A Pilot Study of Allogeneic Hematopoietic Stem Cell Transplantation for Pediatric and Adolescent-Young Adults Patients With High Risk Solid Tumors
Phase: PHASE2
Conditions: Desmoplastic Small Round Cell Tumor, Ewing Sarcoma/Peripheral Primitive Neuroectodermal Tumor, Recurrent Desmoplastic Small Round Cell Tumor, Recurrent Malignant Peripheral Nerve Sheath Tumor, Recurrent Malignant Solid Neoplasm, Recurrent Neuroblastoma, Recurrent Rhabdomyosarcoma, Refractory Desmoplastic Small Round Cell Tumor, Refractory Malignant Peripheral Nerve Sheath Tumor, Refractory Malignant Solid Neoplasm, Refractory Neuroblastoma, Refractory Rhabdomyosarcoma
Sponsor: M.D. Anderson Cancer Center

 
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A PILOT STUDY OF ALLOGENEIC HEMATOPOIETIC STEM CELL TRANSPLANTATION FOR 
PEDIATRIC AND ADOLESCENT-YOUNG ADULTS PATIENTS WITH HIGH RISK SOLID TUMORS 
 
 
 
Principal Investigator:   Jeremy Connors, MD       University Texas at MD Anderson 
 
 
Co-Investigators: 
Jonathan Gill, MD 
University Texas at MD Anderson 
Priti Tewari, MD 
Demetrios Petropoulos, MD 
Najat Daw, MD 
Douglas Harrison, MD 
University Texas at MD Anderson 
University Texas at MD Anderson 
University Texas at MD Anderson 
University Texas at MD Anderson 
 
 
 
 
Biostatistician: 
Clark Andersen 
Jian Wang 
University Texas at MD Anderson 
University Texas at MD Anderson 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
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Table of Contents: 
Pages 
 
i. 
Face sheet 
1 
ii. 
Table of Contents 
2 
iii. 
Synopsis                                                                                        3 
1. 
Purpose 
3 
2. 
Objectives 
3 
3. 
Hypotheses 
4 
4. 
Trial design 
4 
5. 
Definitions 
6 
6. 
Background 
9 
7. 
Patient and Donor Selection 
13 
8. 
Enrollment on Study 
17 
9. 
Treatment Regimen and Procedures                                           17 
10. 
Drug Formulation and Administration 
21 
11. 
Standard Observations 
29 
12. 
Monitoring 
31 
13. 
Adverse event reporting requirements 
33 
14. 
Statistical Considerations 
35 
15. 
Data and Safety Monitoring Plan                                                  38 
16. 
Confidentiality of Study Data                                                        38 
17. 
Informed Consent Process                                                            39 
18. 
References                                                                                      40 
19. 
Appendix A: Bearman Regimen-Related Toxicities Scale          43 
20. 
Appendix B: Standard Observations and Interventions             44 

 
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Synopsis: A PILOT STUDY OF ALLOGENEIC HEMATOPOIETIC STEM CELL TRANSPLANTATION FOR 
PEDIATRIC AND ADOLESCENT-YOUNG ADULTS PATIENTS WITH HIGH RISK SOLID TUMORS 
Primary Objectives:  The primary objectives are to assess tolerability of allogeneic HCT for patients with 
chemo-responsive recurrent/refractory solid tumors as defined by transplant-related mortality (TRM) at day 
30 and the rate of grade III or higher organ toxicity (Bearman Regimen-Related Toxicities Scale) attributable 
to conditioning occurring within 30 days. 
 
Secondary Objectives: Assess: (i)Median time to platelet and neutrophil engraftment,(ii)incidence of acute 
graft-versus-host disease (aGVHD) by day 100, (iii)incidence of chronic GVHD(cGVHD) at day 100 and one 
year (iv)rate of grade II organ toxicity through day 100,(v)rate of graft failure (primary and secondary) through 
day 100,(vi)rate of infectious complications through day 100,(vii)progression free survival (PFS) at day 100,180 
and 365, (viii) cumulative incidence of relapse,(ix) overall survival(OS) at day 100 and 365.   
 
Eligibility Criteria:  Patients aged 0-25 years, confirmed diagnosis of a malignant recurrent/refractory solid 
tumors with chemo- responsive disease, an available suitable HCT donor and patients have adequate organ 
function to undergo the conditioning regimen as outlined in section 7.0. Up to 200 patients will be enrolled.  
Method: This is a non-randomized, non-blinded ,phase II clinical trial. Patients will be assigned to one of two 
arms based on the HCT donor and the stem cell source that is available as detailed in section 7.3.A non 
radiation based conditioning regimen will be used as detailed in section 9.1.Patients will receive standard 
supportive care as per best clinical practice in addition to the required observations detailed in Appendix B.  
 
1.0 
Purpose 
 
This is a pilot study of allogeneic hematopoietic stem cell transplantation (HCT) among patients 
with chemo-responsive recurrent/refractory solid tumors.  
 
2.0 
Objectives 
 
2.1 
Primary Objectives 
To assess tolerability of allogeneic HCT for patients with chemo-responsive 
recurrent/refractory solid tumors as defined by transplant-related mortality (TRM) at day 30 
and the rate of grade III or higher organ toxicity (Bearman Regimen-Related Toxicities 
Scale)[1] attributable to conditioning occurring within 30 days.  
 
2.2 
Secondary Objectives: 

 
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Assess 
              I. Median time to platelet and neutrophil engraftment. 
             II. Incidence of acute graft-versus-host disease (aGVHD) by day 100 
             III. Incidence of chronic GVHD(cGVHD) at day 100 and one year 
            IV. Rate of grade II organ toxicity through day 100 
            V. Rate of graft failure (primary and secondary) through day 100. 
            VI. Rate of infectious complications through day 100. 
             VII. Progression Free Survival (PFS) at day 100,180 and 365 
VIII. Cumulative incidence of relapse, overall survival (OS) at 100 days and 1 year.   
 
3.0 
Hypotheses 
 
Allogeneic HCT may be a consideration for the treatment of patients with recurrent/refractory 
chemo- responsive solid tumors. High dose chemotherapy may reduce tumor burden and 
associated inhibitory immune escape signals. Allogeneic HCT confers a Graft- Versus-Tumor effect 
(GvT) to eliminate residual disease after conditioning chemotherapy which may decrease disease 
recurrence and improve overall survival [2].   
 
 
 
4.0 Trial Design 
 
This is a non randomized, non blinded, phase II clinical trial in which eligible patients (see section 7.2 and 
7.3) will be enrolled to receive one of the two treatments based on the availability of the donor stem cell 
source as outlined in section 7.4. Up to 20 pediatric and AYA patients (Age 0-25) will be enrolled for each 
treatment group. Assessment of the tolerability will be conducted in each treatment group.   
 
 
 
 
 
 
 
 
 

 
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Figure 1: A Pilot Study of Allogeneic Hematopoietic Stem Cell Transplantation for Pediatric and Adolescent-
Young-Adult Patients (age 0-25) with High Risk Solid Tumors  
 
 
 
VP-16: Etoposide 
CSA: Cyclosporine 
MMF: Mycophenolate Mofetil       ATG: Anti-Thymocyte Globulin 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient with Chemo Responsive Recurrent/Refractory Solid Tumor
Matched Related Donor
Thiotepa/Melphalan/Fludarabine/VP-16
Tacrolimus/CSA + MMF
Matched Allogeneic Umbilical 
Cord Donor
Thiotepa/Melphalan/Fludarabine/VP-16
Rabbit Thymoglobulin (ATG) 
1.25 mg/kg (Day -4)
Rabbit Thymoglobulin (ATG)
1.75 mg/kg (Day -3)
Tacrolimus/CSA + MMF
Matched Unrelated Donor
Thiotepa/Melphalan/Fludarabine/VP-16
Rabbit Thymoglobulin (ATG)
1.25 mg/kg (Day -4)
Rabbit Thymoglobulin (ATG)
1.75 mg/kg (Day -3)
Tacrolimus/CSA + MMF

 
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5.0 Definitions 
 
5.1 Engraftment: Engraftment is defined as recovery of blood counts (neutrophil and platelet 
engraftment, as defined in 5.1.1) with cells of donor origin, documented by either bone marrow 
or peripheral blood chimerism assays after hematopoietic cell transplant. 
5.1.1 Neutrophil engraftment. Neutrophil engraftment is defined as the first day of 
three consecutive days when the absolute neutrophil count (ANC) is >500/mm3. 
            
 
 Platelet engraftment.        Platelet engraftment is defined as the first of three 
consecutive days when the platelet count is >20 K/uL (and the patient has not 
received a platelet transfusion for seven days preceding the first day). 
 
5.1.2. Donor chimerism. Donor cells in either peripheral blood or bone marrow, as 
documented by fluorescent in situ hybridization (FISH), for 
sex-mismatched 
donor/recipients)   or   short-tandem   repeat   testing   (STR)   for   sex-matched donor 
recipient pairs. 
 
5.2 Immunological function 
5.2.1 T lymphocyte recovery.   T lymphocyte recovery is defined as absolute number  of donor-
derived CD3+ T lymphocytes >100/mm3. 
5.2.2. Mitogen-specific T lymphocyte function recovery. Mitogen-specific T lymphocyte function is 
defined as proliferative responses to phytohemagglutinin (PHA) 
>25,000 CPM of titrated thymidine incorporation. 
5.2.3 Antigen-specific B lymphocyte function recovery. Antigen-specific B lymphocyte function is 
defined as normal titers of specific antibody to immunization with tetanus toxoid (TET) 
and not receiving IVIG for at least 3 months. 
 
5.3 Toxicity 
5.3.1 Acute conditioning regimen related toxicity is defined according Bearman Regimen-
Related Toxicities Scale) Grade III or higher of the following organs are to be documented: 
5.3.1.1 Hepatic 
5.3.1.2 Pulmonary 
5.3.1.3 Renal 
5.3.1.4 Cardiac 
5.3.1.5 Bladder 
5.3.1.6 Central Nervous System 
5.3.1.7 Mucosal (stomatitis) 
5.3.1.8 Gastrointestinal 
 
 
 
5.4 Acute and Chronic Graft Versus Host Disease 

 
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Acute Graft-Versus-Host Disease (aGVHD): Acute graft-versus-host disease usually develops within  
the first three months after transplantation and may appear as a characteristic dermatitis which may  
be accompanied by cholestasis and/or enteritis. Staging of acute GVHD will follow the  
Glucksberg staging criteria. 
 
Chronic Graft-Versus-Host Disease: Chronic graft-versus-host disease is typically a  
late complication of HCT characterized by a connective-tissue disease-like syndrome and usually,  
but not always, occurring greater than 100 days following transplantation. Occasionally, its onset  
may closely follow aGVHD (known as progressive presentation of cGVHD). 
Initial symptoms of cGVHD frequently include nausea and anorexia with ocular and oral sicca.  
Rash characteristically appears with pigmentary changes progressing to sclerosis and  
contractures. Other organs may be involved.  Symptoms may mimic those seen in patients 
with scleroderma and other autoimmune disorders. Chronic GVHD will be assessed by the criteria 
set up by the National Institutes of Health Consensus Development Project on criteria for clinical 
trials in cGVHD. The following organs are evaluated for grading of cGVHD: 
               5.4.1 Skin: Assessment of skin for erythematous maculopapular rash,  
                        scleroderma, hypertrophy or atrophic changes of skin, hyperpigmentation  
                         or hypopigmentation, lichen planus or lichenoid reactions 
5.4.2 Joints and fascia: Tightness, contractures and decrease range of motion 
5.4.3 Eyes: Xerophthalmia and photophobia. 
5.4.4  Mucosa: Erythema, lichenoid changes, and ulcers of mucosal surfaces of the 
mouth, vagina. 
5.4.5 Gastrointestinal: Anorexia, nausea, vomiting, abdominal pain and weight loss  
may be manifestations of GI involvement. Esophageal stenosis and dysmotility may 
also be a GVHD presentation. 
5.4.6 Liver function abnormalities with cholestasis and fibrosis, resulting in elevated 
serum levels of bilirubin, alkaline phosphatase, and hepatic transaminases and 
transferases. 
5.4.7 Obliterative bronchiolitis (OB) may occur as a pulmonary manifestation of 
cGVHD. 
5.4.8 Genital tract: Vaginal scarring, labial agglutination, phimosis or urethral scarring. 
 
 
5.5 Sinusoidal Obstructive Syndrome (SOS) will be diagnosed and graded according to  
Pediatric and AYA modified EBMT Consensus Criteria 
 
 

 
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5.6 Chronic toxicities                                                                                                               
Chronic toxicities are defined as those occurring at least 100 days post HCT and will be monitored       
and graded using the Common Terminology Criteria (CTCAE) version 5.0. The CTCAE v5.0 will be 
used as it allows standardized reporting of adverse events through the use of assigned uniformed 
terminology and severity grading. The following specific toxicities that represent common chronic 
effects related to HCT will also be monitored:              
              5.6.1     Chronic GVHD (see above 5.4). 
5.6.2 Hypogammaglobinemia (see B lymphocyte recovery above 5.2). 
5.6.3 Learning disability and/or neurocognitive dysfunction. Determined by both school 
performance and appropriate battery of age-appropriate neurocognitive tests. 
 
 
 
5.7 
EVALUATION OF RESPONSE 
 
This study will use the revised (RECIST 1.1) Response Evaluation Criteria in Solid Tumors[3]. 
PET scan, bone marrow examinations, and/or tumor specific markers may be used as described 
below.   
 
5.8 
Response criteria  
5.8.1 Complete Response (CR): disappearance of all lesions. For lymph nodes reduction of the 
short axis to 10 mm or less, and no new lesions 
5.8.2 Partial Response (PR): At least a 30% decrease in the total tumor burden.  Reference is 
disease measurement prior to starting treatment, and no new lesions   
5.8.3 Progressive Disease (PD): At least 25% increase in the total tumor burden.  Reference is 
disease measurement prior to starting treatment.  
5.8.4 Stable Disease (SD): Changes that do not meet definition of CR, PR, or PD. 
 
 
5.9 
Response Criteria for Solid Tumors with FDG-PET positive lesions 
 
A ‘positive’ FDG-PET scan lesion is one that is FDG avid with an uptake greater than twice that of 
the surrounding tissue on the attenuation corrected image. Patients without measurable disease with 
only FDG-PET positive lesions will have disease evaluated by FDG-PET response. 
 
 
FDG-PET Response 
Complete response: resolution of all FDG-PET positive lesions 
Incomplete response: resolution of at least one positive FDG-PET lesions with persistence of other 
FDG-PET lesions 

 
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Stable Disease: No change in FDG-PET scan in number of positive lesions 
Progressive disease Development of new FDG-PET positive lesion and/or massive unequivocal 
increase of FDG-PET lesions.    
 
          5.9.2  Response Criteria for tumors with only bone marrow metastasis or elevated tumor 
markers. 
Patients without measurable disease with only bone marrow metastasis or elevated tumor marker 
will have disease evaluated by bone marrow or tumor marker response. 
 Bone marrow metastasis is defined by the presence of metastatic disease identified on a bone 
marrow aspirate or biopsy sample prior to initiation of therapy 
Elevated tumor marker is defined by a level above upper limit of normal for age and sex 
 
5.9.3 Tumor Marker or Bone Marrow Response 
 Complete response: resolution of bone marrow metastasis and/or normalization of tumor markers. 
 Incomplete response/stable disease: does not meet definition of complete response nor 
progressive disease. 
Progressive disease: For patients with no measurable disease at baseline will only contribute to 
overall progression disease if develops new measurable disease that can be used to compare 
subsequent responses 
 
6.0 Background 
 
            Allogeneic HCT/Immunotherapy for high-grade solid tumors: 
 
Relapsed, and/or metastatic solid tumors are associated with a 5-year survival as low as <35%. 
Outcomes for these patients have failed to significantly improve over the past two decades despite 
the use of novel agents, increased chemotherapy dose intensity, new chemotherapy combinations 
and high dose chemotherapy requiring autologous stem cell rescue. The addition of novel agents 
such as cixutumumab and temozolamide to an already dose intensified regimen for newly diagnosed 
patients with rhabdomyosarcoma metastatic at sites other than regional lymph nodes, resulted in a 
3 year event free survival (EFS) of 16% and 18% and OS of 47 and 33% respectively[4].The EURO-
E.W.I.N.G 99  and Ewing-2008 trials compared the effect of consolidation therapy with  combined 
high dose chemotherapy- Busulfan/Melphalan (BuMel) followed by autologous stem cell 
transplantation versus standard chemotherapy- vincristine/dactinomycin/ifosfamide (VAI)for patients 
with localized high risk  Ewing sarcoma. Three year EFS rates for VAI and BuMel followed by 
autologous stem cell transplantation were 56.7% and 69% respectively with this benefit being 
sustained at 8 years where the EFS was 47.1% vs 60.7% respectively[5]. While The International 
Society of Pediatric Oncology European Neuroblastoma (SIOPEN) group added a combination of 

 
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topotecan, vincristine, and doxorubicin to patients who failed induction therapy with only 6.4% of 
patients achieving clinical remission.[6] 
With approximately 25% of children and young adults presenting with metastatic disease, the 
development of new modalities of cancer therapy including hematopoietic stem cell therapy (HCT) 
for these tumors is therefore essential to the improvement of patient outcomes 
 
The ability to rescue a patient with hematopoietic progenitor cells allows the use of very high-doses 
of chemotherapy that could overcome resistance.  Autologous transplants have been viewed more 
favorably because the high morbidity/mortality due to GVHD with allogeneic transplants. The 
research, however shows inconclusive data to support high-dose chemotherapy with autologous 
stem-cell rescue and as mentioned above, finds about 20-30% overall and event free survival [7, 8]. 
With autologous HCT, adequate collection depends, on the bone marrow reserve after chemo and/or 
radiotherapy, and bone/bone marrow involvement with disease. Marrow that has been irradiated may 
be unable to mobilize sufficiently to provide the increased number of cells needed for collection. 
Furthermore, if disease has disseminated to the bones and bone marrow, subsequent fibrosis may 
reduce the marrow’s efficacy. Finally, disseminated bone marrow disease may increase the risk of 
potential contamination of an autologous stem cell collection. For these patients, it becomes 
unlikely to obtain an adequate autologous stem cell source. At present, it is not possible to separate 
a malignant cell from a peripheral stem cell harvest leaving the potential risk of re-infusing malignant 
cells after the high-dose therapy leading to disease recurrence. Therefore, these patients are not 
ideal candidates for marrow-ablative therapy with autologous HCT 
 
This paradigm is shifting with new advancements in allogeneic transplant management [9]. There is 
evidence to suggest that allogeneic immune effect can be seen in solid tumors [10-14]. A group in 
Spain performed allogeneic HCT among 6 patients with a variety of high-risk solid tumors 
(neuroblastoma, Ewing sarcoma, desmoplastic tumor, nasopharyngeal carcinoma, and embryonal 
rhabdomyosarcoma) and found response among all 6 patients, with 3 developing complete 
response (CR), 2 developing partial response, and 1 patient having stable disease for greater than 
9 months. Three patients remained alive in CR at a median follow-up of 15 (4-65) months[15]. Lang 
et al reported allogeneic HCT for treatment of solid tumors. Four patients with neuroblastoma (NB), 
a patient with rhabdomyosarcoma (RMS), and a patient with Ewing sarcoma (EWS) were included 
in this study. All patients entering transplant had significant tumor burden. All patients had primary 
engraftment at a median of 11 days. One patient had secondary graft failure. Acute GVHD grade 
II was seen in 4 patients while 2 experienced limited cGVHD; no TRM occurred. Four patients died 
from progression while two are alive, with an overall median survival of 6 (2-11) months [16].  
GvT effect in allogeneic transplants is clearly a benefit over autologous transplants. There is 
emerging clinical evidence which suggests a clinically meaningful GvT effect following allogeneic 

 
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HCT in Ewing sarcoma and rhabdomyosarcoma [17-24].  
Donor T lymphocytes in the allograft, reactive to host histocompatibility antigens, can directly kill 
human cancer cells in vitro and in vivo. This can occur even after donor T lymphocytes are rejected 
and suggests that host lymphocytes might mediate the anti- tumor effect of donor allogeneic 
lymphocytes[25]. 
Donor lymphocyte infusion (DLI) has been reported to induce GvT after allogeneic HCT in a patient 
with multiply-relapsed rhabdomyosarcoma to sustain remission.  At 31 months post- transplant, this 
patient remained disease-free[24]. In a case-report, Donker et al reported a patient with stage IV 
rhabdomyosarcoma who at 4 years post-allogeneic transplant remains in CR[23]. Baird et al 
reported a clinical trial of 23 sarcoma patients who underwent reduced intensity HCT [26] (44). 
All patients had successful donor engraftment. Five of 23 patients remained alive (OS of 30% at 
3 years), including 3 of 7 (42%) transplanted without gross disease (median survival 14.5 versus 
29.0 months from HCT). Koscielniak et al reported long-term remission in a patient with Ewing 
sarcoma after HCT[21]. Capitini et al reported response of metastatic Ewing sarcoma after 
allogeneic HCT[18]. Hosono et al reported clinically significant GvT effect in a patient with pulmonary 
Ewing sarcoma who failed high-dose chemo with autologous transplantation[19].  
Additionally, tumors have evolved sophisticated mechanisms to avoid immune detection. They may  
down-regulate expression of MHC class I and other proteins involved in antigen presentation.[27-
29] Tumors can also decrease, or shed, expression of proteins that are recognized by the immune  
system (immunoediting) and they can by-pass death mechanisms by elevating expression levels of 
survival factors, such as anti-apoptotic proteins (survivin, BCL-XL), metastatic proteins (VEGF, 
MMPs) and proliferation factors (EGFR, c-Myc). The transcription factor STAT3 is upregulated in a 
number  of tumors and controls expression of some of these genes.[30]  Tumor cells adapt to 
immune recognition by down regulating expression of antigens, and can also adapt to 
chemotherapy by increasing expression of adenosine-triphosphate binding cassette (ABC) pumps 
to actively secrete intracellular drugs.[31] However chemotherapies have the potential to enhance 
cancer vaccine-induced immune responses by lowering the defenses of the tumor[32],  targeting 
the immune system to reduce tumor-induced immune suppressive cells and/or targeting the tumor 
to increase immunogenicity (increase MHC or antigen expression) and/or directly stimulating 
effector response by activating T cells.  
Some chemotherapy agents/combinations, such as fludarabine,[33] may induce significant and 
relevant T cell depletion and seems to generate a micro milieu suitable for subsequent T cell 
activation.  Hence, high-dose chemotherapy may lower the defences of the  
tumor and allow a suitable micro milieu for subsequent allogeneic donor immune-surveillance.   
Effective combination treatments hinge on our understanding of the role of the immune system in 
tumor rejection. Combining chemotherapies and immunotherapies effectively to attack the tumor 
from multiple sides may enhance our ability  to quickly and thoroughly eliminate enhance our ability  

 
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to quickly and thoroughly eliminate cancer.[34] 
 
Cord blood (CB) natural killer (NK) cells represent another promising effector cell immunotherapy  
due to their recognition of malignant cells without the need for a known target and their potential to 
expand exponentially.[35] Natural killer cells have documented activity against 
medulloblastoma.[36, 37]However, complete elimination of tumor by autologous NK cells is unlikely 
as the inhibitory signals from the tumor generally render their own NK cells incapable of inducing 
potent cytolytic activity. Although most NK cell clinical trials have used allogeneic peripheral blood 
(PB) as  a cell source [38], in vitro studies suggest that umbilical cord blood (CB) NK cells may 
possess better cytolytic ability.[39, 40]  The use of cord blood as a source of allogeneic NK cells is 
also advantageous because: (a) they can be ex vivo expanded to clinically useful cell numbers; and 
(b) they allow a  higher chance of identifying HLA-compatible and KIR-mismatched products 
because of their immediate availability in established cord blood banks. Such a readily available 
“off-the-shelf” source of NK cells greatly enhances the feasibility of using these cells as therapy.[35]   
In this study, for patients lacking matched related donors, cord blood graft(s) or matched unrelated 
donor (MUD) grafts will be used as an alternative donor source.  This study may inform the design 
of future pivotal studies regarding use of HLA-compatible and KIR-mismatched products as well as 
CB derived NK cells in combination with HCT. 
 
Finally more precise patient selection, pre-transplant work-up, the use of reduced intensity 
preparative regimens and better supportive care medications to aide with side-effects/GVHD has led 
to improved overall survival post HCT.[41-44] 
Taken altogether, the main advantages of the proposed approach can be summarized as 
follows: 
- 
Overcome the challenges in autologous bone morrow/PBSC collection in patients who 
are heavily pre- treated and/or have disseminated disease within the bone/bone 
marrow. 
- 
Use of radiation sparing thiotepa based regimen 
- 
Eliminate the risk of autologous graft contamination with tumor cells. 
- 
Provide GvT to eliminate residual disease after conditioning chemotherapy. 
 
The main potential risks are GVHD, risk for post-HCT infections and delayed immune recovery. 
The use of allografting with the proposed regimen combines the benefits of high dose 
chemotherapy and an immune approach to disease therapy 
 
 
7.0 
Patient (Recipient) and Donor Selection: 
 

 
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7.1 
Recipient inclusion criteria 
7.1.1 Pathological criteria, including malignant recurrent/refractory solid tumors. This would 
include: 
7.1.1.1 Ewing’s sarcoma with the following translocations*: 
EWS-FLI1 
EWS-ERG 
EWS-ETV1 
EWS-ETV4 
EWS-FEV 
FUS-ERG 
FUS-FEV 
7.1.1.2  Ewing-like sarcoma with the following translocations*: 
EWS-NFATC2 
EWS-POU5F1 
EWS-SMARCA5 
EWIS-PATZ1 
EWS-SP3 
CIC-DUX4 
 
BCOR-CCNB3 
*Additional translocations may be considered based on changes in classification and discussion with the PI  
7.1.1.3 Peripheral PNET  
7.1.1.4 Malignant peripheral nerve sheath tumor, neurofibrosarcoma 
7.1.1.5 Rhabdomyosarcoma 
7.1.1.6 Neuroblastoma (patients who are ineligible for tandem autologous 
transplant or who are at least 3 months post autologous HCT) 
7.1.1.7 Desmoplastic small round cell tumor (DSRCT)- both new diagnoses as 
well as recurrent/refractory disease 
7.1.1.8 Synovial Sarcoma 
 
 
7.1.2 Extent of disease eligibility: Patients must have chemo-responsive disease, defined as; 30% 
or greater decrease in the tumor target lesions when compared to its pre-treatment 
evaluation.  Patients with complete response will be eligible to participate. 
 
7.1.3 Available suitable HCT donor as defined below. 
 
 
7.1.4 Eligible patients must have adequate organ function to tolerate the chemotherapy 
conditioning regimen and the HCT, as measured by: 
7.1.4.1 Renal: creatinine clearance or GFR ≥50 ml/min/1.73m2, and not requiring dialysis 
7.1.4.2 Pulmonary: Diffusing Capacity of lung for carbon monoxide (DLCO) (corrected for 
hemoglobin) ≥ 50% predicted. If unable to perform pulmonary function tests, then 
O2 saturation ≥ 92% in room air. 

 
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7.1.4.3 Bilirubin ≤3x upper limit of normal (ULN) and ALT and AST ≤ 5x for age (with the 
exception of isolated hyperbilirubinemia due to Gilbert’s syndrome). 
7.1.4.4 Patients will be 0 – 25 years of age. 
 
7.1.5 Non-English speakers will be eligible to participate in this study 
 
7.2 
Recipient exclusion criteria 
7.2.1 Lack of histocompatible suitable related donor/ graft source as defined in 7.4 
7.2.2 End-organ failure that precludes the ability to tolerate the transplant procedure, including 
conditioning regimen 
7.2.3 Renal failure requiring dialysis 
7.2.4 Congenital heart disease resulting in congestive heart failure 
7.2.5 Ventilatory failure: requires invasive mechanical ventilation 
7.2.6 HIV infection 
7.2.7 Uncontrolled bacterial, viral, or fungal infections (currently taking medication yet clinical 
symptoms progress); stable, controlled disease with treatment is not an exclusion criteria 
7.2.8 A female of reproductive potential who is pregnant, planning to become pregnant during the 
study, or is nursing a child 
7.2.9 Any patient who does not fulfill the inclusion criteria listed above 
7.2.10 Patient, parent, guardian or LAR unable/unwilling to provide consent and when indicated, 
assent 
 
7.3 
Vulnerable populations 
a. There will be pediatric patients as the patients may experience prolongation of life. Adequate 
safeguards as outlined in the HRP-416 checklist will be followed to protect their rights and 
welfare.  
b. When possible, the research will be explained to the child compatible with the child’s 
understanding. 
• 
Any person that has not achieved the age of 18 is considered a child. 
 
• 
For research conducted in the state, HRP-013 - SOP - LARs, Children, and 
Guardians to be aware of which individuals in the state meet the definition of 
“children” will be followed. 
 
• 
Research will not be conducted outside of the state. 
 
• 
Parental permission will be obtained from one or both parents as determined by the 
IRB. 
 
• 
In the event a LAR is used, we will follow consent SOP-04_Informed Consent Process 
and HRP-013_SOP Legally authorized representative. 
 
• 
Assent will be obtained per the SOP-04_informed consent process. 
 
• 
Assent will be documented per the SOP-04_informed consent process. 

 
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c. This research may involve adults unable to consent as this vulnerable population may 
experience prolongation of life. Adequate safeguards as outlined in the HRP-417 checklist 
will be followed to protect their rights and welfare.  
• 
For this population this will include: 
 -  when appropriate, the IRB would allow a legally authorized representative or family 
member to sign proxy informed consent, if that person is authorized to make 
decisions about medical care for the subject.  The investigator should document in the 
medical and research record who is legally authorized to make medical decisions. 
• 
-The investigator will provide detailed information of the risks and benefits of the research to 
the proxy and the subject (if the subject can possibly understand).  The protocol should be 
based on good science and sound research design with the potential for significant beneficial 
results 
• 
Patients have medical decision-making capacity if they can demonstrate 
understanding of the situation, appreciation of the consequences of their decision, 
and reasoning in their thought process, and if they can communicate their wishes. 
• 
For patients of who carry a diagnosis of a genetic condition leading to a lack of 
decision making capacity (e.g. Trisomy 21), no further evaluation will be required.  For 
patients without a known diagnosis, further evaluation will be made based on the 
patient’s history including possible evaluation by neurology or neuro-psychology to 
determine decision-making capacity. A determination of lack of decision-making 
capacity shall be made after an appropriate medical evaluation that concludes there is 
little or no likelihood that the participant will regain decision-making capacity in a 
reasonable period of time. 
• 
Physician will do the following:  
(1) assessment of any language or communication barriers interfering with the 
patient's understanding 
(2) identification and treatment of any reversible causes of incapacity 
(3) a directed interview to assess the elements of consent 
 
• 
For research conducted in the state, HRP-013 - SOP - LARs, Children, and 
Guardians to be aware of which individuals in the state meet the definition of “legally 
authorized representative” will be followed. 
• 
Research will not be conducted outside of the state. 
• 
Assent will be required of some of the subjects.  Assent will be obtained on subjects 
that have the capacity to provide assent.   
• 
Documentation of assent will be documented in the note documenting the consent 
process. 
• 
Subjects will be particularly closely monitored. 
• 
Subjects will be withdrawn if they appear to be unduly distressed. 
 
 
 
 
 
7.4 
Donor Selection 
HCT will be done using stem cell sources in the following order of preference: 
7.4.1 
Matched related donor bone marrow (10 of 10 HLA alleles [HLA-A, B, C, DR, and 
DQ]. Matched related donor PBSC is allowed only if collection of BM is not available 

 
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or refused by parents/donor. 
7.4.2 
Umbilical Cord Blood (UCB) 
Related 
7.4.2.1 Single Matched allogeneic umbilical cord blood (UCB): (Single Cord) Related 
• 
High-resolution matching at A, B, DRB1 (minimum 4/6) 
• 
Patients must have one CB unit available which is matched with 
the patient at 4/6, 5/6, or 6/6 HLA class I (serological) and II 
(molecular) antigens. The cord must contain a minimum of 2.5 x 
10e7 total nucleated cells/Kg recipient body weight (pre-thaw), with 
optimal goal of 4.0 x 10e7 total nucleated cells/Kg 
7.4.2.2 Double Matched allogeneic umbilical cord blood (UCB): (Double Cord) Related 
• 
High-resolution matching at A, B, DRB1 (minimum 4/6) 
• 
Patients who lack an appropriately matched single cord unit ), with 
an optimal dose of 4.0 x 10e7 total nucleated cells/Kg recipient 
body weight (pre-thaw)  as defined above (7.3.2.1), may receive 
two CB units which are matched with the patient at 4/6, 5/6, or 6/6 
HLA class I (serological) and II (molecular) antigens. Each cord 
must contain at least 1.5 x 10e7 total nucleated cells/Kg recipient 
body weight (pre-thaw) to achieve a cumulative cell dose of at least 
3.0 x 10e7 with the goal to be above 4.0 x 10e7 total nucleated 
cells/Kg 
 
Unrelated 
7.4.2.3 Single Matched allogeneic umbilical cord blood (UCB): (Single Cord) Unrelated 
• 
High-resolution matching at A, B, DRB1 (minimum 4/6) 
• 
Patients must have one CB unit available which is matched with 
the patient at 4/6, 5/6, or 6/6 HLA class I (serological) and II 
(molecular) antigens. The cord must contain a minimum of 2.5 x 
10e7 total nucleated cells/Kg recipient body weight (pre-thaw), with 
optimal goal of 4.0 x 10e7 total nucleated cells/Kg 
7.4.2.4 Double Matched allogeneic umbilical cord blood (UCB): (Double Cord) 
Unrelated 
• 
High-resolution matching at A, B, DRB1 (minimum 4/6) 
• 
Patients who lack an appropriately matched single cord unit ), with 

 
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an optimal dose of 4.0 x 10e7 total nucleated cells/Kg recipient 
body weight (pre-thaw)  as defined above (7.3.2.3), may receive 
two CB units which are matched with the patient at 4/6, 5/6, or 6/6 
HLA class I (serological) and II (molecular) antigens. Each cord 
must contain at least 1.5 x 10e7 total nucleated cells/Kg recipient 
body weight (pre-thaw) to achieve a cumulative cell dose of at least 
3.0 x 10e7 with the goal to be above 4.0 x 10e7 total nucleated 
cells/Kg 
7.4.3 
Matched unrelated donor bone marrow (10 of 10 HLA alleles [HLA-A, B, C, DR, 
and DQ]. Matched unrelated donor PBSC is allowed only if collection of BM is not 
available or refused by parents/donor. 
 
8.0 
Enrollment on the Study: 
 
Principal investigators or designee will review each patient’s eligibility prior to patient 
enrollment. Patients are considered enrolled on this study after all of the following: (i) 
patient, and/or parent(s) or legal guardian (s) consent (and assent when appropriate) for the 
patient to undergo the transplant procedure under this study protocol, (ii) patient meets all 
inclusion/exclusion criteria, and patient subsequently undergoes HCT under this study. 
 
9.0  Treatment Regimen and Procedure: 
 
Potential subjects will initially undergo screening for eligibility and a request for financial clearance will 
be submitted, once obtained, a written informed consent and assent (when appropriate) for HCT on 
this protocol will be obtained by the principal investigator or study designees prior to initiation of the 
conditioning regimen. 
 
 
 
 
 
9.1    TREATMENT SCHEMA 
 
Day 
Conditioning Regimen 
GVHD Prophylaxis 
 
-8 
Thiotepa 300 mg/m2 IV (10 mg/kg for < 12 Kg) 
Etoposide 100 mg/m2 IV (3.3 mg/kg for < 12 Kg) 
 
-7 
Thiotepa 300 mg/m2 IV (10 mg/kg for < 12 Kg), 
Etoposide 100 mg/m2 IV (3.3 mg/kg for < 12 Kg) 
 

 
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-6 
Thiotepa 300 mg/m2 IV (10 mg/kg for < 12 Kg), 
Etoposide 100 mg/m2 IV (3.3 mg/kg for < 12 Kg) 
 
-5 
Melphalan 70 mg/m2 IV (2.3 mg/kg for < 12 Kg), 
Fludarabine 30 mg/m2 
 
-4 
Melphalan 70 mg/m2 IV (2.3 mg/kg for < 12 Kg), 
Fludarabine 30 mg/m2 
 
(UCB and MUD: rATG 1.25 mg/kg) 
 
-3 
Fludarabine 30 mg/m2 IV 
(UCB and MUD: rATG 1.75 mg/kg) 
 
-2 
Rest 
Start Tacrolimus1 0.05 
mg/kg 
-1 
Rest 
 
0 
HSC Infusion 
Start MMF
2 15 mg/kg q8hr 
1Cyclosporine (CSA) may be substituted for Tacrolimus: 
• 
Age ≤ 6 years old: (CSA) 6 mg/kg IV QD in divided doses (e.g. 2 mg/kg 
q8hrs). 
• 
Age > 6 years old: (CSA) 3 mg/kg IV QD in divided doses (1.5mg/kg 
q12hrs) 
2MMF first dose 4-6 hours following HSC infusion 

 
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9.2 
   HSC processing and administration will be performed per institutional SOP. 
 
9.3 
 Graft-Versus-Host Disease prophylaxis and treatment 
9.3.1 
GVHD prophylaxis. All patients will receive a calcineurin inhibitor per 
institutional practice to prevent GVHD. 
9.3.1.1 
Calcineurin inhibitor: The patient will receive a calcineurin inhibitor (CI), either 
tacrolimus or cyclosporine (CSA), starting on Day -2 sufficient to maintain a 
serum trough level of approximately 7-12 ng/dl for tacrolimus, or 150-300 ng/dl 
for CSA. 
 
                  Tacrolimus will begin on Day –2 pre-HCT at a starting dose of 0.05 mg/ kg/ day as 
a continuous infusion. 
 
       Cyclosporine (CSA) may be substituted for Tacrolimus: 
• 
Age ≤ 6 years  old: 6 mg/kg IV QD in divided doses (e.g. 2 mg/kg q8hrs) 
• 
Age > 6 years old: 3 mg/kg IV QD in divided doses (1.5 mg/kg q12hrs) 
 
Tapering schedule for Calcineurin inhibitors (if no active GVHD): Recipients of 
Matched (10/10 allele matched) related Donors 
• 
Start taper at Day +60 at approximately 20% of the original therapeutic 
dose/week to be and complete by Day +100. 
 
Recipients of all other donors 
• 
Start taper at Day +100 at approximately 10% of the original therapeutic 
dose/week to be completed by Day +180. 
 
 
 
 
 
 
 
 
 

 
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9.3.1.2 
Mycophenolate mofetil (MMF) 
                   MMF will be given at 15 mg/kg q 8 hours (45 mg/kg/day; max.3g/day) PO, 
or IV if indicated (i.e. first dose 4-6 hours following stem c e l l  infusion) to Day 
+40 post-transplant. MMF will be given until Day +40 post-transplant and then 
tapered by 10% per week to be discontinued by Day +90. 
                   Taper for both Tacrolimus (CSA)/MMF may be halted or modified as clinically 
indicated or with the development of any evidence of GVHD at the evaluation 
of the treating physician. 
                    For 
patients 
with 
suspected 
recurrence 
a 
more 
rapid 
taper 
of 
immunosuppression can be done at the discretion of the treating physician. 
 
9.3.1.3 
Rabbit Anti-thymocyte globulin (rATG)  
rATG will be given on days -3 and -4 to patients receiving umbilical cord blood 
transplants. 
 
 
9.3.2 GVHD treatment: If clinical GVHD develops, then further immunosuppressive 
treatment may be required. The individual aspects of each case would affect the 
choice of immunosuppression. Therefore, the method of immunosuppression, if 
necessary, would be decided on a case-by-case basis, using standard treatments 
as prescribed by the treating physician and in consultation with the study chair. 

 
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9.4 
Duration of participation on the study 
Patients should be followed and remain in the hospital until there is evidence of engraftment 
of donor cells and there is recovery from the side effects of the transplant procedure, per 
institutional guidelines. Monitoring parameters will be performed weekly until day 42 or longer, 
if the engraftment process is delayed. If the patient is engrafted and stable enough to be 
discharged from the inpatient facility, patients will be followed as outpatients at regular 
intervals. Study assessment data will be collected around the weeks of Day +100, +180, +270 
and +365 post-transplant (please refer to Section 11.3). Subject participation will continue for 
1 year post- HCT under this study. Patients are considered off-study only if death occurs, they 
withdraw consent/assent, and/or are confirmed lost to follow-up after a 12- month period of 
effort to locate the patient. 
 
10.0 Drug Formulation and Administration 
 
10.1 
  Fludarabine (FLUDARA®) 
10.1.1Source and Pharmacology 
Supplier: Berlex Laboratories, Inc. FLUDARA FOR INJECTION contains fludarabine 
phosphate, a fluorinated nucleotide analog of the antiviral agent vidarabine, 9-ß-D- 
arabinofuranosyladenine (Ara-A) that is relatively resistant to deamination by adenosine 
deaminase. The chemical name for fludarabine phosphate is 9H-Purin-6-amine, 2- fluoro-9-
(5-O-phosphono-ß-D-arabinofuranosyl). Fludarabine phosphate is rapidly dephosphorylated 
to 2-fluoro-ara-A and then phosphorylated intracellularly by deoxycytidine kinase to the active 
triphosphate, 2-fluoro-ara-ATP. This metabolite appears to act by inhibiting DNA polymerase 
alpha, ribonucleotide reductase and DNA primase, thus inhibiting DNA synthesis. The 
mechanism of action of this antimetabolite is not completely characterized and may be multi-
faceted. 
 
10.1.2 Formulation and Stability 
Each vial of sterile lyophilized solid cake contains 50 mg of the active ingredient fludarabine 
phosphate, 50 mg of mannitol, and sodium hydroxide to adjust pH to 7.7. The pH range for 
the final product is 7.2-8.2. Reconstitution with 2 mL of Sterile Water for Injection USP results 
in a solution containing 25 mg/mL of fludarabine phosphate intended for intravenous 
administration. FLUDARA FOR INJECTION is supplied in a clear glass single dose vial (6 
mL capacity) and packaged in a single dose vial carton in a shelf pack of five. 
 
10.1.3 Solution Preparation 
FLUDARA should be prepared for parenteral use by aseptically adding Sterile Water for 

 
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Injection USP. When reconstituted with 2 mL of Sterile Water for Injection, USP, the solid 
cake should fully dissolve in 15 seconds or less; each mL of the resulting solution will contain 
25 mg of fludarabine phosphate, 25 mg of mannitol, and sodium hydroxide to adjust the pH to 
7.7. The pH range for the final product is 7.2-8.2. In clinical studies, the product has been 
diluted in 100 cc or 125 cc of 5% Dextrose Injection USP or 0.9% Sodium Chloride USP. 
 
10.1.4 Storage and Stability 
FLUDARA is supplied as a white, lyophilized solid cake. Each vial contains 50 mg of 
fludarabine phosphate, 50 mg of mannitol and sodium hydroxide to adjust pH to 7.7. The 
pH range for the final product is 7.2-8.2. Store under refrigeration, between 2°-8° C (36°-46° 
F). 
 
10.1.5 Administration: 
FLUDARA will be administered by the central venous catheter over 1 hour, daily for 3 days. 
Patients will receive antiemetics prior to administration of this chemotherapy. 
 
10.2 Thiotepa 
10.2.1 Source and Pharmacology 
Thiotepa is a cytotoxic agent of the polyfunctional type, related chemically and 
pharmacologically to nitrogen mustard. The radiomimetic action of thiotepa is believed to 
occur through the release of ethylenimine radicals which, like irradiation, disrupt the bonds of 
DNA. One of the principal bond disruptions is initiated by alkylation of guanine at the N-7 
position, which severs the linkage between the purine base and the sugar and liberates 
alkylated guanines. Thiotepa is desulfurated by cytochrome P-450 enzymes such as 2B1 
and 2C11 which catalyze the conversion of thiotepa to tepa. 
Tepa is less toxic than thiotepa and has been demonstrated to produce alkali-labile sites 
in DNA, rather than cross-links. These findings indicate that tepa reacts differently from 
thiotepa and produces monofunctional alkylation of DNA. A second metabolite of thiotepa, a 
mercapturic acid conjugate, is formed via glutathione conjugation. Monochlorotepa is the third 
metabolite found in the urine. 
 
10.2.2 How supplied and storage 
Thiotepa for Injection USP, for single use only, is available in vials containing 15 mg of 
nonpyrogenic, sterile lyophilized powder. Store in a refrigerator at 2° to 8°C (36° to 46°F). 
PROTECT FROM LIGHT AT ALL TIMES. 
 
10.2.3 Dosage and Administration 
Reconstitute Thiotepa for Injection with 1.5 mL of Sterile Water for Injection resulting in a 

 
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drug concentration of approximately 10 mg/mL. (As per manufacturer’s information: Actual 
content per vial 15.6 mg; withdrawable amount 14.7 mg/1.4 mL; approximate reconstituted 
concentration: 10.4 mg/mL). When reconstituted with Sterile Water for Injection, solutions 
of thiotepa should be stored at refrigerated temperatures 2°-8°C (36°-46°F) and used 
within 8 hours. The reconstituted solution is hypotonic. For administration by intermittent or 
continuous infusion, the reconstitution solution should be further diluted with Sodium 
Chloride Injection or 5% Dextrose Injection to a concentration of between 1-5 mg/mL. 
Thiotepa 1 mg/mL in 0.9% sodium chloride is nearly isotonic. Reconstituted solutions 
further diluted with Sodium Chloride Injection should be used immediately. In order to 
eliminate haze, filter solutions through a 0.22 micron filter [Polysulfone membrane (Gelman’s 
Sterile Aerodisc®, Single Use) or triton- free mixed ester of cellulose/PVC (Millipore’s 
MILLEX®-GSFilter Unit)] prior to administration. Filtering does not alter solution potency. 
Reconstituted solutions should be clear. Solutions that remain opaque or precipitate after 
filtration should not be used. 
 
10.3 Antithymocyte Globulin (Rabbit) (rATG)  
10.3.1 Source & Pharmacology:  
Antithymocyte globulin (rabbit) is a polyclonal antibody which appears to cause  
immunosuppression by acting on T-cell surface antigens and depleting CD4 lymphocytes. 
Its onset of action (T-cell depletion) occurs within 24 hours with a half-life of 2-3 days. 
Its resulting lymphopenia may persist for up to 1 year. 
 
10.3.2 How Supplied 
rATG for injection is available in sterile multiple dose vials of 25mgs each. Its pH: 6.5 to 
7.2 when reconstituted and it contains glycine, mannitol and sodium chloride. 
 
10.3.3 Dosage and Administration 
Store intact vial at 2°C to 8°C (36°F to 46°F); do not freeze. Protect from light.  
Allow vials to reach room temperature, then reconstitute each vial with 5 mL sterile water 
for injection (SWFI). Rotate vial gently until dissolved; resulting concentration is  
5 mg/mL of thymoglobulin. Further dilute dose to a final concentration of 0.5 mg/mL  
(e.g., one vial [25 mg] in 50 mL saline or dextrose); in adults, total volume is usually  
50 to 500 mL depending on total number of vials needed per dose. 
Mix by gently inverting infusion bag once or twice. Reconstituted product is stable 
for up to 24 hours at room temperature; however, the product contains no preservative  
and room temperature storage is not recommended. Immediate use is recommended 
after reconstitution and preparation for infusion in D5W or NS. 

 
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Infuse the first dose over at least 6 hours in adults and 6-12 hours in 
pediatric patients; subsequent doses may be infused over at least 4 hours.  
Infuse through a high-flow vein (central line). Administer through an in-line 
0.22 micron filter. Premedication with corticosteroids, acetaminophen, and/or an 
antihistamine 1 hour prior to infusion may reduce the incidence and 
severity of infusion-related reactions.  
Reducing the infusion rate may minimize infusion reactions. 
No dosing adjustments are required for renal or hepatic impairment 
 
10.4 Etoposide (VP-16) 
10.4.1Source and Pharmacology 
Etoposide is a semisynthetic derivative of podophyllotoxin that forms a complex with 
topoisomerase II and DNA which results in single and double strand DNA breaks. Its 
main effect appears to be in the S and G2 phase of the cell cycle. The initial t½ is 1.5 
hours and the mean terminal half-life is 4 to 11 hours. It is primarily excreted in the 
urine. In children, approximately 55% of the dose is excreted in the urine as etoposide in 
24 hours. The mean renal clearance of etoposide is 7 to 10 mL/min/m² or about 35% of the 
total body clearance over a dose range of 80 to 600 mg/m². 
 
10.4.2 How Supplied 
Etoposide for Injection is available in sterile multiple dose vials. The pH of the clear, nearly 
colorless to yellow liquid is 3 to 4. Each mL contains 20 mg etoposide, 2 mg citric acid, 30mg 
benzyl alcohol, 80 mg modified polysorbate 80/tween 80, 650 mg polyethylene glycol 300, 
and 30.5 percent (v/v) alcohol. Vial headspace contains nitrogen. Unopened vials of 
Etoposide are stable until expiration date on package at room temperature (25°C). 
 
10.4.3 Dosage and Administration 
Etoposide will be given through an IV. Preparation, administration, and monitoring will be 
according to standard practice procedures. 
 
10.5 Melphalan 
10.5.1 Source and Pharmacology 
Melphalan is a derivative of nitrogen mustard, it is a bifunctional alkylating agent which causes 
miscoding, cross-linkage of DNA and single-strand breakage of DNA. It inhibits glycolysis, 
respiration and protein synthesis. It is not phase specific. After IV administration the μ t½ 
is 8 minutes and the b t½ is 2 hours. Oral absorption is erratic, but averages 60% of IV dose. 
Initial half-life after oral dose is 90 minutes. Dosage may need reduction in patients with renal 
impairment 

 
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10.5.2 How Supplied 
For injection, it is supplied as 50mg sterile, lyophilized powder with 10ml special diluent for 
reconstitution. After reconstitution to 5 mg/mL, shake until clear solution obtained. 
 
10.5.3 Dosage and Administration 
Prior to administration, further dilute the solution with 0.9% sodium chloride to a concentration 
no greater than 0.45 mg/mL. Intact packages and reconstituted solutions should be stored 
at room temperature (15°-30°C), protected from light. The manufacturer recommends 
melphalan administration should be completed within 60 minutes of reconstitution. IV 
infusion over 20 minutes and good IV hydration with 3000 mL/m2 of D5W 1/2 normal saline 
24 hours after melphalan infusion. Lasix may also be given to maintain urine output. 
 
10.6 Cyclosporine A (cyclosporine, CYA, CSA, Sandimmune®, Neoral®, Gengraf®) 
10.6.1Source and Pharmacology 
Cyclosporine (CSA) is a lipophilic fungal peptide consisting of 11 amino acids. CSA is a potent 
immunosuppressive agent, which prolongs survival of allogeneic transplants involving skin, 
heart, kidney, pancreas, bone marrow, small intestine, and lung. CSA binds to a cellular 
protein, cyclophilin, which, like tacrolimus, then binds to calcineurin. The inhibition of 
calcineurin inhibits the transcription of IL-2, the action of which stimulates the proliferation of 
activated T-lymphocytes. The terminal half-life of CSA is approximately 19 hours (ranges 
from 10-27 hours). Ninety-nine percent of CSA is metabolized. Elimination is primarily biliary 
with approximately 6% excreted in the urine. In the circulation, CSA is mainly bound to high, 
low, or very low density lipoproteins and to chylomicrons. Only a small fraction circulates 
unbound. The volume of distribution varies from 3.5 L/kg to 13 L/kg, with higher 
concentrations of drug found in the liver, lymphocytes, kidney, heart, lung, pancreas, fat, 
neural, and muscle cells. CSA clearance rates have been shown to be higher in pediatric 
patients and for patients <25 years old. The absorption of CSA from the gastrointestinal 
tract is incomplete and variable, exhibiting large intra- and inter-patient variability. Drugs that 
stimulate or inhibit hepatic P-450 enzymes will alter clearance of CSA; thus, close attention 
to potential drug interactions is crucial. 
 
10.6.2 Formulation, Stability and Storage 
IV formulation: Cyclosporine (Sandimmune®) is available as a (50 mg/mL) 5 mL ampoule 
containing 650 mg polyoxyethylated castor oil (cremophor) and 32.9% alcohol. It should be 
stored at temperatures below 30°C (86°F) and protected from light. 
Oral formulations: Cyclosporine (Sandimmune®) is available as 25mg, 50mg and 100mg 

 
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capsules, or in a 100 mg/mL oral solution Inactive ingredients include: Sandimmune® Capsule 
= Dehydrated alcohol, sorbitol, glycerol, corn oil, gelatin, polyoxyethylated glycolysed 
glycerides; Sandimmune® Solution = Olive oil, dehydrated alcohol, polyoxyethylated 
glycolysed glycerides. 
Cyclosporine USP modified (microemulsion) (Neoral®, Gengraf®) 25 mg, 100 mg capsule, 
100 mg/mL oral solution. Inactive ingredients include: Neoral® capsule and solution = 
dehydrated alcohol, corn oil, polyoxyl 40 hydrogenated castor oil, α- tocopherol, gelatin, and 
propylene glycol. Gengraf® Capsule and solution = dehydrated alcohol, gelatin, polyethylene 
glycol, polyoxyl 35 castor oil, polysorbate 80, propylene glycol, and sorbitan monooleate. 
 
Store capsules in the original unit-dose container at controlled room temperature 15°- 30°C 
(59°-86°F). Store oral solutions in the original container at controlled room temperature 68°-
77°F (20°-25°C). Do not store in the refrigerator. Once opened, the contents must be used 
within two months. At temperatures below 68°F (20°C), the solution may form a gel; light 
flocculation or the formation of a light sediment may also occur. There is no impact on product 
performance or dosing using the syringe provided. Allow to warm to room temperature 77°F 
(25°C) to reverse these changes. 
 
NOTE: Sandimmune®, Neoral® and Gengraf® ARE NOT BIOEQUIVALENT. Liquid 
formulations of each trade name are equivalent to capsules of that same trade name. 
Conversion from one trade name product to another is generally done at a 1:1 ratio, but 
requires close monitoring. Conversions from IV to PO are usually done at a 1:3 ratio, but 
should be monitored closely. Adjusting emulsion products to the same trough concentration 
as other oral products results in greater total exposure to the drug. 
 
10.6.3 Solution Preparation 
Dilute IV concentrate 1 mL (50mg) of Cyclosporine for Injection in 20 mL-100 mL 0.9% Sodium 
Chloride Injection or 5% Dextrose Injection (0.5 - 2.5 mg/mL). Diluted infusion solutions are 
stable for 24 hours at room temperature under fluorescent light. 
 
10.6.4 Administration 
The Cremophor® EL (polyoxyethylated castor oil) contained in concentrate for IV infusion can 
cause phthalate stripping from PVC. It is highly recommended that glass bottles and non-
PVC tubing be used to minimize patient exposure to DEHP. Monitor closely for an acute 
allergic reaction for the first 30 minutes and at frequent intervals thereafter. Note: 
Cyclosporine absorbs into plastics and can give falsely high serum or blood concentrations if 
blood samples are collected from the same line through which Cyclosporine was 
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Oral: Administer at a consistent time of day and at consistent intervals with regard to meals. 
Do not use plastic or Styrofoam cups. If diluted with juice or milk, use a glass container and 
rinse with additional diluent, and then consume to ensure that complete dose has been taken. 
Do not use water or cleaning agents on the dosing syringe. To improve palatability, mix 
Sandimmune® with milk, chocolate milk or orange juice; mix Neoral® or Gengraf® with 
orange juice or apple juice, but NOT milk. After mixed, have patient consume immediately. 
DO NOT MIX GRAPEFRUIT JUICE with any CSA product. 
 
10.7 
Tacrolimus 
10.7.1 Source and Pharmacology 
Tacrolimus is a macrolide immunosuppressant produced by Streptomyces tsukubaensis. 
Tacrolimus prolongs the survival of the host and transplanted graft in animal transplant 
models of liver, kidney, heart, bone marrow, small bowel and pancreas, lung and trachea, 
skin, cornea, and limb. Experimental evidence suggests that tacrolimus binds to an 
intracellular protein, FKP-12. A complex of tacrolimus- FKBP-12, calcium, calmodulin, 
and calcineurin is then formed, and the phospatase activity of calcineurin is inhibited. 
This effect may prevent the dephosphorylation and translocation of nuclear factor of 
activated T-cells (NF-AT), a nuclear component thought to initiate gene transcription for 
the formation of lymphokines (such as interleukin-2, gamma interferon). The net result is 
the inhibition of T-lymphocyte activation (i.e., immunosuppression). 
 
10.7.2 Formulation and Stability 
Prograf injection (tacrolimus injection) 5 mg (for IV infusion only). Supplied as a sterile 
solution in 1 mL ampoules, containing the equivalent of 5 mg of anhydrous tacrolimus 
per mL. 
 
10.7.3 Dosage and Administration 
The usual dose of the drug is 0.05 mg/kg to 0.1 mg/kg/IV per day to achieve the trough 
level of 10-15mg/ml. Orally, the patient needs to be started on 0.15 to 0.2 mg/kg q12 
hours to achieve the same trough level. The dose may have to be decreased if other 
nephrotoxic agents are being administered. 
 
10.7.4 
Preparation for Administration/Stability 
Tacrolimus will be stored in glass or polyethylene containers and should be discarded after 
24 hours. The diluted infusion solution should not be stored in a PVC container due to 
decreased stability and the potential for extraction of phthalates. In situations where more 
dilute solutions are utilized (e.g., pediatric dosing, etc.), PVC-free tubing should, likewise, 
be used to minimize the potential for significant drug absorption onto the tubing. Parenteral 

 
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drug products should be inspected visually for particulate matter and discoloration prior to 
administration, whenever solution and container permit. Due to the chemical instability of 
tacrolimus in alkaline media, Prograf injection should not be mixed or co-infused with solutions 
of pH 9 or greater (e.g., Ganciclovir or Acyclovir). 
Store between 5° C and 25° C (41° F and 77° F). Prograf capsules (tacrolimus capsules) 5 
mg, oblong, grayish/red, branded with white “5 mg” on the capsule cap and containing the 
equivalent of 5 mg anhydrous tacrolimus. 
 
10.8 Mycophenolate mofetil (MMF, Cellcept® Myfortic®) 
10.8.1 Action and Pharmacology 
MMF is a potent, selective, uncompetitive and reversible inhibitor of inosine monophosphate 
dehydrogenase (IMPDH), and therefore inhibits the de novo pathway of guanosine nucleotide 
synthesis without incorporation into DNA. Because T- and B- lymphocytes are critically 
dependent for their proliferation on de novo synthesis of purines, whereas other cell types 
can utilize salvage pathways, MPA has potent cytostatic effects on lymphocytes. MPA 
inhibits proliferative responses of T- and B- lymphocytes to both mitogenic and allo-specific 
stimulation. 
 
10.8.2 Formulation and Stability 
Capsules, 250 mg and 500 mg Store at 25°C (77°F); excursions permitted to 15° to 30°C 
(59° to 86°F). Dispense in light-resistant containers, such as the manufacturer's original 
containers. Oral Suspension Supplied as a white to off-white powder blend for constitution to 
a white to off-white mixed-fruit flavor suspension. Storage: Store dry powder at 25°C (77°F); 
excursions permitted to 15° to 30°C (59° to 86°F). Store constituted suspension at 25°C 
(77°F); excursions permitted to 15° to 30°C (59° to 86°F) for up to 60 days. Storage in a 
refrigerator at 2° to 8°C (36° to 46°F) is acceptable. Do not freeze. Intravenous Supplied in a 
20 mL, sterile vial containing the equivalent of 500 mg mycophenolate mofetil as the 
hydrochloride salt in cartons of 4 vials: Store powder and reconstituted/infusion solutions at 
25°C (77°F); excursions permitted to 15° to 30°C (59° to 86°F). 

 
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In the setting of marrow transplantation, several etiologies may contribute to alterations 
in gastrointestinal and hematologic parameters; therefore, MMF dose adjustments are 
not encouraged. 
 
10.8.3 Administration Guidelines 
Initial dosage will be IV or PO with switch to PO when tolerated. Starting doses will be 
15 mg/kg/day Q 8 hours (total dose 45 mg/kg/day, maximum 3 g/day; IV same as 
PO dose) beginning day 0 with the first dose given approximately 4-6 hours after the 
stem cell infusion. 
 
11.0 
Standard Observations 
Frequent clinical and laboratory evaluation will be performed to provide appropriate medical 
care to the patients as per standard practice. For this study’s assessment laboratory data 
will be collected once weekly or as defined below for analysis. Please refer to appendix B for 
summary of required observations 
 
 
11.1 Baseline/Pre-Conditioning 
Baseline laboratory testing must be done within 7 days prior to the start of the conditioning 
regimen. 
All baseline imaging, cardiac evaluation and pulmonary evaluation must be done within 28 
days prior the start of the conditioning regimen. Baseline/pre conditioning evaluation is 
summarized in Appendix B  
11.1.1 History, physical examination, pregnancy test for females of reproductive 
potential, weight, height, BSA and head circumference (if appropriate for age). 
11.1.2 CBC, differential, platelet count, ABO and Rh typing. 
11.1.3  Liver function tests (bilirubin, ALT). 
11.1.4  Renal function tests (creatinine, BUN, creatinine clearance or GFR). 
11.1.5 Cardiac evaluation: echocardiogram, MRI or MUGA with ejection fraction 
( or shortening fraction) as appropriate. 
11.1.6 Pulmonary function evaluation: CT chest and pulmonary function tests (if 
age appropriate and feasible) or O2 Saturation in room air. 
11.1.7 Serology for CMV, Hep. B &C, HSV, VSV, HTLV and HIV (if HIV NAT testing 
not obtained). 
11.1.8 NAT testing for HIV/HCV. (HIV and HCV PCRs may replace serology or    
NAT testing). 
11.1.9 Immune assessment: Immunophenotyping (CD3, CD4, CD8, CD19, CD56, 
CD4+/CD45RA+, 
CD4+/CD45RO+), 
lymphoproliferative 
responses 
to 

 
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mitogens, Quantitative Immunoglobulins (IgG, IgA, IgM). 
11.1.10 Archived blood sample for short tandem repeat (STR) and/or FISH analyses of 
blood to document a genetic marker that can be used to distinguish donor and 
recipient cells as per standard of care (as clinically appropriate). 
11.1.11 Blood sample for circulating tumor cells prior to the start of conditioning 
regimen to be sent to Dr.Shulin Li’s lab 
11.1.12 Karnofsky or Lansky score (age appropriate) 
11.1.13 Evaluation of other disease specific manifestations/sites as clinically 
appropriate which may include: Imaging (e.g. MRI, PET/CT, Bone scan, 
skeletal surveys); LP/CSF analysis and bone marrow aspirate/biopsy. Bone 
marrow aspirate and biopsy will be obtained prior to HCT to evaluate for 
disease by morphology. 
 
11.2 During Conditioning 
11.2.9 History, physical examination, pregnancy test for females of reproductive potential, 
weight, height, BSA and head circumference (if appropriate for age). 
            CBC and serum chemistries, Tacrolimus or CSA level (as clinically appropriate) starting 
one day after initiation of tacrolimus, until levels are stable on oral dosing or until 
discharge. 
Evaluation required during conditioning is summarized in Appendix B 
 
11.3 
Post-Transplant 
After transplant, frequent clinical and laboratory evaluation will be performed to provide 
appropriate medical care to the patients. Post-transplant evaluation summarized in Appendix 
B The post-transplant data will be captured once a week for the assessment of the study. 
In the first year, studies scheduled for Days +100, +180, +270 and +365 can be performed 
at any Day ± 15 of the scheduled test. 
11.3.1 Weekly CBC, differential (after WBC >500/mm3) until ANC = 500/mm3 for 3 
consecutive days; 
Post-engraftment: CBC and platelet count weekly until discharge; 
Post-discharge: CBC and platelet count weekly until PRBC and platelet transfusion 
independent and at Days +100, +180, +270, and +365. Differential must be done if 
WBC < 500/mm3 at any time post-engraftment and at Days 
+100, +180, +270, and +365 
11.3.2 Donor chimerism study at Day +28 ± 3 days (if engrafted for neutrophils) and at 6 
months and at 1 year. 
11.3.3 Bone marrow aspirate on Day +42 (+/- 3 days) for patients who do not have an 
ANC = 500/mm3 by Day +42. 

 
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11.3.4 Weekly assessment for toxicity: Mucositis and SOS until Day +30 or until resolution 
(whichever is longer). 
11.3.5 Perform and document: Karnofsky/Lansky performance score, GVHD, history and 
physical examination weekly for 6 weeks, twice a month until Day +100, 
                          then Day +180, +270, and +365. 
11.3.6 CBC, renal and liver function tests weekly for 6 weeks; cardiac function tests 
(echocardiogram), pulmonary assessment, thyroid function tests, height, 
weight, head circumference (if age appropriate) at one year follow-up as 
part of the study. However, it is recommended as general part of a general 
long-term follow-up to assess yearly for a minimum of 4 years. 
11.3.7 
Immune assessment: Immunophenotyping (CD3, CD4, CD8, CD19, CD56), 
lymphoproliferative responses to mitogens, quantitative Immunoglobulins (IgG, IgA, 
IgM) will be monitored at Days +100, +180, +270, +365 post-transplant.  
11.3.8 Three months, 6 months, 9 months, and 12 months post-tetanus immunization, 
lymphoproliferative responses to tetanus and antibody titer to tetanus. 
11.3.9 Evaluation of disease specific manifestations/sites as clinically appropriate/per 
standard disease assessment which may include: Imaging (e.g. MRI, PET/CT, 
Bone scan, skeletal surveys); LP/CSF analysis and bone  marrow 
aspirate/biopsy on at least on Day +100 with subsequent testing on Days 
+180,+270 and 1 year post-HCT. 
 
12.0 Monitoring 
 
12.1 
Supportive Care                                                                                                                
Before, during and after the transplant, subjects of this study will require standard 
supportive care. Programmatic supportive care guidelines will be adhered to, but 
may vary with the condition or problems of individual patients. Supportive care will 
include red blood cell and platelet transfusion; antibiotic treatment of bacterial, 
fungal and viral infections; prevention of bacterial, fungal and viral infections, 
including Pneumocystis jiroveci; administration of prophylactic and therapeutic 
intravenous immunoglobulin (IVIG); isolation; treatment of hepatic sinusoidal 
obstruction syndrome/veno-occlusive disease; and treatment of mucositis. 
Aggressive supportive care improves outcome, particularly in high-risk patient 
populations receiving very intensive chemotherapy as incorporated in this protocol. 
These supportive care guidelines are provided for institutional consideration,  
in order to optimize patient care as well as to encourage uniformity in the treatment 
of this study population. 
 
 

 
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12.2 
General Guidelines 
12.2.1 Complete blood counts (Hemoglobin, platelet count, WBC and ANC) should be 
monitored after blood counts drop (i.e. ANC <1000, platelets <50,000), daily for in- patients 
until blood count recovery commences. Hospitalization is required until the patient achieves 
and sustains an absolute neutrophil count (ANC) of at least 500/μL for at least five days. 
Growth factors (e.g. granulocyte colony stimulating factor) can be used at the discretion of 
the treating physician. 
12.2.2  Blood Products 
• 
Irradiated and leukodepleted platelets must be transfused to maintain a platelet count 
above 20,000/mm3. 
• 
Irradiated and leukodepleted packed red blood cells must be transfused to maintain a 
hemoglobin > 8 g/dL. 
• 
All blood products should be leukodepleted and irradiated and/or prepared in a 
manner to prevent the occurrence of acute graft-versus-host disease with the 
exception of blood stem cells or bone marrow. 
12.2.3 Prophylactic Antimicrobial Therapy is required for viral, fungal and bacterial 
infections 
HSV/VZV Viral prophylaxis with acyclovir IV or Valacyclovir is strongly recommended 
(dosing per institutional standards). Prophylaxis for cytomegalovirus (CMV) with 
intravenous ganciclovir (10 mg/kg/day) during conditioning through Day -2 and then 
high dose acyclovir (1500 mg/m2/day) is recommended. After engraftment and when 
patients are able to tolerate oral medications, oral acyclovir or valganciclovir 
depending on pre-HCT CMV serology may be used for viral prophylaxis; this should 
be continued for at least one year after HCT. 
IV caspofungin (25 mg/m2 daily for infants, 70 mg/m2/day on day 1 then 50 
mg/m2/day after for children and adolescents). This may be transitioned to oral 
posaconazole or voriconazole following engraftment and when clinically appropriate. 
IV liposomal amphoterecin B (3-5 mg/kg/day) is strongly recommended as fungal 
prophylaxis for patients with a history of invasive fungal infection. 
Weekly surveillance with viral polymerase chain reactions (PCR) and 
galactomannans should be performed. 
Trimethoprim-sulfamethoxazole (5 mg/kg/day) or pentamidine for pneumocystis 
jiroveci pneumonia (PJP) prophylaxis should be initiated from admission until Day -2 
then restarted at Day +30 (or at the time of engraftment) until one year post-HCT or 
until appropriate T-cell recovery is achieved. 
IVIG replacement per the institutional guidelines.  
All antimicrobial prophylaxis medications are strongly recommended to be continued 

 
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until patients achieved acceptable evidence of immune reconstitution. 
12.2.4 Sinusoidal obstruction syndrome/Veno-occlusive disease prophylaxis: Prophylaxis 
with oral ursodeoxycholic acid should also be considered from admission until Day 
+28. Patients who develop SOS/VOD should be promptly started on defibrotide 
definitive treatment per institutional guidelines. 
 
 
12.3 
Pre-Transplant assessment as outlined in 11.1 
 
 
12.4    Post-Transplant weekly assessment as outlined in 11.3 
 
 
12.5   Post-Transplant monthly assessment as outlined in 11.3 
 
 
13.0 
Adverse Event Reporting Requirements 
 
13.1  Assessment of the Adverse Events Severity. 
The severity of the adverse events (AEs) will be graded according to the Common 
Terminology 
Criteria v5.0 (CTCAE). Events not included in the CTCAE chart will be scored as follows: 
General grading: 
Grade 1: Mild: discomfort present with no disruption of daily activity, no treatment required 
beyond prophylaxis. 
Grade 2: Moderate: discomfort present with some disruption of daily activity, require 
treatment. 
Grade 3: Severe: discomfort that interrupts normal daily activity, not responding to first line 
treatment. 
Grade 4: Life Threatening: discomfort that represents immediate risk of death. 
 
 
13.2 
Casualty Assessment. 
For the purpose of this study the treatment plan (preparative regimen followed by allogeneic 
stem cell transplantation) is defined as the “transplant package”; therefore adverse events 
known to be caused by components of the transplant package and its direct consequences will 
be scored as definitive related. Adverse events known to be related to drugs used for the 
treatment of GVHD and infection episodes will be scored as probable related. When the 
relationship of the adverse event cannot be ruled out with certainty the AE may be considered 
possible related. Adverse events known to be related to drugs used for supportive treatment 
will be scored as unrelated. 

 
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The principal investigator will be the final arbiter in determining the casualty assessment. 
 
13.3 
List of most common expected adverse events. 
1. Infections in the presence or absence of neutropenia: fungal, bacterial and or viral 
infections. 
2. Fever: Non-neutropenic or neutropenic without infection 
3. Acute graft versus host disease (aGVHD): most commonly manifested by skin rash, 
diarrhea and abnormal liver function tests could also present with some degree of fever, upper 
gastrointestinal symptoms (nausea and vomiting) mucositis and eye dryness. 
4. Gastrointestinal (GI tract): the GI tract manifestations could be not only due to direct 
damage from the preparative regiment but also be a manifestation of GVHD or infections. 
Therefore, the time course and its presentation are crucial when assessing these as adverse 
events. Nausea/vomiting, mucositis, diarrhea when presented within first 7 to 10 days most 
likely will be related to the preparative regimen. 
5. Skin rash: not related to GVHD could be caused by chemotherapy used for the preparative 
regimen or antibiotics used a supportive treatment. 
6. Transaminitis: liver function test elevation. 
7. Pulmonary events:  Idiopathic pneumonia syndrome, pneumonia and/or pleural effusions 
8. Cytokine Storm/ engraftment syndrome: most likely caused by released cytokines. 
9. Hemorrhagic cystitis: not related to chemotherapy agents used in the proposed preparative 
regimen is most likely caused by viral infection. 
10. Thrombotic thrombocytopenic purpura (TTP). 
11. Sinusoidal obstruction syndrome  
12. Fluid overload due to hydration required for conditioning regimen, blood product 
transfusions and or IV alimentation 
13. Graft failure. 
14. Chronic GVHD. 
15. For the purpose of this study the following events would not be considered adverse events 
and would not be recorded in the database: 
1. Flu-like symptoms not associated with infection 
2. Abnormal laboratory findings considered associated to the original disease 
3. Isolated changes in laboratory parameters such as electrolyte, magnesium and metabolic 
imbalances, uric acid changes, elevations of ALT, AST, LDH and alkaline phosphatase. 
 
13.4  Adverse events considered serious. 
1. Prolonged hospitalization due to infections and/or organ failure requiring extensive 
supportive care (i.e. dialysis, mechanical ventilation). 
2. Readmissions from any cause resulting in a prolonged hospitalization (>10 days). 

 
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3. Graft Failure/ rejection. 
4. Any expected or unexpected event resulting in an irreversible condition and/or leading to 
death. 
 
13.5  Adverse events data collection. 
From the start of preparative regimen up to D+100 the collection of adverse events will reflect 
the onset and resolution date and maximum grade; beyond this point some events considered 
related to chronic GVHD or late complications post-transplant  may be recorded only with the 
first date of their awareness with no grade or resolution date. Pre-existing medical conditions 
will be recorded only if an exacerbation occurs during the active treatment period. Co-morbid 
events will not be scored separately. 
 
13.6 
 AE and Protocol Deviations Reporting Requirements. 
Adverse events will be reported accordingly to MDACC (HSRM chapter 15.001) and SCT&CT 
Department (HSRM chapter 15.053) policy and procedures. This study will be conducted in 
compliance however in the event of any protocol deviations or violations these will be reported 
accordingly to MDACC (HSRM chapter 25). 
 
 
14.0 
Statistical Considerations 
 
14.1 Overview 
This is a pilot study of allogeneic hematopoietic stem cell transplantation in high risk solid 
tumors. The study plans to enroll a maximum of 20 patients in each of the two groups: 1) 
Patients with a matched related donor, 2) Patients with a matched allogeneic umbilical cord 
donor. The primary objective is to assess the tolerability in each treatment group by transplant-
related mortality (TRM) at day 30, as well as the rate of grade III or higher organ toxicity 
(Bearman Regimen-Related Toxicities Scale) attributable to conditioning occurring within 30 
days. Secondary objectives are listed in section 2.0. Specifically, the primary endpoints 
include the TRM at day 30 and the rate of grade III or higher organ toxicity within 30 days. The 
secondary endpoints include time to platelet and neutrophil engraftment, incidence of aGVHD 
by day 100, incidence of chronic GVHD at day 100 and one year, rate of grade II organ toxicity 
through day 100, rate of graft failure (primary and secondary) through day 100, rate of 
infectious complications through day 100, progression free survival at day 180 and cumulative 
incidence of relapse, overall survival, and progression-free survival at 100 days and 1 year. 
 
14.2  Statistical Considerations and Analysis Methods 
We will use Bayesian monitoring rules to monitor the 30-day TRM rate and stop the trial if there is 
strong evidence at any time that this rate exceeds 20%. Formally, we will stop accrual if at any time: 

 
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Pr (Day 30 TRM> 0.20 | Data) > 0.80. We assume a Beta (0.4, 1.6) prior distribution for the probability 
of TRM corresponding to a 20% mean, and assume a constant rate of 20% for the standard of care. 
Stopping boundaries and operating characteristics were generated using the Department of 
Biostatistics’ Bayesian Toxicity Monitoring Shiny version v2.1.1.2 
(https://biostatistics.mdanderson.org/shinyapps/BTOX/). Patients will be monitored in cohorts of size 
5. The stopping boundaries for this rule corresponding to the probability criterion above are: 
 
No of total Patients (Cohorts of 
5) 
Discontinuation if No of 30-day TRM is: 
5 
3-5 
10 
4-10 
15 
5-15 
20 
6-20 
 
Corresponding operating characteristics for toxicity stopping rule for 30-day TRM: 
 
True 30-day TRM Rate 
Prob. of Early Stop 
Avg. N Patients 
.1 
.02 
20 
.15 
.09 
19 
.2 
.21 
18 
.25 
.36 
16 
.3 
.53 
15 
.35 
.68 
13 
.4 
.81 
11 
 
Similarly for rate of grade III or higher organ toxicity attributable to conditioning occurring 
within 30 days, we will stop the trial if there is strong evidence at any time that this rate 
exceeds 30%. Formally, we will stop accrual if at any time: Pr (Day 30 grade III or higher 
organ toxicity > 0.30 | Data) > 0.80. We assume a Beta (0.6, 1.4) prior distribution for the 
probability of toxicity corresponding to a 30% mean, and assume a constant rate of 30% for 
the standard of care. Stopping boundaries are: 
 
No of total Patients (Cohorts of 
5) 
Discontinuation if No of 30-day grade III or 
higher organ toxicity is: 
5 
3-5 
10 
5-10 
15 
7-15 
20 
8-20 

 
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Corresponding operating characteristics for toxicity stopping rule for 30-day grade III or 
higher organ toxicity: 
 
True Grade III or Higher Organ Toxicity 
Rate 
Prob. of 
Early Stop 
Avg. N Patients 
.2 
.08 
19 
.25 
.15 
18 
.3 
.26 
17 
.35 
.39 
15 
.4 
.53 
14 
.45 
.66 
12 
.5 
.78 
10 
 
 
14.3 Analysis Methods 
 
The proportion of patients with 30-day TRM and the proportion of patients with 30-day grade III or 
higher organ toxicity will be reported together with the corresponding 95% Bayesian credible interval.  
Given 20 patients with the stopping criteria thresholds of 20% and 30%, respectively, corresponding 
95% Bayesian credible intervals span (.07, .40) and (.13, .51).   
 
The 100-day and 1-year rates of relapse, overall survival (OS) and progression-free survival (PFS) 
will be calculated and illustrated from the time of transplant by the method of Kaplan and Meier[45].  
The same approach will be applied to the time to failure of platelet and neutrophil engraftment. The 
progression free survival at day 180 will be assessed using the method of Kaplan and Meier.  
 
The 100-day rates of acute and chronic GVHD with the competing risk of relapse will be estimated 
using the method of Gooley[46].  The same approach will also be applied to 100-day and 1-year 
chronic GVHD and 30-day TRM. The 100-day rates of grade II organ toxicity, primary and secondary 
graft failure, and infectious complications will be reported as counts with percentages. 
Frequency counts and percentages will also be presented of subjects with serious adverse events 
and adverse events leading to withdrawal. All other safety parameters will be summarized using 
descriptive statistics or frequency counts. All time-to-event modeling will include corresponding 
illustrations. Other statistical approaches might be employed.  
 
15.0 Data and Safety Monitoring Plan 
 
This study is monitored by the MDA DSMC. 

 
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16.0 Confidentiality of Study Data 
Participant confidentiality and privacy is strictly held in trust by the participating investigator, their staff, 
the safety and oversight monitor(s), and the sponsor(s) and funding agency. This confidentiality is 
extended to the data being collected as part of this study. Data that could be used to identify a 
specific study participant will be held in strict confidence within the research team. No personally 
identifiable information from the study will be released to any unauthorized third party without prior 
written approval of the sponsor/funding agency, as applicable. 
 
All research activities will be conducted in as private a setting as possible. 
 
Access to Study Records 
Study records may be accessed by IRB approved study personnel, or authorized inspectors. The 
study monitor, other authorized representatives of the sponsor or funding agency, representatives of 
the Institutional Review Board (IRB), regulatory agencies or representatives from companies or 
organizations supplying the product, may inspect all documents and records required to be 
maintained by the investigator, including but not limited to, medical records (office, clinic, or hospital) 
and pharmacy records for the participants in this study. The clinical study site will permit access to 
such records. 
 
Methods of Storage of Study Records 
All data collected from MD Anderson Cancer Center (MDACC) sources will be maintained in 
REDCap. Study staff will have role based restricted access to REDCap, according to project 
responsibilities. Only those with data entry permissions can add records. The PI or a delegate will 
review the conditions under which data will be released to recipient- investigators. Each application 
for use will need IRB approval and consents, if appropriate. The level of identifiability will determine 
the process for review and approval as well as the way information is shared. 
 
Any study data or records maintained in paper documents will be stored in the offices of the PI or 
other delegated study staff, in a locked cabinet or other comparable controlled environment, and will 
be accessible only to authorized study team members or authorized inspectors.   
 
Duration of Study Record Storage 
The study participant’s contact information will be securely stored internal use during the study. At the 
end of the study, all records will continue to be kept in a secure location for as long a period as 
dictated by the reviewing IRB, Institutional policies, or sponsor/funding agency requirements. 
 
Sharing of Study Records 
There are no plans to share study data with entities external to MD Anderson Cancer Center, aside 
from authorized inspectors as applicable (i.e. authorized representatives of the sponsor or funding 
agency, representatives of the Institutional Review Board (IRB), regulatory agencies or 
representatives from companies or organizations supplying the product).  If data will be shared, IRB 
approval will be sought, and applicable inter-institutional agreements executed, prior to data sharing.   
 
 
17.0 
Informed Consent Process 
Each subject / legal representative or proxy consenter will have ample time and opportunity to 
ask questions and will be informed about the right to withdraw from the study at any time 
without any disadvantage and without having to provide reasons for this decision. Only if the 
subject / legal representative or proxy consenter voluntarily agrees to sign the informed 
consent form and has done so, may he/she enter the study.  Additionally, the investigator and 
other information provider (if any) will personally sign and date the form.  The subject / legal 

 
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representative or proxy consenter will receive a copy of the signed and dated form. The signed 
informed consent statement is to remain in the investigator site file or, if locally required, in the 
patient’s note/file of the medical institution. In the event that informed consent is obtained on 
the date that baseline study procedures are performed, the study record or subject’s clinical 
record must clearly show that informed consent was obtained prior to these procedures. 
The informed consent form and any other written information provided to subjects / legal 
representatives or proxy consenters will be revised whenever important new information 
becomes available that may be relevant to the subject’s consent, or there is an amendment to 
the protocol that necessitates a change to the content of the subject information and / or the 
written informed consent form.  The investigator will inform the subject / legal representative or 
proxy consenter of changes in a timely manner and will ask the subject to confirm his/her 
participation in the study by signing the revised informed consent form.  Any revised written 
informed consent form and written information must receive the IEC/IRB`s approval / favorable 
opinion in advance of use. 
Consent Process and Documentation 
Please select one of the following: 
☒ This protocol will follow the SOP 04_Informed Consent Process. SOP 04 has been read 
by the research staff and investigators. 
☐ 
This protocol will follow SOP 04_Informed Consent Process with the following changes: 
________. SOP 04 has been read by the research staff and investigators. 
Informed consent may be obtained using the following methods: (check all that apply): 
☒ Remote consent 
☒ In-person consent 
 
18.0  References 
 
1. 
Bearman, S.I., et al., Regimen-related toxicity in patients undergoing bone marrow 
transplantation. Journal of Clinical Oncology, 1988. 6(10): p. 1562-1568. 
2. 
Llosa, N.J., et al., Reduced-Intensity Haploidentical Bone Marrow Transplantation with Post-
Transplant Cyclophosphamide for Solid Tumors in Pediatric and Young Adult Patients. Biol Blood 
Marrow Transplant, 2017. 23(12): p. 2127-2136. 
3. 
Eisenhauer, E.A., et al., New response evaluation criteria in solid tumours: revised RECIST 
guideline (version 1.1). Eur J Cancer, 2009. 45(2): p. 228-47. 
4. 
Malempati, S., et al., The addition of cixutumumab or temozolomide to intensive multiagent 
chemotherapy is feasible but does not improve outcome for patients with metastatic 
rhabdomyosarcoma: A report from the Children's Oncology Group. Cancer, 2019. 125(2): p. 290-
297. 
5. 
Whelan, J., et al., High-Dose Chemotherapy and Blood Autologous Stem-Cell Rescue Compared 

 
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With Standard Chemotherapy in Localized High-Risk Ewing Sarcoma: Results of Euro-
E.W.I.N.G.99 and Ewing-2008. J Clin Oncol, 2018: p. JCO2018782516. 
6. 
Amoroso, L., et al., Topotecan-Vincristine-Doxorubicin in Stage 4 High-Risk Neuroblastoma 
Patients Failing to Achieve a Complete Metastatic Response to Rapid COJEC: A SIOPEN Study. 
Cancer Res Treat, 2018. 50(1): p. 148-155. 
7. 
Meyers, P.A., et al., High-dose melphalan, etoposide, total-body irradiation, and autologous stem-
cell reconstitution as consolidation therapy for high-risk Ewing's sarcoma does not improve 
prognosis. J Clin Oncol, 2001. 19(11): p. 2812-20. 
8. 
Brissot, E., et al., Improvement of overall survival after allogeneic hematopoietic stem cell 
transplantation for children and adolescents: a three-decade experience of a single institution. 
Bone Marrow Transplant, 2016. 51(2): p. 267-72. 
9. 
Thiel, U., et al., Allogeneic stem cell transplantation for patients with advanced 
rhabdomyosarcoma: a retrospective assessment. Br J Cancer, 2013. 109(10): p. 2523-32. 
10. 
Kasow, K.A., et al., Possible allogeneic graft-versus-tumor effect in childhood melanoma. J 
Pediatr Hematol Oncol, 2003. 25(12): p. 982-6. 
11. 
Ruggeri, L., et al., Effectiveness of donor natural killer cell alloreactivity in mismatched 
hematopoietic transplants. Science, 2002. 295(5562): p. 2097-100. 
12. 
Takada, S., et al., Three AML patients with existing or pre-existing intracerebral granulocytic 
sarcomas who were successfully treated with allogeneic bone marrow transplantations. Bone 
Marrow Transplant, 1999. 23(7): p. 731-4. 
13. 
Ueno, N.T., et al., Rapid induction of complete donor chimerism by the use of a reduced-intensity 
conditioning regimen composed of fludarabine and melphalan in allogeneic stem cell 
transplantation for metastatic solid tumors. Blood, 2003. 102(10): p. 3829-36. 
14. 
Venstrom, J.M., et al., KIR and HLA genotypes are associated with disease progression and 
survival following autologous hematopoietic stem cell transplantation for high-risk neuroblastoma. 
Clin Cancer Res, 2009. 15(23): p. 7330-4. 
15. 
Perez-Martinez, A., et al., Natural killer cells can exert a graft-vs-tumor effect in haploidentical 
stem cell transplantation for pediatric solid tumors. Exp Hematol, 2012. 40(11): p. 882-891 e1. 
16. 
Lang, P., et al., Haploidentical stem cell transplantation in patients with pediatric solid tumors: 
preliminary results of a pilot study and analysis of graft versus tumor effects. Klin Padiatr, 2006. 
218(6): p. 321-6. 
17. 
Burdach, S., et al., Allogeneic and autologous stem-cell transplantation in advanced Ewing 
tumors. An update after long-term follow-up from two centers of the European Intergroup study 
EICESS. Stem-Cell Transplant Programs at Dusseldorf University Medical Center, Germany and 
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19.0   Appendix A: Bearman Regimen-Related Toxicities Scale 
 
 
 
 
 
*Grade IV regimen related toxicity is defined as fatal toxicity  
 
 

 
20.0 APPENDIX B: STANDARD OBSERVATIONS  & INTERVENTIONS 
 
Observation/Intervention 
Baseline 
During Conditioning 
Post-Transplant 
Weekly for 6 
weeks 
2x’s/mo Week 7 - Day+100 
Day +180 
Day +270 
Day +365 
History 
X 
X 
X 
X 
X 
X 
X 
Physical Examination 
X 
X 
X 
X 
X 
X 
X 
Weight, Height, and BSA 
X 
X 
X 
X 
X 
X 
X 
Head Circumference (if age appropriate) 
X 
X 
X 
X 
X 
X 
X 
Karnofsky/Lansky Score (as age appropriate) 
X 
X 
X 
X 
X 
X 
X 
Pregnancy Test 
X 
GvHD Assessment Score 
X 
X 
X 
X 
X 
Serum Chemistries 
X 
X 
X 
X 
X 
X 
X 
Liver Function Test 
Bilirubin 
X 
X 
X 
X 
X 
X 
X 
ALT 
X 
X 
X 
X 
X 
X 
X 
Renal Function Test 
Creatinine 
X 
X 
X 
X 
X 
X 
X 
BUN 
X 
X 
X 
X 
X 
X 
X 
Creatinine Clearance or 
GFR 
X 
X 
Xa 
Xa 
Xa 
Xa 
Xa 
 
 
Pre 
engraftment 
Post- 
Engraftment 
Post- 
Discharge 
Day 
Weekly 
Weekly 
Weekly 
+100 
+180 
+270 
+365 
CBC/Dif 
X 
X 
X 
X 
X 
X 
X 
X 
X 
ABO/Rh 
X 
Immune 
Assessment 
Immunophenotyping 
(CD3, CD4, CD8, CD19, 
CD56) 
X 
X 
X 
X 
X 
Lymphoproliferative 
Responses to Mitogens  
X 
X 
X 
X 
X 
Quantitative 
Immunoglobulin 
(QuIGs = IgG, IgA, IgM) 
X 
X 
X 
X 
X 
Anti- tetanus antibody 
titers 
X 
X 
X 
X 
X 
Circulating tumor cells sample 
 
X 
 
 
 
 
 
Archived Blood Sample for STR and/or FISH Analyses 
X 

Post-Tra 
 
Observation/Intervention 
Baseline 
During Conditioning 
 
1 Year Post-Transplant 
Cardiac Evaluation 
Echo 
X 
X 
MRI or MUGA 
w/ejection fraction (or 
shortening fraction) as 
X 
X 
Pulmonary Function 
Evaluation 
CT Chest 
X 
X 
PFT (if age appropriate 
& feasible) or O2 
Saturation in room 
X 
X 
Thyroid Function Tests 
X 
Serology 
CMV 
X 
Hep B&C 
X 
HSV 
X 
VSV 
X 
HTLV 1&2 
X 
HIV (if HIV NAT 
testing not obtained) 
X 
NAT Testing for HIV/HCV 
X 
Day +42 
Done as clinically appropriate/per standard disease 
assessment 
Day +100c 
Day +180 
Day +270 
Day +365 
Evaluation of Other 
Disease Specific 
Manifestations/Sites* 
Imaging 
X 
X 
X 
X 
X 
LP/CSF Analysis 
X 
X 
X 
X 
X 
Bone Marrow 
Aspirate/Biop
X 
Aspirate if ANC < 500m3 
by Day +42 
X 
X 
X 
X 
Pre- 
Transplant 
Weekly starting 1 day after initiation of tacrolimus/CSA, until stable levels on oral dosing or until discharge 
Tacrolimus or CSA 
Level 
X 
X 
Taperc 
Day +60 to Day +100 
Day +100 to D+180 
20% of original therapeutic dose/wk 
10% of original therapeutic dose/wk 
Donor Chimerism (D+28 only if engrafted by then) 
Xd 
X 
X 
Weekly assessment until Day +30 or until resolution (whichever is longer) 
Toxicity 
Mucositis 
X 
VOD 
X 

 
 
 
 
* When applicable to primary disease 
a  Only if clinically indicated 
b Post-discharge: CBC and platelet count weekly until PRBC and platelet transfusion independent and at Days +100, +180, +270, and +365 
c  If no active GvHD, then begin taper as follows: 
Recipients of matched related donors start taper at Day +60 at approximately 20% of the original therapeutic dose/week to be and complete by Day +100. 
Recipients of other donors start taper at Day +100 at approximately 10% of the original therapeutic dose/week to be completed by Day +180 as possible. 
d Donor chimerism study done on D+28 can be done ±3 days if engrafted for neutrophils