A Phase II Trial of Low-Dose Interleukin-2 (IL-2) Added to Extra-Corporeal Photopheresis for Steroid-Refractory Chronic Graft-versus-Host-Disease
Phase: PHASE2
Conditions: Chronic Graft-versus-host-disease
Sponsor: Dana-Farber Cancer Institute

 
 
 
 
STATUS PAGE 
PROTOCOL 14-479 
 
 
 
 
Closed To New Accrual 
 
 
Closure Effective Date: 04/28/2017 
Reason: Study Accrual Goal Met 
 
 
No new subjects may be enrolled in the study- as described above. 
Any questions regarding this closure should be directed to the study’s 
Principal Investigator 

DFCI Protocol No: 14-479
Front Sheet
06/12/2018 09:41 AM
Report Generated:
A Phase II Trial of Low-Dose Interleukin-2 (IL-2) Added to Extra-Corporeal Photopheresis for Steroid-Refractory
Chronic Graft-Versus-Host-Disease
Title:
Overall Principal Investigator
Email
Institution
Koreth, John
Dana-Farber Cancer Institute
Overall Institution:
Dana-Farber Cancer Institute
Primary Contact(s) for Questions
Email
Phone
Hipolito, Evelyn
Total Study-Wide Enrollment Goal:
25
Total DF/HCC Estimated Enrollment Goal:
25
Phase: II
Age:
Adults
Age Ranges:
18+
Will all subjects be recruited from pediatric clinics?
CTEP Study:
No
Management Group(s):
Primary Management Group:
DF/HCC Transplant
DF/HCC Transplant
DFCI/BWH Transplant
DFCI/BWH Treatment Plan
(BMT/Non-Research)
Sponsor Name
Sponsor Protocol No
Roles
Grant Number(s)
DF/HCC Investigator
Funding; Regulatory
Prometheus Laboratories
Funding
Dana-Farber/Harvard Cancer Center
Funding
Investigational Drug?
This study does not use a Drug/Biologic.
Investigational Device?
This study does not use an Investigational Device.
Risk Category:
Greater Than Minimal Risk
Human Material Banking; Human Material Collection; Immunotherapy;
Questionnaires/Surveys/Interviews
Protocol Involves:
Date Range: (Medical Record Review and Specimen Collection studies)
IRB of Record:
Participating Sites under the DFCI IRB
Institution:
Brigham and Women's Hospital
Dana-Farber Cancer Institute
Participating Institutions Under Other IRB
None

 
Log Sheet 
Page 1 of 1 
 
Protocol Number: 14-479 
 
Approval Date:  
12/02/2014 
(IRB meeting date when protocol/consent  
 approved or conditionally approved) 
 
Activation Date:  
02/02/2015      (Date when protocol open to patient entry) 
 
Approval signatures are on file in the Office for Human Research Studies, tel. 617-632-3029. 
 
Date 
Posted 
Revised Sections 
IRB 
Approval 
Date 
OHRS 
Version 
Date 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
Protocol Version Date: Version 2.0; August 15, 2016  
 
NCI Protocol #: N/A 
 
Local Protocol #: 14-479   
 
 
TITLE: A PHASE II TRIAL OF LOW-DOSE INTERLEUKIN-2 (IL-2) ADDED TO EXTRA-
CORPOREAL PHOTOPHERESIS FOR STEROID-REFRACTORY CHRONIC GRAFT-
VERSUS-HOST-DISEASE 
 
 
Principal Investigators:  
John Koreth, MBBS, DPhil  
 
Sub-Investigator: 
William Savage, MD PhD (Transfusion Medicine) 
 
Dana-Farber Cancer Institute 
 
Coordinating Center:  
Dana-Farber Cancer Institute 
  
Statistician:  
Haesook Kim, PhD 
Dana-Farber Cancer Institute  
 
 
Responsible Research Nurse:  
Mildred Pasek, RN 
Susan Stephenson, RN 
 
Responsible Data Manager: N/A 
 
Agent(s):  Interleukin-2 (Proleukin®) (exempt) – Prometheus Laboratories, Inc  
 

Phase II ECP+IL-2 for chronic GVHD 
 
 
Version 2.0; August 15, 2016 
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SCHEMA 
OBJECTIVES 
To assess the efficacy of daily subcutaneous (SC) low-dose interleukin-2 (IL-2) added to 
extra-corporeal photopheresis in patients with chronic GVHD (cGVHD) 
PATIENT POPULATION 
• 
Patients with cGVHD requiring systemic therapy. Patients with either extensive cGVHD 
or limited cGVHD requiring systemic therapy are eligible. 
• 
Inadequate response to at least 4 weeks of prednisone at a dose of ≥0.25 mg/kg/day (or 
equivalent).  
 
Specific inclusion and exclusion criteria are detailed in section 3.1 and 3.2 respectively. 
NUMBER OF PATIENTS 
25  
STUDY DESIGN AND METHODOLOGY 
Phase II  
 
 
 
 
 
  
                      
 
    ECP alone 8 wks; ECP+IL-2 8 wks  
 
  
 
 
 
  
 
                                     Lab studies & Clinical Assessment 
 
  
 
 
 
 
                  
 
                   
               
 Wks            0 1 2   4   6   8  9 10  12  14 16 Extended ECP+IL-2 in Responders 
 
SAFETY AND EFFICACY DATA  
 
The following assessments will be conducted to assess the efficacy of ECP plus IL-2: 
 
- 
Overall cGVHD response rate at week 16 
- 
Toxicity of 8 week daily IL-2 added to ECP 
- 
Immunologic effects of ECP plus low-dose IL-2  
- 
Prednisone use during ECP plus low-dose IL-2 
- 
Overall and progression-free survival, non-relapse mortality, and relapse at 1 year after 
study entry 
 
 
  
Recipient  

Phase II ECP and IL-2 for chronic GVHD 
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TABLE OF CONTENTS 
1. 
OBJECTIVES .................................................................................................................................................... 1 
1.1 
Study Design .................................................................................................................................................... 1 
1.2 
Primary Objective ........................................................................................................................................... 1 
1.3 
Secondary Objectives ...................................................................................................................................... 1 
2. 
BACKGROUND ................................................................................................................................................ 2 
2.1 
Study Disease: Graft vs. Host Disease ............................................................................................................ 2 
2.2 
Study Agent: Interleukin-2 ............................................................................................................................... 3 
2.3 
Rationale ......................................................................................................................................................... 7 
2.4 
Correlative Studies Background...................................................................................................................... 8 
3. 
PARTICIPANT SELECTION ........................................................................................................................ 10 
3.1 
Eligibility Criteria ......................................................................................................................................... 10 
3.2 
Exclusion Criteria ...................................................................................................................................... 11 
3.3 
Inclusion of Women, Minorities and Other Underrepresented Populations ................................................. 12 
4. 
REGISTRATION PROCEDURES ................................................................................................................ 13 
4.1 
General Guidelines for DF/HCC and DF/PCC Institutions ......................................................................... 13 
4.2 
Registration Process for DF/HCC and DF/PCC Institutions ................................................................. 13 
4.3 
General Guidelines for Other Participating Institutions ................................................................... 14 
4.4 
Registration Process for Other Participating Institutions ........................................................................... 14 
5. 
TREATMENT PLAN ...................................................................................................................................... 14 
5.1 
Pre-treatment Criteria ............................................................................................................................ 16 
5.2 
Agent Administration .............................................................................................................................. 18 
5.3 
General Concomitant Medication and Supportive Care Guidelines ............................................................. 19 
5.4 
Duration of Therapy ....................................................................................................................................... 19 
5.5 
Duration of Follow Up .................................................................................................................................. 20 
5.6 
Criteria for Removal from Study ................................................................................................................... 20 
6. 
EXPECTED TOXICITIES AND DOSING DELAYS/DOSE MODIFICATIONS .................................... 21 
6.1 
Anticipated Toxicities .................................................................................................................................... 21 
6.2 
Dose Modifications/Delays ........................................................................................................................... 23 
7. 
DRUG FORMULATION AND ADMINISTRATION ................................................................................. 25 
7.1 
IL-2 ................................................................................................................................................................ 25 
8. 
CORRELATIVE/SPECIAL STUDIES .......................................................................................................... 29 
8.1 
Pharmacokinetic Studies ............................................................................................................................... 29 
8.2 
Pharmacodynamic Studies ............................................................................................................................ 29 

Phase II ECP and IL-2 for chronic GVHD 
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9. 
STUDY CALENDAR ...................................................................................................................................... 30 
10. 
MEASUREMENT OF EFFECT..................................................................................................................... 32 
10.1 
cGVHD Assessments ................................................................................................................................ 32 
10.2 
Chronic GVHD Symptom Score ............................................................................................................... 33 
10.3 
Steroid Use for Chronic GVHD ................................................................................................................ 33 
10.4 
Immune Assessment .................................................................................................................................. 33 
11. 
ADVERSE EVENT REPORTING REQUIREMENTS ............................................................................... 34 
11.1 
Definitions ................................................................................................................................................ 34 
11.2 
Procedures for AE and SAE Recording and Reporting ............................................................................ 36 
11.3 
Reporting Requirements ........................................................................................................................... 36 
11.4 
Reporting to the Study Sponsor ................................................................................................................ 36 
11.5 
Reporting to the Institutional Review Board (IRB) ................................................................................... 38 
11.6 
Reporting to Prometheus .......................................................................................................................... 38 
11.7 
Reporting to Hospital Risk Management .................................................................................................. 39 
11.8 
Monitoring of Adverse Events and Period of Observation ....................................................................... 39 
12. 
DATA AND SAFETY MONITORING .......................................................................................................... 40 
12.1 
Data Reporting ......................................................................................................................................... 40 
12.2 
Safety Meetings ......................................................................................................................................... 40 
12.3 
Monitoring ................................................................................................................................................ 41 
13. 
REGULATORY CONSIDERATIONS .......................................................................................................... 42 
13.1 
Protocol Review and Amendments ........................................................................................................... 42 
13.2 
Informed Consent ..................................................................................................................................... 42 
13.3 
Ethics ........................................................................................................................................................ 42 
13.4 
Study Documentation ................................................................................................................................ 43 
13.5 
Records Retention ..................................................................................................................................... 43 
13.6 
Multi-center Guidelines ............................................................................................................................ 43 
13.7 
Cooperative Research and Development Agreement (CRADA)/Clinical Trials Agreement (CTA) .......... 43 
14. 
STATISTICAL CONSIDERATIONS ............................................................................................................ 45 
14.1 
Study Design/Endpoints ............................................................................................................................ 45 
14.2 
Sample Size/Accrual Rate ......................................................................................................................... 45 
14.3 
Stratification Factors ................................................................................................................................ 46 
14.4 
Analysis of Secondary Endpoints .............................................................................................................. 46 
14.5 
Monitoring for Adverse Events. ................................................................................................................ 47 
15. 
PUBLICATION PLAN .................................................................................................................................... 47 

Phase II ECP and IL-2 for chronic GVHD 
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16. 
REFERENCES ................................................................................................................................................. 48 
17. 
APPENDICES .................................................................................................................................................. 52 
17.1 
Appendix A: PERFORMANCE STATUS .................................................................................................. 53 
17.2 
Appendix B: BODY SURFACE AREA AND CREATININE CLEARANCE .............................................. 54 
17.3 
Appendix C: New York Heart Association Classification of Heart Disease ............................................. 55 
17.4 
Appendix D: DEFINITE AND PROBABLE cGVHD MANIFESTATIONS ............................................... 56 
17.5 
Appendix E: CHRONIC GVHD SYMPTOM SCORING SCALE .............................................................. 57 
17.6 
Appendix F: cGVHD PARTIAL RESPONSE CRITERIA .......................................................................... 59 
17.7 
Appendix G: cGVHD PROGRESSION CRITERIA ................................................................................... 60 
17.8 
Appendix H: NCI COMMONTOXICITY CRITERIA ................................................................................ 61 
17.9 
Appendix J: INSTRUCTIONS FOR SUBCUTANEOUS INJECTION/DRUG DIARY .............................. 59 

Phase II ECP and IL-2 for chronic GVHD 
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1 
1. OBJECTIVES 
 
1.1 Study Design 
 
• Phase II trial to assess the efficacy of 16 week extracorporeal photopheresis (ECP) with 
the addition of daily low-dose subcutaneous (SC) interleukin-2 (IL-2) (Proleukin®) for 
weeks 8-16 in patients with steroid-refractory chronic graft-versus-host disease 
(cGVHD). 
 
1.2 Primary Objective 
 
• To determine the overall clinical response rate of ECP plus low-dose daily SC IL-2 in 
steroid-refractory cGVHD. 
 
1.3 Secondary Objectives 
 
• To determine toxicity of ECP plus low-dose SC IL-2 therapy. 
• To assess the immunologic effects of ECP plus low-dose daily SC IL-2 
• To determine ongoing prednisone use with ECP plus low-dose IL-2 therapy.   
• To assess overall survival, progression-free survival, non-relapse mortality and relapse at 
1 year after start of ECP plus low-dose IL-2. 
 

Phase II ECP and IL-2 for chronic GVHD 
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2 
2. BACKGROUND 
 
2.1 Study Disease: Graft vs. Host Disease 
For many patients with severe benign and malignant hematologic disorders, allogeneic 
hematopoietic stem cell transplant (HSCT) offers the only opportunity for cure.  Unfortunately, 
significant obstacles remain: most notably disease recurrence and GVHD. Over 40% of adult 
patients undergoing HSCT relapse while more than 50% will develop chronic GVHD (cGVHD), 
a debilitating condition with multi-system immune manifestations associated with a considerable 
morbidity and mortality. 1,2 Although the incidence in the pediatric population is lower, cGVHD 
remains a leading cause of non-relapse morbidity and mortality following allogeneic HSCT for 
malignant disease, occurring in 20 to 50% of children surviving greater than 100 days post-
HSCT. 3 Donor cell mediated immune responses are responsible for GVL and GVHD reactions. 
Inadequate recognition and destruction of residual tumor cells by a newly engrafted donor 
immune system permits recurrence of a patient’s malignancy, while uncontrolled reactions 
against host antigens lead to GVHD. 4,5 Chronic GVHD pathogenesis involves inflammatory T- 
and B-cell responses to allogeneic (donor/recipient polymorphic) and autologous 
(donor/recipient non-polymorphic) antigens. 
 
cGVHD remains a common problem and major therapeutic challenge after allogeneic HSCT, 
and long-term survivors often experience impaired quality of life and increased late mortality. 6  
The increasing use of mobilized peripheral blood progenitor cells rather than bone marrow as a 
source of stem cells for HCT has resulted in a clear increase in the incidence of cGVHD. 7,8 The 
inflammatory or fibrotic changes associated with cGVHD most commonly involve the skin, 
eyes, mouth, liver and respiratory tract. Systemic steroids are routinely used as first-line therapy 
to treat cGVHD but have limited efficacy and considerable toxicity. Second-line treatment 
options are limited and steroid-refractory cGVHD presents a major therapeutic challenge.  
 
Extracorporeal photopheresis (ECP) is an apheresis procedure that consists of UVA irradiation of 
apheresis-collected, autologous leukocytes that are sensitized with 8-methoxypsoralen (8-MOP) 
and subsequently reinfused. The mechanisms of ECP are incompletely understood. Most data 
about the mechanism of ECP are derived from mouse models, which support the regulatory T-
cell (Treg) hypothesis9-11. Treg are naturally occurring CD4+CD25+FOXP3+ T lymphocytes that 
comprise ~5-10% of the circulating CD4+ T cell population and act to dominantly suppress 
autoreactive lymphocytes and control innate and adaptive immune responses. 12-19  Additionally, 
in the context of ECP, induction of immature and plasmacytoid dendritic cells (DCs) through 
apoptotic T cells may precede increases in Treg20-23. Human data on ECP mechanisms selectively 
report Treg24,25 or DC phenotype26, but in heterogeneous populations, often without inclusion 
criteria or pre-ECP baseline data. 
 

Phase II ECP and IL-2 for chronic GVHD 
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3 
Despite mechanistic ambiguity, ECP is a routinely recommended and CMS-approved second-
line treatment for cGVHD.27 However, while safe, clinical benefit of ECP is limited. 
Approximately half of treated patients do not have a clinical response; partial response is the 
norm for responders; and taper of immune suppressants during extended ECP is slow and often 
incomplete. Improvements in treatment efficacy that can make ECP a more efficient therapy, 
with responses and steroid tapers achieved more quickly, is desirable. 
 
2.2 
Study Agent: Interleukin-2 
Native interleukin-2 (IL-2), a secreted glycoprotein with a molecular weight of approximately 15 
kilodalton (kD), was first identified in 1976 as a growth factor for T lymphocytes. It is produced 
by the majority of human CD4+ lymphocytes; and some cells of the CD8+ T-cell phenotype. IL-
2 is known to play a central role in the generation of immune responses.  
 
In cancer clinical trials, high-dose recombinant IL-2 (e.g. IV bolus dose of 600,000 international 
units (IU)/kg every 8 hours for up to 14 doses) demonstrated antitumor activity in metastatic 
renal cell carcinoma (RCC) and metastatic melanoma. IL-2 was approved for the treatment of 
metastatic RCC in Europe in 1989 and in the US in 1992. In 1998, approval was obtained to treat 
patients with metastatic melanoma. Recombinant human IL-2 (Aldesleukin) (Proleukin®-
Novartis Inc. & Prometheus Labs Inc.) is currently approved by the United States Food and Drug 
Administration (US FDA). 
 
2.2.1 Mechanism of Action 
 
Native interleukin-2 (IL-2) was initially identified as a lymphocyte growth factor, and thought 
primarily to promote effector T cell responses in vivo, is now known to be a cytokine critical for 
the development, expansion, survival and peripheral activity of regulatory T cells (Treg). 28,29  
 
Treg are naturally occurring CD4+CD25+FOXP3+ T lymphocytes that comprise ~5-10% of the 
circulating CD4+ T cell population, act to dominantly suppress autoreactive lymphocytes, and 
control innate and adaptive immune responses. 12-19  Treg may be of benefit in the graft-versus-
host disease (GVHD) context. In a murine model, a 1:1 mix of CD4+CD25+ Treg and CD25- 
effector T cells added to bone marrow stem cells suppressed alloimmune activation and GVHD 
without increasing malignant relapse post-transplant. 30 In the clinical context, we documented 
impaired Treg reconstitution in allogeneic transplant recipients with active chronic GVHD 
(cGVHD). 31,32 
 
This hitherto unexpected role for IL-2 in Treg homeostasis and function may explain its limited 
efficacy as anti-cancer therapy, and explain in part the finding that in-vivo administration of IL-2 
plus syngeneic T cell depleted donor marrow prevents GVHD after mismatched murine allo-

Phase II ECP and IL-2 for chronic GVHD 
Version 2.0; August 15, 2016 
 
 
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4 
SCT, without impacting GVL responses. 33,34 More directly, in murine allo-HSCT models co-
infusion of Tregs expanded ex-vivo with IL-2 also resulted in suppression of GVHD, with 
improved immune reconstitution and preserved GVL responses. 35,36 In humans, IL-2 has been 
shown to regulate FOXP3 expression in Tregs and induce their expansion in-vivo. 37 We 
hypothesized that in patients with active cGVHD, Treg enhancement in-vivo with IL-2, if 
achievable, may help suppress effector T cell responses to allo-antigens (and auto-antigens) 
expressed in the recipient, and promote tolerance to these antigens. 
 
2.2.1.1  Nonclinical Pharmacology 
 
Il-2 pharmacokinetics has been evaluated in mice, rats, rabbits, sheep, pigs, cynomolgus 
monkeys. All species tested exhibited effects that were directly or secondarily related to the 
pharmacological actions of IL-2. After SC administration, absorption of IL-2 was slow and the 
mean resident time was prolonged compared with IV administration. In general, the 
pharmacokinetics of IL-2 appear to be linear across tested species (including humans), and are 
discussed in the clinical pharmacology section below.  
2.2.1.2 Nonclinical Toxicity 
 
IL-2 administration by the SC route has been evaluated in several multiple-dose studies in rats 
for up to 13 weeks of daily administration (Study Numbers 452480, 452496, and CIQ/002). They 
confirmed that the SC high-dose toxicity profile in rats was comparable to the high-dose toxicity 
profile after IV administration. IL-2-related findings included lymphocytosis, eosinophilia, slight 
anemia, extramedullary hematopoiesis, lymphoid hyperplasia, hepatomegaly and splenomegaly. 
Infiltrative and proliferative changes were seen in many organs, including liver, lung, lymph 
nodes, kidney, spleen and bone marrow. In rabbit SC tolerability studies (Study Numbers 562794 
and 3391.9), after 7 days of dosing, local inflammatory responses at the injection site were 
consistent with the known effects of IL-2 and with injection-site reactions reported in human 
trials.  
 
In summary, the toxicity of IL-2 in animals has been shown to be dose- and duration-related, 
with all toxic effects being directly or secondarily related to IL-2 pharmacological activity. In all 
species, treatment-related effects were fully or partially reversible after a treatment-free period of 
2-4 weeks. Findings were comparable after repeated IV or SC administration of IL-2. The 
severity of target organ toxicity has been correlated with the extent of inflammatory cell 
infiltration into these organs. Biological effects in animals were generally similar to effects 
reported in clinical trials. However, these MTD studies relate to the high-dose IL-2 used for 
treatment of metastatic RCC and melanoma, rather than the low-dose IL-2 proposed for in-vivo 

Phase II ECP and IL-2 for chronic GVHD 
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5 
Treg enhancement in our study. Additional information regarding the nonclinical pharmacology 
and toxicology of IL-2 may be found in the September 10, 2003 Proleukin Investigator’s 
Brochure (Chiron Corporation). 
2.2.1.3 Clinical Pharmacokinetics and Pharmacodynamics 
IL-2 pharmacokinetics has been evaluated in patients with cancer and with HIV. Following a 
short IV infusion, the pharmacokinetic profile of IL-2 was characterized by high plasma 
concentrations, rapid distribution into the extravascular space, and elimination from the body 
with a half-life of 1-2 hours. After SC administration absorption of IL-2 was slow and the mean 
resident time was prolonged compared with IV administration. Maximum plasma concentration 
of IL-2 in HIV patients was achieved within 2-5 hours after SC dosing and the terminal phase 
half-life was estimated at 5 hours, suggesting prolonged absorption. 
The clearance rates for bolus infusion and continuous IV infusions are approximately equal. As 
expected from its short half-life, steady state is expected to be reached approximately 6 hours 
after infusion. Data on SC IL-2 administration suggest that approximately 35% is absorbed into 
the bloodstream, with greater bioavailablity (>60%) reported in a study involving HIV-infected 
participants.  
Five days of treatment by either SC or continuous IV administration in cancer patients or HIV 
patients resulted in a time-dependent increase in IL-2 clearance. This increase was associated 
with an increase in serum levels of soluble IL-2 receptor. Drug-free days between cycles of IL-2 
dosing restored the clearance of IL-2 to its initial value. 
There are at least 3 mechanisms of clearance that account for the systemic removal of IL-2: 
glomerular filtration, peritubular extraction, and an inducible receptor-mediated mechanism (in 
man). Peritubular extraction of small peptides and proteins from the postglomerular capillaries 
into the renal tubules and subsequent intracellular catabolism is a renal mechanism of 
elimination that occurs independent of glomerular filtration. Receptor-mediated clearance is 
primarily a function of IL-2 engaging its specific cellular receptor on responsive cells. The 
majority of IL-2 receptors are on T cells, and NK cells, though other cell types such as B cells 
have functional IL-2 receptors. 
In patients with metastatic melanoma or renal cell cancer treated with high-dose bolus IL-2, 
nearly 6 fold increase in CD4+CD25+ Treg cells was observed, with 4 fold increase in the 
frequency of circulating CD4+FOXP3+ Treg cells. 38 Considerable clinical data on the effects of 
IL-2 in patients with metastatic cancer have been accumulated over the past two decades. At the 
high doses of IL-2 used in most cancer trials, considerable toxicity has been documented, with 
only occasional tumor responses. Fever, hypotension, jaundice, and azotemia have been frequent 
complications, often necessitating admission to intensive care units. HSCT patients are unlikely 
to tolerate the toxicity of high-dose IL-2.  

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Low-dose IL-2, administered S.C. for extended periods, has been evaluated in patients with HIV 
infection and cancer.  In one study of ‘ultra-low-dose’ IL-2, seven patients with HIV and Non-
Hodgkin’s Lymphoma in first remission received 1 x 106 IU/m2/d of IL-2 (Chiron). 39. After ~8 
weeks of treatment, single-agent IL-2 therapy led to statistically significant, proportional 
increases in NK cells (1.6-fold) and Tregs (9-fold). Other lymphocyte subsets were not 
significantly changed. Toxicity was mild (fatigue, local pruritis, myalgia, increased 
transaminases etc.), with no Grade 3 adverse events. 
Low-dose IL-2 has also been safely used in patients with hematologic malignancy after 
allogeneic HSCT. In one study, IL-2 (Amgen, Roche) was administered by continuous IV 
infusion to 29 asymptomatic patients after CD6+ T-cell depleted (TCD) allogeneic HSCT at 
doses ranging from 2-6 x 105 IU/m2/d, (≈ 0.6-1.8 x 106 U/m2/d of IL-2 (Chiron): personal 
communication) for periods of up to 3 months. 40 Low dose IL-2 was well tolerated, with only 4 
patients withdrawn early due to toxicity. Interestingly, acute GVHD developed in only 1 of the 
29 patients. In addition to the expected NK cell expansion, in 7 of 8 patients evaluated, a 45% 
median increase in CD4+ CD25+ T lymphocytes occurred, likely representing Tregs. Further, a 
median ~8.5 fold increase of FOXP3 expression was noted, also indicating substantial Treg 
enhancement. 37 
Since low-dose IL-2 has been tolerable post allo-SCT, and can result in significant expansion of 
Tregs that function to suppress allo-immune responses underlying GVHD, we postulated that it 
may be safe and effective therapy for active chronic GVHD.  Since IL-2 also has stimulatory 
effects on cytotoxic T and NK cells, it was however possible that exacerbation or progression of 
chronic GVHD may occur while on IL-2. 
2.2.1.4 Clinical Experience 
 
In DFCI 07-083, we assessed safety of low-dose interleukin-2 in participants with refractory 
active cGVHD. 41 The primary objective was to determine the MTD and toxicity of an 8-week 
course of low-dose IL-2 in chronic GVHD participants with an inadequate response to steroids. 
Eligibility included cGVHD that had not responded to at least 0.25 mg/kg prednisone for a 4 
week period, the absence of infection, and stable doses of immune suppression for 4 weeks prior. 
The study had a Phase 1 dose escalation design with 3 dose levels (0.3-, 1-, 3-; x 106 IU/m2/day 
for 8 weeks).   
 
29 participants accrued: 28 evaluable for toxicity; 23 for response. IL-2 at 1 x 106 IU/m2/day was 
determined to be MTD. Two participants developed dose-limiting-toxicity (thrombotic 
microangiopathy). None experienced GVHD flare. There was no malignant disease relapse. 12 
of 23 participants had objective clinical responses. Low-dose IL-2 selectively increased Treg 
counts in-vivo (Figure 1) without impacting conventional CD4+ T (Tcon) counts. The Treg:Tcon 
ratio also rose (Figure 2). NK cell counts rose to a lesser extent. Low-dose IL-2 did not impact 
CD8+ T, B, or NKT counts. Treg count and Treg:Tcon ratio remained elevated at 8 weeks of IL-

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2, then declined off IL-2. IL-2-induced Treg expressed FoxP3+ and were functional in Tcon 
suppression assays. Importantly, clinical and immunologic responses were sustained in 
responders on extended-duration IL-2 therapy beyond 12 weeks, enabling a taper of concomitant 
immunosuppression.  
 
Figure 1 (below left). Expansion of CD4 Treg during treatment with daily low-dose IL-2. Gating on 
CD3+CD4+ T, Treg are defined as CD25+CD127- (black) and Tcon are CD25-CD127+ (blue). The 
%Treg within the CD4 gate is indicated in each plot. Figure 1 depicts a representative patient on Dose 
Level B. 
 
 
 
 
 
 
 
Figure 1  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Figure 2 
Figure 2 (above right): Median Treg:Tcon ratio on IL-2 therapy. There was a rapid rise and sustained 
plateau within a few weeks of starting IL-2, and a decline after stopping IL-2. Medians with inter-quartile 
range are shown. 
 
These data indicate that low-dose IL-2 is safe in cGVHD and preferentially augments Treg. 
Similar Treg enhancement and clinical benefit was also documented in HCV-induced vasculitis. 
42 However, despite Treg enhancement, clinical responses occurred in only half the treated 
cGVHD participants; that we have confirmed in our recently accrued phase II trial (DFCI 11-
149, unpublished data). Additional combination-immunomodulatory strategies to enhance IL-2-
mediated immunologic and clinical responses may be beneficial.  
 
2.3 
Rationale 
 
The most common indication for ECP is glucocorticoid-refractory cGVHD after 
allogeneic HSCT. Initial studies in mouse models of acute GVHD indicate that the 
therapeutic mechanism of ECP is dependent on CD4+CD25+FOXP3+ regulatory T cells 
(Treg), which act to control auto- and alloimmune responses mediated by conventional 
T cells (Tcon). However, human data in support of the ECP Treg hypothesis are scant. In 

Phase II ECP and IL-2 for chronic GVHD 
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parallel, human trials of low-dose interleukin-2 (IL-2) for glucocorticoid-refractory 
cGVHD show clinical responses alongside in vivo increases in Treg number and 
function. As both ECP and low-dose IL-2 likely work through in vivo Treg 
enhancement, there is significant biologic plausibility that ECP treatment can be 
augmented with low-dose IL-2. 
 
Combination ECP and low-dose IL-2 is a novel and innovative strategy that offers 
conceptual and practical advantages over either approach alone. The combined 
intervention strategy is designed to maximally modulate Treg expansion in order to 
better suppress cGVHD. IL-2 delivers a proliferative and survival signal to Treg both in 
vitro and in vivo. We previously showed that low-dose IL-2 can be safely administered 
to cGVHD patients and preferentially expands Treg in vivo to induce clinical responses. 
The one randomized, phase II trial of ECP for cGVHD showed that complete or partial 
skin responses were higher in the ECP group (40% vs. 10%, P=0.002)43. Of all GVHD 
manifestations, skin GVHD is the most responsive to ECP.44 IL-2 therapy likewise has 
greatest success with skin responses (44% response rate)41. To maximally enhance 
suppressive Treg for cGVHD control, we will evaluate the mechanism and efficacy 
of ECP plus the sequential addition of daily low-dose IL-2 administration in 
patients with glucocorticoid-refractory cGVHD. 
 
Importantly, 4 DFCI patients are already receiving IL-2+ECP for refractory cutaneous 
cGVHD with no side effects. All had objective cGVHD responses at 3 months with 
increased skin suppleness and all elected to continue ECP+IL-2. Importantly, 2 of 2 
subjects tested had an in vivo Treg rise with ECP+IL-2 compared to monotherapy. One 
patient with a PR to IL-2 initiated ECP during extended IL-2 therapy, with enhanced 
cGVHD clinical response and a 1.7-fold rise in Treg compared to IL-2 alone. In another 
patient with inadequate response to ECP, the addition of low-dose IL-2 induced 
cGVHD response along with a 33-fold rise in Treg compared to ECP alone. 
 
We therefore plan a phase II clinical trial combining ECP plus low-dose IL-2 for 
glucocorticoid-refractory cGVHD. Our short-term goals are to evaluate the Treg 
impact of ECP and of ECP plus low-dose IL2 in glucocorticoid-refractory cGVHD. We 
hypothesize that clinical and immunologic responses to ECP can be further enhanced 
by low-dose IL-2; as both ECP and IL-2 quantitatively and qualitatively enhance Treg 
function in cGVHD. We will evaluate these hypotheses in a 16 week trial of twice-
weekly ECP in weeks 1-16, with the sequential addition of daily low-dose IL-2 dosed at 
1x106 IU/m2/day during weeks 8-16, with the long-term goal of optimizing ECP 
treatment for cGVHD. 
 
  
2.4 
Correlative Studies Background 
 

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As in the previous Phase I clinical trial, peripheral blood samples obtained before, 
during and after ECP and ECP + IL-2 therapy will be used to assess the immunologic 
effects of treatment. The types of studies carried are briefly summarized below. 
 
Phenotypic analysis of lymphocyte subsets: Incubation of peripheral blood samples 
with monoclonal antibodies specific for lymphocyte markers is used routinely to 
identify functionally distinct lymphocyte subsets. After incubation of peripheral blood 
cells with directly fluorochrome-conjugated monoclonal antibodies, individual subsets 
are enumerated by flow cytometry. In this clinical trial, antibody panels have been 
developed to identify CD4+ regulatory T cells as well as other CD4 and CD8 T cell 
subsets, B cells, dendritic cell (DC) subsets, and natural killer (NK) cells. These studies 
will allow us to measure quantitative changes of individual populations that occur as a 
result of IL-2 treatment. We will correlate these changes with dose of ECP treated cells, 
determined by flow cytometric cell counts of the reinfused buffy coat from each ECP 
procedure. 
 
Plasma cytokines:  ELISA assays will be used to measure levels of IL-2 in plasma 
samples. Other cytokines, such as IL-7, IL-10, and IL-15, which play a role in T cell 
homeostasis, can also be measured in these samples. 
 
Functional assays:  To assess the functional capacity of regulatory T cells that expand 
in response to ECP and ECP + IL-2 treatment, selected samples will be used to assess 
the immune suppressive function of these cells.  In these experiments, Treg are purified 
by high speed cell sorting and subsequently tested for their ability to suppress the 
proliferation of autologous T cells. 
 
Taken together, these assays will define and quantify the immunologic effects of ECP 
and ECP + IL-2 treatment on regulatory T cells and other immune cells.  
 

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3. PARTICIPANT SELECTION 
 
3.1 
Eligibility Criteria 
 
Participants must meet the following criteria on screening examination to be eligible to 
participate in the study: 
 
3.1.1 Recipients of 7-8/8 HLA matched adult donor allogeneic stem cell transplantation 
with myeloablative or non-myeloablative conditioning regimens. 
 
3.1.2 Participants must have steroid-refractory cGVHD. Steroid-refractory cGVHD is 
defined as having persistent signs and symptoms of cGVHD (Appendix D; section 
17.4) despite the use of prednisone at ≥ 0.25 mg/kg/day (or 0.5 mg/kg every other 
day) for at least 4 weeks (or equivalent dosing of alternate corticosteroids) without 
complete resolution of signs and symptoms. Patients with either extensive chronic 
GVHD or limited chronic GVHD requiring systemic therapy are eligible. 
 
3.1.3 Stable dose of corticosteroids for 4 weeks prior to enrollment. Exception permitted 
with overall PI approval.  
 
3.1.4 No addition or subtraction of other immunosuppressive medications (e.g., 
calcineurin-inhibitors, sirolimus, mycophenolate-mofetil) for 4 weeks prior to 
enrollment. The dose of immunosuppressive medicines may be adjusted based on 
the therapeutic range of that drug 
   
3.1.5  Patient age ≥18 years old. Because no dosing or adverse event data are currently 
available on the use of IL-2 in participants <18 years of age, children are excluded 
from this study. 
 
3.1.6 Estimated life expectancy greater than 3 months. 
 
3.1.7 ECOG performance status 0-2 (Appendix A; section 17.1). 
  
3.1.8 Participants must have adequate organ function as defined below: 
• Hepatic: Adequate hepatic function (total bilirubin <2.0 mg/dl-exception 
permitted in patients with Gilbert’s Syndrome; AST (SGOT)/ALT (SGPT) ≤2x 
ULN), unless hepatic dysfunction is a manifestation of presumed cGVHD.  For 
patients with abnormal LFTs as the sole manifestation of cGVHD, documented 
GVHD on liver biopsy will be required prior to enrollment.  Abnormal LFTs in the 
context of active cGVHD involving other organ systems may also be permitted if 

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the treating physician documents the abnormal LFTs as being consistent with 
hepatic cGVHD, and a liver biopsy will not be mandated in this situation. 
• Renal: Serum creatinine within normal institutional limits or creatinine 
clearance > 60 mL/min/1.73 m2 for participants with creatinine levels above 
institutional normal. 
• Pulmonary: FEV1 ≥ 50% or DLCO(Hb) ≥ 40% of predicted, unless pulmonary 
dysfunction is deemed to be due to chronic GVHD. 
• Adequate bone marrow function indicated by ANC>1000/mm3 and 
platelets>50,000/mm3 without growth factors or transfusions 
• Cardiac: No myocardial infarction within 6 months prior to enrollment or 
NYHA Class III or IV heart failure, uncontrolled angina, severe uncontrolled 
ventricular arrhythmias, or electrocardiographic evidence of acute ischemia or 
active conduction system abnormalities. Prior to study entry, any ECG abnormality 
at screening must be documented by the investigator as not medically relevant. 
 
3.1.9 The effects of IL-2 on the developing human fetus are unknown. For this reason 
and because chemotherapeutic agents are known to be teratogenic, women of child-
bearing potential and men must agree to use adequate contraception (hormonal or 
barrier method of birth control; abstinence) prior to study entry and for the duration 
of study participation. Should a woman become pregnant or suspect she is pregnant 
while participating in this study, she should inform her treating physician 
immediately. 
 
 
 
3.1.10 Ability to understand and the willingness to sign a written informed consent 
document. 
 
3.2 
Exclusion Criteria 
 
Participants who exhibit any of the following conditions at screening will not be 
eligible for admission into the study. 
 
3.2.1 Ongoing prednisone requirement >1 mg/kg/day (or equivalent).  
 
3.2.2 Concurrent use of calcineurin-inhibitors plus sirolimus. Either agent alone is 
acceptable. 
 
3.2.3 History of thrombotic microangiopathy, hemolytic-uremic syndrome or thrombotic 
thrombocytopenic purpura. 
3.2.4 Exposure to any new immunosuppressive medication in the 4 weeks prior to 
enrollment. 

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3.2.5 Extra-corporeal Photopheresis (ECP) or rituximab therapy within 4 weeks prior to 
enrollment 
3.2.6  Any contraindication to ECP, i.e. contraindication to heparin or 8-MOP. 
3.2.7 Post-transplant exposure to any novel immunosuppressive medication (e.g., 
alemtuzumab) within 100 days prior to enrollment.  
3.2.8 Donor lymphocyte infusion within 100 days prior to enrollment.  
3.2.9 Active malignant relapse.  
3.2.10 Active uncontrolled infection. 
3.2.11 Inability to comply with IL-2 treatment regimen. 
3.2.12 Uncontrolled cardiac angina or symptomatic congestive heart failure (NYHA 
Class III or IV: Appendix C; section 17.3). 
3.2.13 Organ transplant (allograft) recipient. 
3.2.14 HIV-positive individuals on combination antiretroviral therapy are ineligible 
because of the potential for pharmacokinetic interactions with the agents used after 
allogeneic HSCT. In addition, these individuals are at increased risk of lethal infections. 
Appropriate studies will be undertaken in participants receiving combination 
antiretroviral therapy when indicated. 
3.2.15 Individuals with active hepatitis B or C are ineligible as they are at high risk of 
lethal treatment-related hepatotoxicity after HSCT. 
 
3.2.16 Other investigational drugs within 4 weeks prior to enrollment, unless cleared by 
the Principal Investigator. 
 
3.2.17 Pregnant women are excluded from this study because of the potential for 
teratogenic or abortifacient effects. Because there is an unknown but potential risk of 
adverse events in nursing infants secondary to treatment of the mother, breastfeeding 
should be discontinued. 
3.3 
Inclusion of Women, Minorities and Other Underrepresented Populations 
 
We do not restrict study access for any participant based on gender, ethnicity or 
socioeconomic status. 
 
 

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4. REGISTRATION PROCEDURES 
   
4.1 
General Guidelines for DF/HCC and DF/PCC Institutions 
 
Institutions will register eligible participants with the DF/HCC Quality Assurance 
Office for Clinical Trials (QACT) central registration system. Registration must 
occur prior to the initiation of therapy. Any participant not registered to the protocol 
before treatment begins will be considered ineligible and registration will be denied.  
 
A member of the study team will confirm eligibility criteria and complete the 
protocol-specific eligibility checklist. 
  
Following registration, participants may begin protocol treatment. Issues that 
would cause treatment delays should be discussed with the Principal Investigator. If 
a participant does not receive protocol therapy following registration, the participant’s 
protocol status must be changed. Notify the QACT Registrar of participant status 
changes as soon as possible. 
 
4.2 
Registration Process for DF/HCC and DF/PCC Institutions 
 
The QACT registration staff is accessible on Monday through Friday, from 8:00 AM to 
5:00 PM Eastern Standard Time. In emergency situations when a participant must begin 
treatment during off-hours or holidays, call the QACT registration line at 
 
and follow the instructions for registering participants after hours. 
   
The registration procedures are as follows: 
 
1. 
Obtain written informed consent from the participant prior to the performance 
of any study related procedures or assessments. 
 
2. 
Complete the protocol-specific eligibility checklist using the eligibility 
assessment documented in the participant’s medical/research record. To be 
eligible for registration to the study, the participant must meet each 
inclusion and exclusion criteria listed on the eligibility checklist. 
  
Reminder: Confirm eligibility for ancillary studies at the same time as 
eligibility for the treatment study. Registration to both treatment and ancillary 
studies will not be completed if eligibility requirements are not met for all 
studies. 
  
3. 
Fax the eligibility checklist(s) and all pages of the consent form(s) to the 
QACT at 
 

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Exception: DF/PCC Affiliate sites must fax the entire signed consent form 
including HIPAA Privacy Authorization and the eligibility checklist to the 
Network Affiliate Office. The Network Affiliate Office will register the 
participant with the QACT. 
  
4. 
The QACT Registrar will (a) validate eligibility, (b) register the participant on 
the study, and (c) randomize the participant when applicable. 
  
5. 
The QACT Registrar will send an email confirmation of the registration 
and/or randomization to the person initiating the registration immediately 
following the registration and/or randomization. 
  
4.3 General Guidelines for Other Participating Institutions 
 
Please refer to Section 2.3 of the Data and Safety Monitoring Plan (Appendix I). 
 
4.4 
Registration Process for Other Participating Institutions 
 
Please refer to Section 4.7 of the Data and Safety Monitoring Plan (Appendix I) 
 
5. TREATMENT PLAN  
 
Study therapy: 
 
Each study participant will receive standard-of-care twice-weekly ECP for 16 weeks as per 
the transfusion medicine SOP.  Briefly, ECP will be performed with the Therakos UVAR 
XTS or Cellex systems. Blood volume processed and 8-MOP dosing will be determined by 
subject hematocrit and blood volume per manufacturer guidelines. Clinical responders may 
continue ECP as standard-of-care after week 16, with or without extended-duration IL-2 
therapy. If participants on ECP experience worsening of cGVHD requiring additional therapy 
prior to week 8, they may initiate low-dose IL-2 early, in consultation with the study PI. 
 
After week 8, participants will initiate daily low-dose SC IL-2 (1 x 106 IU/m2/day) for self-
administration for the remaining 8 weeks of ECP, i.e. from end of week 8-16. IL-2 will be 
typically administered on an outpatient basis. Expected toxicities and potential risks as well as 
dose modifications are described in Section 6 (Expected Toxicities and Dosing Delays/Dose 
Modification).  Reference the extended-duration therapy section below for information 
concerning IL-2 therapy starting after Week 16. 
 

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Prednisone (or equivalent steroid) will be continued concomitantly with IL-2 without dose 
modification. Taper of prednisone will be permitted at the discretion of the treating physician 
if deemed in the participant’s interest (e.g. steroid toxicity). 
 
Of note, clinically stable cGVHD during taper of other immune suppression medications will 
be considered evidence of IL-2 efficacy; and progression of cGVHD during taper of other 
immunosuppressive therapy will not be considered evidence of IL-2 toxicity or lack of 
efficacy. 
 
Reference Section 6.2 for instructions on dose modifications and delays of IL-2. 
 
Extended-duration therapy:  
After completing the 16 week study, patients experiencing clinical benefit (complete or partial 
response; as well as minor response not meeting NIH criteria for partial response) with an 
acceptable toxicity profile will be permitted to continue extended-duration IL-2 treatment 
indefinitely at the discretion of the treating physician. Restarting on extended-duration 
treatment can be delayed for only up to 2 weeks for justifiable clinical or administrative 
reasons.  Longer delays in restarting treatment will have to be approved by the Principal 
Investigator. While on extended-duration IL-2, patients will be reassessed every 4 weeks to 
determine if IL-2 therapy should continue, at the discretion of the treating physician, who will 
document the rationale for the continued IL-2 therapy.  
 
Toxicity data for extended-duration IL-2 will be collected on an ongoing basis and all 
treatment-related SAEs (per section 11.2) will be reported to the Principal Investigator and the 
IRB.  Taper of other immune suppression medications during extended-duration IL-2 will be 
at the discretion of the treating physician. Addition of other cGVHD therapies to enhance 
response may be permitted for participants continuing on extended-duration therapy, at the 
discretion of the treating physician. While on extended-duration therapy, participants may 
have their dose modified in the event of toxicity per guidelines in Section 6.2 or at the 
discretion of the treating physician, in consultation with the Overall PI.  
The required assessments for patients on extended-duration IL-2 therapy include:  
 
1) Clinic visits locally or at study center for evaluation of toxicity and clinical benefit of IL-2 
every 4 weeks (± 2 weeks). Required laboratory tests: CBC with differential; Serum 
Chemistries-glucose, BUN, creatinine, total bilirubin, alkaline phosphatase, AST, ALT, 
calcium. 
 
2) Clinic visits at study center every 8 weeks (± 4 weeks). Required laboratory tests (in 
addition to above): immune assays that include quantitative serum immune globulins, plasma 
banking, and storage of additional mononuclear cells. 
 

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3) cGVHD assessments (Section 10.1) and cGVHD symptom score sheet every 16 weeks (± 4 
weeks) until 1 year from the start of IL-2 treatment or the participant stops IL-2 therapy, 
whichever comes first.    
 
 
5.1 
Pre-treatment Criteria 
  
5.1.1 The following evaluations must be performed within four weeks prior to ECP for 
all patients 
 
• 
Medical history and documentation of the rationale for treatment of the patient’s 
disease (including steroid dose). 
• 
Physical examination, including vital signs, weight, performance status. 
• 
cGVHD assessment (Section 10.1) 
• 
Pregnancy test for women of childbearing potential. 
• 
Hematology: Complete blood count (CBC) with differential. 
• 
Serum chemistries: glucose, BUN, creatinine, uric acid, total bilirubin, alkaline 
phosphatase, LDH, total protein, albumin, AST, ALT, and calcium. 
• 
Thyroid function tests (TSH, T4, free T4). 
• 
CMV viral load 
• 
Quantitative serum immune globulins 
• 
Immunology: plasma banking; and storage of additional mononuclear cells. 
 
5.1.2 The following evaluations are required (except where indicated) within four weeks 
prior to ECP for patients with cGVHD involving specific organ systems 
 
• 
Ocular examination with a Schirmer’s test, for patients with ocular cGVHD 
(optional). 
• 
Dermatologic assessment (± biopsy), for patients with cutaneous cGVHD. 
• 
Oral examination (± biopsy), for patients with oral cGVHD (optional). 

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• 
Pulmonary function tests, for patients with pulmonary manifestations of cGVHD 
(within 4 weeks prior to treatment to 1 week after). 
• 
Flexion assessment of affected joints, for individuals with contractures or 
musculoskeletal involvement related to cGVHD. 
 
5.1.3 Evaluations during ECP and IL-2 treatment (End of Weeks 1, 2, 4, 6, 8, 9, 10, 12, 
14), and off-study (End of Week 16) 
 
• 
Medical history and clinical examination (including steroid dose, weeks 8 & 16).  
• 
Drug diary review with member of study team (starting with IL-2 treatment). 
• 
Toxicity assessment will be done on the same day as history and clinical 
examination. 
• 
Hematology: CBC with differential. 
• 
Serum chemistries: glucose, BUN, creatinine, uric acid, total bilirubin, alkaline 
phosphatase, LDH, total protein, albumin, AST, ALT, and calcium.  
• 
CMV Viral load (or per institutional practice). 
• 
Quantitative serum immune globulins (weeks 4, 8, 12, 16). 
• 
Immunology: plasma banking; and storage of additional mononuclear cells (weeks 
1, 2, 4, 6, 8, 9, 10, 12, 14, 16) 
• 
Thyroid function tests (TSH, T4, free-T4) (week 16) 
5.1.4 The following assessments are required (except where indicated) at end of week 8 
and 16 of study (in addition to cGVHD symptom score) for patients with cGVHD 
involving specific organs:  
 
• 
cGVHD assessment (Section 10.1)  
• 
Ocular examination with a Schirmer’s test, for patients with ocular cGVHD 
(optional). 

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• 
Dermatologic assessment (± biopsy), for patients with cutaneous cGVHD. 
• 
Oral examination (± biopsy), for patients with oral cGVHD (optional). 
• 
Pulmonary function tests, for patients with pulmonary manifestations of cGVHD. 
• 
Flexion assessment of affected joints, for individuals with contractures or 
musculoskeletal involvement related to cGVHD. 
 
5.2 Agent Administration  
 
 
5.2.1 IL-2 
 
Recombinant human IL-2 (Aldesleukin) (Proleukin®-Novartis Inc. & Prometheus 
Labs, Inc.) for this study is supplied free of charge by Prometheus Laboratories, 
Inc. 
 
5.2.2 Clinical Trial Materials 
Recombinant human IL-2 (Proleukin®) is supplied as a sterile, white to off-white, 
lyophilized cake in single-use vials containing 22 MIU of aldesleukin intended for 
intravenous (IV) administration. Store vials of lyophilized IL-2 in a refrigerator at 
2-8°C (36-46°F). Do not use beyond the expiration date printed on the label. 
 
5.2.3 Preparation, Handling, and Storage of Study Drug  
  Please refer to section 7.1 for detailed information in this regard.  
 
5.2.4 Drug administration and dosage schedule   
IL-2 may be self-administered by daily subcutaneous injection.  Teaching will be 
provided before the first subcutaneous injection (see Appendix J for instructions for 
subcutaneous injection).  
The pharmacist, or the primary pharmacy technician working under the 
supervision of the pharmacist, will prepare the drug under aseptic conditions.  The 
amount (in IU) of drug to be administered will be determined based on body surface 
area (BSA).  BSA is to be calculated using the DuBois formula. (Appendix B; section 
17.2).  The dose should be calculated based on body weight at screening, at a dose of 1 x 

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106 IU/m2/day. Subsequent dose modifications, if any, will be per the guidelines in 
section 6.2.    
DO NOT ADMINISTER AS INTRAVENOUS PUSH OR BOLUS.  
Premedications are not required prior to the first dose or later doses. 
 
5.3 
General Concomitant Medication and Supportive Care Guidelines   
Antiviral, antifungal and antibacterial prophylaxis and monitoring should follow 
institutional practice for routine cGVHD management guidelines. These typically 
include: daily acyclovir (or equivalent) for HSV prophylaxis, bactrim (or equivalent) for 
PCP prophylaxis, IV gammaglobulin for hypo-gammaglobulinemia, and optional azole 
use for fungal prophylaxis in higher risk patients; as well as monitoring of CMV viral 
load, beta-glucan and galactomannan levels. 
 
5.4 
Duration of Therapy 
 
Duration of therapy will be as per the schema outlined previously. In the absence of 
treatment delays due to adverse events, ECP plus IL-2 treatment may continue until 
one of the following criteria applies: 
 
• The subject withdraws consent 
• Non-compliance 
• Administrative reasons 
• Unacceptable adverse event 
• Life threatening anaphylactic reaction to IL-2 
• Other grade 4 toxic event (unless it is an asymptomatic correctable laboratory 
result, e.g. uric acid) 
• Recurrent or non-resolving grade 3 toxic event 
• Severe hematologic toxicity that persists or recurs (section 6.2). 
• Life threatening infection on IL-2, at the discretion of the treating physician. 
• Malignant relapse 
• Clinical worsening of GVHD requiring the addition of a new immunosuppressive 
medication per the judgment of the treating physician. An increase in the 
corticosteroid dose will be considered evidence of worsening GVHD. Changes in 
other immunosuppressive medication doses to maintain a therapeutic level alone 
will not be criteria for removal from the trial. 
• General or specific changes in the participant's condition render the participant 
unacceptable for further treatment in the opinion of the treating investigator. 
 

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5.5 
Duration of Follow Up  
 
Participants will be followed for 1 year from the start of ECP plus IL-2 therapy 
or until death, whichever occurs first. Participants removed from study for 
unacceptable adverse events will be followed until resolution or stabilization of the 
adverse event. Participants will also be asked to allow for long-term follow up so that 
late toxicities, should they occur, may also be identified.  Follow-up for participants 
benefiting on extended-duration therapy may continue beyond 1 year post start of IL-2. 
 
Follow up will be at study center if patients live locally or with their local oncology 
providers if they live remotely. For patients living remotely, phone calls to their local 
oncology providers may be made on a 6 monthly basis. 
  
5.6 
Criteria for Removal from Study  
 
Participants will be removed from study when any of the criteria listed in Section 
5.4 applies. The reason for study removal and the date the participant was 
removed must be documented in the study-specific case report form (CRF). 
Alternative care options will be discussed with the participant. 
 
In the event of unusual or life-threatening complications, participating investigators 
must immediately notify the Principal Investigator.  
 
John Koreth, MBBS DPhil, 
 
 
 

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6. EXPECTED TOXICITIES AND DOSING DELAYS/DOSE MODIFICATIONS  
 
Dose delays and modifications will be made using the following recommendations. Toxicity 
assessments will be done using the CTEP Version 4.0 of the NCI Common Terminology 
Criteria for Adverse Events (CTCAE) which is identified and located on the CTEP website 
at: http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm.  
 
ECP is a standard-of-care therapy and its adverse events, for instance, hemorrhage from 
heparin exposure, cytopenias, and procedure intolerance (i.e. constitutional symptoms or 
cardiovascular instability) are rare. 45 Apheresis physicians will evaluate for procedure-
related toxicities per the transfusion medicine SOP. ECP may also exacerbate underlying 
constitutional symptoms or cardiovascular instability, e.g. in the setting of mild dehydration, 
or suboptimally controlled hypertension. Such exacerbations are rare and transient and 
routinely managed by apheresis physicians per the transfusion medicine SOP.  
 
If possible, symptoms should be managed symptomatically. In the case of toxicity, 
appropriate medical treatment should be used (including anti-emetics, anti-diarrheals, etc.). 
 
All CTCAE grade 3 and higher adverse events experienced by participants will be collected, 
through the study and until the final week 16 study visit. Participants continuing to 
experience toxicity at the off study visit may be contacted for additional assessments until the 
toxicity has resolved or is deemed irreversible. 
 
The dose modifications in section 6.2 are recommended but not mandatory for participants 
proceeding on indefinite extended-duration IL-2 at the end of the 16 week study. 
  
6.1 
Anticipated Toxicities 
  
A list of the adverse events and potential risks associated with the agents administered 
in this study appear below and will determine whether dose delays and modifications 
will be made or whether the event requires expedited reporting in addition to routine 
reporting. 
 
6.1.1 Adverse Event List for IL-2 
 
IL-2 (Proleukin) is a commercial agent. The relevant side effects of low-dose IL-2 in HSCT 
patients are described below. Additional detailed toxicity information may be found in the 
Proleukin package insert that relates primarily to high-dose IL-2. 
 
• Local Reaction 

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Most patients receiving daily SC low-dose IL-2 reported injection site reactions, 
typically focal erythema that resolved in a few days; and induration that resolved 
after 2-3 weeks. Dose interruptions were occasionally required in patients with 
more marked induration (CTC grade 3).  Lengthy dose interruptions may result in 
patients being unevaluable for response (Section 6.2) 
 
• Constitutional symptoms 
In the HSCT setting, some patients on low-dose IL-2 developed fever, nausea and 
arthralgia within 72 hours of starting IL-2. Interruption of therapy resulted in 
symptom resolution with 3 days. Patients tolerated re-introduction of IL-2 at lower 
dose, with subsequent escalation to MTD dose. 
• Thyroid dysfunction  
Thyroid function test abnormalities were noted in some HSCT patients on low-
dose IL-2. Only one patient however developed clinical hypothyroidism 
necessitating therapy while on IL-2. After cessation of IL-2, thyroid function 
returned to normal. Hence, a thyroid panel (TSH, T4, free T4) levels will be 
checked at study entry and week 12 while on study. Patients with evidence for 
hypothyroidism will be worked up (antimicrosomal, antithyroglobulin antibodies) 
and given replacement thyroxine as clinically indicated. 
• Hematopoiesis 
Early post-HSCT, low-dose IL-2 caused an initial decrease in the absolute 
lymphocyte count in most patients after 1 week of therapy. Thereafter, with 
continued infusion, a steady increase in lymphocyte count occurred in all patients. 
Low dose IL-2 also caused an initial increase in eosinophil counts (peak at 3 weeks) 
followed by a gradual decline. No changes in monocyte or neutrophil counts were 
observed. 
The platelet count decreased by >20% in some HSCT patients on low-dose 
IL-2. This decrease was noted within the first 2 weeks on IL-2, and continued 
treatment was not associated with further declines in platelet count. No 
patients had >40% decline in platelet counts, and none required platelet 
transfusions or had bleeding episodes. 
No significant impact of low-dose IL-2 on hemoglobin levels or reticuloctye 
counts was noted. 
Suggested Guidelines for the Management of severe hematologic toxicity are per 
section 6.2. 
• Thrombotic Microangiopathy (TMA)  

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In DFCI 07-083, 2 patients on daily SC low-dose IL-2 developed SAE of 
thrombotic microangiopathy (thrombocytopenia, microangiopathic hemolytic 
anemia with schistocytosis, renal dysfunction) that was thought possibly related to 
IL-2. TMA is also a known complication of calcineurin-inhibitor and of sirolimus 
(both of which both the patients were on). One of the patients has required long-
term hemodialysis for management of renal dysfunction.  
 
6.1.2 Adverse Event Lists for Other Agents 
 
There is toxicity related to cGVHD and to the immune suppressive medications used in its 
treatment. These toxicities are routinely managed by the study investigators. For a 
comprehensive list of adverse effects, please refer to the package inserts of the individual 
immune suppressive agents 
 
 
6.2 
Dose Modifications/Delays 
 
Toxicities are to be assessed according to the NCI Common Toxicity Criteria for Adverse 
Events (CTCAE), Version 4.0 (Appendix H; section 17.8) 
 
• Anaphylaxis: Life threatening anaphylaxis related to IL-2 requires discontinuation of 
IL-2. 
• Thrombotic microangiopathy: TMA during IL-2 therapy requires discontinuation of 
IL-2 if it is associated with CNS dysfunction, renal dysfunction requiring 
hemodialysis/CVVH, or need for hospitalization. 
• CTC Grade 4 toxicity: Grade 4 non-hematologic toxicity related to IL-2 requires 
discontinuation of IL-2, unless it is an asymptomatic correctable lab test abnormality 
(e.g. uric acid). 
• CTC Grade 3 toxicity: IL-2 will be withheld for Grade 3 non-hematologic toxicities 
related to IL-2, unless it is an asymptomatic and correctable lab test result abnormality 
(e.g. uric acid). If the toxicity resolves to grade 1 or below within 2 weeks, IL-2 can be 
restarted at 50% dose that will not be re-escalated. If the toxicity does not resolve in 2 
weeks to grade 1 or below, or recurs to grade 3 or above after restarting IL-2, it will be 
discontinued. IL-2 may also be withheld for Grade 3 non-hematologic toxicities 
unrelated to IL-2 per physician discretion. If withheld, subsequent management is 
suggested per above guidelines.  
• Expected non-hematologic toxicity: IL-2 can be withheld and/or restarted at 50% dose 
for less than grade 3 toxicity (local site reactions, persistent constitutional symptoms) 
depending on patient tolerability and the discretion of the treating physician.  

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• Severe hematologic toxicity: IL-2 will be withheld for severe declines in peripheral 
counts (ANC<500, Plts<10,000) not related to malignant disease relapse, infection or 
other etiologies. If counts improve (ANC>1000, Plts>20,000) within 2 weeks, IL-2 
will be restarted at 50% dose and not re-escalated. If peripheral counts do not improve 
within 2 weeks, or drop again (ANC<500, Plts<10,000) after restarting IL-2, it will be 
discontinued. 
• Worsening of cGVHD: Clinical signs of worsening cGVHD while on IL-2 that require 
the addition of a new immunosuppressive medication (at the discretion of the treating 
physician), will be a criterion for IL-2 discontinuation. An increase in the 
corticosteroid dose above baseline will be considered evidence of worsening cGVHD. 
Changes in other immunosuppressive medication doses to maintain a therapeutic level 
alone will not be criteria for discontinuation of IL-2 or considered evidence of cGHVD 
worsening. 
• Infection: Of note, infection during IL-2 treatment is not considered IL-2 related, since 
both cGVHD and the concurrent use of immune suppression medications are known 
risk factors for infection. Infection is therefore considered an expected complication of 
cGVHD. However, patients who develop a CTC grade 3 or higher infection prior to 
week 6 of IL-2 therapy will have IL-2 withheld. They can be considered for restarting 
IL-2 at their prior dose after control of infection, at the discretion of the treating 
physician. 
 

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7. DRUG FORMULATION AND ADMINISTRATION 
 
7.1 
IL-2 
 
7.1.1 Description 
Native interleukin-2 (IL-2) is a secreted glycoprotein with a molecular weight of 
approximately 15 kilodalton (kD). The gene for IL-2 was isolated from the Jurkat 
leukemia cell line and expressed in Escherichia Coli. In contrast to native IL-2, 
recombinant IL-2 is non-glycosylated and differs at two amino acid positions. 
There are no discernable functional differences between native and recombinant 
forms of IL-2. 
 
IL-2 pharmacokinetics has been evaluated in patients with cancer and with HIV. 
Following a short IV infusion, the pharmacokinetic profile of IL-2 was 
characterized by high plasma concentrations, rapid distribution into the 
extravascular space, and elimination from the body with a half-life of 1-2 hours. 
After SC administration, absorption of IL-2 was slow and the mean resident time 
was prolonged compared with IV administration. Maximum plasma concentration 
of IL-2 in HIV patients was achieved within 2-5 hours after SC dosing and the 
terminal phase half-life was estimated at 5 hours, suggesting prolonged 
absorption. Data on SC IL-2 administration suggest that approximately 35% is 
absorbed into the bloodstream, with greater bioavailablity (>60%) reported in 
HIV-infected participants.  
 
There are at least 3 mechanisms of clearance of IL-2: glomerular filtration, 
peritubular extraction, and an inducible receptor-mediated mechanism (in man). 
Peri-tubular extraction of small peptides and proteins from the post-glomerular 
capillaries into the renal tubules and subsequent intracellular catabolism is a renal 
mechanism of elimination that occurs independent of glomerular filtration. 
Receptor-mediated clearance is primarily a function of IL-2 engaging its specific 
cellular receptor on responsive cells. The majority of IL-2 receptors are on T 
cells, and NK cells, though other cell types such as B cells have functional IL-2 
receptors. 
 
No pharmacologic interactions with other agents are anticipated in-vivo. 
  
7.1.2 Form 
 
Recombinant human IL-2 (Aldesleukin) (Proleukin®: Novartis Inc., & 
Prometheus Laboratories, Inc) is supplied as a sterile, white to off-white, 
lyophilized cake in single-use vials containing 22 MIU of aldesleukin.  

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For the 22 million international unit (MIU) vial, when reconstituted with 1.2 mL 
Sterile Water for Injection (SWFI), each mL contains 18 MIU (1.1mg) IL-2, 50 
mg mannitol and ~180 mcg sodium dodecyl sulphate, buffered with ~170 mcg 
sodium phosphate monobasic and 890 mcg sodium phosphate dibasic to a pH of 
7.5 (range: 7.2-7.8) 
  
7.1.3 Storage and Stability 
 
Store vials of lyophilized IL-2 in a refrigerator at 2-8°C (36-46°F). Do not use 
beyond the expiration date printed on the label. Vials should be entered only once 
for reconstitution to minimize the chances of contamination. If not used 
immediately, in-use storage times should normally not be longer than 24 hours at 
2-8°C, unless reconstitution has been performed under controlled and validated 
aseptic conditions in a laminar airflow hood. 
 
Data support stability and sterility of reconstituted diluted IL-2 preparations 
(reconstituted with SWFI and further diluted with D5W); and the stability and 
sterility of product reconstituted with SWFI but not further diluted, for up to 14 
days at 2-8°C (36-46°F) when single-use syringes for daily use are prepared by 
qualified health-care professionals under aseptic conditions (per Proleukin® 
Investigator’s Brochure (Chiron Corporation, 10 Sep 2003, pp113).  
 
Therefore, reconstitution and dilution of lyophilized IL-2 is to be performed under 
controlled and validated aseptic conditions in a laminar flow hood per DFCI 
pharmacy policy and procedure manual . The dose or doses thus prepared and 
stored at 2-8°C (36-46°F) need to be used within 14 days.  
  
7.1.4 Compatibility 
 
IL-2 should be reconstituted with sterile water for injection (SWFI) plus D5W. 
Reconstitution or dilution with Bacteriostatic Water for Injection or 0.9% Sodium 
Chloride for Injection should be avoided due to increased aggregates. 
 
IL-2 is not given IV, or in combination with other agents, hence compatibility 
issues are not applicable. 
7.1.5 Handling 
 
The single-daily-use syringes containing reconstituted and diluted solutions 
should be stored in a refrigerator at 2-8°C. DO NOT FREEZE. The product 

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should be inspected visually for particulate matter or discoloration and brought to 
room temperature before administration. 
 
7.1.6 Availability 
 
IL-2 (Proleukin®) is a commercial agent
 
 
 
7.1.7 Preparation 
 
IL-2 will be reconstituted in 1 ml Becton Dickinson single use syringes. All IL-2 
 
 
 
  
 
 
  
7.1.8 Administration 
 
After reconstitution, an up to 2-week IL-2 supply will be provided in single-use 
syringes (in a cool-pack if necessary), for home refrigerator storage at 2-8 C. One 
single-use syringe will be used each day during home SC self-administration, and 
discarded in the sharps’ containers provided. Participants will be instructed to 
rotate injection sites, if feasible. 
  
7.1.9 Ordering 
 
 
 
  
 
  
  
 
 
 

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7.1.10 Accountability 
 
The investigator, or a responsible party designated by the investigator, must 
maintain a careful record of the inventory and disposition of the agent 
(investigational or free of charge) using the NCI Drug Accountability Record or 
another comparable drug accountability form.  
 
7.1.11 Destruction and Return 
 
At the end of the study, unused supplies of IL-2 should be destroyed according 
to institutional policies. Destruction will be documented in the Drug 
Accountability Record Form. 
 

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8. CORRELATIVE/SPECIAL STUDIES  
Investigational blood samples will be processed and banked with the Pasquarello Tissue 
Laboratory at DFCI.  Please refer to the study operations manual for details regarding 
processing and handling of study specimens. 
8.1 
Pharmacokinetic Studies 
 
N/A 
8.2 
Pharmacodynamic Studies 
 
N/A 
 

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9. STUDY CALENDAR 
 
Table 2: Summary of Required Data 
 
Within 4 
Wks prior 
(baseline) 
During Therapy 
(End of Wks 1, 
2, 4, 6, 8, 9, 10, 
12, 14)a 
End of 
Wk 16a 
Extended-
duration 
IL-2  
(4 Wkly)c 
Medical History 
X 
X 
X 
X 
Physical Exam 
X 
X 
X 
X 
Toxicity Assessment 
 
X 
X 
X 
cGVHD Symptom Score 
X 
Xb 
X 
 X# 
EKG 
X 
 
 
 
Pregnancy Test¶ 
X 
 
 
 
Pulmonary Function  
ο 
οb 
ο 
ο# 
Dermatologic Assessment 
ο 
οb 
ο 
ο# 
Oral Assessment 
ο 
οb 
ο 
ο# 
Flexion Assessment 
ο 
οb 
ο 
ο# 
Ocular Assessment 
ο 
οb 
ο 
ο# 
CBC with Diff 
X 
X* 
X 
X 
Serum Chemistry 
X 
X* 
X 
X 
Quantitative Immune 
Globulins 
X 
Xd 
X 
Xδ 
Immunology1 
X 
X 
X 
 Xδ 
Steroid Assessment2 
X 
Xb 
X 
 Xδ 
CMV Viral Load 
X 
X 
X 
X 
Thyroid Function 
X 
 
X 
 Xδ 
Drug Diary+ 
 
X 
X 
X 
X- Required Evaluation  
ο- Required for patients with clinical involvement of these organ systems (oral and ocular assessments are 
optional),  Baseline pulmonary function tests can be scheduled up to 4 weeks prior to start of treatment to 
1 week after for scheduling flexibility. 
1  Immunology: plasma banking; storage of additional mononuclear cells. 
2  Systemic steroids should not be tapered unless there is toxicity, e.g severe hyperglycemia (with 
permission of study PI). 
a  Testing at end of weeks 1, 2, 4, 6, 8, 9, 10, 12, 14 will be performed ±4 days, to allow for scheduling 
and administrative flexibility around weekends, holidays etc. 
b   Week 8 for steroid dose and cGVHD assessments.  
c  Testing during extended-duration therapy will be performed ±2 weeks, to allow for scheduling and 
administrative flexibility around patient travel, work, holidays etc. 
d Week 4, 8, 12. 

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* Laboratory testing of CBC/manual diff, serum creatinine and LDH will also be performed 4±2 days 
after IL-2 initiation, to assess for anemia, thrombocytopenia, schistocytes and/or renal dysfunction 
associated with thrombotic microangiopathy. 
 δ  Every 8 weeks (±4 weeks) at time of mandatory study-center follow-up. 
# Every 16 weeks (+/- 4 weeks) during year 1 at time of mandatory study-center follow-up. 
¶    For women of child-bearing potential. 
+   To be completed and returned to clinic at least every 2 weeks during study IL-2 treatment. To be 
completed at and returned to clinic at least every 8 weeks for extended-duration IL-2. 

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10. MEASUREMENT OF EFFECT  
 
Evaluable for toxicity- Participants who receive at least one dose of IL-2 will be 
evaluable for toxicity of IL-2 treatment. 
 
Evaluable for response- Participants who have received at least 4 weeks of ECP+IL-2 
and have had their disease re-assessed will be considered evaluable for combination 
ECP+IL-2 response. These participants will have their response classified according to 
the definitions stated below 
10.1 cGVHD Assessments 
Patients will undergo standardized cGVHD assessment per NIH guidelines (e.g., 
http://asbmt.affiniscape.com/associations/11741/files/ResponseCriteriaAPPENDIXAFor
mA.pdf ) at baseline and week 8 and 16 on study. 46  cGVHD response will be assessed 
per NIH consensus criteria. 47 Of note, oral and ocular sites will not be included in 
determination of response, as additional topical therapy is permitted for those sites. 
10.1.1 Complete response is defined as- Organ response: resolution of all reversible 
manifestations related to cGVHD in a specific organ; Overall response: resolution of all 
reversible manifestations in each organ or site of cGVHD involvement. Depending on 
relevant organ system involvement, patients will undergo repeat detailed assessment of 
ocular, oral, cutaneous, musculoskeletal and pulmonary systems. 
10.1.2 Partial response is defined as- Organ response: at least 50% improvement in the 
scale used to measure disease manifestations related to cGVHD (e.g. a 50% decrease in 
skin rash from 80% BSA to 40% BSA), with a minimum of 25% improvement in the full 
scale as opposed solely to a percentage of the starting value (Appendix F; Section 17.6); 
Overall response: improvement in measure at least one organ or site, without progression in 
measures at any other organ or site. Of note, for global ratings and categorical scales, a 1-
point change in a 3- or 7- point scale or a 2- to 3- change on a 0- to 10- point scale (0.5 SD 
change) would be considered clinically meaningful. Additionally, the hallmark for response 
to therapy for bronchiolitis obliteraans syndrome (BOS) is stabilization of lung function 
with no further decrease in FEV1 during a 3-month period.  
10.1.3 Non-responders (e.g., minor response, stable disease) will not have changes in 
cGVHD meeting NIH criteria for partial response or disease progression.  
10.1.4 Progressive disease- Organ progression: an absolute increase of at least 25% in the 
scale used to measure disease manifestations related to cGVHD (Appendix G; Section 
17.7). Of note, for global ratings and categorical scales, a 1-point change in a 3- or 7- point 
scale or a 2- to 3- change on a 0- to 10- point scale (0.5 SD change) would be considered 

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clinically meaningful. Additionally, ‘clinical worsening of cGVHD’ is not synonymous 
with progressive cGVHD per NIH criteria, as patients may experience worsening 
symptoms that do not meet objective NIH criteria for progression. If so, they still have the 
option of discontinuation of IL-2 and initiating additional immunosuppression for lack of 
IL-2 efficacy; at the judgment of the treatment physician, as per section 6.2. 
10.2 Chronic GVHD Symptom Score 
Patients will self-report symptoms and signs of cGVHD using the validated chronic GVHD 
Symptom Scale (Appendix E; section 17.5). Self-Reported symptom Scales will be 
obtained at baseline and weeks 8 and 16. 
10.3 Steroid Use for Chronic GVHD 
Patients will have their total daily dose of corticosteroids recorded at baseline, and at 8 and 
16 weeks. In the case of alternate daily dosing of corticosteroids, the average daily dose 
will be recorded for study purposes. 
10.4 Immune Assessment 
 
Patients will undergo testing for immunologic function, performed at baseline, and at 
weeks 1, 2, 4, 6, 8, 9, 10, 12, 14 and 16.  Testing will include: plasma banking and 
storage of additional mononuclear cells. Quantitative immune globulins will be tested at 
baseline and weeks 4, 8, 12, and 16.  
 

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11. ADVERSE EVENT REPORTING REQUIREMENTS 
11.1 Definitions 
11.1.1 Adverse Event (AE) 
 
An adverse event (AE) is any undesirable sign, symptom or medical condition or 
experience that develops or worsens in severity after starting the first dose of 
study treatment or any procedure specified in the protocol, even if the event is not 
considered to be related to the study.  
 
Abnormal laboratory values or diagnostic test results constitute adverse events 
only if they induce clinical signs or symptoms or require treatment or further 
diagnostic tests.  
11.1.2 Serious adverse event (SAE) 
 
A serious adverse event (SAE) is any adverse event, occurring at any dose and 
regardless of causality that:  
• Results in death 
• Is life-threatening. Life-threatening means that the person was at 
immediate risk of death from the reaction as it occurred, i.e., it does not 
include a reaction which hypothetically might have caused death had it 
occurred in a more sever form. 
• Requires or prolongs inpatient hospitalization (i.e., the event required at 
least a 24-hour hospitalization or prolonged a hospitalization beyond the 
expected length of stay). Hospitalization admissions and/or surgical 
operations scheduled to occur during the study period, but planned prior to 
study entry are not considered SAEs if the illness or disease existed before 
the person was enrolled in the trial, provided that it did not deteriorate in 
an unexpected manner during the trial (e.g., surgery performed earlier than 
planned). 
• Results in persistent or significant disability/incapacity. Disability is 
defined as a substantial disruption of a person’s ability to conduct normal 
life functions. 
• Is a congenital anomaly or birth defect; or 
• Is an important medical event when, based upon appropriate medical 
judgment, it may jeopardize the participant and require medical or surgical 
intervention to prevent one of the outcomes listed above. Examples of 
such medical events include allergic bronchospasm requiring intensive 
treatment in an emergency room or at home; blood dyscrasias or 

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convulsions that do not result in inpatient hospitalization, or the 
development of drug dependency or drug abuse. 
 
Events not considered to be serious adverse events are hospitalizations for: 
• routine treatment or monitoring of the studied indication, not associated 
with any deterioration in condition, or for elective procedures 
• elective or pre-planned treatment for a pre-existing condition that did not 
worsen 
• emergency outpatient treatment for an event not fulfilling the serious 
criteria outlined above and not resulting in inpatient admission 
• respite care 
 
11.1.3 Expectedness 
 
Adverse events can be 'Expected' or 'Unexpected.'  
11.1.3.1 Expected adverse event 
 
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.   
 
Refer to Section 6.1 for a listing of anticipated adverse events 
associated with IL-2. 
11.1.3.2 Unexpected adverse event 
 
 
For the purposes of this study, an adverse event is considered unexpected 
when it varies in nature, intensity or frequency from information 
provided 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.   
11.1.4 Attribution 
 
Attribution is the relationship between an adverse event or serious adverse event 
and the study treatment. Attribution will be assigned as follows: 
 
• Definite – The AE is clearly related to the study treatment. 

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• Probable – The AE is likely related to the study treatment. 
• Possible – The AE may be related to the study treatment.  
• Unlikely - The AE is doubtfully related to the study treatment. 
• Unrelated - The AE is clearly NOT related to the study treatment. 
11.2 Procedures for AE and SAE Recording and Reporting 
 
Reporting Participating investigators will assess the occurrence of AEs and SAEs at all 
participant evaluation time points during the study.  
 
All CTC grade 3 or higher AEs and all SAEs whether reported by the participant, 
discovered during questioning, directly observed, or detected by physical examination, 
laboratory test or other means, will be recorded in the participant’s medical record and 
on the appropriate study-specific case report forms. 
 
The descriptions and grading scales found in the CTEP Version 4.0 of the NCI 
Common Terminology Criteria for Adverse Events (CTCAE) will be utilized for AE 
reporting. The CTEP Version 4.0 of the CTCAE is identified and located on the CTEP 
website at: 
 
 http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm.  
 
All appropriate treatment areas should have access to a copy of the CTEP Version 4.0 
of CTCAE. 
11.3 Reporting Requirements 
 
For multi-site trials where a DF/HCC investigator is serving as the principal 
investigator, each participating investigator is required to abide by the reporting 
requirements set by the DF/HCC. The study must be conducted in compliance with 
FDA regulations, local safety reporting requirements, and reporting requirements of the 
principal investigator.  
 
Each investigative site will be responsible to report SAEs that occur at that institution 
to their respective IRB. It is the responsibility of each participating investigator to 
report serious adverse events to the study sponsor and/or others as described below.  
11.4 Reporting to the Study Sponsor 
11.4.1 Serious Adverse Event Reporting 
 

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DF/HCC: All serious adverse events that occur after the initial dose of IL-2 study 
treatment, during treatment, or within 30 days of the last dose of treatment must 
be reported to the DF/HCC Overall Principal Investigator on the local institutional 
SAE form. This includes events meeting the criteria outlined in Section 11.1.2, as 
well as the following: 
 
• Grade 2 (moderate) and Grade 3 (severe) events that are unexpected and at 
least possibly related/associated with the intervention. 
 
• All Grade 4 (life-threatening or disabling) events that are unexpected and 
not specifically listed in the protocol as not requiring reporting. Grade 4 
expected events related to stem cell transplantation that do not require 
reporting as SAEs include: neutropenia, neutropenic fever, 
thrombocytopenia, minor bleeding episodes (e.g. epistaxis), rashes, 
diarrhea, infections (e.g. pneumonia, line sepsis, cellulitis), VOD, TMA 
and GVHD as these are expected events related to stem cell 
transplantation. 
 
• All Grade 5 (fatal) events while the participant is enrolled and actively 
participating in the trial OR when the event occurs within 30 days of the 
last study intervention.  
 
Note: If the participant is in long term follow up, report the death at the time 
of continuing review.  
 
Participating investigators must report each serious adverse event to the DF/HCC 
Overall Principal Investigator within 24 hours of learning of the occurrence. In 
the event that the participating investigator does not become aware of the serious 
adverse event immediately (e.g., participant sought treatment elsewhere), the 
participating investigator is to report the event within 24 business hours after 
learning of it and document the time of his or her first awareness of the adverse 
event. Report serious adverse events by telephone, email or facsimile to: 
 
 
 
 
 
Within the following 24-48 hours, the participating investigator must provide 
follow-up information on the serious adverse event. Follow-up information should 
describe whether the event has resolved or continues, if and how the event was 

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treated, and whether the participant will continue or discontinue study 
participation. 
11.4.2 Non-Serious Adverse Event Reporting  
 
Non-serious adverse events will be reported to the DF/HCC Overall Principal 
Investigator on the toxicity Case Report Forms.   
11.5 Reporting to the Institutional Review Board (IRB) 
 
Investigative sites within DF/HCC will report all serious adverse events directly to the 
DFCI Office for Human Research Studies (OHRS). 
 
Other investigative sites should report serious adverse events to their respective IRB 
according to the local IRB’s policies and procedures in reporting adverse events. A 
copy of the submitted institutional SAE form should be forwarded to: 
 
 
 
 
 
The DF/HCC Principal Investigator will submit SAE reports from outside institutions 
to the DFCI Office for Human Research Studies (OHRS) according to DFCI IRB 
policies and procedures in reporting adverse events. 
  
11.6  Reporting to Prometheus 
 
A copy of any SAE report submitted to the DFCI IRB or FDA must be sent to Prometheus 
Laboratories. If the Interleukin-2 is a suspect or co-suspect drug reported on the FDA Form 
3500A MedWatch report, Prometheus Laboratories also requests a courtesy copy of the FDA 
Form 3500A MedWatch report that was submitted to the US Food and Drug Administration, 
via email or fax, to Drug Safety and Pharmacovigilance at Prometheus Laboratories, Inc. 
Please also include your contact information.  
 
 
 
 
 

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11.7 Reporting to Hospital Risk Management 
 
Participating investigators will report to their local Risk Management office any subject 
safety reports or sentinel events that require reporting according to `institutional policy. 
11.8 Monitoring of Adverse Events and Period of Observation 
 
All adverse events, both serious and non-serious, and deaths that are encountered from 
initiation of study intervention, throughout the study, and within 30 days of the last 
study intervention should be followed to their resolution, or until the participating 
investigator assesses them as stable, or the participating investigator determines the 
event to be irreversible, or the participant is lost to follow-up. The presence and 
resolution of AEs and SAEs (with dates) should be documented on the appropriate case 
report form and recorded in the participant’s medical record to facilitate source data 
verification.  
 
For some SAEs, the study sponsor or designee may follow-up by telephone, fax, and/or 
monitoring visit to obtain additional case details deemed necessary to appropriately 
evaluate the SAE report (e.g., hospital discharge summary, consultant report, or 
autopsy report).  
 
Participants should be instructed to report any serious post-study event(s) that might 
reasonably be related to participation in this study. Participating investigators should 
notify the DF/HCC Overall Principal Investigator and their respective IRB of any 
unanticipated death or adverse event occurring after a participant has discontinued or 
terminated study participation that may reasonably be related to the study.   
 

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12. DATA AND SAFETY MONITORING 
 
12.1 Data Reporting 
12.1.1 Method  
The QACT will collect, manage, and monitor data for this study.  
12.1.2 Data Submission  
The schedule for completion and submission of case report forms (paper or 
electronic) to the QACT is as follows: 
 
Form 
Submission Timeline 
Eligibility Checklist 
Complete prior to registration with QACT 
On Study Form 
Within 14 days of registration 
Baseline Assessment Form 
Within 14 days of registration 
Treatment Form 
Within 10 days of the last day of the cycle 
Adverse Event Report Form 
Within 10 days of the last day of the cycle 
Response Assessment Form 
Within 10 days of the completion of the cycle 
required for response evaluation 
Off Treatment/Off Study Form Within 14 days of completing treatment or 
being taken off study for any reason 
Follow up/Survival Form 
Within 14 days of the protocol defined follow 
up visit date or call 
 
12.2 Safety Meetings 
 
The DF/HCC Data and Safety Monitoring Committee (DSMC) will review and monitor 
toxicity and accrual data from this trial. The committee is composed of clinical 
specialists with experience in oncology and who have no direct relationship with the 

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study. Information that raises any questions about participant safety will be addressed 
with the Principal Investigator and study team. 
 
The DSMC will meet regularly to review toxicity and accrual data.  Information to be 
provided to the committee may include:  up-to-date participant accrual; current dose 
level information; DLT information; all grade 2 or higher unexpected adverse events 
that have been reported; summary of all deaths occurring within 30 days for Phase I or 
II protocols; for gene transfer protocols, summary of all deaths while being treated and 
during active follow-up; any response information; audit results, and a summary 
provided by the study team. Other information (e.g. scans, laboratory values) will be 
provided upon request.  
 
12.3 Monitoring  
 
Involvement in this study as a participating investigator implies acceptance of 
potential audits or inspections, including source data verification, by representatives 
designated by the DF/HCC Overall Principal Investigator (or Protocol Chair) or 
DF/HCC. The purpose of these audits or inspections is to examine study-related 
activities and documents to determine whether these activities were conducted and 
data were recorded, analyzed, and accurately reported in accordance with the protocol, 
institutional policy, and any applicable regulatory requirements.  
 
All data will be monitored for timeliness of submission, completeness, and adherence 
to protocol requirements. Monitoring will begin at the time of participant registration 
and will continue during protocol performance and completion.  
 

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13. REGULATORY CONSIDERATIONS 
13.1 Protocol Review and Amendments 
This protocol, the proposed informed consent and all forms of participant 
information related to the study (e.g., advertisements used to recruit participants) and 
any other necessary documents must be submitted, reviewed and approved by a 
properly constituted IRB governing each study location.  
Any changes made to the protocol must be submitted as amendments and must be 
approved by the IRB prior to implementation. Any changes in study conduct must be 
reported to the IRB. The DF/HCC Overall Principal Investigator (or Protocol Chair) 
will disseminate protocol amendment information to all participating investigators.  
All decisions of the IRB concerning the conduct of the study must be made in 
writing. 
13.2 Informed Consent 
 
All participants must be provided a consent form describing this study and 
providing sufficient information for participants to make an informed decision 
about their participation in this study. The formal consent of a participant, using 
the IRB approved consent form, must be obtained before the participant is 
involved in any study-related procedure. The consent form must be signed and 
dated by the participant or the participant’s legally authorized representative, and 
by the person obtaining the consent. The participant must be given a copy of the 
signed and dated consent document. The original signed copy of the consent 
document must be retained in the medical record or research file.  
13.3 Ethics 
This study is to be conducted according to the following considerations, which 
represent good and sound research practice: 
• 
US Code of Federal Regulations (CFR) governing clinical study conduct and 
ethical principles that have their origin in the Declaration of Helsinki 
o Title 21 Part 50 – Protection of Human Subjects 
www.access.gpo.gov/nara/cfr/waisidx_02/21cfr50_02.html  

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o Title 21 Part 54 – Financial Disclosure by Clinical Investigators 
www.access.gpo.gov/nara/cfr/waisidx_02/21cfr54_02.html  
o Title 21 Part 56 – Institutional Review Boards 
www.access.gpo.gov/nara/cfr/waisidx_02/21cfr56_02.html  
o Title 21 Part 312 – Investigational New Drug Application 
www.access.gpo.gov/nara/cfr/waisidx_02/21cfr312_02.html  
• 
State laws 
• 
DF/HCC research policies and procedures        
http://www.dfhcc.harvard.edu/clinical-research-support/clinical-research-unit-
cru/policies-and-procedures/  
It is understood that deviations from the protocol should be avoided, except when 
necessary to eliminate an immediate hazard to a research participant. In such case, 
the deviation must be reported to the IRB according to the local reporting policy.  
13.4 Study Documentation 
 
The investigator must prepare and maintain adequate and accurate case histories 
designed to record all observations and other data pertinent to the study for each 
research participant. This information enables the study to be fully documented and the 
study data to be subsequently verified. 
 
Original source documents supporting entries in the case report forms include but are 
not limited to hospital records, clinical charts, laboratory and pharmacy records, 
recorded data from automated instruments, microfiches, photographic negatives, 
microfilm or magnetic media, and/or x-rays.  
13.5 Records Retention 
 
All study-related documents must be retained for the maximum period required by 
applicable federal regulations and guidelines or institutional policies.  
13.6 Multi-center Guidelines 
N/A 
13.7 Cooperative Research and Development Agreement (CRADA)/Clinical Trials 
Agreement (CTA)  

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N/A. 
 

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14. STATISTICAL CONSIDERATIONS  
 
14.1 Study Design/Endpoints 
 
This is a one-stage Phase II trial to assess the efficacy of 16 weeks extracorporeal photopheresis 
(ECP) with the addition of daily low-dose subcutaneous (SC) interleukin-2 (IL-2) for weeks 8-16 
in patients with steroid-refractory chronic graft-versus-host disease (cGVHD).   The primary 
endpoint is overall response as defined in Section 10.0. Response will be evaluated at 16 weeks 
of treatment.  
 
Our previous studies of low-dose IL-2 alone (DFCI#07-083, 11-149) for steroid refractory 
cGVHD showed a overall response rate of ~50-60%, and  a randomized phase 2 trial of ECP vs. 
placebo showed a 40% response rate of skin cGVHD and 33% response rate of non-skin 
cGVHD)43. Conservatively extrapolating this information, we would consider ECP+IL-2 
potentially efficacious if the overall response rate is 75% or higher and unworthy if 50% or 
lower. With 25 evaluable patients, if 17 or more patients respond, the treatment will be 
considered efficacious for the treatment of steroid refractory cGVHD.  
 
With this design, the probability of concluding the treatment efficacious is 0.85 if the true but 
unknown response rate is 75% and 0.05 if the true rate is 50%. This decision rule is calculated 
using the exact binomial method. Table 1 below presents the operating characteristics of this 
design.  Patients will be considered evaluable for response if they receive at least one week of 
ECP, which we anticipate to occur to all patients based on our prior experience. Patient will be 
replaced if the patient is removed from the study for reasons unrelated to the treatment (see 
Section 5.4).  
 
Table 1. Operating Characteristics 
  
True but Unknown Response Rate  
  
50% 
55% 
60% 
65% 
70% 
75% 
Prob(≥17 responses in 25) 
0.05 
0.13 
0.27 
0.47 
0.68 
0.85 
 
 
14.2 Sample Size/Accrual Rate 
 
14.2.1 Sample Size 
 

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The target accrual is 25 evaluable patients.  
 
14.2.2 Accrual 
 
Based on our prior studies of 07-083 and 11-149, we anticipate that the accrual will complete 
within two years. Patients will be followed for 12 months after completing study accrual. 
 
Gender of subjects will not be used as a criterion for inclusion or exclusion in this study and 
there are no restrictions on the accrual of minorities. In 2013, 41% of all transplanted patients 
were women and approximately 10% of patients were minorities. Based on this self-reported 
ethnicity and gender in our transplant program in 2013, the anticipated accrual in subgroups 
defined by gender and race is summarized in the table below. 
 
Accrual Targets 
Ethnic Category 
Sex/Gender 
Females 
 
Males 
 
Total 
Hispanic or Latino 
1 
+ 
1 
= 
2 
Not Hispanic or Latino 
9 
+ 
14 
= 
23 
Ethnic Category: Total of all subjects 
10 
 
+ 
15 
 
= 
25 
 
Racial Category 
 
American Indian or Alaskan Native 
0 
+ 
0 
= 
0 
Asian 
1 
+ 
1 
= 
2 
Black or African American 
1 
+ 
1 
= 
2 
Native Hawaiian or other Pacific 
Islander 
0 
+ 
0 
= 
 
White 
8 
+ 
13 
= 
21 
Racial Category: Total of all subjects 
10 
 
+ 
15 
 
= 
25 
 
 
14.3 Stratification Factors 
N/A 
14.4 Analysis of Secondary Endpoints 
 
Secondary endpoints include toxicity, immunologic effects, prednisone use, overall survival, 
progression-free survival, non-relapse mortality, and relapse. All analyses will be reported 
descriptively. Predictors for response will be explored in univariable analysis, including the 
impact of number of prior cGVHD therapies. 

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14.5 Monitoring for Adverse Events. 
 Adverse events will be monitored closely. The monitoring guidelines will serve as a 
trigger for consultation with the DF/HCC Data Safety and Monitoring Committee (DSMC) 
for additional review, and are not regarded as formal stopping rules that would mandate 
automatic closure of study enrollment. ECP+IL-2 treatment was well tolerated in the 4 
DFCI patients treated thus far.  
If in the first 10 patients who start the IL-2 treatment, we observe 3 or more patients with 
grade 3 or higher treatment related toxicity, further accrual will be halted pending review 
by the DSMC. Depending on the findings of its review, the DSMC may recommend the 
permanent closure of enrollment or continuation of enrollment. With this design, the 
probability of halting the enrollment is 0.07 if the true but unknown  grade 3 or higher 
treatment related toxicity rate is 10%, 0.62 if the rate is 30%, and 0.95 if the rate is 50%. 
The same rule will be applied to non-relapse mortality, relapse, and cGVHD 
progression. 
15. PUBLICATION PLAN 
The initial study results will be made public within 12 months of the end of data collection. 
The study report is planned for publication in a peer-reviewed journal, and the initial 
release may be an abstract that meets the requirements of the International Committee of 
Medical Journal Editors. A final report of study outcomes will be made public no later than 
3 years after the end of data collection.  
The study PI holds the primary responsibility for publication of study results. Permission 
of the study PI will be required before any unpublished study information can be used or 
passed on to a third party. 
  

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48 
16. REFERENCES 
 
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Cederbom L, Hall H, Ivars F. CD4+CD25+ regulatory T cells down-regulate co-
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16. 
Maloy KJ, Salaun L, Cahill R, Dougan G, Saunders NJ, Powrie F. CD4+CD25+ T(R) cells 
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lymphoma and graft-versus-host disease. The Journal of investigative dermatology 
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care in chronic graft-versus-host disease. British journal of haematology 2012;158:62-78. 
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Immunol 2004;4:665-74. 
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30. 
Edinger M, Hoffmann P, Ermann J, et al. CD4+CD25+ regulatory T cells preserve graft-
versus-tumor activity while inhibiting graft-versus-host disease after bone marrow 
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Zorn E, Kim HT, Lee SJ, et al. Reduced frequency of FOXP3+ CD4+CD25+ regulatory T 
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32. 
Matsuoka K, Kim HT, McDonough S, et al. Altered regulatory T cell homeostasis in 
patients with CD4+ lymphopenia following allogeneic hematopoietic stem cell transplantation. J 
Clin Invest 2010;120:1479-93. 
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Sykes M, Romick ML, Sachs DH. Interleukin 2 prevents graft-versus-host disease while 
preserving the graft-versus-leukemia effect of allogeneic T cells. Proc Natl Acad Sci U S A 
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T cell-depleted syngeneic marrow prevents graft-versus-host disease mortality and permits 
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cells favor immune reconstitution and control graft-versus-host disease while maintaining graft-
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Zorn E, Nelson EA, Mohseni M, et al. IL-2 regulates FOXP3 expression in human 
CD4+CD25+ regulatory T cells through a STAT dependent mechanism and induces the 
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Ahmadzadeh M, Rosenberg SA. IL-2 administration increases CD4+ CD25(hi) Foxp3+ 
regulatory T cells in cancer patients. Blood 2006;107:2409-14. 
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Soiffer RJ, Murray C, Gonin R, Ritz J. Effect of low-dose interleukin-2 on disease relapse 
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host disease. N Engl J Med 2011;365:2055-66. 
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interleukin-2 in HCV-induced vasculitis. N Engl J Med 2011;365:2067-77. 
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Greinix HT, Volc-Platzer B, Rabitsch W, et al. Successful use of extracorporeal 
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Bisaccia E, Vonderheid EC, Geskin L. Safety of a new, single, integrated, closed 
photopheresis system in patients with cutaneous T-cell lymphoma. Br J Dermatol 2009;161:167-
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Filipovich AH, Weisdorf D, Pavletic S, et al. National Institutes of Health consensus 
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Diagnosis and staging working group report. Biol Blood Marrow Transplant 2005;11:945-56. 

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47. 
Pavletic SZ, Martin P, Lee SJ, et al. Measuring therapeutic response in chronic graft-
versus-host disease: National Institutes of Health Consensus Development Project on Criteria for 
Clinical Trials in Chronic Graft-versus-Host Disease: IV. Response Criteria Working Group 
report. Biol Blood Marrow Transplant 2006;12:252-66. 
 

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17. APPENDICES  
 
 
 

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17.1 
Appendix A: PERFORMANCE STATUS 
 
ECOG Performance Status Scale 
 
 
Karnofsky Performance Scale 
Grade 
Description 
Percent 
Description 
0 
Normal activity. Fully active, able 
to carry on all pre-disease 
performance without restriction. 
100 
Normal, no complaints, no 
evidence of disease. 
90 
Able to carry on normal activity; 
minor signs or symptoms of 
disease. 
1 
Symptoms, but ambulatory. 
Restricted in physically strenuous 
activity, but ambulatory and able to 
carry out work of a light or 
sedentary nature (e.g., light 
housework, office work). 
80 
Normal activity with effort; 
some signs or symptoms of 
disease. 
70 
Cares for self, unable to carry on 
normal activity or to do active 
work. 
2 
In bed < 50% of the time. 
Ambulatory and capable of all self-
care, but unable to carry out any 
work activities. Up and about more 
than 50% of waking hours. 
60 
Requires occasional assistance, 
but is able to care for most of 
his/her needs. 
50 
Requires considerable assistance 
and frequent medical care. 
3 
In bed >50% of the time. Capable 
of only limited self-care, confined 
to bed or chair more than 50% of 
waking hours. 
40 
Disabled, requires special care 
and assistance. 
30 
Severely disabled, 
hospitalization indicated. Death 
not imminent. 
4 
100% bedridden. Completely 
disabled. Cannot carry on any self-
care. Totally confined to bed or 
chair. 
20 
Very sick, hospitalization 
indicated. Death not imminent. 
10 
Moribund, fatal processes 
progressing rapidly.  
5 
Dead. 
0 
Dead. 
 
 

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17.2 Appendix B: BODY SURFACE AREA AND CREATININE CLEARANCE  
 
Body surface area (BSA) should be calculated using Dubois formula that yields the 
following results in meters squared (m2): 
BSA = (W 0.425 x H 0.725) x 0.007184 
where the weight is in kilograms and the height is in centimeters. 
 
Creatinine clearance (CrCl) can be calculated using the Cockroft-Gault equation as 
follows: 
  
CrCl (ml/min) =  
 (140 - age) (actual wt in kg)  
  
 72 × serum creatinine (mg/dl) 
For females, use 85% of calculated CrCl value. 
 
Note:  In markedly obese patients, the Cockroft-Gault formula will tend to overestimate 
the creatinine clearance.  (Adipose tissue tends to contribute little creatinine requiring 
renal clearance.) 

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17.3 Appendix C: New York Heart Association Classification of Heart Disease 
 
The following table presents the NYHA classification of cardiac disease. 
Class 
Functional Capacity 
Objective Assessment 
I 
Patients with cardiac disease but without resulting limitations of physical 
activity.  Ordinary physical activity does not cause undue fatigue, 
palpitation, dyspnea, or anginal pain. 
No objective evidence of 
cardiovascular disease. 
II 
Patients with cardiac disease resulting in slight limitation of physical 
activity.  They are comfortable at rest.  Ordinary physical activity results in 
fatigue, palpitation, dyspnea, or anginal pain. 
Objective evidence of 
minimal cardiovascular 
disease. 
III 
Patients with cardiac disease resulting in marked limitation of physical 
activity.  They are comfortable at rest.  Less than ordinary activity causes 
fatigue, palpitation, dyspnea, or anginal pain. 
Objective evidence of 
moderately severe 
cardiovascular disease. 
IV 
Patients with cardiac disease resulting in inability to carry on any physical 
activity without discomfort.  Symptoms of heart failure or the anginal 
syndrome may be present even at rest.  If any physical activity is undertaken, 
discomfort is increased. 
Objective evidence of 
severe cardiovascular 
disease. 
Source:  The Criteria Committee of New York Heart Association.  Nomenclature and Criteria for Diagnosis of 
Diseases of the Heart and Great Vessels.  9th Ed. Boston, MA:  Little, Brown & Co; 1994:253-256. 

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17.4 Appendix D: DEFINITE AND PROBABLE cGVHD MANIFESTATIONS  
 
Organ System 
Definite manifestations of 
chronic GVHD 
Possible manifestations of 
chronic GVHD 
Skin 
Scleroderma (superficial or 
fasciitis), lichen planus, vitiligo, 
scarring alopecia, hyperkeratosis 
pilaris, contractures from skin 
immobility, nail bed dysplasia 
Eczematoid rash, dry skin, 
maculopapular rash, hair loss, 
hyperpigmentation  
Mucous 
membranes 
Lichen planus, non-infectious 
ulcers, corneal erosions/non-
infectious conjunctivitis 
Xerostomia, 
keratoconjunctivitis sicca 
GI tract 
Esophageal strictures, 
steatorrhea 
Anorexia, malabsorption, 
weight loss, diarrhea, 
abdominal pain 
Liver 
None  
Elevation of alkaline 
phosphatase, transaminitis, 
cholangitis, hyperbilirubinemia 
GU tract 
Vaginal stricture, lichen 
planus  
Non-infectious vaginitis, 
vaginal atrophy 
Musculoskeletal 
/Serosa 
Non-septic arthritis, myositis, 
myasthenia, polyserositis, 
contractures from joint 
immobilization 
Arthralgia 
Hematologic 
None 
Thrombocytopenia, 
eosinophilia, autoimmune 
cytopenias 
Lung 
Bronchiolitis obliterans  
Bronchiolitis obliterans with 
organizing pneumonia, 
interstitial pneumonitis 
 
 
 

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17.5 Appendix E: CHRONIC GVHD SYMPTOM SCORING SCALE  
 
Name:  
 
 
 
 
 
 
 
MRN:   
 
 
Signature:  
 
 
 
 
Date:  
 
Have you had any of the following problems in the past 2 weeks? 
 
 
Not at all 
 
Slightly 
 
Moderately  
 
Quite a 
bit 
 
Extremely  
SKIN: 
 
 
 
 
 
a.  Abnormal skin color 
0 
1 
2 
3 
4 
b.  Rashes 
0 
1 
2 
3 
4 
c.  Thickened skin 
0 
1 
2 
3 
4 
d.  Sores on skin 
0 
1 
2 
3 
4 
e.  Itchy skin 
0 
1 
2 
3 
4 
 
 
 
 
 
 
EYES AND MOUTH: 
 
 
 
 
 
f.  Dry eyes 
0 
1 
2 
3 
4 
g.  Need to use eye drops 
frequently 
0 
1 
2 
3 
4 
h.  Difficulty seeing clearly 
0 
1 
2 
3 
4 
i.  Need to avoid certain foods 
due to mouth pain 
0 
1 
2 
3 
4 
j.  Ulcers in mouth  
0 
1 
2 
3 
4 
k.  Receiving nutrition from an 
intravenous line or feeding tube 
0 
1 
2 
3 
4 
 
 
 
 
 
 
BREATHING: 
 
 
 
 
 
l.  Frequent cough 
0 
1 
2 
3 
4 
m.  Colored sputum 
0 
1 
2 
3 
4 
n.  Shortness of breath with 
exercise 
0 
1 
2 
3 
4 
o.  Shortness of breath at rest 
0 
1 
2 
3 
4 
p.  Need to use oxygen 
0 
1 
2 
3 
4 
 
 
 
 
 
 
EATING AND DIGESTION: 
 
 
 
 
 
q.  Difficulty swallowing solid 
foods 
0 
1 
2 
3 
4 
r.  Difficulty swallowing liquids 
0 
1 
2 
3 
4 
s.  Vomiting 
0 
1 
2 
3 
4 

Phase II ECP and IL-2 for chronic GVHD 
Version 2.0; August 15, 2016 
 
 
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58 
t.  Weight loss 
0 
1 
2 
3 
4 
 
 
 
Not at all 
 
Slightly 
 
Moderately  
 
Quite a 
bit 
 
Extremely  
MUSCLES AND JOINTS: 
 
 
 
 
 
u.  Joint and muscle aches 
0 
1 
2 
3 
4 
v.  Limited joint movement 
0 
1 
2 
3 
4 
w.  Muscle cramps 
0 
1 
2 
3 
4 
x.  Weak muscles 
0 
1 
2 
3 
4 
 
 
 
 
 
 
ENERGY: 
 
 
 
 
 
y.  Loss of energy 
0 
1 
2 
3 
4 
z.  Need to sleep more/take naps 
0 
1 
2 
3 
4 
Aa.  Fevers 
0 
1 
2 
3 
4 
 
 
 
 
 
 
MENTAL AND 
EMOTIONAL: 
 
 
 
 
 
Bb.  Depression 
0 
1 
2 
3 
4 
Cc.  Anxiety 
0 
1 
2 
3 
4 
Dd.  Difficulty sleeping 
0 
1 
2 
3 
4 
 
 

Phase II ECP and IL-2 for chronic GVHD 
Version 2.0; August 15, 2016 
 
 
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59 
17.6 Appendix F: cGVHD PARTIAL RESPONSE CRITERIA  
 
Suggested calculations for partial organ response in cGVHD 
 
Organ and Starting Score or Value   
 
 
 
 
Partial Response Criterion*  
 
Skin (percent of body surface)   
 
 
 
> 50 %    
 
 
 
 
 
 
 
 
 
 
 
 
 
e/s ≤ 0.5 and e > 0  
25 – 50 %    
 
 
 
 
 
 
 
 
 
 
 
 
s – e ≥ 25 and e > 0  
< 25 %    
 
 
 
 
 
 
 
 
 
 
 
 
 
only CR; no PR possible 
 
Platelet count   
 
 
 
 
 
 
 
 
 
 
 
e – s ≥ 100,000/uL and e < LLN  
 
Gastrointestinal (and other 0 – 3 scales) 
3   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
e = 1 or 2   
2    
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
e = 1  
1    
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
only CR; no PR possible 
 
Liver function tests (ALT, alkaline  
phosphatase and bilirubin)  
≥ 3x ULN    
 
 
 
 
 
 
 
 
 
 
 
 
e/s ≤ 0.5 and e > ULN  
< 3x ULN    
 
 
 
 
 
 
 
 
 
 
 
 
only CR; no PR possible 
 
 
 *s, starting score or value; e, ending score or value; ULN, upper limit of normal; LLN, lower 
limit of normal  
    
Examples 
1.  Skin: start score = 85, end score = 30; e/s = 30/85 = 0.35 = PR  
2.  Skin: start score = 65, end score = 45; e/s = 45/65 = 0.75 = not PR  
3.  Skin: start score = 45, end score = 15; s – e = 30 = PR  
4.  Skin: start score = 30, end score = 15; s – e = 15 = not PR 
 

Phase II ECP and IL-2 for chronic GVHD 
Version 2.0; August 15, 2016 
 
 
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60 
17.7 Appendix G: cGVHD PROGRESSION CRITERIA 
 
Suggested calculations for organ progression in cGVHD 
 
Organ and Starting Score or Value   
 
 
 
 
 
 
Progression Criterion*  
 
Skin (percent of body surface)    
 
 
 
 
 
 
 
e – s  ≥ 25  
 
Platelet count     
 
 
 
 
 
 
 
 
 
 
 
 
s – e  ≥ 50,000/uL and e < LLN   
 
Gastrointestinal (and other 0 – 3 scales)    
 
 
 
 
e – s  ≥ 1  
 
Liver (ALT, alkaline phosphatase and bilirubin) 
s ≥ 3x ULN    
 
 
 
 
 
 
 
 
 
 
 
 
 
e – s  ≥ 3 x ULN  
s < 3x ULN    
 
 
 
 
 
 
 
 
 
 
 
 
 
e – s  ≥ 2 x ULN  
 
Lungs (12-point Lung Function Scale)¶   
 
 
 
 
e – s  ≥ 3† 
   
 
*s, starting score or value; e, ending score or value; ULN, upper limit of normal 
 
 ¶The lung function scale is the sum of the FEV1 and DLCO (corrected for Hb) scores, each 
computed as: > 80% of predicted = 1; 70-79% = 2; 60-69% = 3; 50-59% = 4; 40-49% = 5; <40% 
= 6. 
 
†If the starting lung function score is ≥ 10, progression is defined as ≥ 5% decrease of FEV1 in 
two tests measured at least 2 weeks apart. This time interval was selected because these 
syndromes can progress rapidly. 
 
 
 
 
 
 
 
 
 
 
 

Phase II ECP and IL-2 for chronic GVHD 
Version 2.0; August 15, 2016 
 
 
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61 
 
 
 
17.8 Appendix H: NCI COMMONTOXICITY CRITERIA 
 
Please refer to the CTEP website: http://ctep.cancer.gov/reporting/ctc.html 
Forms available upon request.  
 
 
 

Phase II ECP and IL-2 for chronic GVHD 
Version 2.0; August 15, 2016 
 
 
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59 
17.9 Appendix J: INSTRUCTIONS FOR SUBCUTANEOUS INJECTION/DRUG DIARY 
 
 
INSTRUCTIONS FOR 
SUBCUTANEOUS INJECTION 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Phase 2 IL-2 for chronic GVHD 
Version 1.5; March 17, 2016 
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60 
 
 
1. 
Once you have all your supplies, clean the work surface with isopropyl alcohol and wash your 
hands. 
 
2. 
Remove the plastic cap or peel back the paper and attach the needle to the syringe without 
touching the hub of needle as you have been shown. 
 
3. 
Wipe the top with an alcohol wipe. 
 
4. 
Choose your injection site (see diagram).  Rotate injection sites, if feasible. Avoid areas that 
are inflamed, edematous, scarred or covered by a mole, birthmark or other lesion. 
 
5. 
Clean your skin with an alcohol wipe, using a circular motion, working outwards. Allow area 
to dry. 
 
6. 
Remove the cap and hold the needle at a 45○ angle (as you would a pencil).  Gently grasp skin 
with one hand and quickly insert the needle with the other. 
 
7. 
Pull back the plunger; if blood is seen in the syringe, remove the needle from the skin and 
change the needle to a clean one of the same size.  It is alright to use the drug already in the 
syringe. 
 
8. 
Inject the drug slowly. 
 
9. 
Remove the needle and press the site gently with an alcohol swab or 2x2 gauze until the 
bleeding has stopped. 
 
10. Dispose of the needle and syringe in the sharps’ container provided. 
 
If you have any questions, please call:                             
 
COMMENTS: 
 
 
 
 

A Phase II Trial of Low-Dose Interleukin-2 (IL-2) Added to Extra-Corporeal Photopheresis for Refractory cGVHD
DOSING LOG
Study Participant
Self-Administration
Study Drug Diary
Dana-Farber/Harvard Cancer Center
Please indicate the date, if the contents of syringe were injected, and any comments. 
Participant Identifier: ____________________
Protocol # : 
Your MD ____________________ Phone ____________________
Ex:
6/1/2009
Your RN _____________________ Phone ____________________
Day 1
Day 2
STUDY DRUG INSTRUCTIONS:
Day 3
Day 4
Study Drug: Interleukin-2
Day 5
How Much:  Your dose is  1.0 x 10^6 IU/m^2
Day 6
How Often: You will self-administer each dose DAILY 
Day 7
Day 8
Day 9
Day 10
Day 11
Day 12
Day 13
Day 14
SPECIAL INSTRUCTIONS:
Study Participant Initials __________
Date _________
An up to 2 week IL-2 supply will be provided in single-use syringes
IL-2 must be chilled for transit and for home refrigerator storage at 2-8 C.
One single-use syringe will be used each day during subcutaneous
FOR STUDY TEAM USE ONLY
self-administration, and discarded in the sharps' containers provided.
Missed doses should not be made up.
Staff Initials:
Rotate your injection sites, if possible.
Date Dispensed:
DO NOT FREEZE IL-2.
Discrepancy Notes:
Yes
Date
Comments
Were contents of syringe 
injected?