A Phase II Trial of Allogeneic Peripheral Blood Stem Cell Transplantation From Matched Unrelated Donors in Patients With Advanced Hematologic Malignancies and Hematological Disorders
Phase: PHASE2
Conditions: Chronic Myeloproliferative Disorders, Graft Versus Host Disease, Leukemia, Lymphoma, Multiple Myeloma and Plasma Cell Neoplasm, Myelodysplastic Syndromes, Myelodysplastic/Myeloproliferative Diseases, Precancerous/Nonmalignant Condition
Sponsor: City of Hope Medical Center

IRB 01089 
 
01/13/2020 
Packet: 13 
CITY OF HOPE NATIONAL MEDICAL CENTER 
1500 E. DUARTE ROAD 
DUARTE, CA 91010 
DIVISION OF HEMATOLOGY AND HEMATOPOIETIC CELL TRANSPLANTATION  
 
TITLE: A Phase II Trial of Allogeneic Peripheral Blood Stem Cell Transplantation From Matched 
Unrelated Donors in Patients with Advanced Hematologic Malignancies and 
Hematological Disorders 
 
 
CITY OF HOPE PROTOCOL NUMBER/VERSION:  IRB # 01089   PROTOCOL DATE: 01/13/2020 
DATE(S)/ OF AMENDMENT(S)/REVISION(S):  
 
COH Amendment 01 
01/18/02 
Version: 01 
 
COH Amendment 02 
08/06/02 
Version 02 
 
COH Amendment 03 
01/15/03 
Version 03 
 
COH Amendment 04 
09/12/03 
Version 04 
 
COH Amendment 05 
03/10/04 
Version 05 
COH Amendment 06 
11/18/04 
Version 06 
COH Amendment 07 
01/16/05 
Version 07 
COH Amendment 08 
03/25/05 
Version 08 
COH Amendment 09 
03/16/06 
Version 09 
COH Amendment 10 
10/14/2011 
Version 10 
COH Amendment 11 
09/06/13 
Version 11 
COH Amendment 12 
01/13/2020 
Version 12 
COH Amendment 13 at Continuation 
Protocol Dated 01/13/2020 (tp) 
Packet: 13 
 
SITE:  
 
 
 
 
 
 
Bone Marrow  
 
 
 
STAGE (If applicable): 
 
 
 
 
Advanced 
 
MODALITY: 
Allogeneic peripheral blood stem cell 
transplant from unrelated donor 
 
TYPE:  
 
 
 
 
 
 
Phase II 
 
PRINCIPAL INVESTIGATOR: 
 
 
 
Monzr Al Malki, M.D. 
 
 
 
COLLABORATING INVESTIGATOR(S):  
 
Stephen Forman, M.D. 
 
 
 
 
 
 
 
 
Joyce Niland, Ph.D. 
 
 
 
 
 
  
  
 
 
 
PARTICIPATING CLINICIANS: 
Ravi Bhatia, M.D., Amrita Krishnan, M.D., 
 
Ryotaro Nakamura, M.D., Leslie Popplewell, M.D.,  
 
 
 
 
 
 
 
Anthony Stein, M.D.  Eileen Smith, M.D.,  
  
 
Joseph Alvarnas, M.D., Jeffrey Wong, M.D., Anna 
Pawlowska, M.D., Joseph Rosenthal, M.D. 
 

 
 
 
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CITY OF HOPE NATIONAL MEDICAL CENTER 
1500 E. DUARTE ROAD 
DUARTE, CA 91010 
DIVISION OF HEMATOLOGY AND HEMATOPOIETIC CELL TRANSPLANTATION  
 
TITLE: A Phase II Trial of Allogeneic Peripheral Blood Stem Cell Transplantation From 
Matched Unrelated Donors in Patients with Advanced Hematologic 
Malignancies and Hematological Disorders 
 
 
CITY OF HOPE PROTOCOL NUMBER/VERSION: 
IRB # 
01089 Version 12 
DATE(S)/ OF AMENDMENT(S)/REVISION(S):   
Amendment 1/18/02 - COH Version: 01 
 
 
 
 
 
 
 
Amendment 8/6/02 –   COH Version 02 
 
 
 
 
 
 
 
Amendment 1/15/03 – COH Version 03 
 
 
 
 
 
 
 
Amendment 9/12/03 – COH Version 04 
 
 
 
 
 
 
 
Amendment 3/10/04 – COH Version 05 
 
 
 
 
 
 
 
Amendment11/18/04 - COH Version 06 
 
 
 
 
 
 
 
Amendment 01/6/05 – COH Version 07 
 
 
 
 
 
 
 
Amendment 03/25/05- COH Version 08 
 
 
 
 
 
 
 
Amendment 03/16/06- COH Version 09 
 
 
 
 
 
 
 
Amendment 10/14/11- COH Version 10 
 
 
 
 
 
 
 
Amendment 09/06/13- COH Version 11 
 
 
 
 
 
 
 
Amendment 01/13/20- COH Version 12 
 
SITE:  
 
 
 
 
 
Bone Marrow 
 
 
 
 
STAGE (If applicable):  
 
 
 
Advanced 
 
MODALITY: 
Allogeneic peripheral blood stem cell 
transplant from unrelated donor 
 
TYPE:  
 
 
 
 
 
Phase II 
 
PRINCIPAL INVESTIGATOR:  
 
 
Monzr Al Malki, M.D. 
Designs, responsible for study conduct  
 
 
 
 
and data analysis 
 
COLLABORATING INVESTIGATOR(S): 
 
Stephen Forman, M.D. 
Key individual; Assists in study design and development; Joyce Niland, M.D. 
May be involved in analysis of data  
 
 
 
  
 
PARTICIPATING CLINICIANS: 
Ravi Bhatia, M.D.,  
Enrolls and follows eligible patients on study; 
Amrita Krishnan, M.D., Ryotaro Nakamura, M.D., 
Not involved in study development or data analysis 
Leslie Popplewell, M.D., 
(Physician or research support staff)                         
Key individual; Assists in study design and development: 
David Snyder, M.D.  Anthony Stein, M.D.  
May be involved in analysis of data 
Eileen Smith, M.D., Firoozeh Sahebi, M.D., 
Warren Chow, M.D., Joseph Alvarnas, M.D., 
Jeffrey Wong, M.D., Anna Pawlowska, M.D., 
Joseph Rosenthal, M.D. 
 
 
 
 
 
 
 

 
 
 
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TABLE OF CONTENTS 
 
1.0 
INTRODUCTION..................................................................................................4 
 
2.0 
BACKGROUND ....................................................................................................4 
2.1 
MOBILIZATION OF NORMAL DONORS ...........................................................4 
2.2 
GRAFT VERSUS HOST DISEASE .....................................................................5 
2.3 
EXPERIENCE WITH SIROLIMUS PROPHYLAXIS IN UNRELATED OR 
MISMATCHED-RELATED TRANSPLANTS…………………………………….8 
2.4 
PBSC TRANSPLANTATION:  RELATED DONORS ............................................8 
2.5 
RANDOMIZED STUDIES COMPARING ALLOGENEIC BMT VS. PBSCT IN 
MATCHED SIBLINGS ......................................................................................9 
2.6 
BM TRANSPLANTATION:  UNRELATED DONORS ...........................................9 
2.7 
PBSC FOR UNRELATED DONOR TRANSPLANTATION……………………11 
2.8 
CLINICAL EFFECT OF HLA MATCHING IN UNRELATED DONOR MARROW 
TRANSPLANTATION .....................................................................................11 
2.9 
RATIONALE FOR ALLOGENEIC PBSCT FROM UNRELATED DONORS .12 
3.0 
OBJECTIVES ......................................................................................................12 
 
3.1 
PRIMARY OBJECTIVES .................................................................................12 
3.2 
SECONDARY OBJECTIVES ............................................................................13 
4.0 
STUDY DESIGN ..................................................................................................13 
5.0 
STUDY POPULATION.......................................................................................14 
6.0 
PATIENT SELECTION ......................................................................................14 
 
6.1 
INCLUSION CRITERIA ..................................................................................14 
 
6.2 
EXCLUSION CRITERIA ..................................................................................15 
 
6.3 
DONOR SELECTION .....................................................................................16 
 
6.4 
REGISTRATION ............................................................................................16 
7.0 
MATERIALS AND METHODS .........................................................................16 
 
7.1 
MOBILIZATION AND LEUKAPHERESIS (PBSC COLLECTIONS) .....................16 
 
7.2 
CYTOREDUCTIVE THERAPY.........................................................................16 
 
8.0 
TREATMENT PLAN ..........................................................................................17 
 
8.1 
DONOR MOBILIZATION ...............................................................................17 
 
8.2 
CONDITIONING REGIMENS ..........................................................................18 
 
8.3 
GVHD PROPHYLAXIS .................................................................................22 
 
8.4 
TREATMENT OF GVHD ...............................................................................26 
 
8.5 
USE OF GROWTH FACTORS ..........................................................................28 
 
8.6 
GRAFT FAILURE ..........................................................................................28 
 
8.7 
SUPPORTIVE CARE ......................................................................................28 
 
8.8 
RELAPSE .....................................................................................................28 

 
 
 
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9.0 
PATIENT EVALUATIONS ................................................................................28 
 
9.1 
BASELINE DONOR DATA .............................................................................28 
 
9.2 
BASELINE RECIPIENT DATA ........................................................................29 
 
9.3 
PBSC  .........................................................................................................29 
9.4 
PREPARATIVE CYTOREDUCTION AND TRANSPLANTATION ..........................29 
 
10.0 
ASSESSMENTS ...................................................................................................31 
 
10.1 
PRIMARY OBJECTIVES .................................................................................31 
 
10.2 
OTHER ........................................................................................................31 
 
11.0 
ADVERSE EVENT REPORTING .....................................................................31 
12.0 
STATISTICAL CONSIDERATIONS ...............................................................33 
13.0 
ADMINISTRATIVE CONSIDERATIONS ......................................................34 
 
13.1 
ADVERSE EXPERIENCES ..............................................................................34 
 
13.2 
CRITERIA FOR REMOVAL FROM STUDY .......................................................34 
 
13.3 
INSTITUTIONAL REVIEW .............................................................................34 
 
13.4 
INFORMED CONSENT ...................................................................................34 
14.0 
WOMEN AND MINORITIES GUIDELINES .................................................34 
15.0 
REFERENCES .....................................................................................................36 
APPENDICES…………………………………………………………………………..39 
A 
PHARMACEUTICAL INFORMATION ...........................................................................40 
B 
METHOTREXATE AND CYCLOSPORINE DOSE MODIFICATION GUIDELINES ..............57 
C 
FRACIONATED TOTAL BODY IRRADIATION SCHEMA .........................................60 
D 
GVHD ASSESSMENT ..............................................................................................61 
E 
PERFORMANCE STATUS ..........................................................................................63 
F 
STUDY CALENDAR ..................................................................................................65 
G 
IV BUSULFAN KINETICS .........................................................................................66 
H 
CTC VERSION 2.0 
 

 
 
 
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1.0 
INTRODUCTION 
 
Reported studies have shown that mobilized autologous peripheral blood stem 
cells (PBSC) can engraft patients following myeloablative therapy.  The rate of 
engraftment following autologous stem cell transplantation (PBSCT) is reported 
to be more rapid with PBSC than with bone marrow. Shorter engraftment times 
have resulted in a shorter duration of hospitalization and a reduction in transfusion 
requirements. 
 
Hesitation to use PBSC for allogeneic transplantation can be attributed to 
reluctance to administer cytokines to normal donors and concern that the number 
of lymphocytes in PBSC infusions may increase the risk of graft versus host 
disease (GVHD).  Studies now indicate that Filgrastim (G-CSF) can be 
administered safely to normal volunteers, and that they can undergo apheresis 
with minimal side effects.(1) In addition, recent randomized studies have 
suggested that PBSCT do not result in a higher rate of severe GVHD in matched 
sibling transplants when compared to BM transplants even though up to tenfold as 
many T-cells may be infused with PBSC, provided that adequate GVHD 
prophylaxis is given.(2) Moreover, typical PBSC products contain 3-4 times more 
CD 34+ cells than do typical marrow products. These larger stem cell doses may 
be beneficial since marrow cell doses were independently associated with 
improved transplant outcome, especially following unrelated donor transplants.(3) 
Recent studies have also shown that immunologic recovery is more rapid 
following allogeneic PBSCT.(4) Thus the potential advantages of allogeneic 
PBSCT include rapid engraftment resulting in decreased transplant-related 
mortality, rapid immunologic recovery, and higher number of stem cells infused. 
This study proposes to evaluate the outcome of allogeneic PBSCT from unrelated 
donors for patients with hematologic disorders and hematologic malignacies.    
 
2.0 
BACKGROUND 
 
 
2.1 
Mobilization of Normal Donors  
 
There is increasing experience using filgrastim (granulocyte-colony 
stimulating factor, G-CSF) in normal donors.  Several investigators have 
treated many healthy volunteers with G-CSF for five to six days.  The 
most common adverse effect experienced by the donors was bone pain.  
Other symptoms include nausea, vomiting, and influenza-like symptoms, 
including headache, fatigue, myalgia, and night sweats.(5) During 
apheresis, donors may experience bone pain, which was relieved by 
analgesics, and a decrease in platelet counts and hematocrit.  The decrease 
in platelet count and hematocrit appears to be due in part to numbers of 
platelets and red cells contaminating in the stem cell products, and do not 
fall below a clinically significant range.  None of the donors required 
blood product transfusions.  There have been no long-term side effects 
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Mobilized PBSC from healthy allogeneic transplant donors are now being 
investigated as an alternative to bone marrow stem cells.  Lane et al  
demonstrated that it is feasible to collect sufficient PBSC from normal 
donors for allogeneic transplantation by mobilizing with G-CSF, or GM-
CSF, or a combination of both with minimal risk to the donor.(6) Other 
published regimens for mobilization and collection of normal donor PBSC 
typically include a dose of  10 g/kg/day of rhG-CSF with apheresis 
initiated after the fourth dose of G-CSF (day 5).(7) Using this regimen, 
peak blood levels of CD34+ cells on day 5 have been reported to be in the 
range of 33-113/L, depending on the center, with a wide range of CD34 
cells collected.  Schmitz et al report collection of 3-8 x 106 CD34 cells/kg 
recipient weight with 1-3 standard volume apheresis procedures. Urbano-
Ispizua et al reported a median collection of 6 x 106 CD34 cells/kg 
recipient weight with 1-2 standard volume aphereses.(8) Brown et al 
report a mean of 107 CD34cells/kg recipient weight with most (91%) 
donors requiring only a single large volume apheresis.(9) Using a higher 
dose of G-CSF for mobilization (16 g/kg/day), Bensinger et al report 
collecting a median of 13 x 106 CD34 cells/kg recipient weight in two 
standard volume apheresis procedures.(10) While the optimal mobilization 
and apheresis schedule is not clear, it is clear that sufficient numbers of 
PBSC can be routinely collected. 
 
Potential advantages of the use of mobilized PBSC in allogeneic 
transplantation include elimination of the need for hospitalization, general 
anesthesia and blood transfusions for the donor and potential for 
accelerated neutrophil and platelet engraftment for the recipient (compared 
to BM). Potential disadvantages of allogeneic PBSC transplantation 
include the theoretical increased risk of GVHD due to the presence of 
large numbers of T lymphocytes in the harvest.  Recent reports have 
suggested that although the incidence and severity of acute GVHD are not 
increased, the incidence of chronic GVHD may be significantly higher in 
recipients of PBSC.(11)  
 
Currently, the National Marrow Donor Program has announced the 
availability of G-CSF stimulated PBSCs for hematopoietic transplants 
from unrelated donors, as an alternative to bone marrow.  NMDP donors 
who elect to donate PBSC will participate in NMDP protocol entitled “ 
Filgrastim-Mobilised Peripheral Blood Stem Cells for Primary Allogeneic 
Transplantation with Unrelated Donors”  
  
 2.2 
Graft versus Host Disease   
 
In transplants from matched related donors, early results suggest that 
recipients of unselected PBSC from matched sibling donors experience 
acute GVHD at rates similar to recipients of BM from matched sibling 

 
 
 
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donors despite the large difference in T cell content, provided that they 
receive adequate GVHD prophylaxis (two drug therapy).  Even with 
adequate immunosuppressive therapy, approximately 35% of recipients of 
bone marrow from matched sibling donors will develop moderate to 
severe acute GVHD and at least 30% will develop manifestations of 
chronic graft versus host disease. 
 
Adequate GVHD prophylaxis typically consists of cyclosporine plus 
methotrexate or prednisone. Clinical studies have demonstrated a 
significant reduction in acute GVHD and associated improved survival 
using a combination of methotrexate and cyclosporine compared to 
cyclosporine alone in leukemia patients, however, the addition of 
methotrexate is also associated with potential engraftment delays due to its 
myelosuppressive effects.(12) 
 
 
The use of FK-506 (Prograf) for the prevention of AGVHD has been 
reported since 1995.(13) In a randomized trial comparing CSA and FK-
506 with MTX for AGVHD prophylaxis in allogeneic matched sibling 
transplant patients, FK-506 was found to be more effective in AGVHD 
prevention but patients with advanced disease had a higher incidence of 
regimen related toxicity and a lower survival.(14) A separate randomized 
trial between FK-506 and CSA with MTX for AGVHD prophylaxis in 
unrelated donor transplant patients showed an incidence of grade II-IV 
AGVHD of 56% for FK-506 and 74% for CSA with no difference in long 
term survival.(15) Another Phase II trial with FK-506 and MTX for 
AGVHD prophylaxis in unrelated donor transplants showed an incidence 
of grade II-IV AGVHD of 34% compared to 43% incidence of grade II-IV 
acute GVHD reported in 1423 unrelated donor transplant patients given 
CSA/MTX, T Depletion or other prophylaxis. FK-506 has also been 
shown to work synergystically with MMF to treat chronic GVHD in 26 
patients who had progressed after standard therapy with CSA and 
prednisone with an objective response rate of 46%. 
 
Mycophenolate mofetil (MMF) is the 2-(4-morpholino) ethyl ester of 
mycophenolic acid (MPA). MMF is rapidly absorbed following oral 
administration and hydrolyzed to the active MPA which blocks purine 
synthesis in the T and B lymphocytes. Preclinical studies in allogeneic 
transplant models demonstrate activity in preventing graft rejection and 
GVHD. Preliminary evidence after transplantation of unrelated DLA-
mismatched marrow in dogs is that MMF synergizes with CSA to prevent 
GVHD and improve survival; in this unrelated transplant model the 
combination of CSA/MMF was more powerful in preventing GVHD and 
rejection than CSA/MTX.(16) Additional clinical studies using oral 
CSA/MMF for acute GVHD prophylaxis in the non-myeloablative setting 
have further demonstrated that this combinationis very effective in 

 
 
 
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preventing AGVHD and leads to less mucositis than expected with 
MTX.(17) 
 
 
With pre-clinical studies showing the drug is more effective in AGVHD 
prevention and clinical data showing there is less mucositis compared to 
MTX the drug has become a prime candidate for clinical studies in 
AGVHD prophylaxis. It's use in AGVHD prevention in the myeloablative 
allogeneic transplant setting had not been studied until recently due to the 
lack of availability of an intravenous (IV) formulation which would allow 
use during the post high dose chemotherapy and radiation phase of 
mucositis.  IV MMF is now available. We have currently approved a 
multi-institutional protocol (IRB#99106) to study the use of IV MMF in 
combination with CSA for AGVHD prophylaxis in allogeneic sibling 
BMT patients.  
 
2.2.1 Sirolimus 
 
Sirolimus (Rapamune, Wyeth-Ayerst) is a commercially available 
immunosuppressant licensed for use in solid organ transplantation. 
Sirolimus is a macrocyclic lactone similar in structure to tacrolimus and 
cyclosporine but with different mechanism of action from the calcineurin 
inhibitors. Sirolimus was shown to be synergistic with cyclosporine and 
tacrolimus in animal models and has a distinct toxicity profile, allowing 
their use in combination. In the solid organ transplantation setting, 
sirolimus has rapidly become the standard of care, allowing for reduced 
doses of calcineurin inhibitors and as a consequence, less renal toxicity. In 
addition, the use of sirolimus has lead to improved allograft survival 
without an increase in the rate of serious infections. 
 
Sirolimus is a macrocyclic lactone immunosuppressant derived from 
Streptomyces hygroscopicus that is similar in structure to tacrolimus. 
Sirolimus has excellent antirejection activity in organ transplantation (11) 
and combination therapy with cyclosporine or tacrolimus appears to be 
extremely effective in human organ allografting (12-14) and mouse 
models of hematopoietic stem cell transplantation (HSCT) (15,16). There 
is also a study demonstrating the activity of sirolimus in steroid-resistant 
graft-versus-host disease (GVHD) (17).  
 
Sirolimus binds to the same family of intracellular FK-506 (tacrolimus)
 
-binding proteins (FKBP12 and others) at a site distinct from 
tacrolimus. Sirolimus-FKBP complexes inhibit the mammalian target of 
rapamycin (mTOR), a kinase that regulates cell cycle entry in response to 
interleukin 2 (IL-2) signaling and other cellular functions. Cell cycle entry 
in the presence of sirolimus induces T cell apoptosis, and deprivation of 
IL-2 signaling renders antigen-activated T cells unresponsive. Both 
mechanisms are thought to contribute to T cell immunologic tolerance. 
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mTOR suppresses cytokine-driven T cell proliferation by inhibiting: 1) 
transcription of a family of mRNA’s needed for cell cycle progression; 2) 
IL-2 induced transcription of PCNA which is necessary for DNA 
replication; 3) CD28-mediated upregulation of IL-2 transcription; 4) 
kinase activity of cdk4/cyclin B and cdk2/cyclin E complexes thus 
preventing cell cycle progression.  Thus, G1 S progression is blocked.  
Sirolimus may also inhibit dendritic cell function (18, 19, 20, 21, 22, 23). 
 
While both tacrolimus and sirolimus bind to FKBP12, there appear to be 
adequate binding sites for both molecules. Therefore, contrary to 
expectations, the drugs are not competitive, and, in fact, they appear to be 
synergistic (24, 25, 26). Sirolimus also is free of nephrotoxicity and 
neurotoxicity, making combination therapy appealing. Sirolimus affects 
lymphocyte activation at a later stage than either cyclosporine or 
tacrolimus, and activation stimuli that resist inhibition to the latter agents 
have been shown to be sensitive to sirolimus. Despite the activity observed 
in organ transplantation, its application to HSCT was delayed by concerns 
about bioavailability of an oral agent, as well as neutropenia and 
thrombocytopenia, which may complicate its use. 
 
2.3  Experience with Sirolimus Prophylaxis in Unrelated or Mismatched-Related    
Transplants 
Investigators from Boston performed an open label phase 1/2 trial in 39 
patients receiving a mismatched related (n=5) or unrelated donor (n=34) 
transplant (36). Patients were conditioned with cyclophosphamide and 
TBI (14 Gy). GVHD prophylaxis consisted of tacrolimus/sirolimus and 
MTX 5 mg/m2 on days 1, 3, 6 and 11 post-transplant.  The median age 
was 42 (19-62). Diagnoses were CML (12),  ALL (9), AML (10), MDS 
(7) and NHL (2). Despite its oral formulation, sirolimus blood levels of 3-
12 ng/mL was maintained in most patients. All patients attained durable 
engraftment, with median times to neutrophil and platelet engraftment of 
18 days and 29 days, respectively. Grade 0-1 acute GVHD occurred in 
75% of patients. Grades 2, 3, and 4 acute GVHD occurred in 13%, 8%, 
and 5%, respectively (total grades 2-4 GVHD, 26%). Mortality from RRT 
included hepatic VOD (3), IP (2), infection (3), hemorrhage (1), and 
multiorgan failure (1). Sirolimus-related toxicities were hyperlipidemia, 
which was well controlled with lipid lowering agents, and 1 case of HUS 
which resolved with reduction of sirolimus and tacrolimus doses. Relapse 
was observed in 10 patients. 100-day survival was 80%. The 1-year RFS 
and OS were 52% and 45%, respectively. 
 
2.4 
PBSC Transplantation: Related Donors  
 
In a retrospective study reported by Bensinger et al, 37 patients 
transplanted with unselected PBSC from HLA-matched siblings and the 
outcomes were compared to an historical group of bone marrow 

 
 
 
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transplants.(18) Donor mobilization was with G-CSF, 16 μg/kg/d for five 
days, with PBSC collections on days 4 and 5. Average age of the PBSC 
group was 38 (range 20-52 years). The diagnoses included AML (41%), 
NHL (24%), ALL (14%), Hodgkin’s disease (11%), CML (5%) and 
multiple myeloma (5%). The majority of patients were relapsed (89%), 
5% were in >second remission, and 5% were CML patients in blast crisis. 
GVHD prophylaxis was either CSA plus MTX in 19/37 (51%) or CSA 
plus prednisone in 18/37 (49%).  Grade II-IV acute GVHD occurred in 
37% of the recipients.    
 
 
 
The median time to neutrophil engraftment (ANC >500/μL) was 14 days 
in the PBSC group compared to 16 days in the historical bone marrow 
controls (p=0.0063), and to platelet engraftment (first of 7 consecutive 
days with >20,000/μL) was 11 and 15 days respectively for the PBSC and 
bone marrow groups. These results suggest that allogeneic PBSC approach 
was associated with faster engraftment, fewer transfusions and no greater 
incidence of acute or chronic GVHD. 
 
Several Phase II studies of PBSC transplant from matched sibling donors 
have been reported by several investigators. Most patients received PBSC 
products containing > 5 x 106 CD34+ cells/kg.   Engraftment was rapid in 
all patients with no late graft failure observed.  All patients received 
various GVHD prophylaxis regimens. The incidence of grade II-IV acute 
GVHD were similar to historical BMT data for HLA-identical pairs. 
However, the risks of chronic GVHD were higher in some studies. 
 
2.5 
Randomized Studies Comparing Allogeneic BMT vs. PBSCT in Matched 
Siblings  
 
Two prospective, randomized clinical trials with relatively small numbers 
of patients comparing PBSC and BM have been reported.(19) Time to 
platelet recovery was shorter in the PBSC group in both studies, and 
neutrophil engraftment was shorter in one study.  Acute GVHD incidence, 
DFS, and LFS did not differ between the groups in either study, but a 
trend towards a higher incidence of chronic GVHD was seen in both 
studies, a finding suggested by a large retrospective study reported by the 
International Bone Marrow Transplant Registry (IBMTR).(20) 
 
A large prospective randomized study of PBSC or BM for patients 
undergoing allogeneic stem cell transplant was recently reported by 
Bensinger et al. on behalf of investigators from the FHCRC, COHNMC 
and Stanford University.(2) PBSC transplantation was associated with 
faster engraftment without any difference observed in acute or chronic 
GVHD at a median follow-up of 20 months.  Although survival 
differences were not seen in patients with good risk disease, PBSC 
transplantation was associated with lower transplant-related mortality and 

 
 
 
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relapse in patients with advanced disease.  Similar results from two 
additional large studies from Canada and Europe have also been reported.   
 
 
2.6 
BM Transplantation: Unrelated Donors 
 
Approximately 70% of patients with hematologic malignancies and other 
hematologic disorders for whom allogeneic stem cell transplantation is 
potentially curative, lack matched sibling donors.  For these patients, other 
options for stem cell sources for transplantation currently include partially 
matched relatives, matched unrelated donors (URD) and cord blood.   
 
The National Marrow Donor Program was established in 1988 to provide 
bone marrow from unrelated donors to patients lacking suitable family 
donors.  As of December 1998, the NMDP had facilitated more than 7,860 
unrelated donor transplants.  Essentially all of these represent transplants 
of bone marrow collected from donors during general or regional 
anesthesia. Over the last few years NMDP has established procedures to 
allow the collection of PBSC as an alternative to bone marrow in the 
second donation setting. As the experience with allogeneic PBSC has 
grown, PBSC is now being used as an alternative to bone marrow for first 
donation.    
 
 
 
Data from 1384 patients receiving URD BMT between November 1991 
and August 1995 facilitated by the NMDP have been recently 
analyzed.(21) These data summarize the experience using bone marrow in 
these transplant pairs and should serve as the baseline for examining the 
initial data from unrelated donor PBSC transplant. Sixty-three (63%) of 
the pairs in the NMDP summary (n = 869) were matched at HLA-A, B 
(serological) and DRB1 (molecular).  HLA-C typing was not available for 
the majority of pairs.  T-cell depletion was performed for the prevention of 
GVHD in 30% of the cases.   
 
Neutrophil engraftment (defined as the first of three consecutive days on 
which ANC > 500/L) occurred at a median time of 20 days after marrow 
transplantation (all patients).  Although neutrophil engraftment was more 
rapid in patients who received T-depleted marrow (median 17 days), and 
in patients not given methotrexate, both of these groups were at greater 
risk for graft failure. Neutrophil engraftment by day 42 occurred in 92% of 
patients who received either T-depleted marrows or no methotrexate 
compared to 96% of patients receivingT-replete marrows and 95% of 
patients who received methotrexate. Delay of engraftment beyond 42 days 
was associated with reduced survival.  Primary graft failure was reported 
to occur in 5% of patients, and secondary graft failure in 14%.  Recipients 
of T-depleted grafts were not at higher risk for secondary graft failure.  
 

 
 
 
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Platelet engraftment  (defined as >50,000/L without transfusion for seven 
days) occurred at a median time of 82 days after marrow transplant, and 
was achieved by 54% of recipients by day 100. Favorable risk factors 
included higher cell dose, HLA-A, B and DRB1 matching, CMV 
seronegative recipients and female recipients.  Platelet recovery was 
significantly slower in patients with Grades III-IV GVHD.  In this series 
of patients, platelet engraftment was an important predictor of survival, 
and appears to be a valuable clinical indicator of likely outcome. 
 
In a separate analysis of 1423 consecutive CML patients transplanted with 
unrelated donor bone marrow reported rates of severe acute (Grades III-
IV) and extensive chronic GHVD were 33% and 60%, respectively.(22)  
In this series, primary graft failure occurred in 10.3% of patients and 
secondary graft failure in 6.9%.  
 
2.7 
PBSC for Unrelated Donor Transplantation 
 
Reports of PBPC transplants from unrelated donors have recently been 
published.  Ringden and colleagues reported successful and faster 
engraftment of platelets and neutrophils without significant increase in 
acute GVHD in patients receiving PBSC from unrelated donors without 
differences in acute GVHD or survival.(23) A case control study of 90 
patients receiving transplants from unrelated donors was conducted, with 
45 patients receiving PBPC and 45 patients receiving BM.(24) A short 
time to platelet count recovery was seen in the PBPC group.  Grade II - IV 
acute GVHD was 20% in the BM controls and 30% in the PBPC group.  
The probability of chronic GVHD was 85% in the BM groups, 59% in the 
PBPC group.  One-year transplant related mortality (TRM), and overall 
survival differences were not significant.  
 
2.8       Clinical Effect of HLA Matching in Unrelated Donor Marrow      
Transplantation 
 
Important advances have been made in understanding how the HLA 
system relates to the success of hematopoietic sell transplantation. It has 
been known for sometime that HLA disparity increases both the risks of 
GHVD and graft rejection.(25) Recent studies using molecular techniques 
have suggested that graft rejection is primarily attributable to disparity of 
class I alleles, while GVHD has been attributed to disparity of class II 
alleles. In retrospective study reported by Petersdorf et al, molecular 
mismatch at HLA-C was found to be an independent risk factor for graft 
failure.(26)There was also a trend toward an increased risk of rejection 
with single HLA-A, or –B mismatches. The incidence of rejection 
increased with multiple class I allele mismatches.   
 

 
 
 
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GVHD was also related to HLA disparity.  (27)Early studies with HLA 
mismatched related donors demonstrated an increasing incidence and 
severity of GVHD with increasing numbers of mismatches. In related 
donor setting, a single antigen mismatch at HLA-DR was associated with 
higher risk of GVHD than single antigen mismatch at HLA-A, or –B.(28)  
 
In unrelated donor setting, several of studies have shown that there was an 
increased risk of GVHD in serologically matched unrelated donor 
recipients compared to matched related donor recipients.(29) In a study 
performed at the Fred Hutchinson Cancer Research Center (FHCRC), 
using ssop typing, increased risks of GVHD and death were found in 
HLA-DRB1 mismatched patients.(30) A subsequent study also found that 
molecular mismatching at DQB1 conferred a significantly increased risk 
of GVHD that was further increased with a combined DRB1 and DQB1 
mismatch. A single class I allele mismatch did not increase the risk of 
GVHD.  However, multiple Class I and Class II mismatches increased the 
risk of GVHD.(31)Contrary to the findings at the FHCRC, a recent 
Japanese study found that class I disparity at HLA-A and –C alleles 
contributed significantly to the risk of GVHD and death.(32) Class II 
disparity, in that study, did not contribute to GVHD or death. The 
differences in results are, as yet, unexplained.    
 
 
2.9 
Rationale for Allogeneic PBSCT from Unrelated Donors 
 
  
The recent analysis of 1423 consecutive CML patients transplanted with 
unrelated donor bone marrow facilitated by the NMDP indicates that 
overall survival is similar in recipients of related and unrelated marrow 
grafts.  Further, in good risk cohorts of patients, the 3-year disease free 
survival was similar in both groups.   Interest in the use of mobilized 
PBSC from unrelated donors has increased as experience with the use of 
mobilized PBSC from related donors has increased.  Based on this 
experience, there appear to be several potential advantages of the use of 
mobilized PBSC in the unrelated setting, including more rapid 
engraftment, decreased transplant-related morbidity and mortality, and the 
ability to provide large doses of stem cells. 
 
  
Potential disadvantages may be related to the increased number of T-cells 
infused with mobilized PBSC and the potential for increased GVHD, 
acute or chronic. This increased risk of chronic GVHD may contribute to 
long term complications, increased costs and decreased quality of life in 
these patients. 
 
3.0 
OBJECTIVES 
   
 
This is a Phase II study designed to evaluate the hematopoietic recovery, the 
incidence of acute and chronic GVHD and survival outcome of patients with 

 
 
 
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advanced hematologic malignancies or hematological disorders who are 
undergoing PBSC transplants from matched unrelated donors. The criteria for 
HLA matching in this protocol, in general, will be similar to those used at the City 
of Hope for conventional unrelated BMT. Donors and recipients should be 
matched for HLA –A, -B, and -DRB1 at least to the level of high resolution 
molecular typing. If possible, matching for HLA -C, and -DQB1 alleles will be 
preferred, but not mandatory.  
  
 
3.1 
Primary Objectives  
 
 
 
 
The primary objectives of the study are:  
 
 
 
 
1. To evaluate hematopoietic recovery, using neutrophil and platelet 
engraftment as the primary criterion, following unrelated donor PBSC 
transplant.  
 
2. To evaluate the incidence of acute and chronic GVHD in recipients of 
matched unrelated donor PBSC transplant. 
 
3.2 
Secondary Objectives 
 
1. To evaluate the impact of HLA class I and class II alleles matching on 
the incidence of GVHD and on the survival outcome following 
PBSCT from unrelated donors. 
 
2. To evaluate the overall survival, disease-free survival and relapse 
following unrelated donor PBSCT.  Using both myeloablative and 
non-myeloablative conditioning regimens. 
 
4.0 
STUDY DESIGN 
 
 
This is a phase II trial of allogeneic matched unrelated PBSC transplants for 
patients with Hematologic malignancies or disorders who do not have matched 
sibling donors, or are not a candidates for autologous stem cell transplant. 
 
 
Patients must have a matched unrelated donor who meets donor evaluation 
criteria and who has agreed to the mobilization and apheresis procedures 
according to National Marrow Donor Program Standard. Several preparative 
regimens will be used depending on their diagnosis, their ages, their disease status 
at transplant and whether they had a prior transplant. All patients will receive 
unrelated donor PBSC transplant. Three different GVHD prophylaxis will be used 
either the combination of FK 506 (prograf) and methotrexate, or the combination 
of cyclosporine, mycophenolate mofetil (MMF) and mini-methotrexate, or the 
combination of FK 506, sirolimus and mini-methotrexate.   
 
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All observed toxicities and side effects will be recorded, and the severity and 
degree of GHVD will be assessed.  Toxicities and side effects of particular 
interest include engraftment delays, renal toxicity, hepatic toxicity, and graft 
rejection or failure. Durability of engraftment will be monitored by following 
hematopoietic parameters for a minimum of 6 months following transplantation.  
Acute and chronic GVHD will be assessed and documented using City of Hope 
criteria.   Patients will be seen twice a week during the first 100 days then weekly 
until 6 months post transplant, and at 12, 18, and 24 months after the transplant.  
Patients will be followed at least for two years for disease-free and overall 
survival and then indefinitely. 
 
Matched unrelated donors will be identified through standard donor search 
procedures, and will be screened, mobilized, and apheresed according to usual 
NMDP standards. 
  
5.0 
STUDY POPULATION 
 
Male or female patients who meet eligibility requirements and for whom an HLA-
identical unrelated donor has been identified. 
 
6.0 
 PATIENT SELECTION 
 
6.1 
Inclusion Criteria : The following conditions must be met before a patient 
may be enrolled in the study. 
 
6.1.1 
There is no upper age limits for this protocol. Patients age > 55 
years with hematologic diseases treatable for allogeneic stem cell 
transplant who are not eligible for IRB # 99190 will be enrolled 
on this protocol. 
 
6.1.2 
Disease Criteria: 
 
Patients with ALL in first relapse or beyond, or high risk ALL 
defined as: 
 
 
-  
hypoploidy ( 44 chromosomes) 
- 
pseudodiploidy with translocations or molecular 
evidence of t(9;22), 11q23, or t(8;14), excluding B-
ALL 
- 
elevated WBC at presentation (>20,000/mm3 >18 yrs; 
>200,000/mm3 12-18 yrs);  
  
 
 
OR 
  
 
Patients with AML in 1CR, or failed to achieve remission (IF), or 
first relapse or beyond; 
 
OR  
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Patients with CML in first or second chronic phase or accelerated 
phase, or blast crisis,  (Blast crisis is defined as > 30% 
promyelocytes plus blasts in the bone marrow.)  
 
  
 
 
OR 
 
Patients with myelodysplastic syndrome (MDS), including 
RAEB, CMML, and RAEB-T. Patients with secondary AML (> 
30% blast in the marrow aspirate) should receive induction 
chemotherapy to obtain a remission if possible before transplant.   
Patients with myeloproliferative disorders (MPS)/myelofibrosis 
can be considered on a case by case basis and transplant must be 
approved by review committees and the principal investigator.  
 
OR 
 
Patients with refractory NHL, CLL, HD and Multiple Myeloma 
who have received and failed frontline therapy, high-dose therapy 
and autologous stem cell transplant  or salvage therapy. 
 
OR 
 
Patients with severe aplastic anemia, or PNH, or any other 
hematologic disorder requiring transplantation 
 
  
 
6.1.3 
Patients with consenting unrelated volunteer donor that meets 
donor selection criteria. 
 
6.1.4 
Patients with adequate organ function as measured by: 
  
 
 
 
  
 
 
Cardiac: 
Left ventricular ejection fraction at rest must be ≥ 
45%. 
 
 
 
 
 
 
Hepatic: 
SGOT within 2x normal range and total bilirubin  
<1.5x 
normal 
range 
unless 
liver 
function 
abnormalities are related to underlying disease. 
 
  
 
 
Renal:  
Serum creatinine within 1.5x normal range or 
creatinine clearance  60 ml/min. 
 
  
 
 
Pulmonary: 
DLCO (diffusion capacity)  40% of predicted 
(corrected for hemoglobin). 
 
  
 
6.1.5 Written informed consent conforming to institutional guidelines 
obtained from patient or parent (if a minor). 
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6.1.6 
Life expectancy > 8 weeks and absence of co-existing medical 
problems which would significantly increase the risk of the 
transplant procedure in the judgment of the principal investigator. 
 
6.2 
Exclusion Criteria : Any one of the following conditions eliminates a 
patient from participating in this protocol. 
 
6.2.1 
Availability of a 6/6 matched related donor. 
 
6.2.2 
Uncontrolled CNS involvement with disease. 
 
  
 
6.2.3 
Female who are pregnant 
 
  
 
6.2.4 
Karnofsky performance status < 50%. 
 
  
 
6.2.5 
Seropositivity for HIV. 
 
6.3 
Donor Selection 
 
6.3.1 
Donors must meet criteria set forth by the NMDP for donors of 
Filgrastim-mobilized peripheral blood stem cells for primary 
allogeneic transplantation.  Please refer to the NMDP protocol 
entitled “Filgrastim-Mobilized Peripheral Blood Stem Cells for 
Primary Allogeneic Transplantation with Unrelated Donors” (City 
of Hope IRB #99064). 
 
6.3.2 
HLA-phenotypically identical with the patient for HLA-A, and –
B and identical for DRB1 alleles. Matching assessed by DNA 
typing for both Class I and Class II antigens. Allele mismatch for 
HLA class I (i.e. B 2701 vs. B 2702) is acceptable if no 
alternative donors. Allele mismatch for class II (i.e. DRB1 0401 
vs. 0402), or minor mismatch for class I Cross Reactive Group 
(CREG, i.e. A 2 vs. A 28) is acceptable in patient age ≤ 35 years 
old requiring urgent transplant.   
 
6.3.3 
Written informed consent from donor. 
 
 
 
 
6.4 
Registration   
 
At the time informed consent is obtained, qualified patients will be 
assigned a COH study number. 
 
7.0 
MATERIALS AND METHODS 
 
7.1 
Mobilization and Leukapheresis (PBSC Collections)  

 
 
 
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7.1.1 
G-CSF (Neupogen®) 
 
 
 
 
  
See Appendix 14.2 for pharmaceutical information. 
 
 
7.1.2 
Equipment 
 
 
 
Apheresis will be performed using a peripheral or central venous 
access at donor center’s discretion. 
 
 
7.2 
Cytoreductive Therapy  
 
 
 
See appendix for pharmaceutical information on drugs used in this study. 
 
8.0 
TREATMENT PLAN 
 
8.1 
Donor Mobilization 
 
 
PBSC donors must meet the criteria set forth by the NMDP for donors of 
Filgrastim-mobilized peripheral blood stem cells for primary allogeneic 
transplantation.  Please refer to the NMDP protocol entitled “Filgrastim-
Mobilized Peripheral Blood Stem Cells for Primary Allogeneic 
Transplantation with Unrelated Donors”  
 
8.1.1 
Donor search, donor selection, donor work-up and donor 
informed consent are per NMDP protocol.    
 
8.1.2 
Eligible donors will begin mobilization with G-CSF at 
approximately 10 g/kg/day subcutaneously (rounded off to full 
vials) per NMDP protocol. 
 
8.1.3 
Starting on Day 5 of mobilization, two large volume apheresis 
procedures will be performed.  The first apheresis will be on Day 
5 and the second on Day 6.  PBSC will be collected using the 
Fenwal CS-3000, COBE Spectra or comparable automated cell 
separator according to established procedures.    Typically 15-20 
liters of blood will be processed during each apheresis collection. 
Both apheresis product will be shipped via courier after 
completion of collection to the Transplant Center.   
 
8.1.4 The goal is to collect and infuse  5.0 x 106 CD34 + cells/kg 
recipient weight, if possible.  

 
 
 
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8.1.5 
G-CSF administration to the donor may be modified at any time 
during the mobilization procedure if the WBC exceeds 75,000/µL. 
The following table summarizes appropriate schedules for donor 
mobilization that may be used. 
 
 
 
M 
Tu 
W 
Th 
F 
Sa 
Su 
M 
Tu 
W 
Th 
F 
I 
SF 
RF 
 
F1 
F2 
F3 
F4 
F5 
A1 
 
A2 
 
 
 
II 
 
SF 
RF 
 
F1 
F2 
F3 
F4 
 
F5 
A1 
 
A2 
 
 
III 
 
 
SF 
RF 
 
F1 
F2 
F3 
F4 
 
F5 
A1 
 
A2 
 
IV 
 
 
 
SF 
RF 
 
F1 
F2 
F3 
F4 
Fg5 
A1 
 
A2 
SF: Ship Filgrastim, RF: Receive Filgrastim, Fx: Administer day x of 
Filgrastim, Ax: Perform day x of apheresis. 
 
8.2 
Conditioning regimens: Several preparative regimens will be used. The 
choice of regimen will be depending upon patients’ diagnoses, age, 
disease status, prior radiation therapy and prior autologous stem cell 
transplant (ASCT).   Reduced-Intensity myeloablative regimens will be 
recommended in: older patients, prior ASCT, and those with underlying 
medical problems which place them at increased the risk of transplant-
related morbidity or mortality. 
   
 
Regimen I: TBI and Cyclophosphamide 
 
 
Day -8 
 
Admission 
 
Day -7 
 
TBI 
 
 
120 cGyx3 
  
 
 
Day -6 
 
TBI 
 
 
120 cGyx3 
 
  
 
 
Day -5 
 
TBI 
 
 
120 cGyx3 
  
 
 
Day -4 
 
TBI 
 
 
120 cGyx2 
  
 
 
Day -3 
 
Cyclophosphamide 
60 mg/kg (IBW) 
  
 
 
Day -2 
 
Cyclophosphamide 
60 mg/kg (IBW) 
  
 
 
  
 
 
Day  0 
 
Infusion of PBSC.  
 
For patients who weigh  120% of ideal body weight, the dose of Cy will 
be based on the patient’s ideal body weight.  For patients who weigh > 
120% of ideal body weight, the dose of Cy will be based on the adjusted 
ideal body weight (AIBW), calculated as follows: 
 
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AIBW = Ideal Body Wt. + [(0.25) x (Actual Body Wt - Ideal Body Wt)] 
 
 
 
To prevent hemorrhagic cystitis, Mesna will be administered 
intravenously before cyclophosphamide at a dose equal to 40% of 
cyclophosphamide dose over 15 minutes, and then will be repeated every 
3 hours for a total of 48 hours. 
 
To accommodate stem cell arrival date and total body radiation schedule, 
cyclophosphamide may be given before TBI as follows: 
 
Cyclophosphamide and TBI 
Day – 7 
Cyclophosphamide 60 mg/kg IBW 
Day – 6 
Cyclophosphamide 60 mg/kg IBW 
Day – 5 
Rest day 
Day – 4 
TBI 120 cGyx3 
Day – 3 
TBI 120 cGyx3 
Day – 2 
TBI 120 cGyx3 
Day – 1 
TBI 120 cGyx2 
Day – 0 
Infusion of PBSC 
 
 
[If patients receive Tacrolimus/Sirolimus/MTX for GVHD prophylaxis the 
conditioning regimen (Regimen I) will be started two days earlier so 
sirolimus will not be given the same day with chemotherapy to prevent 
interaction between chemotherapy and sirolimus. There will be no change 
in the conditioning schedule if Cyclophosphamide is given prior to TBI as 
allowed to accommodate stem cell arrival and TBI schedule.] 
 
  
 
 
 
Regimen II: Busulfan and Cyclophosphamide 
 
Day -12 
start dilantin 300 mg p.o. t.i.d. x 1 day, then 
300mg p.o.daily for 10 days. 
Day-8 
Admission, dilantin blood levels will be 
checked and dose adjusted as needed to 
meet therapeutic range.  Further adjustments 
if clinically indicated.  Busulfan test dose 
administered at 6 a.m. as a single dose.  The 
I/V dose is calculated as follows: 
 
1. 
Body 
surface 
area 
(BSA) 
is 
calculated by the equation: 
 
BSA= (Actual body weight(kg) x 
height (cm) 
 
 
 
 
 
 
 
                                3600 
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2. 
0.8 
mg/kg 
adjusted 
BW) 
I/V 
Busulfan will be given over 2 hours.  
Blood levels will be obtained with 
the first dose as per Appendix G and 
shipped via overnight mail to Quest 
Diagnostics. Inc. 
 
 
 
 
Day –7 
 
 
Busulfan AUC will be calculated by 
standard methods available in the City of 
Hope 
Analytical 
Pharmacology 
Core 
Facility (APCF) or those standards used at 
that site.  The resulting AUC will be used to 
determine the dose required to achieve target 
AUC of 1200 µM* min (range 800-1400) 
according to the following formula: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
The maximum dose given will not exceed 
32 mg/m2. There is no limit on dose 
reduction Busulfan dose will only be 
adjusted for AUC’s <800. 
 
Day -7 
Busulfan 0.8 mg/kg q 6 hrs starting at noon 
Day-6 
Busulfan 0.8 mg/kg q 6 hrs 
Day-5 
Busulfan 0.8 mg/kg q 6 hrs 
Day –4 
Busulfan 0.8 mg/kg q 6 hrs; total 16 doses 
Day –3 
Cyclophosphamide 60 mg/kg IBW 
Day –2 
Cyclophosphamide 60 mg/kg IBW 
Day 0 
PBSC infusion   
 
Busulfan will be dose calculated based on Adjusted Body Weight. 
To prevent hemorrhagic cystitis, Mesna will be administered 
intravenously before cyclophosphamide at a dose equal to 40% of 
cyclophosphamide dose over 15 minutes, and then will be repeated every 
3 hours for a total of 48 hours 
 
[If patients receive Tacrolimus/Sirolimus/MTX for GVHD prophylaxis the 
conditioning regimen (Regimen II) will be started two days earlier so 
sirolimus will not be given the same day with chemotherapy to prevent 
interaction between chemotherapy and sirolimus.] 
 
 
 
 
 
 
 
    800µMx min 
Adj dose = Current dose x  
 
 
 
 
    test dose AUC 
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Regimen III: TBI and VP-16 
 
 
 
Day-7  
TBI 120 cGyx3 
 
Day-6  
TBI 120 cGyx3 
 
Day-5  
TBI 120 cGyx3 
 
Day-4  
TBI 120 cGyx2 
 
Day-3  
Etoposide 60 mg/kg (adjusted BW) 
 
Day-0  
PBSC Infusion 
 
[If patients receive Tacrolimus/Sirolimus/MTX for GVHD prophylaxis the 
conditioning regimen (Regimen III) will be started one day earlier so 
sirolimus will not be given the same day with chemotherapy to prevent 
interaction between chemotherapy and sirolimus.] 
 
Reduced-Intensity Myeloablative Regimen 
 
 
 
 
Regimen IV: Fludarabine and Melphalan 
 
 
 
 
 
 
 
Day-7  
Fludarabine 25 mg/m2 IV  
 
 
 
Day-6  
Fludarabine 25 mg/m2 IV  
 
 
 
Day-5  
Fludarabine 25 mg/m2 IV  
 
 
 
Day-4  
Fludarabine 25 mg/m2 IV  
 
Day-3  
Fludarabine 25 mg/m2 IV 
 
Day-2  
Melphalan 140 mg/m2 IV 
 
Day  0  
PBSC infusion 
 
Both Fludarabine and melphalan doses will calculated based on 
actual body weight.  
 
[If patients receive Tacrolimus/Sirolimus/MTX for GVHD prophylaxis the 
conditioning regimen (Regimen IV) will be started two days earlier so 
sirolimus will not be given the same day with chemotherapy to prevent 
interaction between chemotherapy and sirolimus.] 
 
 
Regimen V:  Fludarabine and TBI 
 
 
Day-4  
Fludarabine 30 mg/m2 IV 
 
Day-3  
Fludarabine 30 mg/m2 IV 
 
Day-2  
Fludarabine 30 mg/m2 IV 
 
Day 0 
TBI 200 cGy to be administered between 10.00 
a.m.and 1.00 pm 
 
 
 
PBSC infusion  
 
[ For Regimen V, no change will be made to the fludarabine and TBI 
schedule if patients receive Tacrolimus/Sirolimus/MTX for GVHD 
prophylaxis.]  
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Regimen VI:  Busulfan  and Fludarabine 
 
Day-8  
Begin Dilantin 
Day-5  
Busulfan 0.8 mg/kg IV over 3 hrs 
 
 
Fludarabine 30 mg/m2 IV 
Day-4  
Busulfan 0.8 mg/kg IV over 3 hrs 
 
 
Fludarabine 30 mg/m2 IV 
Day-3  
Busulfan 0.8 mg/kg IV over 3 hrs 
 
 
Fludarabine 30 mg/m2 IV 
Day-2  
Busulfan 0.8 mg/kg IV over 3 hrs  
 
 
Fludarabine 30 mg/m2 IV 
Day-0  
PBSC infusion 
 
Calculation of Ideal Body weight 
 
1.  Male    
IBW= 50 kg + 2.3 kg (height [in]-60) 
2.  Female 
IBW = 45.5 kg+ 2.3kg (height [in]-60) 
 
[If patients receive Tacrolimus/Sirolimus/MTX for GVHD prophylaxis the 
conditioning regimen (Regimen VI) will be started two days earlier so 
sirolimus will not be given the same day with chemotherapy to prevent 
interaction between chemotherapy and sirolimus.] 
 
8.3 
GVHD Prophylaxis  
 
 
 
 
 
 
Three different GVHD prophylaxis will be allowed including: 
 
 
 
 
 
 
 
 
 
 
 
 Prograf and methotrexate.  
 
 
 
 
 
 
 
 
OR 
 
 
 
 
 
Cyclosporine, MMF and mini-methotrexate. 
 
 
 
 
 
 
 
 
OR 
 
 
 
 
 
Prograf, sirolimus and mini-methotrexate 
 
 
 
 
 
 
All patients should have cyclosporine and prograf levels monitored to 
insure a therapeutic range is achieved.  (For dose reduction guidelines, see 
Appendix B) 
 
 
8.3.1 GVHD PROPHYLAXIS REGIMEN A: PROGRAF+MTX 
 
 
 
 
Day –1 start FK506 .03 mg/kg/day IV until day +21 then switch to po (see 
below) 
 
 
 
Methotrexate 
  
 
Day +1 
15 mg/m2 IV starting 24 hours after the PBSC infusion is 
complete 
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Day +3 
10 mg/m2 IV 
  
 
Day +6 
10 mg/m2 IV 
  
 
Day +11 
10 mg/m2 IV 
 
Leucovorin rescue may be used per discretion of primary Hematologist.  
Guidelines for MTX dose adjustment in patients with renal dysfunction, 
mucositis, or peripheral capillary leak are outlined in Appendix B.  In such 
patients, MTX levels may be checked beginning 24 hours after MTX 
administration and if the MTX level is high, leucovorin may be 
administered according to institutional standards/guidelines 
 
 
 
 
FK506: All patients will receive FK-506 .03 mg/kg/day IV from day –1 
until day +21 , then switch to 0.1 mg/kg/day orally.  Dosing should be 
based on adjusted ideal body weight.  FK-506 whole blood levels will be 
monitored twice a week and adjusted to maintain therapeutic levels of 10-
20 ng/ml.  If GVHD is absent, FK-506 will be then tapered by 5%/week 
until a dose of 0.02 mg/kg/day is reached. This dose will be maintained 
until day 180.  Further decisions on tapering FK-506 will then be made by 
the primary physician. 
 
8.3.2 GVHD PROPHYLAXIS REGIMEN B: Cyclosporine, MMF and 
mini-Methotrexate 
 
 
Cyclosporine 
Day  -1 through +21 
3 mg/kg/day by continuous infusion or 1.5 
mg/kg i.v. q 12 hours 
 
Day +21 through +180 
Switch to oral dose at 5 mg/kg or up to 6.25 
mg/kg 
po 
BID 
to 
maintain 
plasma 
cyclosporine trough levels as measured by 
fluorescence polarization immunoassay (TDX) 
of 200-600 ng/mL (170-500 by HPLC; whole 
blood levels by TDX of 900-1500 ng/mL).   
 
 
The scheduling of cyclosporine administration should be such that a full 
24 hour dose has been given before the PBSC are infused.  Oral dosing is 
not allowed prior to day 14. 
 
 
 
   
 
 
 
Day  0 start MMF at 15 mg/kg IV BID  
  
  
  
  
 
 
 
 
until day +27.  May be switched to oral after day +14 
 
MMF: IV will begin day 0 a minimum of 2 hours after the end of the stem 
cell infusion. MMF will be administered at 15 mg/kg/twice a day from day 
0 until day 27. The intravenous formulation will be administered until at 
least day 14 after transplant. MMF will be administered as a 2 hour IV 
infusion. MMF will be infused with 5% dextrose. When patients have 
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recovered from radiation and chemotherapy induced gastroenteritis and 
are capable of taking the oral MMF, they will be converted at an oral to 
intravenous ratio of 1:1. This can be done because of the high 
bioavailability of MMF. The oral formulation of MMF is available in 
250 mg capsules. The prescribed dose will be rounded to the nearest dose 
possible with these capsules. Both intravenous and oral doses of MMF 
will be calculated using adjusted ideal body weight. If actual body weight 
is less than ideal body weight, actual body weight will be used.  
 
 
 Mini-Methotrexate 
 
Day +1 
10 mg/m2 IV 24 hrs after PBSC infusion is complete 
 
Day +3 
5 mg/m2 IV 
 
Day +6 
5 mg/m2 IV 
 
8.3.3 GVHD PROPHYLAXIS REGIMEN C: Prograf, Sirolimus and 
mini-methotrexate  
 
- 
Prograf 0.02 mg/kg/d CI V, beginning day –3 
- 
Sirolimus 12 mg PO loading dose on day –3 followed by 4 mg PO 
daily   beginning on day –2 
- 
Methotrexate 5mg/m2 iv on day +1, +3, and + 6 
 
Medications will be dosed based on adjusted ideal body weight 
 
Prograf will be administered intravenously at a dose of 0.02 mg/kg 
q 24h by continuous infusion starting on Day –3. Intravenous 
tacrolimus will be discontinued once the patient starts eating and 
the drug will then be given orally at a dose of approximately 3 
times the intravenous dose.  
 
 
Dose Modifications of Prograf.   
 
 
Suggested Prograf Dose Adjustment Guidelines 
 
Plasma levels 
Toxicity 
Grade 
Tacrolimus Dose 
<5 ng/ml 
0 
Increase 25% 
5-20 ng/ml 
0,1 
No change 
“  
II 
Decrease 25% 
“ 
III 
Decrease 50% 
“ 
IV 
Stop 100% 
>20 ng/ml 
0 
Decrease 
25% 
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every 3-4 days 
 
Drug Interactions 
 
Drugs that may increase tacrolimus levels: Fluconazole, 
Itraconazole, 
Ketoconazole, 
erythromycin, 
H2 
blockers, 
Verapamil, 
Diltiazem, 
nicardipine, 
danazol, 
bromocriptine, 
metoclopramide, methylprednisolone, somatostatin (octreotide). 
 
Drug 
that 
may 
decrease 
tacrolimus 
levels: 
Rifampin, 
Phenobarbital, phenytoin, carbamazepne, Octreotide (may lower 
serum levels by decreasing intestinal absorption of the oral drug). 
 
Drugs that may result in additive nephrotoxicity: Aminoglycosides, 
Amphotericin B, Acyclovir, Furosemide, TMP-SMX. 
 
 Sirolimus 
 
Sirolimus Dosing 
 
For adults, sirolimus will be administered at 12 mg orally loading 
dose on day –3, followed by 4 mg orally single morning daily dose 
(target serum level 3-12 ng/ml by HPLC). For Pediatric patients 
<40 kg, sirolimus will be administered at 3 mg/m2 orally on day –
3, followed by 1 mg/m2 orally single morning daily dose. Dosing 
of sirolimus will be based on adjusted ideal body weight. If actual 
body weight is less than ideal body weight, actual body weight will 
be used. 
 
Sirolimus Dose Modifications 
 
Dose adjustments are based on clinical toxicity, blood levels, 
GVHD and clinical judgement involving the rate of rise or decline 
of the serum level.  For levels <3 ng/mL, it is suggested that the 
dose be increased by approximately 25% increments no more 
frequently than every 2 days, rounded to the nearest full milligram 
until the target range is achieved. Conversely, for levels >12 
ng/mL, it is suggested that the dose be decreased by approximately 
25% no more frequently than every 2 days until the target level is 
achieved.  If vomiting occurs within 20 minutes of administration 
the dose should be repeated. Anti-nausea medication may be given 
as needed. Sirolimus treatment may be discontinued or 
interrupted at any time for patient refusal to continue treatment or 
drug related SAE. The most serious reported SAE’s from sirolimus 
in previous clinical studies after HSCT included hyperlipidemia, 
hypertension, rash, thrombocytopenia, leukopenia, arthralgias, 
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diarrhea and HUS. For management of cytopenias, it is 
recommended that patients receive growth factors or transfusions if 
necessary. For patients with HUS, sirolimus should be adjusted to 
maintain therapeutic levels; discontinuation of tacrolimus is 
recommended in this setting, particularly for cases requiring 
hemodialysis, seizures or severe hemolysis. No dose modification 
is recommended for hyperlipidemia; lipid-lowering agents should 
be instituted, with careful attention to the occurrence of 
rhabdomyolysis when HMGCoA reductase inhibitors are used. 
Sirolimus may be re-instituted if, in the judgment of the 
investigator, the primary clinical cause(s) for dose adjustment have 
been resolved.  
 
Sirolimus treatment may also be interrupted for inability to 
swallow due to stomatitis; for patients with severe stomatitis who 
may not be able to resume oral intake in several days, 
mycophenolate mofetil (MMF) should be started as GVHD 
prophylaxis, at a dose of 15 mg/kg intravenously twice a day, until 
oral intake resumes, when sirolimus may substitute MMF.  
  
Sirolimus should be adjusted for hepatic impairment, as follows: 
for bilirubin >2.0, reduce maintenance dose by 30%. 
 
Sirolimus Serum Levels 
 
Sirolimus trough levels should be measured at least weekly during 
the first 50 days post transplant. Levels of 3-12 ng/ml are 
considered therapeutic. Trough levels should be measured 20-24 
hours after the last dose. 
 
Drug Interactions 
 
Sirolimus is a substrate for both cytochrome CYP3A4 and P-
glycoprotein. Simultaneous administration with cyclosporine 
capsules  
 
 
 
 
 
Methotrexate 
 
  
 
Day +1 
5 mg/m2 IV starting 24 hours after the HSC infusion is 
complete 
 
 
Day +3 
5 mg/m2 IV starting 72 hours after the HSC infusion is            
complete 
  
 
Day +6 
5 mg/m2 IV 
  
 
 
  
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8.4 
Treatment of GVHD  
 
 
 
 Diagnosis of Acute GVHD.  Acute GVHD generally develops at time of 
engraftment or within the first three months after marrow transplantation.  
It is a clinicopathological syndrome involving the skin, the liver, and the 
gut. Serial biopsies and observations are used to help establish the 
diagnosis and severity of GVHD.  The clinical appearance of skin GVHD 
can be mimicked by toxicity of the conditioning regimen and by drug 
reactions; therefore, documentation by skin biopsy should be performed 
when possible.  Hepatic GVHD cannot be assessed solely on clinical 
grounds in patients who have concurrent drug toxicity, viral hepatitis, or 
toxicity caused by the conditioning regimen, and liver biopsy is helpful 
when possible.  Gastrointestinal GVHD can be difficult to distinguish 
from infectious enteritis, and endoscopic biopsy should be done whenever 
possible.  Appendix D presents a commonly used staging and grading 
system for acute GVHD.  
 
 
 
 Indications for Initial Treatment of Acute GVHD.  In general treatment for 
GVHD should be started when Grade II GVHD criteria have been met.  
Grade II GVHD is moderately severe disease and usually consists of 
multiorgan disease.  The decision to treat is based on the clinical 
assessment of the patient’s condition, the onset time relative to the day of 
transplant, and the rapidity with which symptoms progress.   
 
Agents to be Used for Initial Treatment of Acute GVHD.  Acute GVHD 
should 
be 
treated 
with 
a 
corticosteroid-containing 
regimen.  
Methylprednisolone can be administered at a dose of at least 1 mg/kg body 
weight every 12 hours for 10-12 days.  Tapering should begin between 10-
20 days after starting initial treatment; the tapering of steroids can be 
determined by the institution. 
 
New investigational agents for treatment of GVHD may become available; 
patients on this study are not routinely allowed to participate on other 
studies of drugs being evaluated for GVHD prophylaxis.   
 
Patients who have received both methylprednisone  and cyclosporine and 
have failed to respond may be treated with salvage regimens per 
institutional protocols.  Salvage regimens may include antithymocyte 
globulin, anti-T cell antibodies, or psoralen and ultraviolet A irradiation 
(PUVA).  
 
 
 
 Diagnosis of Chronic GVHD.  Manifestations of chronic GVHD typically 
do not occur until one to three months after marrow transplantation. The 
clinico-pathological classification of chronic GVHD is shown is Appendix 
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chronic GVHD.  Biopsies of the liver are recommended for patients who 
present with abnormal liver function tests in the absence of overt 
involvement of the skin, eyes, or mouth.  Endoscopy and biopsy is 
recommended to establish gut involvement. 
 
 
 
 Agents to be used for Treatment of Chronic GVHD.  Patients diagnosed 
with extensive chronic GVHD should be treated for 9-12 months with 
cyclosporine and prednisone per institutional protocol.  Suggested dosages 
are prednisone at a dose of 1 mg/kg/day given as an oral dose in the 
morning.  Cyclosporine may be administered at 6 mg/kg orally twice a 
day.  FK-506 may be used instead of CSA .  Thalidomide may also be 
used as allowed by FDA-reviewed protocols. 
 
 
8.5 
Use of Growth Factors.   
 
Growth factors will not be used for 14 days post-transplant.  After 14 days 
growth factor therapy may be administered at the discretion of the primary 
hematologist to patients with confirmed fungal infections or patients with 
systemic toxicities attributable to suspected or confirmed bacterial 
infections.   
 
8.6 
Graft Failure 
 
 
Patients who have not engrafted by day 21 should undergo a bone marrow 
biopsy and aspirate, and chimerism studies should be performed. If the 
marrow cellularity is less than 5%, growth factor (G-CSF or GM-CSF) 
should be used.  If there is no response in 7 subsequent days, graft failure is 
diagnosed.   
 
8.7 
Supportive Care  
 
Patients will receive transfusions of blood products (platelets, RBC), 
antimicrobial drugs, nutritional support and other supportive measures as 
determined by their needs and according to the accepted standards of 
competent medical care.  Patients should be given prophylaxis for 
Pneumocystis carinii, Herpes simplex, and fungal infections, administered 
according to institutional guidelines.  HIV negative and hepatitis Bs Ag 
negative blood products (as determined by currently available serologic 
testing) will be used at all times.  All blood products will be irradiated 
(>1500cGy) to circumvent the risk of GVHD caused by contaminating 
lymphocytes in the transfused fractions.  Standard blood bank procedures 
should be followed to decrease the risk of CMV exposure in patients who 
are CMV seronegative.   
 
8.8 
Relapse  
 
 
 
 
 

 
 
 
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 Donor lymphocytes will be allowed to treat documented relapse, including 
molecular and cytogenetic relapse.  
 
9.0 
PATIENT  EVALUATIONS 
 
 
Donor and recipient data will be collected and maintained by the NMDP 
according to their usual procedures.  
 
9.1 
Baseline Donor Data  
 
Baseline donor evaluation will be per NMDP criteria. HLA typing should 
be by high resolution molecular methods for both HLA-A,-B,-C, DRB1 
and DQB1 alleles.   
 
9.2 
Baseline Recipient Data  
a. 
documentation of  diagnosis and risk assignment  
b. 
complete history and physical exam, performance status, height, 
weight, and all prior treatments 
c. 
CBC, platelet, differential 
d. 
complete ABO, Rh, and HLA typing; HLA typing should be by high 
resolution molecular methods for both  HLA-A,-B,-C, DRB1 and 
DQB1 alleles. 
e. 
cardiac, hepatic, renal and pulmonary function results 
 
 
f. 
chest and other x-rays as clinically indicated 
g. 
coagulation profile (PT, PTT) 
h. 
chemistries not limited to but must include TSP, albumin, SGOT, 
SGPT, LDH, alkaline phosphatase, total bilirubin, Ca++, Phos, Mg, 
uric acid, glucose, BUN, creatinine 
i. 
viral screen, including CMV, HIV, hepatitis B and C 
j. 
unique marker studies for use to assess chimerism 
 
9.3 
 PBSC  
 
Data collected will include the following: 
 
9.3.1 
Apheresis product  
 
 
a. 
total nucleated cell count  
 
 
b. 
FACS analysis for enumeration of CD34+ and T cells 
 
 
c. 
sterility and viability 
 
9.4 
Preparative Cytoreduction and Transplantation  
 
9.4.1 
Pre-administration of chemotherapy/radiation therapy  
a. 
CBC, differential, platelet 
b. 
chemistries not limited to but must include TSP, albumin, 
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indirect bilirubin, Ca++, Phos, Mg, uric acid, glucose, BUN, 
creatinine 
 
9.4.2 
During cytoreductive therapy  
a. 
vital signs daily 
b. 
toxicities 
 
9.4.3 
Following completion of cytoreductive therapy  until 
engraftment is documented. 
 
 
a. 
CBC, platelet, daily until WBC>500/µL  
 
 
b. 
vital signs daily 
 
 
c. 
adverse experience reporting 
 
9.4.4 
Immediately following infusion of PBSC 
a. 
vital signs (BP, pulse, temperature) 
b. 
adverse experience reporting 
 
9.4.5 
Daily until hospital discharge - toxicities 
 
 
 
9.4.6 
Weekly until hospital discharge 
a. 
chemistries  
b. 
cyclosporine/prograf  levels 
c. 
infection assessments 
d. 
GVHD summary - grades II-IV acute GVHD should be 
biopsy documented 
 
9.4.7 
Thirty days post-transplant  
a. 
CBC, platelet, differential 
b. 
chemistries  
c. 
disease status assessment  
d. 
GVHD assessment, including treatment summary 
e. 
toxicities and adverse events including infection assessment 
f. 
transfusion assessments (packed RBC, platelets) 
g. 
brief physical exam, performance status 
h. 
days in hospital, day ANC 500, and 1000/µL, and day 
platelets  20,000 and 50,000/µL 
i. 
assessment of chimerism 
j. 
Bone marrow aspiration and biopsy to document remission 
for those with bone marrow involvement at transplant 
 
9.4.8 
Follow-up at three and six months post-transplant  
 
 
a. 
disease status 
 
 
b. 
CBC, platelet 
 
 
c. 
date platelet recovery > 100,000/µL 
d. 
hospitalizations 
e. 
GVHD assessment, including treatment summary 
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f. 
adverse experiences, toxicities & infection 
g 
performance status 
h 
assessment of chimerism 
i. 
bone marrow for CML, relapsed leukemia patients, or those 
with bone marrow involvement at SCT 
 
9.4.9 
Follow-up every 6 months for 2 years and then yearly after that 
until death. 
a. 
disease assessment 
b. 
GVHD assessment, including treatment summary 
c. 
assessment of chimerism at 6 months; if > 90% are of 
donor origin, additional evaluations not required unless 
relapse. 
d. 
CBC, platelet, differential 
e.  hospitalizations 
f. 
adverse events & infection 
g. 
Bone marrow aspiration and biopsy at one year after 
transplant 
 
10.0 
ASSESSMENTS 
 
Patient evaluations will be directed toward the acquisition of data addressing the 
primary and secondary objectives of the study. 
 
10.1 
Primary Objectives 
 
10.1.1 
Engraftment will be monitored by measuring the duration and 
extent of myelosuppression as shown by the days until ANC 
recovery (500, 1000/µL) and unmaintained platelet recovery 
(20,000; 50,000; and 100,000/µL).  The primary engraftment 
endpoint is defined as the first of three consecutive days on 
which the absolute neutrophil count is > 500/µL.  
 
 
 
Failure to engraft will be defined as either (a) ANC consistently 
<500/µL in patients who survive for at least 21 days after 
transplant with marrow aplasia (cellularity < 5% at day 21), and 
who do not respond to 7 subsequent days of growth factor 
(primary graft failure, day 28), or (2) documented engraftment 
followed by severe neutropenia (ANC <300/µL), marrow aplasia 
(<5% cellularity) or absence of donor cells in the marrow or 
blood as demonstrated by a chimerism assay, without subsequent 
improvement occurring either spontaneously or after growth 
factor by Day 180 post-transplant (secondary graft failure). 
 
 
Patients who are deceased prior to day 28 post-transplant will be 
considered inevaluable for engraftment failure. 
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10.1.2  
Acute GVHD will be summarized weekly after transplant while 
the patients are in hospital and at each follow-up visit.  Clinical 
observations including the existence of a skin rash, diarrhea and 
jaundice will be recorded.  Evidence of grade II-IV GVHD will 
be documented by biopsy, if feasible. Use of drugs to treat 
GVHD and increase in dosages of drugs will be recorded.  
Chronic GVHD will be graded at each follow-up visit until day 
180, and then every six months for two years.  
 
10.2 
Toxicities and side effects which will be evaluated include, but are not 
limited to, veno-occlusive disease, infections, renal toxicity, hepatic 
toxicity, and pulmonary toxicity.  Methods of assessment will include 
monitoring blood chemistries, including peak serum bilirubin and 
creatinine levels, the incidence and severity of infectious complications, 
the incidence and severity of adverse events, including veno-occlusive 
disease, the requirements for transfusion products and causes of treatment 
failures.  All grade III and IV non-hematological adverse events and all 
infectious episodes will be graded and documented. Toxicities will be 
recorded up to day 100 post transplant.  Hepatic, pulmonary, and renal 
toxicities and infectious disease episodes will be summarized at the three 
and six month follow-ups.   
 
Disease free survival will be monitored for two years post-transplant. New 
malignancy, lymphoproliferative or myeloproliferative disorders will be 
recorded.  
 
11.0 
ADVERSE EVENT REPORTING 
 
This study will utilize the CTC (NCI Common Toxicity Criteria) Version 2.0 for 
toxicity and adverse event reporting.  A copy of the CTC Version 2.0 can be 
downloaded from the CTEP web site (http://ctep.cancer.gov).    
 
Definition of Adverse Events (AE): 
An AE is defined as any untoward medical occurrence in a patient after 
administration of a study drug and/or procedure.  An AE does not necessarily 
have a causal relationship with the use of a study drug and/or procedure.  An AE 
can therefore be any unintended sign (including an abnormal laboratory finding), 
symptom, or disease temporarily associated with the use of a study drug and/or 
procedure, whether or not related to the study drug and /or procedure.  Attempt 
will be made to distinguish AEs that are probably the result of GVHD versus AEs 
that are possibly or probably related to study drugs and/or procedures. 
 
Attribution Categories: 
Definite-  
The adverse event is clearly related to the treatment 
Probable- 
The adverse event is likely related to the treatment 
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Possible- 
The adverse event may be related to the treatment 
Unlikely- 
The adverse event is doubtfully related to the treatment 
Unrelated- 
The adverse event is clearly NOT related to the treatment 
 
Definition of Serious Adverse Event (SAE): 
For reporting purposes, a serious adverse event (SAE) is any adverse event (AE) 
that is: 
a) 
life threatening,  
b) 
results in death,  
c) 
requires hospitalization or prolongs an existing hospitalization,  
d) 
results in persistent or significant disability,  
e) 
causes a congenital birth defect,  
f) 
causes cancer, or  
g) 
is the result of a dosing error  
h) 
certain medical events that may not result in death, be life-threatening, or 
require hospitalization, may also be considered a serious adverse event when 
medical or surgical intervention is necessary to prevent one of the outcomes listed 
above, as determined by appropriately trained personnel. 
 
An SAE occurring in this study which meets the above definitions and is > grade 
3 and possibly, probably, or definitely related to the study procedure, or > grade 4 
regardless of the attribution must be reported until day 100. 
 
SAE expedited reporting is not required for hematologic AEs or < G3 AEs due to 
the following transplant procedure-related morbidities; nausea and vomiting, 
diarrhea, mucositis, hemorrhagic cystitis, hepatitis, or graft versus host disease in 
its various organ manifestations. 
 
Serious Adverse Event (SAE) Reporting:  All reports of SAEs occurring in City 
of Hope subjects must include a completed City of Hope Adverse event Report 
(COH AER) form (http://resadmin.coh.org/doc/irb3820.doc) that contains a 
narrative describing the event.   
 
12.0 
STATISTICAL CONSIDERATIONS 
 
  
Patients receiving myeloablative therapy will be evaluated separately from the 
patients receiving reduced-intensity myeloablative therapy. The main objective is 
the estimation of the incidence of engraftment failure. The secondary objectives 
include evaluating toxicities, the rate of acute and chronic GVHD and relapse-free 
survival.  
 
12.1  
One hundred and thirty patients in each subgroup are sufficient to estimate 
the failure to engraft rate to within 9% (95% CI), and provide 80% power 
to detect an engraftment failure rate less than 10%, when the true failure 
rate is less than 5% (χ2-test).   There is less than a 10% one-sided 
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probability of concluding  the failure rate is less than 10% when the true 
failure rate is 10% (1-sided α=0.1). 
 
12.2  
The accrual rate to this study is expected to be approximately 40 patients 
per year, with a 1:1 ratio between the myeloablative and reduced-intensity 
myeloablative regimens. The expected length of accrual is 6.5 years. 
 
12.3  
With 130 evaluable patients in each group, any toxicity occurring with at 
least a 4% probability is likely to be seen at least once (99% probability). 
 
12.4  
Survival will be calculated from date of transplant. Relapse-free, disease-
free, and overall survival will 
 
be estimated using Kaplan-Meier statistics.  
 
13.0 
ADMINISTRATIVE CONSIDERATIONS 
 
13.1 
Adverse Experiences  
 
Serious adverse events (SAE) must be recorded and reported to the COH 
IRB and DSMB by the Investigator. A full report, including clear 
photocopies of hospital records, consultants' reports, autopsy findings here 
appropriate, and a summary of the outcome of the reaction by the 
investigator. 
 
13.2 
Criteria for Removal from Study  
 
13.2.1 
Death 
 
 
13.2.2 
Patient refused to continue 
 
13.2.3 
Grade 4 non-hematologic toxicity related to the administration of 
cells. 
 
13.2.4 
Impression or opinion of principal investigator that continuation 
is not in the best interest of the patient. 
 
13.3 
Institutional Review  
 
Prior to implementation of this study, the research protocol and the 
proposed patient consent form must be reviewed and approved by a 
properly constituted Institutional Review Committee. 
 
13.4 
Informed Consent  
 
Written consent will be obtained from each patient prior to entering the 
trial and will become part of the patient's permanent study record.  Each 
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patient will be assured that study participation is voluntary and that 
he/she may withdraw at any time, without penalty. 
 
At the time of obtaining written consent, the investigator will advise 
patients of the experimental nature of the study, the duration of the trial, 
alternate modes of treatment, and prevalent adverse reactions, which 
might occur.  The patient's signature is to be witnessed.  Parents or legal 
guardians of minor donors/recipients must provide fully informed consent 
for their children. 
 
14.0 
WOMEN AND MINORITIES GUIDELINES 
 
All eligible patients from both genders and from all racial/ethnic groups will be 
recruited equally  into this trial, with the only exclusionary criteria being those 
stated in Section 5.0.  Based on our patient populations and previous experience 
with BMT for advanced hematological malignancies, the anticipated rates of entry 
into this study by gender and race/ethnicity are as follows:  
 
Race/Ethnicity by Gender for Advanced Malignancy Patients  
 
Receiving BMT at City of Hope 
 
American 
Indian or 
Alaskan 
Native 
Asian or 
Pacific 
Islander 
Black, not of 
Hispanic 
Origin 
Hispanic 
White, not 
of Hispanic 
Origin 
Other or 
unknown 
Female 
0% 
8% 
1% 
32% 
58% 
1% 
Male 
<1% 
8% 
3% 
33% 
54% 
3% 
Total 
<1% 
8% 
2% 
33% 
55% 
2% 
 

 
 
 
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15.0 
 REFERENCES 
 
 (1)  Bensinger WI, Price TH, Dale CD, et al. The effects of daily recombinant human 
granulocyte colony stimulating factor administration on npormal granulocyte 
donors undergoing leukapheresis. Blood 1993; 81:1883. 
 (2)  Bensinger W, Martin PJ, Storer B,  et al. Transplantation of bone marrow as 
compared with peripheral blood cells from HLA-identical relatives in patients with 
hematologic cancers. N Engl J Med 2001; 344:175-181. 
 (3)  Sierra J, Storer B, Hansen JA, et al. transplantation of marrow cells from unrelated 
donors for treatment of high-risk acute leukemia: The effect of leukemic 
burden,donor HLA matching, and marrow cell dose. Blood 1997; 89:4226-4235. 
 (4)  Ottinger HD, Beelen DW, Scheulen B, et al. Improved immune reconstitution after 
allotransplantation of peripheral blood stem cells instead of bone marrow. Blood 
1996; 88:2775-2779. 
 (5)  Dreger P, Haferlach T, Eckstein V, et.al. G-CSF mobilized peripheral blood 
progenitor cells for allogeneic transplantation: safety, kinetics of mobilization, and 
composition of the graft. Br J Haematol 1994; 87:609. 
 (6)  Lane TA, Law P, Maruyama M, Young D, et.al. Harvesting and enrichment of 
hematopoietic progenitor cells mobilized into the peripheral blood of normal donors 
by granulocyte-macrophage colony-stimulating factor (GM-CSF) or G-CSF: 
potential role in allogeneic marrow transplantation. Blood 1995; 85:275. 
 (7)  Schmitz N, Dreger P, Suttorp M,  et.al. Primary transplantation of allogeneic 
peripheral blood progenitor cells mobilized by filgrastim (granulocyte colony-
stimulating factor). Blood 1995; 85:1666. 
 (8)  Urbano-Ispizua A, Solano C, Brunet S, et.al. Allogeneic peripheral blood progenitor 
cell transplantation: analysis of short-term engraftment and acute GVHD incidence 
in 33 cases. Bone Marrow Transplant 1996; 18:35. 
 (9)  Brown RA, Adkins D, Goodnough LT, et.al. Factors that influence the collection 
and engraftment of allogeneic peripheral blood stem cells in patients with 
hematologic malignancies. J Clin Oncol 1997; 15:3067. 
(10)  Bensinger W, Weaver C, Appelbaum FR, et.al. Transplantation of allogeneic 
peripheral blood stem cells mobilized by recombinant human granulocyte colony-
stimulating factor. Blood 1995; 85:1655. 
(11)  Brown RA, Adkins D, Khoury H, et.al. Long-term follow-up of high-risk allogeneic 
peripheral blood stem cell transplant recipients: Graft-versus-host disease and 
transplant-related mortality. J Clin Oncol 1999; 17:806. 

 
 
 
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(12)  Chao NJ, Schmidt G, Niland JC, Amylon MD, et.al. Cyclosporine,methotrexate,and 
prednisone compared with cyclosporine and prednisone for prophylaxis of acute 
graft-versus-host disease. N Engl J Med 1993; 329:1225. 
(13) Nash RA, Etzioni R, Storb R, et al. tacrolimus (FK506) alone or in combination 
with methotrexate or methylprednisolone for the prevention of acute graft-versus-
host disease after marrow transplantation from HLA-matched siblings: A single-
center study. Blood 85, 3746. 1995.  
 
(14) Ratanatharathorn V, Nash RA, Przepiorka D, et al. Phase III study comparing 
methotrexate and tacrolimus (Prograf,FK506) with methotrexate and cyclosporine 
for graft-versus-host disease prophylaxis after HLA identical sibling bone marrow 
transplantation. Blood 92, 2303-2314. 10-1-1998.  
 
(15) Nash RA, Antin J, Karanes C, Fay JW, et al. Phase III study comparing tacrolimus 
(FK506) with cyclosporine (CSP) for prophylaxis of acute graft-versus-host disease 
(GVHD) after marrow transplantation from unrelated donors. Blood (Suppl) 90, 
561a. 1997.  
(16) Yu C, Siedel K, Nash RA, Deeg HJ, et al. Synergism between mycophenolate 
mofetil and cyclosporine in preventing graft-versus-host disease among lethally 
irradiated dog given DLA-nonidentical unrelated marrow grafts. Blood 1998; 
91:2581-2587. 
(17)  Bornhauser M, Schuler U, Porksen G, et al. Mycophenolate mofetil and 
cyclosporine as graft-versus-host isease prophylaxis after allogeneic blood stem cell 
transplantion. Transplantation 1999; 67:499-504. 
(18)  Bensinger WI, Clift R, Martin P,  et al. Allogeneic peripheral blood stem cell 
transplantation in patients with advanced hematologic malignancies: A 
retrospective comparison with marrow transplantation. Blood 1996; 88:2794-2800. 
(19)  Schmitz N, Bacigalupo A, Hasenclever D, et.al. Allogeneic bone marrow 
transplantation vs. filgrastim-mobilised peripheral blood progenitor cell 
transplantation in patients with early leukemia: first results of a randomized 
multicenter trial of the European Group for Blood and Marrow transplantation. 
Bone Marrow Transplant 1998; 21:995. 
(20)  Champlin RE, Schmidt N, Horowitz MM,  et al. Blood stem cells compared with 
bone marrow as a source of hematopoietic cells fo allogeneic transplantation. Blood 
2000; 95:3702-3709. 
(21)  Davies SM, Kollman C, Anasetti C,  et al. Engraftment and survival after unrelated-
donor bone marrow transplantation: a report from the National Marrow Donor 
program. Blood 2000; 96:4096-4102. 

 
 
 
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(22) McGlave PB, Shu XO, Wen W,  et al. Unrelated donor marrow transplantation for 
chronic myelogenous leukemia: 9 years' experience of the National Marrow Donor 
Program. Blood 95, 2219-2225. 4-1-2000.  
 
(23) Ringden O, Runde V, Hagglund H, et al. Transplantation of peripheral blood 
progenitor cells from unrelated donors. Transplantation 1998; 66:142-143. 
(24)  Ringden O, Remberger M, Runde V,  et al. Faster engraftment of neutrophils and 
platelets with peripheral blood stem cells from unrelated donors: A comparison with 
marrow transplantation. Bone Marrow Transplant 2000; 26 Suppl 2:S6-S8. 
(25)  Anasetti C, Amos D, Beatty PG, et al. Effect of HLA Compatibility on Engraftment 
of Bone Marrow Transplants in Patients with Leukemia or Lymphoma. N Engl J 
Med 1989; 320:197-204. 
(26)  Petersdorf EW, Longton GM, Anasetti C, et.al. Association of HLA-0C disparity 
with graft failure after marrow transplantation from unrelated donors. Blood 1997; 
89:1818-21823. 
(27)  Beatty PG, Clift RA, Mickelson EM, et al. Marrow transplantation from related 
donors other than HLA-identical siblings. N Engl J Med 1985; 313:765-771. 
(28)  Servida P, Gooley T, Hansen JA, et.al. Improved survival of haploidentical related 
donor marrow transplants mismatched for HLA-A or B versus HLA-DR. Blood 
(Suppl) 88, 484a. 1996.  
 
(29)  Kernan NA, Bartsch G, Ash RC, et al. Analysis of 462 transplantations from 
unrelated donors facilitated by the National marrow donor program. N Engl J Med 
1993; 328:593-602. 
(30)  Petersdorf EW, Longton GM, Anasetti C,  et al. The significance of HLA-DRB1 
matching on clinical outcome after HLA-A,B,DR identical unrelated donor marrow 
transplantation. Blood 1995; 86:1606-1613. 
(31) Petersdorf EW, Mickelson EM, Anasetti C, et al. Effect of HLA mismatcjes on the 
outcome of hematopoietic transplants. Curr Opin Immunol 1999; 11:521-526. 
(32) Sasazuki T, Juji T, Morishima Y, et.al. Effect ofmatching of class I HLA alleles on 
clinical outcome after transplantation of hematopoietic stem cells from an unrelated 
donor. The New England Journal of Medicine 339, 1177-1185. 1998.  
 
 
 

 
 
 
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APPENDICES 
 
A 
Pharmaceutical Information 
B 
Methotrexate and Cyclosporine Dose Modification Guidelines 
C 
Total Body Irradiation 
D 
GVHD Assessment 
E 
Performance Status 
F 
Study Calendar 
G 
IV Busulfan Kinetics 
H 
CTC Version 2.0 

 
 
 
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APPENDIX A 
 
 
PHARMACEUTICAL INFORMATION  
 
 
1.0 
G-CSF (NEUPOGEN®) 
 
 
 
GENERAL: 
 
 
 Recombinant 
Human 
Granulocyte 
Colony 
Stimulating 
Factor 
(rHu-G-CSF, E. coli./CSF, Neupogen®, Amgen, Thousand Oaks, CA) is 
a growth factor that stimulates proliferation and differentiation of 
committed granulocytic progenitor cells and enhances the number of 
circulating progenitor cells.   
 
 
 
ADMINISTRATION: 
 
 
 G-CSF is available in single use vials of preservative-free solution 
containing 300 mg/mL of material (1 mL vial = 300 mg and 1.6 mL vial 
= 480mg).  The donor will receive G-
subcutaneous injection for 5-10 days with day 5 being the first day of 
leukapheresis.    
 
 
 
TOXICITY: 
 
 
 The major expected toxicity is bone pain which can be treated 
successfully with analgesics.  Fever, flu-like symptoms, pleuritis, 
pericarditis and other systemic reactions may occur with G-CSF, usually 
at high dosages.  Reversible and mild elevation in uric acid, LDH, 
alkaline phosphatase have been noted.  Transient decreases in blood 
pressure, not requiring treatment were noted in 4% of patients in one trial 
of G-CSF.  Allergic toxicities have rarely been observed, at a rate of 
approximately one in one hundred thousand administrations. 
 
2.0 
TOTAL BODY IRRADIATION 
 
 
TOXICITIES: 
 
 
 Gastrointestinal: virtually all patients will experience nausea and 
vomiting after irradiation.  This can be diminished somewhat with 
antiemetics.  Most patients develop some diarrhea in the first week post 
irradiation.  This can be treated symptomatically 
 
 
 Parotitis: some patients will experience symptomatic parotitis within the 
first 24 hours post irradiation.  This resolves spontaneously over several 
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 Fever:  significant fever (greater 
irradiation.  This can be treated symptomatically. 
 
 
 Skin: erythema may occur in patients within 24 hours and resolve in 2-3 
days. Most patients will get some degree of hyperpigmentation within 2-3 
weeks of transplantation. 
 
Mucositis - most patients will develop moderate to severe mucositis of the 
oral and GI tracts, which will be managed with aggressive nursing mouth 
care and prophylactic antifungal and antiviral agents. 
 
 
 LATE EFFECTS:  
 
 
 There is the possibility of cataract formation.  Although mild cataracts 
may occur in up to 30-50% of cases with single dose TBI, cataracts have 
been seen in <10% of patients treated with hyperfractionated TBI. 
 
 
 There is a possibility that secondary malignancies may develop, 
particularly due to the combined effects or irradiation and an alkylating 
agent (cyclophosphamide).  Lung fibrosis may also develop from 
frequent use of chemotherapy and irradiation. 
 
 
 Sterility may result following total body irradiation and administration of 
alkylating chemotherapy (cyclophosphamide); the risk increases with the 
number of years since puberty. 
 
 
 Hypothyroidism has been reported in small numbers of adults routinely 
monitored post transplant with hormonal replacement as indicated. 
 
3.0 
CYCLOPHOSPHAMIDE (CYTOXAN®, NEOSAR®) 
 
 
 
GENERAL: 
 
 
 Cyclophosphamide is a synthetic antineoplastic drug chemically related 
to the nitrogen mustards.  It is biotransformed principally in the liver to 
active alkylating metabolites.  These metabolites interfere with the 
growth of susceptible rapidly proliferating malignant cells.  The 
mechanism of action is thought to involve cross-linking of DNA.  It is 
eliminated primarily in the form of metabolites, but from 5-25% of the 
drug is excreted in the urine unchanged.   
 
 
ADMINISTRATION: 
 
 
 Lyophilized cyclophosphamide (Cytoxan™) for injection contains 75 mg 
mannitol per 100 mg cyclophosphamide (anhydrous) and is supplied in 

 
 
 
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vials for single-dose use (100, 200 and 500 mg vials).  It should be 
reconstituted by adding Sterile Water for Injection, USP, to the vial and 
shaking to dissolve.   
 
 
 
TOXICITIES: 
 
 
 Hematologic: 
myelosuppression 
[leukopenia 
(nadir 
8-14 
days), 
thrombocytopenia, anemia].  Hematocrit decrements out of proportion to 
cessation of production will occur at this dose, presumably due to 
hemolysis. 
 
 
 Urinary: hemorrhagic cystitis (patients must be well hydrated before, 
during, and after treatment and have adequate renal function).  Hematuria 
is not uncommon at this dose but is usually not symptomatic or severe 
unless there is inadequate diuresis.  An occasional patient will get severe 
cystitis despite adequate urine flow.  Pyridium and/or continuous bladder 
irrigation will give symptomatic relief. 
 
 
 Gastrointestinal: nausea, vomiting, anorexia and, less frequently, 
abdominal discomfort or pain and diarrhea may occur.  Variable 
combinations of antiemetics usually provide significant symptomatic 
relief. 
 
 
 Cardiac: cardiotoxicity has been observed in patients receiving high 
doses of cyclophosphamide.  At doses greater than 7.6 g/m2, clinical heart 
failure and fatal cardiac necrosis have been observed.   
 
 
 Fluid retention: Cyclophosphamide has an anti-diuretic effect usually 
counteracted 
by 
furosemide 
administration. 
 
Careful 
physical 
examination should be made and accurate weights should be determined 
to detect fluid overload early. 
 
 
 Pulmonary: High dose cyclophosphamide is associated with significant 
pulmonary toxicity characterized by dyspnea, decreased pO2, pulmonary 
infiltrates and occasional effusions.  This can be prevented and/or 
reversed by use of corticosteroids. 
 
 
 Skin: Alopecia occurs commonly and is reversible.  Hair may be different 
in texture or color.  Skin rash occurs occasionally, and pigmentation of 
the skin and changes in nails can occur. 
 
 
 Other: sterile phlebitis, gonadal abnormalities, teratogenicity.  With too 
rapid IV push, oropharyngeal tingling, "metallic" taste, headache, 
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4.0 
BUSULFAN (MYLERAN) 
 
 
 
MECHANISM OF ACTION:   
 
Busulfan is a bifunctional alkylating agent.  In aqueous media, busulfan 
hydrolyses to produce reactive carbonium ions that can alkylate DNA. 
 
Formulation and stability:  Busulfan injection is a sterile, pyrogen-free 
solution provided in a mixture of dimethylacetamide (DMA) and 
polyethlyeneglycol 400 (PEG 400).  It is supplied in 10-ml single use 
ampules at a concentration of 6-mg Busulfan per ml.  Each ampule 
contains 60mg of Busulfan in 3.3 ml of DMA and 6.7 ml of PEG 400.  
When diluted in normal saline or D5W to a concentration of 0.5mg/mL, 
the resulting solution must be administered within eight (8) hours of 
preparation; including the 2 hours of infusion of the drug. 
 
Stable at 4º C for at least twelve months.  Ampules should be stored 
refrigerated at 2-8º C.  Do not freeze.  Ampules may be stored for up to 
seven days at room temperature. 
 
 
  
Solution preparation: prepare the Busulfan solution as follows: Use sterile, 
non-pyrogenic, disposable containers, syringes, needles, stopcocks, and 
transfer tubing, etc.  Calculate the amount of drug to be administrated 
based on the dosage and the patient’s body weight. 
 
 
  
 
Prepare a solution of 0.9% sodium chloride injection USP (normal saline) 
calculated Busulfan dose in ml from the step above. 
 
 
  
 
Break off the top of the ampule and remove the calculated volume of 
Busulfan from the container by using a syringe fitted with a filter needle 
or equivalent.  Transfer the contents of the syringe into the calculated 
amount of either normal saline or D5W making sure that the drug flows 
into and through the solution.  Mix by inverting the bag. 
 
ADMINISTRATION: 
 
Each dose of the drug will be given by slow central intravenous infusion 
over 2 hours.  Caution: Do not administer as an intravenous push or bolus. 
 
 
SUPPLIER: 
 
This drug is commercially available; manufactured by Orphan Medical 
Inc. 
 
TOXICITIES: 
 

 
 
 
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Toxicity from busulfan includes: 
a). 
Severe bone marrow hypoplasia, which would be fatal 
without administration of bone marrow, stem cells. 
b). 
Nausea and vomiting which can be decreased by the use 
of sedation and anti-emetics. 
c). 
Stomatitis 
and 
diarrhea 
which 
can 
be 
treated 
symptomatically with fluid replacement and atropine or 
diphenoxylate  H C1. 
d). 
Pulmonary fibrosis characterized by delayed onset of 
cough, shortness of breath and low-grade fever. 
e). 
Hepatic damage, which can occur in combination with 
cytoxan or as a single agent and can result in significant 
hepatic toxicity which, can be fatal. 
f). 
Temporary hyperpigmentation of the skin and nail bed 
changes. 
g). 
Grand mal seizures which can be prevented by the 
prophylactic administration of Dilantin. 
 
5.0 
MELPHALAN  (L-phenylalanine mustard, L-PAM, Alkeran) 
 
FORMULATION:  
 
Melphalan is supplied as a freeze-dried powder. Each single-use vial  
contains melphalan hydrochloride equivalent to 50mg of melphalan and 
20mg povidone. Reconstitute with the sterile diluent provided.  Each vial 
of diluent contains sodium citrate 0.2g, propylene glycol 6ml, ethanol 
(96%) 0.52ml and water for injection to total 10ml. 
 
PREPARATION FOR USE:  
 
Reconstitute each 50ml vial by rapidly injecting 10ml diluent  
provided. Immediately shake vial vigorously until a clear solution is 
obtained. This  provides a 5mg/ml solution. 
 
STORAGE AND STABILITY:  
 
Intact vials are stored at room temperature (15-30C) protected  
from light. Once reconstituted with the diluent provided, the solution is 
chemically and physically stable at room temperature for 90 minutes.  
Melphalan, when reconstituted with the diluent provided and subsequently 
diluted in NS to a concentration of 0.1-0.45mg/ml is chemically and 
physically stable for 60 minutes at room temperature. Do not refrigerate. 
 
ADMINISTRATION:   
 
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central line using doses of 70-200mg/m2 over 2 to 20 minutes. 
 
6.0 
MESNA (NSC-113891) 
 
 
 
MODE OF ACTION: 
 
 
 
Sodium-2-mercapto-ethanesulfonate (Mesna) is a urothelial protectant.  It 
binds to acrolein, the urotoxic metabolite of ifosfamide, and also inhibits 
the breakdown of its 4-hydroxy metabolites.  It is excreted exclusively in 
the urine. 
 
 
 
SUPPLY, RECONSTITUTION AND ADMINISTRATION: 
 
 
 
Mesna is available from Bristol-Meyer Squibb as a l00 mg/ml solution 
(400 mg/4 ml ampule).  It may be administered intravenously by bolus 
an/or continuous infusion. 
 
 
 
TOXICITIES: 
 
 
 
Nausea and vomiting are the only side effects observed with Mesna. 
 
7.0 
METHOTREXATE 
 
 
GENERAL: 
 
 
 Methotrexate is an antimetabolite that binds to dihydrofolic acid 
reductase, thereby preventing the reduction of folic acid to 
tetrahydrofolate.  It interferes with DNA synthesis, repair, and cellular 
replication.  Actively proliferating tissues are in general more sensitive to 
this effect. 
 
 
ADMINISTRATION:  
 
 
 Methotrexate LPF® Sodium (methotrexate sodium injection), Isotonic 
Liquid, Preservative Free, for single use only, is available in 25 mg/mL, 2 
mL, 4 mL, 8 mL, and 10 mL vials, containing 50 mg, 100 mg, 200 mg, 
and 250 mg of methotrexate respectively.  If desired, the solution may be 
further diluted immediately prior to use with an appropriate sterile, 
preservative-free medium. 
 
 
 Methotrexate Sodium for Injection, Freeze Dried, Preservative Free, Low 
Sodium, for single use only, is available in 20 mg, 50 mg, and 1 gram 
vials, containing approximately 0.14, 0.33 and 7 mEq of sodium 
respectively.  Reconstitute immediately prior to use with an appropriate 
sterile, preservative-free medium.     
 

 
 
 
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 Methotrexate Sodium Injection, Isotonic Liquid, Preservative Protected, 
is available in 25 mg/mL, 2 mL (50 mg), and 10 mL (250 mg) vials.  The 
preservative formulation contains benzyl alcohol and must not be used 
for intrathecal or high dose therapy.  If desired, the solution may be 
further diluted with a compatible medium. 
 
 
 TOXICITIES: 
 
 
 Hematologic: myelosuppression [leukopenia (nadir 7 days), thrombo-
cytopenia, anemia].  
 
 
 Hepatic: acute (elevated transaminases) and chronic (fibrosis and 
cirrhosis) hepatic toxicity.  Chronic toxicity has generally occurred after 
prolonged use (generally 2 years or more) and after a total dose of at least 
1.5 grams. 
 
 
 Urogenital: severe nephropathy or renal failure, azotemia, cystitis, 
hematuria; 
defective 
oogenesis 
or 
spermatogenesis, 
transient 
oligospermia, menstrual dysfunction and vaginal discharge; infertility, 
abortion, fetal defects.  Close attention to renal function including 
adequate hydration, and urine alkalinization are essential for safe 
administration.   
 
 
 Gastrointestinal: gingivitis, pharyngitis, stomatitis, anorexia, nausea, 
vomiting, diarrhea, hematemesis, melena, gastrointestinal ulceration and 
bleeding, enteritis.  Should be used with extreme caution in the presence 
of peptic ulcer disease or ulcerative colitis.  Therapy may be discontinued 
if ulcerative stomatitis or other severe GI adverse reactions occur. 
 
 
 Pulmonary: interstitial pneumonitis deaths have been reported, and 
chronic interstitial obstructive pulmonary disease has occasionally 
occurred.  Pulmonary symptoms or a nonspecific pneumonitis may be 
indicative of a potentially dangerous lesion and require interruption of 
treatment and careful investigation; infection needs to be excluded.  This 
lesion can occur at all dosages. 
 
 
 Skin: 
erythematous 
rashes, 
pruritus, 
urticaria, 
photosensitivity, 
pigmentary 
changes, 
alopecia, 
ecchymosis, 
telangiectasia, 
acne, 
furunculosis. 
 
 
 Central Nervous System: headaches, drowsiness, blurred vision.  There 
have been reports of leukoencephalopathy following intravenous 
administration of methotrexate to patients who have had craniospinal 
irradiation.  Aphasia, hemiparesis, paresis, and convulsions have also 
occurred following administration of methotrexate.  Following low doses, 

 
 
 
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occasional patients have reported transient subtle cognitive dysfunction, 
mood alteration, or unusual cranial sensations. 
 
 
 Other: 
opportunistic 
infection, 
arthralgia/myalgia, 
loss 
of  
libido/impotence, diabetes, osteoporosis and sudden death.  A few cases 
of anaphylactoid reactions have been reported. 
 
8.0 
CYCLOSPORINE (SANDIMMUNE® OR EQUIVALENT, NEORAL®) 
 
 
GENERAL: 
 
 
 Cyclosporine is a cyclic polypeptide immunosuppressant agent consisting 
of 11 amino acids.  It is a potent immunosuppressant and has been 
demonstrated to suppress some humoral immunity and to a greater extent, 
cell-mediated reactions such as allograft rejection and GVHD in many 
animal species for a variety of organs. Evidence suggests that the 
effectiveness is due to specific and reversible inhibition of 
immunocompetent lymphocytes in certain phases of the cell cycle; T 
lymphocytes are preferentially inhibited. 
 
ADMINISTRATION: 
 
 
 Sandimmune® Soft Gelatin Capsules are supplied 25, 50 or 100 mg 
capsules in unit dose packages of 30 capsules.  Should be stored in the 
original unit-dose container at temperatures below 86oF (30oC). 
 
 
 Sandimmune® Oral Solution is supplied in 50 mL bottles containing 100 
mg of cyclosporine per mL.  Should be stored in the original container at 
temperatures below 86oF (30oC). Do not store in the refrigerator.  Once 
opened, the contents must be used within 2 months. 
 
 
 Sandimmune® Injection (cyclosporine concentrate) for intravenous 
infusion is supplied as a 5 mL sterile ampule containing 50 mg of 
cyclosporine per mL.  Should be stored at temperatures below 86oF and 
protected from light and freezing. Immediately before use, the i.v. 
concentrate should be diluted 1 mL Sandimmune injection in 20-100 mL 
with an appropriate sterile preservative free media and given in slow 
intravenous infusion over approximately 2-6 hours.  Diluted infusion 
solutions should be discarded after 24 hours. 
 
 
 
 Neoral ® Soft Gelatin Capsules are supplied as 25 and 100 mg capsules.  
Neoral® has greater bioavailability than Sandimmune form.  Less 
Neoral® is needed to yield the same blood concentration derived from 
Sandimmune. 
 

 
 
 
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Neoral® Oral Solution is supplied in 50mL bottles.  Neoral® has greater 
bioavailability than Sandimmune form.  Less Neoral® is needed to yield 
the same blood concentration derived from Sandimmune. 
 
TOXICITIES: 
 
Hematologic: leukopenia, thrombocytopenia, anemia; lymphoma 
 
 
 Urogenital: renal dysfunction.  It is not unusual for serum creatinine and 
BUN levels to be elevated during cyclosporine therapy. Overt 
nephrotoxicity early after transplantation is characterized by rapidly 
rising BUN and creatinine.  This form is usually responsive to dosage 
reduction. Mild nephrotoxicity, generally noted 2-3 months after 
transplant, is often responsive to dose reduction.  A form of chronic 
progressive cyclosporine-associate nephrotoxicity characterized by serial 
deterioration in renal function and morphologic changes in the kidneys, 
will often fail to show a reduction in rising serum creatinine despite a 
decrease or discontinuation of cyclosporine administration. 
 
 
 Gastrointestinal: gum hyperplasia, oral thrush, diarrhea, nausea, 
vomiting, hepatotoxicity, and abdominal discomfort. 
 
Pulmonary: sinusitis 
 
Skin: hirsutism, acne. 
 
 
 Central 
Nervous 
System: 
tremor, 
convulsions, 
headache.  
Hypomagnesemia has been reported in some, but not all, patients 
exhibiting convulsions while on cyclosporine therapy. 
 
Cardiovascular: hypertension (usually mild to moderate), cramps.  
 
 
 
 Other: sinusitis, flushing, increased low-density lipoproteins,    A few 
cases of anaphylactoid reactions have been reported in patients receiving 
Sandimmune injection®, believed to be due to the Cremophor EL® used 
as the vehicle for the i.v. formulation.  Closely monitor patients 
receiving i.v. infusions of the drug. 
 
9.0  MYCOPHENOLATE MOFETIL (MMF) (CELLCEPT) 
 
DESCRIPTION 
 
MECHHANISM OF ACTION:  
 
MMF is a morpholinoethyl ester of mycophenolic acid (MPA). A product 
of several penicillium species, MPA possesses antibacterial, antifungal, 

 
 
 
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antiviral, antitumor and immunosuppressive properties. MMF is a pro-
drug since the immunosuppressive activity is evident only after hydrolysis 
to MPA [26]. MMF was developed to enhance the bioavailability of MPA. 
MPA mediates its effect by inhibiting inosine monophosphate 
dehydrogenase (IMPDH), an enzyme that catalyzes the oxidation of 
inosine monophosphate to xanthine monophosphate, an intermediate 
metabolite in the synthesis of guanosine triphosphate (GTP). Lymphocytes 
rely on the de novo purine synthesis pathway for the nucleotides necessary 
for DNA synthesis; other cells can also rely on the salvage pathway [5,6]. 
The action of MPA results in the depletion of the nucleotide pool in cell 
synthesis. An additional mode of action of MPA may be that, by depletion 
of GTP, it inhibits recruitment of leukocytes to sites of inflammation by 
inhibiting the glycosylation of lymphocyte glycoproteins that are involved 
in intercellular adhesion [27]. 
 
PHARMACOKINETICS:   
 
MMF absorbtion 94%, rapidly absorbed and converted to MPA in the liver 
and undergoes enterohepatic recirculation; 97% bound to albumin.  MPA 
is metabolized in the liver to an inactive metabolite, less than 1% is 
excreted in urine; half-life 18 hours and is not removed by hemodialysis. 
 
FORMULATION:   
 
Oral MMF supplied in 250 mg hard gelatin capsules and as a liquid 
suspension. Capsules can be stored at room temperature. A liquid 
suspension is also available (200 mg/ml, 175 ml bottle).  
 
 
 
IV MMF: Intravenous: MMF for intravenous use will be supplied as a 
lyophilized powder. The intravenous formulation will be stored and 
prepared according to the drug company instructions. Appendix A 
describes formulation, preparation, reconstitution, administration, and 
precautions. 
 
SUPPLIER:  
 
This drug is commercially available 
 
HUMAN TOXICOLOGY:   
 
There have only been limited studies of MMF in patients after marrow 
transplantation. Previous clinical studies in patients after renal allografting 
suggested that the principal adverse reactions associated with the 
administration of MMF include GI: hemorhage (3%), diarrhea (16-36%), 
constitpation, dyspepsia, severe neutropenia (2%), leukopenia, sepsis, 
vomiting and possibly a higher incidence of certain viral infections (CMV, 

 
 
 
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VZV, Herpes Simplex). Commonly seen post-op day 30–180 increased 
incidence of lymphoma (1%) compared to azathioprine may have less 
myelosuppression than azathioprine due to its selective mechanism. 
 
DRUG INTERACTIONS:   
 
Anitacids decrease abosorbtion food decreases the peak concentration by 
40%, but not the extent of absorbtion drugs that interfere with 
enterohepatic recirculation may decrease absorbtion, i.e cholestyramine 
 
10.0 
TACROLIMUS OR FK5O6 (PROGRAF) 
 
DESCRIPTION: 
 
Prograf is available as and oral administration and a sterile solution 
(tacrolimus injection containing the equivalent of 5 mg anhydrous 
tacrolimus in 1ml for administration by IV infusion only.  Each ml 
contains polyoxyl 60 hydrogenated caster oil (HCO-0), 200 mg, and 
dehydrated alcohol, USP, 80.0% v/v.  Prograf injection must be diluted 
with 0.9% Sodium Chloride Injection or 5% Dextrose Injection before use. 
 
Tacrolimus, previously known as FK506, is active ingredient in Prograf.  
Tacrolimus is a macrolide immunosuppressant produced by Streptomyces 
tsukubanensis.   
 
 
MECHANISM OF ACTION:  
 
Tacrolimus prolongs the survival of the host and transplanted graft in 
animal transplant models of liver, kidney, heart, bone marrow, small 
bowel and pancreas, lung and trachea, skin, cornea, and limb.  In animals, 
tacrolimus has been demonstrated to supress some humoral immunity and, 
to a greater extent, cell-mediated reactions such as allograft rejection, 
delayed type hypersensitivity, collagen induced arthritus, experimental 
allergic encephalomyelitis, and graft versus host disease. 
 
HUMAN TOXICOLOGY: 
 
Headache, tremor, insomnia, parathesia, diarrhea, nausea, constipation, 
LFT abnormality, anorexia, vomiting, hypertension, creatinine increased, 
BUN 
increased, 
UTI, 
oliguria, 
hyperkalemia, 
hypokalemia, 
hyperglycemia, hypomagnesemia, anemia, leukocytosis, abdominal pain, 
pain, fever, asthenia, ascites, peripheral edema, pleural effusion, 
atelectasis, dyspnea, pruritus, rash, renal. Increased susceptibility to 
infection and possible development of lymphoma. 
 
KINETICS: 

 
 
 
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Tacrolimus activity is primarily due to the parent drug.  The 
pharmacokinetic parameters of tacrolimus have been determined 
following IV and PO administration in healthy volunteers, liver transplant 
and kidney patients.  Due to intersubject variability in tacrolimus 
pharmacokinetics, individualization of dosing regimen is necessary for 
optimal therapy.  PK data indicate that whole blood concentrations rather 
than plasma concentrations serve as the more appropriate sampling 
compartment to describe tacrolimus pharmacokinetics 
. 
 
 SUPPLIER:   
 
 
 This drug is commercially available 
. 
11.0 
METHYLPREDNISOLONE (SOLU-MEDROL®) 
 
GENERAL: 
 
Methylprednisolone is a synthetic analog of the naturally occurring 
glucocorticoids, which have profound and varied metabolic effects 
including salt retention, anti-inflammatory properties and modification of 
the immune response.  Methylprednisolone is a potent anti-inflammatory 
steroid with less tendency than prednisolone to induce sodium and water 
retention.  Methylprednisolone sodium succinate (SOLU-MEDROL®) has 
the same metabolic and anti-inflammatory actions as methylprednisolone. 
 
ADMINISTRATION : 
 
Methylprednisolone sodium succinate is available in 40, 125, 500, 1000, 
and 2000 mg vials as a sterile powder which must be reconstituted before 
use.  Use only the accompanying diluent or bacteriostatic water for 
injection with benzyl alcohol when reconstituting SOLU-MEDROL®. 
 
TOXICITIES: 
 
Metabolic: fluid and salt retention, glucosuria and hyperglycemia, obesity. 
Gastrointestinal: peptic ulcer. 
Neurologic: irritability, muscle weakness. 
Cardiovascular: hypertension. 
Other:  hirsutism, osteoporosis, pancreatitis, cataracts and seizures (very 
rare). 
 
12.0  FLUDARA® 
 
(Fludarabine phosphate) 
 

 
 
 
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MECHANISM OF ACTION:  
 
Fludarabine is rapidly dephosphorylated to 2-fluoro-ara-A and then 
phosphorylated intracellularly by deoxycytidine kinase to the active 
triphosphate, 2-fluoro-ara-ATP.  This metabolite appears to act by 
inhibiting DNA polymerase alpha, ribonucleotide reductase and DNA 
primase, thus inhibiting DNA synthesis.  The mechanism of action of this 
antimetabolite is not completely characterized and may be multi-faceted. 
 
PHARMACOLOGY: 
 
Phase I studies in humans have demonstrated that fludarabine phosphate is 
rapidly converted to the active metabolite, 2-fluoro-ara-A, within minutes 
after intravenous infusion.  In a study with 4 patients treated with 
25mg/m2/day for 5 days, the half-life of 2-fluoro-ara-A was approximately 
10 hours.  Approximately 23% of the dose was excreted in the urine as 
unchanged 2-fluoro-ara-A.  The mean Cmax after Day 1 dose was 0.57 
mcg/ml and after the Day 5 dose was 0.54 mcg/ml. 
 
DOSE AND ADMINISTRATION: 
 
The recommended dose of fludarabine is 25 mg/m2 administered 
intravenously over a period of approximately 30 minutes daily for five 
consecutive days.  Each 5 day course of treatment should commence every 
28 days.  The optimal duration of treatment has not been clearly 
established. The dose of fludarabine used in this protocol is 
nonmyeloablative, but does cause significant immunosuppression. 
 
ADVERSE REACTIONS: 
 
Hematopoietic Systems:  Hematologic events (neutropenia, 
thrombocytopenia, and/or anemia).  Life-threatening and sometimes fatal 
autoimmune hemolytic anemia have been reported. 
Metabolic:  Tumor lysis syndrome. 
Nervous System:  Objective weakness, agitation, confusion, visual 
disturbances, coma and peripheral neuropathy. 
Pulmonary System:  Pneumonia, dyspnea, cough and interstitial 
pulmonary infiltrate. 
Gastrointestinal System:  Nausea, vomiting, anorexia, diarrhea, stomatitis 
and gastrointestinal bleeding. 
Cardiovascular:  Edema 
Genitourinary System:  Rare cases of hemorrhagic cystitis. 
Skin:  Skin rashes. 
 
PREPARATION OF SOLUTIONS: 
 

 
 
 
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Each vial contains 50 mg of fludarabine phosphate, 50 mg of mannitol and 
sodium hydroxide to adjust pH to 7.7.  Fludarabine for injection should be 
prepared for parenteral use by aseptically adding 2ml of sterile water.  
Each ml of the resulting solution will contain 25 mg of fludarabine 
phosphate.  In clinical studies, the product has been diluted in 100 cc or 
125 cc of 5% Dextrose Injection USP or 0.9% Sodium Chloride USP. 
 
STORAGE AND STABILITY: 
 
Fludarabine should be stored under refrigeration, between 2º-8ºC.  
Fludarabine contains no antimicrobial preservative and thus should be 
used within 8 hours of reconstitution. 
 
 
13.0 
VP-16 (VP-16-213) (Etoposide) (Vepesid) 
 
 
 
CHEMISTRY: 
 
VP-16 is a semi-synthetic podophyllotoxin derivative from the plant 
podophyllum pletatum, has anti-neoplastic properties in experimental 
animals and in man. The empiric formula C29 H32  O13 has a molecular 
weight of 588. 
 
MECHANISM OF ACTION: 
 
The epipodophyllotoxin exert phase-specific spindle poison activity with 
metaphase arrest, but in contrast to the vinca alkaloids, have an additional 
activity of inhibiting cells from entering mitosis. Suppression of tritiated 
thymidine, uridine, and leucine incorporation in human cells in tissue 
culture suggest effects against DNA, RNA and protein synthesis. 
 
ANIMAL TUMOR DATA:  
 
Significant anti-tumor effect has been demonstrated in L-1210, mouse 
sarcoma 37 and 180, Walker carcinosarcoma and Erlich ascites tumor. 
With the L 1210 system, activity was schedule-dependent, having greater 
effect with a twice weekly administration than with daily dosing or the 
administration of single large doses.  The drug is active given 
intraperitoneally or orally in L 1210. No effect was demonstrated 
intracerebrally inoculated L 1210. 
 
ANIMAL TOXICOLOGY:  
 
The predominant toxicities of VP-16 in animal studies involve the 
hematopoietic system, with toxicity to the liver and GI tract occurring only 
at doses producing profound myelosuppression. Anemia, leukopenia, and 
lymphoid involution occur in mice, rats and monkeys. Acute toxicity 
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investigations have been complicated by the toxicity of the solvent system. 
The LD-50 of the solvent plus drug approached that of the solvent alone. 
Immuno-suppressive effects occur with an inhibition of antibody 
production in mice and monkeys, and prevention of experimental allergic 
encephalomyelitis in rats (cell mediated immunity). 
 
HUMAN TOXICOLOGY: 
 
Reversible myelotoxicity has been uniformly observed to be the major 
toxicity of VP-16 and to represent the only clinically significant side 
effect.  Following a single IV injection, peak myelotoxicity occurs at 7 to 
9 days. Following daily IV injections for 5 to 7 days, myelotoxicity is 
maximal between 12 to 16 days from the initiation of therapy.  Bone 
marrow suppression is mainly manifested as granulcytopenia with 
thrombocytopenia and anemia occurring to a lesser extent. Transient, 
modest nausea, usually without vomiting, is common.  Occasional 
alopecia is reported. VP-16 does not produce stomatitis, phlebitis, 
neurotoxicity, hepato-toxicity or nephro-toxicity. Hypotension and 
anaphylaxis are occasional side effects.  Hypotension can be managed by 
infusing the drug over at least a 30 minute period.  Occasionally, fever 
may be a result of VP-16 administration. 
 
PHARMACEUTICAL DATA: 
 
Formulation: 100 mg of VP-16 is supplied as 5 ml of solution in clear 
ampules for injection. Each ampule also contains anydrous citric acid 10 
mg, benzylalcohol 150 mg, polysorbate 80 purified 400 mg, polyethylene 
glycol and absolute alcohol.  The contents of the ampule are non-aqueous 
and must be diluted with 20 to 50 volumes of sodium chloride injection 
USP.  The time before precipitation depends on concentration. 
 
 
Dilution 
Time 
 
1:20 
 
30 minutes 
 
1:50 
 
 3 hours 
 
1:100  
 6 hours 
 
Storage and stability:  The drug is available as a box of 10 ampules that 
are stored at room temperature.  Each ampule should be kept in the box to 
protect it from light.  VP-16 is less stable in 5% Dextrose injection and 
precipitation is reported.  VP-16has a minimum infusion time of 30 
minutes to reduce hypotension. 
 
SUPPLIER:  
 
VP-16 is commercially available. 
 

 
 
 
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14. Sirolimus (Rapamune®) 
 
14.1 
Mechanism of action: see section 2.2 
14.2 
Toxicity: The most commonly reported toxicities are hyperlipidemia, 
arthralgia, cytopenias, epistaxis, edema and rash. Despite the similarity 
between sirolimus and tacrolimus, there is no neurotoxicity or 
nephrotoxicity with sirolimus because of its inability to inhibit calcineurin.  
Phase III clinical trials have indicated that the primary toxicities are 
hypertriglyceridemia, hypercholesterolemia, mild thrombocytopenia, 
anemia, leukopenia, hypokalemia, elevated LDH, arthralgia, epistaxis, 
edema, and infections.  Clinically significant elevations in hepatic 
transaminases without sequelae were noted in the prior phase II study with 
this drug, however, the incidence of veno-occlusive disease of the liver 
was not noted to be higher than expected in trials of unrelated 
transplantation.   A syndrome of thrombotic microangiopathy, comprised 
of microangiopathic hemolytic anemia, thrombocytopenia and renal 
dysfunction has been described in association with sirolimus and 
tacrolimus use.  In common with all other immunosuppressants, it may 
increase the risk of opportunistic infections and post-transplant 
lymphoproliferative disorders. 
 
14.3 
Pharmacology Description 
Similar to the calcineurin inhibitors, sirolimus has low oral bioavailability 
due to first pass metabolism by the liver and intestinal wall as well as poor 
absorption because it is countertransported in the gut lumen by the 
multidrug efflux pump, P-glycoprotein (P-gp). However, the median tmax 
value for the oral suspension is <1 hour indicating that there is rapid 
absorption, however, systemic availability is ~14% in stable renal 
transplant patients. Total body clearance is 127 to 240 mL/hr/kg and is not 
related to dose. Half-life is 57 to 63 hours. It is extensively bound by 
blood cells and plasma proteins. It is excreted by hepatic and gut 
metabolism. In phase III studies, whole blood trough levels for a 2 mg/day 
dose were 8.59  4.01 ng/mL and correlate with the AUC (r2=0.95). Only 
~2% is excreted in the urine.   
 
The mean bioavailability of sirolimus after administration of the tablet is 
about 27% higher relative to the oral solution. Sirolimus oral tablets are 
not bioequivalent to the oral solution; however, clinical equivalence has 
been demonstrated at the 2-mg dose level.  Differences in absorption 
kinetics and bioavailability in renal transplant patients are shown in the 
table below: 
 
Formulation, 2 mg 
Cmax,ss 
(ng/mL) 
tmax 
(h) 
AUC 0 
(ngh/mL) 
CL/F/WT 
(mL/h/kg) 
Oral solution  
14.4 ± 5.3 
2.12 ± 0.84 
194 ± 78 
173 ± 50 
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Tablet 
15.0 ± 4.9 
3.46 ± 2.40 
230 ± 67 
139 ± 63 
 
Renal failure does not affect the excretion of sirolimus, but excretion is 
reduced in liver failure as shown below:  
 
Population 
Cmax,ss 
(ng/mL) 
tmax 
(h) 
AUC 0 
(ngh/mL) 
CL/F/WT 
(mL/h/kg) 
Healthy subjects 
78.2  18.3 
0.83  0.17 
970  272 
215  76 
Hepatic impairment 
77.9  23.1 
0.84  0.17 
1567  616 
4  62 
 
14.5     Packaging, Formulation, Preparation and Storage  
 
 14.5.1  Sirolimus oral solution: Rapamune oral solution (bottles and foil 
pouches) should be stored protected from light and refrigerated at 
2C to 8C (36F to 46F).  Rapamune oral solution is stable for 24 
months under this storage condition.  Once the bottle is opened, it 
should be kept in a refrigerator and the contents used within one 
month.  However, both the opened bottles and pouches may be 
stored at room temperature (15C to 30C; 59F to 86F) for up to 
one month. An amber syringe and cap are provided for dosing from 
the bottle and the product may be kept in the syringe for a maximum 
of 24 hours at room temperatures up to 25C (77F) or refrigerated at 
2C to 8C (36F to 46F).  The syringe should be discarded after 
one use.  After dilution, the preparation should be used immediately. 
Rapamune oral solution is provided in bottles may develop a slight 
haze when refrigerated.  If such a haze occurs allow the product to 
stand at room temperature and shake gently until the haze 
disappears.  The presence of this haze does not affect the quality of 
the product. 
 
 
14.5.2Sirolimus tablets:  Rapamune tablets are available as white 
triangular shaped tablets marked “RAPAMUNE 1 mg” in bottles of 
100 tablets or as cartons containing ten blister cards of ten tablets 
each.  Rapamune tablets should be stored at 20° to 25°C (68°-77°F). 
Cartons should be used to protect the blister cards and strips from 
light. Rapamune tablets should be dispensed in a tight, light-resistant 
container.  
 
 
14.5.3 Supplies: Commercially available. 

 
 
 
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APPENDIX B 
 
 
 
Methotrexate, Cyclosporine and MMF Dose Modification Guidelines  
 
 
 
 
Methotrexate Dose Modifications 
 
Guidelines for methotrexate dose adjustments for the indicated toxicities 
are provided in the following table.  Refer to Appendix 14.4 for toxicity 
grading criteria. 
 
 
 
Grade I 
Mild 
Grade II 
Moderate 
Grade III  
Severe 
Grade IV 
Life-threatening 
 
% Methotrexate Dose Reduction 
RENAL 
 Creatinine 
 
0 
 
50 
 
100 
 
100 
GI 
 Mucositis 
 Stomatitis 
 Esophagitis 
 Dysphagia 
 
0 
0 
0 
0 
 
0 
0 
0 
0 
 
50 
50 
50 
50 
 
100 
100 
100 
100 
CARDIAC 
 Peripheral   
Capillary Leak 
     Day 1-3 
     Day 6-11 
 
 
 
0 
0 
 
 
 
0 
0 
 
 
 
50 
100 
 
 
 
 
100 
 
Routine leucovorin rescue is not allowed.  Guidelines for MTX dose 
adjustment in patients with renal dysfunction, mucositis, or peripheral 
capillary leak are outlined in Appendix 14.3.1.  In such patients, MTX 
levels may be checked beginning 24 hours after MTX administration and 
if the MTX level is high, leucovorin may be administered according to 
institutional standards/guidelines. 
 
 
 
Cyclosporine Dose Modfication Guidelines 
 
Cyclosporine trough levels should be measured weekly during the first 50 
days post-transplant.  With a fluorescence polarization immunoassay 
(TDX), plasma cyclosporine levels between 200-600 ng/mL (170-500 by 
HPLC; whole blood levels by TDX of 900-1500 ng/mL) are acceptable in 
patients who manifest no evidence of toxicity or GVHD.   
 
 
 
 It is essential that plasma cyclosporine levels represent trough values.  
Trough plasma cyclosporine levels should be drawn 10-12 hours after the 
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continuous infusion, the levels can be drawn at any time.  Cyclosporine 
levels should not be drawn from the catheter lumen used for the 
intravenous infusion of cyclosporine. 
 
Adjustment of cyclosporine dose should not be based exclusively on 
plasma levels.  Studies have demonstrated only a weak relationship 
between cyclosporine levels (plasma serum or whole blood) and the 
occurrence of GVHD or solid organ graft rejection.  A better but still weak 
relationship between cyclosporine levels and toxicity has been 
demonstrated.  Other factors may be important in determining clinical 
outcome.  Biologic availability of the drug to the cells may be determined 
by the serum lipid concentration and profile (HDL, LDL, VLDL).  
Cellular factors (cyclophilin, calmodulin, calcineurin) determining the 
biologic effectiveness of cyclosporine may also vary between patients.  
Therefore, cyclosporine levels should be used as a guide in conjunction 
with clinical observations of the biologic effects of the drug, i.e., toxicity 
and immunosuppression.  Guidelines provided in the following table are 
based on renal or neurologic toxicities as measured by creatinine (renal); 
neurosensory, neuro-motor, neuro-cortical, neuro-cerebellar, neuro-mood 
and neurovision (neurological) parameters. 
 
Plasma Levels 
 TDX 
Plasma Levels 
HPLC 
Toxicity 
Grade 
Cyclosporine Dose  
Modification 
< 200 ng/Ml 
< 170 
0 
Increase 25% 
201-600 ng/mL 
171-500 
0- I 
No change 
201-600 ng/mL 
171-500 
II 
Decrease 50% 
201-600 ng/mL 
171-500 
III-IV 
Decrease 100% 
 
>501 
0 
Decrease 25% every 
3-4 days 
 
 
 
Guidelines for MMF Dose Adjustment 
 
If in clinical judgment of the investigator the observed toxicity is related to 
MMF administration, a dose adjustment will occur. Based on previous 
organ transplant studies, dose adjustment may occur because of 
gastrointestinal adverse effects. If G.I. toxicity requires medical 
intervention including medication for control of persistent vomiting or 
diarrhea and is considered not related to GVHD, a dose reduction to 50% 
will occur first and if there is no improvement, MMF will be stopped. For 
more severe G.I. toxicity, MMF will be stopped. Patients should be 
evaluated by the primary investigator or the GVHD attending physician 
before reducing MMF. A consult with Gastroenterology is also 
recommended if the study drug is to be stopped. If renal insufficiency 
develops with an estimated creatinine clearance of 25-60 ml/mm, the dose 

 
 
 
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of MMF will be reduced to 75% of the calculated dose by ideal body 
weight of the patient. If the estimated creatinine clearance is 25 ml, the 
dose of MMF will be reduced to 50%. No adjustments of MMF are 
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APPENDIX C 
 
FRACTIONATED TOTAL BODY IRRADIATION SCHEMA 
 
Session Day Time Direction 
Energy  
 
Dose (cGy) 
 
notes 
 
1 
-7 
7:30 
AP 
 
8X or 10X 
 
120 cGy 
 
TLD, 
 ck testes thickness (ALL only) 
2 
-7 
12  
PA 
 
8X or 10X 
 
120 cGy 
 
TLD 
 
3 
-7 
16:30  AP 
 
8X or 10X 
 
120 cGy     
 
4 
-6 
7:30 
PA 
 
8X or 10X 
 
120 cGy 
 
 
5 
-6 
12 
AP 
 
8X or 10X 
 
120 cGy 
 
 
 
AP rt & lt CW electrons BOOST 
300 cGy  to pleural surface  
 
6 
-6 
16:30 PA 
 
8X or 10X 
 
120 cGy 
 
 
 
PA rt & lt CW electrons BOOST 
300 cGy  to pleural surface 
 
7 
-5 
7:30 
AP 
 
8X or 10X 
 
120 cGy 
 
8 
-5 
12 
PA 
 
8X or 10X 
 
120 cGy 
AP rt & lt CW electrons BOOST 
300 cGy  to pleural surface 
 
9 
-5 
16:30 AP 
 
8X or 10X 
 
120 cGy 
 
 
 
PA rt & lt CW electrons BOOST 
300 cGy  to pleural surface 
 
10 
-4 
7:30  
PA 
 
8X or 10X 
 
120 cGy 
 
11 
-4 
12 
AP 
 
8X or 10X 
 
120 cGy 
 
Photon dose is calculated at mid-depth, central axis. Electron  energies are  selected  as per 
computerized treatment planning system to deliver 300 cGy/fx to  the pleural surface of each 
chest wall field.  AP and PA portal films will be obtained prior to treatment to assure proper lung 
block placement. 
 
During the first AP and PA sessions, the radiation dose received by the patient will be monitored 
by means of thermoluminescent dosimeters (TLD) placed on the anterior surface of the patient’s 
skin at the following anatomic locations: forehead, SSN, Xiphoid process, umbilicus, pelvis, mid-
thigh, knee, mid-calf, and ankle. The middle dose to the patient can be calculated from the sum of 
entrance and exit doses recorded by TLD dosimeter. If the dosimeter indicates a deviation of 
greater than + 5%  (+  10% for lower extremities) in the planned dose, then either the 
compensating filter, the machine monitor units (due to change in patient’s thickness) , or both 
may be modified for subsequent sessions.  

 
 
 
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APPENDIX D 
 
GVHD ASSESSMENT  
 
ASSESSMENT OF ACUTE GVHD 
 
CRITERIA FOR ASSESSMENT OF GVHD  
 
SKIN  
 
Stage  
 
+1 
A maculopapular eruption involving less than 25% of the body surface.  
+2 
A maculopapular eruption involving 25-50% of the body surface.  
+3 
Generalized erythroderma. 
+4 
Generalized erythroderma with bullous formation and often with desquamation.   
 
LIVER   
 
Stage  
 
+1 
Moderate increase of SGOT (150-750 IU) and bilirubin (2.0-2.9 mg/dl).  
+2 
Bilirubin rise (3.0-5.9 mg/dl) with or without an increase in SGOT.  
+3 
Bilirubin rise (6.0-14.9 mg/dl) with or without an increase in SGOT.  
+4 
Bilirubin rise to >15 mg/dl with or without an increase in SGOT.  
 
GUT   
 
Stage 
  
+1 
>30 ml/kg or >500 ml of stool/day or biopsy for GVHD.  
+2 
>60 ml/kg or >1,000 ml of stool/day.  
+3 
>90 ml/kg or 1,500 ml stool/day.  
+4 
>90 ml/kg with abdominal pain or >2,000 ml of stool/day.   
 
Diarrhea volume is measured as the average for the day of evaluation and the two 
preceding days, in order to minimize errors caused by large day-to-day variation.   
 
Reference:  Modified from Glucksberg, et al., Transplantation.  1974; 18/295-304.   
 

 
 
 
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OVERALL STAGING - GVHD  
 
Degree of Organ Involvement 
 
 
 
 
Grade 
 
Grade 1-2 skin rash with no GI or liver  
 
I (mild) 
involvement and no clinical impairment. 
 
Grade 1-3 skin rash with grade 1 GI or   
 
II (moderate) 
liver involvement or both, and mild 
clinical impairment or grade 3 skin only. 
 
Grade 2-3 skin rash with grade 2-3 GI or  
 
III (severe) 
liver involvement or both, and marked 
clinical impairment. 
 
Grade 2-4 skin rash with grade 2-4 GI or  
 
IV (life-threatening) 
liver involvement or both, and extreme    
clinical impairment, or grade 4 skin only  
with desquamation and extreme clinical 
impairment. 
 
CHRONIC GVHD GRADING SCALE    
 
Limited Chronic GVHD 
 
Either or both:   
 
1. Localized skin involvement  
 
2. Hepatic dysfunction   
 
Extensive Chronic GVHD 
 
Either:   
 
1. Generalized skin involvement, or  
 
2. Localized skin involvement and/or hepatic dysfunction, plus  
 
 
a. Liver histology showing chronic aggressive hepatitis, bridging necrosis or 
cirrhosis, or  
 
 
b. Involvement of eye: Schirmer's test with <5 mm wetting, or  
 
 
c. Involvement of minor salivary glands or oral mucosa demonstrated on 
labial biopsy specimen, or  
 
 
d. Involvement of any other target organ (e.g., esophageal abnormalities, 
polymyositis)    
 
Sullivan K. Acute and chronic Graft-versus-Host Disease in Man. Int J Cell Cloning. 
1986;4:42-93 (suppl 1).  

 
 
 
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APPENDIX E 
 
PERFORMANCE STATUS  
 
% 
Karnofsky† 
Grade 
WHO* 
Status 
ECOG** 
100 Normal; no complaints/ no 
evidence of disease 
0 
Able to carry out normal 
activity without 
restriction 
0 
Normal activity 
 
90 
 
Able to carry on normal 
activity; minor signs or 
symptoms of disease 
 
 
 
 
 
 
80 
 
Normal activity with effort; 
some signs or symptoms of 
disease 
1 
Restricted in physically 
strenuous activity but 
ambulatory and able to 
carry out work 
1 
Symptoms but 
ambulatory 
 
70 
 
Cares for self; unable to 
carry on normal activity or 
do active work 
 
 
 
 
 
60 
 
Requires occasional 
assistance but is able to care 
for most of his needs 
2 
Ambulatory and capable 
of all self-care but unable 
to carry out any work; up 
and about more than 50% 
of waking hours 
2 
In bed <50% of 
time 
50 
Requires considerable 
assistance and frequent 
medical care 
 
 
 
 
 
40 
 
Disabled, requires special 
care and assistance 
3 
Capable of only limited 
self-care; confined to bed 
or chair more than 50% 
of waking hours 
3 
In bed >50% of 
time 
30 
Severely disabled; 
hospitalization is indicated 
though death not imminent 
 
 
 
 
 
20 
 
Very sick; hospitalization is 
necessary 
4 
Completely disabled; 
cannot carry on any 
self-care; totally confined 
to bed or chair  
4 
100% bedridden 
10 
Moribund; fatal process 
progressing rapidly 
 
 
 
 
 
 
* WHO =  World Health Organization **  ECOG =  Eastern Cooperative Oncology Group  
 
 
†  Karnofsky=  D.A., et al., Cancer 1: 634-656, 1948

 
 
 
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APPENDIX F 
 
STUDY CALENDAR 
 
 
TESTING 
 
 
PRE- 
BMT 
 
WEEK 1 
 
WEEK 2 
 
WEEK 3 
 
WEEK 4/ 
DAY 30 
 
DAY 60 
 
DAY 100 
 
6 
MONTHS 
 
1 
YEAR 
HISTORY AND PHYSICAL 
EXAM 
KPS 
X 
 
X 
 
 
 
X 
 
X 
X 
 
X 
X 
 
X 
X 
 
X 
X 
 
X 
LABORATORY: 
 
 
 
 
 
 
 
 
 
 
CBC/PLATELETS 
X 
Qd 
qd 
qd 
qd 
X 
X 
X 
X 
 
SMA-18 + Mg 
X 
q M-W-F 
q M-W-F 
q M-W-F 
q M-W-F 
X 
X 
X 
X 
 
CMV Blood Cultures* 
X 
 
 
q Mon + Thurs 
q Mon + Thurs 
until day 100 
 
 
 
 
 
Ig Levels 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
24 hour Urine 
 
Clearance 
X 
 
 
 
 
 
 
 
 
 
HIV, Hepatitis Screen  
X 
 
 
 
 
 
 
 
 
 
CMV Titer (Serum) 
X 
 
 
 
 
 
 
 
 
 
HSV Titer 
X 
 
 
 
 
 
 
 
 
OTHER TESTS: 
 
 
 
 
 
 
 
 
 
 
CXR 
X 
X 
X 
X 
X 
 
 
 
 
 
Cardiac Echo 
X 
 
 
 
 
 
 
 
 
 
Chest/Abd CT 
X 
 
 
 
 
 
 
 
 
 
BM Asp + Bx † 
X 
 
 
 
X 
 
X 
X 
X 
 
Chimerism Study 
 
 
 
 
X 
X 
X 
X 
X 
GVHD ASSESSMENT 
 
 
 
 
X 
X 
X 
X 
X 
TOXICITY ASSESSMENT 
 
 
 
 
X 
X 
X 
X 
X 
* CMV Bl C/S or PCR analysis 
† For patients with bone marrow involvement at transplant
8/6/02

 
 
 
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APPENDIX G 
IV BUSULFAN KINETICS FORM  
IRB#:  ______________________ 
 
 
DATE: ______________________  (CIRCLE WEIGHT USED) 
PATIENT ___________________  
 
 
DOSE #_____________________   Actual Body Weight ________ 
Medical Record #_____________ 
 
 
Start time: ___________________   Ideal Body Weight _________ 
MD/Pager # _________________ 
 
 
Stop Time: ___________________  Adjusted IBW _____________ 
Coordinator/Pager #___________ 
 
    
DOSE: ____________mg (_______mg/m2) BSA_______m2 
 
 
 
 
 
 
 
 
INFUSION TO RUN OVER 2 HOURS 
**LABEL EACH TUBE BY NUMBER CONSECUTIVELY WITH THE APPROPRIATE BLOOD DRAW TIME 
Tube # 
Collection Schedule 
Proposed Collection Time 
Actual Collection Time 
1 
Immediately prior to beginning of infusion 
APPROX. 0555 
 
2 
Immediately prior to end of infusion 
APPROX. 0755 
 
3 
15 minutes post infusion 
APPROX. 0815 
 
4 
30 minutes post infusion 
APPROX. 0830 
 
5 
60 minutes post infusion (1 hour) 
APPROX. 0900 
 
6 
180 minutes post infusion (3 hours) 
APPROX. 1100 
 
7 
240 minutes post infusion (4 hours) 
APPROX. 1200 
 
**CALL SPD FOR STAT PICK-UP AFTER EACH BLOOD DRAW** 
**CALL Cara Ortega at 62681 or Jim Manwaring at 64515 if not picked up within 15 minutes** 
1. ALL samples to be obtained in 7cc green top tubes (Sodium Heparin).  DO NOT draw from Busulfan line. (use opposite port of Hickman 
Catheter for blood draw). 
2. After EACH DRAW, send sample on ice to HLA LAB via SPD. 
3. After last draw, call SPD STAT for pick-up to take to HLA LAB. 
4. Send a copy of this completed form to HLA LAB with last blood draw. 
Please call,        ext 62394 or Kathy Patane, ext 63238 to pick up this form. 
 
RN SIGNATURE _________________________________ 
Addressograph