Biomarkers in Acute Graft-Versus-Host Disease (GVHD) and Extracorporeal Photopheresis Added to Investigator Chosen Therapies of Steroid Refractory Acute GVHD
Phase: PHASE2
Conditions: Chronic Graft vs. Host Disease, Graft vs Host Disease, Graft-Versus-Host Disease
Sponsor: National Cancer Institute (NCI)

Abbreviated Title:  Biomarkers & ECP in Acute GVHD 
Version Date:  October 02, 2018 
1 
 
Abbreviated Title: Biomarkers & ECP in Acute GVHD 
CC Protocol #: 15-C-0039 
Version Date:  October 02, 2018 
Amendment: D 
NCT Number: NCT02322190  
Title:  Biomarkers in Acute Graft-Versus-Host Disease (GVHD) and Extracorporeal 
Photopheresis added to Investigator Chosen Therapies of Steroid Refractory Acute GVHD 
 
Principal Investigator:    
Ronald Gress, M.D. 
Chief, Experimental Transplantation and Immunology Branch  
Center for Cancer Research, National Cancer Institute 
National Institutes of Health  
10 CRC, Room 3-3332 
9000 Rockville Pike  
Bethesda, MD 20892 
Ph: (240) 760-6167 
Fax: (301) 480-4354 
                                                Email: gressr@mail.nih.gov 
 
 
 
 
 
IDE Exempt Non-significant 
Device: 
Extracorporeal photopheresis (ECP) Machine 
Manufacture 
Generic 
 
Commercial Agent: Methoxsalen (Uvadex(R) 
Study Exempt from IND Requirements per 21 CFR 312.2(b) 
 
    
 
 

Abbreviated Title:  Biomarkers & ECP in Acute GVHD 
Version Date:  October 02, 2018 
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PRECIS 
Background: 
x Acute graft versus host disease (GVHD) remains a difficult to manage complication of 
allogeneic hematopoietic stem cell transplantation causing significant morbidity and 
mortality.  
x Biomarkers have recently been described in acute GVHD that have the potential to better 
predict onset, severity, steroid failure, and non-relapse mortality. 
x First line  treatment of acute GVHD with high dose corticosteroids will fail in 
approximately 30% of patients and is associated with significant steroid related 
complications 
x No second line treatment of acute GVHD after a failure of steroids has been established 
as a standard approach.  
x Choice of second line therapy for acute GVHD is currently based primarily on physician 
familiarity, existing toxicities, and patient's ability to tolerate new potential toxicities. 
x Extracorporeal photopheresis (ECP) is an attractive therapy to combine with other  
therapies for steroid refractory disease due to a unique mechanism of action involving 
immunomodulation as well as an extremely low rate of reported side effects and 
complications.  
x Biomarkers may also prove useful in predicting the success or failure of specific  
treatments for steroid refractory diasease, including those combined with ECP. 
x This study will allow for collection of biomarker data in patients undergoing allogeneic 
transplantation on NCI protocols, including those who develop acute GVHD, and 
investigate their role in predicting outcomes in initial corticosteroid therapy as well as in 
currently used treatments in the management of patients with steroid refractory acute 
GVHD with or without the addition of ECP. 
Objective: 
x To study biomarkers in patients undergoing allogeneic transplantation, with acute GVHD 
including their ability to predict steroid refractoriness and predict outcome of investigator 
chosen second line therapies with and without Extracorporeal Photopheresis (ECP). 
Eligibility: 
x Adult patients on an NCI allogeneic transplantation protocol. 
Design: 
x Non-randomized, single institution study. 
x Research blood for biomarkers will be collected on all patients enrolled. 
x ECP will be offered as an addition to investigator chosen  treatments in patients who 
develop  steroid refractory acute GVHD.  
x The study will enroll a total of up to 450 patients.  

Abbreviated Title:  Biomarkers & ECP in Acute GVHD 
Version Date:  October 02, 2018 
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TABLE OF CONTENTS  
PRECIS ........................................................................................................................................... 2 
TABLE OF CONTENTS ................................................................................................................ 3 
1. 
INTRODUCTION .................................................................................................................. 6 
1.1 
Study Objectives .............................................................................................................. 6 
1.1.1 
Primary Objective ..................................................................................................... 6 
1.1.2 
Secondary Objective ................................................................................................. 6 
1.2 
Background and Rationale ............................................................................................... 6 
1.2.1 
Acute GVHD ............................................................................................................ 6 
1.2.2 
Biomarkers ................................................................................................................ 6 
1.2.3 
Steroid Refractory GVHD ........................................................................................ 8 
1.2.4 
Current Therapy of Steroid Refractory Acute GVHD .............................................. 8 
1.2.5 
Extracorporeal Photopheresis ................................................................................... 9 
1.2.6 
Background and Rationale: Summary .................................................................... 12 
2 
ELIGIBILITY ASSESSMENT AND ENROLLMENT ....................................................... 12 
2.1 
Eligibility Criteria .......................................................................................................... 12 
2.1.1 
Inclusion Criteria .................................................................................................... 12 
2.1.2 
Exclusion Criteria ................................................................................................... 13 
2.2 
Screening Evaluation...................................................................................................... 13 
2.2.1 
The following will be documented prior to protocol entry. .................................... 13 
2.3 
Registration Procedures.................................................................................................. 13 
2.3.1 
Patient Assignment or Stratification Procedure ...................................................... 14 
3 
STUDY IMPLEMENTATION ............................................................................................ 14 
3.1 
Study Design .................................................................................................................. 14 
3.1.1 
Diagnosis of steroid refractory acute GVHD .......................................................... 15 
3.2 
Extracorporeal Photopheresis (ECP) .............................................................................. 16 
3.2.1 
Schedule of ECP treatments.................................................................................... 16 
3.2.2 
ECP Procedure ........................................................................................................ 16 
3.3 
Study Calendar ............................................................................................................... 17 
3.4 
Criteria for Removal from Protocol Therapy  and Off Study Criteria ........................... 18 
3.4.1 
Criteria for removal from protocol therapy. ........................................................... 18 

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3.4.2 
Off Study Criteria ................................................................................................... 18 
3.4.3 
Off Protocol Therapy and Off Study Procedure ..................................................... 18 
4 
CONCOMITANT MEDICATION ....................................................................................... 18 
5 
BIOSPECIMEN COLLECTION .......................................................................................... 18 
5.1 
Correlative Studies for Research .................................................................................... 18 
5.1.1 
Biomarker Assays ................................................................................................... 18 
5.2 
Storage, Tracking and Disposition ................................................................................. 19 
5.2.1 
Storage/Tracking in the Preclinical Development and Clinical Monitoring Facility 
(PDCMF) .............................................................................................................................. 19 
5.2.2 
Protocol Completion/Sample Destruction .............................................................. 20 
6 
DATA COLLECTION AND EVALUATION ..................................................................... 20 
6.1 
Data Collection ............................................................................................................... 20 
6.2 
Response Criteria ........................................................................................................... 21 
6.2.1 
Recording of Steroid Dose ...................................................................................... 21 
6.2.2 
Measurement of GVHD Outcome and Response ................................................... 21 
6.3 
Toxicity Criteria ............................................................................................................. 22 
7 
SAFETY REPORTING REQUIREMENTS/DATA AND SAFETY MONITORING PLAN
 
22 
7.1 
Definitions ...................................................................................................................... 22 
7.1.1 
Adverse Event ......................................................................................................... 22 
7.1.2 
Suspected Adverse Reaction ................................................................................... 22 
7.1.3 
Unexpected Adverse Reaction ................................................................................ 22 
7.1.4 
Unanticipated adverse device effect ....................................................................... 23 
7.1.5 
Serious..................................................................................................................... 23 
7.1.6 
Serious Adverse Event ............................................................................................ 23 
7.1.7 
Disability ................................................................................................................. 23 
7.1.8 
Life-threatening adverse experience ....................................................................... 23 
7.1.9 
Protocol Deviation (NIH Definition) ...................................................................... 23 
7.1.10 Non-compliance (NIH Definition) .......................................................................... 23 
7.1.11 Unanticipated Problem............................................................................................ 23 
7.2 
NCI-IRB and Clinical Director Reporting ..................................................................... 24 
7.2.1 
NCI-IRB and NCI CD Expedited Reporting of Unanticipated Problems and Deaths
 
24 

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7.2.2 
NCI-IRB Requirements for PI Reporting at Continuing Review. .......................... 24 
7.3 
Data and Safety Monitoring Plan ................................................................................... 24 
7.3.1 
Principal Investigator/Research Team .................................................................... 24 
8 
STATISTICAL CONSIDERATIONS.................................................................................. 25 
9 
HUMAN SUBJECTS PROTECTIONS ............................................................................... 26 
9.1 
Rationale For Subject Selection ..................................................................................... 26 
9.2 
Participation of Children ................................................................................................ 27 
9.3 
Participation of Subjects Unable to Give Consent ......................................................... 27 
9.4 
Evaluation of Benefits and Risks/Discomforts .............................................................. 27 
9.4.1 
Related to Blood Collection .................................................................................... 27 
9.4.2 
Related to Methoxsalen Administration and ECP Procedure ................................. 27 
9.4.3 
Related to Pregnancy .............................................................................................. 27 
9.5 
Risks/Benefits Analysis(including those that do and do not have the capacity to 
consent) ..................................................................................................................................... 27 
9.6 
Consent and Assent Process and Documentation .......................................................... 28 
9.6.1 
Telephone re-consent procedure ............................................................................. 28 
9.6.2 
Informed Consent of Spanish Speaking Subjects: .................................................. 28 
9.6.3 
Short form consent process for other non-English speaking patients ..................... 28 
10 PHARMACEUTICAL INFORMATION ............................................................................. 29 
10.1 Methoxsalen Sterile Solution (Uvadex(R)) .................................................................... 29 
10.2 Therakos Photopheresis Procedure ................................................................................ 29 
10.2.1 Warnings and Precautions....................................................................................... 30 
11 REFERENCES ..................................................................................................................... 32 
 
 
 

Abbreviated Title:  Biomarkers & ECP in Acute GVHD 
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1. INTRODUCTION 
1.1 
STUDY OBJECTIVES 
1.1.1 Primary Objective 
To study biomarkers in patients undergoing allogeneic transplantation, with acute GVHD 
including their ability to predict steroid refractoriness and predict outcome of investigator chosen 
second line therapies with and without Extracorporeal Photopheresis (ECP). 
1.1.2 Secondary Objective 
To study steroid requirement, GVHD outcome, and overall survival at 6 months in patients with 
acute GVHD.  
1.2 
BACKGROUND AND RATIONALE  
1.2.1 Acute GVHD 
Depending on the type of allogeneic transplant and the level of donor-recipient disparity, between 
30%-60% of transplant patients will be diagnosed with acute GVHD despite strategies for 
prophylaxis 1. Acute GVHD involves donor T cells causing damage in the target tissues of liver, 
bowel, and skin. This classically was defined as occurring in the first 100 days after transplant but 
it is increasingly recognized as occurring at later times after immunosuppression withdrawal and 
subsequent to donor lymphocyte infusions. Standard intervention is 1-2 mg/kg/day of 
methylprednisolone or equivalent steroid. Unfortunately, approximately 40%-50% of patients will 
be deemed steroid refractory and require some form of second line therapy.  
1.2.2 Biomarkers 
The role of biomarkers in acute GVHD has been the subject of several recent reviews 2, 3, 
4,5.Gander Lugt et al recently showed that the biomarkers, ST2 and REG3a have promise in 
predicting adverse outcomes of acute GVHD, including steroid refractoriness 6.  Haige et al 
demonstrated that a Lipopolysaccharide-Binding Protein (LPS-BP) level above 15,000 ng/ml at 
day 7 and 14 after transplant was independently associated with later acute GVHD.7 Dietrich et 
al demonstrated that high levels of serum nitrate prior to transplant could independently predict 
for steroid refractory GVHD and that this risk could be abrogated by pre-transplant use of 
statins.8 Jinhuan et al demonstrated that serum and mononuclear mRNA levels of Indoleamine 
2,3 Dioxygenase (IDO), combined with interferon Gamma levels, was a powerful predictor of 
acute GVHD 9.  A summary of candidate biomarkers is shown in the table . 
 
 

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Abbreviated Title:  Biomarkers & ECP in Acute GVHD 
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(Figure from: Paczesny S. Discovery and validation of graft-versus-host disease biomarkers 3) 
It is hoped that biomarkers will improve future predictive and prognostic testing leading to better 
prophylaxis and treatment outcomes, especially in steroid refractory disease. None of these 
biomarkers has yet found its way into routine clinical decision making 4,5. Prospective collection 
of biomarker data in patients remains an important goal of acute GVHD studies to further define 
their utility in understanding the biology and choosing effective treatments of acute GVHD. 
Patients enrolled on this study will have blood collected for biomarkers at enrollment and various 
time points throughout transplant.As this field is rapidly evolving, the exact panel of biomarkers 
that will be eventually be examined may change over time. Based on the current validation of 
candidate biomarkers in various studies,  serum TIM3, IL-6, Reg-3-a, ST2, LPS-BP, Nitrate, 
TNFR1, IL-2Ra, CXCL10, and HGF will initially be studied. 
 
1.2.3  Steroid Refractory GVHD 
To date, there are no proven treatments based on Phase III trials for steroid-refractory acute 
GVHD 10. The bulk of the data from treatment of these patients often rely on small Phase II trials 
with different eligibility criteria making comparisons and treatment decisions difficult. The 
choice of therapy when steroids fail is often based on pre-existing organ toxicity and prior 
GVHD prophylaxis of the patient 11. In addition, treatment choices are further complicated by no 
universally accepted single definition of steroid refractoriness in acute GVHD, despite attempts 
at formalizing the criteria in recent reviews, and guidelines 12, 13,14, 15,16 Dignan et al suggested 
that no response by day 5 of treatment with steroids is a reliable marker of poor outcome; 
patients who respond to 2 mg/kg/day of steroids by day 5 had a non-relapse mortality of 27%, 
compared to 49% non-relapse mortality for day-5 non-responders. A recent European review 
adopts this five day cutoff but also specifies that worsening of acute GVHD at day 3 days also 
constitutes steroid failure 13,14. Guidelines recently put forth by American Society for Bone 
Marrow Transplantation  used a criterion of lack of improvement despite 7 days of full dose 
steroids to define steroid refractoriness with poor outcomes in those so defined 12. Stool volume, 
bilirubin levels, and area of skin rash are used as objective measures, although the decision to 
declare steroid refractoriness remains partly subjective and organ specific. For the purposes of 
instituting second line therapies, this study will utilize both objective and subjective measures to 
define steroid refractoriness as worsening despite 3 days, no improvement despite 7 days, or 
inadequate response despite 14 days of adequately dosed corticosteroids. 
1.2.4 Current Therapy of Steroid Refractory Acute GVHD 
It was hoped that recently conducted randomized trials of the most promising agents for the 
initial treatment of acute GVHD combined with steroids would provide some guidance as to 
which agents might also be used after steroids for the treatment acute GVHD. 17The Bone 
Marrow Transplant Clinical Trials Network investigated the role of etanercept, mycophenolate 
moxetil (MMF), denileukin, or pentostatin plus corticosteroids for initial treatment of aGVHD. 
In this randomized Phase II trial, the day 28 complete response rates were 60%, 53%, 38%, and 
26% for mycophenylate, denileukin, pentostatin, and etanercept, respectively. The combination 
of steroids and MMF was chosen for a Phase III trial for initial treatment of aGVHD. A follow 
up randomized Phase III trial which compared MMF/steroids with steroids alone for initial 

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treatment of acute GVHD was stopped by its futility end points 18. Unfortunately, these trials 
failed to suggest an added benefit when further immunosuppressive agents are added to steroids 
for the initial treatment of aGVHD. Additionally, these efforts also did not point to any preferred 
agent for use as in second line therapy.  
 
Despite the lack of a standard, all steroid refractory patients are offered second line and beyond 
therapies given the fatal nature of uncontrolled acute GVHD. In general, investigators have 
tended to use a single additional therapy added to some combination of calcineurin inhibitor and 
continued steroids in order to try and assess the balance of side effects and benefit. The choice 
and order of agents tried remains dictated largely by investigator experience and bias due to the 
lack of clear guidance from the available studies. Two broad classes of agents are used to treat 
GVHD; agents aimed at impairing cellular effectors and agents aimed at limiting cytokine 
activity in the effected tissues 1. This study neither dictates the choice of secondary agents nor is 
designed to examine the activity or superiority of any particular agent or agents. This study will 
measure biomarkers in patients with acute GVHD and pilot the addition of extracorporeal 
photopheresis to current therapeutic choices in those patients with steroid refractory acute 
GVHD   
1.2.5 Extracorporeal Photopheresis 
Extracorporeal Photopheresis (ECP) is currently approved by the FDA for the treatment of 
refractory cutaneous T-cell lymphoma (CTCL) 19, 20. Over the past two decades, ECP has also been 
further applied and studied in the treatment of several autoimmune diseases as well as for treatment 
for cardiac, renal and lung allograft rejection 21, 22,23,24,10,25. Based on the presumed 
immunomodulation in these situations, ECP has been previously attempted in both acute and 
chronic GVHD 26, 27, 28,29. The procedure involves separating the white blood cells (buffy coat) 
from the plasma and red blood cells, which are infused back to the patient. The buffy coat 
leukocytes are then exposed to UVA irradiation following pretreatment with 8-methoxypsoralen, 
which has been shown to result in apoptosis of the majority of cells within 48 hours 30. Both in 
vitro and in vivo studies suggest that the subsequent clearance of these apoptotic cells can result 
in significant immunomodulation 31. However, the specific immunologic mechanism by which 
ECP works has not been clearly elucidated10. Modulation of Th1/Th2 balance has been often 
invoked. In CTCL, where early stage disease is associated with Th2 skewing, ECP results in a shift 
toward Th1 cytokines and a restoration of the normal Th1/Th2 balance 32. Alternatively Gorgun et 
al. 33 demonstrated that patients with cGVHD treated with ECP demonstrated an increase in DC2 
dendritic cell subsets and concomitant shift in Th2 cytokine production by T cells. In addition, 
Silva et al. 34 demonstrated an increase in Th1 cells in patients with cGVHD. Other studies have 
showed ECP appears to alter cytokine profiles with increases in IL-10, a type 2 cytokine frequently 
associated with immunosuppression 35, 34. These discrepancies suggest the complexity of the 
Th1/Th2 system and the biologic effects of ECP. Another important consideration when 
interpreting these studies is that many of the diseases treated with ECP, including GVHD, are 
associated with a Th1/Th2 shift which makes it difficult to know whether the restoration of this 
balance reflects a therapeutic mechanism of ECP or is a simply a secondary marker of disease 
improvement.  
Another potential mechanism of ECP in the treatment of GVHD is the impact of ECP on dendritic 
cells. ECP has demonstrated reproducible decreases in circulating CD80+ and CD123+ dendritic 
cell subsets 34, 36. Further studies have suggested that ECP causes a shift toward immature dendritic 

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cell populations with lower levels of co-stimulatory molecule expression. This has several 
consequences including a decreased migratory response to MIP-3ȕ, decreased T cell proliferation, 
and increased production of IL-10 which further diminishes dendritic cell maturation and 
allostimulatory capacity 37, 38, 39. Such changes have been importantly demonstrated to characterize 
tolerogenic dendritic cells 40, 41, 42.  
Meloni et al.43 showed that there is an increase in central memory CD8 T cells and a decrease in 
central memory CD4 T cells in patients with cGVHD. It was demonstrated that the balance of 
memory T cells normalizes after ECP treatment and is associated temporally with improvement of 
clinical symptoms 43. Recently, expansion of regulatory T cells has been associated with ECP 
treatment in humans 43, 44, 45 and in murine models 46, 29.  
As noted above, the clinical application of ECP to a variety of disease processes has preceded a 
full understanding of the mechanisms by which this therapy might exert a therapeutic effect. 
Evidence continues to emerge from clinical studies, animal models and in vitro studies elucidating 
that significant immune modulation occurs with ECP. This, associated with the clinical safety of 
the procedure, has justified ECP's continued application even while knowledge of related areas 
such as apoptotic cell clearance, regulatory T cell biology, and tolerogenic dendritic cell 
manipulations are leading to better understanding of the mechanism of ECP in various disease 
states such as GVHD.  
The safety of ECP has been extensively documented and the development of ECP arose, in part, 
from concerns with the safety of another commonly employed skin-directed treatment, PUVA. 
PUVA was introduced in the early 1970s as an effective treatment for many skin conditions but is 

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associated with a large number of adverse effects. PUVA is performed by giving patients oral 8-
MOP capsules followed 1–2 hours later by exposure to a UVA light source. Unfortunately, the 
pharmacokinetics of oral 8-MOP has shown large variability as high as 18-fold. Variable GI 
absorption and extensive hepatic metabolism, including first-pass hepatic elimination, seem 
responsible for this variability. The unpredictable blood concentrations of oral 8-MOP likely 
underlie inconsistent UVA exposure leading to the toxicity or diminished therapeutic effect of 
PUVA. In contrast, with ECP, 8-MOP is mixed ex vivo with the patient’s buffy coat cell layer, 
which is then re-infused back into the patient. The half-life of the drug administered in this fashion 
is extremely short resulting in substantially lower and much more predictable drug exposure.  
ECP utilizing the Therakos system has an established safety profile with over 500,000 treatments 
performed to date (Therakos User Manual 2001). The only absolute contraindication for ECP is in 
patients who cannot tolerate extracorporeal volume loss (severe heart failure, hypotension, sepsis) 
or patients with coagulation disorders. In addition, methoxsalen (Oxsoralen-Ultra®), the FDA-
approved 8-MOP compound used with the Therakos device, is contraindicated in patients with 
idiosyncratic reactions to psoralen compounds, those with a history of light-sensitive disease (such 
as patients with systemic lupus erythematous with photosensitive disease), or those with aphakia. 
Serious side effects with the procedure itself have rarely been reported, most of which are related 
to hypotension secondary to changes in extracorporeal volume. A large, multicenter survey 
focusing on immediate adverse effects of therapeutic apheresis reported no adverse events from a 
total of 79 ECP procedures with the majority of these procedures done using the Therakos 
system47. More recently, a phase II, randomized, controlled trial did not show significant 
differences in safety outcomes between the arm receiving ECP therapy for chronic graft versus 
host disease and the control-arm. The overall rates of infections (53.1% versus 44%), diarrhea 
(20.4% versus 20%), and nausea (18.4% versus 12%) were not significantly different between 
those receiving ECP and steroids versus steroids alone, while anemia occurred more frequently in 
those receiving ECP treatment (24.5% versus 6%; p = 0.02)29. In clinical practice, anemia in 
patients receiving ECP therapy can be seen and is most likely attributed to small volume blood 
loss over repeated procedures. In contrast to other GVHD therapies, studies have found that ECP 
therapy does not have immunosuppressive effects and therefore does not add to the risk for 
opportunistic infections26, 29,48, 49. Secondary malignancies have not been associated with ECP; 
however, photosensitivity may occur and patients are instructed to take standard precautions as it 
relates to sun exposure. Fatigue, pruritus and fevers have also been reported during or after ECP 
treatment. Because intravenous (IV) access is required, patients are at risk for catheter-related 
complications including infection and thrombosis.  
Because of the apparent safety, especially a reported lack increased infections, ECP is an 
attractive therapy to combine with other commonly used therapies of acute GVHD.  ECP has 
been studied in acute GVHD with variable results (see Table below) leading to an inconsistent 
recommendation about the potential clinical role. In a pilot trial of 21 patients with steroid-
refractory aGVHD by Greinix et al.49, 60% responded to ECP. However, none of the patients 
with acute GI GVHD responded to this intervention. Greinix et al.50 reported the results of a 
follow-up Phase II trial of 59 patients treated with a more aggressive schedule of ECP with a 
complete response rate of 82%, 61%, and 61% in patients with skin, liver, and GI GVHD, 
respectively. A review, published in 2002, summarized the results on the use of ECP in aGVHD 
in 76 patients treated in 11 separate studies. Of the 76 patients, 59%, 47%, and 28% presented 

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with skin, liver, and GI manifestations of aGVHD, respectively.  Treatment duration ranged from 
1 to 24 months. Regression of skin manifestations was observed in 83% of the patients with a 
complete response in 67%. A complete regression of liver and gut manifestations was reported in 
38% and 54% of the patients, respectively. Despite these preliminary results, the optimal role of 
ECP in the management of steroid refractory acute GVHD remains undefined and there is little 
reported experience combining ECP with other therapies other than corticosteroids. 
1.2.6  Background and Rationale: Summary 
Current therapy of acute GVHD, especially steroid refractory disease, is unsatisfactory in a 
majority of patients due to both limited effectiveness and highly variable morbidity of many of 
the treatments. No single treatment regimen has been shown to consistently alter outcomes. 
Immunosuppression and subsequent infection contribute to the poor outcome steroid refractory 
disease. ECP is an attractive treatment modality due to its unique mechanism of action and low 
toxicity profile. Combining ECP with other treatments for  GVHD is likely feasible, tolerable, 
and, based on prior experiences in the literature, not be expected to increase the toxicity of 
treatment. The potential of ECP to improve outcomes in this setting, either alone or in 
combination, has been incompletely explored. Recently described acute GVHD biomarkers have 
the potential to improve future prediction of refractory disease and therapeutic outcome of the 
varied treatments currently in use. Data will be collected on the procedure specific complications 
of ECP  in combination with other therapies currently in use for acute  GVHD. 
2 
ELIGIBILITY ASSESSMENT AND ENROLLMENT  
2.1 
ELIGIBILITY CRITERIA 
2.1.1 Inclusion Criteria 
2.1.1.1 Age > 18 years. 

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2.1.1.2 Ability of subject to understand and the willingness to sign a written informed 
consent document. 
2.1.1.3 Subject must be also enrolled on an NCI allogeneic transplant protocol. 
2.1.1.4 Patients must agree to practice effective contraception (both male and female 
subjects, if the risk of conception exists). The effects of ECP on the developing 
human fetus are unknown.  For this reason and as well as other Methoxsalen used in 
this trial is in a class of agents that is known to be teratogenic, men must agree to use 
adequate contraception (hormonal or barrier method of birth control; abstinence) 
prior to study entry and for the duration of study participation, and for 4 months after 
the completion of study treatment.  Should a woman become pregnant or suspect she 
is pregnant while her partner is participating in this study, she should inform her 
treating physician immediately.   
2.1.2 Exclusion Criteria 
2.1.2.1 Any physical or mental condition that, in the opinion of the PI, would cause the 
risk/benefit ratio of participation to be unacceptable. 
2.1.2.2 Inclusion of ECP in the treatment of any patient  is contraindicated by any of the 
following:  
x Unstable hemodynamics requiring vasopressors or other support measures not 
amenable to or medically appropriate for continuation during the procedure. 
x Uncontrolled infection. 
x Inability to maintain acceptable venous access. 
x Uncontrolled or uncorrectable coagulopathy. 
2.1.2.3 Pregnant women are excluded from ECP because methoxsalen, an agent utilized for 
the study procedure, may cause fetal harm.  Because there is an unknown but 
potential risk for adverse events in nursing infants secondary to treatment of the 
mother with methoxsalen, breastfeeding should be discontinued if the mother is 
treated with methoxsalen. Pregnancy will be evaluated prior to initiation of ECP.  
2.1.2.4 History of allergic or idiosyncratic/hypersensitivity reactions to 8- 
methoxypsoralen/psoralen compounds. 
2.1.2.5 History of a light-sensitive cutaneous disease 
2.1.2.6 Subjects with aphakia 
2.2 
SCREENING EVALUATION 
2.2.1 The following will be documented prior to protocol entry. 
x Concurrent participation in an ETIB allogeneic transplant protocol. 
2.3 
REGISTRATION PROCEDURES 
Authorized staff must register an eligible candidate with NCI Central Registration Office (CRO) 
within 24 hours of signing consent.  A registration Eligibility Checklist from the web site 
(http://home.ccr.cancer.gov/intra/eligibility/welcome.htm) must be completed and sent via 

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encrypted email to:  NCI Central Registration Office ncicentralregistration-l@mail.nih.gov.  
Verification of Registration will be forwarded electronically via e-mail to the research team. A 
recorder is available during non-working hours. 
2.3.1 Patient Assignment or Stratification Procedure  
 
 
Patients will be enrolled based on their participation on any NCI allogeneic transplant protocol. 
Specific treatments for steroid refractory acute GVHD, including the use of ECP, will be at the 
discretion of the patient's primary transplant protocol PI (or designee) in consultation with the PI 
of this protocol. Patients will not be randomizedor otherwise assigned. Patients may enter the 
protocol at any point during their participation on a separate NCI transplant protocol and absence 
of any biomarker time point(s) will be noted but will not constitute a deviation from this 
protocol. 
 
 
3 
STUDY IMPLEMENTATION 
3.1 
 STUDY DESIGN 
Please note that as of January 27, 2017  Accrual has been suspended on this protocol. 
Amendment D (version date: 10/02/2018) serves as the formal notification to the IRB of an 
Administrative Hold pending delivery of a new ECP device. Potential resources are being 
explored that would allow the protocol to begin to accrue in the future. No new patients will be 
enrolled. We enrolled total of 5 patients on this study, all 5 patients have completed the follow 
up period and are off study. 

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Subjects will be followed according the the schedule outlined in section 3.3 for either three 
months post transplant (D+100), six months post transplant, or six months following the last 
ECP procedure. A final assessment will be completed prior to removing the subject from the 
study. Biomarker time points will commence when the patient is enrolled and enrollment at any 
point of the patient’s transplant is allowed.  
 
3.1.1 Diagnosis of steroid refractory acute GVHD 
Diagnosis of steroid refractory acute GVHD in any patient will be defined at a minimum as 
clinical worsening despite 3 days, no clinical response despite 7 days, or an inadequate clinical 
response despite 14 days of methylprednisolone IV (or equivalent corticosteroid) at a minimum 
dose of 2mg/kg/day.  
x
Clinical responses are determined by measurements specific to the organ(s) 
affected.  

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16 
 
x The determination of an inadequate clinical response to steroids will be made 
by the PI of the patient's primary transplant protocol (or their designee) in 
consultation with the PI of this protocol.  
x General guidelines to be used for this determination by system will be as 
follows: 
GI: failure to show at least a 50% reduction in stool volume compared to the 
highest daily stool volume.  
SKIN: failure to show at least a 50% improvement of skin rash severity or 
distribution compared to the worst severity or extent of the rash.  
LIVER: failure to demonstrate at least a 50% reduction in direct bilirubin 
compared to the peak preceding value.  
3.2 
EXTRACORPOREAL PHOTOPHERESIS (ECP) 
3.2.1 Schedule of ECP treatments  
Patients who have ECP included in their treatment of steroid refractory acute GVHD will in 
general follow this recommended schedule: 
x Twice weekly for 1 month 
x Twice every other week for 2 months 
x Twice during one week per month  for4 months for a total of up to 7 months of 
treatment 
The frequency or duration of therapy can be individualized at PI discretion based on clinical risk 
and potential benefit of the variation. The rationale for the variation should be clearly 
documented in the study note of patient's medical record.  
3.2.2 ECP Procedure 
Patients who will undergo ECP will be treated according to the standard operating procedure of 
the Clinical Center Department of Transfusion Medicine. The procedure may be done in a 
hospital room, an outpatient department, or in DTM 
The UVAR will be used to perform therapeutic ECP under the direction of a Department of 
Transfusion Medicine (DTM) physician, in accordance with specific NIH Clinical Center 
Protocols, and the Medical Chief of Blood Services Section (BSS). Unless otherwise stated, the 
apheresis staff will adhere to the manufacturer’s recommendations when performing ECP. 
Registered Nurses will perform ECP as ordered by DTM physicians in the Clinical Research 
Information System (CRIS). The Operator’s Manual for the UVAR and the directions for use 
with the apheresis kit will be followed at all times. 
If the patient lacks adequate existing venous access for ECP, they may need to have a catheter 
placed by Interventional Radiology or the VAD Service. 

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17 
 
3.3 
 STUDY CALENDAR  
 
Procedure 
 
 
Baseline 
/ 
Enrollm
ent 
(+/- 2 
days) 
At D0 of 
transpla
nt 
If no 
acute 
GVHD 
or 
steroid
s,colle
ct at 
D100  
(+/- 
1week) 
 
At 
diagnos
is of 
acute 
GVHD  
(+/- 1 
week) 
At 
diagnosis 
of steroid 
refractor
y or 
responsiv
e acute 
GVHD 
 (+/- 1 
week) 
If acute 
steroid 
refracto
ry 
GVHD 
with no 
ECP, 
collect 
at 6 
months 
post 
transpla
nt 
(+/- 1 
month) 
ECP Only 
 
 
At first 
ECP of 
each 
month 
of 
treatme
nt 
 
At 6 
mont
hs 
from 
last 
ECP 
(+/- 1 
mont
h) 
Study 
Note 
X 
 
X 
X 
X 
X 
X 
X 
TBNK 
X 
X 
X 
X 
X 
X 
X 
X 
Urine or 
serum 
ȕ+&* in 
women of 
childbeari
ng 
potential 
 
 
 
 
 
 
X 
 
Biomarker
s 
X 
X 
X 
X 
X 
X 
X 
X 
*9+' 
Evaluatio
n 
 
 
 
 
X 
X 
X 
X 
X 
E&3 
Adverse 
Events 
 
 
 
 
 
 
X 
X 
*9+' 
Meds 
 
X 
 
X 
X 
X 
X 
X 

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3.4 
CRITERIA FOR REMOVAL FROM PROTOCOL THERAPY  AND OFF STUDY CRITERIA 
Prior to removal from off study , effort must be made to have all subjects complete a safety visit 
approximately 30 days following the last dose of study therapy. 
 
3.4.1 Criteria for removal from protocol therapy. 
x The patient refuses to continue therapy. 
x At the principal investigator’s discretion, if the PI deems the patient to be at an 
unacceptable risk/benefit ratio to remain on the study. 
x PI of the patient's primary transplantation protocol requests removal. 
x Participant becomes pregnant  
3.4.2 Off Study Criteria 
x Completed either D+100 post-transplant evaluation, 6 month post-transplant 
evaluation,or 6 months evaluation after completion of ECP)   
x Participant requests to be withdrawn from study 
x Death 
x PI decision to end this study  
3.4.3 Off Protocol Therapy and Off Study Procedure 
Authorized staff must notify Central Registration Office (CRO) when a subject is taken off-
study. A Participant Status Updates Form from the web site 
(http://home.ccr.cancer.gov/intra/eligibility/welcome.htm) main page must be completed and 
sent via encrypted email to:  NCI Central Registration Office ncicentralregistration-
l@mail.nih.gov. 
4 
 CONCOMITANT MEDICATION 
There are no specific restrictions on the use of any other agents or procedures deemed necessary 
for the ongoing care of the patients on this study.  
5 
BIOSPECIMEN COLLECTION 
5.1 
 CORRELATIVE STUDIES FOR RESEARCH 
5.1.1 Biomarker Assays 
One (1) 10 mL Sodium-Heparin/Green-top tube, and up to five (5) 8 mL CPT/Sodium-
Heparin/Red+Green-top tubes will be sent via escort to ETIB Preclinical Development and 
Clinical Monitoring Facility (PDCMF) (Bldg 10, Room 12C216).  All enrolled patients will have 
this blood work drawn at time points as detailed in the study calendar (see Section 3.3). TIM3, 
IL-6, Reg-3-a, ST2, LPS-BP, Nitrate, TNFR1, IL-2Ra, CXCL10, and HGF will initially be 

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19 
 
studied. Assay will be either by Luminex Microbead (Luminex, Austin, TX) or enzyme linked 
immunosorbent assay (ELISA) using commercially available reagents and protocols. 
5.2 
 STORAGE, TRACKING AND DISPOSITION 
5.2.1 Storage/Tracking in the Preclinical Development and Clinical Monitoring Facility 
(PDCMF) 
x Samples will be ordered in CRIS and tracked through a Clinical Trial Data Management 
system .  Should a CRIS screen not be available,the CRIS downtime procedures will be 
followed.  Samples will not be sent outside NIH without IRB notification and an 
executed MTA. 
x Normal donor and patient blood and tissue samples, collected for the purpose of research 
under IRB approved protocols of the Experimental Transplantation and Immunology 
Branch, may be archived by the ETIB Preclinical Development and Clinical Monitoring 
Facility (PDCMF). All data associated with archived clinical research samples is entered 
into the ETIB PDCMF’s’ Microsoft Excel databases on frozen cells and plasma. These 
databases are stored on the NCI group drive in the ETIB ‘PRECLINSERVICE’ folder.  
Access to this folder is limited to PDCMF staff and  ETIB clinical staff, requiring 
individual login and password. All staff in thePDCMF laboratory receive annually 
updated NIH/CIT training and maintain standards of computer security. 
x The data recorded for each sample includes the patient ID, trial name/protocol number, 
date drawn, treatment cycle/post-transplant time point, cell source (e.g., peripheral blood, 
lymphapheresis, mobilized peripheral blood stem cells, marrow, pleural fluid) as well as 
box and freezer location. Patient demographics that correlate treatment outcomes and 
therapies with the samples can be obtained only through the NCI/ETIB clinical records. 
As of January 2007, all newly received samples will receive a unique bar code number, 
which is included in the samplerecord in the PDCMF database. Only this bar code is 
recorded on the sample vial and the vials will not be traceable back to patients without 
authorized access to the PDCMF database. All non-coded samples previously archived 
will be stripped of identifiers prior to distribution for any use other than as a primary 
objective of the protocol under which they were collected. 
x Samples are stored in locked freezers. All samples will be labeled solely with a bar code 
(which includes the date, and serially determined individual sample identifier). The key 
will be available to a restricted number of ETIB investigators and associate investigators 
on the protocol. Coded samples will be stored frozen at -20, -80° or liquid nitrogen vapor 
phase to -180 C according to stability requirements in a single location under the 
restricted control of the PDCM Facility of ETIB. 
x Access to samples from a protocol for research purposes will be by permission of the 
Principal Investigator of that protocol in order to be used (1) for research purposes 
associated with protocol objectives for which the samples were collected, or (2) for a new 
research activity following submission and IRB approval of a new protocol and consent, 
or (3) for use only as unlinked or coded samples under the OHSRP Exemption Form 
guidelines stipulating that the activity is exempt from IRB review. Unused samples must 
be returned to the PDCMF laboratory. 

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x Samples, and associated data, will be stored permanently unless the patient withdraws 
consent. If researchers have samples remaining once they have completed all studies 
associated with the protocol, they must be returned to the PDCMF laboratory. 
x These freezers are located onsite at the Preclinical Service laboratory (12C216) or in 
ETIB common equipment space (CRC/3-3273).  
 
5.2.2 Protocol Completion/Sample Destruction  
x Once research objectives for the protocol are achieved, researchers can request access to 
remaining samples, providing they have both approval of the Principal Investigator of the 
original protocol under which the samples or data were collected and either an IRB 
approved protocol and patient consent or OSHRP approval. 
x The PDCMF staff will report to the Principal Investigators any destroyed samples, if 
samples become unsalvageable because of environmental factors (ex. broken freezer or 
lack of dry ice in a shipping container), lost in transit between facilities or misplaced by a 
researcher. The Principal Investigators will annually report this information to the IRB 
and the NCI Clinical Director, and the office of the CCR, NCI. 
x The PI will report destroyed samples to the IRB if samples become unsalvageable 
because of environmental factors (ex. broken freezer or lack of dry ice in a shipping 
container) or if a patient withdraws consent. Samples will also be reported as lost if they 
are lost in transit between facilities or misplaced by a researcher.  Freezer problems, lost 
samples or other problems associated with samples will also be reported to the IRB, the 
NCI Clinical Director, and the office of the CCR, NCI. 
 
6 
DATA COLLECTION AND EVALUATION  
6.1 
DATA COLLECTION 
An enrollment log will be maintained in the regulatory binder/file which is the only location of 
personal identifiers with unique subject identification number. 
No IND agents, equipment or procedures are being used in this study. 
Study data will be maintained, entered, and audited for accuracy in the C3D Database by the 
research nurse(s) and data managers assigned to the study.  
Only adverse events related to the ECP procedure will be collected as part of this study. All other 
AEs will continue to be collected on the patient’s primary transplant protocol. Since AEs 
collected are only ECP related, baseline AEs will only be collected on patient’s that proceed with 
ECP. The baseline will be considered the immediate time before their first ECP treatment. 
The PI will be responsible for overseeing entry of data into an in-house password protected 
electronic system (C3D) and ensuring data accuracy, consistency and timeliness. The principal 
investigator, associate investigators/research nurses and/or a contracted data manager will assist 
with the data management efforts. All data obtained during the conduct of the protocol will be kept 
in secure network drives or in approved alternative sites that comply with NIH security standards. 

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21 
 
Primary and final analyzed data will have identifiers so that research data can be attributed to an 
individual human subject participant. 
All AEs, including clinically significant abnormal findings on laboratory evaluations, regardless 
of severity, will be followed until return to baseline or stabilization of event. Patients will be 
followed for adverse events for at least 30 days after removal from study treatment or until off 
study, whichever comes first.   
 
An abnormal laboratory value will be considered an AE if the laboratory abnormality is 
characterized by any of the following: 
• 
Results in discontinuation from the study 
• 
Is associated with clinical signs or symptoms  
• 
Requires treatment or any other therapeutic intervention 
• 
Is associated with death or another serious adverse event, including hospitalization.  
• 
Is judged by the Investigator to be of significant clinical impact 
• 
If any abnormal laboratory result is considered clinically significant, the investigator will 
provide details about the action taken with respect to the test drug and about the patient’s 
outcome. 
 
End of study procedures: Data will be stored according to HHS, FDA regulations and NIH 
Intramural Records Retention Schedule as applicable.  
Loss or destruction of data: Should we become aware that a major breach in our plan to protect 
subject confidentiality and trial data has occurred, the IRB will be notified.  
6.2 
RESPONSE CRITERIA 
6.2.1 Recording of Steroid Dose 
Steroid dose will be recorded in prednisone mg equivalency.    
6.2.2  Measurement of GVHD Outcome and Response  
Patients  will be followed for  outcome using overall survival, GVHD free survival, and steroid 
free survival at either 3 months post-transplant (D+100), 6 months post-transplant, or 6 months 
after the last ECP procedure. The definitions of GVHD response that will be used are outlined in 
an American Society for Bone Marrow Transplantation consensus statement.51 
6.2.2.1 Complete Response (CR) 
x No residual organ specific symptoms or findings. 
6.2.2.2 Very Good Partial Response(VGPR) 
x Skin:  Active erythematous rash involving less than 25% of the body surface area. Rash 
that is pink, fading or turning to brown is not included in the measurement, since these 
findings indicate resolving lesions. 
 

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x Liver: Persisting low-level hyperbilirubinemia that might be related to antecedent 
regimen-related hepatotoxicity, concomitant hemolysis or administration of hepatotoxic 
agents such as voriconazole, cyclosporine, or total parental nutrition (TPN), or other 
factors such as sepsis. A serum total bilirubin concentration of less than 2 mg/dL 
approximates normal values, and a reduction to less than 25% of the baseline 
concentration provides strong evidence of progression toward normal liver function 
among patients with levels greater that 2 mg/dL. 
 
x Gut: Gastrointestinal function and water resorption in the colon are approaching normal. 
These criteria have some imprecision and rely heavily on patient recall, rather than 
measurement of stool volume. In certain cases, it might be necessary to make allowances 
for the effects of pre-transplant diseases that cause diarrhea. 
6.2.2.3 Partial Response (PR) 
x Any improvement over baseline symptoms or findings not included in VGPR. 
6.2.2.4 Progressive Disease (PD) 
x Stable or worsening organ specific findings requiring change of therapy. 
6.3 
TOXICITY CRITERIA 
The following adverse event management guidelines are intended to ensure the safety of each 
patient while on the study.  The descriptions and grading scales found in the revised NCI 
Common Terminology Criteria for Adverse Events (CTCAE) version 4.0 will be utilized for AE 
reporting. All appropriate treatment areas should have access to a copy of the CTCAE version 
4.0. A copy of the CTCAE version 4.0 can be downloaded from the CTEP web site 
(http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm#ctc_40).  
7 
SAFETY REPORTING REQUIREMENTS/DATA AND SAFETY MONITORING 
PLAN 
7.1 
DEFINITIONS 
7.1.1 Adverse Event 
Any untoward medical occurrence in a human subject, including any abnormal sign (for 
example, abnormal physical exam or laboratory finding), symptom, or disease, temporally 
associated with the subject’s participation in research, whether or not considered related to the 
subject’s participation in the research. 
 
  
7.1.2 Suspected Adverse Reaction 
Suspected adverse reaction means any adverse event for which there is a reasonable possibility 
that the procedure caused the adverse event.  
7.1.3 Unexpected Adverse Reaction 

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23 
 
An adverse event or suspected adverse reaction is considered “unexpected” if it is not consistent 
with the risk information described in the general investigational plan or elsewhere in the current 
application.  
7.1.4 Unanticipated Adverse Device Effect 
Any serious adverse effect on health or safety, any life-threatening problem or death caused by, 
or associated with a device, if that effect, problem, or death was not previously identified in 
nature, severity, or degree of incidence in the application; or any other unanticipated serious 
problem associated with a device that relates to the rights, safety, or welfare of subjects. 
7.1.5 Serious  
An Unanticipated Problem or Protocol Deviation is serious if it meets the definition of a Serious 
Adverse Event or if it compromises the safety, welfare or rights of subjects or others. 
7.1.6 Serious Adverse Event 
An adverse event or suspected adverse reaction is considered serious if in the view of the 
investigator or the sponsor, it results in any of the following: 
• 
Death 
• 
A life-threatening adverse experience 
• 
Inpatient hospitalization or prolongation of existing hospitalization 
• 
Persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions, or 
• 
A congenital anomaly/birth defect. 
• 
Important medical events that may not result in death, be life-threatening, or require 
hospitalization may be considered a serious adverse experience when, based upon 
appropriate medical judgment, they may jeopardize the patient or subject and may require 
medical or surgical intervention to prevent one of the outcomes listed in this definition. 
7.1.7 Disability 
A substantial disruption of a person’s ability to conduct normal life functions. 
7.1.8 Life-threatening adverse experience 
Any adverse event or suspected adverse reaction that places the patient or subject, in the view of 
the investigator or sponsor, at immediate risk of death from the reaction as it occurred, i.e., it 
does not include a reaction that had it occurred in a more severe form, might have caused death. 
7.1.9 Protocol Deviation (NIH Definition) 
Any change, divergence, or departure from the IRB-approved research protocol.   
7.1.10 Non-compliance (NIH Definition) 
The failure to comply with applicable NIH Human Research Protections Program (HRPP) 
policies, IRB requirements, or regulatory requirements for the protection of human research 
subjects. 
7.1.11 Unanticipated Problem 

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24 
 
Any incident, experience, or outcome that: 
• 
 Is unexpected in terms of nature, severity, or frequency in relation to  
(a) the research risks that are described in the IRB-approved research protocol and 
informed consent document; Investigator’s Brochure or other study documents, and 
(b) the characteristics of the subject population being studied; AND 
• 
Is related or possibly related to participation in the research; AND 
• 
Suggests that the research places subjects or others at a greater risk of harm (including 
physical, psychological, economic, or social harm) than was previously known or 
recognized. 
7.2 
NCI-IRB AND CLINICAL DIRECTOR REPORTING 
7.2.1 NCI-IRB and NCI CD Expedited Reporting of Unanticipated Problems and Deaths 
The Protocol PI will report in the NIH Problem Form to the NCI-IRB and NCI Clinical Director: 
 
• 
All deaths, except deaths due to progressive disease  
• 
All Protocol Deviations 
• 
All Unanticipated Problems 
• 
All non-compliance 
Reports must be received within 7 days of PI awareness via iRIS. 
7.2.2 NCI-IRB Requirements for PI Reporting at Continuing Review. 
The protocol PI will report to the NCI-IRB:  
1. A summary of all protocol deviations in a tabular format to include the date the deviation 
occurred, a brief description of the deviation and any corrective action. 
2. A summary of any instances of non-compliance 
3. A tabular summary of the following adverse events: 
• 
All Grade 2 unexpected events that are possibly, probably or definitely related to the 
research;  
• 
All Grade 3 and 4 events that are possibly, probably or definitely related to the 
research;  
• 
All Grade 5 events regardless of attribution;  
• 
All Serious Events regardless of attribution.  
NOTE: Grade 1 events are not required to be reported 
7.3 
DATA AND SAFETY MONITORING PLAN 
7.3.1 Principal Investigator/Research Team 

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Version Date:  October 02, 2018 
25 
 
The clinical research team will meet on a regular basis, once a week, when patients are being 
actively treated on the trial to discuss each patient. 
All data will be collected in a timely manner and reviewed by the principal investigator or a lead 
associate investigator.  Adverse events will be reported as required above.  Any safety concerns, 
new information that might affect either the ethical and or scientific conduct of the trial, or 
protocol deviations will be immediately reported to the IRB using iRIS. 
The principal investigator will review adverse event and response data on each patient to ensure 
safety and data accuracy. The principal investigator will personally conduct or supervise the 
investigation and provide appropriate delegation of responsibilities to other members of the 
research staff.  
8 
STATISTICAL CONSIDERATIONS   
The primary objectives of this trial are to determine, in an exploratory fashion, if any information 
obtained from biomarkers in patients who undergo allogeneic transplantation may be used to 
predict whether patients will develop acute GVHD. In addition, it will be used to determine if 
biomarkers obtained from patients with acute GVHD may be used to predict steroid 
refractoriness and the outcome of investigator chosen therapies for steroid refractory disease with 
and without ECP. As secondary objectives, the study will evaluate acute GVHD outcome, 
overall survival at 6 months, and steroid use.  
This study is intended to be a companion trial to other efforts in the ETIB by collecting   
information on a set of acute GVHD biomarkers at various times throughout the course of an 
allogeneic transplant. In order to allow for a large enough number of patients to conduct a series 
of analyses at several main points, the study will have an accrual ceiling of 450 transplanted, of 
which approximately 200 patients would be expected to develop acute GVHD.  
It will be estimated that approximately 90% of 450 NCI patients who are transplanted over a 10 
year period will enroll on this trial, and of that approximately 400 patients, 160 will develop 
aGVHD and 240 will not. As noted in the schema and sections 3.3 of the protocol, biomarkers 
will be collected on patients at various times, starting with collections at enrollment and just 
prior to transplantation. If a large set of biomarkers at baseline is able to predict 80% of those 
who develop aGVHD and 80% of those who do not develop aGVHD, then these estimates could 
be made with 95% two sided confidence intervals of 73.3% to 85.7 and 74.6% to 84.7% 
respectively. If we are able to actually obtain such a large enough number of patients, the results 
could also be divided into two groups to allow for 50% of patients to train the prediction 
classifier and 50% to test the prediction.  
With up to 165 patients maximally available with acute GVHD, the following analyses could be 
undertaken. 
1. A very large number of biomarkers could be obtained at baseline, and at the time a 
patient is declared to either have a steroid response or be determined to be steroid 
refractory. If there are at least 75-100 patients available overall for these analyses, for 
example, with 88 total patients, 44 with a response and 44 with refractory disease, there 
would be 80% power to detect a difference between the two groups, responsive vs. 
refractory, using a 0.01 two-tailed significance level two-group t-test for each biomarker 
evaluated with respect to either a baseline value or change from baseline, with an effect 
size of 0.75 (that is, if the difference in the biomarker values was equal to 0.75 SD of 

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Version Date:  October 02, 2018 
26 
 
either the marker itself or the change in marker, for each arm, assuming equal SD on both 
arms). With more patients, such as 50-75 per group, there could be over 85% power for 
this comparison. 
2. From among those who are refractory to steroids, patients may be assigned by the 
investigator to receive a second line therapy with or without ECP. This assignment is not 
made by random selection but will be done by the investigator based on whatever criteria 
they choose, including availability of the equipment necessary to do the procedure at the 
time it would be needed.  If there are 44 patients available with refractory disease and 
half of those are assigned to receive ECP, it would be of interest to determine if there are 
any differences in biomarkers between those who survive to 6 months or longer or do not 
live to 6 months after determined to be refractory to steroids, among those who receive 
ECP. With 22 patients receiving ECP, there would be 79% power to detect a difference in 
biomarkers between those who survive to 6 months or do not, with an effect size of 1.25 
using a 0.05 two-sided significance test for a given biomarker. With sufficient patients to 
obtain 34 who have received ECP (perhaps from among 70 with refractory disease), there 
would be 80% power to detect a difference in biomarkers between those two groups, with 
an effect size of 1.0 using a 0.05 two-sided significance test for a given biomarker. 
3.  Similarly, from among all patients who develop acute GVHD and require systemic 
steroids, the association of biomarkers among those who respond or are refractory to 
steroids alone will be explored using all available patient data to determine if these 
outcomes could be predicted on the basis of the biomarker results. The association 
between biomarkers and outcomes among those not requiring steroids or not developing 
acute GVHD will also be considered for evaluation. 
As this is entirely an exploratory study and patients are not randomly assigned to treatment, the 
results of the analyses above as well as any others undertaken must be considered entirely 
hypothesis generating and will be used to potentially guide future clinical decisions if the findings 
are able to be validated. The power results presented above are illustrations of what may be 
undertaken. Furthermore, as shown in the Schema, since this study may enroll several subsets for 
evaluation or comparison, any specific analyses of these subsets will be reported as being entirely 
exploratory. Additionally, any set of exploratory analyses felt to be reasonable by a statistician 
associated with this study may be performed and presented in the context of being exploratory. 
The ETIB currently transplants approximately 45 patients per year and approximately 45% of these 
patients ordinarily develop acute GVHD. Thus, approximately 20 patients per year may develop 
acute GVHD. Approximately half of these will respond to steroids and half will be refractory to 
steroids. Thus, approximately 10 per year may be refractory patients and will be eligible to be 
assigned to receive ECP. As such, in order to have adequate patients to address any questions 
regarding the association between biomarkers and the development of acute GVHD, as well as 
biomarkers and ECP, the accrual ceiling will be set at 450 total patients in order to have up to 200 
total patients with acute GVHD which may yield up to 100 patients who may be evaluable for any 
analyses restricted to patients who receive ECP. 
9 
HUMAN SUBJECTS PROTECTIONS  
9.1 
RATIONALE FOR SUBJECT SELECTION 

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27 
 
Both men and women of all races and ethnic groups are eligible for this trial. The nature and size 
of this study does not make any specific predictions of diversity in enrolled patients possible. 
There is nothing to suggest that the results of the study will be affected by any specific level of 
participation of women or minorities.  
9.2 
PARTICIPATION OF CHILDREN 
This study will be limited to subjects of age 18 years or older. 
9.3 
PARTICIPATION OF SUBJECTS UNABLE TO GIVE CONSENT 
Adults unable to give consent are excluded from enrolling in the protocol.  However re-consent 
may be necessary and there is a possibility, though unlikely, that subjects could become 
decisionally impaired. For this reason and because there is a prospect of direct benefit from 
research participation (section 9.5), all subjects  age 18 will be offered the opportunity to fill in 
their wishes for research and care, and assign a substitute decision maker on the “NIH Advance 
Directive for Health Care and Medical Research Participation” form so that another person can 
make decisions about their medical care in the event that they become incapacitated or cognitively 
impaired during the course of the study. Note: The PI or AI will contact the NIH Ability to Consent 
Assessment Team(ACAT) for evaluationas needed for the following: an independent assessment 
of whether an individual has the capacity to provide consent; assistance in identifying and 
assessing an appropriate surrogate when indicated; and/or an assessment of the capacity to appoint 
a surrogate. For those subjects that become incapacitated and do not have pre-determined 
substitute decision maker, the procedures described in MEC Policy 87-4 and NIH HRPP SOP 14E  
for appointing a surrogate decision maker for adult subjects who are (a) decisionally impaired, and 
(b) who do not have a legal guardian or durable power of attorney, will be followed. 
9.4 
EVALUATION OF BENEFITS AND RISKS/DISCOMFORTS 
9.4.1 Related to Blood Collection 
Minor complications including bleeding, pain, and hematoma formation at the site of blood draws, 
or infections may rarely occur. 
9.4.2 Related to Methoxsalen Administration and ECP Procedure 
Potential risks of methoxsalen and the ECP procedure are described in Section 10 and the consent 
form. There may also be unexpected side effects. All subjects will be carefully monitored for side 
effects. In addition, if additional intravenous access is required, there will be risks associated with 
catheter insertion and maintenance including bleeding  infection, pain, and rarely death. 
9.4.3 Related to Pregnancy 
Methoxsalen is in a class of agents that is known to be teratogenic.  Women of child-bearing 
potential and men must agree to continue to adhere to methods of contraception and other fertility 
control measures as already prescribed by their primary transplant protocol.   
9.5 
RISKS/BENEFITS ANALYSIS(INCLUDING THOSE THAT DO AND DO NOT HAVE THE 
CAPACITY TO CONSENT) 
Risks of participating in this trial if receiving ECP include the side effects of methoxsalen and 
the risk of the ECP procedure. Patients may receive benefit from the clinical monitoring or 

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28 
 
potentially experience improvement in acute GVHD symptoms or quality of life. Therefore, this 
research represents more than minimal risk to subjects with prospect of direct benefit to 
individual subjects.  
9.6 
CONSENT AND ASSENT PROCESS AND DOCUMENTATION 
The investigational nature and research objectives of this trial, the procedure and its attendant risks 
and discomforts will be carefully explained to the subject. The potential subject will be educated 
regarding the nature of the condition, proposed intervention, and outcome measures. Study 
subjects will be informed that participation is entirely voluntary and that withdrawal from the study 
can be made at any time without penalty of benefits to which they may be entitled. Informed 
consent will be obtained by Dr. Gress or his designee. At any time during participation in the 
protocol if new information becomes available relating to risks, adverse events, or toxicities, this 
information will be provided orally or in writing to all enrolled or prospective participants. 
Documentation will be provided to the IRB and if necessary the informed consent amended to 
reflect relevant information. 
9.6.1 Telephone re-consent procedure 
Re-consent on this study may be obtained via telephone according to the following procedure: 
the informed consent document will be sent to the subject.  An explanation of the study will be 
provided over the telephone after the subject has had the opportunity to read the consent form.  
The subject will sign and date the informed consent. A witness to the subject’s signature will 
sign and date the consent.  The original informed consent document will be sent back to the 
consenting investigator who will sign and date the consent form with the date the consent was 
obtained via telephone.  A fully executed copy will be returned via mail for the subject’s records.  
The informed consent process will be documented on a progress note by the consenting 
investigator. 
9.6.2 Informed Consent of Spanish Speaking Subjects: 
We anticipate the enrollment of Spanish speaking research participants into our study. The IRB 
approved full consent document will be translated into that language in accordance with the 
Clinical MAS Policy M77-2.  
9.6.3 Short form consent process for other non-English speaking patients 
If there is an unexpected enrollment of a research participant for whom there is no translated extant 
IRB approved consent document, the principal investigator and/or those authorized to obtain 
informed consent will use the Short Form Oral Consent Process as described in MAS Policy M77-
2, OHSRP SOP 12, and 45 CFR 46.117 (b) (2).  The summary that will be used is the English 
version of the extant IRB approved consent document.  Signed copies of both the English version 
of the consent and the translated short form will be given to the subject or their legally authorized 
representative and the signed original will be filed in the medical record. 
Unless the PI is fluent in the prospective subject’s language, an interpreter will be present to 
facilitate the conversation (using either the long translated form or the short form). Preferably 
someone who is independent of the subject (i.e., not a family member) will assist in presenting 
information and obtaining consent. Whenever possible, interpreters will be provided copies of the 
relevant consent documents well before the consent conversation with the subject (24 to 48 hours 
if possible).  

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We request prospective IRB approval of the use of the short form process and will notify the IRB 
at the time of continuing review of the frequency of the use of the Short Form. 
10 PHARMACEUTICAL INFORMATION   
10.1 METHOXSALEN STERILE SOLUTION (UVADEX(R)) 
Methoxsalen Sterile Solution is used in conjunction with THERAKOS Photopheresis. 
Methoxsalen Sterile Solution is indicated for extracorporeal administration with the 
THERAKOS UVAR XTS® or THERAKOS CELLEX Photopheresis System Instrument. 
Methoxsalen Sterile Solution is contraindicated in patients exhibiting idiosyncratic reactions to 
psoralen compounds. Patients possessing a specific history of a light-sensitive disease state 
should not initiate methoxsalen therapy. 
Methoxsalen Sterile Solution is contraindicated in patients with aphakia, because of the 
significantly increased risk of retinal damage due to the absence of a lens. 
Special care should be exercised in treating patients who are receiving concomitant therapy 
(either topically or systemically) with known photosensitizing agents. 
Patients should be told emphatically to wear UVA absorbing, wrap- around sunglasses for 
twenty-four (24) hours after treatment. Patients should wear these glasses any time they are 
exposed to direct or indirect sunlight, whether they are outdoors or exposed through a window. 
Methoxsalen Sterile Solution should be used only by physicians who have special competence in  
THERAKOS CELLEX Photopheresis Systems. 
Safety in children has not been established. 
10.2 THERAKOS PHOTOPHERESIS PROCEDURE 
The THERAKOS  Photopheresis System Instrument / THERAKOS CELLEX® Photopheresis 
System Instrument is indicated for use in the ultraviolet-A(UVA) irradiation, in the presence of 
the photoactive drug 8-methoxypsoralen (Uvadex), of extracorporeally circulating leukocyte-
enriched blood. 
The THERAKOS  or THERAKOS CELLEX Photopheresis Systems are not designated, sold or 
intended for use except as indicated. Certain underlying medical conditions contraindicate 
THERAKOS Photopheresis, including patients who cannot tolerate extracorporeal volume loss 
during the leukocyte-enrichment phase, patients exhibiting idiosyncratic or hypersensitivity 
reactions to 8- methoxypsoralen/psoralen compounds, and patients with uncontrolled coagulation 
disorders.  
THERAKOS Photopheresis treatments should always be performed in locations where standard 
medical emergency equipment is available. Volume replacement fluids and/or volume expanders 
should be readily available throughout the procedure. 
Hypotension may occur during any treatment involving extracorporeal circulation. Closely 
monitor the patient during the entire treatment for hypotension. Transient pyretic reactions, 37.7-
38.90C (100-102 0F), have been observed in some patients within six to eight hours of reinfusion 
of the photoactivated leukocyte-enriched blood. A temporary increase in erythroderma may 

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30 
 
accompany the pyretic reaction. Treatment frequency exceeding labeling recommendations may 
result in anemia. Venous access carries a small risk of infection and pain. 
The ECP is not approved for the disease under investigation on this study.  However, it will be 
used as a Non-Significant Risk Device. Therfore IDE from FDA is not required for ECP machine 
(Non Excempt NSR) use in this protocol per the below justification: 
x Is not intended as an implant and does not present a potential for serious risk to the health, 
safety, or welfare of a subject. 
x Is not purported or represented to be for a use in supporting or sustaining human life and 
does not present a potential for serious risk to the health, safety, or welfare of a subject. 
x Is not for a use of substantial importance in diagnosing, curing, mitigating, ot treating 
disease, or otherwise preventing impairment of human health and does not present a 
potential for serious risk to the health, safety, or welfare of a subject. 
 
10.2.1 Warnings and Precautions 
10.2.1.1 Patient-Related Precautions and Education Special care should be exercised in 
treating patients who are receiving concomitant therapy (either topically or 
systemically) with known photosensitizing agents.  
10.2.1.2 Oral administration of methoxsalen followed by cutaneous UVA exposure (PUVA 
therapy) is carcinogenic. Because the dose of methoxsalen with UVADEX® therapy 
is about 200 times less than with PUVA therapy and the skin is not exposed to high 
cumulative doses of UVA light, the risk of developing skin cancer following 
UVADEX® therapy may be lower. 
10.2.1.3 Patients exhibiting multiple basal cell carcinomas or having a history of basal cell 
carcinoma should be diligently observed and treated. Methoxsalen may cause fetal 
harm when given to a pregnant woman. Women undergoing photopheresis should be 
advised to avoid becoming pregnant. 
10.2.1.4 Patients should be told emphatically to wear UVA absorbing, wrap-around 
sunglasses for twenty-four (24) hours after UVADEX® treatment (Cloud 1961). 
They should wear these glasses any time they are exposed to direct or indirect 
sunlight, whether they are outdoors or exposed through a window. The sunglasses 
will be provided to participants if they are necessary. 
10.2.1.5 Patients who may not be able to tolerate the fluid changes associated with ECP 
should be monitored carefully. Procedures, such as renal dialysis, which might cause 
significant fluid shifts (and expose the patient to additional anticoagulation) should 
not be performed on the same day. If procedures on the same day are unavoidable, 
maximizing the time between procedures is recommended. Refer to UVAR-XTS 
Technical Bulletin #3 entitled, “Avoid Performing Extracorporeal Photopheresis and 
Procedures Such As Dialysis on the Same Day” (January 10, 2013). Consideration 
should be taken for each patient’s’ clinical status. Unless otherwise medically 
indicated or instructed, DTM requires minimum platelet threshold of 20 K/uL. 

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10.2.1.6 Extracorporeal volume management is critically important. American Association of 
Blood Banking (AABB) guidelines recommend that extracorporeal blood volume 
does not exceed 15% of the estimated total blood volume. Members of the patient’s 
medical care team will coordinate with DTM/BSS Nurses and DTM Physicians to 
ensure blood volume management needs are met prior to therapy initiation. 
10.2.1.7 In clinical practice, anemia in patients receiving ECP therapy can be seen and is most 
likely attributed to small volume blood loss over repeated procedures. For this 
reason, DTM requires manual blood return of all fluid remaining within the 
procedural kit. When this requirement is met, there has been no observed decreasing 
of hemoglobin due to the procedure. 
10.2.1.8 High lipids or triglycerides can cause plasma to have a milky or opaque appearance. 
This could potentially trigger the optic sensor prematurely and may result in 
collection of a large volume of plasma with little to no leukocyte content. To avoid 
this potential, DTM recommends the following per Therakos guidelines: 
x Stop Lipids at least seven hours prior to ECP. 
x Encourage a low-fat diet for 24-hours prior to ECP 
x Re-schedule triglyceride-producing medication until after ECP 
x Administer a lipid-lowering agent 
Refer to Therakos UVAR XTS Operators Manual Section Appendix B: 
Additional Troubleshooting (B-1) for further guidance.  
 
 

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