A Phase II Study of Microtransplantation in Patients With Refractory or Relapsed Hematologic Malignancies
Phase: PHASE2
Conditions: Acute Myeloid Leukemia (AML), Myelodysplastic Syndrome (MDS)
Sponsor: St. Jude Children's Research Hospital

MITREL 
 
 
Amendment 1.0, dated:  10-21-2015 
 
IRB approval date: 12-1-2015 
 
 
Protocol document dated:  11-30-2015 
St. Jude 
MITREL – NCT02433483 
Initial version, dated: 01-22-2015. Resubmitted to CT-SRC 02-18-2015 and 03-20-2015 
(IRB approved: 04-22-2015).  
Activation date:  05-20-2015 
Amendment 1.0, dated 10-21-2015. Resubmitted to CT-SRC 11-11-2015. Resubmitted to 
IRB on 11-30-15. (IRB approved: 12-01-2015) 
Activation date: 12-16-2015 
 
 
 
A PHASE II STUDY OF MICROTRANSPLANTATION IN PATIENTS WITH 
REFRACTORY OR RELAPSED HEMATOLOGIC MALIGNANCIES 
 
 
 
Principal Investigator 
Jeffrey E. Rubnitz, MD, PhD1 
 
Co-Principal Investigator 
Ewelina Mamcarz, MD2 
 
Co-Investigators 
 
Stanley Pounds, PhD3 
 
Departments of 1Oncology, 2Bone Marrow Transplantation & Cellular Therapy, and 3Biostatistics  
 
 
St. Jude Children's Research Hospital 
262 Danny Thomas Place 
Memphis, Tennessee 38105-3678 
Telephone: (901) 595-3300 
 
 
 
 
 
 
 
Contents of this document may not be extracted without permission from the Principal Investigator. 

MITREL 
 
 
Amendment 1.0, dated:  10-21-2015 
 
IRB approval date: 12-1-2015 
 
 
Protocol document dated:  11-30-2015 
Protocol Summary 
MITREL, A Phase II Study of Microtransplantation in Patients with Refractory or 
Relapsed Hematologic Malignancies 
Principal Investigator: Jeffrey Rubnitz, MD, PhD 
Sponsor/IND-holder: St. Jude Children’s Research Hospital; non-IND study. 
Brief overview: Pilot study to explore the safety, feasibility, and efficacy of chemotherapy 
plus GCSF-mobilized Hematopoietic Progenitor Cell, Apheresis (HPC-A) in pediatric 
patients with relapsed or refractory acute myeloid leukemia (AML) or myelodysplastic 
syndrome (MDS). 
Intervention: Interventional, primary therapeutic 
Drug: Cytarabine (Ara-C) 
Drug: (Donor) Filgrastim (G-CSF) 
Procedure: Intrathecal chemotherapy with methotrexate, cytarabine and hydrocortisone 
Procedure: GCSF-mobilized donor Hematopoietic Progenitor Cell, Apheresis (HPC-A) 
infusion. 
Brief outline of treatment plan: Patients will receive standard chemotherapy followed 
by infusion of donor peripheral blood mononuclear cells 2 days after the completion of 
chemotherapy. Patients who have at least a partial response are eligible to receive a 
second cycle.  
 
Diagnostic lumbar puncture and intrathecal (IT) chemotherapy will be given prior to 
cycle 1. Patients without evidence of central nervous system (CNS) leukemia will receive 
no further IT therapy during cycle 1. Patients with CNS disease will receive weekly IT 
therapy (age-adjusted methotrexate, hydrocortisone, and cytarabine) until the 
cerebrospinal fluid (CSF) becomes free of leukemia (minimum of 4 doses).  
 
Bone marrow aspiration (BMA) and biopsy to assess response will be performed on 
approximately day 29 of therapy.   
Study design: Simon 2-stage design.  
Sample size: Maximum of 19 AML/MDS patients and 19 donors 
Data management: Data management and statistical analysis will be provided by the 
Cancer Center Clinical Trials, Leukemia/Lymphoma Division, and Biostatistics 
Department at St. Jude Children’s Research Hospital. 
Human subjects: The risks to subject will be related to the toxicity of high-dose 
cytarabine and to the infusion of HLA-mismatched GCSF-mobilized Hematopoietic 
Progenitor Cell, Apheresis (HPC-A). Patients will be informed of all risks of drugs and 
procedures during informed consent. Adverse events will be monitored, reported, and 
treated appropriately.  

MITREL 
 
 
Amendment 1.0, dated:  10-21-2015 
 
IRB approval date: 12-1-2015 
 
 
Protocol document dated:  11-30-2015 
TABLE OF CONTENTS 
 
1.0 
OBJECTIVES ...................................................................................................................1 
1.1 Primary Objectives.................................................................................................. 1 
1.2 Secondary Objectives.............................................................................................. 1 
1.3 Exploratory Objectives ........................................................................................... 1 
2.0 
BACKGROUND AND RATIONALE .............................................................................1 
2.1 Background ............................................................................................................. 1 
2.2 Rationale for This Study ......................................................................................... 2 
2.3 Rationale for Exploratory Studies ........................................................................... 3 
3.0 
ELIGIBILITY CRITERIA AND STUDY ENROLLMENT ...........................................4 
3.1 Inclusion Criteria .................................................................................................... 4 
3.2 Inclusion Criteria - HPC-A Cell Donor .................................................................. 5 
3.3 Enrollment On Study at St. Jude ............................................................................. 5 
4.0 
TREATMENT PLAN .......................................................................................................6 
4.1 Overview ................................................................................................................. 6 
4.2 Treatment Administration ....................................................................................... 6 
4.3 Mobilization and Apheresis of Donor HPC-A........................................................ 8 
4.4 Definitions of Unacceptable Toxicities ................................................................ 10 
4.5 Concomitant Therapy and Supportive Care .......................................................... 11 
5.0 
DRUG/DEVICE/BIOLOGIC AGENT INFORMATION ..............................................12 
5.1 Cytarabine (Cytosine arabinoside, Ara-C, Cytosar®) ........................................... 12 
5.2 G-CSF (Filgrastim) (Neupogen) ........................................................................ 12 
5.3 Intrathecal Triples ................................................................................................. 13 
6.0 
REQUIRED EVALUATIONS, TESTS, AND OBSERVATIONS ...............................14 
6.1 Pre-Treatment Clinical Evaluations ...................................................................... 14 
6.2  Evaluations During Study Treatment.................................................................... 15 
6.3 After Completion of Therapy................................................................................ 15 
6.4 Exploratory Research Studies ............................................................................... 15 
7.0 
EVALUATION CRITERIA ...........................................................................................16 
7.1 Response Criteria .................................................................................................. 16 
7.2 Toxicity Evaluation Criteria ................................................................................. 16 
8.0 
OFF THERAPY AND OFF-STUDY CRITERIA ..........................................................17 
8.1 Off-Therapy Criteria ............................................................................................. 17 
8.2 Off-Study Criteria (Recipient) .............................................................................. 17 
8.3 Off-Study Criteria (Donor) ................................................................................... 17 
9.0 
SAFETY AND ADVERSE EVENT REPORTING REQUIREMENTS .......................17 
9.1 Reporting Adverse Experiences and Deaths to St. Jude IRB ............................... 17 
9.2 Recording and Reporting AEs and SAEs ............................................................. 19 
10.0 
DATA COLLECTION, STUDY MONITORING, AND CONFIDENTIALITY..........20 
10.1 Data Collection ..................................................................................................... 20 
10.2 Study Monitoring .................................................................................................. 21 
10.3 Confidentiality ...................................................................................................... 22 
11.0 
STATISTICAL CONSIDERATIONS............................................................................22 
11.1 Study Design ......................................................................................................... 22 
11.2 Statistical Analysis Plans ...................................................................................... 23 
12.0 
OBTAINING INFORMED CONSENT .........................................................................24 

MITREL 
 
 
Amendment 1.0, dated:  10-21-2015 
 
IRB approval date: 12-1-2015 
 
 
Protocol document dated:  11-30-2015 
12.1 Consent Prior to Research Interventions............................................................... 24 
12.2 Consent at Enrollment........................................................................................... 24 
12.3 Consent at Age of Majority................................................................................... 25 
12.4 Consent When English is Not the Primary Language .......................................... 25 
13.0 
REFERENCES ...............................................................................................................26 
 
 
APPENDICES 
 
Appendix I: 
Performance Status Criteria 
Appendix II: Children’s Oncology Group (COG) Stem Cell Committee Consensus Guidelines 
for Establishing Organ Stage and Overall Grade of Acute Graft Versus Host 
Disease (GVHD) 
Appendix III: Tests Performed for Routine Care and for Research 
 
 

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Amendment 1.0, dated:  10-21-2015 
 
IRB approval date: 12-1-2015 
 
 
Protocol document dated:  11-30-2015 
1.0 
OBJECTIVES 
 
1.1 
Primary Objectives 
 
1.1.1 To assess the safety and feasibility of standard chemotherapy plus GCSF-
mobilized Hematopoietic Progenitor Cell, Apheresis (HPC-A) in pediatric 
patients with relapsed or refractory acute myeloid leukemia (AML) or 
myelodysplastic syndrome (MDS). 
 
1.1.2 To estimate the response rates to standard chemotherapy plus GCSF-
mobilized HPC-A in pediatric patients with relapsed or refractory 
hematologic malignancies. 
  
1.2 
Secondary Objectives 
 
1.2.1 To describe the event-free and overall survival of patients treated with 
standard chemotherapy plus GCSF-mobilized HPC-A. 
 
1.2.2 To estimate the time to neutrophil and platelet recovery after treatment 
with standard chemotherapy plus GCSF-mobilized HPC-A. 
 
1.2.3 To determine the cumulative incidence of acute and chronic graft-versus-
host disease (GVHD). 
 
1.3 
Exploratory Objectives 
 
1.3.1 To characterize donor chimerism and microchimerism. 
 
1.3.2 To explore associations between dose of donor T cells, donor KIR type, 
and response to therapy. 
 
1.3.3 To explore associations between levels of PR1+ and WT1+ HLA-A*02:01 
CD8 T cells in peripheral blood and response to therapy. 
 
2.0 
BACKGROUND AND RATIONALE 
 
2.1 
Background 
   
The outcome for children with relapsed or refractory leukemia is very poor, necessitating 
the development of novel salvage regimens. Allogeneic hematopoietic stem cell 
transplantation (HSCT) reduces the risk of relapse and is commonly used in the treatment 
of patients with high-risk or relapsed leukemia. In contrast to chemotherapy alone, the 
beneficial effects of HSCT are primarily due to cellular reactivity, resulting in graft-
versus-leukemia and graft-versus-host effects. The potent effects of the immune system at 
controlling or eliminating leukemia were first recognized over 35 years ago and have 
been extensively reviewed.1 The eradication of leukemia in irradiated mice that received 

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IRB approval date: 12-1-2015 
 
 
Protocol document dated:  11-30-2015 
allogeneic marrow transplants was the first demonstration of the antileukemic effects of 
alloreactivity.2 In the 1970s, many investigators demonstrated the important graft-versus-
leukemia (GVL) effects of donor T-cells in patients undergoing allogeneic hematopoietic 
stem cell transplantation (HSCT).3-5 The anti-leukemia effects of alloreactive donor T 
lymphocytes are likely greatest in the setting of donor-recipient HLA mismatch (e.g., 
haploidentical HSCT), in which they recognize differences in major histocompatibility 
antigens. Subsequently, donor lymphocyte infusions given after HSCT were shown to 
have anti-leukemic effects that could enhance the GVL effects of the original graft, and 
are commonly used today.6,7 Although early studies suggested that GVL effects were due 
to donor-derived T cells, more recent studies demonstrated the contributions of donor-
derived, KIR-mismatched natural killer cells.8-13   
 
The safety and efficacy of infusions of HLA-mismatched peripheral blood stem cells 
(PBSCs), also referred to as Hematopoietic Progenitor Cell, Apheresis (HPC-A), has 
been demonstrated in several studies. In one study, 58 adults (ages 60-88 years) with 
acute myeloid leukemia (AML) were randomized to receive mitoxantrone and cytarabine 
alone (n=28) or mitoxantrone and cytarabine followed by infusion of GCSF-mobilized 
PBSCs (n=30).14 The complete remission rates (80% vs. 43%) and 2-year disease-free 
survival estimates (39% vs. 10%) were significantly higher, and time to count recovery 
was shorter, in patients who received cell infusions. No graft-versus-host disease 
(GVHD) was observed. In another study, 101 patients with AML in first remission 
received 3 cycles of high-dose cytarabine following by infusions of GCSF-mobilized 
HLA-mismatched PBSCs as post-remission therapy.15 The therapy was well tolerated and 
no GVHD was observed. Despite the high doses of cytarabine (2.5 g/m2 every 12 hours x 
6 doses), the time to neutrophil recovery was remarkably short, with median times of 8, 
9, and 12 days after courses 1, 2, and 3. Platelet recovery was also brisk, occurring at 
median times of 11, 12, and 14 days. Of the 101 patients, 97 had no mixed donor or full 
donor chimerism, whereas 4 patients had low levels of mixed chimerism that persisted for 
less than 2 weeks. Among 23 patients who were evaluable for microchimerism testing, 20 
had detectable donor microchimerism (range, 7 x 10-6 to 0.46) that peaked at 1-2 weeks 
after microtransplantation. Leukemia-free and overall survival rates were excellent, and 
were higher in patients who received greater than 1.1 x 108/kg donor CD3+ T cells 
compared to those who received lower doses of donor T cells (LFS: 76% vs. 50%; OS: 
82% vs. 55%). Multivariable analysis revealed that the dose of donor T cells was 
significantly associated with better leukemia-free and overall survival.  
 
2.2 
Rationale for This Study 
   
Based on the encouraging results described above, we propose to test the safety and 
activity of microtransplantation in pediatric patients with relapsed AML or MDS. The 
outcome for patients with relapsed AML is poor, with survival rates less than 40%.16 The 
development of new agents has been slow and treatment options are therefore limited. 
Microtransplantation appears to be safe, even in elderly patients, and may be beneficial. 
The results of this study may lead to the incorporation of microtransplantation into the 
upfront therapy for patients with high-risk disease.  
 

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Amendment 1.0, dated:  10-21-2015 
 
IRB approval date: 12-1-2015 
 
 
Protocol document dated:  11-30-2015 
2.3 
Rationale for Amendment 1.0 
 
The first two subjects enrolled on MITREL experienced complete donor engraftment, an 
unanticipated event that led to the voluntary suspension of accrual. The main purpose of 
Amendment 1.0 is to reduce risks to subjects by reducing the potential for engraftment.  
 
The major changes include the following: 
 
1. The removal of fludarabine from the conditioning regimen. Fludarabine is known to 
be more immunosuppressive than cytarabine and likely contributed to the lack of 
graft rejection observed in the first two patients. The fludarabine/cytarabine regimen 
has been replaced by cytarabine alone based on the trial reported by Guo et al,15 
which used a dose of 2.5 g/m2/dose given every 12 hours for 6 doses. The dose used 
in Amendment 1.0 is slightly lower (2 g/m2/dose given every 12 hours for 6 doses), as 
there is no evidence that increasing the dose of cytarabine beyond 2 g/m2 provides 
any clinical or pharmacological benefit.  
2. The dose of infused cells has been changed from “the minimum cell dose that will be 
infused is 1 x 108 total nucleated cells (TNC)/kg and the maximum is 10 x 108 
TNC/kg” to “the minimum cell dose that will be infused is 1 x 108 total nucleated 
cells (TNC)/kg and the maximum is 5 x 108 TNC/kg” based on the report by Guo et 
al,15 in which a maximum of 5.6 x 108 cells/kg were safely infused.  
3. The addition of engraftment to the stopping rules. 
4. The stipulation that the first 6 patients will be enrolled sequentially, rather than 
simultaneously.  
 
2.4 
Rationale for Exploratory Studies 
 
In addition to the well-characterized GVL effects described above, there is emerging 
evidence that graft rejection mediated by host-versus-graft responses may possess 
antileukemic effects.17 Although the mechanism is not fully understood, it appears that 
host CD4+ and CD8+ T cells are involved.18,19 
 
In the present trial, we will explore the potential roles of the patient and donor immune 
systems by measuring patient and donor-derived PR1+ and WT1+ CD8+ T cell counts at 
various time points after infusion of the HPC-A product.20,21 Associations between levels 
and origins (patient versus donor) of these T cells and response to therapy may provide 
clues regarding the mechanism of action of this treatment. Similarly, we will explore 
associations between donor T cell dose and response, as well as associations between 
donor KIR type and response, the results of which may suggest that donor T cells, donor 
NK cells, or both, are important mediators of the graft versus leukemia effect.  Although 
any conclusions will be limited by the small numbers of patients enrolled in this trial, 
these analyses may help direct future studies.  
 

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Amendment 1.0, dated:  10-21-2015 
 
IRB approval date: 12-1-2015 
 
 
Protocol document dated:  11-30-2015 
3.0 
ELIGIBILITY CRITERIA AND STUDY ENROLLMENT  
 
According to institutional and NIH policy, the study will accession research participants 
regardless of gender and ethnic background. Institutional experience confirms broad 
representation in this regard. 
 
3.1 
Inclusion Criteria 
 
3.1.1 Participants must have a diagnosis of AML or MDS and must have disease that 
has relapsed or is refractory to chemotherapy, or that has relapsed after HSCT. 
 
a) Refractory disease is defined as persistent disease after at least two 
courses of induction chemotherapy. 
b) Patients with AML must have ≥ 5% leukemic blasts in the bone marrow or 
have converted from negative MRD status to positive MRD status in the 
bone marrow as assessed by flow cytometry. If an adequate bone marrow 
sample cannot be obtained, patients may be enrolled if there is 
unequivocal evidence of leukemia in the peripheral blood. 
 
3.1.2 Participant is ≤ 21 years of age (i.e., has not reached 22nd birthday). 
 
3.1.3 Adequate organ function defined as the following: 
 
 Total bilirubin  ≤ ULN for age, or if total bilirubin is > ULN, direct 
bilirubin is ≤ 1.5 mg/dL 
 AST (SGOT)/ALT (SGPT) < 5 x ULN 
 Calculated creatinine clearance > 50 ml/min/1.73m2 as calculated by the 
Schwartz formula for estimated glomerular filtration rate  
 Left ventricular ejection fraction ≥ 40% or shortening fraction ≥ 25%. 
3.1.4 Has an available HPC-A donor. 
 
3.1.5 Performance status: Lansky ≥ 50 for patients who are ≤ 16 years old and 
Karnofsky ≥ 50% for patients who are > 16 years old (Appendix I) 
 
3.1.6 Does not have an uncontrolled infection requiring parenteral antibiotics, 
antivirals, or antifungals within one week prior to first dose. Infections controlled 
on concurrent anti-microbial agents are acceptable, and anti-microbial 
prophylaxis per institutional guidelines is acceptable. 
 
3.1.7 Patient has fully recovered from the acute effects of all prior therapy and must 
meet the following criteria. 
 
 At least 14 days must have elapsed since the completion of 
myelosuppressive therapy. 

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Protocol document dated:  11-30-2015 
 At least 24 hours must have elapsed since the completion of low-dose or 
non-myelosuppressive therapy, such as hydroxyurea or low-dose 
cytarabine (up to 200 mg/m2/day). 
 At least 30 days must have elapsed since the use of investigational agents. 
 For patients who have received prior HSCT, there can be no evidence of 
GVHD and greater than 60 days must have elapsed since the HSCT. 
Patients cannot be receiving therapy, including steroids, for GVHD. All 
such medications must be discontinued at least 72 hours prior to 
enrollment. 
 
3.1.8 Post-menarchal female has had negative serum pregnancy test within 7 days prior 
to enrollment. 
 
3.1.9 Male or female of reproductive potential has agreed to use effective contraception 
for the duration of study participation. 
 
3.1.10 Not breastfeeding 
 
3.2 
Inclusion Criteria - HPC-A Cell Donor 
 
3.2.1 At least 18 years of age. 
 
3.2.2 Family member (first degree relative). 
 
3.2.3 Not pregnant as confirmed by negative serum or urine pregnancy test within 7 
days prior to enrollment (if female). 
 
3.2.4 Not breast feeding. 
 
3.2.5 Meets donation eligibility requirements as outlined by 21 CFR 1271.  
 
3.3 
Enrollment On Study at St. Jude 
 
A member of the study team will confirm potential participant eligibility as defined in 
Section 3.1-3.2, complete and sign the Participant Eligibility Checklist. The study team 
will enter the eligibility checklist information into the Patient Protocol Manager (PPM) 
system. Eligibility will be reviewed, and a research participant-specific consent form and 
assent document (where applicable) will be generated. The complete signed 
consent/assent form(s) must be faxed or emailed to the CPDMO at 595-6265 to complete 
the enrollment process.   
 
The CPDMO is staffed 7:30 am-5:00 pm CST, Monday through Friday. A staff member 
is on call Saturday, Sunday, and holidays from 8:00 am to 5:00 pm. Enrollments may be 
requested during weekends or holidays by calling the CPDMO “On Call” cell phone 
(901-413-8591) or referencing the “On Call Schedule” on the intranet). 
 

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Amendment 1.0, dated:  10-21-2015 
 
IRB approval date: 12-1-2015 
 
 
Protocol document dated:  11-30-2015 
4.0 
TREATMENT PLAN 
 
4.1 
Overview 
 
Patients will receive chemotherapy followed by infusion of donor HPC-A. All patients 
will be transferred to the BMT service prior to the infusion of HPC-A. The first 6 patients 
enrolled on the trial will remain inpatient until the time of graft rejection. 
 
4.2 
Treatment Administration 
 
General assumptions regarding chemotherapy administration for all treatment phases: 
 
 The timing and duration for administration for all commercially available agents 
are provided in the treatment phase sections as guidelines only. Variations in the 
timing and duration of chemotherapy infusions according to institutional practice 
or variations based on patient care needs are acceptable, as long as the treating 
investigator and/or PI determines that there was no impact on patient safety.  
These variations will not be considered protocol deviations, as long as the total 
dose is given within 10% of protocol specified dose. 
 The term “day” does not refer to an absolute calendar day. It refers to a general 
24-hour period as per St. Jude Nursing P&P. 
 Medication dosing may be modified for research recipients based upon actual 
body weight or adjusted ideal body weight when clinically indicated. Criteria for 
medication calculations based on body weight/body surface area can be found in 
any version of the St. Jude Formulary. Medication doses may be rounded to the 
nearest integer or to the nearest appropriate quantity when clinically or 
pharmaceutically indicated as per the M.D. and Pharm.D. 
 

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Amendment 1.0, dated:  10-21-2015 
 
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Protocol document dated:  11-30-2015 
4.2.1 Intrathecal Treatment 
 
Diagnostic lumbar puncture and intrathecal (IT) chemotherapy will be given prior to each 
cycle of therapy. Patients with no evidence of CNS disease (CNS1: no leukemic blast 
cells on CSF cytospin) will receive no further IT therapy during cycle 1. Patients with < 5 
leukocytes per μl of CSF and the presence of leukemic blast cells on CSF cytospin 
(CNS2) will receive weekly intrathecal therapy until the CSF is free of blast cells. 
Patients with overt CNS leukemia (CNS3: ≥ 5 leukocytes per μl of CSF and the presence 
of leukemic blast cells on CSF cytospin) will receive weekly intrathecal therapy until the 
CSF is free of blast cells (minimum number of doses, 4).  
 
Patient Age  
Methotrexate 
Hydrocortisone 
Cytarabine 
Volume 
< 1 year 
6 mg 
12 mg 
18 mg 
6 ml 
1-2 years 
8 mg 
16 mg 
24 mg 
8 ml 
2-3 years 
10 mg 
20 mg 
30 mg 
10 ml 
> 3 years 
12 mg 
24 mg 
36 mg 
12 ml 
 
Leucovorin rescue (5 mg/m2/dose, max 5 mg) PO will be given at 24 and 30 hours after 
each triple intrathecal treatment. Follow plasma methotrexate levels (starting 24 hours 
after intrathecal therapy and until level becomes undetectable) in patients with renal 
dysfunction or extra fluid in third space, and rescue with leucovorin according to PharmD 
recommendation. 
 
4.2.2 Cycle 1 
 
Drug/Procedure Dose 
Route 
No. 
doses 
Schedule 
Cytarabine 
2 g/m2/dose 
IV over 3 hours 
Q12 hours 
6 
Days -4 through -2 
Donor HPC-A 
infusion 
 
 
1 
Day 0 (± 1 day) 
 
All participants should undergo response evaluations at the time of count recovery (ANC 
>0.3 x 109/L and platelet count >30 x 109/L) after each course of therapy. If counts have 
not recovered by day 29 of cycle 1, bone marrow aspiration (BMA) should be performed 
to evaluate for persistent leukemia. In addition to bone marrow aspiration, bone marrow 
biopsy should be considered to evaluate cellularity if clinically indicated. In cases with 
hypocellular marrows (<10 % cellularity), repeat bone marrow examination should be 
considered if feasible. If multiple bone marrow examinations are performed after a course 
of therapy, the last examination will be used to classify the response to that course. 
 
Participants who have at least a partial response to Cycle 1 are eligible to receive Cycle 2.  
 

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Protocol document dated:  11-30-2015 
4.2.3  Cycle 2 
 
Cycle 2 may begin after count recovery from Cycle 1 (WBC ≥ 1000/mm3, ANC 
≥500/mm3 and platelet count ≥30 x 109/L) and is identical to Cycle 1 
 
Bone marrow aspirate and MRD will be performed following count recovery or on day 
29 (whichever comes first): ANC ≥ 300/mm3 and platelet count ≥ 30 x 109/L.  
  
4.2.4 Cellular Infusion Procedures and Monitoring 
 
For the proper infusion procedures and monitoring of the HPC product, refer to 
BMT&CT SOP 40.02 “Hematopoietic Progenitor Cell Infusion – FRESH (Allogeneic): 
IV Push and IV Drip” or SOP 40.03 “Hematopoietic Progenitor Cell Infusion – 
FROZEN: IV Push”. All relevant SOPs can be found on the BMT&CT Clinical 
Transplant Program intranet page: 
http://home.web.stjude.org/bone_marrow/clinicalHome.shtml 
  
During the cellular infusions, monitoring of vital signs, breath sounds, heart rate, pulse 
oximetry, and I/O will be done per the established nursing procedure, as well as 
appropriate Department of BMT&CT SOPs, and then documented on the Cellular 
Product Infusion Record. If a reaction is suspected at any time during the infusion, the 
nurse will stop the infusion and notify the attending physician but will not discard the 
product until physician orders are given. Proper documentation (symptoms of patient, 
vital signs, actions taken, outcome, and follow-up) will be completed in the Cellular 
Product Infusion Record.  
 
The HPC-A infusion may be delayed by approximately 24 hours in order to 
accommodate stem cell collection with the donor, the Blood Donor Center and/or HAL as 
well as the research participant clinical condition. 
 
4.3 
Mobilization and Apheresis of Donor HPC-A 
 
4.3.1 Donor Selection 
 
If more than one family member donor is acceptable, then donor selection will be based 
on the preference of the primary attending. Factors in selection will include donor-
recipient matching of CMV serology, donor-recipient red blood cell compatibility, degree 
of HLA matching, size of the potential donor, previous use as a donor, presence of donor-
specific antibody, and overall health of the potential donor.  
 
Donor eligibility for cell collection will be determined through the guidelines outlined in 
21 CFR 1271 and the Guidance for Industry: Eligibility Determination for Donors of 
Human Cells, Tissues, and Cellular and Tissue-Based Products (HCT/Ps). Potential 
donors will undergo an initial screening process that will include at least a complete 
physical exam, history and testing for relevant communicable diseases. Physical exams to 
evaluate donor candidacy will be conducted by a non-Department of BMT&CT physician 

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Protocol document dated:  11-30-2015 
(St. Jude or non-St. Jude). For subsequent therapeutic cell collection procedures, if a 
complete screening procedure has been performed within the previous 6 months, an 
abbreviated donor screening procedure may be used for these repeat donations. The 
abbreviated screening procedure must determine and document any changes in the 
donor’s medical history since the previous donation that would make the donor ineligible, 
including changes in relevant social behavior. 
 
If a donor is determined to be ineligible, the donor is not automatically excluded. Part 21 
CFR 1271.65 allows use of ineligible donors who are first or second degree blood 
relatives. In this situation, the physician will follow BMT&CT SOP 30.08.00, “Statement 
of Acknowledgment and Consent to Receive Stem Cells or Bone Marrow from a Donor 
with Abnormal Findings.” Recipients or their legal guardians will be informed of the use 
of an ineligible donor. 
 
4.3.2 Donor Mobilization and Graft Collections 
 
G-CSF mobilized HPC-A products will be used for this study. Donors will undergo a 
standard hematopoietic stem cell mobilization regimen consisting of 5 days of G-CSF 
given subcutaneously at 10 g/kg. HPC-A will be collected by leukapheresis on day 6.  
The dose of G-CSF may require modification based on the donor’s white blood cell 
(WBC) count. If the donor’s WBC count is > 75 x 106/ml, the dose of G-CSF will be 
reduced. The guidelines for dose modification can be found in the St. Jude Children's 
Research Hospital Department of BMT&CT SOP 30.06.00 “The practice for the 
evaluation, preparation and care of allogeneic and autologous donors mobilized with 
growth factor.” 
 
4.3.3 Quality Assurance for Cellular Products  
 
The Department of Therapeutic Production and Quality has established an independent 
division of Quality Assurance (QA). This group is responsible for the management of 
Quality Control, Quality Assurance and Quality Improvement processes for the Human 
Applications Laboratory. Production and QA Systems include Standard Operation 
Procedures (SOPs) for production and quality processes, Documentation of Donor 
Eligibility, Documentation of processes captured in Batch Records, In-process quality 
control testing including sterility, Release Specifications established for all products, Out 
of Specification Reporting and Investigation Process, Authorization by QA for the release 
of all products after review of records and release specification test results, Product 
labeling procedures with multiple person review, Variance Management Process, 
Personnel Competence and Proficiency Program, and Inventory control and 
documentation of product history through patient infusion.  
 
Test results that are out of specification for products that are needed on a clinically urgent 
basis will be evaluated by the laboratory medical director. The patient's physician or 
attending transplant physician will be informed of the test result prior to infusion of the 
product. Notification regarding positive sterility results before or after infusion will be 
given to the primary attending physician and patient and/or parent/guardian. Notification 

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to the FDA and St. Jude IRB will be given and will include testing results or adverse 
events and any required intervention. An investigation following TPQ/HAL SOPs will be 
completed, reviewed by TPQ Quality Assurance and outcomes of the investigation 
reported. 
 
4.3.4 Dose of Cellular Product 
 
Each donor will undergo leukapheresis one time. Based on current BMT&CT protocols 
and common clinical practice, the minimum cell dose that will be infused is 1 x 108 total 
nucleated cells (TNC)/kg and the maximum is 5 x 108 TNC/kg. In addition, the maximum 
number of CD3+ cells infused is 2 x 108 cells/kg. In general, patients will receive 2 
cycles of therapy on the MITREL study. Thus, if the apheresis product contains at least 2 
x 108 TNC/kg, the product will be split into 2 equal aliquots; one aliquot will be given 
after cycle 1 and the other will be frozen and given after cycle 2, with a maximum dose 
of 5 x 108 TNC/kg for each infusion. In the unlikely event that the apheresis product 
contains less than 1 x 108 TNC/kg, the product will not be infused. If the product contains 
1-2 x 108 TNC/kg, the entire product will be given after cycle1 and the patient will not 
receive cycle 2. Guidelines for product infusion: 
 
 < 1 x 108 TNC/kg: HPC-A not infused 
 1-2 x 108 TNC/kg: entire HPC-A infused after cycle 1 
 ≥ 2 x 108 TNC/kg: 50% of HPC-A infused after each cycle (max dose, 5 x 108 
TNC/kg per infusion) 
 
4.4 
Definitions of Unacceptable Toxicities 
 
Toxicities will be graded according to the CTEP Common Terminology Criteria for 
Adverse Events (CTCAE) version 4.0. Grade 3 and 4 hematologic toxicities will be 
monitored, but will not be considered unacceptable toxicity except as described below. 
GVHD will be assessed and graded according to the Children’s Oncology Group (COG) 
Stem Cell Committee Consensus Guidelines for Establishing Organ Stage and Overall 
Grade of Acute Graft Versus Host Disease (GVHD) – see Appendix II. 
 
Death from causes other than leukemia progression, ≥ Grade 3 acute GVHD that is 
associated with detectable MITREL donor chimerism, and persistent engraftment defined 
as > 5% donor chimerism at the time of count recovery (ANC > 0.3 x 109/L and platelet 
count > 30 x 109/L) will be considered unacceptable toxicities. Acute GVHD that is not 
associated with detectable MITREL donor chimerism, but that is only associated with 
detectable donor chimerism from a previous HSCT, will be recorded but will not be 
considered an unacceptable toxicity. As described in Section 12.1, six patients will be 
enrolled and evaluated for toxicity. If two or more patients experience unacceptable 
toxicity during or after completion of two cycles of therapy, then the cohort will close 
due to intolerability. 
 

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4.5 
Concomitant Therapy and Supportive Care 
 
Antineoplastic therapy:  Concurrent cancer therapy, including chemotherapy, 
immunotherapy, or biologic therapy is prohibited. 
 
Investigational agents:  No investigational agents may be given while the patient is on 
protocol therapy. 
 
Growth factors:  The routine use of filgrastim (G-CSF, Neupogen®) or other growth 
factors is discouraged, but may be used in cases of documented infection or sepsis during 
periods of neutropenia, according to institutional practice. 
 
Conjunctivitis prophylaxis:  Dexamethasone or prednisolone ophthalmic solution or 
artificial tears (e.g., hydroxymethylcellulose, hypromellose, polyvinyl alcohol), 2 drops 
in each eye every 4 hours while awake, should be used during cytarabine administration 
and for 24 hours after completion to prevent conjunctival irritation. 
 
Prophylaxis and treatment of metabolic derangement:  Care should be taken to prevent 
hyperuricemia and hyperphosphatemia in participants with large tumor burdens. Such 
participants should receive IV hydration at 1500-3000 mL/m2/day before the initiation of 
therapy, oral phosphate binders, and recombinant urate oxidase or allopurinol as needed. 
 
Prophylaxis for Pneumocystis jiroveci pneumonia:  All participants should receive 
TMP/SMZ (trimethoprim 150 mg/m2/day in 2 divided doses on Monday, Tuesday, and 
Wednesday of each week). For those who cannot tolerate TMP/SMZ, monthly 
pentamidine may be substituted. Other options include atovoquone or dapsone. Please 
consult with clinical pharmacists and local institutional guidelines. 
 
Prophylaxis for fungal infections:  Because patients with relapsed leukemia are at high 
risk for fungal infections, all participants should receive antifungal prophylaxis according 
to institutional guidelines. Prophylaxis with voriconazole, posaconazole, micafungin, or 
caspofungin is acceptable.   
 
Prophylaxis for bacterial infections:  Because patients with relapsed leukemia are also at 
high risk for bacterial infections, all participants should receive antibiotic prophylaxis 
according to institutional guidelines. Prophylactic antibiotics should be started when the 
ANC ≤ 1000 and falling or predicted to fall and should be continued until the ANC ≥ 100 
and rising. The recommended prophylactic regimen is intravenous vancomycin plus oral 
ciprofloxacin. An acceptable alternative regimen is oral or intravenous levofloxacin.  
 
Management of febrile neutropenia: Participants with fever (defined as a single oral 
temperature  38.3 C (101F) or temperature of  38.0 C (100.4 F) sustained over a 
one hour period and neutropenia (defined as ANC  500 cells/L) should be given IV 
antibiotics immediately..  
 

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5.0 
DRUG/DEVICE/BIOLOGIC AGENT INFORMATION  
 
5.1 
Cytarabine (Cytosine arabinoside, Ara-C, Cytosar®) 
 
Source and pharmacology:  Cytarabine is a deoxycytidine analogue. It must be tri-
phosphorylated to its active form, ARA-CTP, by deoxycytidine kinase and other nucleotide 
kinases.  Ara-CTP inhibits DNA polymerase. In addition, ara-CTP is incorporated into 
DNA as a false base, causing inhibition of DNA synthesis. It is cell cycle, S phase specific.  
Cytarabine does penetrate the blood brain barrier. It is converted to its inactive form, uracil 
arabinoside, by pyrimidine nucleoside deaminase. Approximately 80% of the dose is 
recovered in the urine, mostly as uracil arabinoside (ara-U). 
 
Formulation and stability: Cytarabine is available in multi-dose vials containing 100, 500, 
1000 and 2000mg of lyophilized drug. Intact vials can be stored at room temperature.  For 
IV use, either sterile water for injection or bacteriostatic water for injection can be used to 
reconstitute the lyophilized drug. For intrathecal use, only sterile water for injection should 
be used for reconstitution. The 100 and 500 mg vials are reconstituted with 2 and 10 ml 
respectively resulting in a final concentration of 50 mg/ml. The 1000 and 2000 mg vials are 
reconstituted with 20 ml and 40 ml respectively resulting in a final concentration of 50 
mg/ml. After reconstitution, the drug is stable for 8 days at room temperature. 
 
Supplier:  Commercially available. 
 
Toxicity:  Myelosuppression is the dose limiting adverse effect, with leukopenia and 
thrombocytopenia being predominant. Other adverse effects reported commonly include 
nausea and vomiting (may be severe at high doses), diarrhea, mucositis, anorexia, 
alopecia, skin rash and liver dysfunction. A flu-like syndrome characterized by fever, 
muscle and bone aches is common. Less common side effects include allergic reactions 
and cellulitis at the injection site. High doses of cytarabine can cause conjunctivitis, 
hepatitis, and a group of CNS symptoms including somnolence, peripheral neuropathy, 
ataxia, and personality changes. CNS symptoms are usually reversible and are more 
common in patients who have received previous cranial irradiation. In addition, a 
syndrome of sudden respiratory distress progressing to pulmonary edema has occurred. 
 
Guidelines for administration:  Intrathecal and intravenous. See treatment administration 
sections. 
 
5.2 
G-CSF (Filgrastim) (Neupogen) 
 
Source and pharmacology:  G-CSF (granulocytic colony stimulating factor), is a 
biosynthetic hematopoietic agent that is made using recombinant DNA technology in 
cultures of Escherichia coli. G-CSF stimulates production, maturation and activation of 
neutrophils. In addition, endogenous G-CSF enhances certain functions of mature 
neutrophils, including phagocytosis, chemotaxis and antibody--dependent cellular 
cytotoxicity. 
 

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Formulation and stability:  G-CSF is supplied in vials containing 300 mcg and 480 mcg 
of G-CSF at a concentration of 300 mcg/ml. The intact vials should be stored under 
refrigeration. The vials can be left out of refrigeration for 24 hours, but should be 
discarded if left at room temperature for longer periods of time. G-CSF can be drawn up 
into tuberculin syringes for administration and stored under refrigeration for up to 7 days 
prior to usage. G-CSF can be further diluted for IV infusion in 5% dextrose. Do not dilute 
in saline-precipitate may form. If the final concentration of this product is < 15 mcg/ml, it 
is recommended that albumin be added to a final concentration of 2mg/ml (0.2%) to 
minimize adsorption of the drug to infusion containers and equipment. 
 
Supplier:  Commercially available 
 
Toxicity:  G-CSF causes marked leukocytosis. Adverse reactions reported commonly 
include bone pain, thrombocytopenia, diarrhea, nausea, rash, alopecia, fever, anorexia 
and pain or bruising at the injection site. Allergic reactions, MI, atrial fibrillation, and 
splenomegaly have been reported rarely. G-CSF is contraindicated in participants with 
allergy to E. coli derived products. 
 
Dosage and route of administration:  Donors: 10 mcg/kg/day for standard hematopoietic 
stem cell mobilization.  See Section 4.3.2. 
 
5.3 
Intrathecal Triples  
 
(ITMHA, methotrexate/hydrocortisone/cytarabine) 
 
Source and pharmacology: The intrathecal route of administration of a drug produces 
more consistent CSF drug concentrations at relatively smaller doses because of the 
volume difference between the CSF and blood compartments (140 mL vs. 3500 mL in an 
adult). (The CSF volume of children after the first 3 years is equivalent to that of an 
adult). Drug half-lives are longer as well because clearance is related to flow rather than 
metabolism or protein binding. Intrathecal methotrexate has a biphasic elimination curve 
from the CSF with a t½ of 4.5 and 14 hours respectively. Following IT injection of 
cytarabine the elimination of the drug from the CSF is biphasic with a t½ of 1 and 3.4 
hours respectively which is 8-fold longer than the clearance from plasma. The 
elimination of hydrocortisone is similarly prolonged. 
 
Formulation and stability:  Methotrexate 25 mg/mL preservative free 2 mL vial or 
methotrexate 20 mg preservative free sterile powder for injection vial. Cytarabine 100 mg 
preservative free sterile powder for injection. Hydrocortisone sodium succinate100 mg 
vial sterile powder for injection. 
 
Toxicity:  Nausea, vomiting, fever, headache. 
 
Guidelines for administration:  Intrathecal.  See Section 4.2.1. 
 

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6.0 
REQUIRED EVALUATIONS, TESTS, AND OBSERVATIONS 
 
All entry/eligibility studies must be performed within 2 weeks prior to study enrollment 
(unless otherwise specified). Reasonable adjustments can be made in the schedule to allow 
for weekends or holidays.  
 
6.1 
Pre-Treatment Clinical Evaluations 
 
 Physical exam, height, weight, BSA 
 CBC with differential 
 Chemistry profile: glucose, electrolytes, BUN, creatinine, LDH, uric acid, 
bilirubin, SGOT, SGPT, calcium, phosphorous, magnesium, total protein and 
albumin 
 Coagulation screen 
 HLA typing, if not done previously 
 Chest x-ray, as clinically indicated 
 EKG, echocardiogram 
 Bone marrow evaluation for morphology, immunophenotyping, cytogenetics, 
molecular diagnosis, and minimal residual disease (MRD). Morphologic 
examination and MRD are required for all patients. Immunophenotyping, 
cytogenetic analysis, and molecular analysis should be performed as clinically 
indicated (e.g., if not done at the time of relapse). If an adequate bone marrow 
specimen cannot be obtained, all diagnostic studies may be performed on blood 
rather than bone marrow.  
 Lumbar puncture with CSF cell count and cytology. 
 Serum pregnancy test of females of childbearing potential 
 

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6.2  
Evaluations During Study Treatment  
 
STUDIES TO BE OBTAINED 
Timing 
Physical exam with vital signs 
Weekly 
Height, weight, BSA 
Weekly 
CBC with differential 
Weekly 
Chemistry profile1 
Weekly 
Bone marrow evaluation2 
Day 29 of each cycle2 
Lumbar puncture with CSF cell count and 
cytology 
Prior to each cycle and with 
every dose of IT therapy 
Serum pregnancy test of females of 
childbearing potential 
Prior to each cycle 
Microchimerism (blood) 
Weekly follow infusion of 
HPC-A 
Microchimerism (bone marrow) 
Day 29 of each cycle2  
Detection of PR1+ and  WT1+ HLA-A*02:01 
CD8 T cells (blood) 
Days 15 and 29 of each 
cycle 
1Chemistry profile:  glucose, electrolytes, BUN, creatinine, LDH, uric acid, bilirubin, 
SGOT, SGPT, calcium, phosphorous, magnesium, total protein and albumin 
2Bone marrow evaluation for morphology and minimal residual disease (MRD) should be 
performed at the time of count recovery (ANC > 0.3 x 109/L and platelet count > 30 x 
109/L) after each course of therapy. If counts have not recovered by day 29, bone marrow 
evaluation should be performed to evaluate for persistent leukemia. 
 
Obtain other studies as needed for good patient care. 
 
6.3 
After Completion of Therapy 
 
When a participant discontinues the study, a final visit will be conducted. Following 
discontinuation of the study treatment, the participant will be treated according to the 
investigator’s discretion. If a participant discontinues from the study due to an adverse 
event considered related to study treatment, a follow-up visit should be conducted no 
later than 30 days after the last dose of protocol therapy. Safety assessments are 
recommended at least every 30 days, until all toxicities resolve, return to baseline or 
become clinically satisfactory, stable, or are considered irreversible. 
 
6.4 
Exploratory Research Studies 
 
Dr. Shurtleff’s laboratory will use a quantitative PCR assay (sensitivity of 0.008%) to 
measure donor chimerism following infusion of HPC-A.22 Patients who have HLA-
A*02:01 or whose donors have HLA-A*02:01 will be monitored for PR1+ and WT1+ 
HLA-A*02:01 CD8 T cells in peripheral blood before and after microtransplantation.20,21  
 

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7.0 
EVALUATION CRITERIA 
 
7.1 
Response Criteria 
 
Because morphologic examination of the bone marrow during periods of hematopoietic 
recovery after intensive chemotherapy may be unreliable, bone marrow response will be 
based on blast percentage by flow cytometry. Blast percentages determined by 
morphology will be used in cases that are not evaluable by flow cytometry. 
 
Note that the following criteria apply to patients who have ≥ 5% blasts at the time of 
enrollment.  
 
7.1.1 Complete remission (CR) 
 Bone marrow with < 5% blasts confirmed by flow cytometry 
 ANC ≥ 500/μL and platelets ≥ 75,000/μL without transfusions 
 No evidence of extramedullary disease 
 
7.1.2 Complete remission with incomplete blood count recovery (CRi) 
 Bone marrow with < 5% blasts confirmed by flow cytometry 
 ANC < 500/μL or platelets < 75,000/μL without transfusions 
 No evidence of extramedullary disease 
 
7.1.3 Partial response (PR) 
 Bone marrow with 5% to 25% blasts by flow cytometry and a decrease of at 
least 50% in blast percentage 
 No evidence of extramedullary disease 
 
7.1.4 No response (NR) 
Participant fails to qualify for any of the categories listed above 
 
7.1.5 Relapse 
Subsequent appearance, after achievement of CR, of ≥ 5% blasts in the bone 
marrow with confirmation by flow cytometry or the development of 
extramedullary disease after achievement of CR 
 
For patients who have < 5% blasts at the time of enrollment, “therapeutic success” is 
defined as ≥ 10-fold decrease in MRD level. 
 
7.2 
Toxicity Evaluation Criteria 
 
Common Terminology Criteria for Adverse Events v4 (CTCAE): This study will utilize 
the CTCAE of the National Cancer Institute (NCI) for toxicity and performance 
reporting. A copy of the current version of the CTCAE can be downloaded from the 
Cancer Therapy Evaluation Program (CTEP) home page (http://ctep.info.nih.gov). 
Additionally, toxicities will be reported on the appropriate data collection screens.   

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GVHD will be assessed and graded according to the Children’s Oncology Group (COG) 
Stem Cell Committee Consensus Guidelines for Establishing Organ Stage and Overall 
Grade of Acute Graft Versus Host Disease (GVHD) – see Appendix II. 
 
8.0 
OFF THERAPY AND OFF-STUDY CRITERIA 
 
8.1 
Off-Therapy Criteria 
 
 No response to therapy 
 Relapse 
 Second malignancy 
 Treatment with other antineoplastic therapy or hematopoietic stem cell 
transplantation 
 Development of unacceptable toxicity 
 Refusal of further protocol therapy by participant, parent, or guardian 
 Completion of protocol therapy 
 
8.2 
Off-Study Criteria (Recipient) 
 
 Death 
 Lost to follow up 
 Withdrawal of consent 
 
8.3 
Off-Study Criteria (Donor) 
 
 Donors will be considered off study 7 days after apheresis 
 
9.0 
SAFETY AND ADVERSE EVENT REPORTING REQUIREMENTS 
 
9.1 
Reporting Adverse Experiences and Deaths to St. Jude IRB 
 
Only “unanticipated problems involving risks to participants or others” referred to 
hereafter as “unanticipated problems” are required to be reported to the St. Jude IRB 
promptly, but in no event later than 10 working days after the investigator first learns of 
the unanticipated problem. Regardless of whether the event is internal or external (for 
example, an IND safety report by the sponsor pursuant to 21 CFR 312.32), only adverse 
events that constitute unanticipated problems are reportable to the St. Jude IRB. As 
further described in the definition of unanticipated problem, this includes any event that 
in the PI’s opinion was: 
 
 Unexpected (in terms of nature, severity, or frequency) given (1) the research 
procedures that are described in the protocol-related documents, such as the IRB-
approved research protocol and informed consent document, as well as other 
relevant information available about the research; (2) the observed rate of 
occurrence (compared to a credible baseline for comparison); and (3) the 
characteristics of the subject population being studied; and 

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 Related or possibly related to participation in the research; and 
 Serious; or if not serious suggests that the research places subjects or others at a 
greater risk of harm (including physical, psychological, economic, or social harm) 
than was previously known or recognized.  
 
Unrelated, expected deaths do not require reporting to the IRB. Though death is 
“serious”, the event must meet the other two requirements of “related or possibly related” 
and “unexpected/unanticipated” to be considered reportable. 
 
Deaths meeting reporting requirements are to be reported immediately to the St. Jude 
IRB, but in no event later than 48 hours after the investigator first learns of the death.  
The following definitions apply with respect to reporting adverse experiences:  
 
Serious Adverse Event: Any adverse event temporally associated with the subject’s 
participation in research that meets any of the following criteria: 
 
 results in death; 
 is life-threatening (places the subject at immediate risk of death from the event as 
it occurred); 
 requires inpatient hospitalization or prolongation of existing hospitalization; 
 results in a persistent or significant disability/incapacity; 
 results in a congenital anomaly/birth defect; or 
 any other adverse event that, based upon appropriate medical judgment, may 
jeopardize the subject’s health and may require medical or surgical intervention to 
prevent one of the other outcomes listed in this definition (examples of such 
events include:  any substantial disruption of the ability to conduct normal life 
functions, allergic bronchospasm requiring intensive treatment in the emergency 
room or at home, blood dyscrasias or convulsions that do not result in inpatient 
hospitalization, or the development of drug dependency or drug abuse), a 
congenital anomaly/birth defect, secondary or concurrent cancer, medication 
overdose, or is any medical event which requires treatment to prevent any of the 
medical outcomes previously listed.   
 
Unexpected Adverse Event:  
 
 Any adverse event for which the specificity or severity is not consistent with the 
protocol-related documents, including the applicable investigator brochure, IRB 
approved consent form, Investigational New Drug (IND) or Investigational 
Device Exemption (IDE) application, or other relevant sources of information, 
such as product labeling and package inserts; or if it does appear in such 
documents, an event in which the specificity, severity or duration is not consistent 
with the risk information included therein; or  
 The observed rate of occurrence is a clinically significant increase in the expected 
rate (based on a credible baseline rate for comparison); or  

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The occurrence is not consistent with the expected natural progression of any 
underlying disease, disorder, or condition of the subject(s) experiencing the adverse 
event and the subject’s predisposing risk factor profile for the adverse event.    
 
Internal events: Events experienced by a research participant enrolled at a site under the 
jurisdiction of St. Jude IRB for either multicenter or single-center research projects.   
 
Unanticipated Problem Involving Risks to Subjects or Others: An unanticipated 
problem involving risks to subjects or others is an event which was not expected to occur 
and which increases the degree of risk posed to research participants.   
 
Such events, in general, meet all of the following criteria:  
 
 unexpected;  
 related or possibly related to participation in the research; and  
 suggests that the research places subjects or others at a greater risk of harm 
(including physical, psychological, economic, or social harm) than was previously 
known or recognized.  An unanticipated problem involving risk to subjects or 
others may exist even when actual harm does not occur to any participant.  
 
Although some adverse events will qualify as unanticipated problems involving risks to 
subjects or others, some will not; and there may be other unanticipated problems that go 
beyond the definitions of serious and/or unexpected adverse events. Examples of 
unanticipated problems involving risks to subjects or others include: 
 
 Improperly staging a participant’s tumor resulting in the participant being 
assigned to an incorrect arm of the research study; 
 The theft of a research computer containing confidential subject information 
(breach of confidentiality); and  
 The contamination of a study drug.   
 
Unanticipated problems generally will warrant consideration of substantive changes in 
the research protocol or informed consent process/document or other corrective actions in 
order to protect the safety, welfare, or rights of subjects or others.  
 
9.2 
Recording and Reporting AEs and SAEs 
 
Adverse events (AEs) will be evaluated and documented by the clinical staff and 
investigators throughout inpatient hospitalizations and each outpatient visit. CRAs are 
responsible for reviewing documentation related to AEs and entering directly into CRIS 
protocol-specific database. The data to be recorded are 1) the event description, 2) the 
NCI CTCAE v4.0 code and grade, 3) the onset date, 4) the resolution date (or ongoing), 
4) action taken for event, 5) patient outcome 6) relationship of AE to protocol 
treatment/interventions, 7) if AE was expected or unexpected, and 8) comments, if 
applicable.  AEs that are classified as serious, unexpected, and at least possibly related 
will be notated as such in the database as “Reportable Events”.  

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Attribution of an Adverse Event 
 
Not related - The lack of a temporal relationship of the event to study treatment makes a 
causal relationship not reasonably possible, or other drugs, therapeutic interventions or 
underlying conditions provide a sufficient explanation.  
 
Unlikely related - The temporal relationship of the event to study treatment makes a 
causal relationship reasonably unlikely, and other drugs, therapeutic interventions or 
underlying conditions may not provide sufficient explanation for the observed event. 
Possibly related – The temporal relationship of the event to study treatment makes a 
causal relationship reasonably possible, and the event is more likely explained by 
exposure to the study treatment than by other other drugs, therapeutic interventions or 
underlying conditions. 
 
For the purpose of safety analyses, all AE’s that are classified as unlikely or possible will 
be considered treatment-related events. 
 
These events will be reported expeditiously to the St. Jude IRB within the timeframes as 
described above. Cumulative summary of Grades 3-5 events will be reported as part of 
the progress reports to IRB at the time of continuing review. Specific data entry 
instructions for AEs and other protocol-related data will be documented in protocol-
specific data entry guidelines, which will be developed and maintained by study team and 
clinical research informatics. 
 
Patients with abnormal blood counts due to bone marrow involvement by disease (i.e. all 
leukemia patients and lymphoma patients with bone marrow involvement) will be 
considered non-evaluable for hematological toxicities. 
 
The study team will meet regularly to discuss AEs (and other study progress as required 
by institutional DSMP). The PI will review Adverse Event reports generated from the 
research database, and corrections will be made if applicable. Once the information is 
final the PI will sign and date reports, to acknowledge his/her review and approval of the 
AE as entered in the research database. 
 
10.0 
DATA COLLECTION, STUDY MONITORING, AND CONFIDENTIALITY 
 
10.1 
Data Collection  
 
Electronic case report forms (e-CRFs) will be completed by the clinical trials staff from 
the Cancer Center Comprehensive Center, Hematological Malignancies Program. Data 
will be entered from record directly into a secure CRIS database, developed and 
maintained by St. Jude Clinical Research Informatics.  
 
Data Management will be supervised by the Director of Clinical Trials Management, and 
Manager of Clinical Research Operations for the Hematological Malignancies Program, 
working with Dr. Rubnitz or his designee. All protocol-specific data and all grade 3-5 

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adverse events will be recorded by the clinical research associates into the CRIS 
database, ideally within 2-4 weeks of completion of study phase. All questions will be 
directed to the attending physician and/or PI and reviewed at regularly-scheduled 
working meetings. The attending physicians (or their designees) are responsible for 
keeping up-to-date roadmaps in the patient’s primary SJCRH medical chart. Regular (at 
least monthly) summaries of toxicity and protocol events will be generated for the PI and 
the department of Biostatistics to review. 
 
10.2 
Study Monitoring 
 
Monitoring of this protocol is considered to be in the moderate-risk category. The 
Monitoring Plan is outlined in a separate document from this protocol, but has been 
submitted for review and approval by the Clinical Trials Scientific Review Committee 
and the Institutional Review Board. 
 
The study team will hold monthly meetings and review case histories or quality 
summaries on active participants.  
 
Source document verification of eligibility and informed consent for 100% of St. Jude 
participants will be performed by the Eligibility Coordinators within 5 working days of 
completion of enrollment. 
 
The Clinical Research Monitor will monitor applicable essential regulatory 
documentation and review the timeliness of serious adverse event reporting (type, grade, 
attribution, duration, timeliness and appropriateness) for selected study participants semi-
annually and track accrual continuously. The monitor will verify those data points 
relating to the primary study objective for a certain number of study enrollees as specified 
in the Moderate Risk monitoring plan checklist for this study. Protocol compliance 
monitoring will include participant status, safety assessments, eligibility, the informed 
consent process, participant protocol status, off-study, and off-therapy criteria.  The 
Monitor will generate a formal report which is shared with the Principal Investigator (PI), 
study team and the Internal Monitoring Committee (IMC).  Monitoring may be 
conducted more frequently if deemed necessary by the CPDMO or the IMC.   
 
Continuing reviews by the IRB and CT-SRC will occur at least annually. In addition, 
SAE reports in TRACKS (Total Research and Knowledge System) are reviewed in a 
timely manner by the IRB/ OHSP. 
 
Source document verification of eligibility for all SJCRH cases will be performed within 
two weeks of completion of enrollment. This will include verification of appropriate 
documentation of consent. Monitoring of timeliness of serious adverse event reporting 
will be done as events are reported in TRACKS.  
 

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10.3 
Confidentiality 
 
Study numbers will be used in place of an identifier such as a medical record number.  
No research participant names will be recorded on the data collection forms. The list 
containing the study number and the medical record number will be maintained in a 
locked file and will be destroyed after all data have been analyzed. The medical records 
of study participants may be reviewed by the St. Jude IRB, FDA, and clinical research 
monitors. 
 
11.0 
STATISTICAL CONSIDERATIONS 
 
11.1 
Study Design 
 
The primary objectives of this protocol are to evaluate the tolerability and response rate 
of microtransplantation in patients with relapsed or refractory AML or MDS 
 
We will use a cohort of six patients to evaluate the tolerability of the treatment regimen. 
If two or more patients experience unacceptable toxicity as defined in Section 4.4, then 
the trial will close due to intolerability (section 4.4). The first six patients will be enrolled 
sequentially; a patient may not be enrolled until the previous patient has reached day +28 
after the infusion of HPC-A. 
 
We will use a Simon minimax two-stage phase II design23 to evaluate efficacy. All 
patients (including those used in evaluation of tolerability) will be counted towards this 
two-stage design. For implementing this design, we define a therapeutic success as 
follows. For patients with fewer than 5% blasts at enrollment, therapeutic success is 
defined as ≥ 10-fold decrease in level of minimal residual disease (MRD) after one or 
two cycles of therapy. A therapeutic success for patients with greater than 5% leukemic 
blasts in the marrow at the time of enrollment is defined as achieving CR or CRi (as 
defined in section 8.1) after one or two cycles of therapy. Any patient who dies before 
achieving therapeutic success will be counted as a failure in terms of efficacy. All 
patients who receive at least one dose of protocol chemotherapy will be counted as a 
failure or success in terms of efficacy for this phase II design. Only subjects who 
withdraw or die prior to receiving the first dose of protocol chemotherapy will be 
considered inevaluable and replaced. Also, the evaluation of tolerability described above 
and this phase II design will be performed concurrently, i.e., the first enrollees will be 
counted for both tolerability and efficacy. 
 
The first stage will enroll nine patients. If there are four or more therapeutic successes 
among the first nine patients, then ten additional patients will be enrolled. If there are 
eleven or more therapeutic successes among the total of 19 patients, then the therapy will 
be considered worthy of further investigation according to the statistical design. The 
design has 80% power at the 10% level to detect a desirable success rate of 65% against 
the null hypothesis of an unacceptable success rate of 40%.   
 

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The success rate parameters for the two-stage design are aligned with recent published 
experience of clinical trials.16,24-27 Clinical trials enrolling relapsed pediatric AML 
patients report complete response rates ranging from 1/3 (33%) to 8/11 (73%), whereas 
those enrolling relapsed ALL patients report complete response rates ranging from 14/34 
(41%) to 16/22 (73%). The wide variability in response rates on these studies is largely 
attributable to the heterogeneity of patients with respect to multiple risk factors including 
duration of previous remission presence of previous relapse. We will use the methods of 
Jung and Kim28 and Koyama and Chen29 to adjust for the two-stage design in estimating 
the confidence interval for the true success rate. The design was computed with the 
ph2simon function in the clinfun R package. The confidence interval for the response rate 
will be computed with the twostage.inference function of the same package.   
 
All patients who receive at least one course of therapy from the treatment regimen will be 
considered evaluable for both toxicity and efficacy in this design. Any patients who die 
prior to observing a complete response will be counted as a failure in execution of the 
two-stage design.  
 
Based on historical data, we anticipate that this study will be able to accrue 19 patients in 
3 years.    
 
11.2 
Statistical Analysis Plans 
 
Statistical analysis plans for each objective are described separately below. 
Objective 1.1.1: To assess the safety and feasibility of standard chemotherapy plus 
GCSF-mobilized Hematopoietic Progenitor Cell, Apheresis (HPC-A) in pediatric 
patients with relapsed or refractory AML or MDS. (Statistician: Dr. Stanley Pounds, 
Investigator: Dr. Jeffrey Rubnitz) 
 
As described above, the study design includes formal stopping criteria to close the study 
if two or more of the first 6 patients experience unacceptable toxicity as defined in 
Section 4.4. If this stopping rule is satisfied, then we will report that the protocol 
treatment has unacceptable toxicity and describe the toxicities observed. Otherwise, we 
will report descriptive statistics for various categories of toxicities and provide 95% 
confidence binomial intervals for the proportion of subjects experiencing various 
categories of toxicity during the first two courses. 
 
Objective 1.1.2:  To estimate the response rates to standard chemotherapy plus GCSF-
mobilized HPC-A in pediatric patients with relapsed or refractory AML or MDS. 
(Statistician: Dr. Pounds, Investigator: Dr. Rubnitz).   
 
The proportion of patients experiencing therapeutic success will be reported with a 
confidence interval that adjusts for the two-stage design as described above in section 12.1. 
 
Objective 1.2.1:  To describe the event-free and overall survival of patients treated with 
standard chemotherapy plus GCSF-mobilized HPC-A.   
 

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We will use the Kaplan-Meier method to describe the event-free and overall survival. 
Event-free survival will be defined as the time from enrollment to death, relapse, or 
refractory disease with event-free subjects’ time censored at the date of last follow-up. 
Overall survival will be defined as the time from enrollment to death, with living 
subjects’ time censored at the date of last follow-up. 
 
Objective 1.2.2:  To estimate the time to neutrophil and platelet recovery after treatment 
with standard chemotherapy plus GCSF-mobilized HPC-A. (Statistician: Dr. Pounds, 
Investigator: Dr. Rubnitz)   
 
The time to neutrophil and platelet recovery will be summarized using descriptive statistics. 
If there are no deaths prior to recovery of neutrophils and platelets, nonparametric 
confidence intervals for the median time to recovery will be computed by inverting the sign 
test. Otherwise, we will compute cumulative incidence curves to describe the time to 
platelet and neutrophil recovery while adjusting for competing events.   
 
Objective 1.2.3:  To determine the cumulative incidence of acute and chronic graft-
versus-host disease (GVHD). (Statistician: Dr. Pounds, Investigator: Dr. Rubnitz) 
 
We will estimate the cumulative incidence of acute and chronic graft-versus host disease. 
 
Objectives 1.3.1 and 1.3.2: To characterize donor chimerism and microchimerism and 
levels of PR1+ and WT1+ HLA-A*02:01 CD8 T cells in peripheral blood after 
microtransplantation(Statistician: Dr. Pounds, Investigator: Dr. Leung) 
 
We will compute descriptive statistics for the donor chimerism and microchimerism 
percentages at each time point and produce graphics for visualization. Similar exploratory 
analyses will be performed for levels of PR1+ and WT1+ CD8+ T cells, as well as for 
associations between donor T cell dose and outcome.   
 
 
12.0 
OBTAINING INFORMED CONSENT 
 
12.1 
Consent Prior to Research Interventions  
 
Initially, informed consent will be sought for the institutional banking protocol (TBANK 
research study), PGEN5, and for other procedures as necessary for standard medical care.  
During the screening process for eligibility, informed consent for SCREEN protocol OR 
for MITREL is required before any research tests are performed.   
 
12.2 
Consent at Enrollment 
 
The process of informed consent for MITREL will follow institutional policy. The 
informed consent process is an ongoing one that begins at the time of diagnosis and ends 
after the completion of therapy. Informed consent should be obtained by the attending 
physician or his/her designee, in the presence of at least one non-physician witness.  
Initially, informed consent will be sought for the institutional banking protocol (research 

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study), blood transfusion and other procedures as necessary. After the diagnosis of 
relapsed or refractory leukemia is established, we will invite the patient to participate in 
the MITREL protocol.   
 
Throughout the entire treatment period, participants and their parents receive constant 
education from health professionals at SJCRH and collaborating sites, and are encouraged to 
ask questions regarding alternatives and therapy. All families have ready access to chaplains, 
psychologists, social workers, and the St. Jude ombudsperson for support, in addition to that 
provided by the primary physician and other clinicians involved in their care. 
 
We will also obtain verbal assent from children 7 to 14 years old and written assent for 
all participants >14 years of age. 
 
12.3 
Consent at Age of Majority 
 
Participants who reach the age of majority while on study will be re-consented for 
continued participation on MITREL at the time of their next clinic visit after turning 18 
year according to Cancer Center and institutional policy. 
 
12.4 
Consent When English is Not the Primary Language 
 
When English is not the participant, parent, or legally authorized representative’s primary 
language, the Social Work department will determine the need for an interpreter. This 
information will be documented in the participant’s medical record. Either a certified 
interpreter or the telephone interpreter’s service will be used to translate the consent 
information. The process for obtaining an interpreter and for the appropriate use of an 
interpreter is outlined on the Interpreter Services, OHSP, and CPDMO websites. 

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13.0 
REFERENCES 
 
 
1.  Ringden O, Karlsson H, Olsson R, et al. The allogeneic graft-versus-cancer effect. Br J 
Haematol. 2009;147:614-33. 
 
2.  BARNES DW, CORP MJ, LOUTIT JF, et al. Treatment of murine leukaemia with X rays 
and homologous bone marrow; preliminary communication. Br Med J. 1956;2:626-7. 
 
3.  Odom LF, August CS, Githens JH, et al. Remission of relapsed leukaemia during a graft-
versus-host reaction. A "graft-versus-leukaemia reaction" in man? Lancet. 1978;2:537-40. 
 
4.  Weiden PL, Flournoy N, Thomas ED, et al. Antileukemic effect of graft-versus-host 
disease in human recipients of allogeneic-marrow grafts. N Engl J Med. 1979;300:1068-73. 
 
5.  Weiden PL, Sullivan KM, Flournoy N, et al. Antileukemic effect of chronic graft-versus-
host disease: contribution to improved survival after allogeneic marrow transplantation. N 
Engl J Med. 1981;304:1529-33. 
 
6.  Kolb HJ, Mittermuller J, Clemm C, et al. Donor leukocyte transfusions for treatment of 
recurrent chronic myelogenous leukemia in marrow transplant patients. Blood. 
1990;76:2462-5. 
 
7.  Levine JE, Barrett AJ, Zhang MJ, et al. Donor leukocyte infusions to treat hematologic 
malignancy relapse following allo-SCT in a pediatric population. Bone Marrow 
Transplant. 2008;42:201-5. 
 
8.  Velardi A, Ruggeri L, Mancusi A. Killer-cell immunoglobulin-like receptors reactivity 
and outcome of stem cell transplant. Curr Opin Hematol. 2012;19:319-23. 
 
9.  Leung W. Use of NK cell activity in cure by transplant. Br J Haematol. 2011;155:14-29. 
 10.  Venstrom JM, Pittari G, Gooley TA, et al. HLA-C-dependent prevention of leukemia 
relapse by donor activating KIR2DS1. N Engl J Med. 2012;367:805-16. 
 11.  Cooley S, Weisdorf DJ, Guethlein LA, et al. Donor killer cell Ig-like receptor B 
haplotypes, recipient HLA-C1, and HLA-C mismatch enhance the clinical benefit of 
unrelated transplantation for acute myelogenous leukemia. J Immunol. 2014;192:4592-600. 
 12.  Oevermann L, Michaelis SU, Mezger M, et al. KIR B haplotype donors confer a reduced 
risk for relapse after haploidentical transplantation in children with ALL. Blood. 
2014;124:2744-7. 
 13.  Knorr DA, Bachanova V, Verneris MR, et al. Clinical utility of natural killer cells in 
cancer therapy and transplantation. Semin Immunol. 2014;26:161-72. 
 14.  Guo M, Hu KX, Yu CL, et al. Infusion of HLA-mismatched peripheral blood stem cells 
improves the outcome of chemotherapy for acute myeloid leukemia in elderly patients. 
Blood. 2011;117:936-41. 
 15.  Guo M, Hu KX, Liu GX, et al. HLA-mismatched stem-cell microtransplantation as 
postremission therapy for acute myeloid leukemia: long-term follow-up. J Clin Oncol. 
2012;30:4084-90. 
 16.  Kaspers GJ, Zimmermann M, Reinhardt D, et al. Improved outcome in pediatric relapsed 
acute myeloid leukemia: results of a randomized trial on liposomal daunorubicin by the 
International BFM Study Group. J Clin Oncol. 2013;31:599-607. 
 17.  Dey BR, McAfee S, Colby C, et al. Anti-tumour response despite loss of donor 
chimaerism in patients treated with non-myeloablative conditioning and allogeneic stem 
cell transplantation. Br J Haematol. 2005;128:351-9. 
 18.  Rubio MT, Saito TI, Kattleman K, et al. Mechanisms of the antitumor responses and 
host-versus-graft reactions induced by recipient leukocyte infusions in mixed chimeras 

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Protocol document dated:  11-30-2015 
prepared with nonmyeloablative conditioning: a critical role for recipient CD4+ T cells 
and recipient leukocyte infusion-derived IFN-gamma-producing CD8+ T cells. J 
Immunol. 2005;175:665-76. 
 19.  Rubio MT, Kim YM, Sachs T, et al. Antitumor effect of donor marrow graft rejection 
induced by recipient leukocyte infusions in mixed chimeras prepared with 
nonmyeloablative conditioning: critical role for recipient-derived IFN-gamma. Blood. 
2003;102:2300-7. 
 20.  Rezvani K, Yong AS, Mielke S, et al. Leukemia-associated antigen-specific T-cell 
responses following combined PR1 and WT1 peptide vaccination in patients with 
myeloid malignancies. Blood. 2008;111:236-42. 
 21.  Rezvani K, Yong AS, Savani BN, et al. Graft-versus-leukemia effects associated with 
detectable Wilms tumor-1 specific T lymphocytes after allogeneic stem-cell 
transplantation for acute lymphoblastic leukemia. Blood. 2007;110:1924-32. 
 22.  Alizadeh M, Bernard M, Danic B, et al. Quantitative assessment of hematopoietic 
chimerism after bone marrow transplantation by real-time quantitative polymerase chain 
reaction. Blood. 2002;99:4618-25. 
 23.  Simon R. Optimal two-stage designs for phase II clinical trials. Control Clin Trials. 
1989;10:1-10. 
 24.  Bhojwani D, Pui CH. Relapsed childhood acute lymphoblastic leukaemia. Lancet Oncol. 
2013;14:e205-e217. 
 25.  Schrappe M, Hunger SP, Pui CH, et al. Outcomes after induction failure in childhood 
acute lymphoblastic leukemia. N Engl J Med. 2012;366:1371-81. 
 26.  Tallen G, Ratei R, Mann G, et al. Long-term outcome in children with relapsed acute 
lymphoblastic leukemia after time-point and site-of-relapse stratification and intensified 
short-course multidrug chemotherapy: results of trial ALL-REZ BFM 90. J Clin Oncol. 
2010;28:2339-47. 
 27.  Ko RH, Ji L, Barnette P, et al. Outcome of patients treated for relapsed or refractory acute 
lymphoblastic leukemia: a Therapeutic Advances in Childhood Leukemia Consortium 
study. J Clin Oncol. 2010;28:648-54. 
 28.  Jung SH, Kim KM. On the estimation of the binomial probability in multistage clinical 
trials. Stat Med. 2004;23:881-96. 
 29.  Koyama T, Chen H. Proper inference from Simon's two-stage designs. Stat Med. 
2008;27:3145-54. 
 
 

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APPENDIX I: PERFORMANCE STATUS CRITERIA 
PERFORMANCE STATUS CRITERIA 
Karnofsky and Lansky performance scores are intended to be multiples of 10 
ECOG (Zubrod) 
Karnofsky 
Lansky 
Score Description 
Score Description 
Score Description 
0 
Fully active, able to carry 
on all pre-disease 
performance without 
restriction 
100 
Normal, no complaints, no 
evidence of disease 
100 
Fully active, normal 
90 
Able to carry on normal 
activity, minor signs or 
symptoms of disease 
90 
Minor restrictions in 
physically strenuous 
activity 
1 
Restricted in physically 
strenuous activity by 
ambulatory and able to 
carry out work of a light 
or sedentary nature, e.g., 
light housework, office 
work 
80 
Normal activity with effort; 
some signs or symptoms of 
disease 
80 
Active, but tires more 
quickly 
70 
Cares for self; unable to carry 
on normal activity or do 
active work 
70 
Both greater restriction of 
and less time spent in 
play activity 
2 
Ambulatory and capable 
of self-care but unable to 
carry out any work 
activities; up and about 
more than 50% of 
waking hours 
60 
Requires occasional 
assistance, but is able to care 
for most of his/her needs 
60 
Up and around, but 
minimal active play; 
keeps busy with quieter 
activities 
50 
Requires considerable 
assistance and frequent 
medical care 
50 
Gets dressed, but lies 
around much of the day; 
no active play, able to 
participate in all quiet 
play and activities 
3 
Capable of only limited 
self-care, confined to bed 
or chair more than 50% 
of waking hours 
40 
Disabled, requires special 
care and assistance 
40 
Mostly in bed; 
participates in quiet 
activities 
30 
Severely disabled, 
hospitalization indicated; 
death not imminent 
30 
In bed; needs assistance 
even for quiet play 
4 
Completely disabled; 
cannot carry on any self-
care; totally confined to 
bed or chair 
20 
Very sick, hospitalization 
indicated.  Death not 
imminent 
20 
Often sleeping; play 
entirely limited to very 
passive activities 
10 
Moribund, fatal processes 
progressing rapidly 
10 
No play; does not get out 
of bed 
 

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Protocol document dated:  11-30-2015 
APPENDIX II: COG STEM CELL COMMITTEE CONSENSUS GUIDELINES FOR 
ESTABLISHING ORGAN STAGE AND OVERALL GRADE OF ACUTE GRAFT 
VERSUS HOST DISEASE (GVHD) 
Table 1 outlines standard criteria for GVHD organ staging. However, confounding clinical 
syndromes (such as non-GVHD causes of hyperbilirubinemia) may make staging GVHD in a 
given organ difficult. In addition, timing of organ specific symptoms affects whether that 
symptom is more or less likely to be true GVHD. Please refer to Tables 2 and 3 to assist you in 
deciding whether to attribute these clinical findings to GVHD, especially in situations where a 
biopsy is not possible. For additional help, please see the text which follows the tables. Table 4 
reviews the approach to assessing GVHD as acute, chronic, or the overlap between the two. 
 
Finally, engraftment syndrome will be reported separately from the GVHD scoring presented 
below. 
 
Engraftment Syndrome 
A clinical syndrome of fever, rash, respiratory distress, and diarrhea has been described, just 
prior to engraftment in patients undergoing unrelated cord blood and mismatched 
transplantation. If, in the judgment of the treating physician, a patient experiences this 
syndrome, details of the event will be recorded in the medical record. 
 
Modified Glucksberg Staging Criteria for Acute Graft versus Host Disease 
 
Table 1:  Organ Staging (See tables and text below for details) 
Stage 
Skin 
Liver (bilirubin) 
Gut (stool output/day) 
0 
No GVHD rash 
< 2 mg/dL 
Adult: < 500 mL/day 
Child: < 10 mL/kg/day 
1 
Maculopapular rash 
< 25% BSA 
2-3 mg/dL 
Adult: 500-999 mL/day 
Child: 10-19.9 mL/kg/day. 
Or persistent nausea, vomiting, or 
anorexia, with a positive upper GI 
biopsy. 
2 
Maculopapular rash 
25-50% BSA 
3.1-6 mg/dL 
Adult: 1000-1500 mL/day 
Child: 20-30 mL/kg/day 
3 
Maculopapular rash 
> 50% BSA 
6.1-15 mg/dL 
Adult: > 1500 mL/day 
Child: > 30 mL/kg/day 
4 
Generalized 
erythroderma plus bullous 
formation and 
desquamation > 5% BSA 
>15 mg/dL 
Severe abdominal pain with or 
without ileus, or grossly bloody stool 
(regardless of stool volume). 
 

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Overall Clinical Grade (based on the highest stage obtained):  
Grade 0: No stage 1-4 of any organ 
Grade I: Stage 1-2 skin and no liver or gut involvement 
Grade II: Stage 3 skin, or Stage I liver involvement, or Stage l GI  
Grade III: Stage 0-3 skin, with Stage 2-3 liver, or Stage 2-3 GI  
Grade IV: Stage 4 skin, liver or GI involvement 
 
 
Table 2 Evaluating Liver GVHD in the Absence of Biopsy Confirmation (See Table 3.0 below) 
 
Establishing liver GVHD with no skin or GI GVHD 
No Skin/GI  GVHD 
Day 0-35 
Assume no liver GVHD, unless proven by biopsy 
No Skin/GI  GVHD  
Day 36-100 
If NO other etiology identified, 
NO improvement with stopping 
hepatotoxic medications/TPN: 
Stage as liver GVHD 
If other etiology identified or improves 
with stopping hepatotoxic drugs/TPN: 
Do not stage as liver GVHD 
 
Establishing liver GVHD with skin or GI GVHD and other cause of hyperbilirubinemia 
Skin and/or GI GVHD 
present 
Worsening bilirubin level 
(includes worsening just prior 
to onset of skin or GI tract 
GVHD) OR stable elevated 
bilirubin despite resolution of 
non-GVHD cause of increased 
bilirubin: 
Stage as liver GVHD 
Stable or improving bilirubin after 
diagnosis of skin or GI GVHD, 
irrespective of treatment: 
Do not stage as liver GVHD 
 
For GI staging:  The “adult” stool output values should be used for patients > 50 kg in weight.  Use 
3 day averages for GI staging based on stool output.  If stool and urine are mixed, stool output is 
presumed to be 50% of total stool/urine mix (see 3.2 below).   
 
For Stage 4 GI:  the term “severe abdominal pain” will be defined as: 
 
a) Pain control requiring institution of opioid use, or an increase in on-going opioid use, PLUS 
b) Pain that significantly impacts performance status, as determined by the treating MD. 
 
If colon or rectal biopsy is +, but stool output is < 500 mL/day (< 10 mL/kg/day), then consider as 
GI stage 0. 
 
There is no modification of liver staging for other causes of hyperbilirubinemia. 

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Protocol document dated:  11-30-2015 
Changing liver GVHD stage with other cause of hyperbilirubinemia 
Skin and GI GVHD 
stable, improving, or 
absent 
Liver GVHD staging is carried forward without increase in stage until 
other disease process resolves (e.g., if TTP is diagnosed in the presence 
of stage 2 liver GVHD, the liver GVHD stage 2 is carried forward 
despite rising bilirubin level until TTP is resolved.  If there is no liver 
GVHD – stage 0 – and new onset TTP, the stage 0 is carried forward 
until TTP is resolved). 
Skin and/or GI GVHD 
worsening 
Liver GVHD is staged according to the Glucksberg criteria. The 
elevated bill is attributed to GVHD alone. 
 
Thus, when skin or GI GVHD is worsening, there is no downgrading of 
liver GVHD staging for other causes of hyperbilirubinemia. (e.g., if 
TTP is diagnosed in the presence of stage 2 liver GVHD and worsening 
skin or GI GVHD, the liver is staged according to the actual bilirubin 
level even if some of the rise in bilirubin is attributed to TIP). 
 
Similarly, even if there is no liver GVHD at onset of a new process, 
(such as TPN cholestasis), but skin or GI GVHD worsen during that 
process,  then liver GVHD is diagnosed and staged according to the 
height of the bilirubin. 
 
There is one exception to this: the diagnosis of TTP, with high LDH 
and unconjugated bilirubin precludes the diagnosis and staging of new 
liver GVHD in the absence of a confirmatory liver biopsy. 
 
Table 3 Evaluating GI GVHD in the Absence of Biopsy Confirmation (See Table 4.0 below) 
 
Establishing GI GVHD with new onset diarrhea and no skin or liver GVHD 
No skin/liver GVHD  
Day 0 through engraftment 
Assume no GI GVHD, unless proven by biopsy 
No skin/liver GVHD 
engraftment through Day 100 
NO other etiology of diarrhea 
identified: 
Stage as GI GVHD 
Any other etiology of diarrhea 
identified: 
Do not stage as GI GVHD 
 
Establishing GI GVHD with pre-existing diarrhea and skin or liver GVHD 
Skin and/or liver GVHD 
present 
Worsening diarrhea (includes 
worsening just prior to onset of 
skin or liver GVHD) OR 
persistent diarrhea despite 
resolution of non-GVHD cause: 
Stage as GI GVHD 
Improving diarrhea after the 
diagnosis of skin or liver 
GVHD (irrespective of 
treatment) OR persistent 
diarrhea without resolution of 
underlying non-GVHD cause: 
Do not stage as GI GVHD 
 

MITREL 
 
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Protocol document dated:  11-30-2015 
Category 
Time of Symptoms 
after HCT or DLI 
Presence of Acute 
GVHD features 
Presence of Chronic 
GVHD  features 
Acute GVHD 
 
 
 
Classic acute GVHD 
<100 d 
Yes 
No 
Persistent, recurrent, 
or late-onset acute 
>100 d 
Yes 
No 
Chronic GVHD 
 
 
 
Classic chronic GVHD 
No time limit 
No 
Yes 
Overlap syndrome 
No time limit 
Yes 
Yes 
 
Differentiating Acute GVHD, Chronic GVHD, and Overlap Syndrome: 
There is often confusion differentiating acute from chronic GVHD, especially in the setting of 
reduced intensity transplants, DLI and new prophylactic treatments. The NIH Working Group 
recently published new classifications for GVHD: 
 
Table 4 Acute GVHD, Chronic GVHD, and Overlap Syndrome 
 
 
 
 
 
 
 
 
 
 
 
 
 Scoring of acute GVHD may need to occur past day 100.  In particular, patients should 
continue to be scored for acute GVHD when classic acute GVHD symptoms 
(maculopapular rash, nausea, vomiting, anorexia, profuse  diarrhea - particularly if 
bloody and ileus) persist past day 100 or if identical symptoms previously scored as acute 
GVHD resolve and then recur within 30 days during immunosuppression taper but past 
day 100. 
 
 Those patients being scored as having acute GVHD should NOT have diagnostic or 
distinctive signs of chronic GVHD. 
 
 Patients with both acute and chronic symptoms should be diagnosed as having 
Overlap Syndrome and scored according to their chronic GVHD score. 
 
Further Explanation of Criteria presented in Tables 2 and 3 
 
1.0 Assessment of Skin GVHD 
 
1.1 Presence or Absence of Skin GVHD: Skin GVHD will be considered present if a rash 
characteristic of acute GVHD develops after allogeneic marrow transplantation involving 
more than 25% of the body surface not clearly attributable to causes such as drug 
administration or infection.  The extent of the body surface area involved can be estimated by 
the "Rule of Nines". In estimating the extent of skin GVHD, the area involved is calculated 
for individual anatomic areas, such as the arm or leg, and then the total is derived from a 
simple summation.  Areas that are non-blanching should not be considered involved 
regardless of the overlying color of the rash (red, brown, etc.). Limited distribution erythema 
(with the exception of palms and soles) in the absence of associated rash elsewhere on the 
body will not be considered GVHD. 
 

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Protocol document dated:  11-30-2015 
2.0 Assessment of Liver GVHD 
 
2.1 Assessing for the Presence or Absence of Liver GVHD 
 
A. Hyperbilirubinemia (total bilirubin > 2.0 mg/dL) in the absence of other signs of acute 
GVHD in the skin or GI tract: 
 
i) Day 0-35: If hyperbilirubinemia alone is present with no other signs of acute GVHD 
in other organ systems, acute GVHD will not be diagnosed based solely on laboratory 
abnormalities.   
 
Acute GVHD will be diagnosed if findings on histopathology studies of liver from a 
biopsy or autopsy are confirmatory. 
 
ii) Day 35-100: If hyperbilirubinemia (must be conjugated bilirubin) is not improving or 
is exacerbated (especially if serum alkaline phosphatase is increased), in the absence 
of acute GVHD in other organ systems, no other etiologies are identified, and does 
not improve with discontinuation of hepatotoxic drugs, acute GVHD will be 
diagnosed.  However, it is distinctly unusual to develop ascites or a coagulopathy in 
the early stages of acute GVHD of the liver alone.  In the absence of histopathology 
studies of liver from a biopsy or autopsy specimen, ascites or a coagulopathy  
secondary  to liver dysfunction  will be considered  to indicate  the  presence  of  
another  disease process  (e.g., veno-occlusive disease).  Recommended  non-invasive 
studies to define an etiology for hyperbilirubinemia are: 
 
a. Imaging of liver (CT or ultrasound) 
b. Hepatitis screen (only if ALT is elevated) 
c. PT 
d. Blood cultures 
e. Review of medication list for potentially hepatotoxic drugs 
f. Review of risk factors for viral liver infection (HSV, CMV, VZV, adenovirus, 
EBV, HBV, and HCV) 
g. Hemolysis screen 
 
B. Pre-existing hyperbilirubinemia clearly attributed to an etiology other than acute GVHD 
in the presence of signs of acute GVHD in other organ systems. 
 
i) If pre-existing non-GVHD liver disease (documented clinically, by lab assessment, or 
by imaging studies) is stable or improving at the onset of signs of acute GVHD in 
other organs, then acute GVHD of the liver will not be considered to be present 
unless proven by liver biopsy or autopsy. 
 
ii) If hyperbilirubinemia worsens several days before or at the time of onset of signs of 
acute GVHD in other organ systems, GVHD will be considered to be present unless 
histopathology studies of liver are available and negative on a biopsy during that time 
interval or autopsy results exclude GVHD. 
 

MITREL 
 
Amendment 1.0, dated:  10-21-2015 
 
IRB approval date: 12-1-2015 
 
 
Protocol document dated:  11-30-2015 
iii) If hyperbilirubinemia persists and is not improving after resolution of a pre-existing 
non-GVHD liver disease process (e.g., localized infection of liver, systemic sepsis, 
biliary tract obstruction) when signs of acute GVHD are present in other organ 
systems or no other intervening cause has been diagnosed, then acute GVHD will be 
considered to be present in the absence of a new, clearly identifiable cause of non-
GVHD liver disease or unless a liver biopsy or autopsy specimen is negative. 
 
C. Prior acute GVHD in liver with new onset of a disease process that exacerbates pre-
existing or recently resolved hyperbilirubinemia: 
 
i) If an etiology other than acute GVHD is clearly identified as causing or exacerbating 
hyperbilirubinemia and acute liver GVHD has been diagnosed and has been stable, 
improving, or resolved, then the liver will not be restaged for acute GVHD until the 
resolution or stabilizing of the concurrent disease process (i.e., the liver stage prior to 
the onset of the new disease process will be carried forward until the new disease 
process resolves).  Example: Acute GVHD of the liver and gut is diagnosed on day 
20. Treatment of acute GVHD results in falling bilirubin levels to liver stage 1. Sepsis 
or TTP develops with transient worsening of the hyperbilirubinemia. The liver stage 
is not increased, despite a higher bilirubin level, because the cause of worsening 
hyperbilirubinemia is attributed to sepsis or TTP. 
 
ii) If an etiology other than acute GVHD is clearly identified as causing or exacerbating 
hyperbilirubinemia in the presence of already worsening acute liver GVHD or 
GVHD of the skin or GI tract is simultaneously worsening, then the liver GVHD will 
be staged according to the actual bilirubin level, even though another cause of 
hyperbilirubinemia is present. 
 
3.0 Assessment of GVHD of the Gastrointestinal Tract 
 
3.1 Assessing for the Presence or Absence of GVHD of the Gastrointestinal Tract 
 
A. Diarrhea (>500 mL/day in adults or > 10 mL/kg in pediatric patients) in the absence of 
other signs of acute GVHD in other organ systems 
 
i) Day 0-engraftment: If diarrhea alone is present without other signs of acute GVHD in 
other organ systems, acute GVHD will not be considered present. Diarrhea will be 
attributed to acute GVHD if histopathology studies of gastrointestinal tract from a 
biopsy or autopsy are diagnostic. 
 
ii) Engraftment-day 100: If diarrhea persists and is not improving, is exacerbated, or 
develops de novo in the absence of acute GVHD in other organ systems, 
histopathology studies of gut biopsies or from autopsy specimens are not available, 
and no other etiologies are clearly identified, acute GVHD will be considered to be 
the cause. A stool specimen should be examined to rule out infectious causes (e.g., 
rotavirus, adenovirus, and C. difficile toxin). It is recommended, if at all possible, that 
biopsies be obtained for diagnostic purposes. 
 

MITREL 
 
Amendment 1.0, dated:  10-21-2015 
 
IRB approval date: 12-1-2015 
 
 
Protocol document dated:  11-30-2015 
B. Pre-existing diarrhea clearly attributed to an etiology other than acute GVHD in the 
presence of signs of acute GVHD in other organ systems: 
 
i) If pre-existing diarrhea caused by a process other than GVHD has been documented 
clinically or by lab assessment and is stable or improving at the onset of signs of 
acute GVHD in the skin or liver, then acute GVHD of the intestine will not be 
considered to be present in the absence of biopsy confirmation or autopsy report. 
 
ii) If diarrhea or gastrointestinal symptoms are already present, but worsen significantly 
at the time of onset  of signs of acute GVHD in the skin or liver, GVHD will be 
considered present, unless biopsy or autopsy are negative. 
 
iii) If diarrhea persists after resolution of a pre-existing disease process with signs of 
acute GVHD present in other organ systems, GVHD will be considered present, 
unless biopsy or autopsy are negative. 
 
C. Prior or present acute GVHD in other organ systems with new onset of diarrhea: 
 
If diarrhea is clearly attributable to an etiology other than acute GVHD (e.g., infection) 
and a history of acute GVHD exists or acute GVHD is present in other organ systems and 
is stable, then the gastrointestinal tract will not be evaluable for acute GVHD until the 
resolution or stabilizing of the other disease process (e.g., infection) in the absence of 
biopsy or autopsy confirmation.  
 
D. Persistent anorexia, nausea or vomiting in the absence of signs of acute GVHD in other 
organ systems: 
 
Persistent anorexia, nausea or vomiting in the absence of other known causes of these 
symptoms will be considered stage I acute GVHD if confirmed by endoscopic biopsy. 
 
If a biopsy is not possible (e.g. secondary to thrombocytopenia) but the clinical findings 
are compatible with acute GVHD, then the patient will be treated and recorded as having 
acute GVHD. 
 
3.2 Staging of the Gastrointestinal Tract for the Severity of Acute GVHD 
 
The severity of gastrointestinal tract GVHD will be staged according to modified Glucksberg 
criteria. To minimize errors caused by large day-to-day variation, diarrhea volume is 
measured as an average over 3 days and reported as the volume in milliliters per day. When 
urinary mixing is noted the stool volume will be considered half of the total volume unless 
nursing staff is able to give a better estimate from direct observation. Abdominal cramps are 
considered significant for staging if the severity results in a clinical intervention (e.g. 
analgesia, fasting, etc.). Blood in the stools is considered significant if the blood is visible or 
hematochezia/melena is present and not clearly attributed to a cause other than GVHD (e.g., 
epistaxis/hemorrhoids). 

MITREL 
 
Amendment 1.0, dated:  10-21-2015 
 
IRB approval date: 12-1-2015 
 
 
Protocol document dated:  11-30-2015 
APPENDIX III:  TESTS PERFORMED FOR ROUTINE CARE AND FOR RESEARCH 
 
Routine care 
 
 Physical exam, height, weight, BSA 
 CBC with differential 
 Chemistry profile: glucose, electrolytes, BUN, creatinine, LDH, uric acid, bilirubin, 
SGOT, SGPT, calcium, phosphorous, magnesium, total protein and albumin 
 Coagulation screen 
 HLA typing 
 Chest x-ray 
 EKG, echocardiogram 
 Bone marrow evaluation for morphology, immunophenotyping, cytogenetics, molecular 
diagnosis, and minimal residual disease (MRD).  
 Lumbar puncture with CSF cell count and cytology. 
 Serum pregnancy test of females of childbearing potential 
 
Research 
 
 Hematopoietic Progenitor Cell, Apheresis (HPC-A) infusion 
 Microchimerism studies – blood and bone marrow 
 All donor tests/evaluations, GCSF and hematopoietic stem cell mobilization procedure