A Phase Ib/2 Trial of Fludarabine/Melphalan/Total Body Irradiation With Post Transplant Cyclophosphamide as Graft Versus Host Disease Prophylaxis in Matched-Related and Matched-Unrelated Allogeneic Hematopoietic Cell Transplantation
Phase: PHASE1
Conditions: Acute Myeloid Leukemia in Remission, Adult Acute Lymphoblastic Leukemia in Complete Remission, Chronic Myelogenous Leukemia, BCR-ABL1 Positive in Remission, Chronic Myelomonocytic Leukemia in Remission, Graft Versus Host Disease, Hodgkin Lymphoma, Minimal Residual Disease, Myelodysplastic Syndrome, Myeloproliferative Neoplasm, Non-Hodgkin Lymphoma, Plasma Cell Myeloma, Severe Aplastic Anemia, Waldenstrom Macroglobulinemia
Sponsor: Roswell Park Cancer Institute

Document Coversheet 
 
 Study Title: 
   
A Phase 1b/2 Trial of Fludarabine/Melphalan/Total Body Irradiation with Post Transplant 
Cyclophosphamide as Graft versus Host Disease Prophy 
 
Institution/Site:  
Roswell Park Comprehensive Cancer Center 
Document (Approval/Update) Date: 
06/05/2023 
NCT Number: 
NCT03192397 
IRB Number 
I 44417 
 

Roswell Park Protocol No.: I 44417
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PROTOCOL TITLE:
A Phase 1b/2 Trial of Fludarabine/Melphalan/Total Body Irradiation with Post Transplant 
Cyclophosphamide as Graft versus Host Disease Prophylaxis in Matched-Related and Matched-
Unrelated Allogeneic Hematopoietic Cell Transplantation
ROSWELL PARK STUDY NUMBER: 
I 44417
PRINCIPAL INVESTIGATOR:
Maureen Ross, MD
Roswell Park Comprehensive Cancer Center
Elm and Carlton Streets
Buffalo, New York 14263
716-845-1145
Maureen.Ross@roswellpark.org
VERSION NUMBER: 17
DATE: 19APR2023
Confidentiality Statement
Any and all information presented in this document shall be treated as confidential and shall remain the 
exclusive property of the party(ies) mentioned above (Roswell Park Cancer Institute Corporation d/b/a 
Roswell Park Comprehensive Cancer Institute). The use of such confidential information must be 
restricted to the recipient for the agreed purpose and must not be disclosed, published, or otherwise 
communicated to any unauthorized persons, for any reason, in any form whatsoever without the prior 
written consent of the party(ies) above.
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Table of Contents
1
Objectives ............................................................................................................................................7
2
Background..........................................................................................................................................7
3
Inclusion and Exclusion Criteria .......................................................................................................13
4
Local and Study-Wide Number of Subjects ......................................................................................15
5
Local and Study-Wide Recruitment Methods ...................................................................................15
6
Multi-Site Research ...........................................................................................................................15
7
Study Timelines.................................................................................................................................15
8
Study Endpoints.................................................................................................................................15
9
Design................................................................................................................................................16
10
Treatment...........................................................................................................................................21
11
Procedures Involved ..........................................................................................................................26
12
Withdrawal of Subjects......................................................................................................................28
13
Risks to Subjects................................................................................................................................28
14
Potential Benefits to Subjects ............................................................................................................32
15
Data and Specimen Banking..............................................................................................................32
16
Measurement of Effect ......................................................................................................................32
17
Safety Evaluation...............................................................................................................................33
18
Data Management and Confidentiality..............................................................................................37
19
Statistical Plan ...................................................................................................................................38
20
Provisions to Monitor the Data to Ensure the Safety of Subjects......................................................39
21
Vulnerable Populations......................................................................................................................41
22
Community-Based Participatory Research........................................................................................41
23
Sharing of Results with Subjects .......................................................................................................41
24
Setting................................................................................................................................................41
25
Provisions to Protect the Privacy Interests of Subjects .....................................................................41
26
Resources Available ..........................................................................................................................41
27
Prior Approvals..................................................................................................................................41
28
Compensation for Research-Related Injury.......................................................................................41
29
Economic Burden to Subjects............................................................................................................41
30
Consent Process.................................................................................................................................41
31
Process to Document Consent in Writing..........................................................................................42
32
Drugs or Devices ...............................................................................................................................42
33
References..........................................................................................................................................47
34
Appendices/Supplements...................................................................................................................51
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ABBREVIATIONS
alloHCT
Allogeneic hematopoietic cell transplantation
AML
Acute Myeloid Leukemia
ANC
Absolute Neutrophil Count
BM
Bone Marrow Hematopoietic Cell Transplant
BMT
Blood or Marrow Transplantation
BU
Busulfan
CLL
Chronic Lymphocytic Leukemia
CMV
Cytomegalovirus
CY
Cyclophosphamide
DLI
Donor Lymphocyte Infusion
DLT
Dose Limiting Toxicity
DVT
Deep Vein Thrombosis
EBV
Epstein Barr Virus
FK506
Tacrolimus
FLU
Fludarabine
G-CSF
Filgrastim-sndz 
(or 
other 
approved 
biosimilar 
is 
acceptable)
GM-CSF
Sargramostim
GVNH
Graft-versus- Host Disease
GVL
Graft-versus- Leukemia
GVT
Graft-versus- Tumor
HCT
Hematopoietic Cell Transplantation
HLA
Human Leukocyte Antigen
MDS
Myelodysplastic Syndrome
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MEL
Melphalan
MHC
Major Histocompatability
MM
Multiple Myeloma
MMF
Mycophenolate Mofetil
MPD
Myeloproliferative Disorder
MTD
Maximum Tolerated Dose
MUD
Matched Unrelated Donor
NHL
Non Hodgkin Lymphoma
NRM
Non Relapse Mortality
OS
Overall Survival
PB
Peripheral Blood 
PBHCT
Peripheral Blood Hematopoietic Cell Transplant
PMN
Polymorphonuclear Cell
PNH
Paroxysmal Nocturnal Hemoglobinuria
RIC
Reduced Intensity Conditioning
RRT
Regimen Related Toxicity
SOP
Standard Operating Procedure
SOS
Sinusoidal Obstructive Syndrome
TRM
Transplant Related Mortality
VOD
Veno-occlusive Disease
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1
OBJECTIVES
1.1
Primary Objective

To determine the cumulative incidence of extensive chronic graft versus host disease (GVHD) 
at 1 year after transplantation utilizing the novel conditioning/GVHD prophylactic regimen for 
patients undergoing allogeneic hematopoietic cell transplantation, in patients who do not 
progress before Day 100.
1.2
Secondary Objectives

To evaluate clinical response, engraftment rate, progression-free survival (PFS) at one year 
and, overall survival (OS).

To determine the cumulative incidence of relapse.

To evaluate the Day 100 transplant-related mortality rate.

To determine the cumulative incidence of grade III-IV acute GVHD.
2
BACKGROUND
Allogeneic hematopoietic cell transplantation (alloHCT) is a potentially curative treatment for many of 
the hematologic malignancies1. Although there have been significant advances towards the success of this 
procedure including improvements in HLA typing, donor selection, and infectious antibiotics, graft-
versus-host disease (GVHD) remains a major cause of morbidity and mortality. Despite the use of current 
GVHD prophylactic regimens, acute GVHD still occurs in 40-50% of allogeneic transplants and chronic 
GVHD occurs in approximately 10-80% of transplants2. To improve the safety and efficacy of alloHCT, 
there needs to be a balance between allowing enough alloreactivity to induce graft-versus-tumor (GVT) 
effect while minimizing the occurrence of graft-versus-host disease. Additionally, the effects of the agents 
used in GVHD prophylaxis on immune reconstitution must also be considered. As such, there remains a 
need to develop new GVHD regimens. Recently, several studies have evaluated the efficacy of post-
transplant cyclophosphamide as GVHD prophylaxis.
Preclinical studies using post-transplant cyclophosphamide in rodents showed that it could alleviate 
GVHD after major histocompatibility (MHC) mismatched lymphocyte infusion. Also, similar to human 
leukocyte antigen (HLA) -matched transplants, it could induce tolerance to grafts despite mismatches at 
multiple minor histocompatibility antigens3.
Additionally, there are certain features of cyclophosphamide that make it an appealing agent to use for 
GVHD prophylaxis2. Cyclophosphamide is an alkylating agent that exerts it effects predominantly on 
rapidly proliferating cells whereas hematopoietic cells are resistant to its DNA damaging effects given 
their ability to convert cyclophosphamide into its inactive metabolite. Thus, engraftment following 
alloHCT is not effected by cyclophosphamide. Cyclophosphamide is also capable of triggering apoptosis 
of T cells. This is in contrast to the standard agents used for GVHD prophylaxis including calcineurin 
inhibitors, sirolimus, and mycophenolate mofetil (MMF), all of which lead to inhibition of the T cells, not 
cell death. Another mechanism of action of cyclophosphamide is that it leads to clonal deletion of 
intrathymic host-reactive T cells resulting in maintenance of long-term tolerance. These effects were 
demonstrated in a mouse model in which cyclophosphamide was shown to selectively cause clonal 
destruction of both alloreactive donor cells as well as clonal deletion of host-reactive cells. The 
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implications of these properties of cyclophosphamide are that it can be effective in preventing graft-
versus-host disease without compromising immune reconstitution and engraftment.
2.1
Clinical Studies Supporting Post-transplant Cyclophosphamide
The initial studies utilizing post-transplant cyclophosphamide were in haploidentical bone marrow 
transplants. In a trial by Luznik, et al4, patients with advanced hematologic malignancies or paroxysmal 
nocturnal hemoglobinuria underwent haploidentical transplants with T cell-replete bone marrow. A 
nonmyeloablative conditioning regimen was used consisting of fludarabine, cyclophosphamide, and total 
body irradiation (TBI). The GVHD prophylaxis regiment was cyclophosphamide 50 mg/kg on days 3 as 
a single dose or on days 3 and 4 as split doses. Tacrolimus and MMF were initiated the day after 
completion of cyclophosphamide. Graft failure occurred in 13% of patients evaluated. Non-relapse 
mortality and relapse at 1 year were 15% and 5% respectively. The incidences of grades II-IV acute GVHD 
was 36% and grades III-IV was 6%. With regards to chronic GVHD, the incidence was 5% in those 
patients who received two doses of cyclophosphamide versus 25% in those who received one dose. This 
study demonstrated the efficacy of post-transplant cyclophosphamide in improving rates of extensive 
chronic GVHD (although associated with relatively high relapse rates).
Since this study, there have been additional trials with variation of the transplant regimen aiming to 
improve on both the GVHD and relapse rates. Solomon, et al5 performed haploidentical transplants for 
patients with hematologic malignancies. T cell-replete grafts were used from peripheral blood stem cells 
(PBSCs). They used a myeloablative conditioning regimen consisting of fludarabine, busulfan, and 
cyclophosphamide with GVHD prophylaxis consisting of cyclophosphamide on days 3 and 4 with 
tacrolimus and MMF starting at day 5. The incidences of grades II-IV acute GVHD was 30% and grades 
III-IV was 10%. Chronic GVHD occurred in 35% of patients. The one-year estimate of relapse was 40%. 
Another study by Castagna, et al6 was a retrospective comparison of bone marrow versus peripheral blood 
as the hematopoietic cell source in haploidentical transplants. A nonmyeloablative conditioning regimen 
was used and GVHD prophylaxis included post-transplant cyclophosphamide. The incidence of acute 
GVHD was 33% for PBSC and 25% for BM and chronic GVHD was 13% for both. The 1 year NRM was 
12% for PBSC and 22% for BM with similar rates of relapse between the two modalities.
Based on these results, subsequent studies further expanded the use of post-transplant cyclophosphamide 
as GVHD prophylaxis. Luznik, et al7 evaluated the use of post-transplant cyclophosphamide as single 
agent GVHD prophylaxis in patients receiving myeloablative alloHCT from HLA matched related and 
matched unrelated donors. The patients received myeloablative conditioning with busulfan and 
cyclophosphamide followed by stem cells from T cell-replete bone marrow. GVHD prophylaxis consisted 
of cyclophosphamide at 50 mg/kg/d on days 3 and 4. The results of this study showed that the incidence 
of grade II-IV acute GVHD was 43% and grades III-IV was 10%. The incidence of chronic GVHD was 
10%. The rate of relapse at 2 years was 44% for all patients and 26% for those patients who were in 
complete remission (CR) prior to transplant.
More recently, Mielcarek, et al8 performed a study where 43 patients with high risk hematologic 
malignancies underwent allogeneic hematopoietic cell transplantation with allografts from related and 
unrelated donors. They used a myeloablative conditioning regimen consisting of fludarabine and busulfan. 
GVHD prophylaxis consisted of post-transplant cyclophosphamide at 50mg/kg/day on days +3 and +4 
along with cyclosporine starting on day +5. Stem cell source was peripheral blood. The results of this 
study showed cumulative incidence of grades II-IV and III-IV acute GVHD of 77% and 0% respectively. 
Rates of chronic GVHD were 16%. Estimates of the cumulative incidence of non-relapse mortality and 
relapsed disease at 2 years were 14% and 17% respectively.
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Additionally, the initial studies with post-transplant cyclophosphamide as GVHD prophylaxis utilized 
bone marrow as the stem cell source. However, many institutions have gravitated towards the use of 
peripheral blood stem cells. Compared to bone marrow, there are several advantages to using peripheral 
blood as the stem cell source. Procurement of stem cells from growth factor mobilized peripheral blood is 
generally easier to tolerate and poses less risk to the donor in contrast to a bone marrow harvest. Some 
randomized trials have shown that use of peripheral blood stem cells from HLA identical siblings is 
associated with more rapid engraftment. However, this potentially comes with a higher risk of acute and 
chronic GVHD. Anasetti, et al9 performed a phase 3, randomized, multicenter trial of alloHCT using either 
peripheral blood stem cells or bone marrow from unrelated donors. Their results showed similar overall 
survival rates at 2 years between the two modalities. There was also no difference in rates of relapse or 
acute GVHD. However, the overall incidence of graft failure was 3% in patients receiving peripheral 
blood versus 9% in patients receiving bone marrow (P=0.002). The incidence of chronic GVHD at 2 years 
was 53% with peripheral blood versus 41% with bone marrow (P=0.01).
Reduced intensity conditioning (RIC) during alloHCT reduces transplant related mortality (TRM) by 
relying more on the graft-versus-malignancy effect rather than the conditioning regimen to eradicate 
disease. Reduced intensity conditioning regimens can provide a curative option for patients with 
hematologic malignancies who might otherwise not be candidates for myeloablative (intensive) 
transplantation because of age or poor performance status. Since the ability to perform transplant safely is 
the primary measure of efficacy for reduced intensity conditioning, TRM is the appropriate measure of 
efficacy of the conditioning regimen.
RIC regimens are characterized by: 1) Reversible myelosuppression and autologous hematopoietic 
recovery without allogeneic stem cell support (usually within 28 days), 2) Mixed chimerism in a 
proportion of patients early after transplant, 3) Low rates of non-hematologic toxicity. We now have over 
a decade of data pertaining to reduced intensity conditioning regimens and over 10,000 reduced intensity 
transplants have been reported worldwide.
There were 2 trials performed at Roswell Park utilizing RIC alloHCT. The first was a pilot trial utilizing 
FLU/MEL/50TBI as a RIC regimen (protocol number I-118807). Fludarabine was dosed at 40 mg/m2, 
melphalan at 50 mg/m2, and TBI at 400cGy. This study did not meet early stopping rules for the planned 
interim analysis of safety. Based on the safety and efficacy data from this study, a phase II study utilizing 
FLU/MEL/75TBI was performed. The dosing regimen was Fludarabine at 40 mg/m2, melphalan at 
75 mg/m2, and TBI at 400cGy. A retrospective analysis comparing the results of these 2 prospective 
clinical trials with a concurrent cohort of patients who received FLU/MEL was performed. Overall, for 
all patients, the 1 year cumulative incidence of extensive chronic GVHD were 77% (95% CI 67-84%) for 
FLU/MEL, 69% (95% CI 52-82%) for FLU/MEL/50TBI, and 66% (95% CI 53-76%) for 
FLU/MEL/75TBI. The patients were then stratified by age. For patients between the ages of 40-59, the 
1 year cumulative incidence of extensive chronic GVHD was 75% (95% CI 61-84%) for FLU/MEL, 64% 
(95% CI 37-82%) for FLU/MEL/50TBI, and 62% (95% CI 40-78%) for FLU/MEL/75TBI. For patients 
ages ≥ 60, the 1 year cumulative incidence of extensive chronic GVHD was 81% (95% CI 60-91%) for 
FLU/MEL, 74% (95% CI 42-90%) for FLU/MEL/50TBI, and 71% (95% CI 52-84%) for 
FLU/MEL/75TBI.
Given the promising results of these studies, we have designed a phase 1b/2 trial in which patients with 
high-risk hematologic malignancies will undergo an alloHCT with a conditioning regimen of fludarabine, 
melphalan, and TBI to test post-transplant cyclophosphamide as GVHD prophylaxis with the goal to lower 
rates of both TRM and chronic GVHD. As described above, there will be a dose escalation component 
based on melphalan dosing for early toxicity and stopping points. Given that we will be administering 
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post-transplant cyclophosphamide, we will be starting with a lower dose of melphalan 25 mg/m2 
administered on day -2 which will be on age stratified. There will be an assessment of toxicities and if 
acceptable, there will be a dose escalation of melphalan to 50 mg/m2 followed by a further increased to 
75 mg/m2. The primary objective of this study is determination of the incidence of chronic GVHD at 
1 year after allogeneic hematopoietic cell transplantation utilizing this novel conditioning/GVHD 
prophylaxis regimen. This study will build on our previous experience on Clinical Trial I-118807 and I-
I77110, which utilized a novel reduced intensity conditioning regimen of FLU/MEL/TBI for patients 
undergoing allogeneic hematopoietic cell transplantation. 
Our choice of sirolimus is on the basis of recent data from JHH that suggests sirolimus may be less 
nephrotoxic than tacrolimus in this setting. In the unexpected situation in which a patient is unable to 
tolerate oral medications, IV tacrolimus will be administered instead of sirolimus (which cannot be 
administered intravenously). If tacrolimus is utilized in lieu of sirolimus, it will be dosed and levels will 
be monitored as per physician discretion. 10
2.2
Indications for Allogenic HCT in Various Disease States
Allogeneic HCT has an established role in therapeutic strategies for acute and chronic leukemias, bone 
marrow failure states (aplastic anemia, paroxysmal nocturnal hemoglobinuria and, myelodysplastic 
syndromes), lymphomas, myeloma, second transplant and immunodeficiencies.
2.2.1.1 Acute Myeloid Leukemia
Less than 20% of adults who are ≥ 60 years with acute myeloid leukemia (AML) in first complete 
remission (CR1) will achieve a 3 year DFS with conventional chemotherapy-based consolidation.11,12 
While conventional risk factors like cytogenetics and antecedent hematological disorder play a role, age 
does appear to be an independent variable.13-15 Patients over the age of 60 to 65 and those with poor 
functional status have unacceptable TRM with myeloablative transplant. RIC offers an opportunity to 
achieve a cure in a subset of these patients with outcomes comparable to standard myeloablative allogeneic 
HCT.16,17 
2.2.1.2 Myelodysplastic Syndrome
Myelodysplastic Syndrome (MDS) is incurable except by alloHCT. The risk-benefit ratio favors alloHCT 
for patients as soon as they progress to more advanced disease (Int-2 or higher IPSS score).18 It is estimated 
that only about 5% of MDS patients are eligible to receive myeloablative alloHCT because of age and 
other exclusions. RIC has allowed for a reduction in TRM in this group of patients and allowed for wider 
application of alloHCT as a therapy for MDS.
2.2.1.3 Myeloproliferative Disorder
The only cure for a myeloproliferative disorder (MPD) is an allogeneic HCT, which needs to be balanced 
against the TRM associated with conventional myeloablative HCT. RIC has been used in an effort to 
reduce the TRM in this group of patients.19-21 
2.2.1.4 Non Hodgkin Lymphoma
Reduced intensity allogeneic transplantation has a definite role in the treatment of defined subgroups of 
patients with high-risk Non Hodgkin Lymphoma (NHL) with or without a prior autologous transplant.22 
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2.2.1.5 Hodgkin Lymphoma
Approximately 50% of patients with relapsed and progressive disease after autologous HCT can be 
rescued by a RIC.23 
2.2.1.6 Multiple Myeloma
Durable remissions for multiple myeloma can occur after allogeneic HCT. Previous experience with 
standard myeloablative alloHCT was disappointing due to a high early TRM despite achieving durable 
remissions for survivors.24,25 Reduced intensity transplantation from a suitable related or unrelated donor 
may permit the development of a curative graft-versus-myeloma effect without high TRM.26-28 The usual 
approach is to utilize RIC for selected younger patients with well-matched donors either right after auto 
transplant (“auto-allo”) or after relapse from an auto transplant. A phase III trial has demonstrated 
improved overall and disease-free survivals in newly diagnosed myeloma for recipients of a hematopoietic 
stem-cell autograft followed by a stem-cell allograft from an HLA-identical sibling versus a standard 
tandem autologous transplant.292.2.7 Non-hematologic Malignancy
Patients with solid tumors will be excluded from the current protocol.
2.2.1.7 Non-hematologic Malignancy
Patients with solid tumors will be excluded from the current protocol.
2.2.1.8 Second Allogenic Transplants
Second allogeneic transplantation is often offered for relapse after a first allogeneic or autologous 
transplant and for graft failure. Higher conditioning intensities when used in a second transplant are 
associated with high rate of regimen related toxicity (RRT) and TRM. Therefore, a RIC regimen is an 
appropriate treatment option for these patients.
2.2.1.9 Matched Unrelated Donor (MUD) Transplants
TRM in well matched unrelated donor transplants now approximates that of related transplants because 
of recent advances in supportive care including the use of fludarabine-based conditioning regimens, 
tacrolimus-based GVHD prophylaxis, peripheral blood stem cells and high-resolution HLA typing. In one 
retrospective study of reduced intensity conditioning, overall survival for MUD transplants approximated 
that of sibling donor transplants.30 
2.3
Correlative Studies
Correlative studies will include chimerism analysis by molecular analysis and evaluation of immune 
reconstitution.
2.4
Study Rationale
In this study, we propose to incorporate post-transplant cyclophosphamide into the regimen used for 
GVHD prophylaxis with the goal to lower rates of chronic GVHD. In combination with this GVHD 
prophylaxis regimen, we will also utilize a reduced intensity conditioning regimen consisting of 
fludarabine, melphalan, and TBI. This regimen was developed at Roswell Park (Roswell Park protocol 
numbers: I 118807 and I 177110). The advantages of using this regimen are that it can provide adequate 
cytoreduction while minimizing rates of TRM. It also relies on graft-versus-tumor effect to eradicate 
disease.
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Rationale for Regimen Dose Selection:
Fludarabine (FLU), a purine nucleoside analog is a potent immunosuppressant that will help prevent donor 
cell rejection by the recipient. Doses range from 120-200 mg/m2 over 4 or 5 days and this protocol will 
utilize 40 mg/m2/ per day x 4 days.
Melphalan (MEL) is an alkylating agent and doses above 140 mg/m2 are considered myeloablative. In our 
trial of reduced intensity allogeneic hematopoietic cell transplantation, we evaluated a melphalan dose of 
75 mg/m2 in combination with fludarabine (40 mg/m2/day x 4 days) and lower dose total body irradiation 
(TBI) (400 cGy) (Roswell Park Protocol No. I-118807 and I-177110) with the intention to improve 
cytoreduction and improve disease control while preserving the low rate of transplant-related mortality 
(TRM). The results of this trial showed that the regimen was well tolerated. Final analysis of this study is 
still pending but thus far, the analysis indicates that FLU/MEL/TBI generates the same overall survival as 
FLU/MEL. Our results suggest that for high-risk patients (i.e., patients who are not in remission at the 
time of alloHCT); FLU/MEL/TBI is actually superior. Despite older age and more advanced disease, the 
patients receiving FLU/MEL/TBI did as well as the patients who received Flu/Mel when retrospectively 
compared. Preliminary data also show that there are adequate rates of engraftment with this regimen. One 
year estimate of extensive chronic GVHD for FLU/MEL/TBI was 66% versus 77% for FLU/MEL. In this 
trial, given that we will be administering post-transplant cyclophosphamide, we will be starting with a 
lower dose of melphalan: 25mg/m2 administered on Day -2 to ensure no excess toxicities when used in 
combination with post-transplant cyclophosphamide. A safety dose run-in will be performed. Dosing of 
melphalan will be based on age stratification to account for possible comorbidities. There will be an 
assessment of transplant related mortality and if acceptable, there will be a dose escalation of melphalan 
to 50 mg/m2 followed by a further increased to 75 mg/m2.
Total Body Irradiation (TBI) is considered myeloablative above 500 to 600 centiGray (cGy). There is 
extensive experience with lower doses of TBI with fludarabine in nonmyeloablative conditioning, usually 
at 200 cGy. The TBI dose in this study will be 400 cGy administered in 2 doses of 200 cGy. The 
conditioning intensity, even with 400 cGy TBI, is less than half that of a standard myeloablative Mel 
140 mg/m2/1200 cGy TBI regimen. We therefore consider the dosing range of our regimen to lie within 
the parameters that define "reduced intensity" and to be a regimen that will not generate excess TRM. 
Cyclophosphamide is an alkylating agent which has both antineoplastic and immunosuppressive 
properties. There is a wide range of dosing but at a dose of 50 mg/kg/day x 2 days, it has been shown to 
have primarily an immunosuppressive effect and has been safe and effective at reducing rates of chronic 
GVHD. There has been extensive experience with its use in haploidentical transplants. In our protocol, 
we propose to apply the same regimen to patients undergoing matched related and matched unrelated 
allogeneic hematopoietic cell transplantation with the premise that it will have similar effects in reducing 
rates of GVHD. It will be given again at 50 mg/Kg on days +3 and +4 post-hematopoietic cell infusion.
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3
INCLUSION AND EXCLUSION CRITERIA
3.1
Inclusion Criteria
To be included in this study, participants must meet the following criteria (Appendix A: 
INVESTIGATOR STUDY ELIGIBILITY VERIFICATION FORM: INCLUSION CRITERIA):
1. The patient must have a diagnosis of one of the following (one must be yes):

AML

ALL

CLL

CML (chronic phase intolerant or unresponsive to tyrosine kinase inhibitors, history of 
accelerated phase, or history of blast crisis)

MDS

NHL

HL (received and failed frontline therapy or failed autologous transplantation or inability 
to collect enough PBSC for auto-HCT)

MM

Severe aplastic anemia
2. Histocompatible donor identified:

Related donor  5/6 or better (A, B, DRB1)

Unrelated donor 7/8 or better (A, B, C and DRB1)
3. Age ≥ 18 years.
4. The following are eligible for study inclusion (refer to Appendix H):

AML may be in morphologic CR or CRi (MRD positive is allowed)

ALL may be in morphologic CR or CRi (MRD positive is allowed)

CLL may be in morphologic CR or CRi (MRD positive is allowed)

CML must be in chronic phase (MRD positive is allowed)

MDS- Patients with MDS only require ≤5% myeloblasts on bone marrow evaluation. There 
is no requirement for platelet or neutrophil recovery.

NHL must be in CR

HL must be in CR

MM may be in VGPR

SAA do not have disease response requirements; however, if the patient has a mismatched 
donor, the patient must have had prior therapy with ATG.
5. Have a Karnofsky performance status score of ≥ 50% (refer to Appendix C)
6. Have the following clinical laboratory values:

Diffusing Capacity of the Lung for Carbon Monoxide (DLCO) ≥  40% predicted, corrected 
for hemoglobin and/or alveolar ventilation.

Cardiac: left ventricular ejection fraction ≥ 40%.

Bilirubin, liver alkaline phosphatase, SGOT or SGPT ≤ 3 x upper limit of normal
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
Calculated creatinine clearance ≥ 40 cc/min by the modified Cockroft-Gault formula (refer 
to Appendix D)
7. Patient must be cleared pre-transplant by Radiation Oncology to be able to receive 400 cGy.
8. Participants of child-bearing potential must agree to use adequate contraceptive methods (e.g., 
hormonal or barrier method of birth control; abstinence) prior to study entry. Should a woman 
become pregnant or suspect she is pregnant while she or her partner is participating in this study, 
she should inform her treating physician immediately.
9. Patients who have failed a prior autologous or allogeneic transplant are eligible. However, at least 
6 months must have elapsed between the start of this reduced intensity conditioning regimen and 
the last transplant if patient had a prior autologous or allogeneic BMT.
10. At least 2 weeks since prior radiation treatment and/or surgery. Appropriate washout of prior 
chemotherapy per BMT standard of care (see Appendix K).  If medication is not on the list, go by 
physician discretion.
11. Participant must understand the investigational nature of this study and sign an Independent Ethics 
Committee/Institutional Review Board approved written informed consent form prior to receiving 
any study related procedure.
3.2
Exclusion Criteria
Participants will be excluded from this study for the following (Appendix B: ELIGIBILITY 
VERIFICATION FORM: EXCLUSION CRITERIA):
1. Moderate to severe myelofibrosis within 60 days prior to transplant.
2. Presence of HLA antibodies to the donor within 60 days prior to transplant.
3. Uncontrolled CNS disease (for hematologic malignancies).
4. Patients who in the opinion of the treating physician are unlikely to comply with the restrictions 
of allogeneic stem cell transplantation based on formal psychosocial screening. (i.e., serious, 
uncontrolled psychiatric illness/social situations that would limit compliance with study 
requirements).
5. Uncontrolled diabetes mellitus, cardiovascular disease, active serious infection or other condition 
which, in the opinion of treating physician, would make this protocol unreasonably hazardous for 
the patient.
6. Known HIV positive.
7. Pregnant or nursing female participants.
8. Unwilling or unable to follow protocol requirements.
9. Any condition which in the Investigator’s opinion deems the participant an unsuitable candidate 
to receive study intervention.
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3.3
Special Populations
The following special populations are excluded from this study:

Cognitively impaired adults/adults with impaired decision-making capacity

Individuals who are not yet adults (infants, children, teenagers)

Pregnant women

Prisoners
3.4
Inclusion of Women and Minorities
Both men and women and members of all races and ethnic groups are eligible for this study.
4
LOCAL AND STUDY-WIDE NUMBER OF SUBJECTS
This is a single-institution study.
5
LOCAL AND STUDY-WIDE RECRUITMENT METHODS
Participants will be identified/recruited/screened from patients at the BMT service at Roswell Park 
Comprehensive Cancer Center and from multi-disciplinary conference discussion.
6
MULTI-SITE RESEARCH
Not Applicable.
7
STUDY TIMELINES
Projected accrual is approximately to have a maximum of 33 evaluable patients, and therefore recruitment 
is expected to be complete within 8 years following the study starting point.
Treatment duration is 11 days.
Subjects will be followed for at least 12 months after transplantation and annually thereafter as per BMT 
clinic standard of care.
Therefore, the study completion is approximately 9 years from study activation.
8
STUDY ENDPOINTS
8.1
Primary Endpoints

The primary endpoint is extensive chronic GVHD in the first 365 days from Day 0 of the transplant 
(refer to Appendix E).
8.2
Secondary Endpoints

Clinical response, engraftment rate, progression free survival (PFS) at one year, and overall 
survival (assessments as per BMT standard of care)

Cumulative incidence of relapse

Treatment-related mortality rates 
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
Cumulative incidence of grade III-IV acute GVHD 
Correlative studies will include chimerism analysis by molecular analysis and evaluation of immune 
reconstitution (refer to Section 11.7).
9
DESIGN
This is a Phase 1b/2 open label, non-randomized, single institution study. The primary objective of this 
study is determination of the cumulative incidence of chronic graft-vs.-host disease at 1 year after 
allogeneic hematopoietic cell transplantation utilizing a novel, reduced-intensity conditioning/GVHD 
prophylaxis regimen (Fludarabine/Melphalan/Total Body Irradiation).
The design of this trial consists of two components: 1) A safety run-in component which will be broken 
out into two strata (≤50 years of age, > 50 years of age) and 2) A two-stage efficacy analysis of chronic 
GVHD rates combining subjects from both strata. Prior to the November 16, 2021 revision, each 
component of this Phase Ib trial was broken out into two strata (≤50 years of age, > 50 years of age). The 
safety run-in component of the trial precedes the efficacy analysis. As of the November 16, 2021 revision 
the Phase Ib components are closed to accrual and treatment design.
Phase Ib participants enrolled and treated prior to the November 16, 2021 revision will be analyzed as 
within their respective age strata and cohort.
For Phase II: The November 16, 2021 revision removed the Age ≤50 and Age >50 strata as well as closed 
the previous Age ≤50 and Age >50 groups. Therefore, Phase II participants enrolled and treated after the 
November 16, 2021 revision will receive 75 mg/m2 melphalan on Day -2.
Please see Section 19 regarding prior to November 16, 2021 strata analyses.
9.1
Cohort Management
9.1.1.1 Safety Run-In Design:
o
Age ≤ 50 years (Discontinued to accrual as of November 16, 2021)
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o
Age > 50 years (Accrual met as of July 2019)
Prior to the November 16, 2021 revision, both strata utilized a 3+3 dose escalation scheme in order to 
determine the safest dose from which to utilize in the efficacy analysis. This is slightly different than a 
pure Phase I trial in that the study drug is already in use in the clinic. The goal is to better understand the 
maximum tolerated dose (MTD) within the age strata in a conservative fashion prior to proceeding on to 
the efficacy analysis.

For the age ≤50 years strata we examined two dosing cohorts (A, B) following the administration 
of Fludarabine 40 mg/m2/day on Days -5 to -2.
o
 Cohort A: 50 mg/m2 Melphalan
o
Cohort B: 75 mg/m2 Melphalan

For the age >50 years strata we examined three dosing cohorts (A B C) following the 
administration of Fludarabine 40 mg/m2/day on Days -5 to -2. 
o
Cohort A: 25 mg/m2 Melphalan
o
Cohort B: 50 mg/m2 Melphalan
o
Cohort C: 75 mg/m2 Melphalan
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9.1.1.2 Efficacy Analysis Design
o
Age ≤ 50 years (Discontinued as of November 16, 2021)
Start at MTD from Safety Run-in
If ≥ 6 out of 10 patients 
develop cGVHD
If< 6 out of 10 patients 
develop cGVHD
Stop study
Stage 2
Enroll 10 additional patients
Analysis
If ≤ 9out of 20 patients 
with cGVHD
If > 9 out of 20 patients 
with cGVHD
Therapy deemed 
efficacious
Proceed with study
Therapy not promising
Stop study
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o
Combined Age Groups (as of November 16, 2021)
Stage 1
Start at MTD from Safety Run-in
If ≥ 6 out of 8 patients 
develop cGVHD
If< 6 out of 8 patients 
develop cGVHD
Stop study
Stage 2
Enroll 13 additional patients at MTD 
(Melphalan 75 mg/m2)
Analysis
If ≤ 13 out of 21 patients 
with cGVHD
If > 13 out of 21 patients 
with cGVHD
Therapy deemed 
efficacious
Proceed with study
Therapy not promising 
Stop study
9.2
Definition of Dose-Limiting Toxicity
The timeframe for examining the DLT per subject is 28 days from stem cell infusion (Day 0) DLT will be 
defined as a transplant-related death or, failure to engraft neutrophils by Day 28 post-transplant.
For Phase Ib participants that were treated prior to the November 16, 2021 revision, for each stratum (≤50 
years of age, > 50 years of age) the given cohort will start with three patients, with three patients added to 
any cohort if we observe 1 out of 3 dose limiting toxicities (DLTs). If ≥ 2 out of 3 to 6 subjects have a 
DLT we will not proceed to the next cohort. Cases will be reviewed by HLA match to determine if change 
to eligibility criteria is needed. Overall, accrual within the age ≤50 years strata for this component of the 
trial ranges between 3-12 patients and the accrual within the age >50 years strata for this component of 
the trial ranges between 3-18 patients. It is anticipated that we will escalate to the highest dose per strata. 
However, if ≥2/3 DLTs are observed in Cohort A in either stratum, that component of the trial relative to 
the given strata will be suspended and the dosing scheme will be re-evaluated.
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Evaluable patients are defined as patients who do not have disease progression within Day 100 post-
transplant. Non-evaluable patients (defined as patients that, prior to Day 100 post-transplant: have 
withdrawn, have been removed from study for any reason or, have disease progression) will be replaced.
All participants will sign an informed consent prior to any study-related tests. All participants will meet 
the inclusion and exclusion criteria summarized in Appendix A and Appendix B.
Failure to engraft platelets will not be considered a dose limiting toxicity for the purposes of this protocol.  
There was an initial error and subsequent amendment which led to two artificial DLTs involving platelet 
engraftment in a previous protocol amendment.  The IRB determined that we could proceed with 
enrollment and continue to escalate to subsequent dose levels per protocol.  
10 TREATMENT
Eligible patients will receive conditioning regimen, GVHD prophylaxis, and allogeneic 
hematopoietic stem cell transplant as follows:
For Phase Ib (prior to the November 16, 2021 revision):
Conditioning regimen:

Fludarabine: 40 mg/m2/day on Days -5 to -2

Melphalan: Age > 50 years: 25 mg/m2 on Day -2*
o
Age ≤ 50 years: 50 mg/m2 on Day -2**

Total body irradiation (TBI): 400 cGy (two fractions of 200 cGy each) on Day -1
* Melphalan dosing will be escalated to 50 mg/m2 followed by 75 mg/m2 in subsequent cohorts (Cohort 
B and Cohort C in age > 50 years strata) of patients based on evaluation of TRM in Phase 1.  In Phase 2, 
the MTD (Melphalan 75 mg/m2) will be used for dosing patients.
** Melphalan dosing will be escalated to 75 mg/m2 in Cohort B (age ≤ 50 years strata).
Stem cell infusion:

Hematopoietic stem cell infusion: on Day 0
GVHD prophylaxis regimen:

Cyclophosphamide: 50mg/kg/day Days +3 and +4

Mycophenolate mofetil: starts Day +5§

Sirolimus: starts Day +5
§ Mycophenolate mofetil will start on Day +5 and continue until approximately Day+35 (as per standard 
of care and, physician’s discretion).
Sirolimus
On Day +5, starting dose will be 0.5 mg orally daily.  The sirolimus dose will be adjusted to target trough 
levels between 5-10 ng/mL (as per standard of care, and physician’s discretion).
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Supportive Care:

G-CSF (filgrastim-sndz or other approved biosimilar is acceptable) or GM-CSF: starts Day +5 
and, per standard of care, continues until ANC > 1500 for 2 consecutive days
For Phase II (after the November 16, 2021 revision):
Conditioning regimen:

Fludarabine: 40 mg/m2/day on Days -5 to -2

Melphalan: 75 mg/m2 on Day -2

Total body irradiation (TBI): 400 cGy (two fractions of 200 cGy each) on Day -1
Stem cell infusion:

Hematopoietic stem cell infusion: on Day 0
GVHD prophylaxis regimen:

Cyclophosphamide: 50mg/kg/day Days +3 and +4

Mycophenolate mofetil: starts Day +5§

Sirolimus: starts Day +5
§ Mycophenolate mofetil will start on Day +5 and continue until approximately Day+35 (as per standard 
of care and, physician’s discretion).
Sirolimus
On Day +5, starting dose will be 0.5 mg orally daily.  The sirolimus dose will be adjusted to target trough 
levels between 5-10 ng/mL (as per standard of care, and physician’s discretion).
Supportive Care:

G-CSF (filgrastim-sndz or other approved biosimilar is acceptable) or GM-CSF: starts Day +5 
and, per standard of care, continues until ANC > 1500 for 2 consecutive days
10.1 Treatment Plan
10.1.1.1
Stem Cell Collection

Per BMT Standard of Care
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10.1.1.2
Preparative Regimen
Table 1
400 cGY TBI-based transplant
Day
-5
Day
-4
Day
-3
Day
-2
Day
-1
Day
0
Day
+1
Day
+2
Day
+3
Day
+4
Day
+5
Day
+6
Day
+7
Day
+8*
Fludarabine
(total 160mg/m2)
40
40
40
40
Melphalan 
X
TBI
(400 cGy)
200+
200
Stem cell infusion
X
Sirolimus
X
X
X
X
MMF
X
X
X
X
Cyclophosphamide/
Mesna
X
X
GCSF
X
X
X
X
*After Day +8, the patient will continue with GVHD prophylaxis regimen as per BMT Allo-Treatment 
Plan standard of care and, physician’s discretion.
Fludarabine

Fludarabine: 40 mg/m2 (actual body weight) is infused over 30 minutes on Days -5, -4, -3, and -2 
(total dose 160 mg/ m2).
Melphalan

Phase 1:  Melphalan: mg/m2 per cohort (actual body weight) is infused over 30 minutes 
following fludarabine on Day -2.

Phase 2: For all participants, the dose will be Melphalan 75 mg/m2.
Total Body Irradiation (TBI)

Schedule- on Day -1: Two fractions of 200 cGy will be given at least 6 hours apart.
Total Body Irradiation will be delivered using a nominal photon beam energy of no less than 4 MV. 
Dynamic or static fields may be used. However, the patient should be entirely included within the dynamic 
or static treatment field. Lung shields are to be applied in pairs (both AP & PA) with evenly weighted 
mid-plane dose from each field. When necessary, lung shields can be combined with open (non-shield) 
fields during the same fraction to achieve the required mid-plane and lung dose. Dose heterogeneity 
resulting from lung transmission will be assessed using the AAPM Task Group 29/AAPM-Report Number 
17, The physical aspects of total and half-body photon irradiation.31
TBI, 200 cGy, will be delivered as prescribed to mid-plane at the level of the umbilicus or pelvis; 
whichever region is thicker. Tissue compensators or other devices will be used to optimize dose 
homogeneity within ± 5 % of the prescribed dose. Dose homogeneity will be assessed at a minimum of  
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mid plane points at: a) head, at largest diameter, b) neck, at the level of thyroid notch, c) chest, at the 
xiphoid process, d) umbilicus or pelvis, whichever is thicker, e) mid-thigh, and, f) mid-calf. Optional dose 
points will be located at: g) knee, h) ankle and, i) umbilicus or pelvis, whichever is thinner. In addition, a 
set of lung shields, or an equivalent device, will be used to ensure that the lungs will receive within 90 to 
100 % of the prescribed dose per fraction. The dose rate at the prescription point shall be between 10 cGy 
and 15 cGy per minute. 
Allogeneic Stem Cell Reinfusion

On Day 0 hematopoietic stem cells will be infused per BMT SOP.
Hydration regimens

Per clinicians’ discretion
Supportive medications

Antiemetics, antimicrobials, etc. will be used according to BMT standard of care.

Systemic steroids will not be allowed prior to administration of post-transplant cyclophosphamide.
10.1.1.3
GVHD Prophylaxis
GVHD prophylaxis will be post-transplant cyclophosphamide, Sirolimus with mycophenolate mofetil 
(MMF) as per the BMT SOP. Tacrolimus (IV or oral) or cyclosporine (IV or oral) may be substituted for 
sirolimus in the case of inability to tolerate oral medications or other intolerance or adverse reaction and 
dosed per Roswell Park standards. If this is a temporary issue, a transition back to sirolimus will be made 
once it has resolved; otherwise, the patient may be continued on either tacrolimus or cyclosporine as per 
physician discretion. 
* After Day +8, the patient will continue with GVHD prophylaxis regimen as per BMT Allo-Treatment 
Plan standard of care and, physician’s discretion
Sirolimus

On Day +5, starting dose will be 0.5 mg orally daily.  The sirolimus dose will be adjusted to target 
trough levels between 5-10 ng/mL (as per standard of care, and physician’s discretion).
In the absence of GVHD, sirolimus will continue until Day +100 and then taper with a goal to be 
discontinued at approximately 6 months post-transplant. In the case of disease recurrence, sirolimus may 
be tapered off more rapidly and/or starting before Day +100 post-transplant, as per the treating clinician’s 
discretion
Mycophenolate mofetil (MMF)/ (Cellcept®) 33

MMF starts on Day +5 and, in the absence of GVHD or recurrent disease, will continue as per 
BMT standard of care until approximately Day+35 (or at physician’s discretion).
DAY
0
+1
+2
+3
+4
+5
+6
+7
+8*
Sirolimus
X
X
X
X
MMF
X
X
X
X
Cyclophosphamide
X
X
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
The dose will be 1000 milligrams orally every 8 hours or 1500 milligrams intravenously every 
6 hours.

MMF may be withheld at the discretion of the attending physician for patients with cytopenias or 
other toxicities that are thought to be related to the MMF.
Cyclophosphamide

Cyclophosphamide will be given as 50 mg/kg IV on Days 3 and 4 for GVHD prophylaxis, as 
described above.
o
Mesna will be administered with cyclophosphamide and will be based on the same dosing 
weight as Cyclophosphamide. Dosing of Mesna is 80% of Cyclophosphamide dose every 
3 hours x 4 doses on day +3 and Day +4 starting 30 minutes prior to each 
cyclophosphamide dose.
o
Dosing will be based on ideal body weight or actual weight, whichever is less. If a patient’s 
weight is greater than >125% of their ideal body weight, the adjusted body weight will be 
used. 

Adjusted BW= IBW + 0.25 x (ABW-IBW)

Ideal Body Weight Dosing:

Men= 50 + 0.91 x (height in cm - 152)

Women= 45 + 0.91 x (height in cm - 152)
10.2 Supportive Care Recommendations

Prior to initiating therapy, placement of a multi-lumen indwelling silastic catheter is required, 
preferably a non-tunneled 5 lumen catheter.

Patients will receive full supportive care, including transfusions of irradiated blood and blood 
products, growth factors, antibiotics, anti-emetics, oral care, etc., when appropriate. The reason(s) 
for treatment, dosage, and the dates of treatment should be recorded on the flow sheets.

Mucosal evaluation and care, antifungal prophylaxis, Pneumocystis Pneumonia (PCP), 
prophylaxis, CMV Infections, anti-bacterial prophylaxis, deep venous thrombosis (DVT) 
prophylaxis, sinusoidal occlusive syndrome prophylaxis are per BMT standard of care.

Systemic steroids will not be allowed prior to administration of post-transplant cyclophosphamide.
10.3 Potential Toxicities and their Management
Patients will be managed in the inpatient and outpatient setting per BMT standards of care. Safety will be 
monitored on an ongoing basis and discussed, graded and recorded in weekly outcome rounds.
10.3.1.1
Management of Graft Versus Host Disease (GVHD)

BMT standard measures for prevention and treatment of GVHD will be followed.
10.3.1.2
Toxicities

Infections, hematologic toxicities, organ toxicities, failure to engraft will be managed per BMT 
standards of care.

Secondary malignancy
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o
The cumulative exposure to chemotherapeutic agents and radiation increases the risk of 
developing leukemia or a second cancer. The incidence of secondary malignancy is 
approximately 5%.
11 PROCEDURES INVOLVED
Screening: All screening tests must be performed within 60 days of the on-study date (pre-admission 
clinic visit).
Please contact the Transplant Program Coordinator to enroll patients on the study.
Informed consent: Patient must be aware of the nature of his/her disease and willingly consent after being 
informed of the procedure to be followed, the experimental nature of the therapy, alternatives, potential 
benefits, side-effects, risks, and discomforts. Human protection committee approval of this protocol and 
of its consent form is required and will have been obtained before this study opens.
Histological review: Submission of appropriate tissue samples or outside histo-pathologic slides to 
confirm the underlying diagnosis. Remission/relapse status should be confirmed within 30 days and no 
later than 60 days before transplant conditioning starts.
11.1 Registration
Registration procedures:

Confirm eligibility criteria for patients (Appendix A and Appendix B) and donors.

Complete the transplant registration worksheets for patient and donor. Data pertaining to this 
protocol will be collected by the BMT APPs, MDs, TCs, data managers and/ or any other persons 
assigned by the BMT director.
Eligibility of each participant will be established prior to enrollment.
Informed consent MUST be completed prior to receiving any study related procedures.
11.2 Protocol Date Definitions
On-Study Date
Start Treatment Date
Off-Treatment Date
Off-Study Date
Date of pre-admission 
clinic visit.
Date of conditioning 
regimen initiation
Date of completion of 
the last dose of 
cyclophosphamide
Date of death due to 
any cause or, until 
study completion
11.3 Disease Evaluation

Disease evaluation will be performed pre and post alloHCT as well as once per year clinic visit (in 
accordance with BMT standard of care evaluation
11.4 Safety Assessments

Safety will be evaluated on an ongoing basis with weekly outcome assessment and grading for the 
first 100 days post-transplant (from Day -5 until 100 days after cell infusion).

Acute GVHD will be graded according to the criteria in Appendix F.

All deaths will be reviewed.
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In addition to the adverse events deemed as serious in Section 17.4 and, for the purpose of this study, 
death due to any transplant-related mortality cause (i.e., infection, GVHD, toxicities, etc.) will be reported 
to Clinical Research Services.
11.5 Hematology/ Chemistry

Baseline (Day -5) and daily during hospitalization for transplant (CBC and CMP as per standard 
of care). Weekly after discharge until day 100 after hematopoietic stem cell infusion.

Important hematologic recovery endpoints:
o
The first of 3 consecutive days of absolute neutrophil count (ANC) ≥0.5x109/L
o
Platelets ≥20 x109/L after 7 consecutive days with no platelet transfusions
o
Day (post stem cell infusion) of last platelet transfusion
11.6 Follow-up Evaluations
The following BMT standard of care lab assessments will be performed at Day 30 (± 10 days), Day 100 
(± 20 days) and at 1 year (± 30 days) following transplant:

Hematology :CBC with automated differentials

Chemistry: CMP

Bone marrow biopsy will be performed for chimerism and engraftment evaluation.
Patients will be followed for survival for a minimum of 4 years or until the study closure whichever occurs 
first. Patients will not be taken off protocol for disease progression but will be followed for survival. 
Subsequent transplant and/or DLI will be captured for all patients.
11.7 Important Immunologic Recovery Endpoints

Myeloid and lymphoid chimerism expressed as a percentage of donor cells at the following time 
points: Day 30 (± 10 days), Day 100 (± 10 days), and Day 365 (± 30 days).

Immune reconstitution is evaluated at the following time points: baseline (prior to conditioning), 
Day 30 (± 10 days), Day 100 (± 20 days) and Day 365 (± 30 days) by the BMT SOC 
immunophenotyping panel and by analysis of CMV-specific immunity (CMV dextramer).
11.8 Correlative Studies
11.8.1.1
Chimerism Analysis
Chimerism analysis is clinically useful and important for this study. Samples for chimerism analysis will 
be obtained on all donor and recipient pairs prior to transplant. After transplant, serial samples of blood 
and marrow will be analyzed for chimerism analysis. Lineage specific (separate lymphoid and myeloid) 
chimerism will be analyzed in blood per BMT SOP. Unseparated chimerism may also be analyzed in bone 
marrow (for leukemia and patients with other malignancies if bone marrow was involved previously) 
whenever a bone marrow aspirate is performed.
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11.8.1.2
Immune Reconstitution
Peripheral blood will be collected per BMT SOP. Immune reconstitution will be measured by flow 
cytometry using the BMT SOC Flow Panel. Flow cytometry will be performed by the Roswell Park flow 
cytometry lab.
Refer to Appendix J for a complete Schedule of Procedures and Observations.
12 WITHDRAWAL OF SUBJECTS
12.1 Treatment Discontinuation
Upon treatment discontinuation all end of treatment evaluations and tests will be conducted as per BMT 
standard of care. All participants who discontinue due to an AE must be followed until the event resolves 
or stabilizes. Appropriate medical care should be provided until signs and symptoms have abated, 
stabilized, or until abnormal laboratory findings have returned to acceptable or pre-study limits. The final 
status of the AE will be reported in the participant’s medical records and the appropriate eCRF.
Reasons for treatment discontinuation should be classified as follows:

Death

Progressive disease

Toxicity; treatment related or unrelated

Investigator judgment

The Investigator may discontinue a participant if, in his/her judgment, it is in the best interest of 
the participant to do so.

Noncompliance

Participant voluntary withdrawal

A participant may withdraw from the study at any time, for any reason. If a participant discontinues 
treatment, an attempt should be made to obtain information regarding the reason for withdrawal

Sponsor decision.
* If the constraints of this protocol are detrimental to the patient's health and/or the patient no longer 
wishes to continue protocol therapy, the patient will be removed from protocol treatment and placed on 
follow-up. In this event the reason for withdrawal will be documented, the PI will be notified and the 
patient will be followed for GVHD, disease relapse and survival.
Patients that withdraw or that are taken off-study for any reason will be replaced. These patients do not 
count toward the accrual target. The accrual is based on the Statistical Objective of evaluable patients. 
Therefore, if patients are removed because they are not evaluable, they should be replaced.
13 RISKS TO SUBJECTS
13.1 Fludarabine Monophosphate

Myelosuppression (dose limiting toxicity), fever, nausea, vomiting, stomatitis, diarrhea, 
gastrointestinal bleeding, anorexia, edema, skin rashes, myalgia, headache, agitation, hearing loss, 
transient episodes of somnolence and fatigue, autoimmune hemolytic anemia, autoimmune 
thrombocytopenia, paresthesias, peripheral neuropathy, renal and pulmonary toxicity (interstitial 
pneumonitis).
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
Severe fatal CNS toxicity presenting with loss of vision and progressive deterioration of mental 
status were encountered almost exclusively after very high doses of fludarabine monophosphate. 
Such toxicity has only been rarely demonstrated at the 25-40 milligrams dosage of fludarabine 
monophosphate.

Very rarely described complications include transfusion-associated graft versus host disease, 
thrombotic thrombocytopenic purpura, and liver failure.

Tumor lysis syndrome, complicating fludarabine monophosphate therapy has been observed, 
especially in patients with advanced bulky disease.

Opportunistic infections (protozoan, viral, fungal, and bacterial) have been observed in both pre-
treated patients receiving fludarabine and in individuals receiving fludarabine combined with other 
agents (corticosteroids, mitoxantrone, and cyclophosphamide).
13.2 Melphalan
The most frequently reported adverse events include: leukopenia, thrombocytopenia, irreversible bone 
marrow failure, vasculitis, secondary malignancies, vesiculation of the skin, alopecia, pruritis, rash, 
SIADH, sterility, amenorrhea, nausea, vomiting, stomatitis, diarrhea, hemorrhagic cystitis, anemia, 
hemolytic anemia, pulmonary fibrosis, interstitial pneumonitis.
13.3 Cyclophosphamide
The most frequently reported adverse events include: nausea/vomiting, cardiomyopathy, rash, mucositis, 
stomatitis, sterility, diarrhea, hemorrhagic cystitis, edema, alopecia, anemia, hemolysis, leukopenia, 
alopecia, appetite loss, amenorrhea, thrombocytopenia, anemia, fatigue, pulmonary fibrosis, secondary 
malignancies including urological malignancies.
13.4 Tacrolimus
In patients receiving tacrolimus, 5% to 47% experienced anemia, 8% to 32% experienced leukocytosis, 
and 14% to 24% experienced thrombocytopenia. Rare cases of microangiopathic hemolytic anemia have 
been reported. Mild to moderate hypertension was reported in 38% to 50% of patients receiving 
tacrolimus. Mild to moderate hypertension is a common adverse effect associated with tacrolimus therapy. 
Chest pain was reported in 19%. Antihypertensive therapy may be required.
The most common adverse effects of tacrolimus have involved the central nervous system, and include 
headache (37% to 64%), tremors (48% to 56%), insomnia (32% to 64%), paresthesia (17% to 40%); and 
dizziness (19%). Tremor and headache may respond to a dosage reduction. Agitation, anxiety, confusion, 
seizures, depression, hallucinations, myoclonus, neuropathy, psychosis, incoordination, and abnormal 
dreams have been reported in 3% to 15% of tacrolimus-treated patients.
Hyperkalemia (13% to 45%), hypokalemia (13% to 29%), hypophosphatemia (49%), and 
hypomagnesemia (16% to 48%) have been associated with tacrolimus therapy. In addition, hirsutism 
occurs only rarely with tacrolimus. Hyperuricemia has been reported in greater than 3% of tacrolimus-
treated patients.
Gastrointestinal adverse effects of tacrolimus have included nausea (32% to 46%), vomiting (14% to 
29%), anorexia (7% to 34%), constipation (23% to 35%) and diarrhea (37% to 72%). Gingival hyperplasia 
observed in patients treated with cyclosporine has not been reported with tacrolimus therapy. 
Nephrotoxicity was reported in 36% to 40% and 52% of liver and kidney transplant patients receiving 
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tacrolimus. Overt nephrotoxicity is usually seen early after transplantation and is characterized by an 
increased serum creatinine and a decrease in urine output. Hematuria has been reported in greater than 3% 
of tacrolimus-treated patients (Prod Info Prograf®, 1997). Abnormal liver function tests have been 
reported in 6% to 36% of patients receiving tacrolimus; ascites was reported in 7% to 27% of these 
patients.
Other miscellaneous effects that have occurred in clinical trials include pain (24% to 63%), fever (19% to 
48%), asthenia (11% to 52%), back pain (17% to 30%), and peripheral edema (12% to 36%). The 
incidence of hyperglycemia is 17% and may require therapy with insulin. Other less frequently occurring 
effects (greater than 3%) include: abscess, chills, peritonitis, and photosensitivity reactions. Anaphylaxis 
has been reported in a few patients receiving intravenous tacrolimus. Tacrolimus contains castor oil which 
has been associated with anaphylaxis in other drugs containing castor oil derivatives.
13.5 Sirolimus
In patients receiving sirolimus, 23% to 33% experienced anemia, and 14% to 30% experienced 
thrombocytopenia. Leukopenia has also been reported. Rare cases of microangiopathic hemolytic anemia 
have been reported. Cases of lymphoproliferative disorders have been reported. Lymphocele development 
has been reported.
Hypertension has been reported in 49% of patients receiving sirolimus. Antihypertensive therapy may be 
required. Edema has been reported in 18% to 20% of patients receiving sirolimus. Chest pain, venous 
thromboembolic disease, and tachycardia have also been reported.
Headaches have occurred in 20% to 34% of patients on sirolimus, pain has occurred in 29% to 33% of 
patients, and dizziness has also been reported. Gastrointestinal adverse effects of sirolimus have included 
constipation (36% to 38%), and stomatitis (3% to >20%).
Hypertriglyceridemia has been reported in 45% to 57% of patients taking sirolimus. Amenorrhea, diabetes 
mellitus, hypermenorrhea, hypervolemia, hypokalemia, elevated lactate dehydrogenase, menstrual disease 
and ovarian cyst formation have also been reported.
In patients taking sirolimus, 33% have had urinary tract infections. Herpes simplex infection, herpes 
zoster, pyelonephritis and sepsis have also been reported.
Arthralgia has been reported in 25% to 31% of patients taking sirolimus. Osteonecrosis has also been 
reported. 
A decline in kidney function has been seen in 39% to 40% of patients taking sirolimus.
Epistaxis and pneumonia have been reported in patients who were taking sirolimus.
Other miscellaneous effects that have been noted to occur in patients taking sirolimus include but are not 
limited to wound healing impairment, skin cancers, interstitial pulmonary disease (including pneumonitis, 
pulmonary fibrosis, and bronchiolitis obliterans organizing pneumonia), pulmonary alveolitis, pulmonary 
hemorrhage, reversible posterior leukoencephalopathy syndrome, liver toxicity, and cardiac tamponade.
13.6 Mycophenolate mofetil
The principal adverse reactions associated with the administration of mycophenolate include diarrhea, 
leukopenia, sepsis, vomiting, and there is evidence of a higher frequency of certain types of infections. 
Patients receiving immunosuppressive regimens involving combinations of drugs, including 
mycophenolate, as part of an immunosuppressive regimen are at increased risk of developing lymphomas 
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and other malignancies, particularly of the skin. The risk appears to be related to the intensity and duration 
of immunosuppression rather than to the use of any specific agent. Oversuppression of the immune system 
can also increase susceptibility to infection, including opportunistic infections, fatal infections, and sepsis.
As usual for patients with increased risk for skin cancer, exposure to sunlight and UV light should be 
limited by wearing protective clothing and using a sunscreen. Lymphoproliferative disease or lymphoma 
developed in 0.4% to 1% of patients receiving mycophenolate (2000 to 3000 milligrams daily) with other 
immunosuppressive agents in controlled clinical trials of renal, cardiac, and hepatic transplant patients.
There are no adequate and well-controlled studies in pregnant women. However, as mycophenolate has 
been shown to have teratogenic effects in animals, it may cause fetal harm when administered to a pregnant 
woman. Therefore, mycophenolate should not be used in pregnant women unless the potential benefit 
justifies the potential risk to the fetus. It is recommended that mycophenolate therapy should not be 
initiated by the physician until a report of a negative pregnancy test has been obtained.
In patients receiving mycophenolate (2000 or 3000 milligrams) in controlled studies for prevention of 
renal, cardiac or hepatic rejection, fatal infection/sepsis occurred in approximately 2% of renal and cardiac 
patients and in 5% of hepatic patients.
Severe neutropenia [absolute neutrophil count (ANC) <0.5 × 10 3 / microliter] developed in up to 2.0% of 
renal, up to 2.8% of cardiac, and up to 3.6% of hepatic transplant patients receiving mycophenolate 3000 
milligrams daily respectively. If neutropenia develops (ANC <1.3 × 10 3 / microliter), dosing with 
mycophenolate should be interrupted or the dose reduced, appropriate diagnostic tests performed, and the 
patient managed appropriately. Gastrointestinal bleeding (requiring hospitalization) has been observed in 
approximately 3% of renal transplant patients treated with mycophenolate 3000 milligrams daily. 
Gastrointestinal perforations have rarely been observed.
Allergic reactions to mycophenolate have been observed; therefore, mycophenolate is contraindicated in 
patients with a hypersensitivity to mycophenolate mofetil, mycophenolic acid or any component of the 
drug product. Mycophenolate intravenous is contraindicated in patients who are allergic to Polysorbate 80 
(TWEEN).
13.7 Infusion Risks
Stem Cell reinfusion is associated with the following hazards:

Temporary shortness of breath due to the lodging of small particles in the blood vessels of the 
lungs may occur. This is a less likely side effect.

If the bone marrow or stem cells that are to be used have been cryopreserved (frozen), a chemical 
called DMSO (dimethylsulfoxide) is used during the freezing process. This chemical is used to 
protect the cells from damage during freezing. DMSO produces an odor on the breath that lasts 1 
to 2 days. In rare instances, severe allergic reaction may occur.

There is also a chance of developing a blood transfusion reaction during the reinfusion of stem 
cells. The following less likely side effects may occur: chills, back pain, decreased blood pressure, 
chest pain, and increased rate of breathing. Wheezing, hives, rash, as well as difficulty breathing, 
and increased heart rate are considered unlikely. Rarely, temporary life support with artificial 
ventilation is required. 

Failure to engraft is a rare complication and it is possible that the recipient’s own bone marrow 
might grow back. A second transplant may be needed.
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13.8 Total Body Irradiation
During treatment the most common side effects include:

Headache

Nausea and vomiting

Diarrhea

Fatigue

Skin reaction
Less common is swelling of the salivary glands, which can produce pain in front of the ear and in the jaw.
The following may occur after receiving TBI (and may be caused, in part, by any subsequent 
chemotherapy):

Hair loss.

Discomfort in the throat and mouth.

Change in taste.

Mouth sores.

Nausea and vomiting.

Diarrhea.

Bone marrow suppression (low blood counts).
TBI can cause long-term side effects. They can occur months or years after your transplant.

Sterility is an expected side effect. Sexual function and pleasure will not be affected. Please talk 
to your doctor or nurse about any concerns you have.

About half of the patients will need thyroid supplements.
Other long-term side effects are rare but can occur. They include:

Inflammation of the sac that surrounds the heart.

Inflammation of the lungs.

Cataracts.

Second malignancies or new cancers
14 POTENTIAL BENEFITS TO SUBJECTS
The addition of post-transplant cyclophosphamide to the regimen used for GVHD prophylaxis may lead 
to a decrease in incidence of developing chronic GVHD.
15 DATA AND SPECIMEN BANKING
Not Applicable
16 MEASUREMENT OF EFFECT
The following criteria will be used for study evaluation:
16.1 Disease Response Criteria
Refer to Appendix I for post-transplant response criteria.
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16.2 Study Endpoints

The primary endpoint is extensive chronic GVHD in the first 365 days from Day 0 of the 
transplant.
16.3 Engraftment
Neutrophil engraftment is defined as the first day in which ANC is ≥ 0.5x109/ L for three consecutive 
days. Patient may receive growth factor support. Platelet engraftment is the first day that platelets are ≥ 20 
x109/ L for seven consecutive days without transfusion support.
Chimerism analysis will be performed at regular intervals. Lineage specific (separate lymphoid and 
myeloid) chimerism will be analyzed in blood at the following time points: day 30 (± 10 days), day 100 
(± 20 days) and then at unscheduled intervals until full donor chimerism is attained.
Primary engraftment failure is defined as lack of evidence of neutrophil engraftment at day +28, confirmed 
by a bone marrow biopsy within 2 weeks showing <5% cellularity in the absence of persistent malignancy. 
Late graft failure will be defined as initial neutrophil engraftment by day +28 followed by a drop in ANC 
to <500 for more than three days, independent of myelosuppressive drugs, severe GVHD or infection and 
unresponsive to growth factor in the absence of malignancy.
Graft rejection is defined as graft failure with documentation of return of recipient hematopoiesis as 
determined by cytogenetic/chimerism analysis.
17 SAFETY EVALUATION
17.1 Adverse Events
Only grade 3 or greater adverse events will be captured.
An adverse event or adverse experience (AE) is any untoward medical occurrence associated with the use 
of a drug in humans, whether or not considered drug related. Therefore, an AE can be ANY unfavorable 
and unintended sign (including an abnormal laboratory finding), symptom, or disease temporally 
associated with the use of a medicinal (investigational) product, whether or not considered related to the 
medicinal (investigational) product (attribution of ‘unrelated’, ‘unlikely’, ‘possible’, ‘probable’, or 
‘definite’).
An AE is considered “unexpected” if it is not listed in the investigator brochure or is not listed at the 
specificity or severity that has been observed; or if an investigator brochure is not required or available, 
is not consistent with the risk information described in the general investigational plan in other study-
related documents.
17.1.1.1
Diagnosis Versus Signs and Symptoms
If known, a diagnosis should be recorded on the CRF rather than individual signs and symptoms 
(e.g., record only liver failure or hepatitis rather than jaundice, asterixis, and elevated transaminases). 
However, if a constellation of signs and/or symptoms cannot be clinically characterized as a single 
diagnosis or syndrome at the time of reporting, each individual event should be recorded as an AE or SAE 
on the CRF. If a diagnosis is subsequently established, it should be reported as follow-up information.
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17.1.1.2
Adverse Events Occurring Secondary to Other Events
In general, AEs occurring secondary to other events (e.g., cascade events or clinical sequelae) should be 
identified by their primary cause. For example, if severe diarrhea is known to have resulted in dehydration, 
it 
is 
sufficient 
to 
record 
only 
diarrhea 
as 
an 
AE 
or 
SAE 
on 
the 
CRF. 
However, clinically significant AEs occurring secondary to an initiating event that are separated in time 
should be recorded as independent events on the CRF. For example, if a severe gastrointestinal 
hemorrhage leads to renal failure, both events should be recorded separately on the CRF.
17.1.1.3
Abnormal Laboratory Values
Only clinically significant laboratory abnormalities that are Grade 3-5 and require active management will 
be recorded as AEs or SAEs on the CRF (e.g., abnormalities that require study drug dose modification, 
discontinuation of study treatment, more frequent follow-up assessments, further diagnostic investigation, 
etc.).
If the clinically significant laboratory abnormality is a sign of a disease or syndrome (e.g., alkaline 
phosphatase and bilirubin 5 x the upper limit of normal associated with cholecystitis), only the diagnosis 
(e.g., cholecystitis) needs to be recorded on the Adverse Event CRF.
If the clinically significant laboratory abnormality is not a sign of a disease or syndrome, the abnormality 
itself should be recorded as an AE or SAE on the CRF. If the laboratory abnormality can be characterized 
by a precise clinical term, the clinical term should be recorded as the AE or SAE. For example, an elevated 
blood potassium level of 7 mEq/L should be recorded as “hyperkalemia”.
Observations of the same clinically significant laboratory abnormality from visit to visit should not be 
repeatedly recorded as AEs or SAEs on the CRF, unless their severity, seriousness, or etiology changes.
17.1.1.4
Preexisting Medical Conditions (Baseline Conditions)
A preexisting medical condition should be recorded as an AE or SAE only if the frequency, severity, or 
character of the condition worsens to Grade 3-5 during the study. When recording such events on an 
Adverse Event CRF, it is important to convey the concept that the preexisting condition has changed by 
including applicable descriptors (e.g., “more frequent headaches”).
17.2  Grading and Reporting Adverse Events
17.2.1.1
Grading and Relationship to Drug
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. CTEP Version 4.0 of the CTCAE 
is identified and located at:
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm.
AEs not covered by specific terminology listed should be reported with common medical terminology, 
and documented according to the grading scales provided in the CTCAE Version 4.0.
The relationship of event to study drug will be documented by the Investigator as follows:

Unrelated: The event is clearly related to other factors such as the participant’s clinical state, other 
therapeutic interventions or concomitant drugs administered to the participant.
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
Unlikely: The event is doubtfully related to investigational agent(s). The event was most likely 
related to other factors such as the participant’s clinical state, other therapeutic interventions, or 
concomitant drugs.

Possible: The event follows a reasonable temporal sequence from the time of drug administration, 
but could have been produced by other factors such as the participant’s clinical state, other 
therapeutic interventions or concomitant drugs.

Probable: The event follows a reasonable temporal sequence from the time of drug administration, 
and follows a known response pattern to the study drug. The event cannot be reasonably explained 
by other factors such as the participant’s clinical state, therapeutic interventions or concomitant 
drugs.

Definite: The event follows a reasonable temporal sequence from the time of drug administration, 
follows a known response pattern to the study drug, cannot be reasonably explained by other 
factors such as the participant’s condition, therapeutic interventions or concomitant drugs; AND 
occurs immediately following study drug administration, improves upon stopping the drug, or 
reappears on re-exposure.
17.3 Reporting Adverse Events:
Grade 3-5 AEs occurring between the start date of the conditioning regimen (Day -5) until 30 days after 
stem cell infusion will be reported.
Guidelines for Routine Adverse Event Reporting for Phase 1 Studies (Regardless of Expectedness)
Attribution
Grade 1
Grade 2
Grade 3
Grade 4
Unrelated
X
X
X
X
Unlikely
X
X
X
X
Possible
X
X
X
X
Probable
X
X
X
X
Definite
X
X
X
X
Guidelines for Routine Adverse Event Reporting for Phase 2 Studies (Regardless of Expectedness)
Attribution
Grade 1
Grade 2
Grade 3
Grade 4
Unrelated
X
X
Unlikely
X
X
Possible
X
X
X
X
Probable
X
X
X
X
Definite
X
X
X
X
17.4 Serious Adverse Events
A serious adverse event (SAE) is any adverse event (experience) that in the opinion of either the 
investigator or sponsor results in ANY of the following:

Death.
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
A life-threatening adverse event (experience). Any AE that places a participant or participants, in 
the view of the Investigator or sponsor, at immediate risk of death from the reaction as it 
occurred. It does NOT include an AE that, had it occurred in a more severe form, might have 
caused death.

Inpatient hospitalization or prolongation of existing hospitalization (for > 24 hours).

A persistent or significant incapacity or substantial disruption of the ability to conduct normal 
life functions.

A congenital anomaly or birth defect.

Important Medical Event (IME) that, based upon medical judgment, may jeopardize the 
participant and may require medical or surgical intervention to prevent one of the outcomes 
listed above.
17.4.1.1
Reporting Serious Adverse Events
All new SAEs occurring from the date of conditioning regimen (day -5) until 30 days after the stem cell 
infusion will be reported. The Roswell Park SAE Source Form is to be completed with all available 
information, including a brief narrative describing the SAE and any other relevant information.
SAEs occurring after the 30 days following stem cell infusion and until completion of the Day 100 
follow-up period that the investigator determines to be possibly, probably or definitely related to the study 
intervention should be reported.
SAEs that are unexpected and possibly, probably or definitely related must be reported as an Unanticipated 
Problem. Please refer to Section 17.5.1 for details on reporting Unanticipated Problems.
17.5 Unanticipated Problems
An Unanticipated Problem (UP) is any incident, experience, or outcome that meets all of the following 
criteria:

Unexpected (in terms of nature, severity, or frequency) given:
o
The research procedures that are described in the study-related documents, including 
study deviations, as well as issues related to compromise of participant. 
o
Privacy or confidentiality of data.
o
The characteristics of the participant population being studied.

Related or possibly related to participation in the research (possibly related means there is a 
reasonable possibility that the incident, experience, or outcome may have been caused by the 
procedures involved in the research).

Suggests that the research places participants or others at a greater risk of harm (including 
physical, psychological, economic, or social harm) than was previously known or recognized 
and if in relation to an AE is also deemed Serious per Section 17.4.
17.5.1.1
Reporting Unanticipated Problems:
Unanticipated problem reporting will begin at the time of participant consent. The Reportable New 
Information (RNI) Form will be submitted to the CRS Quality Assurance (QA) Office within 1 business 
day of becoming aware of the Unanticipated Problem. After review, CRS QA Office will submit the 
RNI to the IRB. 
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When becoming aware of new information about an Unanticipated Problem, submit the updated 
information to CRS QA Office with an updated Reportable New Information Form. The site Investigator 
or designated research personnel will report all unanticipated problems to the IRB in accordance with their 
local institutional guidelines.
17.6 FDA Reporting
Not Applicable for this study.
18 DATA MANAGEMENT AND CONFIDENTIALITY
18.1 Data Collection
Full build studies are managed by Roswell Park CRS Data Management for analysis by Roswell Park 
Biostatisticians. All electronic case report form (eCRF) data are captured for these studies.
Data management activities are performed using a CTMS system that enables the collection, cleaning and 
viewing of clinical trial data. CRS data management designs the study-specific database and facilitates 
development by the Information Technology team. Once the database design is approved by the 
Investigator, Statistician, and Clinical Research Coordinator, the database is put into production and data 
entry can begin. Data can be entered and changed only by those with the rights to do so into the eCRFs.
18.2 Confidentiality
All information provided to the Investigator by Roswell Park including preclinical data, protocols, CRFs, 
and verbal and written information, will be kept strictly confidential and confined to the clinical personnel 
involved in conducting this study, and no disclosure shall be made except in accordance with any right of 
publication granted to the Investigator. This information may be related in confidence to the IRB/ERC or 
other committee functioning in a similar capacity. No report or information about the study will be 
provided to anyone not involved in the study without consent of Roswell Park except if required by law.
18.3 Maintenance of Study Documents
Essential documents will be retained per Roswell Park’s policy for 6 years from the study termination 
date. These documents could be retained for a longer period, however, if required by the applicable local 
regulatory requirements or by an agreement with Roswell Park
18.4 Revisions to the Protocol
Roswell Park may make such changes to the protocol as it deems necessary for safety reasons or as may 
be required by the U.S. FDA or other regulatory agencies. Revisions will be submitted to the IRB/ERC 
for written approval before implementation.
18.5 Termination of the Study
It is agreed that, for reasonable cause, either the Roswell Park Investigators or the Sponsor, may terminate 
this study, provided a written notice is submitted within the time period provided for in the Clinical Trial 
Agreement. In addition, Roswell Park may terminate the study at any time upon immediate notice if it 
believes termination is necessary for the safety of participants enrolled in the study.
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19 STATISTICAL PLAN
This trial is designed as an open label, non-randomized, single institution study. The primary objective 
of this study is determination of the cumulative incidence of chronic graft-vs.-host disease (in 
patients who do not progress before Day 100) at 1 year after allogeneic hematopoietic cell 
transplantation utilizing this novel conditioning/GVHD prophylaxis regimen. In addition to the 
sample estimate of this probability, an exact 95% confidence interval will also be provided.
The design of this trial consists of two components: 1) A safety run-in component, which will be broken 
out into two strata (≤50 years of age, > 50 years of age) and 2) A two-stage efficacy analysis of chronic 
GVHD rates combining subjects from both strata. The safety run-in component of the trial will precede 
the efficacy analysis. 
19.1 Descriptive Analyses
Descriptive statistics such as frequencies and relative frequencies will be computed for all categorical 
variables. Numeric variables will be summarized using simple descriptive statistics such as the mean, 
standard deviation and range. A variety of graphical techniques will also be used to display data, ex. 
histograms, boxplots, scatterplots, etc.
19.2 Efficacy Analysis
PHASE 1 b SAFETY RUN-IN DESIGN
For both strata we will utilize a 3+3 dose escalation scheme in order to determine the safest dose from 
which to utilize in our efficacy analysis. This is slightly different than a pure phase I trial in that the study 
drug is already in use in the clinic. The goal is to better understand the maximum tolerated dose (MTD) 
within the age strata in a conservative fashion prior to proceeding on to the efficacy analysis.
For the age ≤50 years strata we will examine two dosing cohorts (A,B) following the administration of 
Fludarabine 40 mg/m2/day on Days -5 to -2. The two cohorts are Cohort A: 50 mg/m2 Melphalan and 
Cohort B: 75 mg/m2 Melphalan. For the age >50 strata we will examine three dosing cohorts (A, B, C) 
following the administration of Fludarabine 40 mg/m2/day on Days -5 to -2. The three cohorts are Cohort 
A: 25 mg/m2 Melphalan, Cohort B: 50 mg/m2 Melphalan and, Cohort C: 75 mg/m2 Melphalan.
Overall, accrual within the age ≤50 years strata for this component of the trial ranges between 3-12 patients 
and the accrual within the age >50 years strata for this component of the trial ranges between 3-18 patients. 
It is anticipated that we will escalate to the highest dose per strata. However, if ≥2/3 DLTs are observed 
in Cohort A in either stratum that component of the trial relative to the given strata will be suspended and 
the dosing scheme will be re-evaluated.
Note: Due to accrual rate differences between the strata, stoppage for interim analysis of one stratum will 
not necessitate that the other stratum be closed to accrual.
PHASE II ANALYSIS OF EFFICACY
Using the dose per strata deemed to be the MTD from the safety run-in design we will carry forth a one-
arm Simon two-stage design combining all eligible age groups. The primary endpoint is the development 
of extensive chronic GVHD (yes/no) at 1 year after transplantation. Let p represent the proportion of the 
evaluable population of interest who develop chronic GVHD (yes/no) prior to 1 year after transplantation. 
The evaluable population is defined as patients who meet eligibility requirements. Note that the subjects 
enrolled in the safety run-in analysis at the MTD will be included in the stage one portions of the respective 
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two-stage designs in the efficacy analysis presented below. In terms of the Simon two-stage design a true 
response of less than p0 is considered acceptable and evidence of such will deem the treatment worthy of 
further study. The null and alternative hypotheses to be tested are 
 versus
. The study 
𝐻0:𝑝= 𝑝0
𝐻0:𝑝< 𝑝0
design stops early for futility only and will proceed in two stages.  
For the Phase II portion of the trial we set 
, which leads to the following decision rules:
𝑝0 = 0.75

Stage 1: If 6 or more of the first 
 evaluable patients develop chronic GVHD, it will be 
𝑛1 = 8
concluded that the therapy is not promising, and the study will end. Otherwise, the study will 
progress to the second stage.

Stage 2: We will accrue 13 additional evaluable patients. If 13 or less of the total of
 
 𝑛1 +  𝑛2 = 21
evaluable patients do not develop GVHD, it will be concluded that p is less than 
 and that the 
𝑝0
therapy is efficacious; otherwise, it will be concluded that the therapy is not promising.
The nominal significance level of this design is α = 0.10. The sample size calculation is based on testing 
the hypotheses concerning the proportion of the population with a response to the treatment. For the ≤50 
years of age strata this two-stage design requires a potential total of 
=8+13 patients in order to 
 𝑛1 +  𝑛2
achieve approximately 1-β = 0.80 power to detect differences of Δ =0.25 percentage points (
 versus
𝑝0
𝑝0
).
‒  𝛥
Secondary efficacy endpoints for each stratum will include the following:

Clinical response, engraftment rate, progression free survival (PFS) at one year, and overall 
survival 

Cumulative incidence of relapse

Treatment-related mortality rates 

Cumulative incidence of grade III-IV acute GVHD 

Correlative studies will include chimerism analysis by molecular analysis and evaluation of 
immune reconstitution
For the time-to-event endpoints we will utilize either straight Kaplan-Meier based estimators or extensions 
of nonparametric survival models to account for competing risks. Other endpoints will be analyzed in a 
descriptive fashion with means +/- standard deviations or frequency counts. In addition, we will examine 
in a post-hoc analysis potential chronic GVHD rates of response by HLA matching status.
20 PROVISIONS TO MONITOR THE DATA TO ENSURE THE SAFETY OF SUBJECTS
Data and Safety Monitoring Plan
The Principal Investigator (PI) will be responsible for continuous monitoring of the safety of the study.
Safety lead-in patients: Study data from the safety lead-in patients (Phase 1 3x3 design) will be reviewed 
at the scheduled Roswell Park Early Phase Clinical Trials Committee meetings and the minutes are 
forwarded to the IRB for review.
Once the MTD from the safety lead-in has been determined, additional participants will be accrued for the 
Phase II portion of the study. Once the Phase II study is initiated, annual review of the study data will be 
assumed by the Roswell Park Data and Safety Monitoring and Accrual Committee (DSMAC). The 
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Roswell Park DSMAC will assess the progress of the study, the safety data, and critical efficacy endpoints. 
The DSMAC will review the study annually and will make recommendations that include but not limited 
to; (a) continuation of the study, (b) modifications to the design, (c) suspension of, or (d) termination of 
the study.
Patient Outcome Rounds are held weekly on the transplant unit at which time active BMT inpatients and 
outpatients are reviewed, including:

Medications: Chemotherapy for conditioning regimens; graft-versus-host disease prophylactic 
and therapeutic medications.

Adverse events related to the hematopoietic stem cell infusion; reports are filed according to 
Roswell Park policy and procedure.

Regimen-related toxicity based on Bearman toxicity grading34 (Appendix G)

Graft-versus-Host Disease based on standard grading and staging of both acute and chronic 
GVHD

Consent: properly signed and dated transplant consent.

Patient Psychosocial Status:
o
Compliance issues that could compromise patient safety.
o
At pretransplant, a conference is held by the BMT for all BMT patients for the purpose of 
describing the need for allogeneic patients to obtain lodging within a 30 mile radius of the 
hospital and to have a caregiver present at all times while the patient is an outpatient up to 
100 days following transplant.
o
In addition, psychosocial evaluations are completed on all transplant patients by one of the 
BMT social worker prior to transplant, to identify any compliance issues.

Safety Monitoring mandated by the BMT Standards of Care and common clinical practice. These 
include daily physical examinations, clinical laboratory testing, routine surveillance cultures, 
therapeutic drug level monitoring (i.e., Vancomycin, Tacrolimus, Tobramycin, Cyclosporine, 
Sirolimus, Mycophenolate), as an inpatient. They are found in the BMT SOPs. 

Patients who have been discharged from the hospital are monitored in the BMT Clinic until all 
transplant-related issues are resolved and they are returned to the care of their referring physicians.

Performance Status: assignment of Karnofsky Performance Status Score
In addition to weekly monitoring, the BMT Quality Assurance plan requires quarterly reporting to the 
BMT Quality Assurance Committee, which in turn reports to the Roswell Park Quality Assurance 
Committee. Indicators for BMT patient safety monitoring include:

Reportable serious adverse events 

Variances in the delivery of standard care that result in a change in practice

Readmissions prior to day +100 post-transplant

Deaths occurring prior to day +100 post-transplant

Engraftment of neutrophils and platelets
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BMT Patient Outcomes are reported to the Center for International Blood and Marrow Transplant 
Research (CIBMTR), and/or the National Marrow Donor Program (NMDP). Registry reports are reviewed 
internally prior to submission to the respective registry. These data are also entered into the Roswell Park 
BMT Database, from which patient outcomes are assessed and reviewed on an annual basis. The patients’ 
medical records serve as original source documents for all reporting. Audits are conducted every 4 years 
by the CIBMTR.
21 VULNERABLE POPULATIONS
Not Applicable.
22 COMMUNITY-BASED PARTICIPATORY RESEARCH
Not Applicable.
23 SHARING OF RESULTS WITH SUBJECTS
Individual response data is shared with the participant as a part of their clinical care.
24 SETTING
Treatment will be conducted in the inpatient and outpatient setting per BMT standards of care at Roswell 
Park’s BMT Center within Roswell Park Cancer Institute.
25 PROVISIONS TO PROTECT THE PRIVACY INTERESTS OF SUBJECTS
Any data, specimens, forms, reports, video recordings, and other records that leave the site will be 
identified only by a participant identification number (Participant ID, PID) to maintain confidentiality. All 
records will be kept in a limited access environment. All computer entry and networking programs will 
be done using PIDs only. Information will not be released without written authorization of the participant.
26 RESOURCES AVAILABLE
Not Applicable
27 PRIOR APPROVALS
Not applicable
28 COMPENSATION FOR RESEARCH-RELATED INJURY
Please refer to the informed consent (Section 13) related to this study.
29 ECONOMIC BURDEN TO SUBJECTS
The participants will not be subject to any economic burden.
30 CONSENT PROCESS
This study will not be initiated until the protocol and informed consent document(s) have been reviewed 
and approved by a properly constituted Institutional Review Board (IRB) or Independent Ethics 
Committee (IEC). Each participant (or legal guardian) shall read, understand, and sign an instrument of 
informed consent prior to performance of any study-specific procedure. It is the responsibility of the 
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investigator to ensure that the participant is made aware of the investigational nature of the treatment and 
that informed consent is given.
The Investigator is responsible for the retention of the participant log and participant records; although 
personal information may be reviewed by authorized persons, that information will be treated as strictly 
confidential and will not be made publicly available. The investigator is also responsible for obtaining 
participant authorization to access medical records and other applicable study specific information 
according to Health Insurance Portability and Accountability Act regulations (where applicable).
This study will be conducted in compliance with all applicable laws and regulations of the state and/or 
country and institution where the participant is treated. The clinical trial should be conducted in 
accordance with the ethical principles embodied in the Belmont Report: Ethical Principles and Guidelines 
for the Protection of Human Subjects of Research, consistent with good clinical practice and the applicable 
regulatory requirements and according to the guidelines in this protocol, including attached appendices.
The Roswell Park SOP: Informed Consent Process for Research (HRP-090) will be followed.
31 PROCESS TO DOCUMENT CONSENT IN WRITING
The Investigator (or IRB specified designee) is responsible for obtaining written consent from each 
participant in accordance with GCP guidelines using the approved informed consent form, before any 
study specific procedures (including screening procedures) are performed. The informed consent form 
acknowledges all information that must be given to the participant according to applicable GCP 
guidelines, including the purpose and nature of the study, the expected efficacy and possible side effects 
of the treatment(s), and specifying that refusal to participate will not influence further options for therapy. 
Any additional information that is applicable to the study must also be included. Additional national or 
institutionally mandated requirements for informed consent must also be adhered to. The participant 
should also be made aware that by signing the consent form, processing of sensitive clinical trial data and 
transfer to other countries for further processing is allowed.
The Investigator shall provide a copy of the signed consent form to the participant and the signed original 
shall be maintained in the Investigator File. A copy of the signed consent form must be filed in the 
participant file. At any stage, the participant may withdraw from the study and such a decision will not 
affect any further treatment options.
The Roswell Park “SOP: Written Documentation of Consent (HRP-091)” will be followed. 
32 DRUGS OR DEVICES
32.1 Fludarabine Monophosphate 
32.1.1.1
Availability
Fludarabine monophosphate (Fludara®), a purine nucleoside analog, is commercially available as a clear, 
sterile solution. Each 2 milliliter vial contains 50 milligrams of fludarabine phosphate, 50 milligrams of 
mannitol, water for injection, and sodium hydroxide to adjust pH to 6.8. Store at 2 to 8°C (36 to 46°F).
32.1.1.2
Storage and Stability
Fludarabine phosphate contains no antimicrobial preservative and thus care must be taken to assure the 
sterility of the prepared solutions and should be discarded eight hours after initial entry.
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32.1.1.3
Preparation
Fludarabine phosphate vials containing 50 milligrams of fludarabine phosphate, 50 milligrams of 
mannitol, water for injection and sodium hydroxide to adjust the pH to 6.8. The product may be further 
diluted for intravenous administration in 100 milliliters or 125 milliliters of 5% Dextrose for Injection 
USP or 0.9% Sodium Chloride, USP.
32.1.1.4
Administration
Parenteral drug products should be inspected visually for particulate matter and discoloration prior to 
administration. Fludarabine will be delivered as a piggy-bag via an ongoing IV line, over a period of 30 
minutes.
32.2 Melphalan
32.2.1.1
Availability
Melphalan (Alkeran®), an alkylating agent, is commercially available as a powder for injection in 
50 milligrams vials.
32.2.1.2
Storage and Stability
Intact vials should be stored between 20 to 25°C (68 to 77°F) and protected from light. Following 
reconstitution with sterile diluent, melphalan hydrochloride solution containing 5 milligrams of melphalan 
per milliliters is stable for up to 60 minutes at room temperature; this reconstituted solution should not be 
refrigerated since a precipitate may form at 5°C.
32.2.1.3
Preparation
Reconstitute by adding 10 milliliters of diluent provided by the manufacturer to a vial labeled as 
containing 50 milligrams of melphalan to provide a solution with a concentration of 
5 milligrams/milliliters. The diluent should be added rapidly and the vial should be shaken vigorously 
until a clear solution is obtained. Reconstituted solutions of melphalan should be inspected visually for 
particulate matter and discoloration prior to administration whenever solution and container permit.
Administration should occur within one hour of drug dissolution.
32.2.1.4
Administration
Administered IV, over 30 minutes.
32.3 Cyclophosphamide 
32.3.1.1
Availability
Cyclophosphamide (Cytoxan®), an alkylating agent for injection, is commercially available as a powder 
for injection in 500 milligram, 1 gram, and 2 gram vials.
32.3.1.2
Storage and Stability
Intact vials should be stored at or below 25°C (77°F). Following reconstitution with sterile diluent, 
cyclophosphamide is stable for up to 24 hours at room temperature and for up to 36 hours if refrigerated.
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32.3.1.3
Preparation
Reconstitute Cyclophosphamide using 0.9% Sodium Chloride Injection, USP or Sterile Water for 
Injection, USP, with 25 mL for a 500 mg vial, 50 mL for a 1 g vial, and 100 mL for a 2 g vial, for a total 
concentration of 20 mg/mL.
32.3.1.4
Administration
Administered IV, over 2 hours.
32.4 Sirolimus
32.4.1.1
Availability
Sirolimus is an agent that inhibits the activation of the mammalian Target of Rapamycin (mTOR). It is 
available for administration as an oral solution containing 1 mg/mL of sirolimus or as a white, triangular-
shaped tablet containing 1 mg of sirolimus, or as a yellow triangular-shaped tablet containing 2 mg of 
sirolimus. Sirolimus is rapidly absorbed. The systemic availability of sirolimus is 14% after administration 
of the solution and 27% after administration of tablets. Sirolimus is extensively metabolized by the 
CYP3A4 isozyme in the intestinal wall and liver. The majority of sirolimus is ultimately excreted into the 
stool, with a small amount excreted in the urine. Due to the reduced intensity nature of the conditioning 
regimen, an oral regimen should be tolerated.
32.4.1.2
 Storage and Stability
Sirolimus solution should be stored, protected from light, and refrigerated at 2°C to 8°C (36°F to 46°F). 
Once the bottle is opened, the contents should be used within one month. If necessary, the patient may 
store the bottles at room temperatures up to 25°C (77°F) for a short period of time (e.g., not more than 15 
days for the bottles). A dose of sirolimus solution may be kept in an oral syringe at room temperature for 
up to 24 hours. Sirolimus tablets should be stored at 20°C to 25°C (USP Controlled Room Temperature) 
(68° to 77°F). Use cartons to protect blister cards and strips from light.
32.4.1.3
Preparation
For Oral Use
For sirolimus solution, a syringe and cap are provided for dosing and the product may be kept in the 
syringe for a maximum of 24 hours at room temperatures up to 25°C (77°F) or refrigerated at 2°C to 8°C 
(36°F to 46°F). The syringe should be discarded after one use. After dilution, the preparation should be 
used immediately.
Sirolimus solution provided in bottles may develop a slight haze when refrigerated. If such a haze occurs 
allow the product to stand at room temperature and shake gently until the haze disappears. The presence 
of this haze does not affect the quality of the product.
Sirolimus tablets should be dispensed in a tight, light-resistant container.
32.4.1.4
Administration
On Day +5, starting dose will be 0.5 mg orally daily.  The sirolimus dose will be adjusted to target trough 
levels between 5-10 ng/mL (as per standard of care, and physician’s discretion). Either sirolimus solution 
or tablets may be utilized, as per discretion of the treating physician. Co-administration with azole anti-
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fungal therapy will be avoided whenever possible in order to mitigate the risk of drug-drug interactions 
(for example, if posaconazole is given between 6 – 8 AM then sirolimus will be given between 1 - 3 PM).
32.5 Tacrolimus 
32.5.1.1
Availability
Tacrolimus (Prograf®), a macrolide compound with potent immunosuppressant properties, is available 
for oral administration as capsules, containing the equivalent of 0.5, 1, or 5 milligrams of anhydrous 
tacrolimus and compounded oral suspension containing the equivalent of 1 milligram/milliliter of 
anhydrous tacrolimus. For IV use, tacrolimus is available as a sterile solution in 1 milliliter ampules 
containing the equivalent of 5 milligrams of anhydrous tacrolimus per mL.
The oral absorption of tacrolimus is erratic and incomplete; absolute bio-availability is approximately 
25%. Peak serum levels are seen 1 to 3 hours after an oral dose. Therapeutic trough blood concentrations 
have ranged from 5-15 nanograms/milliliter. Tacrolimus is extensively metabolized in the liver, with only 
small amounts of unchanged drug (2% or less) being recovered in the urine. The elimination half-life of 
tacrolimus is approximately 10 hours.
Tacrolimus suppresses both humoral (antibody) and cell-mediated immune responses. The compound is 
chemically distinct from cyclosporine but both agents elicit similar immunosuppressant effects. The 
immunosuppressive activity of tacrolimus is, however, more marked than that of cyclosporine.
32.5.1.2
Storage and Stability
Store tacrolimus capsules at controlled room temperature, 15-30°C (59-86°F). An extemporaneous 
suspension of tacrolimus with a final concentration of 1 milligram/milliliter was stable for 56 days when 
it was stored at 24-26°C in glass or plastic amber prescription bottles.
32.5.1.3
Preparation
For IV use
Tacrolimus concentrate for injection must be diluted prior to IV infusion. For IV infusion, the concentrate 
is diluted with 0.9% sodium chloride or 5% dextrose injection to a concentration of 4-20 
micrograms/milliliter. Preparation of the solution in polyethylene or glass containers allows storage for 
24 hours beyond which unused solution should be discarded. A plasticized polyvinyl chloride (PVC) 
container should not be used because stability of the solution is decreased and polyoxyl 60 hydrogenated 
castor oil contained in the formulation may leach phthalates from PVC containers. Tacrolimus concentrate 
for injection and diluted solutions of the drug should be inspected visually for particulate matter and 
discoloration prior to administration whenever solution and container permit.
For Oral use
Tacrolimus 1 milligram/milliliter suspension is compounded using twenty-four 5 milligram capsules, 60 
milliliters of simple syrup, and 60 milliliters of Oraplus ® suspension. Capsules are emptied into an 8 
ounce amber bottle and dissolved in 8 milliliters of sterile water. Simple syrup and Oraplus® are added 
and shaken vigorously. Storage is at room temperature for 56 days. 
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32.5.1.4
Administration
Oral therapy should be started as soon as possible after transplantation at a dose of 0.015 
milligrams/kilogram (ideal body weight or actual if less than ideal) every 12 hours. In patients unable to 
tolerate oral therapy, the recommended intravenous dose is one-third of the oral dose administered every 
12 hours.
32.6 Mycophenolate 
32.6.1.1
Availability
Mycophenolate (CellCept®), a 2-morpholinoethyl ester of mycophenolic acid (MPA), inosine 
monophosphate dehydrogenase (IMPDH) inhibitor, is available for oral administration as capsules 
containing 250 milligrams of mycophenolate mofetil, tablets containing 500 milligrams of mycophenolate 
mofetil, and as a powder for oral suspension, which when constituted contains 200 milligrams/milliliter 
mycophenolate mofetil.
Each vial of mycophenolate intravenous contains the equivalent of 500 milligrams mycophenolate mofetil 
as the hydrochloride salt. Reconstitution and dilution with 5% Dextrose Injection USP yields a solution 
of mycophenolate mofetil, 6 milligrams/milliliter.
32.6.1.2
Storage and Stability
The mycophenolate mofetil powder for reconstitution and reconstituted solution should be stored at 25°C 
(77°F); however, temperature excursions between 15°C to 30°C (59°F to 86°F) are permitted.
32.6.1.3
Preparation and Administration
Mycophenolate mofetil hydrochloride for injection (CellCept Intravenous) must be reconstituted and 
diluted to a concentration of 6 mg/mL using 5% Dextrose Injection USP. CellCept Intravenous is 
incompatible with other intravenous infusion solutions. Following reconstitution, CellCept Intravenous 
must be administered by slow intravenous infusion over a period of NO LESS THAN 2 HOURS by either 
peripheral or central vein. 
CAUTION: CELLCEPT INTRAVENOUS SOLUTION SHOULD NEVER BE ADMINISTERED BY 
RAPID OR BOLUS INTRAVENOUS INJECTION
Refer to package insert for detailed instructions.
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33 REFERENCES
1.
Luznik L, O'Donnell PV, Fuchs EJ. Post-transplantation cyclophosphamide for tolerance 
induction in HLA-haploidentical bone marrow transplantation. Semin Oncol 2012;39:683-93.
2.
Al-Homsi AS, Roy TS, Cole K, Feng Y, Duffner U. Post-transplant high-dose 
cyclophosphamide for the prevention of graft-versus-host disease. Biology of blood and marrow 
transplantation : journal of the American Society for Blood and Marrow Transplantation 2015;21:604-
11.
3.
Luznik L, Fuchs EJ. High-dose, post-transplantation cyclophosphamide to promote graft-host 
tolerance after allogeneic hematopoietic stem cell transplantation. Immunologic research 2010;47:65-77.
4.
Luznik L, O'Donnell PV, Symons HJ, et al. HLA-haploidentical bone marrow transplantation for 
hematologic malignancies using nonmyeloablative conditioning and high-dose, posttransplantation 
cyclophosphamide. Biology of blood and marrow transplantation : journal of the American Society for 
Blood and Marrow Transplantation 2008;14:641-50.
5.
Solomon SR, Sizemore CA, Sanacore M, et al. Haploidentical transplantation using T cell 
replete peripheral blood stem cells and myeloablative conditioning in patients with high-risk 
hematologic malignancies who lack conventional donors is well tolerated and produces excellent 
relapse-free survival: results of a prospective phase II trial. Biology of blood and marrow transplantation 
: journal of the American Society for Blood and Marrow Transplantation 2012;18:1859-66.
6.
Castagna L, Crocchiolo R, Furst S, et al. Bone marrow compared with peripheral blood stem 
cells for haploidentical transplantation with a nonmyeloablative conditioning regimen and post-
transplantation cyclophosphamide. Biology of blood and marrow transplantation : journal of the 
American Society for Blood and Marrow Transplantation 2014;20:724-9.
7.
Luznik L, Bolanos-Meade J, Zahurak M, et al. High-dose cyclophosphamide as single-agent, 
short-course prophylaxis of graft-versus-host disease. Blood 2010;115:3224-30.
8.
Mielcarek M, Furlong T, O'Donnell PV, et al. Posttransplantation cyclophosphamide for 
prevention of graft-versus-host disease after HLA-matched mobilized blood cell transplantation. Blood 
2016;127:1502-8.
9.
Anasetti C, Logan BR, Lee SJ, et al. Peripheral-blood stem cells versus bone marrow from 
unrelated donors. N Engl J Med 2012;367:1487-96.
10.
Imus PH, Blackford A, Franklin C, Jones RJ, DeZern AE. Risks and Outcomes of Cytokine 
Release in Haploidentical Peripheral Blood Stem Cell Transplantation. Biology of Blood and Marrow 
Transplantation 2018;24:S298.
11.
Mayer RJ, Davis RB, Schiffer CA, et al. Intensive postremission chemotherapy in adults with 
acute myeloid leukemia. Cancer and Leukemia Group B. N Engl J Med 1994;331:896-903.
APPROVED RPCI IRB
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Roswell Park Protocol No.: I 44417
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12.
Shimoni A, Hardan I, Shem-Tov N, et al. Allogeneic hematopoietic stem-cell transplantation in 
AML and MDS using myeloablative versus reduced-intensity conditioning: the role of dose intensity. 
Leukemia 2006;20:322-8.
13.
Grimwade D, Walker H, Harrison G, et al. The predictive value of hierarchical cytogenetic 
classification in older adults with acute myeloid leukemia (AML): analysis of 1065 patients entered into 
the United Kingdom Medical Research Council AML11 trial. Blood 2001;98:1312-20.
14.
Leith CP, Kopecky KJ, Godwin J, et al. Acute myeloid leukemia in the elderly: assessment of 
multidrug resistance (MDR1) and cytogenetics distinguishes biologic subgroups with remarkably 
distinct responses to standard chemotherapy. A Southwest Oncology Group study. Blood 1997;89:3323-
9.
15.
Wheatley K, Burnett AK, Goldstone AH, et al. A simple, robust, validated and highly predictive 
index for the determination of risk-directed therapy in acute myeloid leukaemia derived from the MRC 
AML 10 trial. United Kingdom Medical Research Council's Adult and Childhood Leukaemia Working 
Parties. British journal of haematology 1999;107:69-79.
16.
Alyea EP, Kim HT, Ho V, et al. Comparative outcome of nonmyeloablative and myeloablative 
allogeneic hematopoietic cell transplantation for patients older than 50 years of age. Blood 
2005;105:1810-4.
17.
Scott BL, Sandmaier BM, Storer B, et al. Myeloablative vs nonmyeloablative allogeneic 
transplantation for patients with myelodysplastic syndrome or acute myelogenous leukemia with 
multilineage dysplasia: a retrospective analysis. Leukemia 2006;20:128-35.
18.
Cutler CS, Lee SJ, Greenberg P, et al. A decision analysis of allogeneic bone marrow 
transplantation for the myelodysplastic syndromes: delayed transplantation for low-risk myelodysplasia 
is associated with improved outcome. Blood 2004;104:579-85.
19.
Barosi G, Hoffman R. Idiopathic myelofibrosis. Semin Hematol 2005;42:248-58.
20.
Hoffman R, Prchal JT, Samuelson S, Ciurea SO, Rondelli D. Philadelphia chromosome-negative 
myeloproliferative disorders: biology and treatment. Biology of blood and marrow transplantation : 
journal of the American Society for Blood and Marrow Transplantation 2007;13:64-72.
21.
Rondelli D, Barosi G, Bacigalupo A, et al. Allogeneic hematopoietic stem-cell transplantation 
with reduced-intensity conditioning in intermediate- or high-risk patients with myelofibrosis with 
myeloid metaplasia. Blood 2005;105:4115-9.
22.
Khouri IF. Reduced-intensity regimens in allogeneic stem-cell transplantation for non-hodgkin 
lymphoma and chronic lymphocytic leukemia. Hematology Am Soc Hematol Educ Program 2006:390-
7.
23.
Peggs KS, Hunter A, Chopra R, et al. Clinical evidence of a graft-versus-Hodgkin's-lymphoma 
effect after reduced-intensity allogeneic transplantation. Lancet 2005;365:1934-41.
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Roswell Park Protocol No.: I 44417
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24.
Barlogie B, Kyle RA, Anderson KC, et al. Standard chemotherapy compared with high-dose 
chemoradiotherapy for multiple myeloma: final results of phase III US Intergroup Trial S9321. J Clin 
Oncol 2006;24:929-36.
25.
Bensinger WI, Maloney D, Storb R. Allogeneic hematopoietic cell transplantation for multiple 
myeloma. Semin Hematol 2001;38:243-9.
26.
Badros A, Barlogie B, Siegel E, et al. Improved outcome of allogeneic transplantation in high-
risk multiple myeloma patients after nonmyeloablative conditioning. J Clin Oncol 2002;20:1295-303.
27.
Kroger N, Sayer HG, Schwerdtfeger R, et al. Unrelated stem cell transplantation in multiple 
myeloma after a reduced-intensity conditioning with pretransplantation antithymocyte globulin is highly 
effective with low transplantation-related mortality. Blood 2002;100:3919-24.
28.
Maloney DG, Molina AJ, Sahebi F, et al. Allografting with nonmyeloablative conditioning 
following cytoreductive autografts for the treatment of patients with multiple myeloma. Blood 
2003;102:3447-54.
29.
Bruno B, Rotta M, Patriarca F, et al. A comparison of allografting with autografting for newly 
diagnosed myeloma. N Engl J Med 2007;356:1110-20.
30.
Uzunel M, Remberger M, Sairafi D, et al. Unrelated versus related allogeneic stem cell 
transplantation after reduced intensity conditioning. Transplantation 2006;82:913-9.
31.
Van Dyk J, Galvin J, Glasgow G, Podgarsak E. The Physical Aspects of Total and Half Body 
Photon Iradiation. New York: American Association of Physicists in Medicine; 1986. Report No.: 17.
32.
Barker JN, Davies SM, DeFor T, Ramsay NK, Weisdorf DJ, Wagner JE. Survival after 
transplantation of unrelated donor umbilical cord blood is comparable to that of human leukocyte 
antigen-matched unrelated donor bone marrow: results of a matched-pair analysis. Blood 2001;97:2957-
61.
33.
Laughlin MJ, Eapen M, Rubinstein P, et al. Outcomes after transplantation of cord blood or bone 
marrow from unrelated donors in adults with leukemia. N Engl J Med 2004;351:2265-75.
34.
Bearman SI, Appelbaum FR, Buckner CD, et al. Regimen-related toxicity in patients undergoing 
bone marrow transplantation. J Clin Oncol 1988;6:1562-8.
35.
Center for International Blood & Marrow Transplant Research:
Post-HCT Follow-Up Data. at 
http://www.cibmtr.org/DataManagement/DataCollectionForms/Documents/2100/Rev4.0/2100R4.0+.pdf
.)
36.
International Myeloma Working Group (IMWG) Uniform Response Criteria for Multiple 
Myeloma. at http://imwg.myeloma.org/international-myeloma-working-group-imwg-uniform-response-
criteria-for-multiple-myeloma/.)
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37.
Center for International Blood & Marrow Transplant Research. at 
http://www.cibmtr.org/DataManagement/DataCollectionForms/Pages/index.aspx.)
38.
Hughes T, Ross D, Melo J. Handbook of Chronic Myeloid Leukemia. 1 ed: ADIS; 2014.
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34 APPENDICES/SUPPLEMENTS
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Appendix A
ELIGIBILITY VERIFICATION FORM: 
INCLUSION CRITERIA
Participant Name: _____________________________________________________
Medical Record No.: ___________________________________________________
Title: A Phase 1b/2 Trial of Fludarabine/Melphalan/Total Body Irradiation with Post Transplant 
Cyclophosphamide as Graft versus Host Disease Prophylaxis in Matched-Related and Matched-Unrelated 
Allogeneic Hematopoietic Cell Transplantation
INCLUSION CRITERIA
Yes
No
N/A
All answers must be “Yes” or “N/A” for participant enrollment.
Date
1.
The patient must have a diagnosis of one of the following (one must be yes):

AML

ALL

CLL

CML (chronic phase intolerant or unresponsive to tyrosine kinase 
inhibitors, history of accelerated phase or  history of blast crisis)

MDS

NHL

HL (received and failed frontline therapy or failed autologous 
transplantation or inability to collect enough PBSC for auto-HCT)

MM

Severe aplastic anemia
2.
Histocompatible donor identified 

Related donor 5/6 or better (A, B, DRB1)

Unrelated donor 7/8 or better (A, B, C and DRB1)
3.
Age ≥ 18 years.
4.
The following are eligible for study inclusion (refer to Appendix H):

AML may be in morphologic CR or CRi (MRD positive is allowed)

ALL may be in morphologic CR or CRi (MRD positive is allowed)

CLL may be in morphologic CR or CRi (MRD positive is allowed)

CML must be in chronic phase (MRD positive is allowed)

MDS- Patients with MDS only require ≤5% myeloblasts on bone marrow 
evaluation. There is no requirement for platelet or neutrophil recovery.

NHL must be in CR

HL must be in CR

MM may be in VGPR  

SAA do not have disease response requirements; however, if the patient 
has a mismatched donor, the patient must have had prior therapy with 
ATG.
5.
Have a Karnofsky performance status score of ≥ 50 (refer to Appendix C).
6.
Have the following clinical laboratory values:

Diffusing Capacity of the Lung for Carbon Monoxide (DLCO) ≥ 40% 
predicted, corrected for hemoglobin and/or alveolar ventilation.

Cardiac: left ventricular ejection fraction ≥ 40%.
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INCLUSION CRITERIA
Yes
No
N/A
All answers must be “Yes” or “N/A” for participant enrollment.
Date

Bilirubin, liver alkaline phosphatase, SGOT or SGPT ≤ 3 x upper limit of 
normal.

Calculated creatinine clearance ≥ 40 cc/min by the modified Cockroft-
Gault formula (refer to Appendix D)
7.
Patient must be cleared pre-transplant by Radiation Oncology to be able to 
receive 400cGy. 
8.
Participants of child-bearing potential must agree to use adequate 
contraceptive methods (e.g., hormonal or barrier method of birth control; 
abstinence) prior to study entry. Should a woman become pregnant or suspect 
she is pregnant while she or her partner is participating in this study, she 
should inform her treating physician immediately.
9.
Patients who have failed a prior autologous or allogeneic transplant are 
eligible. However, at least 6 months must have elapsed between the start of 
this reduced intensity conditioning regimen and the last transplant if patient 
had a prior autologous or allogeneic BMT.
10. At least 2 weeks since prior  radiation treatment and/or surgery. Appropriate 
washout of prior chemotherapy per BMT standard of care (see Appendix K). 
If medication is not on the list, go by physician discretion.
11. Participant must understand the investigational nature of this study and sign 
an Independent Ethics Committee/Institutional Review Board approved 
written informed consent form prior to receiving any study related procedure.
Investigator Signature: ___________________________________
Date: ___________
Printed Name of Investigator: __________________________________________________
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Appendix B
ELIGIBILITY VERIFICATION FORM: 
EXCLUSION CRITERIA
Participant Name: ____________________________________________________
Medical Record No.: __________________________________________________
Title: A Phase 1b/2Trial of Fludarabine/Melphalan/Total Body Irradiation with Post Transplant 
Cyclophosphamide as Graft versus Host Disease Prophylaxis in Matched-Related and Matched-Unrelated 
Allogeneic Hematopoietic Cell Transplantation
EXCLUSION CRITERIA
Yes
No
N/A
All answers must be “No” or “N/A” for participant enrollment.
Date
1.
Moderate to severe myelofibrosis within 60 days prior to transplant.
2.
Presence of HLA antibodies to the donor within 60 days prior to transplant.
3.
Uncontrolled CNS disease (for hematologic malignancies).
4.
Patients who in the opinion of the treating physician are unlikely to comply 
with the restrictions of allogeneic stem cell transplantation based on formal 
psychosocial screening. (i.e., serious, uncontrolled psychiatric illness/social 
situations that would limit compliance with study requirements)
5.
Uncontrolled diabetes mellitus, cardiovascular disease, active serious 
infection or other condition which, in the opinion of treating physician, 
would make this protocol unreasonably hazardous for the patient
6.
Known HIV positive
7.
Pregnant or nursing female participants
8.
Unwilling or unable to follow protocol requirements
9.
Any condition which in the Investigator’s opinion deems the participant an 
unsuitable candidate to receive study intervention.
Participant meets all entry criteria:
  Yes
  No
If “NO”, do not enroll participant in study.
Investigator Signature: ___________________________________
Date: __________
Printed Name of Investigator: _________________________________________________
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Appendix C
Karnofsky Performance Scale
Karnofsky Performance Scale *
Percent
Description
100
Normal, no complaints, no evidence of disease.
90
Able to carry on normal activity, minor signs or symptoms of disease.
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.
60
Requires occasional assistance, but is able to care for most of his needs.
50
Requires considerable assistance and frequent medical care.
40
Disabled, requires special care and assistance.
30
Severely disabled, hospitalization is indicated although death not imminent.
20
Hospitalization necessary, very sick, active supportive treatment necessary.
10
Moribund, fatal processes progressing rapidly.
0
Dead.
* Karnofsky, D.A., and Burchenal, J.H. (1949). The Clinical Evaluation of Chemotherapeutic Agents in Cancer. In 
Evaluation of Chemotherapeutic Agents: Symposium Held at the New York Academy of Medicine, C.M. MacLeod, 
ed. (New York, Columbia University Press), pp. 191-205.
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Appendix D
Calculation for Creatinine Clearance
Cockroft-Gault Equation*
Men: CrCl = [(140-YR) x IBW] / (SCr x 72)
Women: CrCl = 0.85 x [(140-YR) x IBW] / (SCr x 72)
Where:
CrCl is creatine clearance (mL/min)
IBW is ideal body weight (kg)
SCr is serum creatinine (mg/dL)
YR is age (years)
*Cockcroft D, W, Gault M, H, Prediction of Creatinine Clearance from Serum Creatinine. Nephron. 
1976; 16 (1):31-41).
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Appendix E
Clinical Grading of Chronic GVHD
Chronic Graft Versus Host Disease*
Involvement
Description
Limited
Localized skin involvement and/or hepatic 
dysfunction due to chronic GVHD.
Extensive
One or more of the following:
1)
Generalized skin involvement; or
2)
Liver histology showing chronic aggressive 
hepatitis, bridging necrosis or cirrhosis, or
3)
Involvement of the eye, or
4)
Involvement of minor salivary glands or oral 
mucosa, or
5)
Involvement of any other target organ (lung, 
GI, GU, musculoskeletal, serositis, etc…).
Severity
Description
Mild
Signs and symptoms of chronic GVHD do not 
interfere substantially with function and do not 
progress once appropriately treated with local 
therapy or standard systemic therapy (i.e., 
corticosteroids and/or CSA/Tacro).
Moderate
Signs and symptoms of chronic GVHD interfere 
somewhat with function despite appropriate 
therapy or are progressive through first line 
systemic therapy (i.e., corticosteroids and/or 
CSA/Tacro).
Severe
Signs and symptoms of chronic GVHD limit 
function substantially despite appropriate therapy 
or are progressive through second line therapy.
GVHD type
Description
De novo
No prior acute GVHD.
Progressive
Acute GVHD that progressed directly to chronic 
GVHD.
Interrupted
Acute GVHD that resolved symptoms (may still 
be on tapering treatment), then redeveloped later 
as chronic GVHD.
*Modified from CIBMTR Form 2100, revision 4.35
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Appendix F
Criteria for Acute Graft-vs-Host Disease
Clinical staging of acute graft-vs.-host disease according to organ involvement
STAGE
SKIN
LIVER
LOWER INTESTINAL 
TRACT
UPPER INTESTINAL 
TRACT
0
No rash
Bilirubin
< 2.0 mg/dL
< 34 µmol/L
Diarrhea
< 500 mL/day
Peds: < 10 ml/kg/day
No persistent anorexia, nausea, 
or vomiting
+
Maculopapular rash
< 25% of body 
surface
Bilirubin
2.0-3.0 
mg/dL
34-52 
µmol/L
Diarrhea
500-1000 mL/day
Peds: 10-19.9 ml/kg/day
Persistent anorexia, nausea, or 
vomiting 
++
Maculopapular rash
25-50% of body 
surface
Bilirubin
3.1-6.0 
mg/dL
53-103 
µmol/L
Diarrhea
> 1000-1500 mL/day
Peds: 20-30 ml/kg/day
+++
> 50% body surface
Bilirubin
6.1-15.0 
mg/dL
104-256 
µmol/L
Diarrhea
> 1500 mL/day
Peds: > 30 ml/kg/day
++++
Generalized 
erythroderma
with bullous 
formation
and/or desquamation
Bilirubin
> 15.0 
mg/dL
> 256 
µmol/L
Severe abdominal pain with or 
without ileus
(https://www.cibmtr.org/DataManagement/DataCollectionForms/Documents/2450/Rev4.0/2450R4
.0.pdf)
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Clinical (Glucksberg) grading of severity of acute graft-vs-host disease
GRADE
DEGREE OF ORGAN INVOLVEMENT
I
1 to 2 skin rash; 
no gut involvement; 
no liver involvement; 
no decrease in clinical performance
II
1 to 3 skin rash;
1 gut involvement or
1 liver involvement (or both);
mild decrease in clinical performance
III
2 to 3 skin rash;
2 to 3 gut involvement or
2 to 4 liver involvement (or both)
marked decrease in clinical performance
IV
Similar to Grade II with 
2  to 4 organ involvement and 
extreme decrease in clinical performance
Source: Thomas et al, N Engl. J Med. 1975; 292, 832
IBMTR Severity Index
A – Stage 1 skin involvement, no liver or gut involvement
B – Stage 2 skin involvement; Stage 1 to 2 gut or liver involvement
C – Stage 3 skin, liver, or gut involvement
D – Stage 4 skin, liver or gut involvement
Source: Rowlings et al., Br J Haematol 1997; 97:855
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Appendix G
Bearman Scale
BEARMAN TOXICITY GRADING SCALES
Regimen-Related Toxicity According to Organ System
Grade I
Grade II
Grade III
Cardiac 
toxicity
Mild EKG abnormality, not 
requiring medical 
intervention; or noted heart 
enlargement on chest x-ray 
with no clinical symptoms
Moderate EKG abnormalities 
requiring and responding to 
medical intervention; or requiring 
continuous monitoring without 
treatment; or congestive heart 
failure responsive to digitalis or 
diuretics
Severe EKG abnormalities 
with no or only partial 
response to medical 
intervention; or heart failure 
with no or only minor 
response to medical 
intervention; or decrease in 
voltage by more than 50%
Bladder 
toxicity
Macroscopic hematuria after 2 
days from last chemotherapy 
dose with no subjective 
symptoms of cystitis and not 
caused by infection
Macroscopic hematuria after 7 
days from last chemotherapy 
dose not caused by infection; or 
hematuria after 2 days with 
subjective symptoms of cystitis 
not caused by infection
Hemorrhagic cystitis with 
frank blood, necessitating 
invasive local intervention 
with installation of sclerosing 
agents, nephrostomy or other 
surgical procedure
Renal 
toxicity
Increase in creatinine up to 
twice the baseline value 
(usually the last recorded 
before start of conditioning)
Increase in creatinine above 
twice baseline but not requiring 
dialysis
Requirement of dialysis
Pulmonary 
toxicity
Dyspnea without chest x-ray 
changes not caused by infection 
or congestive heart failure; or 
chest x-ray showing isolated 
infiltrate or mild interstitial 
changes without symptoms not 
caused by infection or 
congestive heart failure
Chest x-ray with extensive 
localized infiltrate or moderate 
interstitial changes combined with 
dyspnea and not caused by 
infection or CHF; or decrease of 
PO2 (> 10% from baseline) but 
not requiring mechanical 
ventilation or > 50% O2 on mask 
and not caused by infection or 
CHF
Interstitial changes requiring 
mechanical ventilatory 
support or > 50% oxygen on 
mask and not caused by 
infection or CHF
Hepatic 
toxicity
Mild hepatic dysfunction with 
bilirubin ≥ 2.0 mg/dL and
≤ 6.0 mg/dL or weight gain > 
2.5% and < 5% from baseline, 
of non-cardiac origin; or SGOT 
increase more than 2- fold but 
less than 5-fold from lowest 
preconditioning
Moderate hepatic dysfunction 
with bilirubin > 6.0 mg/dL and
< 20 mg/dL; or SGOT increase
> 5-fold from preconditioning; or 
clinical ascites or image 
documented ascites > 100 mL; or 
weight gain > 5% from baseline of 
non-cardiac origin
Severe hepatic dysfunction 
with bilirubin > 20 mg/dL; or 
hepatic encephalopathy; or 
ascites compromising 
respiratory function
CNS
toxicity
Somnolence but the patient is 
easily aroused and oriented 
after arousal
Somnolence with confusion after 
arousal; or other new objective 
CNS symptoms with no loss of 
consciousness not more easily 
explained by other medication, 
bleeding or CNS infection
Seizures or coma not 
explained (documented) by 
other medication, CNS 
infection, or bleeding
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Grade I
Grade II
Grade III
Stomatitis
Pain and/or ulceration not 
requiring a continuous IV 
narcotic drug
Pain and/or ulceration requiring a 
continuous IV narcotic drug 
(morphine drip)
Severe ulceration and/or 
mucositis requiring preventive 
intubation; or resulting in 
documented aspiration 
pneumonia with or without 
intubation
GI toxicity
Watery stools > 500 mL but
< 2,000 mL every day not 
related to infection
Watery stools > 2,000 mL every 
day not related to infection; or 
macroscopic hemorrhagic stools 
with no effect on cardiovascular 
status not caused by infection; or 
subileus not related to infection
Ileus requiring nasogastric 
suction and/or surgery and 
not related to infection; or 
hemorrhagic enterocolitis 
affecting cardiovascular 
status and requiring 
Note:
Grade IV regimen-related toxicity is defined as fatal toxicity 
Abbreviation:
IV = intravenous
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Appendix H
Disease Status Requirements to Determine Eligibility
Acute Myeloid Leukemia
Complete Remission (CR)
Hematologic complete remission is defined as meeting all of the following response criteria:

< 5% blasts in the bone marrow

Evidence of trilineage hematopoiesis in the bone marrow  

No extramedullary disease (e.g., CNS, soft tissue disease)

Neutrophils ≥ 1,000/μL

Platelets ≥ 100,000/μL

Transfusion independent
Complete Remission with Incomplete Hematologic Recovery (CRi)
Hematologic complete remission with incomplete hematologic recovery is defined as meeting all of the 
following response criteria:

< 5% blasts in the bone marrow

Evidence of trilineage hematopoiesis in the bone marrow  

Normal maturation of all cellular components in the bone marrow

No extramedullary disease (e.g., CNS, soft tissue disease)
Acute Lymphoblastic Leukemia
Complete Remission (CR)
Hematologic complete remission is defined as meeting all of the following response criteria:

< 5% blasts in the bone marrow

Evidence of trilineage hematopoiesis in the bone marrow  

No extramedullary disease (e.g., CNS, soft tissue disease)

ANC (absolute neutrophil count) ≥ 1,000/μL

Platelets ≥ 100,000/μL
Complete Remission with Incomplete Hematologic Recovery (CRi)
Hematologic complete remission with incomplete hematologic recovery is defined as meeting all of the 
following response criteria:

< 5% blasts in the bone marrow

Evidence of trilineage hematopoiesis in the bone marrow  

No extramedullary disease (e.g., CNS, soft tissue disease)
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Multiple Myeloma* / Plasma Cell Disorder
Stringent Complete Remission (sCR)
Follows criteria for CR as defined below, plus all of the following:

Normal free light chain ratio

Absence of clonal cells in the bone marrow by immunohistochemistry, immunofluorescence, flow 
cytometry (MRD testing)
Complete Remission (CR)
A treatment response where all of the following criteria are met:

Negative immunoelectrophoresis (immunofixation) on serum and urine samples

Disappearance of any soft tissue plasmacytomas

< 5% plasma cells in the bone marrow (confirmation with repeat bone marrow biopsy not needed)

No known evidence of new or progressive bone lesions on radiographic studies.
For recipients with non-secretory myeloma, all of the following criteria must be met:

Disappearance of all soft tissue plasmacytomas

< 5% plasma cells in the bone marrow (confirmation with repeat bone marrow biopsy not needed)

No known evidence of new or progressive bone lesions on radiographic studies.
Very Good Partial Response (VGPR)

Absence of soft tissue plasmacytoma
One or more of the following must be present:

≥ 90% reduction in serum M-protein and urine M-protein level < 100 mg/24 hours
OR

Serum and urine M-protein detectable by immunofixation but not on electrophoresis
At diagnosis, if:

M protein is < 1 g/dL, you must use serum free light chain or urine measurement)

IgA monoclonal protein, you must use an estimate by total IgA or HevyLite®

Urine M-protein is < 200 mg/24 hours, use serum free light chains or if serum free light chains 
are not elevated, then use nonsecretory myeloma criteria
*Modified based on the International Myeloma Working Group (IMWG) Uniform Response Criteria for 
Multiple Myeloma36.
Chronic Myeloid Leukemia

Chronic Phase (<10% blasts in the blood and marrow)

If present, splenomegaly must be < 20 cm in the widest dimension on radiographic imaging 
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Hodgkin and Non-Hodgkin Lymphoma
Complete Remission (CR)

Complete disappearance of all known disease. For typically PET-avid lymphoma, a post-treatment 
residual mass of any size is permitted as long as it is PET negative. For variably, PET-avid 
lymphoma, all lymph nodes and nodal masses must have regressed as measured by CT to < 1.5 
cm (for nodes > 1.5 cm before therapy) or < 1 cm (for nodes 1.1 cm to 1.5 cm before therapy)
CRu

All CR criteria are met except, there may be CT scan abnormalities of uncertain significance. PET 
scan must be negative.
Chronic Lymphocytic Leukemia
Complete Response (CR)
All of the following:

Any lymphadenopathy must be ≤ 1.5 cm in the widest dimension

If present, splenomegaly must be < 20 cm in the widest dimension on radiographic imaging 

Neutrophils ≥ 1.5 × 109/L

Platelets > 100 × 109/L

Hemoglobin > 11 g/dL

Lymphocytes < 4 × 109/L

Bone marrow < 30% lymphocytes 

Absence of constitutional symptoms (including weight loss, fever, and night sweats)
CRi
All of the following:

No evidence of lymphadenopathy

No organomegaly

Absence of constitutional symptoms (including weight loss, fever, and night sweats)
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Appendix I
Post-Transplant Response Criteria37
Acute Myeloid Leukemia
Continued Complete Remission (CCR)

For patients transplanted in CR, the best response post BMT is CCR as long as there is no 
documented disease progression
Complete Remission (CR)
Hematologic complete remission is defined as meeting all of the following response criteria for at least 
four weeks.

< 5% blasts in the bone marrow

No extramedullary disease (e.g., CNS, soft tissue disease)
Relapse (REL)
Relapse is defined as the recurrence of disease after CR, meeting one or more of the following criteria:

≥ 5% blasts in the marrow or peripheral blood

New or recurrence of extramedullary disease
Acute Lymphoblastic Leukemia
Continued Complete Remission (CCR)

For patients transplanted in CR, the best response post BMT is CCR as long as there is no 
documented disease progression
Complete Remission (CR)
Hematologic complete remission is defined as meeting all of the following response criteria for at least 
four weeks.

< 5% blasts in the bone marrow

No extramedullary disease (e.g., CNS, soft tissue disease)
Relapse (REL)
Relapse is defined as the recurrence of disease after CR, meeting one or more of the following criteria:

≥ 5% blasts in the marrow or peripheral blood

New or recurrence of extramedullary disease
Myelodysplastic Syndrome (MDS)
Continued Complete Remission (CCR)

For patients transplanted in CR, the best response post BMT is CCR as long as there is no 
documented disease progression
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Complete Remission (CR)
Bone marrow evaluation:

< 5% myeloblasts with normal maturation of all cell lines
Peripheral blood evaluation:

Hemoglobin ≥ 11 g/dL un-transfused within 7 days without erythropoietic support

ANC ≥ 1000/mm3 without myeloid growth factor support

Platelets ≥ 100,000/mm3 without thrombopoietic support

0% blasts in blood
Hematologic Improvement (HI)

<5% blasts in the bone marrow
Hematologic improvement – erythropoietic (HI-E)

Hemoglobin increase of ≥ 1.5 g/dL un-transfused for 7 days
Hematologic improvement – platelets (HI-P)

For pre-treatment platelet count of > 20 ×109, platelet absolute increase of ≥ 30 ×109

For pre-treatment platelet count of < 20 ×109, platelet absolute increase of ≥ 20 ×109 and ≥ 100% 
increase from pre-treatment level
Hematologic improvement – neutrophils (HI-N)

Neutrophil count increase of ≥ 100% from pre-transplant level and an absolute increase of 
≥ 500/mm3
No Response (NR)/Stable Disease (SD)

Does not meet the criteria for at least HI; but no evidence of disease progression to AML.
Relapse/Progression from Complete Remission (Rel from CR or HI)
Requires at least one of the following:

Bone marrow blasts >5% and clonal

At least a 50% decrease in platelets or granulocytes that is related to the malignant clonal 
population of cells (not due to ABO incompatibility, medication, angiopathy, or other 
nonmalignant causes)

The hemoglobin level must decrease by at least 1.5 g/dL from pre-transplant level.
Progression to AML

≥ 20% blasts in the blood or bone marrow
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Multiple Myeloma / Plasma Cell Disorder
Continued Complete Remission (CCR)

For patients transplanted in CR, the best response post BMT is CCR as long as there is no 
documented disease progression
Stringent Complete Remission (sCR)
Follows criteria for CR as defined below, plus all of the following:

Normal free light chain ratio

Absence of clonal cells in the bone marrow by immunohistochemistry, immunofluorescence, flow 
cytometry (MRD testing)
Complete Remission (CR)

A treatment response where all of the following criteria are met:

Negative immunoelectrophoresis (immunofixation) on serum and urine samples

Disappearance of any soft tissue plasmacytomas

< 5% plasma cells in the bone marrow (confirmation with repeat bone marrow biopsy not needed)

No known evidence of new or progressive bone lesions on radiographic studies.
For recipients with non-secretory myeloma, all of the following criteria must be met:

Disappearance of all soft tissue plasmacytomas

< 5% plasma cells in the bone marrow (confirmation with repeat bone marrow biopsy not needed)

No known evidence of new or progressive bone lesions on radiographic studies.
Very Good Partial Response (VGPR)

Absence of soft tissue plasmacytoma
One or more of the following must be present:

≥ 90% reduction in serum M-protein and urine M-protein level < 100 mg/24 hours
OR

Serum and urine M-protein detectable by immunofixation but not on electrophoresis
At diagnosis, if:

M protein is < 1 g/dL, you must use serum free light chain or urine measurement)

IgA monoclonal protein, you must use an estimate by total IgA or HevyLite®

Urine M-protein is < 200 mg/24 hours, use serum free light chains or if serum free light chains are 
not elevated, then use nonsecretory myeloma criteria
Partial Response (PR)
Both of the following must be present:

≥ 50% reduction in serum M-protein

Reduction in 24-hour urinary M-protein by ≥ 90% or to < 200 mg/24 hours.
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At diagnosis, if:

M protein is < 1 g/dL, you must use serum free light chain or urine measurement)

IgA monoclonal protein, you must use an estimate by total IgA or HevyLite®

Urine M-protein is < 200 mg/24 hours, use serum free light chains or if serum free light chains are 
not elevated, then use nonsecretory myeloma criteria
In addition to the above-listed criteria, if soft tissue plasmacytomas were present at baseline, a ≥ 50% 
reduction in their size is also required.
Stable Disease (SD)

Does not meet the criteria for CR, VGPR, PR, or PD.
Progressive Disease (PD)
Requires one or more of the following:

Increase of ≥ 25% from the lowest post-transplant response value achieved in:

Serum M-component with an absolute increase ≥ 0.5 g/dL 

Urine M-component with an absolute increase ≥ 200 mg/24 hours; 

For recipients without measurable serum and urine M-protein levels, the difference between 
involved and uninvolved free light chain levels with an absolute increase > 10 mg/dL; 

Bone marrow plasma cell percentage with absolute percentage increase of ≥ 10%; 

Definite development of new bone lesions or soft tissue plasmacytomas, or definite increase in the 
size of any existing bone lesions or soft tissue plasmacytomas; 
Chronic Myeloid Leukemia
Continued Complete Remission (CCR)

For patients transplanted in CR, the best response post BMT is CCR as long as there is no 
documented disease progression
Complete Hematologic Remission (CR)
A treatment response where all of the following criteria are met:

White blood count is < 10 × 109/L, without immature granulocytes and with < 5% basophils

Platelet count < 450 × 109/L

Non-palpable spleen
Complete Molecular Remission38

0% BCR/ABL transcripts detected in peripheral blood or bone marrow 
Major Molecular Remission

>0-0.1% BCR/ABL transcripts detected in peripheral blood or bone marrow
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Complete Cytogenetic Response

0% Ph+ cells detected in bone marrow
Partial Cytogenetic Response

>0-35% Ph+ cells in bone marrow
Minor Cytogenetic Response

>35-65% Ph+ cells in bone marrow
Minimal Cytogenetic Response

>65-95% Ph+ cells in bone marrow
No Cytogenetic Response

>95% Ph+ cells in bone marrow
Chronic Phase

Characterized by relatively few blasts (<10%) present in the blood and bone marrow. 
Symptoms are often not present. The chronic phase may last several months to years, 
depending on the recipient and the treatment they receive.
Accelerated Phase
One or more of the following must be present:

10%-19% blasts in blood or marrow

≥ 20% basophils in peripheral blood

Clonal marrow cytogenetic abnormalities in addition to the single Philadelphia chromosome 
(clonal evolution)

Increasing spleen size, unresponsive to therapy

Increasing WBC, unresponsive to therapy

Thrombocytopenia (platelets < 100,000), unrelated to therapy

Thrombocytosis (platelets > 1,000,000), unresponsive to therapy
Blast Phase
Characterized by having ≥ 20% blasts (formerly ≥ 30%) in the peripheral blood or bone marrow. Having 
extramedullary blastic infiltrates (i.e., myeloid sarcoma, granulocytic sarcoma, or chloroma) also qualifies 
as blast phase. The red cell, platelet, and neutrophil counts may decrease and episodes of infection and 
bleeding may result. Symptoms such as fatigue, shortness of breath, abdominal pain, bone pain, and spleen 
enlargement may occur.
Relapse
For reporting purposes, relapse is defined as recurrence of disease after complete hematologic remission. 
In general, relapse should be confirmed by a clinical / hematologic assessment (e.g., pathology, CBC, or 
clinical exam).
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Progression
For reporting purposes, progression is defined as any of the following changes in disease status:

Advancement from chronic phase to accelerated phase.

Advancement from chronic phase to blast phase.

Advancement from accelerated phase to blast phase.
Hodgkin and Non-Hodgkin Lymphoma
Continued Complete Remission (CCR)

For patients transplanted in CR, the best response post BMT is CCR as long as there is no 
documented disease progression
Complete Remission (CR)
Complete disappearance of all known disease. For typically PET-avid lymphoma, a post-treatment 
residual mass of any size is permitted as long as it is PET negative. For variably PET-avid lymphoma, all 
lymph nodes and nodal masses must have regressed as measured by CT to ≤ 1.5 cm (for nodes > 1.5 cm 
before therapy) in the longest diameter or ≤ 1 cm (for nodes 1.1 cm to 1.5 cm before therapy).
Bone Marrow (optional as part of work-up unless it was positive for disease immediately prior to 
transplant): If bone marrow was positive any time prior to transplant, it must be repeated and negative to 
confirm CR.
Partial Remission (PR)

≥ 50% reductions in the greatest diameter of up to six of the largest dominant nodes or nodal 
masses, extranodal sites and no new sites of lymphoma
Stable Disease

Does not meet criteria for CR, PR, or PD
Progressive Disease

Any new lesion and/or > 50% increase in the least diameter of previously involved sites

New or recurrent involvement of bone marrow

New or recurrent extranodal disease
Chronic Lymphocytic Leukemia
Continued Complete Remission (CCR)

For patients transplanted in CR, the best response post BMT is CCR as long as there is no 
documented disease progression
Complete Response (CR)
All of the following:

Any lymphadenopathy must be ≤ 1.5 cm in the widest dimension

If present, splenomegaly must be < 20 cm in the widest dimension on radiographic imaging 
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
Neutrophils ≥ 1.5 × 109/L

Platelets > 100 × 109/L

Hemoglobin > 11 g/dL

Lymphocytes < 4 × 109/L

Bone marrow < 30% lymphocytes 

Absence of constitutional symptoms (including weight loss, fever, and night sweats)
Partial Response (PR)

≥ 50% decrease in peripheral blood lymphocyte count from pretreatment value

≥ 50% reduction in lymphadenopathy if present pretreatment

≥ 50% reduction in liver and/or spleen size if enlarged pretreatment
One or more of the following:

Neutrophils ≥ 1.5 ×109/L or 50% improvement over baseline

Platelets > 100 ×109/L or 50% improvement over baseline

Hemoglobin > 11 g/dL or 50% improvement over baseline
Stable Disease (SD)
Not meeting the definition of complete response, partial response, or progressive disease.
Progressive Disease (PROG)/Relapse
One or more of the following:

≥ 50% increase in the sum of the products of ≥ 2 lymph nodes (≥ 1 lymph node must be ≥ 2 cm) 
or new nodes

≥ 50% increase in liver or spleen size, or new hepatomegaly or splenomegaly

≥ 50% increase in absolute lymphocyte count to ≥ 5 ×109/L

Transformation to a more aggressive histology
Aplastic Anemia
Complete Response:

At least 20% cellularity in the bone marrow with neutrophil and platelet engraftment (ANC >500 
and Platelets <20)
No Response:

Does not meet definition of CR
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Appendix J
Schedule of Procedures and Observations
Tests and Observations
Prior to 
Study1
Day 30 (± 
10 days)
Day 100 (± 
20 days)
1 Year (± 
30 days)
Annual 
Survival 
Follow up7
History and Physical Exam
X
Fulfill Criteria for Standard BMT 
workup per SOP
X
HLA Antibodies Class I/II
X
Physical Exam and Updated History
X
X
X
X
Height/Weight/Body Surface Area
X
Performance Status (KPS)
X
X
CBC w/diff4
X
X
X
X
CMP4
X
X
X
X
MUGA or ECHO
X
Splenomegaly Assessment 
X6
PFT
X
Radiation Oncology Clearance
X
Chimerism Peripheral Blood
X
X
X
X
Chimerism Bone Marrow
X
X
X
Disease Assessment per SOP
X
X
X
X
X
Bone Marrow Biopsy
X5
X
X
X
Immune Reconstitution/Flow3
X
X
X
X
Adverse Events2
X
X
Capture GVHD medication
X
X
X
X
GVHD Assessment
X
X
X
X
Survival Status
X
X
X
X
1 Screening work up must be completed within 60 days of pre admit visit.  Exceptions per PI discretion.  
2 Grade 3-5 adverse events are collected until Day +30, Serious Adverse Events that are considered to be possibly, probably, 
or definitely related to study intervention are collected until Day +100.  SAEs that are ongoing at 1 year follow up will be 
considered ongoing and will not continue to be followed past this timepoint.
3 BMT SOC flow panel (peripheral blood) should be collected for Immune Reconstitution.
4 CBC and CMP should be completed weekly after hospital discharge until Day 100. 
5 Only patients with prior bone marrow involvement are required to have a bone marrow biopsy at baseline.
6 Required for CML patients per SOC.
7 Annual follow up will be completed per treating physician discretion and TCT clinic standard of care.
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Appendix K Chemotherapy Discontinuation Prior to Bone Marrow Transplant
Alkylating Agents:
Generic
Brand
Class/MOA
Half-life
Metabolism/ 
Excretion
Discontinuation 
Prior to BMT
Bendamustine
Treanda
Alkylating Agent
3 hours
Hepatic/ Renal + Fecal
7 Days
Carboplatin
Paraplatin
Alkylating Agent
1-6 hours
Renal
7 Days
Carmustine
BNCU
Alkylating Agent
22 minutes
Hepatic/ Renal
7 Days
Chlorambucil
Leukeran
Alkylating Agent
1.5–2 
hours
Hepatic/ Renal 
7 Days
Cisplatin
Platinol
Alkylating Agent
16-53 
hours
Renal
7 Days
Cyclophosphamide
Cytoxan
Alkylating Agent
4-16 hours 
Hepatic (CYP450)/ 
Renal
7 Days
Ifosfamide
Ifex
Alkylating Agent
7-15 hours
Hepatic (CYP3A4/5)/ 
Renal
7 Days
Melphalan
Alkeran, 
Evomela
Alkylating Agent
0.5–2.5 
hours
Blood/ Fecal + Renal
7 Days
Procarbazine
Matulane
Alkylating Agent
~10 
minutes
Hepatic + Renal/ Renal 
+ Fecal
7 Days
Anthracyclines:
Generic
Brand
Class/MOA
Half-life
Metabolism/ 
Excretion
Discontinuation 
Prior to BMT
Daunorubicin
Cerubidine
Anthracycline
23-40 
hours
Hepatic/ Biliary + 
Renal
7 Days
Doxorubicin
Adriamyci
n
Anthracycline
20-48 
hours
Hepatic 
(CYP3a4/2D6)/ Fecal + 
Biliary + Renal
7 Days
Idarubicin
Idamycin
Anthracycline
~45 hours
Hepatic/ Renal + 
Biliary
7 Days
Antimetabolites:
Generic
Brand
Class/MOA
Half-life
Metabolism/ 
Excretion
Discontinuation 
Prior to BMT
Cladribine
Leustatin
Antimetabolite
6-7 hours
Renal
7 Days
Cytarabine
Cytosar
Antimetabolite
1-3 hours
Hepatic/ Renal
7 Days
Fludarabine
Fludara
Antimetabolite
10-20 
hours
Hepatic/ Renal
7 Days
Hydroxyurea
Hydrea
Antimetabolite
2 – 4.5 
hours
Hepatic/ Renal
1 Day
Mercaptopurine
Purinethol
Antimetabolite
~2 hours
Hepatic/ Renal
7 Days
Methotrexate
Trexall
Antimetabolite
8–15 hours
Hepatic/ Renal
7 Days
BCL-2 Inhibitor:
Generic
Brand
Class/MOA
Half-life
Metabolism/ 
Excretion
Discontinuation 
Prior to BMT
Venetoclax
Venclexta
BCL-2 Inhibitor
~26 hours
Hepatic (CYP3A4)/ 
Fecal + Renal
7 Days
Calcineurin/ mTOR Kinase Inhibitors:
Generic
Brand
Class/MOA
Half-life
Metabolism/ 
Excretion
Discontinuation 
Prior to BMT
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Cyclosporine
Gengraf, 
Neoral
Calcineurin Inhibitor
10-27 
hours
Hepatic (CYP3A4)/
Biliary
7 Days + Levels < 30
Sirolimus
Rapamune
mTOR Kinase inhibitor
~62 hours 
Hepatic (CYP3A4)/ 
Fecal
7 days + Level < 2
Tacrolimus
Prograf
Calcineurin Inhibitor
8.7-11.3 
hours
Hepatic (CYP3A4)/
Biliary
7 Days + Level < 2
DNA Fragmentation Agent:
Generic
Brand
Class/MOA
Half-life
Metabolism/ 
Excretion
Discontinuation 
Prior to BMT
Arsenic Trioxide
Trisenox
DNA Fragmentation
10-14 
hours
Hepatic/Renal
2 Days
FLT-3/Multi-Kinase/Janus Kinase Inhibitors:
Generic
Brand
Class/MOA
Half-life
Metabolism/ 
Excretion
Discontinuation 
Prior to BMT
Gilteritinib
ASP2215
Tyrosine Kinase 
Inhibitor + FLT-3 
Inhibitor 
45-159 
hours
Hepatic/ Renal + Fecal 
+ Biliary
7 Days
Ibrutinib
Imbruvica
Bruton’s Tyrosine 
Kinase Inhibitor
4 – 6 hours
Hepatic 
(CYP3A4/2D6)/ Fecal 
+ Renal
1 Day
Midostaurin
Rydapt
Tyrosine Kinase 
Inhibitor +FLT-3 
Inhibitor
~20 days
Hepatic (CYP3A4)/ 
Fecal + Renal
2 Days
Quizartinib
AC220
Tyrosine Kinase 
Inhibitor +FLT-3 
Inhibitor
~3 Days
Hepatic (CYP3A4)/ 
Fecal
7 Days
Ruxolitinib
Jakafi
Janus Kinase Inhibitor
~5.8 hours
Hepatic (CYP3A4)/ 
Renal + Fecal
1 Day
Sorafenib 
Nexavar 
Multi-kinase Inhibitor 
25–48 
hours
Hepatic (CYP3A4)/ 
Fecal+ Renal
7 Days
Tofacitinib
Xeljanz
Janus Kinase Inhibitor
3-6 hours
Hepatic (CYP3A4)/ 
Renal
1 Day
HDAC Inhibitors:
Generic
Brand
Class/MOA
Half-life
Metabolism/ 
Excretion
Discontinuation 
Prior to BMT
Panobinostat
Farydak
HDAC Inhibitor 
~37 hours
Hepatic (CYP3A4)/ 
Fecal + Renal
7 Days
Vorinostat
Zolinza 
HDAC Inhibitor
~2 hours
Hepatic/ Renal
1 Day
Hydrolysis Catalyzer:
Generic
Brand
Class/MOA
Half-life
Metabolism/ 
Excretion
Discontinuation 
Prior to BMT
Asparaginase
Erwinase
Hydrolysis Catalyzer
15.6 hours
Blood/ Renal
7 Days
Pegaspargase
Oncaspar
Hydrolysis Catalyzer
3.2-5.7 
days
Blood/ Renal
14 Days
Hypomethylating Agents:
Generic
Brand
Class/MOA
Half-life
Metabolism/ 
Excretion
Discontinuation 
Prior to BMT
Azacitadine
Vidaza
Hypomethylating Agent
4 hours
Renal
7 Days
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Decitabine
Dacogen
Hypomethylating Agent
~0.5 hours
Hepatic
7 Days
Immunomodulatory Agents:
Generic
Brand
Class/MOA
Half-life
Metabolism/ 
Excretion
Discontinuation 
Prior to BMT
Lenalidomide
Revlimid
Immunomodulatory 
Agent
3–5 hours
Limited Metabolism/ 
Renal
2 Days
Pomalidomide
Pomalyst
Immunomodulatory 
Agent
~7.5 hours
Hepatic 
(CYP3A4/1A2)/ Renal 
+ Fecal
2 Days
Thalidomide
Thalomid
Immunomodulatory 
Agent
5-7 hours
Hepatic/ Renal
2 Days
Isocitrate Dehydrogenase 2 (IDH2).Inhibitor:
Generic
Brand
Class/MOA
Half-life
Metabolism/ 
Excretion
Discontinuation 
Prior to BMT
Enasidenib
Idhifa
Inhibitor of the enzyme 
isocitrate dehydrogenase 
2 (IDH2).
137 hours
AGI-16903 is the N-
dealkylated metabolite 
of enasidenib and 
represents 10% of 
radioactivity in 
circulation.
1 Day
Kinase Inhibitors:
Generic
Brand
Class/MOA
Half-life
Metabolism/ 
Excretion
Discontinuation 
Prior to BMT
Bosutinib
Bosulif
Tyrosine Kinase 
Inhibitor
22–27 
hours
Hepatic (CYP3A4)/ 
Fecal
5 days
Dasatinib
Sprycel 
Tyrosine Kinase 
Inhibitor 
3–5 hours
Hepatic (CYP3A4)/ 
Fecal + Renal
1 Day
Gilteritinib
ASP2215
Tyrosine Kinase 
Inhibitor + FLT-3 
Inhibitor 
45-159 
hours
Hepatic/ Renal + Fecal 
+ Biliary
7 Days
Ibrutinib
Imbruvica
Bruton’s Tyrosine 
Kinase Inhibitor
4 – 6 hours
Hepatic 
(CYP3A4/2D6)/ Fecal 
+ Renal
1 Day (Assess 
Bleeding Risk)
Imatinib
Gleevec
Tyrosine Kinase 
Inhibitor
~40 hours 
Hepatic (CYP3A4)/ 
Fecal + Renal
7 Days
Midostaurin
Rydapt
Tyrosine Kinase 
Inhibitor +FLT-3 
Inhibitor
~20 days
Hepatic (CYP3A4)/ 
Fecal + Renal
2 Days
Nilotinib
Tasigna
Tyrosine Kinase 
Inhibitor
15–17 
hours
Hepatic (CYP3A4)/ 
Fecal
3 Days
Ponatinib
Iclusig
Tyrosine Kinase 
Inhibitor
~24 hours
Hepatic (CYP3A4)/ 
Fecal + Renal
7 Days
Quizartinib
AC220
Tyrosine Kinase 
Inhibitor +FLT-3 
Inhibitor
~3 Days
Hepatic (CYP3A4)/ 
Fecal
7 Days
Ruxolitinib
Jakafi
Janus Kinase Inhibitor
~5.8 hours
Hepatic (CYP3A4)/ 
Renal + Fecal
1 Day
Sorafenib 
Nexavar 
Multi-kinase Inhibitor 
25–48 
hours
Hepatic (CYP3A4)/ 
Fecal+ Renal
7 Days
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Microtubule Inhibitors:
Generic
Brand
Class/MOA
Half-life
Metabolism/ 
Excretion
Discontinuation 
Prior to BMT
Vincristine
Oncovin
Vinca Alkaloid
~85 hours
Hepatic (CYP3A4/5)/ 
Fecal + Biliary + Renal
7 Days
Monoclonal Antibodies:
Generic
Brand
Class/MOA
Half-life
Metabolism/ 
Excretion
Discontinuation 
Prior to BMT
Adalimumab
Humira
Monoclonal Antibody
2 weeks
N/A
30 Days
Blinatumomab
Blincyto
Monoclonal Antibody
~2 hours
Renal
7 Days
Brentuximab 
Vedotin
Adcetris
Monoclonal Antibody
4-6 days
Hepatic (CYP3A4/5)/
Renal + Fecal
24 days
Etanercept
Enbrel
Monoclonal Antibody
102 hours
N/A
30 Days
Infliximab
Remicade
Monoclonal Antibody
8-14.7 days
N/A
30 Days
Ipilimumab
Yervoy
Anti-CTLA-4 Antibody
~15 days
N/A
30 Days
Nivolumab
Opdivo
PD-1 Inhibitor
26.7 days
N/A
30 Days
Ofatumumuab
Arzerra
Monoclonal Antibody
~17.6 days
N/A
30 Days
Pembrolizumab
Keytruda
PD-1 Inhibitor
23 days
N/A
30 Days
Tocilizumab
Actemra
Monoclonal Antibody
4.2-7.9 
days
N/A
30 Days
Rituximab
Rituxin
Monoclonal Antibody
18-32 days
N/A
30 Days
Vedolizumab
Entyvio
Monoclonal Antibody
25 days
N/A
30 Days
PI3K (delta) Inhibitor:
Generic
Brand
Class/MOA
Half-life
Metabolism/ 
Excretion
Discontinuation 
Prior to BMT
Idelalisib
Zydelig
PI3K (delta) Inhibitor 
~ 8 hours
Hepatic (CYP3A4)/ 
Fecal + Renal
1 Day
Proteasome Inhibitors:
Generic
Brand
Class/MOA
Half-life
Metabolism/ 
Excretion
Discontinuation 
Prior to BMT
Bortezomib
Velcade
Proteasome Inhibitor
9-15 hours
Hepatic (CYP450)/ 
Renal
3 Days
Carfilzomib
Kyprolis
Proteasome Inhibitor
1 hour
Hepatic (CYP450)
1 Day
Ixazomib
Ninlaro
Proteasome Inhibitor
~9.5 days
Hepatic (CYP450)/ 
Renal + Fecal 
14 Days
Protein Synthesis Inhibitor:
Generic
Brand
Class/MOA
Half-life
Metabolism/ 
Excretion
Discontinuation 
Prior to BMT
Omacetaxine
Synribo
Protein Synthesis 
Inhibitor
~14.6 
hours
Blood +Hepatic/ Fecal 
+ Renal
7 Days
Retinoic Acid Derivative:
Generic
Brand
Class/MOA
Half-life
Metabolism/ 
Excretion
Discontinuation 
Prior to BMT
Tretinoin (ATRA)
Vesanoid
Retinoic Acid 
Derivative
0.5–2 
hours
Hepatic (CYP450)/ 
Renal + Fecal
7 Days
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6/5/2023

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TPO Receptor Agonist:
Generic
Brand
Class/MOA
Half-life
Metabolism/ 
Excretion
Discontinuation 
Prior to BMT
Eltrombopag
Promacta
TPO Receptor Agonist
26-35 
hours
Hepatic 
(CYP1A2/2C8)/      
Renal + Fecal
7 Days
Topoisomerase II Inhibitor:
Generic
Brand
Class/MOA
Half-life
Metabolism/ 
Excretion
Discontinuation 
Prior to BMT
Etoposide
Vepesid
Topoisomerase II 
Inhibitor
4-11 hours
Hepatic/ Renal + 
Biliary
7 Days
Mitoxantrone
Novantron
e
Topoisomerase II 
Inhibitor
23-215 
hours
Hepatic/ Fecal +Biliary 
+ Renal
7 Days
APPROVED RPCI IRB
6/5/2023