A Pilot Study of Post-transplant High Dose Cyclophosphamide (PTCY) as Part of Graft-Versus-Host Disease (GVHD) Prophylaxis in T-Cell Replete HLA-Mismatched Unrelated Donor (MMUD) Ablative and Reduced Intensity Hematopoietic Cell Transplantation (HCT) for Hematological Malignancies
Phase: PHASE2
Conditions: Acute Leukemia, Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma, Chronic Myelogenous Leukemia, BCR-ABL1 Positive, Diffuse Large B-Cell Lymphoma, Follicular Lymphoma, Graft Versus Host Disease, Hodgkin Lymphoma, Mantle Cell Lymphoma, Marginal Zone Lymphoma, Myelodysplastic Syndrome, Myeloproliferative Neoplasm, Recurrent Acute Myeloid Leukemia With Myelodysplasia-Related Changes, Recurrent Plasma Cell Myeloma, Refractory Plasma Cell Myeloma, Secondary Myelodysplastic Syndrome
Sponsor: City of Hope Medical Center

 
IRB #16419 
 
07/03/2019 
Packet: 05 
 
  
CITY OF HOPE  
1500 E. DUARTE ROAD 
DUARTE, CA 91010 
 
DEPARTMENT OF HEMATOLOGY AND HEMATOPOIETIC CELL TRANSPLANTATION                            
 
TITLE: A PILOT STUDY OF POST-TRANSPLANT HIGH DOSE CYCLOPHOSPHAMIDE (PTCY) 
AS PART OF GRAFT-VERSUS-HOST DISEASE (GVHD) PROPHYLAXIS IN T-CELL REPLETE 
HLA-MISMATCHED UNRELATED DONOR (MMUD) ABLATIVE  AND REDUCED INTENSITY  
HEMATOPOIETIC CELL TRANSPLANTATION (HCT) FOR HEMATOLOGICAL MALIGNANCIES 
  
 
CITY OF HOPE PROTOCOL NUMBER/VERSION:  IRB # 16419     
PROTOCOL DATE: 07/03/2019 
 
Initial Submission 
 
 
 
Protocol dated 05/22/2017 
 
 
Version: 00 
COH Amendment 01  
 
 
Protocol dated 06/13/2017 
 
 
Version: 01 
COH Amendment 02  
 
 
Protocol dated 12/08/2017 
 
 
Version: 02 
COH Amendment 03  
 
 
Title Page dated 03/11/2019  
 
Version: 03 
COH Amendment 04  
 
 
Protocol dated 07/03/2019 
 
 
Version: 04 
COH Amendment 05  
 
 
Protocol dated 07/03/2019 TP 
 
 Packet: 05 
 
 
 
SITE:  
Bone Marrow and Extramedullary 
 
 
 
 
STAGE (If applicable): 
 
 
 
N/A 
 
 
 
   
 
 
MODALITY:  
 
 
 
 
IV 
 
 
 
 
  
 
 
 
TYPE:  
 
 
 
 
 
Pilot 
 
 
 
  
 
PRINCIPAL INVESTIGATOR: 
 
 
Monzr Al Malki, M.D.  
 
PARTICIPATING CLINICIANS: 
Haris Ali, M.D.,  Ibrahim Aldoss, M.D., L. Elizabeth Budde, 
M.D., Ji-Lian Cai, M.D., Thai Cao, M.D., Leonardo Farol, 
M.D., Stephen Forman, M.D., Alex Herrera, M.D., Myo Htut, 
M.D., Chatchada Karanes, M.D., Samer Khaled, M.D.,  
Amrita Krishnan, M.D., Guido Marcucci, M.D., Matthew Mei, 
M.D., Ryotaro Nakamura, M.D., Nitya Nathwani, M.D., Anna 
Pawlowska, M.D, Leslie Popplewell, M.D.,  Vinod Pullarkat, 
M.D., Joseph Rosenthal, M.D., Michael Rosenzweig, M.D., 
Firoozeh Sahebi, M.D.,  Eileen Smith, M.D.,  Amandeep 
Salhotra, M.D., Tanya Siddiqi, M.D., Anthony Stein, M.D., 
David Snyder, M.D., Ricardo Spielberger, M.D., Jeffrey 
Wong, M.D., Jasmine Zain, M.D., Karamjeet Sandhu, M.D., 
Liana Nikolaenko, M.D., Eric Radany, M.D, Nicole Karras, 
M.D. 
 
 
 
BIOSTATISTICIAN: 
Ni-Chun Tsai 

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Experimental Design Schemas 
Note: A window of 1-2 days is allowed for stem cell availability.  
 
 
Melphalan 
140 mg/m² IV for patients <61 
100 mg/m² IV for patients ≥61 

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Protocol Synopsis 
Protocol Title: 
A PILOT STUDY OF POST-TRANSPLANT HIGH DOSE CYCLOPHOSPHAMIDE (PTCY) AS 
PART OF GRAFT-VERSUS-HOST DISEASE (GVHD) PROPHYLAXIS IN T-CELL REPLETE 
HLA-MISMATCHED UNRELATED DONOR (MMUD) ABLATIVE  AND REDUCED INTENSITY  
HEMATOPOIETIC 
CELL 
TRANSPLANTATION 
(HCT) 
FOR 
HEMATOLOGICAL 
MALIGNANCIES 
Brief Protocol Title for the Lay Public (if applicable): 
Use of Cyclophosphamide for Graft-versus-Host Disease in mismatched unrelated donor HCT.  
Study Phase: 
Pilot 
Participating Sites: 
Single Center: City of Hope National Medical Center 
Rationale for this Study: 
MMUD HCT is associated with poorer outcome primarily due to increased risk of GVHD-related 
mortality. At City of Hope, we have explored and evaluated the use of Tacrolimus/Sirolimus-
based GVHD prophylaxis for MUD and MMUD HCT over the past 10 years. While overall 
results have been satisfactory in MUD HCT, the outcome of MMUD HCT was inferior to MUD 
HCT using Tacrolimus/Sirolimus-based regimens. PTCy has been shown to be effective in 
preventing GVHD in haploidentical donor HCT and MUD HCT. However, limited data exist for its 
efficacy in preventing GVHD and improving outcomes of MMUD HCT. In this protocol, we aim to 
investigate the ability of PTCy to overcome the increased incidence of GVHD and subsequent 
increased risk of non-relapse mortality (NRM) expected after MMUD HCT. 
Objectives: 
In patients undergoing T-cell replete HLA-mismatched unrelated donor hematopoietic cell 
transplantation (HCT) for hematologic malignancy, using either an ablative or reduced intensity 
conditioning regimen: 
Primary objective:  
 
To estimate the GVHD-free relapse/progression-free survival (GRFS) at one-year post 
HCT 
and 
to 
evaluate 
the 
clinical 
activity 
of 
post-transplant 
high 
dose 
cyclophosphamide (PTCy).   
Secondary objectives:  
 
To summarize toxicities/complications/infections including type, frequency, severity, 
attribution, time course and duration through 100 days post-transplant. 
 
To estimate the cumulative incidence (CI) of acute and chronic GVHD. 
 
To characterize the time course of neutrophil and platelet recovery/engraftment. 
 
To estimate overall survival (OS), progression-free survival (PFS), CI of 
relapse/progression, and non-relapse mortality (NRM) at 100 days, 1 year and 2 
years.  
 
To describe quality of life at 100 days, 6 months, 1 and 2 years. 
 
To characterize immune cell reconstitution and T cell repertoire after MMUD HCT with 

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PTCy. 
 
To characterize quality of life. 
Study Design: 
Pilot/Estimation Design, Single Center 
[Estimation: GVHD-free relapse/progression-free survival (GRFS) at one-year post HCT in 
Ablative and Non-Myeloablative strata.] 
Endpoints: 
Primary Endpoint: 
 
GVHD-free relapse/progression-free survival (GRFS) is defined as time from start of 
treatment (HCT) to grade 3-4 acute GVHD or moderate-severe chronic GVHD, relapse, 
progression, or death (from any cause), whichever occurs first. 
Secondary Endpoints: 
 
Toxicity/infections 
 
Acute and Chronic GVHD 
 
Engraftment (Neutrophil and Platelet Recovery) 
 
Overall and Progression-Free Survival 
 
Relapse/Progression  
 
Quality of Life using validated tools 
Sample Size: 
The target sample size is 38 patients accrued into two strata: 19 patients will receive 
myeloablative conditioning (MAC: Regimens B or C) and 19 will receive reduced intensity 
conditioning (RIC: Regimen A). 
Estimated Duration of the Study 
Subject accrual: 24 Months 
Follow-up Period: 24 Months  
Summary of Subject Eligibility Criteria: 
Inclusion Criteria: 
 
Patients with neoplastic hematological disorders with an indication for allogeneic 
transplant according to the standard guidelines as follows:  
o Acute leukemia [AL] in CR1 or subsequent CR or active disease with BM blasts of 
<10%.  
o Chemosensitive Hodgkin, Non-Hodgkin lymphoma [HL or NHL] or chronic 
lymphocytic leukemia [CLL]: high risk upfront with 17q-, relapsed less than 1 year 
after chemotherapy, relapse after previous autologous transplant, or failure to 
achieve CR with chemotherapy. All other types of lymphoma are eligible. 
o Chronic myeloid leukemia [CML] in hematological remission after blast/accelerated 
phase or chronic phase refractory to multiple TKI. 
o Myelodysplastic syndrome [MDS] with intermediate-2 or high risk per IPSS or 
myeloproliferative neoplasm; primary or secondary if high-risk features or refractory 

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disease.  
o High risk, or refractory and relapsed multiple myeloma [MM]. 
 
No available suitable HLA-matched donor.  
 
Age Criteria: 5 to 75 years of age if meets criteria for HCT per SOP.  
 
Organ Function Criteria: The following organ function testing should be done within 30 
days before study registration. In case of active disease evaluation should be within 15 
days.  
o Cardiac: LVEF of 50% or above, by MUGA or Echocardiogram.  
o Pulmonary: FVC, FEV1 and DLCO (corrected) should be ≥50% of expected.  
o Renal: serum creatinine level to be < 2 mg/dl or Measured creatinine clearance 
(CrCl) must be equal or greater than 60 mL/min. The updated Schwartz formula 
should be used for pediatric patients (≥5 to 12 years old).  
o Hepatic: serum bilirubin 1.5 upper limits of normal (ULN), (AST)/ (ALT) 2.5 ULN, and 
alkaline phosphatase 2.5 ULN.  
 
Performance status: Karnofsky ≥ 70%.  
 
Consent: All patients must be informed of the investigational nature of this study and 
given written informed consent in accordance with institutional and federal guidelines.  
Exclusion Criteria: 
 
Psychosocial issues: no appropriate caregivers identified, or non-compliant to 
medications 
 
Uncontrolled medical or psychiatric disorders which may preclude patients to undergo 
clinical studies (Discretion of the attending physician)  
 
Active infection or second malignancy.  
 
HIV1 (Human Immunodeficiency Virus-1) or HIV2 positive.  
 
Patient with active Hepatitis B or C determined by polymerase chain reaction (PCR). 
 
Pregnant or breastfeeding.  
Donor Eligibility Criteria: Donor choice per MUD committee. 
 
7/8 with either antigen or allele mismatched HLA (-A, -B, -C, and -DR) or 8/8 HLA-
matched with either double DQ mismatch (8/10 match) or combined DQ and DP 
mismatch (10/12 match).  
 
Suitable Donor – Medically cleared to donate per NMDP.  
 
Absence of donor-specific antibodies (DSA) to the mismatched HLA- locus.  
Investigational Product Dosage and Administration: 
The conditioning regimen will consist of either myeloablative (MAC) or reduced intensity 
conditioning (RIC): 
Regimen A (RIC): 
- Fludarabine 25 mg/m2/day IV Days –7, –6, –5, –4, –3 
- Melphalan 140 mg/m2 IV Days -2 (or 100 mg/m2 IV if age ≥60) 
- Day 0 will be the day of infusion of T-cell replete PBSC or BM 

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Regimen B (MAC): 
- Fludarabine 40 mg/m2 over 1hr IV Days -5, -4, -3, -2  
- Busulfan 130 mg/m2 over 3 hrs. Days -5, -4, -3, -2 (PK-guided) 
- Day 0 will be the day of infusion of T-cell replete PBSC or BM 
Regimen C (MAC): 
- Fludarabine 30 mg/m2 IV Days -7, -6, -5 
- TBI 150 cGy twice a day Days -4, -3, -2, -1 (total 1200 cGy) 
- Day 0 will be the day of infusion of T-cell replete PBSC or BM 
 
 
GVHD prophylaxis regimen 
-Cy 50 mg/kg/day IV Days +3, +4 (per institutional preference)  
-Tacrolimus 1 mg continuous IV beginning Day +5 with dose adjusted to maintain a level of 5-15 
ng/mL will be changed to equivalent PO dose once stable. Taper starts around day 90+ if no 
active GVHD 
-Mycophenolate mofetil (MMF) 15 mg/kg PO TID beginning Day +5, Maximum dose 1g PO TID. 
MMF will be stopped Day +35 if no severe GVHD  
-G-CSF 5 µg/kg/day beginning Day +5 until ANC >1,500/mm3 for 3 consecutive days 
Clinical Observations and Tests to be Performed: 
Clinical observations include the endpoints;  
 
GRFS, defined as time from start of treatment (HCT) to grade 3-4 acute GVHD or 
moderate-severe chronic GVHD, relapse, progression or death, whichever occurs first. 
 
Toxicity/infections 
 
Acute and Chronic GVHD 
 
Engraftment (Neutrophil and Platelet Recovery) 
 
Overall and Progression-Free Survival 
 
Relapse/Progression  
 
Quality of Life using validated tools 
Other routine evaluations and ancillary tests will be performed as per standard of care (SOC). 
As research correlative studies we will evaluate the reconstitution of the immune system 
including a comprehensive characterization of the T cell receptor (TCR) repertoire in patients 
who underwent MMUD HCT using a next generation sequencing (NSG) approach. 
Statistical Considerations: 
We will be examining the clinical activity and safety of PTCy in patients undergoing T-cell 
replete MMUD HCT for hematologic malignancy. A total of 38 patients, 19 patients per stratum 
is sufficient to estimate the GRFS rate at 1 year with adequate precision (standard error = .08 
overall, = 0.12 per stratum).  
 
Survival estimates will be calculated using the Kaplan-Meier method and Greenwood 
formula will be used to calculate the standard errors.  
 
The cumulative incidence of relapse/progression and non-relapse mortality will be 
calculated as competing risks according to Gooley et al.1  
Sponsor/Licensee: 

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City of Hope 
Case Report Forms 
Medidata Rave EDC® 

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Table of Contents 
SECTION .......................................................................................................................... PAGE 
Experimental Design Schemas 
1 
Protocol Synopsis 
3 
Table of Contents 
8 
Abbreviations 11 
1.0 
Goals and Objectives (Scientific Aims) 
12 
In patients undergoing T-cell replete HLA-mismatched unrelated donor hematopoietic 
cell transplantation (HCT) for hematologic malignancy, using either an ablative or 
reduced intensity conditioning regimen: ........................................................ 12 
1.1 
Primary Objective .............................................................................................. 12 
1.2 
Secondary Objectives ....................................................................................... 12 
2.0 
Background 
12 
2.1 
Introduction/Rationale for Development ........................................................ 12 
2.2 
Overview of Proposed Study ........................................................................... 18 
3.0 
Patient Eligibility 
19 
3.1 
Patient Inclusion Criteria .................................................................................. 19 
3.2 
Donor Inclusion Criteria .................................................................................... 20 
3.3 
Patient Exclusion Criteria ................................................................................. 20 
3.4 
Inclusion of Women and Minorities ................................................................ 20 
3.5 
Co-enrollment with other HCT trials ............................................................... 21 
4.0 
Screening and Registration Procedures 
21 
4.1 
Screening Procedures ...................................................................................... 21 
4.2 
Informed Consent .............................................................................................. 21 
4.3 
Registration Requirements/Process ............................................................... 21 
4.5 
Randomization and/or Dose Level Assignment ........................................... 22 
5.0 
Treatment Program 
22 
5.1 
Study Schema ................................................................................................... 22 
5.2 
Treatment Overview ......................................................................................... 23 
5.3 
Planned Duration of Therapy .......................................................................... 26 
5.4 
Criteria for Removal from Treatment.............................................................. 26 
5.5 
Subject Follow-Up ............................................................................................. 26 

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5.6 
Supportive Care, Other Concomitant Therapy, Prohibited Medications ... 27 
5.7 
Additional Studies ............................................................................................. 27 
6.0 
Expected Toxicities, Dose Delays/Modifications for Adverse Events 
27 
6.1 
Expected Toxicities (most severe and/or persistent) ................................... 27 
6.2 
Dose Delays and Modifications ....................................................................... 28 
7.0 
Data and Safety Monitoring, Unanticipated Problems and Adverse Event Reporting
 
29 
7.1 
Risk Level ........................................................................................................... 29 
7.2 
Monitoring and Personnel Responsible for Monitoring ............................... 29 
7.3 
Definitions ........................................................................................................... 29 
7.4 
Reporting of Unanticipated Problems and Adverse Events ....................... 30 
8.0 
Agent Information 
30 
8.1 
Busulfan .............................................................................................................. 30 
8.2 
Cyclophosphamide ........................................................................................... 31 
8.3 
Fludarabine ........................................................................................................ 32 
8.4 
Melphalan ........................................................................................................... 32 
8.5 
Total Body Irradiation ....................................................................................... 32 
8.6 
Tacrolimus .......................................................................................................... 33 
8.7 
Mycophenolate mofetil (MMF) ......................................................................... 33 
8.8 
MESNA (sodium -2-mercapto ethane-sulphonate) ...................................... 34 
9.0 
Correlative/Special Studies 
34 
10.0 
Study Calendars 
36 
10.1 
Study Assessment Calendar ........................................................................... 36 
10.2 
Conditioning and GVHD regimens ................................................................. 38 
11.0 
Data Reporting/Protocol Deviations 40 
11.1 
Data Reporting................................................................................................... 40 
11.2 
Protocol Deviations ........................................................................................... 41 
12.0 
Endpoint Evaluation Criteria/Measurement of Effect 42 
12.1 
Primary Endpoint ............................................................................................... 42 
12.2 
Secondary Endpoints: ...................................................................................... 42 
12.3 
Response Criteria ............................................................................................. 43 
13.0 
Statistical Considerations 
48 
13.1 
Study Design ...................................................................................................... 48 

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13.2 
Sample Size Accrual Rate ............................................................................... 49 
13.3 
Statistical Analysis Plan ................................................................................... 50 
14.0 
Human Subject Issues 
50 
14.1 
Institutional Review Board ............................................................................... 50 
14.2 
Recruitment of Subjects ................................................................................... 50 
14.3 
Advertisements .................................................................................................. 50 
14.4 
Study location and Performance Sites ........................................................... 51 
14.5 
Confidentiality .................................................................................................... 51 
14.6 
Financial Obligations and Compensation ...................................................... 51 
14.7 
Informed Consent Processes .......................................................................... 51 
References 
53 
15.0 
Appendix 
58 
 
Appendix A: Comorbidity Index Comorbidity Index .......................................... 58 
15.1 
58 
15.2 
Appendix B: Acute GVHD grading ..................................................................... 59 
15.3 
Appendix C: Chronic GVHD grading .............................................................. 60 
15.4 
Appendix D: Karnofsky Performance Scale: ....................................................... 69 
 

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Abbreviations 
 
Abbreviation 
Meaning 
AE 
Adverse Event 
CFR 
Code of Federal Regulations 
COH 
City of Hope 
CR 
Complete Response 
CRA 
Clinical Research Associate 
CRF 
Case Report Form 
CTCAE 
Common Terminology Criteria for Adverse Events 
CTEP 
Cancer Therapy Evaluation Program 
Cy 
Cyclophosphamide 
DLT 
Dose Limiting Toxicity 
DSMC 
Data Safety Monitoring Committee 
FDA 
Food and Drug Administration 
GCP 
Good Clinical Practice 
GvHD 
Graft versus Host Disease 
IB 
Investigator Brochure 
ICF 
Informed Consent Form 
IDS 
Investigational Drug Services 
IND 
Investigational New Drug  
IRB 
Institutional Review Board 
MTD 
Maximum Tolerated Dose 
NCI 
National Cancer Institute 
PD 
Progressive Disease 
PI 
Principal Investigator 
PMT 
Protocol Monitoring Team 
PR 
Partial Response 
SAE 
Serious Adverse Event 
SD 
Stable Disease 
 

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1.0 
Goals and Objectives (Scientific Aims) 
In patients undergoing T-cell replete HLA-mismatched unrelated donor hematopoietic cell 
transplantation (HCT) for hematologic malignancy, using either an ablative or reduced intensity 
conditioning regimen: 
1.1  Primary Objective 
To estimate the GVHD-free relapse/progression-free survival (GRFS) at one-year post HCT and 
to evaluate the clinical activity of post-transplant high dose cyclophosphamide (PTCy). 
 
1.2 Secondary Objectives 
 
To summarize toxicities/complications/infections including type, frequency, severity, 
attribution, time course and duration through 100 days post-transplant. 
 
To estimate the cumulative incidence (CI) of acute and chronic GVHD. 
 
To characterize the time course of neutrophil and platelet recovery/engraftment. 
 
To 
estimate 
overall 
survival 
(OS), 
progression-free 
survival 
(PFS), 
CI 
of 
relapse/progression and non-relapse mortality (NRM) at 100 days, 1 year and 2 years. 
 
To describe quality of life at 100 days, 6 months, 1 and 2 years. 
 
To characterize immune cell reconstitution and T cell repertoire post high dose 
cyclophosphamide in mismatched donor HCT. 
 
To characterize quality of life. 
 
2.0 
Background 
2.1 Introduction/Rationale for Development 
Allogeneic hematopoietic cell transplantation (HCT) is an established treatment for a large 
number of inherited metabolic and immune deficiencies and for benign and malignant blood and 
marrow conditions. However, Graft-versus-Host-Disease (GvHD) continues to be a major 
problem with substantial morbidity and mortality limiting the general value on the procedure. 
GvHD results from a complex interaction between recipient tissues and genetically disparate 
donor immune system.2  
In the initial phase, damage to the host tissues results in a self-limited burst of inflammatory 
cytokines. Later, donor T cells recognize alloantigens presented by host antigen presenting cells 
(APC) leading to amplification of the systemic inflammatory response, now with contribution of 
donor cells. In the last phase, host tissues are subjected to damage and apoptosis driven 
inflammatory cytokines and cellular effectors, thus establishing a positive inflammatory feedback 
loop. Even in the setting of HLA-matched donors, patient and donor can differ in self-peptides 
derived from minor histocompatibility antigens (mHA). Those polymorphic peptides are 
presented by HLA class I antigens (rarely HLA class II) and can trigger the activation of donor-
derived T cells. A number of these mHAs have been identified.3 In fact, mismatches of known 
mHA among HLA identical donor-recipient pairs have been associated with the development of 
GvHD after HCT.4  
The currently used GvHD prophylactic regimens are based on the routine use of different 
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antithymocyte globulins (ATG).5 Yet even in the setting of HLA-matched donors, clinically 
significant (grade II-IV) and severe (grade III-IV) acute GvHD (aGvHD) still occur in about 35-
50% and 15% of cases, respectively. The latter is always associated with decreased survival.6 
Chronic GvHD (cGvHD) occurs in up to 70% of patients either after aGvHD or de novo and is 
also associated with substantial morbidity and mortality.6 Risk of GvHD is further increased in 
those undergoing mismatched donor transplants leading to absolute decrease in survival 
approaching up to 10% in different studies.6-12   Furthermore, it has been suggested that some 
of the drugs used in the prevention of GvHD might indeed have deleterious effects. For 
instance, methotrexate can independently cause tissue injury; paradoxically exacerbating the 
cytokine cascade associated with GvHD.13 Also calcineurin inhibitors, by suppressing IL-2 T-cell 
responses can be damaging to regulatory (CD4+ CD25+ FoxP3+) T cell population. 14 The 
decrease in number and function of regulatory T cell is associated with worsening of cGvHD. 
15,16 
Approximately 40% and up to 70% of patients with acute and chronic GvHD will have durable 
responses to corticosteroid therapy, respectively. Over the past 20 years, there has been little 
change in this response rate, despite addition or substitution of other immunosuppressive drugs 
to GvHD treatment regimens.17  The prognosis of patients with steroid refractory GvHD is 
poor.18  A strategy that minimizes the incidence of GvHD, without other adverse effects, would 
be an effective approach to improve survival after allogeneic HCT. 
GvHD incidence can be decreased with various pharmacologic agents.  Early transplants were 
done using post-transplant methotrexate to prevent GvHD; in the 1980s cyclosporine was 
shown to be superior to methotrexate and in 1986 the combined use of cyclosporine and 
methotrexate was shown to be superior to single agent prophylaxis.19  More recently, other 
calcineurin-inhibitors, such as tacrolimus have been developed as GvHD prophylactic agents 
due to favorable toxicity profiles in comparison with cyclosporine.20,21 In fact, phase III trials 
comparing tacrolimus/methotrexate versus cyclosporine/methotrexate for related and unrelated 
donors have been performed. In the unrelated donor setting, the incidence of grade II-IV acute 
GvHD was 56% among the 46 patients randomized to tacrolimus arm versus 74% among the 
63 
patients 
randomized 
to 
cyclosporine 
arm.22 
Currently, 
the 
combination 
of 
tacrolimus/methotrexate remains a standard for GvHD prophylaxis, despite its limited efficacy. 
However, improved GvHD prophylaxis is a significant clinical need in HCT.  
2.1.1 Rationale for mismatched unrelated donor (MMUD) and suboptimal outcome 
Only 30% of patients in need of HCT have an available matched sibling donor (MSD), therefore 
the majority of patients who are in need of this procedure will have to undergo an alternative 
donor search. Despite the increasing number of unrelated volunteer donors (UD) available 
through the National Marrow Donor Program (NMDP), significant number of patients will not 
have a well-matched (at least; 8/8 HLA-A, B-, C-, DRB1) unrelated donor (MUD).23 The 
likelihood of finding a matched donor through the registry varies among racial and ethnic 
groups, with the highest probability among whites of European descent (at 75%), and the lowest 
probability among blacks of south or Central American descent (at 16%).23 For those who will 
not have a matched donor available to them, options include mismatched unrelated (MMUD), 
cord blood, or haploidentical donors. Early studies of HCT with alterative donor sources have 
reported worse outcome due to poor engraftment, delayed immune reconstitution with increased 
risk of infection, and high incidence of GvHD. Progress in the last decade has significantly 
improved the outcome of alternative donor HCT. This progress is attributed to better donor 
selection, vigorous and on-target GvHD prophylaxis, and the introduction of more suitable 

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preparative regimens. These advances make the alternative donor HCT a feasible option for 
patients who are in need of procedure and lack a suitable matched donor. 
 
In previously reported registry studies, MMUD HCT has been associated with inferior transplant 
outcomes regardless of preparative regimen intensity,8,24,25 and graft source [bone marrow (BM) 
or peripheral blood stem cell (PBSC)]8,10,26  used. This was largely due to increased risk of 
GvHD and NRM resulting in inferior OS. This deleterious effect was seen across all disease 
categories, except possibly the high-risk group where risk of disease relapse significantly 
outweighs risk of TRM.24 This was true with most standard GvHD prophylaxis regimens of 
methotrexate combined with a calcineurin inhibitor (CI). When the novel tacrolimus/sirolimus 
(T/S)-based 
GvHD 
prophylaxis 
regimen 
was 
compared 
with 
“standard 
of 
care” 
methotrexate/tacrolimus (M/T) in a phase III randomized study, results were equivalent in the 
setting of fully matched related donor alloHCT.27  Smaller single center phase II randomized 
study including both MSD and MUD showed similar outcomes with the advantage of decreasing 
grade II-IV aGvHD and possibly moderate to severe chronic GvHD.28  
 
With promising results in matched donor HCT, it has been used in the setting of MMUD with or 
without additional agents (ATG, Methotrexate, bortezomib, etc.). The outcome of this group of 
patients was never studied systemically until recently when it was presented in large 
retrospective cohort by our group (Al Malki, MM. et al. BBMT 2016; Abstract 7712).  In this 
study, we evaluated a consecutive case-series of 482 patients who underwent URD HCT at City 
of Hope from 2005 to 2013 using a MUD (8/8 matched at HLA-A, B, C, and DR: n=351) or 
MMUD (≤7/8 match: n=131). Mini-MTX was added in 25% of patients, ATG in 6.4%, or both in 
1.8%. Conditioning was myeloablative in 45% of patients. Indication for HCT was acute 
leukemia (n=308), MDS/MPN (n=69), NHL (n=68), HL (n=4), CLL (n=12), CML (n=16), and 
multiple myeloma (n=5). Disease risk was low in 38%, intermediate in 22% and high in 40% of 
the patients. With the exception of age (median 54.6 [range: 18.0-73.8] for MUD, 45.2 [range: 
18.7-71.8] 
for 
MMUD, 
p<0.01), 
conditioning intensity 
(MAC: 
41.0% 
in 
MUD, 
55.7% 
in 
MMUD, p<0.01), and 
the use of additional 
agent 
for 
GVHD 
prophylaxis (21% in 
MUD, 
69% 
in 
MMUD, p<0.01) pre-
HCT patient/disease 
characteristics were 
similar. 
With 
the 
median follow-up of 
3.3 
years 
(range: 
0.6-8.9) for surviving 
patients, 
OS 
was 
significantly lower in 
the MMUD group (at 
3-years: 46% [95%CI: 36-54] and 59% [95%CI: 54-64] respectively, p=0.009, Figure 1) 
Figure 1. Overall Survival post-transplant based on HLA matching  

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Figure 2: Treatment schema of patients undergoing haploidentical donor transplants in the 
BMT CTN 0603 clinical trial. 
primarily due to increased non-relapse mortality (34% vs. 19% p=0.002). While differences were 
not seen in relapse, aGvHD (grade 2-4 or 3-4) or cGvHD (limited or extensive), death caused by 
cGvHD and infection was significantly greater in MMUD (13% vs. 7%, p=0.02, 11% vs. 5%, 
p<0.01; respectively).  By multivariable analysis, MMUD (HR=1.4 [95%CI: 1.1-1.9] p=0.02) and 
high-risk disease (HR= 1.9 [CI: 1.4-2.5] p<0.01) were predictive factors for OS.  
 
Therefore, novel GvHD prophylaxis regimens are needed to overcome the inferior outcome in 
this group of patients who receive MMUD HCT.  
 
2.1.2 Rationale for Post-transplant Cyclophosphamide for GvHD prophylaxis 
High dose cyclophosphamide is a potent immunosuppressive agent that has been successfully 
used to prevent GvHD in unrelated, HLA-matched sibling and haploidentical bone 
marrow/PBSC transplants in single center as well as in multi-center studies.29-34 Preclinical 
studies have shown that cyclophosphamide administered early post HCT preferentially kills 
activated alloreactive T cells while sparing resting, non-alloreactive T cells leading to 
suppression of GvHD as well as increased rates of graft rejection.30 Furthermore, a recent study 
showed that human regulatory T cells are resistant to PTCy and contribute to its GvHD 
preventive effects.35 
Recently, cyclophosphamide has been administered in high doses after transplantation as the 
only GvHD prevention strategy both in the setting of myeloablative and reduced intensity 
conditioning.29 Cyclophosphamide inhibits rapidly proliferating T cells in a manner similar to 
methotrexate.36  However, the agent spares the hematopoietic stem cells and gastro- intestinal 
tract because of their high content in aldehyde dehydrogenase (AD), which converts 4-
hydroxcyclophosphamide into a non-alkylating metabolite.37  In a mouse model, the drug 
fostered conversion of naïve CD4 + T cells into regulatory T cells (Ganguly, S. et al. Blood 
2010; Abstract 3749). 
2.1.2.1 Post-transplant Cyclophosphamide in Haploidentical Donor Transplants 
Based on promising pre-clinical results at Johns Hopkins, a Phase I/II clinical trial of 
haploidentical HCT to treat high-risk hematologic malignancies was initiated in 1999.38,39  
Following a non-myeloablative (NMA) regimen of fludarabine, cyclophosphamide, and low-dose 
TBI, GvHD prophylaxis consisted of cyclophosphamide (PTCy) given on Days +3 and +4 post-
transplant, tacrolimus, and mycophenolate mofetil (MMF) (Figure 2).33  Primary graft failure 

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occurred in 13% of patients, and was fatal due to infection in one patient in whom autologous 
hematopoiesis failed to occur.  In general, complete T-cell engraftment was observed by Day 
+28 or the grafts were rejected.  Cumulative incidences of grades II-IV and grades III-IV acute 
GvHD by Day 200 were 34% and 6%, respectively.  There was lower incidence of extensive 
chronic GVHD among recipients of two versus one dose of PTCy (5% versus 25%; p=.05).  
There was no difference in the incidence of severe acute GvHD with one or two doses of PTCy.  
The cumulative incidences of non-relapse mortality and relapse at 1 year were 15% and 51%, 
respectively. Overall and event-free survivals (EFS) at two years after transplantation were 36% 
and 26%, respectively.  Patients with lymphoid malignancies appeared to have improved EFS 
compared to those with myeloid malignancies (p=0.02). 
The Blood and Marrow Transplant Clinical Trials Network (BMT CTN) sponsored a multi-center 
Phase II trial of haploidentical BMT (BMT CTN 0603) for high-risk hematologic malignancies 
modeled after the Hopkins approach.  This was published along with a similar study using cord 
blood grafts without PTCy (BMT CTN 0604).32 The 1-year probabilities of OS and PFS were 
54% and 46% after cord transplantation and 62% and 48% after haploidentical bone marrow 
transplantation.   
The Day +56 cumulative incidence of neutrophil recovery was 94% after double umbilical cord 
blood and 96% after haploidentical marrow transplants.  The 100-day cumulative incidence of 
grade II-IV acute GVHD was 40% with cord blood and 32% with haploidentical bone marrow.  
The 1-year cumulative incidences of NRM and relapse after cord transplantation were 24% and 
31%, respectively; corresponding rates after haploidentical bone marrow transplantation were 
7% and 45%.  
The use of PBSC instead of marrow may allow wider applicability of this approach but there is 
concern about higher risks of acute and chronic GVHD due to the 5-10-fold higher number of T-
cells in the allograft. Recently, groups from Atlanta, Houston and London reported studies in 
which PBSC were substituted for bone marrow with PTCy in the haploidentical donor setting. 
Error! Bookmark not defined.40-42  In those studies, the incidences of severe acute GVHD, 
chronic GVHD and non-relapse mortality at 1 year with PBSC were comparable to the rates 
seen with bone marrow. 
2.1.2.2 PTCy in HLA Matched Donors 
After the success of PTCy in the prevention of GvHD in the setting of haploidentical 
transplantation, Luznik et al29 reported a large study of patients who underwent allogeneic HCT 
from HLA-matched donors after MA conditioning using busulfan-cyclophosphamide (BuCy) and 
PTCy as a single agent for prophylaxis of GvHD. A total of 117 patients with high-risk 
hematologic malignancies were transplanted from MSD (n=78) or MUD (n=39). Half of the 
patients were not in remission at the time of transplant.  Bone marrow grafts were used for all 
patients. The incidence of GvHD was remarkably low (43% grades II-IV acute, 10% grades III/IV 
acute, 10% chronic) showing the effectiveness of the approach (Figure 3).  There was no 
difference in the incidence of acute or chronic GvHD between MSD and MUD.  Almost two-
thirds of the patients did not require any additional immunosuppressive therapy after PTCy.  
Patients who did develop GvHD responded to steroids alone in 20% of cases or steroids plus a 
second agent (calcineurin or non-calcineurin) in 75% of cases.  Rates of grade II-IV acute and 
chronic GVHD were both 10%.  Observed rates of non-relapse mortality and disease relapse 
were 20% and 44%, respectively.  This study showed that PTCy was effective as a single-agent 
to prevent severe acute or chronic GvHD in the vast majority of patients undergoing MAC HCT 
from matched donors.  Only 3% of deaths were due to infection suggesting that immune 

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reconstitution is robust in such patients.  Obviating the need for ongoing immunosuppression 
post-transplant provides an optimal platform for cellular therapy to prevent or treat relapsed 
disease.    
 
Figure 3. GVHD incidence after a myeloablative post-transplant Cy regimen (Luznik et al.29) 
These encouraging outcomes with PTCy in prevention of GvHD were recently reproduced in a 
multi-institutional study that effectively combined this novel single-agent short-course GvHD 
prevention strategy in combination with IV Bu/Flu MA conditioning.  In this study,43 92 adult 
patients (median age 49; range=21-65) with high-risk hematologic malignancies were enrolled 
at three centers.  Forty-five (49%) patients received related allografts, and 47 (51%) received 
unrelated allografts.  GvHD prophylaxis was solely with PTCy at 50 mg/kg/day on post-
transplant days +3 and +4 after bone marrow allografting. The cumulative incidences of grade 
II-IV acute, grade III-IV acute, and chronic GVHD were 51%, 15%, and 14%, respectively.  NRM 
at 100 days and 1 year were 9% and 16%, respectively.  With a 2.2 year median follow-up, the 
two-year EFS and OS were 62% and 67%, respectively.  Donor type did not impact on NRM, 
EFS, or OS.  Patients in complete remission (CR) without evidence of minimal residual disease 
had remarkably high rates of EFS (80%) and OS (79%). 
Champlin, R. el al reported a similar GvHD preventive strategy in the setting of RIC combining 
fludarabine, busulfan with or without rabbit ATG in a group of 31 older and medically frail 
patients receiving matched related or unrelated donor transplant (Alousi, A. et al. Blood 2010; 
Abstract 2314). The incidence of grade III and IV acute GvHD was 13% and of chronic GvHD 
11%. Primary and secondary graft failure occurred in 1 and 2 patients respectively. The 1-year 
OS of was impressive for such a high-risk population.  
In another study conducted by the group in Atlanta44, PTCy was combined with a brief course of 
sirolimus in a calcineurin inhibitor-free regimen. Twenty-six patients (median age, 61 years) 
underwent unmanipulated PBSC HCT from an 8/8 locus-matched donor (MRD= 17; MUD= 9). 
Donor engraftment occurred in all patients. The cumulative incidence of grade II-IV acute 
GVHD, grade III-IV acute GVHD, and chronic GVHD was 46%, 15%, and 31% respectively. 
One-year NRM was 4%. The median time to immunosuppression discontinuation was day 
+138. With a median follow-up of 20 months, the estimated 2-year overall survival was 71%, 
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with a lymphoid malignancy (e.g., chronic lymphoblastic leukemia, non-Hodgkin lymphoma, 
Hodgkin disease), 2-year disease-free survival was 100%, and there were no relapses. Good 
immune reconstitution was evidenced by low cytomegalovirus reactivation rate of 21% (n=4/19).  
Al-Homsi, A. et al. reported feasibility of phase I combining PTCy with a brief course of 
proteasome inhibitor (i.e. bortezomib)45, in this study 15 patients underwent reduced-intensity 
PBSC HCT from MSD or MUD. Cyclophosphamide was given at a fixed dose (50 mg/kg on 
days +3 and +4). Bortezomib dose was started at 0.7 mg/m2, escalated up to 1.3 mg/m2, and 
was administered on days 0 and +3. Patients receiving grafts from MUD also received rabbit 
ATG. The combination was well tolerated and allowed prompt engraftment in all patients. The 
incidences of acute GVHD grades II to IV and grades III and IV were 20% and 6.7%, 
respectively. With a median follow-up of 9.1 months (range, 4.3 to 26.7), treatment-related 
mortality was 13.5% with predicted 2-year disease-free survival and overall survival of 55.7% 
and 68%, respectively.  
With the excellent results obtained in these studies and the ineffectiveness of the available 
“standard” GvHD prophylaxis regimens in overcoming the deleterious effect of HLA- 
mismatched donors, we expect that the use of PTCy for GvHD prophylaxis as a novel regimen 
will improve outcomes of patients undergoing MMUD HCT in this clinical trial. 
2.1.3 Immune reconstitution after PTCy 
The ability to shorten the duration of post-grafting immunosuppression after HLA-matched 
allogeneic HCT with PTCy was marked by prompt immune reconstitution and a low incidence of 
opportunistic infections.  Among 47 patients studied immune-phenotypically after HLA-matched 
HCT; the mean CD4+ T cell count on day 30 was 98 cells/μl and on day 60 was 124 cells/μl.35 At 
both days 30 and 60 after HCT, the CD8+ T cell counts were already within the normal range.  
Effector regulatory T cells rapidly recovered to donor levels by 30 days after HCT, and there 
was favorable memory CD4+ T cell recovery compared with naïve CD4+ T cells. 
In the above-described studies,29,43 no patients died of CMV or invasive fungal infection. 
Reactivation of CMV occurred in 29% of patients, and there were only two documented cases of 
CMV disease. The rapid recovery of CMV-specific immunity correlated with the results of in vitro 
ELISPOT assays.  The frequency of cells secreting interferon gamma in response to stimulation 
with pentadeca-peptides of the immune-dominant CMV protein, pp65, at day 30–60 after 
alloHCT 
did 
not 
differ 
from 
pre-transplantation 
specimens 
from 
CMV-seropositive 
donor/recipient pairs. The absence of post-transplantation Epstein–Barr virus-associated 
lymphoproliferative disease is another indicator of the prompt immunologic recovery seen with 
PTCy. 46 
Immune reconstitution after PTCy was studied in the setting of Haploidentical HCT and has 
been shown to be comparable to immune reconstitution in matched donor (MSD and MUD) 
undergoing transplant with “standard” GvHD prophylaxis regimen.35,46,47 But this needs to be 
studied in the setting of MMUD, which is going to be one of the objectives of this clinical trial as 
well.  
2.2 Overview of Proposed Study 
This is a single center, pilot/estimation study to evaluate the clinical activity associated with the 
use of PTCy in preventing severe grades of acute/chronic GvHD and reducing NRM/PFS in 
patients with hematological disease receiving an HLA-mismatched unrelated donor HCT after 
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assess the clinical activity associated with the addition of PTCy through estimation of GRFS at 1 
year overall and by conditioning regimen (MAC and RIC). 
This study will be conducted in compliance with the protocol, Good Clinical Practice (GCP) and 
the applicable regulatory requirements. 
3.0 
Patient Eligibility 
3.1 Patient Inclusion Criteria  
1. Age Criteria: 5 to 75 years of age if meets criteria for HCT per SOP 
2. Patients with acute leukemia or chronic myelogenous leukemia with no circulating 
blasts and with less than 10% blasts in the bone marrow. 
3. Patients with myelodysplastic syndrome [MDS] with intermediate-2 or high risk per 
IPSS (or intermediate, high, very high risk by IPSS-R) or myeloproliferative neoplasm; 
primary or secondary if high-risk features or refractory disease. 
4. Patients with chronic lymphocytic leukemia/small lymphocytic lymphoma, follicular, 
marginal zone, diffuse large B-cell, Hodgkin Lymphoma, or mantle cell lymphoma with 
chemosensitive disease at time of transplantation. All types of lymphoma are eligible. 
5. High risk, or refractory and relapsed Multiple Myeloma. 
6. No available suitable HLA-matched related donor  
7. Available matched unrelated donor (see Section 3.2) 
8. Cardiac function: Ejection fraction at rest ≥ 50%. 
9. Karnofsky Performance Status (KPS) ≥70 (Appendix D) 
10. Measured creatinine clearance more than 60 mL/min.  The updated Schwartz formula 
should be used for pediatric patients (≥5 to 12 years old. 
11. Pulmonary function: DLCO ≥ 50% (adjusted for hemoglobin) and FEV1 ≥ 50%. 
12. Liver function: total bilirubin < 1.5 x the upper limit of normal and ALT/AST and 
alkaline phosphatase < 2.5x the upper normal limit. Patients who have been 
diagnosed with Gilbert’s Disease are allowed to exceed the defined bilirubin value of 
1.5x the upper limit of normal. 
13. Female subjects (unless postmenopausal for at least 1 year before the screening 
visit, or surgically sterilized), agree to practice two (2) effective methods of 
contraception at the same time, or agree to completely abstain from heterosexual 
intercourse, from the time of signing the informed consent through 12 months post-
transplant. 
14. Male subjects (even if surgically sterilized), of partners of women of childbearing 
potential must agree to one of the following: practice effective barrier contraception, or 
abstain from heterosexual intercourse from the time of signing the informed consent 
through 12 months post-transplant. 
15. All subjects must have the ability to understand and the willingness to sign a written 
informed consent. 

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3.2 Donor Inclusion Criteria  
1. 7 out of 8 at high resolution using DNA-based typing with either antigen or allele 
mismatched HLA (-A, -B, -C, and -DR) or 8/8 HLA-matched with either double DQ 
mismatch (10/12) or combined DQ and DP mismatch. 
2. Donor must be willing to donate peripheral blood stem cells. 
3. Suitable Donor – Medically cleared to donate per NMDP.  
4. Absence of DSA to the mismatched HLA- locus.  
5. Donor choices per MUD committee according to center SOP. 
 
3.3 Patient Exclusion Criteria 
1. Prior allogeneic transplant. 
2. Active CNS involvement by malignant cells. 
3. Patients with uncontrolled bacterial, viral or fungal infections (currently taking medication 
and with progression or no clinical improvement) at time of enrollment. 
4. Patients with transformed lymphoma (e.g., Richter’s transformation arising in follicular 
lymphoma or chronic lymphocytic leukemia). 
5. Patients seropositive for the human immunodeficiency virus (HIV). 
6. Patient with active Hepatitis B or C determined by polymerase chain reaction (PCR). 
7. Myocardial infarction within 6 months prior to enrollment or New York Heart Association 
(NYHA) Class III or IV heart failure, uncontrolled angina, severe uncontrolled ventricular 
arrhythmias, or electrocardiographic evidence of acute ischemia or active conduction 
system abnormalities.  Prior to study entry, any ECG abnormality at screening must be 
documented by the investigator as not medically relevant. 
8. Female patients who are lactating or pregnant. 
9. Patients with a serious medical or psychiatric illness likely to interfere with participation 
in this clinical study 
10. History of another primary malignancy that has not been in remission for at least 3 years 
(the following are exempt from the 3-year limit: non-melanoma skin cancer, fully excised 
melanoma in situ [Stage 0], curatively treated localized prostate cancer, and cervical or 
breast carcinoma in situ on biopsy or a squamous intraepithelial lesion on PAP smear). 
11. Psychosocial issues: no appropriate caregivers identified, or non-compliant to 
medications 
12. Subjects, who in the opinion of the investigator, may not be able to comply with the 
safety monitoring requirements of the study. 
 
3.4 Inclusion of Women and Minorities 
The study is open anyone regardless of gender or ethnicity.  Efforts will be made to extend the 
accrual to a representative population, but in a trial which will accrue approximately 38 subjects, 
a balance must be struck between subject safety considerations and limitations on the number 
of individuals exposed to potentially toxic or ineffective treatments on the one hand and the 
need to explore gender, racial, and ethnic aspects of clinical research on the other. If 
differences in outcome that correlate to gender, racial, or ethnic identity are noted, accrual may 
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3.5 Co-enrollment with other HCT trials 
In principle co-enrollment with other interventional trials is allowed including therapeutic trials for 
GVHD.   
4.0 
Screening and Registration Procedures 
4.1 Screening Procedures 
Diagnostic or laboratory studies performed exclusively to determine eligibility for this trial will be 
done only after obtaining written informed consent. Studies or procedures that were for clinical 
indications (not exclusively to determine study eligibility) may be used for baseline values, even 
if the studies were done before informed consent was obtained. Reference is made to Section 
10.0 – Study Calendar. 
4.2 Informed Consent  
The investigational nature and objectives of the trial, the procedures and treatments involved 
and their attendant risks and discomforts, and potential alternative therapies will be carefully 
explained to the subject and a signed informed consent will be obtained. Documentation of 
informed consent for screening will be maintained in the subject’s research chart and medical 
record.   
4.3 Registration Requirements/Process 
To register a subject, the subsequent procedure is to be followed. 
1. The data manager/coordinator/research nurse should contact the DCC via 
telephone or email to provide notification regarding the pending registration and 
communicate desired timeline of the registration, especially if it must be 
completed promptly to meet the registration window. 
2. The data manager/coordinator/research nurse should then e-mail copies to 
DCC@coh.org of the following documents to the DCC:  
o Completed Eligibility Criteria List 
o Source documentation to support eligibility criteria**  
o Signed informed consent document 
o Signed HIPAA authorization form (if separate from the informed 
consent document) 
o Signed subject’s Bill of Rights  
** Provide copies of source documentation only if not readily available as a finalized record in 
the COH Electronic Medical Record (EMR).  
3. After having received all transferred documentation, the DCC will complete the 
review the documents to verify eligibility, working with the CRC/Protocol Nurse as 
needed to resolve any missing required source elements. A participant failing to 
meet all protocol eligibility requirements will not be registered.  
4. Once eligibility has been confirmed, DCC staff will register the participant by: 
assigning a subject accession number, register the subject on study centrally into 

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COH clinical trials management system and enter the subject into the eCRF 
system, Medidata RAVE. 
5. Once registration has been completed, DCC staff will send a Confirmation of 
Registration Form, including the participant study number to the study team.  
 
4.4 Screen Failures and Registered Participants Who Do Not begin Study Treatment 
The DCC is to be notified of all participants who sign consent but do not meet eligibility criteria 
or do not initiate study treatment. 
 
4.5 Randomization and/or Dose Level Assignment  
Not applicable 
5.0 
Treatment Program 
5.1 Study Schema 
Note: A window of 1-2 days is allowed for stem cell availability. 
 

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5.2 Treatment Overview 
Note: a window of 1-2 days is allowed for stem cell availability. A window of ±7 days is allowed 
for outpatient procedures before day +100. For outpatient procedures between day +100 and 
+270, a window of 14 days; and for outpatient procedures after day +365, a window of 30 days 
is allowed. 
5.2.1 Conditioning Regimens 
Eligible patients will receive either myeloablative (MA) or reduced intensity (RI) conditioning 
regimen following guidelines per institutional SOP and according to the discretion of the 
attending physician and principle investigator as shown in the Table below.  Other regimens not 
included in the Table, might be considered after review by the principle investigator. Patients are 
typically admitted to the hospital the day before the conditioning regimen begins and remain 
inpatient until after engraftment of neutrophils is verified (~2-3 weeks) and they are able to eat. 
After discharge from the hospital, remaining visits and tests are outpatient unless problems are 
encountered. 
 
 TABLE: CONDITIONING REGIMENS 
Reduced Intensity (RIC) Conditioning 
Myeloablative (MAC) Conditioning 
Fludarabine/Melphalan (Flu/Mel) 
 
Fludarabine 25 mg/m2 IV  
Days –7, –6, –5, –4, –3 
 
Melphalan 140 mg/m2 IV Day -2 (or 
100 mg/m2 IV if age ≥60) 
Fludarabine /Total Body Irradiation (Flu/TBI) 
 
Fludarabine 30 mg/m2 IV Days -7,-6,-5 
 
FTBI 150 cGy twice a day Days -4, -3, -2, -1 
(total 1200 cGy) 
 
Fludarabine/ Busulfan (Flu/Bu) 

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5.2.1.1 Fludarabine/Melphalan (Flu/Mel) 
The allowable Flu/Mel regimen is the following: 
 
Fludarabine 25 mg/m2/day infused IV over 60 minutes on Days –7, –6, –5, –4, –3 
 
Melphalan 140 mg/m2 IV (or 100 mg/m2  IV if age ≥60) Day -2 
The sequence of fludarabine and melphalan administration will be done according to 
institutional standards as long as the prescribed doses are the same as the 
recommended regimen above. 
 
5.2.1.2 Fludarabine /Total Body Irradiation (Flu/FTBI) 
The allowable FluFTBI regimen is the following: 
 
Fludarabine 30 mg/m2 IV infused IV over 60 minutes on Days -7, -6, -5 
 
FTBI is administered at a dose rate of < 20 cGy/minute.  Doses of 150 cGy/ fraction are 
administered at a minimum interval of 4 hours between fractions, twice a day for a total 
of 8 doses (1200 cGy) over 4 days (Day -4, -3, -2 and -1).  Sequential doses are 
administered in an anterior/posterior or lateral orientation.  The orientation of FTBI 
chosen will be left to the discretion of the radiation oncology specialist.  In addition, for 
male patients receiving transplants for ALL or AML, the use of boost to the testes is 
allowed according to institutional practices.  General anesthesia is allowed (e.g., young 
children).  
5.2.1.3 Fludarabine/ Busulfan (Flu/Bu) 
The allowable FluBu regimen is the following: 
 
Days -5 to -2: 130 mg/m2 this will be infused over 3 hrs. Daily for 4 days; total dose of 
520 mg/m2. Busulfan should be administered per institutional guidelines and PK 
guidance is advisable.  
 
Days -5 to -2: Flu 40 mg/m2 this will be infused over 1 hrs. Daily for 4 days, total dose of 
160 mg/m2. 
The sequence of busulfan and fludarabine administration will be done according to institutional 
standards as long as the prescribed doses are the same as the allowable regimen above. Only 
IV Busulfan is allowed. For patients receiving busulfan doses according to pharmacokinetics, 
targeting doses to area under the curve of 4000 μMol/min or less is allowed. 
For CNS seizure prophylaxis, the use of Keppra is allowed. Phenytoin and other potent CYP3A4 
inducers are not allowed for seizure prophylaxis to avoid drug interactions. 
 
Fludarabine 40 mg/m2 IV Days -5, -4, -3, -2  
 
Busulfan 130 mg/m2 Days -5, -4, -3, -2 (PK-
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5.2.2 Hematopoietic Cell Graft Source 
Mobilized PBSC is the preferred graft source for patients enrolled in this clinical trial. BM 
could be used alternatively at the discretion of the attending physician and principle 
investigator 
 
Donors will undergo G-CSF mobilization according to institutional and donor center 
practices.  PBSC will be collected by apheresis according to local institutional guidelines.  
Plasma and red cell depletion are allowed for volume reduction or ABO incompatibility 
but any other form of graft manipulation (including ex-vivo T cell depletion) is not 
permitted. The target stem cell dose is between 2 x 106/kg and 6 x 106/kg (actual body 
weight) CD34+ cells. The maximum CD34+ cell dose is 6 x 106/kg.  Up to two 
leukapheresis procedures may be performed to obtain the minimum CD34+ cell target.  
If, after two leukapheresis procedures, fewer than 2 x 106/kg CD34+ cells have been 
collected, transplant centers will have the discretion to continue PBSC cell harvesting or 
to proceed to bone marrow harvesting to obtain sufficient cells.  If more than 6 x 106/kg 
CD34+ stem cells are collected, the excess will be cryopreserved for future use, but will 
not be administered to the patient. 
PBSC will be administered on Day 0 to all patients according to institutional guidelines 
after appropriate processing and quantification has been performed by the local 
laboratory. Stem cells are administered through an indwelling central venous catheter. If 
infusion occurs over two days, Day 0 is the day the last infusion is completed.  
 
Bone marrow harvest can be done under either general or regional (epidural, spinal) 
anesthesia.  Donor bone marrow will be harvested with a target yield of 4 x 108 TNC/kg 
recipient ideal body weight (IBW). The bone marrow graft will not be manipulated to 
deplete T cells. Patients will receive unprocessed marrow unless there is an ABO 
incompatibility, in which case red blood cells or plasma will be depleted from the donor 
marrow using institutional practices. Processing for reduction of volume, plasma or fat 
may be performed by the transplant center according to institutional guidelines. 
 
5.2.3 GvHD prophylaxis (Investigational part)  
5.2.3.1 Tacrolimus/Mycophenolate Mofetil/Cyclophosphamide 
5.2.3.1.1 Tacrolimus 
Tacrolimus will be given by continuous intravenous infusion at flat dose of 1 mg/day 
starting Day +5.  Serum levels of tacrolimus will be measured at Day 7 and then should 
be checked weekly at least thereafter, and the dose adjusted accordingly to maintain a 
suggested level of 5-15 ng/mL.  Tacrolimus taper can be initiated at a minimum of 90 
days post HCT if there is no evidence of active GVHD.  The rate of tapering will be done 
according to institutional practices but patients should be off tacrolimus by Day 180 post 
HSCT if there is no evidence of active GVHD.  
Dose reductions should be made if toxicity is present or whole blood levels are above 
the recommended range, in the absence of toxicity.  Patients with severe intolerance of 
tacrolimus may be placed on cyclosporine (trough level of 200-400 ng/mL) or sirolimus 
(trough level of 3-8 ng/mL). 

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5.2.3.1.2 Mycophenolate mofetil (MMF) 
MMF will be given at a dose of 15 mg/kg TID (based upon actual body weight) with the 
maximum total daily dose not to exceed 3 grams (1g TID, IV or PO).  MMF prophylaxis 
will start Day 5 and discontinue after the last dose on Day 35, or may be continued if 
active GVHD is present.  
5.2.3.1.3 Cyclophosphamide 
Hydration and Mesna support prior to and after cyclophosphamide may be given 
according to institutional standards.  Cyclophosphamide will be given on Day 3 post-
transplant (between 68 and 72 hours after the start of the HPC infusion) and on Day 4 
post-transplant (24 hours after Day 3 cyclophosphamide).  Cyclophosphamide will be 
given as an IV infusion over 1-2 hours (depending on volume) at a dose of 50 mg/kg 
ideal body weight (BW); if Actual BW < Ideal BW, use Actual BW. If Actual BW>125% of 
IBW, use Adjusted BW]. 
It is crucial that no immunosuppressive agents are given prior to transplant, or 
until 24 hours after the completion of the post-transplant cyclophosphamide.  This 
includes corticosteroids as anti-emetics. 
5.2.3.2 G-CSF Support 
G-CSF 5 µg/kg/day will be given beginning Day +5 until ANC >1,500/mm3 for 3 
consecutive days. The G-CSF dose may be rounded per institutional guidelines.  
5.3 Planned Duration of Therapy 
Initial therapy (transplant conditioning, stem cell infusion, start of GVHD prophylaxis) will require 
3-4 weeks of inpatient treatment).  
5.4 Criteria for Removal from Treatment 
Disease relapse or progression and non-compliance with protocol are grounds for removal from 
treatment. 
5.5  Subject Follow-Up 
Outpatient follow-up will be twice weekly for the first 100 days post-transplant, twice monthly 
until 6 months post-transplant, and monthly until the patient is off immunosuppressive therapy 
without evidence of GVHD (see Study Calendar Section 10.0), with at least yearly study follow-
up extending 2 years beyond the date of stem cell infusion. Patients will be co-enrolled in the 
COH long-term follow-up protocol for allogeneic transplantation (Protocol #00029). For relapse 
patients, follow-up at each time point will be for survival only. 
5.5.1 Quality of life (QOL) assessment 
QOL assessments include self-reported patient questionnaires: SF-36, FACT-BMT, and 
MDASI for English and Spanish speaking patients > 18 years, and PedsQL Stem Cell 
Transplant Module for English speaking pediatric patients (ages 8 through 18 years). 
Patients will be asked to fill out QOL assessment forms at 100 days, 6 months, and 18 
months and 2 years post-HCT. 
 

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5.6 Supportive Care, Other Concomitant Therapy, Prohibited Medications 
5.6.1 Supportive Care 
Dietary, anti-infective prophylaxis and blood product support will comply with COH HCT SOPs. 
5.6.2 Concomitant Therapy/Prohibited Medications 
It is crucial that no immunosuppressive agents are given prior to transplant, or until 24 
hours after the completion of the post-transplant cyclophosphamide.  This includes 
corticosteroids as anti-emetics. 
 
5.7 Additional Studies 
We will study the reconstitution of the immune system after T-replete HCT with PTCy as well as 
rate and severity of infectious disease complications.   
5.7.1 Laboratory Studies 
See Section 10.0 – Study Calendar for a complete list of required laboratory procedures. 
Correlative studies including immune cell reconstitution studies (T and B cells, and NK cells)- 
TCR repertoire, and assessment of plasma cytokines and GVHD biomarkers (described in 
Section 9.0) will be performed on patient peripheral blood and plasma samples at pre-
transplant, and post-transplant on days7, 14, 21, 28 (±2 days), 42, 63 (± 7 days) 100 and 180 (± 
14 days), and, 1 and 2 years (± 30 days) post-transplant. 
6.0 
Expected Toxicities, Dose Delays/Modifications for Adverse Events 
6.1 Expected Toxicities (most severe and/or persistent) 
HCT conditioning consists of high dose combination chemotherapy and may results in multiple 
grade 3 and 4 toxicities of both hematological and non-hematological systems by CTCAE v4.03. 
Transplant toxicities are captured using the Modified Bearman Scale for transplant toxicities48. 
See Section 8 for toxicities specific to the agents used for conditioning. Generalized potentially 
lethal or irreversible toxicities expected in allogeneic HCT are listed here. 
6.1.1 Myelosuppression 
All permitted HCT conditioning regimens cause potentially lethal myelosuppression that requires 
stem cell infusion for replacement of blood and immune functions. If the infused stem cells fail to 
engraft, death may result. 
6.1.2 Graft Infusion Reactions 
Symptoms may include changes in heart rate and/or rhythm, changes in blood pressure, 
fever, chills, sweats, nausea, vomiting, diarrhea, abdominal cramping, hemoglobinuria, 
acute renal failure, allergic reactions, respiratory dysfunction, or headache. 
6.1.3 Infections 
Transplantation puts the patient at higher risk for bacterial, viral, or fungal infections, which 
are potentially life-threatening.  Prophylaxis will be initiated and patients will be closely 
monitored for signs of infections and will receive early and appropriate treatment. 

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6.1.4 Graft-versus-host Disease 
After allogeneic transplantation, chronic GVHD may develop that can be disabling and can 
lead to death.  GVHD is thought to be initiated by T-cells contained in the graft.  PTCy 
reduce the number of alloreactive T-cells but GVHD can still occur after transplant. 
6.1.5 Sinusoidal Obstruction Syndrome (SOS)/ Veno-occlusive Disease (VOD) of the 
Liver  
SOS/VOD is a manifestation of damage to the liver by the conditioning regimen that usually 
develops within two weeks after allogeneic transplant and is characterized by at least two of 
the following: 
 
Hyperbilirubinemia (total bilirubin > 2 mg/dL) 
 
Hepatomegaly or right upper quadrant pain, or 
 
Sudden weight gain (> 5% above baseline) 
Recipients developing SOS/VOD will receive appropriate supportive care and careful fluid 
management.   
6.1.6 End Organ Damage 
End organ damage of any or all of the major organs, including the brain, may occur as a result 
of cumulative toxicity from anti-neoplastic therapy, reactions to other drugs, and as a result of 
destructive processes (e.g., infection, GVHD, etc.) and may have a fatal outcome.  Toxicities 
may occur in any individual patient due to multiple events and cumulative effects that may 
involve any and all organs, including the brain.  Brain damage can result in severe loss of 
cognitive or neurologic function 
6.1.7 Lymphoproliferative Syndrome 
Recipients of allogeneic grafts have an increased risk of developing post-transplant 
lymphoproliferative disorder (PTLD) caused by EBV especially in the case of long-term 
immunosuppression therapy.  Patients who develop a fever of unknown origin to > 39oC, 
lymphadenopathy, or hepatosplenomegaly, should undergo CT scanning of the chest and 
abdomen and/or PET scan to rule out or stage EBV PTLD.  Tissue diagnosis that includes 
EBER and LMP-1 IHC should be attempted.  Other diagnostic or staging studies will be 
performed as clinically indicated.  EBV PTLD may rapidly progress and can be fatal if not 
treated.  Management of suspected EBV PTLD should be discussed with principal investigator 
of the study.  EBV PTLD can be treated with rituximab with or without chemotherapy.  It is 
recommended that patients with increased EBV DNA levels receive rituximab pre-emptively.   
6.1.8 Death 
There is an approximate 5-10% risk of transplant-related mortality within the first month of 
transplant due to the risk of severe regimen-related toxicity, hemorrhage, opportunistic infection, 
or other complications.  It is not expected that the regimens to be used in this protocol will 
increase this risk. 
6.2 Dose Delays and Modifications 
Because this is a transplantation regimen and there is only 1 cycle of treatment pre-transplant, 
no dose delays or modifications are possible for the elements of the HCT conditioning regimen. 
Only the components of the GVHD prophylactic regimen may be reduced. 

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6.2.1 Tacrolimus. Tacrolimus will start on day +5 at dose of 1 mg a day on a 
continuous infusion. This will be switched to equivalent oral dose at twice a day 
at the time of discharge and continue until day +180 post HCT. Tacrolimus taper 
will start at 25% on every 1 weeks bases when no evidence of GvHD. Earlier 
taper us allowed in patient with high risk disease. 
6.2.2 Mycophenolate Mofetil MMF will be started on day +5 at 1gram IV three times a 
day and will be switched to oral when ready to be discharged. This will be 
stopped at day +35 post HCT, if no evidence of active GvHD. 
 
7.0 
Data and Safety Monitoring, Unanticipated Problems and Adverse Event Reporting  
7.1 Risk Level 
This is a Risk Level 3 study, as defined in the “City of Hope Data and Safety Monitoring Plan”, 
http://www.coh.org/dsmc/Pages/forms-and-procedures.aspx involving COH as IND holder. 
7.2 Monitoring and Personnel Responsible for Monitoring 
The Protocol Management Team (PMT) consisting of the PI, Collaborating Investigators, 
CRC/protocol nurse, and statistician is responsible for monitoring the data and safety of this 
study, including implementation of the stopping rules for safety and efficacy. 
This study will utilize the Phase I tracking log to monitor data and safety for dose escalation, 
recording doses administered, and resultant adverse events.  The tracking log will contain dose 
levels administered, DLT-defining adverse events, and documentation that the data from a dose 
level is complete before dose escalation.  Those data and safety elements will be reported to 
the COH DSMC as applicable within the PMT report, which will be submitted quarterly from the 
anniversary date of activation. 
7.3 Definitions 
Adverse event (AE) - An adverse event is any untoward medical experience or change of an 
existing condition that occurs during or after treatment, whether or not it is considered to be 
related to the protocol intervention.  
Unexpected Adverse Event [21 CFR 312.32 (a)] – An adverse event is unexpected if it is not 
listed in the investigator’s brochure and/or package insert; is not listed at the specificity or 
severity that has been observed; is not consistent with the risk information described in the 
protocol and/or consent; is not an expected natural progression of any underlying disease, 
disorder, condition, or predisposed risk factor of the research participant experiencing the 
adverse event. 
Expected Adverse Event - Any event that does not meet the criteria for an unexpected event 
OR is an expected natural progression of any underlying disease, disorder, condition, or 
predisposed risk factor of the research participant experiencing the adverse event. 
Serious Adverse Event (SAE) [21 CFR 312.32] - defined as any expected or unexpected 
adverse event that results in any of the following outcomes: 
o Death 
o Is life-threatening experiences (places the subject at immediate risk of death from the 
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o Unplanned hospitalization equal or greater than 24 hours)) or prolongation of existing 
hospitalization 
o A persistent or significant disability/incapacity 
o A congenital anomaly/birth defect 
o Secondary malignancy 
o Any other adverse event that, based upon appropriate medical judgment, may 
jeopardize the subject’s health and may require medical or surgical intervention to 
prevent one of the outcomes listed above (examples of such events include allergic 
bronchospasm requiring intensive treatment in the emergency room or at home, blood 
dyscrasias of convulsions that do not result in inpatient hospitalization, or the 
development of drug dependency or drug abuse). 
Unanticipated problem (UP) - Any incident, experience or outcome that meets all three of the 
following criteria: 
o Unexpected (in term nature, severity, or frequency) given the following: a) the research 
procedures described in the protocol-related documents such as the IRB approved 
research protocol, informed consent document or Investigator Brochure (IB); and b) the 
characteristics of the subject population being studied; AND 
o Related or possibly related to participation in the research (possibly related means there 
is a reasonable possibility that the incident, experience, or outcomes may have been 
caused by the drugs, devices or procedures involved in the research); AND 
o Suggests that the research places subjects or others at greater risk of harm (including 
physical, psychological, economic, or social harm) than previously known or recognized. 
7.4 Reporting of Unanticipated Problems and Adverse Events 
Unanticipated Problems - Most unanticipated problems must be reported to the COH DSMC 
and 
IRB 
within 
5 
calendar 
days 
according 
to 
definitions 
and 
guidelines 
at 
http://www.coh.org/policy/Policies%20and%20Procedures/REVIEWING_AND_REPORTING_U
NANTICIPATED_PROBLEMS.pdf.  Any unanticipated problem that occurs during the study 
conduct will be reported to the DSMC and IRB by submitting electronically in iRIS 
(http://iris.coh.org). 
Serious Adverse Events - All SAEs occurring during this study, whether observed by the 
physician, nurse, or reported by the patient, will be reported according to definitions and 
guidelines 
at 
http://www.coh.org/policy/Policies%20and%20Procedures/REVIEWING_AND_REPORTING_U
NANTICIPATED_PROBLEMS.pdf and Table 2 below.  Those SAEs that require expedited 
reporting will be submitted electronically in iRIS (http://iris.coh.org). 
Adverse Events - Adverse events will be monitored by the PMT.  Adverse events that do not 
meet the criteria of serious OR are not unanticipated problems will be reported only in the 
continuation reports and PMT reports. 
8.0 
Agent Information 
8.1 Busulfan 
8.1.1 Description/Pharmacology 
Busulfan (1, 4-dimethanesulfonoxybutane) is an alkylating agent. The drug is extensively 
metabolized and its metabolites are eventually excreted in the urine. The oral preparation is 

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well absorbed but studies have indicated that there is a ten-fold variability area under the 
curve (AUC) of the drug among patients receiving busulfan by mouth. There is a statistical 
association between increased AUC and the development of VOD of the liver. Since its FDA 
approval in 1999, IV Bu has been used increasingly in combination with CY or Flu. IV Bu 
was initially administered every 6-hours, similar to oral Bu.  However, several studies have 
used the drug with once or twice daily administration.  In terms of safety, IV Bu and oral Bu 
appear to have similar toxicity profiles.  It has been proposed that VOD and mucositis may 
be reduced in incidence and severity with IV Bu.  The IV formulation at a dose of 0.8 mg/kg 
IV every 6-hrs is considered equivalent to the oral formulation at a dose of 1 mg/kg PO 
every 6 hrs. in conditioning regimens.  On this basis a regimen using 4x0.8 = 3.2 mg/kg as a 
single daily dose has been developed.  
8.1.2 Toxicology 
Toxicities associated with busulfan administration include: 
o Gastrointestinal: nausea, vomiting, constipation, diarrhea, abdominal discomfort, 
anorexia, dyspepsia and mucositis 
o Hepatobiliary: Veno-occlusive disease 
o Neurologic: headache, insomnia and seizures 
o Cardiovascular: hypertension, hypotension and tachycardia 
o Pulmonary: dyspnea, lung fibrosis 
o Endocrine 
and 
metabolic: 
hypermagnesemia, 
hyperglycemia 
and 
hyperphosphatemia 
o Miscellaneous: rhinorrhea, amenorrhea, infertility, skin rashes, cataracts 
 
8.2 Cyclophosphamide  
8.2.1 Description/Pharmacology 
Cyclophosphamide (CY) is an alkylating agent which prevents cell division primarily by 
cross-linking DNA strands.  CY is converted to its active form in vivo by hepatic enzymes.  
After a single dose, tissue enzymes degrade most of the active metabolites.  After high 
doses (> 40 mg/kg), the alkylating activity in the plasma is minimal by 24 hours.  Several of 
the metabolites appear to have toxic actions.  One of the metabolic products, acrolein 
(CH2=CH-CHO), is known to be toxic to the bladder urothelium and can cause hemorrhagic 
cystitis when CY is administered at high doses.  
8.2.1 Toxicology 
Some of the most common toxicities associated with cyclophosphamide include: 
o Gastrointestinal: nausea, vomiting and anorexia 
o Hematologic: myelosuppression 
o Cardiovascular: severe chronic heart failure characterized by cardiomegaly, 
pericardial effusions, diffuse voltage decrease on ECG and decreased LVEF 
o Genitourinary: hemorrhagic cystitis (prevented by hydration and mesna therapy or 
bladder irrigation) and gonadal function impairment 
o Miscellaneous: fluid retention, alopecia and rare pulmonary toxicity 
 

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8.3 Fludarabine 
8.3.1 Description/Pharmacology 
Fludarabine is a fluorinated nucleoside analog. After phosphorylation to fluoro-ara-ATP the 
drug appears to incorporate into DNA and inhibit DNA polymerase alpha, ribonucleotide 
reductase and DNA primase, thus inhibiting DNA synthesis. Excretion of fludarabine is 
impaired in patients with impaired renal function.  
8.3.1 Toxicology 
Some of the most common side effects of fludarabine include: 
o Hematologic: hematopoietic suppression including neutropenia and lymphopenia 
with increased risk of infection and immunosuppression 
o Neurologic: peripheral neuropathy and encephalopathy manifested by fatigue, 
weakness, paresthesia, visual disturbances, somnolence and coma 
o Gastrointestinal: nausea, vomiting, diarrhea and stomatitis 
o Miscellaneous: fever, skin rash, cough and idiopathic pneumonitis 
 
8.4 Melphalan 
8.4.1 Description/Pharmacology 
Melphalan, also known as L-phenylalanine mustard, phenylalanine mustard, L-PAM, or L-
sarcolysin, is a phenylalanine derivative of nitrogen mustard. Melphalan is a bifunctional 
alkylating agent that is active against selected human neoplastic diseases. It is known 
chemically as 4-[bis (2-chloroethyl) amino]-L-phenylalanine. The pharmacokinetics of melphalan 
after IV administration has been extensively studied in adult patients. Following injection, drug 
plasma concentrations declined rapidly in a biexponential manner with distribution phase and 
terminal elimination phase half-lives of approximately 10 and 75 minutes, respectively.  
8.4.2 Reconstitution/Administration 
Refer to institutional standards or prescribing information for preparation and administration for 
melphalan. 
8.4.3 Toxicology 
Common toxicities of melphalan include: 
o Hematologic: bone marrow suppression and hemolytic anemia 
o Gastrointestinal: severe stomatitis, mucositis, esophagitis and diarrhea 
o Pulmonary: pulmonary fibrosis and interstitial pneumonitis 
o Dermatologic: skin hypersensitivity and alopecia 
o Miscellaneous: vasculitis and allergic reactions 
 
8.5 Total Body Irradiation 
8.5.1 Description/Pharmacology 
TBI will be administered per standard of care procedure as implemented by radiation 
oncologists. TBI alone for post-pubescent patients with dose/fractionation of 1.5 Gy twice a 

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day for 4 day and total dose of 1200cGy within the tolerance of most normal organs for < 5% 
risk of severe late toxicity (organ failure or major dysfunction) by 5 years. 
8.5.2 Toxicology 
Common toxicities of total body irradiation include: 
o Gastrointestinal: mucositis, nausea, vomiting and diarrhea 
o Hematologic: marrow suppression 
o Dermatologic: reversible skin pigmentation and alopecia 
o Late 
effects: 
cataract 
formation, 
growth 
retardation, 
pulmonary 
damage, 
carcinogenesis and sterilization 
o Miscellaneous: fever and parotiditis 
 
8.6 Tacrolimus 
8.6.1 Description/Pharmacology 
Tacrolimus often called by its original drug code name, FK-506, is a macrolide 
immunosuppressant that inhibits calcineurin (phosphatase 2B)-mediated T-cell activation by 
forming a complex with FK506 binding protein 12 (FKBP12).  
8.6.1 Toxicology 
Some of the most common toxicities associated with Tacrolimus include:  
o Cardiovascular: hypertension 
o Neurologic: confusion, dizziness, insomnia, seizures, tremors, changes in how 
clearly one can think 
o Gastrointestinal: nausea, vomiting 
o Hematologic: microangiopathic hemolytic anemia, thrombocytopenia 
o Endocrine 
and 
metabolic: 
hypomagnesemia, 
hypokalemia, 
hypocalcemia, 
hyperlipidemia 
o Miscellaneous: unwanted hair growth, changes in vision, liver problems, reversible 
renal insufficiency, infections and post-transplant lymphoproliferative disorders  
 
8.7 Mycophenolate mofetil (MMF) 
8.7.1 Description/Pharmacology 
Mycophenolate mofetil, a morpholinoethyl ester of mycophenolic acid antibiotic with 
immunosuppressant properties, is indicated for the prophylaxis of organ rejection in patients 
receiving allogeneic renal transplants. This product should be used concomitantly with 
cyclosporine and corticosteroids 
 
8.7.2 Toxicology 
Some of the most common toxicities associated with MMF include: 
o Neurologic: headache, tremors, insomnia, dizziness, excessive fatigue, weakness  
o Cardiovascular: tachycardia 
o Pulmonary: dyspnea 

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o Gastrointestinal: 
nausea, 
vomiting, 
dyspepsia, 
abdominal 
pain, 
diarrhea, 
hematemesis and hematochezia 
o Hematologic: Neutropenia, thrombocytopenia, unusual bruising, and anemia 
o Endocrine and metabolic: hyperlipidemia 
o Miscellaneous: rash, edema, change in vision, infection, second cancers, 
teratogenicity, miscarriage, limited effectiveness of birth control, and progressive 
multifocal leukoencephalopathy (PML). 
 
8.8 MESNA (sodium -2-mercapto ethane-sulphonate)  
8.8.1 Description/Pharmacology 
Mesna is a prophylactic agent used to prevent hemorrhagic cystitis induced by the 
oxazophosphorines (cyclophosphamide and ifosfamide). It has no intrinsic cytotoxicity and 
no antagonistic effects on chemotherapy. Mesna binds with acrolein; the urotoxic metabolite 
produced by the oxazophosphorines, to produce a non-toxic thioether and slows the rate of 
acrolein formation by combining with 4-hydroxy metabolites of oxazophosphorines.  
8.8.1 Toxicology 
At the doses used for uroprotection, mesna is virtually non-toxic. The most common side 
effects of MESNA are: 
o Cardiovascular: hypotension 
o Dermatologic: rash, urticarial 
o Gastrointestinal: nausea and vomiting, diarrhea, abdominal pain, altered taste 
o Neurologic: headache, joint or limb pain  
o Miscellaneous: fatigue 
 
9.0 
Correlative/Special Studies 
Immune correlative studies will be performed at the Fox South 1st floor (Nakamura). For the 
cellular assays below (#1-3), 30 ml blood samples in heparin Na tubes (green top) will be 
collected on days -9 (between days -30 and -9 as pre-HCT), and post-transplant on days 7, 14, 
21, 28 (± 2 days), days 42-63 (±7 days), days 100 and 180 (± 14 days), 1 year (+/-30days), and 
2 years (± 30 days) post-transplant. When available and with NMDP approval, we also plan to 
obtain 30 ml blood samples from the unrelated donors. Peripheral blood mononuclear cells 
(PBMC) will be separated using Ficoll and cryopreserved for further experiments as below (#1-
3). For plasma cytokine/GVHD biomarker assays (#3 below), 10 ml of blood will be collected in 
lavender top tubes (K2 EDTA) and frozen on days +7, +14, +21, + 28, +35, +42, +63, +100, 
+180, and +365 (total 90ml) (see study calendar for the window). 
 
1) Reconstitution of T cells, NK cells, and B cells: Standard flow-cytometry analyses will be 
performed to enumerate T cell subsets (i.e. effector, memory, naive T cells based on 
CD45RA/CD62L, exhaustion markers such as PD1, and Treg), B cell subsets (naïve/memory 
based on CD27, Breg49), NK subsets (i.e. memory NK with CD3-CD56+/NKG2C+ and other 
functional markers such as CD137)50. 

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2) Functional characterization of T cells recovering post-HCT: Using a CD137 expression 
assay51, we will enumerate CD4 and CD8 T cells capable of responding to specific antigens 
including CMV (pp65Ag), EBV (transformed LCL), VZV antigen, and leukemia antigens (i.e. 
WT1)52,53 at each time point. When possible, CD137+ cells responding to the antigen stimulation 
will be sorted and subjected for T cell receptor (TCR) CDR3 region sequencing by NGS. 
3) Plasma cytokines and GVHD biomarkers: Inflammatory cytokines (i.e. CRP, -2 
microglobulin, IL-6, and TNF-α) and GVHD biomarkers (i.e. IL2R, TNFR1, HGF, ST2, REG3a, 
Elafin)54,55 will be assessed using the Luminex X-MAP bead array-based assay or standard 
ELISA where applicable.   
 

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10.0 
Study Calendars 
10.1 Study Assessment Calendar 
Study Assessments (All Regimens) 
Pre-
HCT 
 
Days post stem cell infusion 
7 
±2 
14 
±2 
21 
±2 
28 
±2 
35 
± 7 
42 
± 7 
49 
± 7 
56 
± 7 
63 
± 7 
100 
± 14 
150 
± 14 
180 
± 14 
270 
± 14 
365 
± 30 
548 
± 30 
730 
± 30 
History, physical exam, weight and height1 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Karnofsky or Lansky performance status  
X 
 
 
 
X 
 
 
 
 
 
X 
 
X 
 
X 
X 
X 
HCT-Specific Co-Morbidity Index (HCT-CI) score 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
HLA typing (recipient and donor) 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CBC2, differential, platelet count, and chemistries3 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Measured creatinine clearance4 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
Infectious disease markers5 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cardiac assessments6  
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
Pulmonary function tests7 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
X 
Disease evaluation8 
X 
 
 
 
 
 
 
 
 
 
X 
 
X 
 
X 
 
 
Chest x-ray or chest CT or CT/PET 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
Pregnancy test9 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
GVHD assessments10 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Toxicity assessments11 
 
 
 
 
X 
 
 
 
X 
 
X 
 
X 
 
X 
X 
X 
CMV Monitoring  
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
EBV Monitoring 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
Quality of Life assessments12 
X 
 
 
 
 
 
 
 
 
 
X 
 
X 
 
 
X 
X 
Research Samples13 
X 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
 

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1Height is only required at the Pre-HCT Baseline visit. 
2CBC and manual WBC differential per SOP at COH 
3Blood chemistries include: serum creatinine, bilirubin, alkaline phosphatase, AST and ALT.  Blood chemistries performed twice weekly until hospital discharge.  Blood chemistries 
performed weekly after hospital discharge until Day 63 post-transplant, then every other week through Day 100 post-transplant, and then at Days 180, 270 and 365 post-
transplant. 
4Measured creatinine clearance. The updated Schwartz formula should be used for pediatric patients (> 5 year to 12 years).  
5Infectious disease markers include: CMV, Hepatitis panel (Hep B S Ag, Hep B Core Ab, Hep C Ab), herpes simplex virus, syphilis, HIV-1 and -2 and HTLV-I and -II antibody, and 
toxoplasmosis. Patient can move forward to transplant with pending results of added infectious disease labs for the following: HTLV 1 & 2 and toxoplasmosis. 
6Cardiac assessments include EKG and left ventricular ejection fraction (LVEF) or shortening fraction by echocardiogram or radionuclide scan (MUGA).  
7Pulmonary function tests include DLCO (Adj. for Hgb), FEV1 and FVC.  For children who are unable to perform for PFTs due to age or developmental ability, there must be no 
evidence of dyspnea at rest and no need for supplemental oxygen (as evidenced by O2 saturation > 92% on room air) at baseline in order to meet eligibility criteria. 
8Disease evaluation: : BM aspirate and biopsy to be done within 30 days of start of conditioning for the following disease: Acute Leukemia: MDS; CLL/small lymphocytic lymphoma, 
follicular marginal zone, diffuse large B-cell, Hodgkin Lymphoma; mantle cell lymphoma with chemo sensitive disease at the time of transplantation.  Myeloproliferative 
neoplasm (included MF).  For patients with active disease BM aspirate and biopsy need to be done within 14 days of start of conditioning.  Active diseases should be verified by 
the MD.  Study PI will decide if a patient with active disease is allowed to move forward without having a BM aspirate and biopsy within 14 days of transplant.  For leukemia 
patients, a bone marrow biopsy is required for disease status evaluation. For lymphoma patients, CT scans or whole body CT/PET scan is required on days indicated on the 
study calendar.  Brain/spine MRIs are allowed on the opinion of the PI.  For multiple myeloma patients, serum studies, BM and bone surveys at all days indicated on the 
calendar.   
9Pregnancy test must be performed < 30 days before the start of the transplant conditioning regimen. Pregnancy test is required for females of childbearing potential (i.e., not 
postmenopausal or surgically sterile), and may be performed per institutional practices. 
10GVHD assessments performed weekly until Day 63 post-transplant, and then at Days 100, 150, 180, 270, 365, and 730. The GVHD assessment will include a review of all 
abnormalities experienced during the entire assessment period and the highest grade for each abnormality (whether attributed to GVHD or not). aGVHD assessment will be 
done per 1994 Keystone consensus criteria and cGVHD assessment (Appendix B) will be done per NIH consensus staging (Appendix C). 
11The toxicity assessment will include a review of all toxicities experienced during the entire assessment period and the highest grade for each toxicity will be recorded from 
Day -9 through Day 30.  The highest grade of toxicities that meet grade 3, 4, & 5 will be recorded from Day 31-100. 
12QOL assessments include self-reported patient questionnaires: SF-36, FACT-BMT, and MDASI for English and Spanish speaking patients > 18 years, and PedsQL Stem Cell 
Transplant Module for English speaking pediatric patients (ages 8 through 18 years). 
13Research Sample collection for patients who weigh > 30.0 kg.The Baseline sample will be collected prior to initiation of the conditioning regimen. 
 
 
 
 

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10.2 Conditioning and GVHD regimens 
Regimens (A, B, or C) 
-7* 
-6* 
-5* 
-4* 
-3* 
-2* 
-1* 
0* 
+3* 
+4* 
+5* 
+6* 
+7* 
+35 
+90 
Regimen A only (Flu/Mel Reduced Intensity) 
Hospital Admission 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fludarabine (25 mg/m2 daily)***  
X 
X 
X 
X 
X 
 
 
 
 
 
 
 
 
 
 
Melphalan (140 mg/m2) (or 100 mg/m2 if age ≥60) 
 
 
 
 
 
X 
 
 
 
 
 
 
 
 
 
HSC infusion (PBSC or BM)**1 
 
 
 
 
 
 
 
X 
 
 
 
 
 
 
 
Cyclophosphamide (50 mg/kg daily) 
 
 
 
 
 
 
 
 
X 
X 
 
 
 
 
 
G-CSF 5 µg/kg daily (until ANC>1500) 
 
 
 
 
 
 
 
 
 
 
X 
X 
X 
 
 
Tacrolimus 1 mg daily starting dose2,  
 
 
 
 
 
 
 
 
 
 
X--------------------------------X 
Mycophenolate Mofetil (MMF)3 
 
 
 
 
 
 
 
 
 
 
X------------------------X 
 
Regimen B only (Flu/Bu Myeloablative) 
Hospital Admission 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fludarabine (40 mg/m2 daily – over 1 hr) 
 
 
X 
X 
X 
X 
 
 
 
 
 
 
 
 
 
Busulfan (130 mg/m2 daily – over 1 hr) 
 
 
X 
X 
X 
X 
 
 
 
 
 
 
 
 
 
HSC infusion (PBSC or BM)1 
 
 
 
 
 
 
 
X 
 
 
 
 
 
 
 
Cyclophosphamide (50 mg/kg daily) 
 
 
 
 
 
 
 
 
X 
X 
 
 
 
 
 
G-CSF 5 µg/kg daily (until ANC>1500) 
 
 
 
 
 
 
 
 
 
 
X 
X 
X 
 
 
Tacrolimus 1 mg daily starting dose2,  
 
 
 
 
 
 
 
 
 
 
X--------------------------------X 
Mycophenolate Mofetil (MMF)3 
 
 
 
 
 
 
 
 
 
 
X------------------------X 
 
Regimen C only (Flu/TBI Myeloablative) 
Hospital Admission 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fludarabine (30 mg/m2 daily)  
X 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Total Body Irradiation 1200 cGy (150 cGy 2x daily) 
 
 
 
X 
X 
X 
X 
 
 
 
 
 
 
 
 
HSC infusion (PBSC or BM)1 
 
 
 
 
 
 
 
X 
 
 
 
 
 
 
 
Cyclophosphamide (50 mg/kg daily) 
 
 
 
 
 
 
 
 
X 
X 
 
 
 
 
 
G-CSF 5 µg/kg daily (until ANC>1500) 
 
 
 
 
 
 
 
 
 
 
X 
X 
X 
 
 
Tacrolimus 1 mg daily starting dose2,  
 
 
 
 
 
 
 
 
 
 
X--------------------------------X 
Mycophenolate Mofetil (MMF) 3 
 
 
 
 
 
 
 
 
 
 
X------------------------X 
 
* A window of 1-2 days is allowed for stem cell availability. 
** Cryopreserved HSCs are allowed in the opinion of study PI. 
***Fludarabine can be given out-patient in the opinion of study PI 
1. HSC = hematopoietic stem cells, PBSC = peripheral blood stem cells, BM = bone marrow 
2. Dose adjusted to keep blood levels between 5-15 ng/mL. Begin taper at ~+90 days and end by 180 if no acute GVHD. 
3. 15 mg/kg PO TID (max 1g – stop at day +35 if no severe GVHD) 

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11.0 
Data Reporting/Protocol Deviations 
11.1 Data Reporting 
11.1.1 Confidentiality and Storage of Records 
The original data collection forms will be sent to in encrypted, password protected, secure 
computers/servers that meet HIPAA requirements. When results of this study are reported in 
medical journals or at meetings, identification of those taking part will not be disclosed.  Medical 
records of subjects will be securely maintained in the strictest confidence, according to current 
legal requirements.  They will be made available for review, as required by the FDA, HHS, or 
other authorized users such as the NCI, under the guidelines established by the Federal Privacy 
Act and rules for the protection of human subjects. 
11.1.2 Subject Consent Form 
At the time of registration, the original signed and dated Informed Consent form, HIPAA 
research authorization form, and the California Experimental Subject’s Bill of Rights (for the 
medical record) and three copies (for the subject, the research record, and the Coordinating 
Center) must be available.  All Institutional, NCI, Federal, and State of California requirements 
will be fulfilled. 
11.1.3 Data Collection Forms and Submission Schedule  
All data will be collected 1-2 weeks using standard Medidata Electronic Data Capture (EDC) 
form. Data will be collected and stored on secure computers as indicated in Section 12.1.1. 
After 2 years, we will access the COH CIBMTR data repository to retrieve data regarding post –
HCR long-term outcomes through study termination.  
The Eligibility Checklist must be completed by a protocol nurse or clinical research associate 
and signed by an authorized investigator prior to registering the subject.  See Section 4.3 for the 
registration procedure. 
11.1.3.1 
Prior Therapy Forms and On-Study Forms 
Within 10 business days of registration, the clinical research associate will submit case report 
forms. 
11.1.4 Data Forms Submission Schedule 
Form 
Submission Timeline 
Eligibility Checklist 
Complete prior to registration 
On Study Forms 
Within 10 business days of registration 
Baseline Assessment Forms 
Within 10 business days of registration 
Treatment Forms 
Within 10 business days of treatment administration 
Adverse Event Report Forms 
Within 5 business days, but only through day 60 (DLT 
period) 
Response Assessment Forms 
Within 10 business days of response assessment 
Other assessment forms (e.g. 
concomitant meds, chemistry, 
hematology, neuro exam, physical 
Within 10 business days of the assessment 

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exam) 
Off Treatment/Off Study Forms 
Within 10 business days of completing treatment or 
being taken off study for any reason 
Follow up/Survival Forms 
Within 10 business days of the protocol defined follow 
up visit date or call 
 
11.2 Protocol Deviations 
11.2.1 Deviation Policy 
This protocol will be conducted in accordance with COH’s “Clinical Research Protocol Deviation 
Policy” located at http://www.coh.org/dsmc/Documents/Institutional%20Deviation%20Policy.pdf. 
Deviations from the written protocol that could increase patient risk or alter protocol integrity 
require prior IRB approval of a single subject exception (SSE) request.  In addition, if 
contractually obligated, the sponsor must also approve the deviation.  IRB pre-approved SSE 
protocol modifications are considered an amendment to the protocol and not a deviation.  The 
submission of a deviation report is not required. 
Brief interruptions and delays may occasionally be required due to travel delays, airport closure, 
inclement weather, family responsibilities, security alerts, government holidays, etc.  This can 
also extend to complications of disease or unrelated medical illnesses not related to disease 
progression.  The PI has the discretion to deviate from the protocol when necessary so long as 
such deviation does not threaten patient safety or protocol scientific integrity.  Examples include, 
but are not limited to:  a) dose adjustments based on excessive patient weight; b) alteration in 
treatment schedule due to non-availability of the research participant for treatment; c) laboratory 
test results which are slightly outside the protocol requirements but at levels that do not affect 
participant safety.  These instances are considered to be deviations from the protocol.  A 
deviation report will be submitted to the DSMC/IRB within five days. 
11.2.2 Reporting of Deviations 
All deviations will be reported to the COH DSMC within five days.  The DSMC will forward to 
report to the IRB following review. 
11.2.3 Resolving Disputes 
The COH Investigational Drug Service (IDS) cannot release a research agent that would cause 
a protocol deviation without approval by the PI.  Whenever the protocol is ambiguous on a key 
point, the IDS should rely on the PI to clarify the issue. 
In situations where there is misperception or dispute regarding a protocol deviation among the 
persons involved in implementing the protocol, it is the responsibility of the PI to resolve the 
dispute and the PI may consult with the DSMC chair (or designee) to arrive at resolution. 
 

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12.0 
Endpoint Evaluation Criteria/Measurement of Effect 
12.1 Primary Endpoint 
 
GVHD-free Relapse/Progression-free Survival (GRFS): defined as time from start of 
treatment (HCT) to grade 3-4 acute GVHD, moderate-severe chronic GVHD, relapse, 
progression or death (from any cause), whichever occurs first. If a patient has not 
experienced any of these events, GRFS is censored at time of last follow-up. 
12.2 Secondary Endpoints: 
 
Toxicity: Toxicities will be graded using the Common Terminology Criteria for Adverse 
Events (CTCAE) Version 4.03 and the Bearman Toxicity Scale (for 100 days post-
HCT)48.   
Note: The highest grade of all toxicities will be recorded from Day -9 to Day 30. The highest 
grade of toxicities that meet grade 3, 4, or 5 per CTCAE v4.03 from day +31 to +100 post-
transplant will be collected. Start and stop dates will also be recorded for any grade 4 
neutropenia. 
 
Unacceptable Toxicity: To be evaluable for toxicity, a patient must start conditioning and 
be observed for 30 days from stem cell infusion or have experienced an unacceptable 
toxicity. For the purposes of this study, unacceptable toxicity will be defined as any of the 
following that are assigned an attribution level of at least possibly related to the study 
regimen: 
o For non-hematologic toxicities, any regimen-related grade III/IV toxicity per 
Bearman Toxicity Grading Scale or 
o For non-hematologic toxicities (not part of the Bearman toxicity grading scale), 
any ≥grade 4 toxicity per NCI CTCAE v4.03, except for metabolic/electrolyte 
disturbances and vomiting controlled by medical management. 
o For hematologic toxicities, per NCI CTCAE v4.03 toxicity criteria, any grade 4 
neutropenia associated with fever or infection and lasting for more than 21 days, 
or grade 4 neutropenia lasting for more than 28 days (engraftment failure) 42 
days acceptable for myelofibrosis patients to achieve engraftment 
o Any other regimen-related cause of death. 
 
Infection: Microbiologically documented infections will be reported by site of disease, 
date of onset, severity and resolution, if any. These data will be captured via case report 
form and will be collected from day 0 until 100 days post-transplant. 
 
Acute Graft versus Host Disease (aGVHD) of grades 2-4 and 3-4: Acute graft versus 
host disease is graded according to the 1994 Keystone Consensus Grading56 (Appendix 
B). The first day of acute GVHD onset at a certain grade will be used to calculate 
cumulative incidence curves for that GVHD grade; relapse/death prior to onset will be 
considered competing events. The endpoint will be evaluated from day 0 through 100 
days post-transplant. 
 
Chronic Graft versus Host Disease (cGvHD): Chronic graft versus host disease is scored 
according to NIH Consensus Staging57,58 (Appendix C). The first day of chronic GvHD 
onset will be used to calculate cumulative incidence curves, with relapse / death prior to 
onset considered competing events. The endpoint will be evaluated from day 100 to the 
onset of chronic GvHD, death or last contact, whichever comes first. 
 
Engraftment: Time to hematological recovery in terms of neutrophil (ANC≥500/μL, 
1.0x103/μL) and platelet (20x103/μL and 100x103/μL) engraftment time.  

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 
Overall survival (OS): Patients are considered a failure for this endpoint if they die, 
regardless of cause. Time to this event is the time from start of protocol therapy to death, 
or last follow-up, whichever comes first. 
 
Progression-free survival (PFS): Patients are considered a failure for this endpoint if they 
relapse/progress or die, regardless of cause. Time to this event is the time from start of 
protocol therapy to death, relapse/progression, or last follow-up, whichever comes first. 
 
Relapse/Progression (CIR): The event is relapse/progression. Time to this event is 
measured from start of therapy. Death without relapse/progression is considered a 
competing risk. Surviving patients with no history of relapse/ progression are censored at 
time of last follow-up. 
 
 Non-relapse Mortality (NRM): Patients are considered a failure for this endpoint if they 
die from causes other than relapse or progression. NRM is measured from start of 
therapy until non-disease related death, or last follow-up, whichever comes first. 
 
Quality of Life (QOL): assessments include self-reported patient questionnaires: SF-
36, FACT-BMT, and MDASI for English and Spanish speaking patients > 18 years, 
and PedsQL Stem Cell Transplant Module for English speaking pediatric patients 
(ages 8 through 18 years). 
 
12.3 Response Criteria  
Response criteria will be specific to each disease with only the following categories being 
relevant post-transplant: 
a. Complete remission 
b. Relapse 
c. Disease persistence/progression  
For detailed description of the corresponding categories within the response criteria for each 
disease please check the following references: 
 
ALL: NCCN guidelines for ALL Version 3.2017 
a. Complete remission: 
 No circulating blasts or extramedullary disease 
 
No lymphadenopathy, splenomegaly, skin/gum infiltration/testicular mass/CNS 
involvement 
 Trilineage hematopoiesis (TLH) and 5% blast 
 Absolute neutrophil count (ANC)>1000/microL 
 Platelets>100,000/microL 
 No recurrence for 4 weeks 
b. Relapse 
 Reappearance of blasts in the blood or BM (>5%) or in any extramedullary site after CR 
c. Disease persistence/progression  
 Failure to achieve CR at the end of induction 
 Increase of at least 25% in the absolute number of circulating or BM blasts or 
development of extramedullary disease. 
AML: Döhner, Estey et al. 201759 
 

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a. Complete remission: 
 CR without minimal residual disease (CRMRD−): 
 
If studied pretreatment, CR with negativity for a genetic marker by RT-qPCR, or 
CR with negativity by MFC 
 Complete remission (CR): 
 
Bone marrow blasts <5%; absence of circulating blasts and blasts with Auer 
rods; absence of extramedullary disease; ANC ≥1.0 × 109/L (1000/µL); platelet 
count ≥100 × 109/L (100 000/µL) 
 CR with incomplete hematologic recovery (CRi): 
 
All CR criteria except for residual neutropenia (<1.0 × 109/L [1000/µL]) or 
thrombocytopenia (<100 × 109/L [100 000/µL]) 
b. Relapse: 
 Hematologic relapse (after CRMRD−, CR, CRi): 
 
Bone marrow blasts ≥5%; or reappearance of blasts in the blood; or development 
of extramedullary disease 
 Molecular relapse (after CRMRD−): 
 
If studied pretreatment, reoccurrence of MRD as assessed by RT-qPCR or by 
MFC 
c. Disease persistence/progression  
  Primary refractory disease: 
 
No CR or CRi after 2 courses of intensive induction treatment; excluding patients 
with death in aplasia or death due to indeterminate cause. 
 Progressive disease (PD): 
 
Evidence for an increase in bone marrow blast percentage and/or increase of 
absolute blast counts in the blood: 
 
>50% increase in marrow blasts over baseline (a minimum 15% point increase is 
required in cases with <30% blasts at baseline; or persistent marrow blast 
percentage of >70% over at least 3 mo; without at least a 100% improvement in 
ANC to an absolute level (>0.5 × 109/L [500/µL], and/or platelet count to >50 × 
109/L [50 000/µL] nontransfused); or, 
 
 >50% increase in peripheral blasts (WBC × % blasts) to >25 × 109/L 
(>25 000/μL) (in the absence of differentiation syndrome); or 
 
New extramedullary disease 
MDS: Savona, Malcovati et al. 201560 
a. Complete Remission(presence of all of the following improvements) 
 Bone marrow:  
 
≤5% myeloblasts (including monocytic blast equivalent in case of CMML) with 
normal maturation of all cell lines and return to normal cellularity 
 
Osteomyelofibrosis absent or equal to “mild reticulin fibrosis” (≤grade 1 fibrosis) 
 Peripheral blood 
 
WBC ≤10 × 109 cells/L 
 
Hgb ≥11 g/dL 
 
Platelets ≥100 × 109/L; ≤450 × 109/L 
 
Neutrophils ≥1.0 × 109/L 
 
Blasts 0% 
 
Neutrophil precursors reduced to ≤ 2% 
 
Monocytes ≤1 × 109/L 
 Extramedullary disease: Complete resolution of extramedullary disease present before 
therapy (eg, cutaneous disease, disease-related serous effusions), including palpable 
hepatosplenomegaly 
 Provisional category of CR with resolution of symptoms: CR as described above, and 
complete resolution of disease-related symptoms as noted by the MPN-SAF TSS 

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 Persistent low-level dysplasia is permitted given subjectivity of assignment of dysplasia 
b. Relapse (Partial Remission) 
 Normalization of peripheral counts and hepatosplenomegaly with bone marrow blasts 
(and blast equivalents) reduced by 50%, but remaining >5% of cellularity except in cases 
of MDS/MPN with ≤5% bone marrow blasts at baseline. 
 Marrow response 
 
Optimal marrow response: Presence of all marrow criteria necessary for CR 
without normalization of peripheral blood indices as presented above. 
 
Partial marrow response: Bone marrow blasts (and blast equivalents) reduced by 
50%, but remaining >5% of cellularity, or reduction in grading of reticulin fibrosis 
from baseline on at least 2 bone marrow evaluations spaced at least 2 mo apart 
c. Disease persistence/progression: (Combination of 2 major criteria, 1 major and 2 minor criteria, or 
3 minor criteria from list) 
 Major criteria 
 
Increase in blast count* 
o 
<5% blasts: ≥50% increase and to >5% blasts 
o 
5-10% blasts: ≥50% increase and to >10% blasts 
o 
10-20% blasts: ≥50% increase and to >20% blasts 
o 
20-30% blasts: ≥50% increase and to >30% blasts 
 
 Evidence of cytogenetic evolution 
o 
Appearance of a previously present or new cytogenetic abnormality in 
complete cytogenetic remission via FISH or classic karyotyping 
o 
Increase in cytogenetic burden of disease by ≥50% in partial cytogenetic 
remission via FISH or classic karyotyping 
 
 New extramedullary disease 
o 
Worsening splenomegaly 
o 
Progressive splenomegaly that is defined by IWG-MRT: the appearance of a 
previously absent splenomegaly that is palpable at >5 cm below the left 
costal margin or a minimum 100% increase in palpable distance for baseline 
splenomegaly of 5-10 cm or a minimum 50% increase in palpable distance 
for baseline splenomegaly of >10 cm 
o 
Extramedullary disease outside of the spleen 
o 
To include new/worsening hepatomegaly, granulocytic sarcoma, skin lesions, 
etc. 
 Minor criteria 
 
 Transfusion dependence§ 
 
 Significant loss of maximal response on cytopenias ≥50% decrement from 
maximum remission/response in granulocytes or platelets 
 
 Reduction in Hgb by ≥1.5g/dL from best response or from baseline as noted on 
complete blood count 
 
 Increasing symptoms as noted by increase in ≥50% as per the MPN-SAF 
TSS|| 
 
 Evidence of clonal evolution (molecular) 
 
Myelofibrosis: Tefferi, Cervantes et al. 201361 and Zang and Deeg 200962 
a. Complete Remission: 
 Bone marrow: Age-adjusted normocellularity; <5% blasts; ≤grade 1 MF and, 
 Peripheral blood: Hemoglobin ≥100 g/L and <UNL; neutrophil count ≥ 1 × 109/L and 
<UNL; 
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 Clinical: Resolution of disease symptoms; spleen and liver not palpable; no evidence of 
EMH 
b. Relapse: 
 No longer meeting criteria for at least CI after achieving CR, PR, or CI, or 
 Loss of anemia response persisting for at least 1 month or 
 Loss of spleen response persisting for at least 1 month 
 Recommendations for assessing treatment-induced cytogenetic and molecular changes 
c. Disease persistence/progression: 
 Appearance of a new splenomegaly that is palpable at least 5 cm below the LCM or 
 A ≥100% increase in palpable distance, below LCM, for baseline splenomegaly of 5-10 
cm or 
 A 50% increase in palpable distance, below LCM, for baseline splenomegaly of >10 cm 
or 
 Leukemic transformation confirmed by a bone marrow blast count of ≥20% or 
 A peripheral blood blast content of ≥20% associated with an absolute blast count of ≥1 × 
10(9)/L that lasts for at least 2 weeks 
 
CLL: NCCN guidelines for CLL, Version 1.2018 
a. Complete remission: 
 Group A Lymphadenopathy: None > 1.5 cm 
 No hepatomegaly 
 No splenomegaly 
 Marrow: 
 
Normocellular  
 
<30%Lymphocytes 
 
No B-lymphoid nodules 
 
Hypercellular marrow defines CR with incomplete marrow recovery 
 Blood lymphocyte<4000/micro/L 
 Group B Platelet count without growth factors>100,000/micro/L 
 Hb without transfusions or growth factors>11.0 g/dL 
 Neutrophils without growth factors>1500/micro/L 
b. Relapse (partial Remission) 
 Group A Lymphadenopathy: decrease≥50% 
 Hepatomegaly≥50% 
 Splenomegaly≥50% 
 Marrow: 50% reduction in marrow infiltrate, or B-lymphoid nodules 
 Blood lymphocyte: Increase or decrease <50% over baseline 
 Group B Platelet count without growth factors>100,000/micro/L or increase ≥50% over 
baseline 
 Hb without transfusions or growth factors>11.0 g/dL or increase ≥50%overbaseline 
 Neutrophils without growth factors>1500/micro/L or >50% improvement over baseline 
c. Disease persistence/progression: 
 Group A Lymphadenopathy: Increase ≥50% 
 Hepatomegaly: Increase ≥50% 
 Splenomegaly: Increase ≥50% 
 Blood lymphocyte: Increase ≥50% over baseline 
 Group B Platelet count without growth factors: Decrease ≥50% over baseline 
 Hb without transfusions or growth factors: Decrease of >g/dL from baseline secondary to 
CLL 
 
Hodgkin and non-Hodgkin Lymphoma: Cheson, Fisher et al. 201463 

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a. Complete remission (CT-Based Response) 
 Lymph nodes and extralymphatic sites: No extralymphatic sites of disease 
 Nonmeasured lesion: Absent 
 Organ enlargement: Regress to normal 
 Lesions: None 
 Bone Marrow: Normal morphology, if indetereminate, IHC negative 
b. Relapse (partial remission) 
 Lymph nodes and extralymphatic sites: ≥ 50% decrease in SPD of up to 6 target 
measurable nodes and extranodal sites 
 Nonmeasured lesions:  
 
When a lesion is too small to measure on CT, assign 5 mm × 5 mm as the 
default value 
 
For a node > 5 mm × 5 mm, but smaller than normal, use actual measurement 
for calculation 
 Organ enlargement: Spleen must have regressed by > 50% in length beyond normal 
 Lesions: None 
 Bone marrow: Not applicable 
c. Disease persistence/progression:  
 Target nodes/nodal masses, extranodal lesions: < 50% decrease from baseline in SPD of 
up to 6 dominant, measurable nodes and extranodal sites; no criteria for progressive 
disease are met 
 Nonmeasured lesions: No increase consistent with progression 
 Organ enlargement: No increase consistent with progression 
 Lesions: None 
 Bone marrow: Not applicable 
Progressive disease requires at least 1 of the following: 
 Extranodal lesions: 
 
An individual node/lesion must be abnormal with: 
o 
LDi > 1.5 cm and 
o 
Increase by ≥ 50% from PPD nadir and 
o 
An increase in LDi or SDi from nadir 
o 
0.5 cm for lesions ≤ 2 cm 
o 
1.0 cm for lesions > 2 cm 
o 
In the setting of splenomegaly, the splenic length must increase by > 50% of the 
extent of its prior increase beyond baseline (eg, a 15-cm spleen must increase 
to > 16 cm). If no prior splenomegaly, must increase by at least 2 cm from 
baseline 
New or recurrent splenomegaly. 
 Nonmeasured lesions: New or clear progression of preexisting nonmeasured lesions 
 Lesions: 
 
Regrowth of previously resolved lesions 
 
A new node > 1.5 cm in any axis 
 
A new extranodal site > 1.0 cm in any axis; if < 1.0 cm in any axis, its presence must be 
unequivocal and must be attributable to lymphoma 
 
Assessable disease of any size unequivocally attributable to lymphoma 
 Bone marrow: New or recurrent involvement 
 
Multiple Myeloma: NCCN Guidelines for Multiple Myeloma Version 2.2018 
a. Complete Response: 
 Negative immunofixation on the serum and urine and disappearance of any soft tissue 
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b. Relapse: Clinical relapse require one or more of the following 
 Direct indicators of increasing disease and/or end organ dysfunction (calcium elevation, 
renal failure, anemia, lytic bone lesion [CRAB features] related to the underlying clonal 
plasma-cell proliferative disorder. It is not used in calculation of time to progression or 
progression-free survival but it is listed as something that can be reported optionally or for 
use in clinical practice; 
 Development of new soft tissue or bone lesions (osteoporotic features do not constitute 
progression); 
  
c. Disease persistence/progression: 
 Stable Disease: not recommended for use as an indicator of response; stability of 
disease is best described by providing the time to progression estimates.  
 Progressive disease: any one or more of the following criteria: 
 
Increase of 25% from lowest confirmed response value in one or more of the 
following criteria: 
o 
Serum M-protein (absolute increase must be ≥0.5 g/dL; 
o 
Serum M-protein increase ≥ g/dL, if the lowest M component was ≥0.5 
g/dL; 
o 
Urine M protein (absolute increase must be ≥200 mg/24 h); 
o 
In patients without measurable serum and urine M-protein levels, the 
differences between involved and uninvolved FLC levels ( absolute 
increase must be>10 mg/dL); 
o 
In patients without measurable serum and urine M-protein levels and 
without measurable involved FLC levels, bone marrow plasma-cell 
percentage irrespective of baseline status (absolute increase must be 
≥10%); 
o 
Appearance of a new lesion(s), ≥50% increase from nadir in SPD of >1 
lesion, or ≥50% increase in the longest diameter of a previous lesion >1 
cm in short axis; 
o 
≥50%increase in circulating plasma cells (minimum of 200 cells per μl) if 
this is the only measure of disease. 
 
CML: Oehler. 201364 and NCCN guidelines for CML version 1.2018 
a. Complete response: 
 Leukocyte count of <10 X 109/L 
 Platelet count < 450 X 109/L 
 Normal differential with no early forms 
 No splenomegaly 
b. Relapse:  
 Any sign of loss of response (defined as hematologic or cytogenetic relapse) 
 1-log increase in BCR-ABL1 transcript levels with loss of MMR should rompt bone 
marrow evaluation for loss of CCyR but is not itself defined as relapse (eg, hematologic 
or cytogenetic relapse) 
 
13.0 
Statistical Considerations 
13.1 Study Design 
We will assess the clinical activity, overall and per stratum (RIC or MAC), and evaluate the 
safety of post-transplant high dose cyclophosphamide (PTCy) in patients undergoing T-cell 
replete HLA-mismatched unrelated donor hematopoietic cell transplantation (HCT) for 

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hematologic malignancy. The primary endpoint for this single center, pilot/estimation study is 
one-year GVHD, relapse/progression-free survival (GRFS). 
13.2 Sample Size Accrual Rate 
Due to a lack of comparable historical data/ estimates65-67 for one-year GRFS in this setting, a 
total of 38 patients, with 19 patients per stratum is sufficient to estimate the GRFS rate at 1 year 
with adequate precision (standard error = .08 overall, = 0.12 per stratum (see the following table 
for detail). On average we perform 15-20 MMUD HCTs annually at City of Hope. (Note: There is 
no competing trial for MMUD HCT since most of the HCT trials avoid MMUD HCT.) We 
anticipate that the accrual of 38 patients will take 2 years to complete. With the primary endpoint 
of 1-yr GRFS, and up to 2-years of follow-up planned, the study is expected to complete in –
approximately 4 years.  
Censored 
Overall (N=38) 
Per Stratum (N=19) 
Before 1 yr 1-yr 
GRFS 
rate 
SE* 
95%CI* 
1-yr 
GRFS 
rate 
SE* 
95%CI* 
None 
42% 
8% 
26% to 57% 
42% 
11% 
20% to 62% 
None 
37% 
8% 
22% to 52% 
37% 
11% 
17% to 57% 
None 
32% 
8% 
18% to 46% 
32% 
11% 
13% to 52% 
None 
26% 
7% 
14% to 41% 
26% 
10% 
10% to 47% 
None 
21% 
7% 
10% to 35% 
21% 
9% 
7% to 41% 
1 patient 
41% 
8% 
25% to 56% 
39% 
12% 
18% to 60% 
1 patient 
36% 
8% 
21% to 51% 
34% 
11% 
14% to 55% 
1 patient 
30% 
8% 
16% to 45% 
28% 
11% 
10% to 49% 
1 patient 
25% 
7% 
12% to 39% 
22% 
10% 
7% to 43% 
1 patient 
19% 
6% 
8% to 33% 
 
 
 
* Standard error (SE) and confidence interval (CI). 
13.3 Stopping Rules for Excessive Toxicity 
The following table will be consulted as relevant toxicities are encountered. Within each stratum, 
the early stopping rule for safety/toxicity will be assessed for each patient at day +30 post-
transplant/stem cell infusion. The expected rate of unacceptable toxicity (defined in 12.2) should 
not be ≥33%. See the table below for detailed early stopping rules. If the specified number of 
patients is met or exceeded, patient accrual will be halted and a full review of the data by the 
Data Safety Monitoring Committee will be mandated. Patient accrual will not resume until 
approved by the Data Safety Monitoring Committee to do so. 
 

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# of patients 
treated 
# 
of 
patients 
with 
unacceptable 
toxicity to halt 
enrollment1 
Cumulative 
probability 
of
early 
stopping 
given 
a
toxicity rate of: 
15% 
33% 
45% 
  6 
  2 
0.22 
0.64 
0.84 
12 
  4 
0.24 
0.73 
0.92 
1: For each unacceptable toxicity, halt enrollment and 
evaluate if the cumulative # of patients reaches or exceeds 
the specified limits. 
 
13.3 Statistical Analysis Plan 
Survival estimates will be calculated using the Kaplan-Meier method, Greenwood formula will be 
used to calculate SE, and log-log transformation method will be used to construct 95% CI. The 
cumulative incidence of relapse/progression and non-relapse mortality will be calculated as 
competing risks using the Gray method. Toxicity information recorded will include the type, 
severity, and the probable association with the study regimen. Tables will be constructed to 
summarize the observed incidence by severity and type of toxicity. Baseline information (e.g. 
the extent of prior therapy) and demographic information will be presented, to describe the 
patients treated in this study. 
 
14.0 
Human Subject Issues 
14.1 Institutional Review Board 
In accordance with City of Hope policies, an Institutional Review Board (IRB) that complies with 
the federal regulations at 45 CFR 46 and 21 CFR 50, 56 and State of California Health and 
Safety code, Title 17, must review and approve this protocol and the informed consent form 
prior to initiation of the study.  All institutional, NCI, Federal, and State of California regulations 
must be fulfilled. 
14.2 Recruitment of Subjects 
Study candidates will be recruited from patients undergoing HCT (cancer treatment) at City of 
Hope Cancer Center for hematological malignancies. Attending physicians and transplant 
coordinators identify potential candidates. The PI and the protocol team will review these cases 
and coordinate with the treating MDs for the consenting and enrollment process.  
14.3 Advertisements  
Advertisements to include print, media (radio, television, billboards), telephone scripts, lay 
summary to be posted on City of Hope’s public Clinical Trials On-Line SM website, etc., will be 
reviewed and approved by the IRB prior to their use to recruit potential study subjects. 

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14.4  Study location and Performance Sites 
This study will be performed at COH.  
14.5 Confidentiality  
This research will be conducted in compliance with federal and state of California requirements 
relating to protected health information (PHI). The principal investigator, co-investigators, and 
laboratory technicians will have access to this information, but all information will be treated 
confidentially.  No identifiers will be used in any subsequent publication of these results  
14.6 Financial Obligations and Compensation 
Eligible diseases in this trial are approved indications for cyclophosphamide. Thus the study 
drug will be covered by the insurance carrier.  Once approved it can be continued for these 
patients. For rare cases the insurance authorization and prescription will be obtained prior to the 
study treatment. Informed consent and enrollment may occur prior to the insurance authorization. 
Since myelofibrosis is the FDA-approved indication we do not expect any denial, and 
cyclophosphamide should be ready by the time of the study treatment. If there is a denial or delay 
for whatever reasons after enrollment (we expect this case to be <1%), the patient will be 
considered as not evaluable and will be replaced  
The standard of care drug(s) and procedures (the 3 acceptable HCT conditioning regimens are 
and HCT procedures and supportive care) provided will be the responsibility of the research 
participant and/or the insurance carrier.  The research participant will be responsible for all 
copayments, deductibles, and other costs of treatment and diagnostic procedures as set forth by 
the insurance carrier.  The research participant and/or the insurance carrier will be billed for the 
costs of treatment and diagnostic procedures in the same way as if the research participant 
were not in a research study.  However, neither the research participant nor the insurance carrier 
will be responsible for the research procedures related to this study. 
In the event of physical injury to a research participant, resulting from research procedures, 
appropriate medical treatment will be available at the City of Hope to the injured research 
participant, however, financial compensation will not be available. 
The research participant will not be paid for taking part in this study. 
14.7 Informed Consent Processes  
The Principal Investigator or IRB approved named designate will explain the nature, duration, 
purpose of the study, potential risks, alternatives and potential benefits, and all other information 
contained in the informed consent document.  In addition, they will review the experimental 
subject’s bill of rights and the HIPAA research authorization form.  Research subjects will be 
informed that they may withdraw from the study at any time and for any reason without 
prejudice, including as applicable, their current or future care or employment at City of Hope or 
any relationship they have with City of Hope.  Research subjects will be afforded sufficient time 
to consider whether or not to participate in the research. 
Before signing the study consent form, HIPAA authorization form and the Experimental 
Subject’s Bill of Rights, research subjects will undergo an assessment of their comprehension of 
the study by the Research Subject Advocate.  Should sufficient doubt be raised regarding the 
adequacy of comprehension, further clarifications will be made and the questionnaire repeated 
until a satisfactory result is obtained.  Prospective research subjects who cannot adequately 
comprehend the fundamental aspects of the research study with a reasonable amount of 

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discussion, education and proctoring will be ineligible for enrollment.  For those subjects who do 
comprehend the fundamental aspects of the study, consent will be obtained and documented, 
followed by eligibility testing.  The research team will review the results of eligibility testing and 
determine if the subject is a candidate for study enrollment.  
 
 

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15.0 Appendix  
15.1  Appendix A: Comorbidity Index Comorbidity Index 
 

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15.2 Appendix B: Acute GVHD grading 
1994 Keystone Consensus Criteria 
Organ Staging of Clinical Acute GVHD 
 
Skin 
Lower GI 
Upper GI 
Liver (Total Bilb) 
0- No Rash 
1- Maculopapular rash, 
<25% of body surface 
2- Maculopapular rash, 25-
50% of body surface 
3- Rash on >50% of body 
surface, or generalized 
erythroderma 
4- Generalized 
erythroderma with bullous 
formation and/or 
desquamation 
0-  ≤500 mL/day or <280 
mL/m2/day 
1-  >500 but ≤1000 mL/day 
or 280-555 mL/m2/day 
2-  >1000 but ≤1500 mL/day 
or 556-833 mL/m2/day 
3-  >1500 mL/day or 833 
mL/m2/day 
4-  Severe abdominal pain 
with or without ileus, or stool 
with frank blood or melena 
0-  No protracted 
nausea and vomiting 
1-  Persistent nausea, 
vomiting, OR biopsy 
showing acute 
GVHD of stomach or 
duodenum 
0-   <2.0 mg/dL 
1-    2.0-3.0 mg/dL 
2-    3.1-6.0 mg/dL 
3-    6.1-15 mg/dL 
4-    >15.0 mg/dL   
 
 
Overall Clinical Grading of Severity of Acute GVHD 
 

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15.3 Appendix C: Chronic GVHD grading 
15.3.1 GVHD scoring criteria stated per Jagasia et al, 2015 (62) 
 
Score 0 
Score 1 
Score 2 
Score 3 
Performance score:______ 
 
KPS  ECOG  LPS 
 Asymptomatic 
and fully active 
(ECOG 0; KPS 
or LPS 100%) 
 Symptomatic, 
fully ambulatory,  
restricted only in 
physically 
strenuous activity 
(ECOG 1, KPS or 
LPS 80-90%) 
 Symptomatic, 
ambulatory, capable 
of self-care, >50% 
of waking hours out 
of bed (ECOG 2, 
KPS or LPS 60-
70%) 
 Symptomatic, 
limited self-care,  
>50% of waking 
hours in bed 
(ECOG 3-4, KPS or 
LPS <60%) 
SKIN† 
Score % BSA:______ 
GVHD features to be scored by 
BSA: 
Check all that apply: 
 Maculopapular 
rash/erythema 
 Lichen planus-like features 
 Sclerotic features 
 Papulosquamous lesions or 
ichthyosis 
Keratosis pilaris-like GVHD 
 No BSA 
involved 
 1-18% BSA 
 19-50% BSA 
 >50% BSA 
SKIN FEATURES SCORE: 
 No sclerotic 
features 
 
 Superficial 
sclerotic features 
“not hidebound” 
(able to pinch)  
Check all that 
apply: 
 Deep sclerotic 
features 
 “Hidebound” 
(unable to pinch) 
 Impaired mobility 
 Ulceration 
Other skin GVHD features (NOT scored by BSA) 
Check all that apply: 
 Hyperpigmentation 
 Hypopigmentation 
 Poikiloderma 
 Severe or generalized pruritus 
 Hair involvement 
 Nail Involvement 
 Abnormality present but explained entirely by non-GVHD documented cause 
(specify):_____________________________ 
† Skin scoring should use both percentage of BSA involved by disease signs and the cutaneous features scales. When 
a discrepancy exists between the percentage of total body surface (BSA) score and the skin feature score, OR if 
superficial sclerotic features are present (Score 2), but there is impaired mobility or ulceration (Score 3), the higher level 
should be used for the final skin scoring. 

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Score 0 
Score 1 
Score 2 
Score 3 
MOUTH 
Lichen planus-like features 
present: 
 Yes 
 No 
 No symptoms 
 Mild symptoms 
with disease 
signs but not 
limiting oral intake 
significantly  
 Moderate 
symptoms with 
disease signs with 
partial limitation of 
oral intake 
 Severe 
symptoms with 
disease signs on 
examination with 
major limitation of 
oral intake   
 
 
 
 
 Abnormality present but explained entirely by non-GVHD documented cause 
(specify):______________________________ 
EYES 
 
Keratoconjunctivitis sicca (KCS) 
confirmed by ophthalmologist: 
 
 Yes 
 No 
 Not Examined  
 No symptoms 
 Mild dry eye 
symptoms not 
affecting ADL 
(requirement of 
lubricant eye 
drops ≤ 3 x per 
day) 
 Moderate dry eye 
symptoms partially 
affecting ADL 
(requiring lubricant 
eye drops > 3 x per 
day or punctal 
plugs), 
WITHOUT new 
vision impairment 
due to KCS 
 Severe dry eye 
Symptoms 
significantly 
affecting ADL 
(special eyeware to 
relieve pain) OR 
unable to work 
because of ocular 
symptoms OR loss 
of vision due to 
KCS 
 Abnormality present but explained entirely by non-GVHD documented cause 
(specify):_______________________________ 
GI Tract 
Check all that apply: 
 Esophageal web/ proximal 
stricture or ring 
 Dysphagia 
 Anorexia 
 Nausea 
 Vomiting 
 Diarrhea 
 Weight loss ≥5% within 3 
months 
 Failure to thrive 
 No symptoms 
 Symptoms 
without significant 
weight loss within 
3 months (<5%) 
 Symptoms 
associated with mild 
to moderate weight 
loss within 3 months 
(5-15%) OR 
moderate diarrhea 
without significant 
interference with 
daily living 
 Symptoms 
associated with 
significant weight 
loss within 3 months 
>15%, requires 
nutritional 
supplement for 
most calorie needs 
OR esophageal 
dilation OR severe 
diarrhea with 
significant 
interference with 
daily living 
 
 
 
 
 Abnormality present but explained entirely by non-GVHD documented cause 
(specify):________________________________ 
LIVER 
 Normal total 
bilirubin and 
ALT or AP <3 x 
ULN 
 Normal total 
bilirubin with ALT 
≥3 to 5 x ULN or  
AP ≥3 x ULN 
 Elevated total 
bilirubin but ≤3 
mg/dL or ALT >5x 
ULN 
 Elevated total 
bilirubin >3 mg/dL  
 Abnormality present but explained entirely by non-GVHD documented cause 
(specify):________________________________ 

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Score 0 
Score 1 
Score 2 
Score 3 
LUNGS** 
 
Symptom score: 
 No symptoms 
 Mild symptoms 
(shortness of 
breath after 
climbing one flight 
of steps) 
 Moderate 
symptoms 
(shortness of breath 
at after walking on 
flat ground) 
 Severe 
symptoms 
(shortness of breath 
at rest; requiring O2) 
Lung score: 
% FEV1  ________ 
 FEV1≥80% 
 FEV1 60-79% 
 EFV1 40-59% 
 FEV1 ≤39% 
Pulmonary function tests 
 Not performed  
 
 
 
 
 Abnormality present but explained entirely by non-GVHD documented cause 
(specify):________________________________ 
**Lung scoring should be performed using both the symptoms and FEV1 scores whenever possible. FEV1 should be 
used in the final lung scoring where there is discrepancy between symptoms and FEV1 scores. 
JOINTS AND FASCIA 
P-ROM score 
(see below) 
Shoulder (1-7):___ 
Elbow (1-7):___ 
Wrist/finger (1-7):___ 
Ankle (1-4)___ 
 No symptoms 
 Mild tightness 
of arms or legs, 
normal or mild 
decreased range 
of motion (ROM) 
AND not affecting 
ADL 
 Tightness of 
arms OR legs or 
joint contractures, 
erythema thought 
due to fasciitis, 
moderate 
decreased ROM 
AND mild to 
moderate limitation 
of ADL 
 Contractures 
WITH significant 
decrease of ROM 
AND significant 
limitation of ADL 
(unable to tie shoes, 
button shirts, dress 
self etc.)  
 Abnormality present but explained entirely by non-GVHD documented cause 
(specify):_______________________________ 
 
Photographic Range of Motion (P-ROM) 
 

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Score 0 
Score 1 
Score 2 
Score 3 
GENITAL TRACT 
(see Appendix-XXD‡) 
 Not examined 
Currently sexually active 
 Yes 
 No 
 No signs 
 Mild signs‡ and 
females with or 
without discomfort 
on exam 
 Moderate signs‡ 
and may have 
symptoms with 
discomfort on exam 
 Severe signs‡  
with or without 
symptoms 
 Abnormality present but explained entirely by non-GVHD documented cause 
(specify):_______________________________ 
 
‡ To be completed by specialist or trained medical providers (see Appendix-XXD: GENITAL GVHD AND SCORING 
FORM) 
Other indicators, clinical features or complications related to chronic GVHD (check all that apply and assign a  
score to severity (0-3) based on functional impact where applicable none — 0,mild -1, moderate -2, severe — 3) 
 Ascites (serositis) _____ 
 Pericardial Effusion_____ 
 Pleural Effusion(s) _____ 
 Nephrotic syndrome 
 Myasthenia Gravis_____ 
 Peripheral Neuropathy_____ 
 Polymyositis_____ 
 Weight loss > 5% within 3 months 
without GI symptoms___ 
 Eosinophilia > 500/μl_____ 
 Platelets <100,000/ μl_____ 
 Others (specify): _____ 
Overall GVHD Severity 
(Opinion of the evaluator)  
 No GVHD 
 Mild 
 Moderate 
 Severe  
 
Abbreviations: ECOG indicates Eastern Cooperative Oncology Group; KPS, Karnofsky Performance Status; LPS, 
Lansky Performance Status; BSA, body surface area; ADL, activities of daily living; LFTs, liver function tests; AP, 
alkaline phosphatase; ALT, alanine aminotransferase; ULN, normal upper limit. 

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15.3.2 Signs and symptoms of chronic GVHD 
Sign and symptoms of chronic GVHD per Jagasia et al., 2015 (62) 
Organ or site 
Diagnostic 
(Sufficient to 
Establish the 
Diagnosis of 
chronic GVHD) 
Distinctive1 (Seen 
in chronic GVHD, 
but Insufficient 
Alone to Establish 
a Diagnosis) 
Other Features or 
Unclassified Entities2 
Common3 (Seen 
with Both Acute 
and chronic 
GVHD) 
Skin 
Poikiloderma 
Lichen planus—like 
features 
Sclerotic features 
Morphea- 
like features 
Lichen sclerosus—
like features 
Depigmentation 
Papulosquamous 
lesions 
Sweat impairment 
Ichthyosis 
Keratosis pilaris 
Hypopigmentation 
Hyperpigmentation 
Erythema 
Maculopapular rash 
Pruritus 
Nails 
 
Dystrophy 
Longitudinal ridging, 
splitting or brittle 
features 
Onycholysis 
Pterygium unguis 
Nail loss (usually 
symmetric, affects 
most nails) 
 
 
Scalp and  
body hair 
 
New onset of 
scarring or 
nonscarring scalp 
alopecia (after 
recovery from 
chemoradiotherapy) 
Loss of body hair 
Scaling 
Thinning scalp hair, 
typically patchy, coarse 
or dull 
(not explained by 
endocrine or other 
causes) 
Premature gray hair 
 
Mouth 
Lichen planus-like 
changes 
Xerostomia 
Mucoceles 
Mucosal atrophy 
Ulcers 
Pseudomembranes 
 
Gingivitis  
Mucositis  
Erythema  
Pain 
Eyes 
 
New onset dry, 
gritty, or painful 
eyes 
Cicatricial 
conjunctivitis KCS 
Confluent areas of 
Photophobia 
Periorbital 
hyperpigmentation 
Blepharitis (erythema of 
the eyelids with edema) 
 

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Organ or site 
Diagnostic 
(Sufficient to 
Establish the 
Diagnosis of 
chronic GVHD) 
Distinctive1 (Seen 
in chronic GVHD, 
but Insufficient 
Alone to Establish 
a Diagnosis) 
Other Features or 
Unclassified Entities2 
Common3 (Seen 
with Both Acute 
and chronic 
GVHD) 
punctate 
keratopathy 
Genitalia 
Lichen planus-like 
features 
Lichen sclerosus-like 
features 
Erosions 
Fissures 
 
 
Females 
Vaginal scarring or 
clitoral/labial 
agglutination 
Ulcers 
 
 
Males 
Phimosis or 
urethral/meatus 
scarring or stenosis 
 
 
 

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Organ or site 
Diagnostic 
(Sufficient to 
Establish the 
Diagnosis of 
chronic GVHD) 
Distinctive1 (Seen 
in chronic GVHD, 
but Insufficient 
Alone to Establish 
a Diagnosis) 
Other Features or 
Unclassified Entities2 
Common3 (Seen 
with Both Acute 
and chronic 
GVHD) 
GI Tract 
Esophageal web 
Strictures or stenosis 
in the upper to mid 
third of the 
esophagus 
 
Exocrine pancreatic 
insufficiency 
Anorexia 
Nausea 
Vomiting Diarrhea 
Weight loss 
Failure to thrive 
(infants and 
children) 
Liver 
 
 
 
Total bilirubin, 
alkaline 
phosphatase > 2 x 
upper limit of 
normal 
ALT > 2 x upper 
limit of normal 
Lung 
Bronchiolitis 
obliterans 
diagnosed with lung 
biopsy BOS4 
Air trapping and 
bronchiectasis on 
chest CT 
Cryptogenic organizing 
pneumonia 
Restrictive lung disease5 
 
 
Muscles, fascia, 
joints 
Fasciitis 
Joint stiffness or 
contractures 
secondary to fasciitis 
or sclerosis 
Myositis or 
polymyositis6 
Edema 
Muscle cramps 
Arthralgia or arthritis 
 
Hematopoietic 
and immune 
 
 
Thrombocytopenia 
Eosinophilia 
Lymphopenia 
Hypo- or hyper-
gammaglobulinemia 
Autoantibodies (AIHA, 
ITP) 
Raynaud's phenomenon 
 
Other 
 
 
Pericardial or pleural 
effusions 
Ascites 
Peripheral neuropathy 
Nephrotic syndrome 
Myasthenia gravis 
Cardiac conduction 
abnormality or 
 

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Organ or site 
Diagnostic 
(Sufficient to 
Establish the 
Diagnosis of 
chronic GVHD) 
Distinctive1 (Seen 
in chronic GVHD, 
but Insufficient 
Alone to Establish 
a Diagnosis) 
Other Features or 
Unclassified Entities2 
Common3 (Seen 
with Both Acute 
and chronic 
GVHD) 
cardiomyopathy 
ALT indicates alanine aminotransferase; AIHA, autoimmune hemolytic anemia; ITP, idiopathic thrombocytopenic 
purpura.  
1. In all cases, infection, drug effect, malignancy, or other causes must be excluded. 
2. Can be acknowledged as part of the chronic GVHD manifestations if diagnosis is confirmed. 
3. Common refers to shared features by both acute and chronic GVHD. 
4. BOS can be diagnostic for lung chronic GVHD only if distinctive sign or symptom present in another organ.  
5. Pulmonary entities under investigation or unclassified. 
6. Diagnosis of chronic GVHD requires biopsy. 
15.3.3 NIH global severity of chronic GVHD 
Criteria for chronic GVHD per Jagasia et al., 2015 (62) 
Mild chronic GVHD 1 or 2 Organs involved with no more than score 1 plus Lung score 0 
Moderate chronic 
GVHD 
3 or More organs involved with no more than score 1 
OR 
At least 1 organ (not lung) with a score of 2 
OR 
Lung score 1 
Severe chronic 
GVHD 
At least 1 organ with a score of 3 
OR 
Lung score of 2 or 3 
Key points: 
 
In skin:  
Higher of the 2 scores to be used for calculating global severity. 
In lung:  
FEV1 is used instead of clinical score for calculating global severity. 
 
If the entire abnormality in an organ is noted to be unequivocally explained by a non-GVHD documented cause, that 
organ is not included for calculation of the global severity. 
 
If the abnormality in an organ is attributed to multifactorial causes (GVHD plus other causes) the scored organ will be 
used for calculation of the global severity regardless of the contributing causes (no downgrading of organ severity 
score).   
 

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15.4 Appendix D: Karnofsky Performance Scale: 
Karnofsky Performance Scale 68 
Percent 
Description 
100 
Normal, no complaints, no evidence of disease. 
90 
Able to carry on normal activity; minor signs or symptoms 
of disease. 
80 
Normal activity with effort; some signs or symptoms of 
disease. 
70 
Cares for self, unable to carry on normal activity or to do 
active work. 
60 
Requires occasional assistance, but is able to care for most 
of his/her needs. 
50 
Requires considerable assistance and frequent medical 
care. 
40 
Disabled, requires special care and assistance. 
30 
Severely disabled, hospitalization indicated.  Death not 
imminent. 
20 
Very sick, hospitalization indicated. Death not imminent. 
10 
Moribund, fatal processes progressing rapidly. 
0 
Dead.