 0.53 standard deviation (SD) difference between the two groups at a two-sided 
5% significance level. For the primary outcome, assuming a standard deviation of 11 
(based on preliminary analysis of the data from the UW cohort), differences of 5.8 points 
or more on the day 28 General Depression subscale of the IDAS will be detectable. This 
difference is almost half of the 11 point difference seen between population controls and 
psychiatric clinic patients.35 
 
Descriptive analyses 
Demographic characteristics to be described for each group will include age, race, 
gender, Karnofsky Performance Score (KPS), body mass index (BMI), comorbidity index 
(HCT-CI), and socioeconomic status (as defined by income and education level). 
Additional medical characteristics to be described for each group include disease, disease 
status, CMV status, conditioning regimen intensity, donor and HLA match, GVHD 
prophylaxis, and graft type. Categorical data will be presented by frequencies and 

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percentages. Descriptive summary statistics (e.g. frequency, mean, median, range and 
standard deviation) will be used to present numeric data. 
 
5.1 Analysis of primary endpoint 
 
SAS 9.3 or newer (SAS Institute, Cary, NC) will be used to analyze study data. We will 
conduct a one-way analyses of covariance (ANCOVA) including data from both control 
and intervention conditions while controlling for baseline depressive symptoms and 
development or presence of aGVHD to compare scores on the depressive scale of IDAS 
(primary objective).  
 
5.2 Analysis of secondary endpoints 
 
5.2.1 QOL outcomes 
 
We will compare anxiety, fatigue, sleep, and pain (secondary objectives) at all time 
points, as well as depressive symptoms at the two additional time-points via repeated 
measures linear model using all time points simultaneously while controlling for baseline 
status on each factor. A mixed effects model with a random subject effect will be used, 
and the inference will focus on contrasts describing within-timepoint differences. 
Additional exploratory regression analyses adjusting for covariates that differ between 
the two groups will be performed. If the groups differ on more than 1-2 covariates, 
propensity-score based adjustment will be used to reduce the number of variables in the 
regression models for the outcome. The same covariates, demographic, and medical 
characteristics as described in Section 5.0 will be used. No adjustment for multiple 
testing will be performed in these exploratory analyses. 
 
5.2.2 Gene expression profiling 
 
Levels of ß-adrenergic mediated gene expression, transcription factor binding motifs, and 
CTRA gene expression profiles will be described for all study participants; baseline 
levels may be compared to later time points. 
 
5.2.3 Rap1 prenylation 
 
Western blotting on the cytosolic and membrane fractions of isolated PBMCs will 
determine the distribution of Rap1 in the different fractions as well as the status of Rap1 
prenylation in collected cells. Baseline Rap1 prenylation will be assessed by the first 
blood draw and may be compared to later time points. 
 
 
 
 

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TABLE 1. PATIENT CLINICAL ASSESSMENTS 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
*Assessments are in addition to those being collected as part of parent protocol 
 
 
 
 
Study Assessments 
Baseline 
 
28 
100 
180 
Income and education level 
X 
 
 
 
Inventory of Depression and Anxiety Symptoms 
X 
X 
X 
X 
Fatigue Symptoms Inventory 
X 
X 
X 
X 
Pittsburgh Sleep Quality Index  
X 
X 
X 
X 
Brief Pain Inventory 
X 
X 
X 
X 
Blood draw (2 tubes) 
X 
X 
X 
X 

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References 
 
1. Carlson LE and Bultz BD. Cancer distress screening:: Needs, models, and methods. J 
Psychosom Res. 2003;55(5):403-409. 
2. Satin JR, Linden W, Phillips MJ. Depression as a predictor of disease progression and 
mortality in cancer patients. Cancer. 2009;115(22):5349-5361. 
3. Loberiza Jr FR, Rizzo JD, Bredeson CN, et al. Association of depressive syndrome and 
early deaths among patients after stem-cell transplantation for malignant diseases. Journal 
of Clinical Oncology. 2002;20(8):2118. 
4. Miller AH, Ancoli-Israel S, Bower JE, Capuron L, Irwin MR. Neuroendocrine-
immune mechanisms of behavioral comorbidities in patients with cancer. Journal of 
Clinical Oncology. 2008;26(6):971-982. 
5. Hill GR, Crawford JM, Cooke KR, Brinson YS, Pan L, Ferrara JLM. Total body 
irradiation and acute graft-versus-host disease: the role of gastrointestinal damage and 
inflammatory cytokines. Blood. 1997;90(8):3204. 
6. Dantzer R, O'Connor JC, Freund GG, Johnson RW, Kelley KW. From inflammation to 
sickness and depression: when the immune system subjugates the brain. Nature Reviews 
Neuroscience. 2008;9(1):46-56. 
7. Pidala J, Kurland B, Chai X, et al. Patient-reported quality of life is associated with 
severity of chronic graft-versus-host disease as measured by NIH criteria: report on 
baseline data from the Chronic GVHD Consortium. Blood. 2011;117(17):4651. 
8. Dowlati Y, Herrmann N, Swardfager W, et al. A meta-analysis of cytokines in major 
depression. Biol Psychiatry. 2010;67(5):446-457. 
9. Alesci S, Martinez PE, Kelkar S, et al. Major depression is associated with significant 
diurnal elevations in plasma interleukin-6 levels, a shift of its circadian rhythm, and loss 
of physiological complexity in its secretion: clinical implications. J Clin Endocrinol 
Metab. 2005;90(5):2522-2530. 
10. El-Gohary GM, Azzam HM, Ahmed OI, El-Shokry MH. Pro-inflammatory cytokines 
and depression in patients with acute leukemia. Egypt J Immunol. 2008;15(1):13-24. 
11. Musselman DL, Miller AH, Porter MR, et al. Higher than normal plasma interleukin-
6 concentrations in cancer patients with depression: preliminary findings. Am J 
Psychiatry. 2001;158(8):1252-1257. 
12. Lutgendorf SK, Weinrib AZ, Penedo F, et al. Interleukin-6, cortisol, and depressive 
symptoms in ovarian cancer patients. J Clin Oncol. 2008;26(29):4820-4827. 
13. Raison CL, Rutherford RE, Woolwine BJ, et al. A randomized controlled trial of the 
tumor necrosis factor antagonist infliximab for treatment-resistant depression: the role of 
baseline inflammatory biomarkers. JAMA Psychiatry. 2013;70(1):31-41. 
14. Calsavara AC, Rodrigues DH, Miranda AS, et al. Late anxiety-like behavior and 
neuroinflammation in mice subjected to sublethal polymicrobial sepsis. Neurotox Res. 
2013;24(2):103-108. 
15. Vogelzangs N, Beekman AT, de Jonge P, Penninx BW. Anxiety disorders and 
inflammation in a large adult cohort. Transl Psychiatry. 2013;3:e249. 
16. Inagaki M, Isono M, Okuyama T, et al. Plasma interleukin-6 and fatigue in terminally 
ill cancer patients. J Pain Symptom Manage. 2008;35(2):153-161. 

Tac/Mtx/Toc for GVHD prophylaxis 
 
Protocol v8.0, Dated November 12, 2015 
C-23 
 
17. Collado-Hidalgo A, Bower JE, Ganz PA, Cole SW, Irwin MR. Inflammatory 
biomarkers for persistent fatigue in breast cancer survivors. Clin Cancer Res. 
2006;12(9):2759-2766. 
18. Wang XM, Lehky TJ, Brell JM, Dorsey SG. Discovering cytokines as targets for 
chemotherapy-induced painful peripheral neuropathy. Cytokine. 2012;59(1):3-9. 
19. Cole SW and Sood AK. Molecular pathways: Beta-adrenergic signaling in cancer. 
Clinical Cancer Research. 2012;18(5):1201-1206. 
20. Powell ND, Sloan EK, Bailey MT, et al. Social stress up-regulates inflammatory gene 
expression in the leukocyte transcriptome via beta-adrenergic induction of myelopoiesis. 
Proc Natl Acad Sci U S A. 2013;110(41):16574-16579. 
21. Azoulay-Alfaguter I, Strazza M, Pedoeem A, Mor A. The coreceptor programmed 
death-1 inhibits T-cell adhesion by regulating Rap1. J Allergy Clin Immunol. 2014. 
22. Kloog Y and Mor A. Cytotoxic-T-lymphocyte antigen 4 receptor signaling for 
lymphocyte adhesion is mediated by C3G and Rap1. Mol Cell Biol. 2014;34(6):978-988. 
23. Gu JJ, Lavau CP, Pugacheva E, Soderblom EJ, Moseley MA, Pendergast AM. Abl 
family kinases modulate T cell-mediated inflammation and chemokine-induced migration 
through the adaptor HEF1 and the GTPase Rap1. Sci Signal. 2012;5(233):ra51. 
24. Königsberger S, Peckl-Schmid D, Zaborsky N, Patzak I, Kiefer F, Achatz G. HPK1 
associates with SKAP-HOM to negatively regulate Rap1-mediated B-lymphocyte 
adhesion. PloS one. 2010;5(9):e12468. 
25. Lin K, Tan P, Freeman S, Lam M, McNagny K, Gold M. The Rap GTPases regulate 
the migration, invasiveness and in vivo dissemination of B-cell lymphomas. Oncogene. 
2009;29(4):608-615. 
26. Katayama Y, Sekai M, Hattori M, Miyoshi I, Hamazaki Y, Minato N. Rap signaling 
is crucial for the competence of IL-7 response and the development of B-lineage cells. 
Blood. 2009;114(9):1768-1775. 
27. Ntantie E, Gonyo P, Lorimer EL, et al. An adenosine-mediated signaling pathway 
suppresses prenylation of the GTPase Rap1B and promotes cell scattering. Sci Signal. 
2013;6(277):ra39. 
28. Williams CL. A new signaling paradigm to control the prenylation and trafficking of 
small GTPases. Cell Cycle. 2013;12(18):2933-2934. 
29. Irvin BJ, Hanson CL, Smith LH, Daniels CK. Cyclic AMP-and IL6-signaling cross 
talk: comodulation of proliferation and apoptosis in the 7TD1 B cell hybridoma. Exp Cell 
Res. 2001;265(1):73-79. 
30. Szabo-Fresnais N, Blondeau J, Pomérance M. Activation of the cAMP pathway 
synergistically increases IL-1-induced IL-6 gene expression in FRTL-5 thyroid cells: 
involvement of AP-1 transcription factors. Mol Cell Endocrinol. 2008;284(1):28-37. 
31. Wen AY, Sakamoto KM, Miller LS. The role of the transcription factor CREB in 
immune function. The Journal of Immunology. 2010;185(11):6413-6419. 
32. Tang S, Chen T, Yu Z, et al. RasGRP3 limits Toll-like receptor-triggered 
inflammatory response in macrophages by activating Rap1 small GTPase. Nature 
communications. 2014;5. 
33. Xie P, Joladarashi D, Dudeja P, Sun L, Kanwar YS. Modulation of angiotensin II-
induced inflammatory cytokines by the Epac1-Rap1A-NHE3 pathway: implications in 
renal tubular pathobiology. Am J Physiol Renal Physiol. 2014;306(11):F1260-74. 

Tac/Mtx/Toc for GVHD prophylaxis 
 
Protocol v8.0, Dated November 12, 2015 
C-24 
 
34. Fredrickson BL, Grewen KM, Coffey KA, et al. A functional genomic perspective on 
human well-being. Proc Natl Acad Sci U S A. 2013;110(33):13684-13689. 
35. Watson D, O'Hara MW, Simms LJ, et al. Development and validation of the 
Inventory of Depression and Anxiety Symptoms (IDAS). Psychol Assess. 
2007;19(3):253. 
36. Hann D, Jacobsen P, Azzarello L, et al. Measurement of fatigue in cancer patients: 
development and validation of the Fatigue Symptom Inventory. Quality of Life research. 
1998;7(4):301-310. 
37. Donovan KA, Jacobsen PB, Small BJ, Munster PN, Andrykowski MA. Identifying 
clinically meaningful fatigue with the Fatigue Symptom Inventory. J Pain Symptom 
Manage. 2008;36(5):480-487. 
38. Vargas S, Wohlgemuth WK, Antoni MH, Lechner SC, Holley HA, Carver CS. Sleep 
dysfunction and psychosocial adaptation among women undergoing treatment for non-
metastatic breast cancer. Psychooncology. 2010;19(6):669-673. 
39. Carpenter JS and Andrykowski MA. Psychometric evaluation of the Pittsburgh Sleep 
Quality Index. J Psychosom Res. 1998;45(1):5-13. 
40. Cleeland CS. Pain assessment in cancer. Effect of cancer on quality of life. 1991:293-
305. 
41. Cleeland CS and Ryan KM. Pain assessment: global use of the Brief Pain Inventory. 
Ann Acad Med Singapore. 1994;23(2):129-138. 
42. Cole SW, Hawkley LC, Arevalo JMG, Cacioppo JT. Transcript origin analysis 
identifies antigen-presenting cells as primary targets of socially regulated gene expression 
in leukocytes. Proceedings of the National Academy of Sciences. 2011;108(7):3080.