A Two Step Approach to Reduced Intensity Allogeneic Hematopoietic Stem Cell Transplantation for Patients With Hematologic Malignancies
Phase: PHASE2
Conditions: Adult Acute Lymphoblastic Leukemia in Remission, Adult Acute Myeloid Leukemia in Remission, Adult Acute Myeloid Leukemia With 11q23 (MLL) Abnormalities, Adult Acute Myeloid Leukemia With Del(5q), Adult Acute Myeloid Leukemia With Inv(16)(p13;q22), Adult Acute Myeloid Leukemia With t(15;17)(q22;q12), Adult Acute Myeloid Leukemia With t(16;16)(p13;q22), Adult Acute Myeloid Leukemia With t(8;21)(q22;q22), Adult Nasal Type Extranodal NK/T-cell Lymphoma, Aplastic Anemia, Childhood Acute Lymphoblastic Leukemia in Remission, Childhood Acute Myeloid Leukemia in Remission, Childhood Myelodysplastic Syndromes, Chronic Eosinophilic Leukemia, Chronic Myelomonocytic Leukemia, Chronic Neutrophilic Leukemia, Essential Thrombocythemia, Extranodal Marginal Zone B-cell Lymphoma of Mucosa-associated Lymphoid Tissue, Juvenile Myelomonocytic Leukemia, Mastocytosis, Myelodysplastic/Myeloproliferative Neoplasm, Unclassifiable, Nodal Marginal Zone B-cell Lymphoma, Polycythemia Vera, Previously Treated Myelodysplastic Syndromes, Primary Myelofibrosis, Recurrent Adult Acute Lymphoblastic Leukemia, Recurrent Adult Acute Myeloid Leukemia, Recurrent Adult Diffuse Small Cleaved Cell Lymphoma, Recurrent Adult Grade III Lymphomatoid Granulomatosis, Recurrent Adult Hodgkin Lymphoma, Recurrent Childhood Acute Lymphoblastic Leukemia, Recurrent Childhood Acute Myeloid Leukemia, Recurrent Cutaneous T-cell Non-Hodgkin Lymphoma, Recurrent Grade 1 Follicular Lymphoma, Recurrent Grade 2 Follicular Lymphoma, Recurrent Marginal Zone Lymphoma, Recurrent Mycosis Fungoides/Sezary Syndrome, Recurrent Small Lymphocytic Lymphoma, Recurrent/Refractory Childhood Hodgkin Lymphoma, Refractory Anemia, Refractory Anemia With Ringed Sideroblasts, Refractory Hairy Cell Leukemia, Refractory Multiple Myeloma, Secondary Myelodysplastic Syndromes, Splenic Marginal Zone Lymphoma, T-cell Large Granular Lymphocyte Leukemia, Waldenström Macroglobulinemia
Sponsor: Sidney Kimmel Comprehensive Cancer Center at Thomas Jefferson University

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Protocol v6.4 dated 2022-06-17 
A Two Step Approach to Reduced Intensity Allogeneic Hematopoietic Stem Cell 
Transplantation for Patients with Hematologic Malignancies  
 
Principal Investigator 
Dolores Grosso, DNP, CRNP 
 
Co-Principal Investigator 
Usama Gergis, MD 
 
Co-Investigators 
S. Onder Alpdogan, MD 
Matthew Carabasi, MD 
Joanne Filicko-OHara, MD 
Margaret Kasner, MD 
William O’Hara, PharmD 
Ubaldo Outschoorn Martinez, MD 
John Wagner, MD 
Neil Palmisiano, MD 
Thomas Klumpp, MD 
 
Pierluigi Porcu, MD 
Lindsay Wilde, MD 
 
Biostatistics 
Inna Chervoneva, PhD 
 
Radiation Oncologists 
Wenyin Shi, MD, PhD 
Maria Werner-Wasik, MD 
 
Thomas Jefferson University (TJU) 
Blood and Marrow Transplantation Program 
Department of Medical Oncology 
Suite 320, 834 Chestnut Street 
Philadelphia, PA 19107 
 

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Protocol v6.4 dated 2022-06-17 
Table of Contents  
 
1.0  
Purpose, Hypothesis, and Objective  
 
 
 
 
p…3 
 
2.0  
Introduction 
 
 
 
 
 
 
 
 
p…5 
 
3.0  
Patient and Donor Selection  
 
 
 
 
 
p…19 
 
4.0  
Informed Consent 
 
 
 
 
 
 
 
p…22 
 
5.0  
Treatment Plan 
 
 
 
 
 
 
 
p…22 
 
6.0  
Study Measurements  
 
 
 
 
 
 
p…28 
 
7.0  
Supportive Care 
 
 
 
 
 
 
 
p…31 
 
8.0  
Drug Information 
 
 
 
 
 
 
 
p…33 
 
9.0  
Patient Safety  
 
 
 
 
 
 
 
p…37 
 
10.  
Statistical Analysis 
 
 
 
 
 
 
 
p…39 
 
11.0 
 References 
 
 
 
 
 
 
 
 
p…41 
 
12.0  Appendices 
 
 
 
 
 
 
 
 
p…49 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Protocol v6.4 dated 2022-06-17 
1.0 Purpose, Hypothesis, and Objectives 
Haploidentical hematopoietic stem cell transplantation (HSCT) is a life-saving therapy for 
patients with hematological malignancies who do not have a fully HLA (Human Leukocyte 
Antigen)-matched donor. This type of approach has been characterized by lower survival rates as 
compared to matched related HSCT. These poorer outcomes are at least in part due to the 
attenuation of the donor graft necessary to avoid catastrophic graft versus host effects and the 
late stage disease status of the patients undergoing haploidentical HSCT. 
 
Recently, approaches to haploidentical HSCT utilizing reduced intensity conditioning (RIC) and 
the drug cyclophosphamide (CY) to establish bidirectional tolerization of donor/recipient T cells 
1, 1-3 have resulted in less graft versus host disease (GVHD) and treatment-related mortality 
(TRM) as compared to historical approaches using haploidentical donors. At our institution, the 
RIC HSCT regimen utilizing CY to tolerize T cells is called the TJU 2 Step approach because 
patients receive the lymphoid and myeloid portions of their graft in two separate steps. This 
transplant methodology has greatly improved overall survival rates for patients undergoing 
haploidentical HSCT at Jefferson.   
 
While these newer approaches have made this type of transplant safer, relapsed disease is a 
major source of mortality in these trials, specifically in patients with evidence of their disease at 
HSCT. 1, 4 Although increasing HLA disparity is known to be associated with a greater risk of 
significant graft versus host disease (GVHD), there is less data as to whether increasing HLA 
disparity is correlated with stronger, clinically significant graft versus tumor (GVT) effects. 
Based on the high degree of major histocompatibility complex (MHC) mismatch in 
haploidentical HSCT, one would expect relapse to occur less frequently than in matched sibling 
HSCT, yet in both myeloablative and RIC haploidentical HSCT, mortality from relapse in 
patients with evidence of their disease at HSCT is very common especially in the acute 
leukemias. It is unclear whether GVT effects are not discerned because the patient has resistant 
disease at the time of HSCT or because the attenuation of the haploidentical graft to avoid 
catastrophic GVHD also circumvents clinically meaningful GVT effects. Of interest, there is 
some data suggesting a superior GVT effect in haploidentical HSCT for the lymphomas as 
compared with other diagnoses. 2, 5 
 
The purpose of this research study is to examine GVT effects in RIC haploidentical HSCT 
utilizing CY tolerization of T cells within the context of lymphoid and myeloid malignancies. 
Because post HSCT relapse may be associated with disease resistance to the conditioning 
regimen or the provision of an RIC approach in patients with active or resistant disease at HSCT, 
patients in remission or with chemosensitive or indolent diseases will be the study group in this 
trial. Durable disease control in this lower risk patient population would be more specifically 
related to GVT effects of the haploidentical donor immune system as opposed to an up-front 
failure to control the disease with chemoradiotherapy.   
 
The hypothesis of this research study is that haploidentical RIC HSCT using the TJU 2 Step 
approach will result in equal or superior overall survival (OS) in patients with better risk disease 
as compared to patients undergoing matched sibling or unrelated donor (URD) RIC HSCT 
despite the fact that a haploidentical donor is used as the hematopoietic cell source. This 
hypothesis is based on the assumption that the Jefferson 2 Step approach to haploidentical HSCT 

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Protocol v6.4 dated 2022-06-17 
has an equivalent rate of treatment related mortality as compared to matched sibling RIC HSCT, 
and that whatever diminution in GVT effects that occur as a result of CY tolerization are 
compensated for by increased alloreactivity from the mismatched graft.  
 
Specific Objectives are: 
 
Primary 
• To compare the OS rate at 2 years post treatment using the Jefferson 2 Step RIC approach 
in patients with haploidentical family donors with hematological malignancies in 
morphological or radiographic remission or with chemosensitive, indolent diseases to 
historical OS rates in similar populations after RIC matched donor HSCT as reported in 
the literature. Based on the historical literature, reviewed in the background section of 
this protocol, we believe that: 
 
o An OS of < 55% at 2 years would demonstrate poor efficacy for the TJU 2 Step 
haploidentical regimen as compared to regimens using matched related and 
unrelated donors, and  
 
o An OS of ≥75% at 2 years would demonstrate that the TJU 2 Step haploidentical 
RIC regimen is equal or superior to those using matched related or unrelated 
donors.  
 
Although there has been approximately 4 years of experience with the TJU 2 Step approach in 
the Jefferson Blood and Marrow Transplant Program, continuing assessment of this transplant 
methodology will be performed on the outcomes of GVHD, engraftment, immune reconstitution, 
TRM, and relapse-related mortality in specific disease groups. Therefore, secondary objectives 
are: 
 
Secondary 
• To compare the TRM rate at 2 years for patients treated on this study to the historical TRM 
rates of patients undergoing RIC matched-sibling HSCT as reported in the literature.  
 
• To compare the 2 year relapse rates and relapse related mortality of patients with myeloid 
diseases to that of patients with lymphoid diseases who are treated on this TJU RIC 2 step 
approach. 
 
• To determine the incidence and severity of graft-versus-host disease (GVHD) in patients 
undergoing treated on the TJU RIC 2 step approach.  
 
• To evaluate engraftment rates and lymphoid reconstitution in patients treated on the TJU 
RIC 2 step approach.  
 
• To evaluate the incidence of TRM at 100 days in patients treated on the TJU RIC 2 step 
approach.  
 

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Protocol v6.4 dated 2022-06-17 
2.0 Introduction and Background 
Allogeneic HSCT is a curative therapy for many disorders of lymphohematopoiesis.6-10 While 
allogeneic transplants are often associated with lower rates of relapse than autografts or 
conventional dose treatment, this advantage is partially offset by higher regimen related 
mortality. 11-28 Much of this increase can be traced to the toxicities of the conditioning regimen, 
GVHD and the immunosuppressive measures required for the prevention and/or treatment of 
GVHD. 29-34 For more than a decade, it has been recognized that long-term disease control after 
allogeneic HSCT  is mediated through the anti-tumor effects of the transplanted immune system 
and less so by the intensity of the conditioning regimen.  This GVT effect can occur even in the 
absence of overt GVHD. 35 In acute myeloid leukemia (AML) and chronic myeloid leukemia 
(CML), for example, relapse rates are higher in recipients of twin transplants than in GVH free 
recipients of matched sibling grafts. 36 Moreover, in CML, many patients who relapse after BMT 
can be rendered disease free through the infusion of additional lymphocytes from the marrow 
donor without any additional chemoradiotherapy. 37-41 
 
Development of less intensive conditioning regimens 
 
Transplant regimens that are not lethally myeloablative (NM HSCT) have been developed over 
the last decade. These approaches do not use dose intensity to eradicate malignancy. Rather they 
use immunosuppressive agents, irrespective of their anti-neoplastic properties, to facilitate donor 
lymphoid and stem cell engraftment. The donor lymphoid elements then destroy the residual 
normal and in some cases malignant lymphohematopoietic elements allowing the transition to 
donor chimerism. These regimens rely less heavily on the conditioning regimen for disease 
control by exploiting the graft versus tumor effects of the donor immune system. They are 
associated with less treatment-related mortality 42 and have allowed older and heavily pretreated 
patients who otherwise would not tolerate the rigors of a fully myeloablative HSCT, to undergo 
transplant successfully.43 Nonmyeloablative HSCT has been dramatically effective in CML, 
chronic lymphocytic leukemia (CLL), and follicular lymphoma in its original application and 
may have utility in other diseases as well. 44-47 
 
Ablative Versus Nonmyeloablative HSCT  
Despite the demonstration of successful outcomes after NM HSCT, this type of therapy cannot 
be universally applied. Many studies contrasting the outcomes between ablative and non-ablative 
conditioning show that the superior results for NM HSCT in terms of treatment related mortality 
are offset by higher rates of relapse.48-50 This issue becomes particularly important in diseases 
not known to have a strong GVT effect such as acute lymphocytic leukemia (ALL)51, 52 and 
certain lymphoma subtypes,53-55 where dose intensity may be just as important as a GVT effect in 
terms of overall survival. Many of the non-myeloablative regimens are minimally 
myelosuppressive, while others are more immunosuppressive and are associated with prompter 
engraftment of donor cells than their less intensive counterparts. The former approach has been 
associated with less TRM but with incomplete initial chimerism and increased rates of relapse.48, 
56, 57 The latter approach, alternately referred to as “reduced intensity” HSCT, has been 
associated with more TRM but less relapse.58, 59 A NM HSCT approach that is not an “either/or” 
proposition has not been clearly identified.   
 
Because many patients, due to age, previous treatment, or comorbid conditions, cannot tolerate 
the rigors of a fully ablative regimen, decreasing the incidence of relapse after this procedure 

6 
Protocol v6.4 dated 2022-06-17 
could result in significant gains in overall survival. Thus, the use of a haploidentical donor as 
opposed to a fully matched related or unrelated donor in NM HSCT may represent a way to 
increase graft versus tumor (GVT) effects resulting in an increase in OS in the setting of RIC 
HSCT. At our institution, the use of haploidentical donors in RIC HSCT has resulted in durable 
disease control with minimal toxicity especially in fit patients without evidence of their disease 
at HSCT. It is this subgroup of patients that may benefit from the GVT effects of a haploidentical 
donor as compared to a matched donor, provided the toxic effects of the regimen are 
commensurate with matched sibling HSCT. In our experience, the 2 Step TJU RIC HSCT 
approach meets this criteria.  
 
TJU 2 Step RIC HSCT 
A Two Step Approach to Reduced Intensity Allogeneic Hematopoietic Stem Cell Transplantation 
for Hematologic Malignancies from HLA Partially-Matched Related Donors was specifically 
designed to treat older patients (> 66 years) or patients who underwent previous transplants and 
could not tolerate the rigors of a second myeloablative conditioning regimen. In this 2 step 
transplant regimen, patients receive fludarabine and either ARA-C or Thiotepa for 4 days. The 
patients then receive one day of TBI (2Gy), followed by an exact dose of 2.0 x 10e8 of their 
donor’s T cells (step 1 of the transplant). After the donor T cell infusion (DLI) the patients 
consistently develop fevers and in many cases a skin rash and diarrhea, consistent with an 
immune reaction. On the 3rd day after the DLI the patients receive the first of two daily doses of 
CY in order to tolerize the reactive lymphocytes. Twenty-four hours after the last dose of CY, 
the patients receive a stem cell product from their donor (step 2 of the transplant). The 
conditioning regimen is shown in Table 1: 
 
Table 1 
2 Step Reduced Intensity HSCT-Conditioning Regimen 
 
 
In general, patients receive Thiotepa if there is evidence of an active malignancy where therapy 
with an alkylating agent is thought to be more beneficial than therapy with an anti-metabolite.  
This is especially important in our patient population which contains a preponderance of patients 
with acute leukemia who have already received front-line therapy with ARA-C. ARA-C is given 
to patients who do not have evidence of disease at the time of HSCT or have diseases in which 
ARA-C is thought to be beneficial such as CLL or follicular NHL. The conditioning regimen has 
been developed in this manner to allow for patient-specific adjustments within a consistent 
 
Fri 
-12 
Sat 
-11 
Sun 
-10 
Mon 
-9 
Tues 
-8 
Wed 
-7 
Thur 
-6 
Fri 
-5 
Sat 
-4 
Sun 
-3 
Mon 
-2 
Tues 
-1 
Wed 
0 
A
M 
Admit 
Fludara 
30  
mg/m2 
Fludara 
30  
mg/m2 
Fludara 
30  
mg/m2 
Fludara 
30  
mg/m2 
Rest 
TBI 
2 Gy 
Rest 
Rest 
CTX 
60 
mg/kg 
CTX 
60 
mg/k
g 
Rest 
 
CD- 
34+ 
PBSC 
Infu-
sion 
P
M 
 
Ara-C 
2 gm/m2 
 
OR 
Thiotepa 
5 mg/kg 
Ara-C 
2 gm/m2 
 
OR 
Thiotepa 
5 mg/kg 
Ara-C 
2 gm/m2 
 
OR 
Thiotepa 
5 mg/kg 
Ara-C 
2 gm/m2 
 
OR 
No 
Chemo-
therapy 
 
DLI 
 
 
 
 
Start 
FK 
506 & 
MMF 
→ 

7 
Protocol v6.4 dated 2022-06-17 
regimen.  Patients are treated with ARA-C versus Thiotepa based on defined programmatic 
guidelines which are part of a greater policy governing patient placement on the various TJU 2 
Step protocols.  
 
Review of the TJU 2 Step RIC HSCT 
Thirty-four patients were treated on the 
TJU 2 Step RIC approach from 2006-
2010, which is now closed to accrual. 
The probability of overall survival at 1 
year is 50% and 43% at 2 years, with a 
follow-up of 5 to 42 months (Figure 1).  
The median age of this group of patients 
is 67 years. 
 
To our knowledge, there are no 
haploidentical reduced intensity trials 
with a patient population as old as the 
group being treated on our study. 
Therefore, we do not have comparison 
survival data for which to assess our 
current results. However, based on 
CIBMTR data for patients over the age 
of 50, the 1 year survival rate advanced 
AML is close to 50% (Figure 2), which 
is comparable to our haploidentical results at the 1 year mark, despite a significantly older 
population.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Table 2 below contains patient information and outcomes to date for this trial. 
Years
0
2
6
1
3
4
5
Probability of Survival After HLA
Probability of Survival After HLA-Identical 
Identical 
Sibling Transplants for AML, 
Sibling Transplants for AML, 
Age 
Age >50 Years, 1998
50 Years, 1998–2006
2006
By Disease Status and Conditioning Regimen Intensity
By Disease Status and Conditioning Regimen Intensity
SUM08_11.ppt
Early, myeloablative (N=660)
Slide 33
0
20
40
60
80
100
10
30
50
70
90
0
20
40
60
80
100
10
30
50
70
90
P=.3745.
Early, reduced-intensity conditioning (N=544)
Intermediate, myeloablative (N=206)
Intermediate, reduced-intensity conditioning (N=77)
0.0 
10.0 
20.0 
30.0 
40.0 
Time after HSCT 
0.0 
0.2 
0.4 
0.6 
0.8 
1.0 
CumSurv
Probability of Survival 
TJU 2 Step RIC HSCT 
43% 
Figure 1 
Figure 2

8 
Protocol v6.4 dated 2022-06-17 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
MDS=myelodysplastic syndrome, AML=acute myeloid leukemia, CLL=chronic lymphocytic 
leukemia, 
NHL=non-Hodgkin 
lymphoma, 
MPD=myeloproliferative 
disorder, 
Myeloma=multiple myeloma, Biphen Leuk=Biphenotypic leukemia 
 
As shown in the table above, the TRM of all of the patients treated on the 2 Step RIC regimen is 
26%, and only 14% in the patient group with better risk disease. We believe this rate is 
acceptable considering the older age of the patient population, although efforts to improve pre-
transplant screening and optimization of the clinical condition of patients continue in the 
Table 2                                           Interim Summary 
(Follow Up 1-39 Months) 
TJUH 2 Step Approach to Reduced Intensity Haploidentical HSCT  3/10/2010 
Sample Size 
34 
Median Age 
67 years 
Diagnoses 
MDS-2   AML-18   ALL-3 
CLL-3   NHL-3      MPD-1 
Myeloma-2 Biphen Leuk-1 
Aplastic Anemia-1 
 
5 patients are S/P previous transplants 
Disease at the time of HSCT 
24/34 (71%) 
Overall Survival  
 
Patients in Remission or with Indolent Disease 
 
Patients Not in Remission 
16/34 (47%) 
 
10/14 (71%) 
 
  6/20 (30%) 
Overall Treatment-Related Mortality 
 
Treatment Related Mortality: 
Patients in Remission or with Indolent Disease 
 
  9/34 (26%) 
 
 
 2/14   (14%) 
Relapse-Related Mortality 
  9/34 (26%) 
Mortality Related to GVHD 
  2/34 (6%) 
Rejection 
 1/34 (3%) 

9 
Protocol v6.4 dated 2022-06-17 
Jefferson Transplant program in order to decrease TRM rates further. Despite this, we believe the 
TJU 2 Step RIC regimen is commensurate in terms of TRM to historical RIC regimens using 
fully matched and unrelated donors especially for patients with better risk disease. Patients 
treated on the TJU 2 Step RIC approach who were in remission at the time of the transplant have 
an 80% probability of OS at 1 year post HSCT. Therefore, we assume that with similar patient 
populations and treatment toxicity, comparisons can be made regarding GVT effects. The 
hypothesis of this current research study is to ascertain if haploidentical HSCT is associated with 
a greater survival benefit as compared to matched donor RIC HSCT in a larger group of patients 
than studied in the initial protocol. 
 
Relapse and Overall Survival in Matched Related and Unrelated RIC HSCT 
In order to demonstrate that RIC HSCT using haploidentical donors may be comparable or even 
superior in terms of GVT effects and OS to regimens utilizing completely matched donors, an 
estimate of OS after related donor RIC HSCT is required for comparison purposes. Because the 
patient population that is served in our institution is older with a preponderance of AML/MDS, 
the comparator studies will primarily reflect this type of population, although other studies will 
be reviewed in order to capture data for patients with other diagnoses. Patients with all of the 
diagnoses discussed below are treated in the Jefferson transplant program and may be treated 
according to this protocol. All of the studies reviewed below are summarized in table 3 which 
follows the discussion section. 
 
 
AML/MDS 
Several larger studies of RIC HSCT are available for patients with better risk AML. A European 
Group for Blood and Marrow Transplantation (EBMT) trial reported by Aoudjhane and 
colleagues49 reviewed the results of 315 patients, median age of 57 years, with intermediate or 
good risk AML (71% in first complete remission (CR1) or second complete remisison CR2) 
undergoing transplant with matched related donors. Probability of OS at 1 year in this group was 
55% which dropped to 44% at 2 years. Relapse related mortality was 18% at 2 years, and 
relapsed disease was the major cause of mortality with 27% of patients dying from relapse at 2 
years most significant in the group with more advanced disease. A second EBMT study utilizing 
the same database and reported by Herr et al.,60 reviewed the outcomes of 361 patients greater 
than 50 years old with AML, 76% in CR1 or CR2, and compared them to a similar group of 
patients undergoing autologous HSCT. In this analysis, the probability of OS in patients 
undergoing RIC HSCT was 54% at 2 years with 29% of patients dying of their disease at 2 years. 
Consistent with the Aoudjhane et al. analysis, patients with advanced disease had a higher 
relapse rate than patients in CR1 or CR2. TRM in this study was 16% at 2 years.  
 
In contrast to the above studies, Kurosawa et al.61 reported on the outcomes of 93 patients 
(median age 55 years) with AML who were all in CR1 undergoing matched related RIC HSCT. 
This type of patient population, i.e. having early stage disease with a matched related donor, 
would be predicted to have the best outcomes. Not surprisingly, the OS rate of 61% at 3 years 
reported for this trial is higher than most survival rates reported for any RIC HSCT trial in AML. 
CIBMTR data (available on the CIBMTR website at www.cibmtr.org/) for 1,198 patients with 
early stage AML undergoing matched related non-myeloablative HSCT showed a 2 years 
probability of OS of 55%, consistent with higher survival rates for good risk disease. The 
EBMTR results reported by Aoudjhane and colleagues contain outcomes of patients with 

10 
Protocol v6.4 dated 2022-06-17 
intermediate risk disease and consequently the 2 years probability of OS was lower at 44% 
which is also consistent with the lower 2 year probability of OS reported by the CIBMTR for 
patients (N=377) with intermediate-risk AML of 50% as compared to the 55% rate of earlier 
stage patients.  
 
In trials in which outcomes for patients treated with AML are combined with outcomes of 
patients with MDS, OS rates are lower for patients with MDS than patients with early stage 
AML. The probability of OS for patients over the age of 40 reported in a CIBMTR study 62 
involving 545 patients with AML in CR1 and 535 patients with MDS was 34-50% for the 
patients with AML and 35-45% for patients with MDS. Outcomes were worse for older patients 
with a TRM of 33-35% at 2 years in the MDS group. Surprisingly, the relapse rate for the AML 
patients was higher at 33-36% than in the MDS group (25-29%), but this may have been due 
early censoring of the patients in the MDS arm that died of toxicity before they were able to 
relapse. Two additional studies, Lim et al.63 which looked at 833 patients with MDS or 
secondary AML (median age of 59) undergoing HSCT with fully matched donors and Martino et 
al.48 reporting on 215 patients with MDS (median age of 56) undergoing matched related RIC 
HSCT  reported OS rates of only 32% at 4 years and 41% at 3 years respectively for these groups 
of patients. In both of these studies relapsed disease was the major cause of death with relapse 
rates of 41% at 4 years in the Lim et al. study, and 45% at 3 years in the Martino et al. study.  
TRM for patients in the LIM et al. study was also a significant cause of mortality at 32% at 4 
years and may have been due to the slightly older patient population in the study.  
 
Based on this data, patients with early stage AML and matched sibling donors can achieve OS 
rates as high as 55-60% after RIC HSCT. Relapse rates are higher and OS is lower in older 
patients and/or those with intermediate stage AML or MDS, with MDS patients also succumbing 
to treatment effects in higher numbers. In this group, OS rates range from 30 to 45% depending 
on the length of follow-up but are certainly lower than patients with better risk disease.  
 
Myeloproliferative Disorders 
There is less data regarding patients with CML undergoing RIC HSCT with the advent of 
transcription kinase inhibiter therapy. One study by Das et al. 64 analyzed the outcomes of 17 
young adults with chronic CML undergoing RIC HSCT. In this small series, the OS rate was 
only 35.5% at a median of 30 months with only 4 patients developing relapsed disease and most 
deaths attributed to toxicity. Because the GVL effect of HSCT in CML is significant, these 
results are not surprising and patients with this disease may be the least likely to require a 
haploidentical donor as opposed to a matched related donor to achieve remission. Stewart and 
colleagues 65 looked at the outcomes of 24 patients with primary myelofibrosis undergoing RIC 
HSCT and reported non-relapse mortality (NRM) rate of 32% at 3 years for the group and an OS 
of only 31%. Relapsed disease was the cause of death for about 1/3 of the patients in this study 
with regimen toxicity accounting for most of the other deaths. Lissandre and colleagues 66 
reported the outcomes of 39 patients with myelofibrosis (1° MF=27, PV=7, ET=5) undergoing 
RIC HSCT from 1994-2008. The patient numbers were equally distributed between low, 
intermediate and high Lille prognosis scores. The 3 year OS, relapse-free survival, and regimen 
related mortality rates were 60%, 54%, and 30%. These figures are consistent with the outcomes 
reported in the other trials for this disease category in that regimen related mortality, not relapsed 
disease is the primary cause of mortality for this subgroup of patients. 

11 
Protocol v6.4 dated 2022-06-17 
 
Lymphoid Disorders 
The outcomes of adults with Hodgkin disease undergoing RIC HSCT from matched related 
donors (N=12) versus umbilical cord blood (N=9) reported by Majhail et al.67, revealed no 
difference in OS between the two groups, and a 2 year progression-free survival (PFS) rate of 
only 20% for the patients undergoing matched related donor RIC HSCT. Progressive disease and 
relapse related mortality were equal in terms of causes of mortality. Patients with refractory 
disease at HSCT had a 0% OS rate. Relapsed disease was the primary cause of mortality in a 
Swedish study reported by Johansson and colleagues 68of 23 adults with advanced stage Hodgkin 
disease. By 3 years, 57% of the patients had relapsed and only 20% of patients were alive at 7 
years. Conversely, Burroughs et al.5 reported a significant decrease in relapse rates for patients 
with Hodgkin disease undergoing RIC HSCT from haploidentical donors. An Italian Group 
study 69examined the outcomes of 104 patients with relapsed Hodgkin disease after autologous 
HSCT undergoing RIC HSCT primarily from matched donors. Relapsed disease was the primary 
source of mortality in this group with advanced disease, and the PFS and OS rates at 2 years 
were only 39.3% and 66% respectively. In summary, patients with Hodgkin disease who are 
treated with RIC HSCT are primarily heavily pretreated with many relapsing after autologous 
HSCT. For this group, OS at 2 years would be expected to be about 50% with a much lower PFS 
rate at that time point.  
 
Patients with low grade non-Hodgkin lymphomas have amongst the highest rates of survival 
after RIC HSCT, with low relapse rates and even higher PFS for patients with chemosensistive 
disease. In trials of patients with follicular lymphoma undergoing RIC HSCT from matched 
donors, OS has been reported to be as high as 62%-85% at 3 to 5 years with a PFS of 55%-
83%.53, 53, 55, 70-72 The majority of patients with CLL will undergo HSCT with refractory disease 
and consequently OS rates are lower than those reported for follicular NHL. Sorror et al.73 and 
Peres et al. 74reported 5 year OS rates of 50-63% for a group of patients with CLL undergoing 
NM/RIC HSCT with 45%-81% of the population having refractory disease. Dreger et al.75 
reported a 72% OS rate at 2 years in patients with CLL, only one-third of whom had refractory 
disease. Whether the higher OS rate in this study is due to shorter follow-up time versus higher 
numbers of better-risk patients is not known. In the Sorror et al. study, patients without refractory 
disease or comorbidities as scored on the hematopoietic cell transplant comorbidity index (HCT-
CI) had an OS rate of 80% at 2 years which decreased to only about 75% at 5 years and is 
comparable to the Dreger et al. study. However for patients with ≥ 1 point on the HCT CI or ≥ 
5cm adenopathy at HSCT, OS rates were lower: 45% to 50% at 2 years and 20% to 40% at 5 
years. Therefore, for fit patients with chemosensitive CLL, OS rates at 2 years may be as high as 
70%. Conversely, patients with resistant disease who have even a few comorbidities, OS rates 
may be as low as 45 to 50%.  
 
Two studies by Corradini et al. 55 and Armand et al.53 reported the outcomes of patients with 
NHL, mostly with responsive disease in both trials, undergoing RIC HSCT based on NHL 
subtype. The Corradini et al. trial was the larger study and consistent with the aforementioned 
CLL and follicular NHL trials, reported a high, 69% OS rate at 3 years for the patients with 
indolent NHL, with this group of patients having the best PFS. The trial by Armand et al. also 
included patients with indolent NHL, and these authors also reported a favorable OS rate of 81% 
at 3 years for patients in this subgroup. Patients with aggressive lymphomas faired well in the 

12 
Protocol v6.4 dated 2022-06-17 
Corradini et al. study as well, with a 3 year OS rate of 69% at 3 years and a PFS rate of 54%. In 
contrast, the 23 patients with diffuse large cell lymphoma or transformed follicular lymphoma in 
the Armand et al. trial had a 3 year PFS and OS of only 22% and 42% despite the fact that most 
of the patients in this study did not have resistant disease. Data specific to patients with this 
disease subtype was not reported by Armand et al. with enough detail to attempt to identify the 
reasons for the discrepancy in outcomes for patients with aggressive NHL in the two trials. 
Patients with mantle cell lymphoma had 3 year survival rates of only 40% to 45% in both trials 
with a 35% relapse rate in patients in the Corradini et al. trial and a higher risk of relapse as 
compared to the indolent lymphomas in the Armand et al. trial. Consistent with the previously 
discussed trials of patients with Hodgkin disease, patients in this subcategory in these two trials 
fared poorly with high relapse rates and an OS rate of only 32% at 3 years in the Corradini study 
and a PFS rate of only 22% in the Armand et al. study. 
 
In summary, patients with chemosensitive indolent lymphoid diseases would be predicted to 
have OS rates of about 70% (60%-80%) at 2 years. Subgroups of patients with more aggressive 
chemosensitive disease would be predictably lower. Patients in any subgroup with resistant 
disease would be expected to have OS rates of closer to 40 to 50% at 2 years and those with 
Hodgkin disease fair the worst with OS rates consistently below 50%.  
 
Multiple Myeloma 
The role of RIC HSCT in the treatment of multiple myeloma remains controversial with many 
studies showing no survival benefit between allogeneic HSCT and autologous HSCT for this 
patient population.76, 77 Some trials have shown a benefit in terms of progression-free survival, 
78but the median rate of OS at 2 to 3 years for 12 trials reviewed by Gahrton was only 49% 
(range 26% to 78%). Four papers, two very recently published, are reviewed here. Patients with 
early stage myeloma with residual disease after their first autologous HSCT had an OS rate of 
61.8% at 5 years after RIC HSCT without a high degree of relapse.77 In contrast, for patients 
with later stage disease, Mohty et al.79 reported only a 41% PFS at 2 years, Shimoni et al. a 34% 
OS at 7 years80, and Efebera et al.81 a 32% OS at 2 years with 43% of patients dying of relapsed 
disease in this study. In summary, despite a small number of patients who are treated with 
allogeneic HSCT earlier in their disease course because of identified high-risk features, patients 
with multiple myeloma undergo RIC HSCT usually later in the disease course when front line 
therapy including autologous HSCT has failed. Based on the above data for this latter population, 
DFS rates in the 40 percentage range would not be unexpected with slightly higher OS 
percentages.  

13 
Protocol v6.4 dated 2022-06-17 
Table 3 
 
 
Table 3 
Authors 
Disease 
NM 
vs. 
RIC 
 
Probability 
Overall  
Survival 
Disease 
Progression/ 
Relapse Data 
Deaths 
from 
Toxicity 
Median 
Age 
Comments 
AML/MDS 
Aoudjhane et al. 
49 
 
AML 
N=315 
(majority good 
or intermediate 
risk disease) 
-matched 
related donors 
RIC 
~55% at 1 year 
44% @ 2 years 
27% died of 
relapsed 
disease at 2 
years 
18% at 2 
years 
57 
EBMT Study 
Herr et al.60 
AML 
N=361 (76% in 
remission at 
HSCT)  
-matched 
related donors 
RIC 
54% at 2 years 
 
29% died of 
relapsed 
disease at 2 
years 
16% at 2 
years 
58 
 
Kurosawa et al. 
61 
AML 
N=93 (all CR1) 
Matched 
related donors 
RIC +MA 
versus 
Chemo 
61% at 3 years 
Disease 
progression 
data specific to 
RIC not given 
Toxic 
deaths 
specific to 
RIC group 
not given 
55 
 
McLune et al. 62 
AML/MDS 
N=1080 
545 AML (all 
CR1) 
535 MDS 
(majority 
intermediate 
risk)  
-matched 
related and 
unrelated 
donors 
RIC 
AML ~34% -
50% at 2 years 
depending on 
age 
 
MDS  ~35% -
45% at 2 years 
depending on 
age 
 
 
Probability 
of Relapse: 
 
AML 33%-
37% 
 
MDS 25-29% 
AML 
22%-34% 
depending 
on age 
 
MDS 
33%-39% 
depending 
on age 
>40 
CIBMTR 
Study 
Lim et al. 63 
MDS and 
Secondary AML 
N=833  
-matched 
related and 
unrelated 
donors  
RIC 
32% at 4 years 
41% relapse 
rate at 4 years 
32% at 4 
years 
59 
EBMT Study 
Martino et al. 48 
MDS 
N=215 
-matched  
RIC 
41% @ 3 years 
45% relapse 
rate at 3 years 
15% at 3 
months 
22% at 3 
years 
56 
EBMT Study 
Authors 
Disease 
NM 
vs. 
RIC 
 
Probability 
Overall  
Survival 
Disease 
Progression/ 
Relapse 
Data 
Deaths 
from 
Toxicity 
Median 
Age 
Comments 
Myeloproliferative Disorders 
Das et al.64 
CML 
N=17  
-matched 
related donors 
RIC 
35.3% at 30 
months 
Not given 
47% at 30 
months 
34 
 
Stewart et al. 65 
1º Myelofibrosis 
N=24  
-matched 
related and 
unrelated 
donors 
RIC 
31% at 3 years 
25% died from 
relapsed 
disease 
 
32% at 3 
years 
54 
 
Lissandre et al. 
66 
1º Myelofibrosis 
2º Myelofibrosis 
N=39 
- matched 
related and 
unrelated 
donors 
RIC 
60% at 3 years 
Relapse-free 
survival 54% 
at 3 years 
30% at 3 
years 
49 
 
Hodgkin Disease 
Majhail et al. 67 
Hodgkin 
N=12 
-matched 
related donors 
RIC 
~65% at 1 year, 
50% at 2 years  
 
20% PFS @ 2 
years 
25% at 6 
months 
42 
 
Johansson et 
al.68 
Hodgkin 
N=39, majority 
relapsed after 
auto BMT 
-primarily 
matched 
unrelated donors 
with a few 
matched related 
donors 
 
RIC 
Only 20% alive 
at 7 years 
57% relapsed 
by 3 years 
22% at 
100 days 
36 
 
Sarina et al. 69 
Hodgkin 
N=104 relapsed 
after auto 
BMT 
-primarily 
matched related 
and unrelated 
donors 
RIC 
66% at 2 years 
39.3% 
PFS at 2 years 
12% at 2 
years 
31 
 

14 
Protocol v6.4 dated 2022-06-17 
Authors 
Disease 
NM 
vs. 
RIC 
 
Probability 
Overall  
Survival 
Disease 
Progression/ 
Relapse 
Data 
Deaths 
from 
Toxicity 
Median 
Age 
Comments 
NHL 
Hari et al. 71 
Follicular NHL 
Primarily 
Chemosensitive 
disease 
N=88 
-all matched 
related donors 
RIC 
62% at 3 
years 
55% 
Progression 
free survival at 
3 years 
23%  
1 year Cumu-
lative 
incidence of 
death from 
treatment  
51 
 
CIBMTR 
Study 
Khouri et al.72 
Relapsed  
Chemosensitive 
Follicular NHL 
N=47 
-mostly matched 
related donors 
NM + 
Rituxan 
85% @ 60 
months 
PFS 83% at 60 
months 
7/47 (15%) 
died 
primarily 
infection 
53 
 
Dreger et al.75 
CLL, 35% with 
refractory disease   
N=77 
-primarily 
matched related 
donors 
RIC 
At  2 years: 
OS 72% 
DFS 56%  
Probability of 
relapse at 2 
years was 31% 
(Patients with 
refractory 
disease fared 
poorly) 
18% at 12 
months 
54 
EBMT Study 
Peres et al. 74 
CLL (81% 
fludarabine 
refractory) 
N=21 
-primarily 
matched related 
and matched 
unrelated 
 
RIC 
63% at 5 
years 
Probability if 
relapse at 2 
years 15.1% 
 
20% 
Cumulative 
incidence of 
TRM at 2 
years 
54 
 
Sorror et al. 73 
CLL (45% 
unresponsive 
disease) 
N=82 
- matched related 
and matched 
unrelated 
NM 
50% 
5 year 
cumulative 
incidence OS 
 
HCT-CI 
+adenopathy: 
0 + <5 cm  
~ 70% at 5 y 
HCT-CI 
+adenopathy 
≥1 + ≥ 5cm 
0% at 5 y 
 
38%/39%  
5 year 
cumulative 
incidence of 
relapse-PFS 
23% 
5 year 
cumulative 
incidence of 
non-relapse 
mortality  
56 
 

15 
Protocol v6.4 dated 2022-06-17 
Corradini et 
al.55 
Relapsed NHL: 
Indol-NHL(63) 
Aggres-NHL(61) 
MCL (14) 
HD(32) 
N=170 
-matched related 
donors 
RIC 
At 3 years: 
69% 
69% 
45% 
32% 
32/170 died 
from relapse 
(19%), highest 
relapse rate in 
HD 
11% at 1 
year 
51 
 
Armand, P. et 
al. 53 
Advanced NHL: 
 
Indol-NHL(13) 
Aggres-NHL(23) 
MCL (15) 
HD(36) 
N=87 
-primarily 
matched related 
and matched 
unrelated 
RIC 
At 3 years: 
 
81% 
42% 
40% 
56% 
PFS 3 years: 
 
59% 
22% 
30% 
22% 
 
 
38% NHL 
15% HD 
 
51  NHL 
36  HD 
 
 
Authors 
Disease 
NM 
vs. 
RIC 
 
Probability 
Overall  
Survival 
Disease 
Progression/ 
Relapse 
Data 
Deaths 
from 
Toxicity 
Median 
Age 
Comments 
Multiple Myeloma 
Mohty et al.79 
Multiple Myeloma 
70% in partial 
remission, 27% 
with progressive 
disease 
N=41 
-matched related 
donors 
RIC 
At 2 years: 
OS 62% 
 
At 2 years: 
DFS 41% 
 
51% 
progressive 
disease after 
HSCT 
17% (at a 
median 
follow-up of 
389 days) 
52 
 
Shimoni et al. 80 
Recurrent/ 
Refractory 
Multiple Myeloma 
N=50 
-matched related 
and unrelated 
RIC 
34% at 7 
years 
48% had 
disease 
progression 
after HSCT 
26% at 5 
years 
53 
 
Efebera et al. 81   Relapsed/refractory 
Myeloma, 82% 
stable to responsive 
disease) 
N=51 
-primarily 
matched related 
donors 
RIC 
32% at 2 
years 
19% at 2 years 
43% died of 
disease 
34% died of 
non-relapse 
causes  
51 
 

16 
Protocol v6.4 dated 2022-06-17 
 
Comparison Point for the Trial 
The hypothesis of this research study is that haploidentical RIC HSCT using the TJU 2 Step 
approach will result in equal or superior overall survival (OS) in patients with better risk disease 
as compared to patients undergoing matched sibling or unrelated donor (URD) RIC HSCT. In 
the initial TJU 2 Step RIC HSCT trial, patients with better-risk disease included those with acute 
leukemia in CR1 or CR2 (n=8), indolent NHL (n=2), myelofibrosis (n=1), myeloma with near 
CR (n=2), and aplastic anemia (n=1). We would expect that patients with the same diagnoses 
would be treated on this current study. We would also expect that our population would continue 
to be significantly older than that of the patients cited in the trials cited above. The median age of 
the patients on the initial RIC haploidentical HSCT trial at Jefferson was 67 years old, which is 
about 10 to 30 years higher than that reported for the trials reviewed above. Based on these trials, 
we anticipate that an OS rate of ≥60% at 2 years would prove the superiority of this 2 step 
approach over matched related or unrelated trials. Conversely, an OS rate of ≤ 35% at 2 years 
would demonstrate poor efficacy of this trial as compared to historical trials utilizing matched 
related or unrelated donors. These figures take into account both the older age of the patient 
population treated at Jefferson as compared to the cited literature, as well as the treatment of a 
preponderance of patients with myeloid malignancies as opposed to those treated for indolent 
non-Hodgkin lymphoma.   
 
The Substitution of Alkylating Agents 
This protocol opened in 2011 and 23 patients has been treated to date on the current conditioning 
regimen of Fludarabine, Thiotepa, 2 Gy TBI and CY. Thiotepa has been used in the 2 step RIC 
approaches since 2008 and in cancer chemotherapy for over 50 years. It was designated as an 
orphan drug in 2007, and a critical shortage of Thiotepa was identified in 2013, (Adienne 
Pharma & Biotech, 2013) originating from market forces which have affected many oncology 
medications.(Chabner, 2011) The drug is no longer manufactured in the United States (American 
Society of Health System Pharmacists, 2014) and purchasing the drug from overseas has been 
associated with increasing cost.(Neergaard, 2011) Therefore, the current expense of the drug 
makes its use in HSCT at TJUH (and most other centers) no longer feasible, and a drug 
substitution in the regimen is required.  
 
Mortality in patients undergoing allogeneic HSCT comes from non-relapse causes in the forms 
of GVHD, organ toxicity, or infection versus mortality from disease recurrence. This protocol 
explores whether a haploidentical donor is superior to a matched related donor in terms of 
preventing relapse and by extension, increasing OS rates at 2 years. Therefore, regimen toxicity 
must be minimized so that disease free survival comparisons can be made. To date, none of the 
23 patients treated on this protocol have died of toxicity. To keep this non-relapse mortality low, 
we will substitute Busulfan 3.2 mg/m2 IV daily x 2 days for Thiotepa in the regimen. Busulfan 
has been used in HSCT for over 30 years and is commonly used in RIC HSCT.(Devillier et al., 
Rosiñol et al. 77  
Patients with early 
stage multiple 
myeloma failing to 
achieve a CR after 
1st auto BMT 
N=25 
-all matched 
related donors 
RIC 
61.8% at 5 
years 
61% PFS 
16% TRM 
52 
 

17 
Protocol v6.4 dated 2022-06-17 
2014; Gupta et al., 2014; Kanda et al., 2014) A comprehensive review of recent data regarding 
Busulfan in HSCT was written by Champlin in 2013(R. E. Champlin, 2013)  and supports the 
efficacy of the drug in this setting. It serves as a reasonable substitute for Thiotepa because like 
Thiotepa, its efficacy in hematopoietic diseases and HSCT, as well as its side effect profile are 
well known. Because only two doses of Busulfan will be used in this regimen, dosing based 
pharmacokinetic analysis is not necessary. In October of 2014, patients treated on the TJUH high 
risk RIC protocol (IRB #12D.501), started to receive Busulfan instead of Thiotepa for the same 
reason. Three patients have been treated on that study, and there have been no deaths and no 
toxicity related to Busulfan.  
 
We will use the dose of Busulfan that is most commonly used with Fludarabine in other RIC 
regimens, including IRB #12D.501. Typically, 3-4 doses of Busulfan are administered in these 
approaches.(Alatrash et al., 2011; Andersson et al., 2008; De Lima et al., 2004; Parmar et al., 
2013)  CY is an additional alkylating drug used in the 2 step regimen to further treat malignancy 
and tolerize lymphocytes. Other regimens using Busulfan do not typically contain a second 
alkylator. Therefore, we will administer only 2 doses of Busulfan. Thiotepa is an alkylating agent 
that was successfully paired with CY, and so this will be a class for class substitution.  
 
Summary 
The purpose of this clinical trial is to compare overall survival rates of patients with lower risk 
hematological malignancies who undergo haploidentical HSCT on the TJU 2 Step approach 
versus patients with similar diseases and disease states who have undergone matched related or 
unrelated RIC HSCT as reported in the literature. Our hypothesis is that patients with 
haploidentical donors will have lower relapse rates than patients with matched donors because of 
the greater degree of HLA mismatch between recipients and donors resulting in greater OS.   
 
Historically, the number of patients with available matched sibling donors presenting for RIC 
HSCT at our institution is very small precluding our ability to develop effective clinical trials for 
this group. Thus, they will be offered this treatment option in lieu of an RIC trial specifically for 
matched sibling transplantation. Only the outcomes of the patient group undergoing HSCT from 
haploidentical donors (2, 3, or 4 antigen mismatches in the GVH direction) will be used in the 
analysis of outcomes for the statistical ends of the trial. Outcomes for patients with matched 
siblings will be reported descriptively.  
 
3.0 Patient and Donor Selection 
Patient Selection 
 
Inclusion Criteria 
1) Any patient with hematologic or oncologic diagnosis in which allogeneic HSCT is 
thought to be beneficial, and in whom front-line therapy has already been applied.  
Patients treated on this protocol will be without morphological evidence of disease, or if 
the patient has evidence of disease, the patient must have had at least a good partial 
response (PR) to the most recent therapy and the disease must be chemoresponsive.   
2) Patients treated on this study will have: 
a. Acute leukemia in 1st or 2nd CR 

18 
Protocol v6.4 dated 2022-06-17 
b. MDS (myelodysplastic syndrome), specific subtypes of RA (refractory anemia) or 
RARS (refractory anemia with ringed sideroblasts) subtypes. 
c. Hodgkins or Indolent Non-Hodgkin’s lymphoma with chemosensitive disease 
d. Myeloma without morphological evidence of disease, or a PR to the most recent 
therapy 
e. Myeloproliferative disorders with at least a PR to current therapy 
f. Aplastic Anemia 
g. A hematological or oncological disease (not listed) that meets the criteria reviewed 
above (section 3, number 1). 
3) Patients must have a related donor who is HLA mismatched at 2, 3, or 4 antigens at the 
HLA-A; B; C; DR loci in the GVHD direction. (Patients with related donors who are 
HLA identical or are a 1-antigen mismatch may be treated on this therapeutic approach, 
but will have their outcomes will not be part of the statistical aims of the study (see 
Summary section). 
4) Patients must have adequate organ function: 
a. LVEF (Left ventricular end diastolic function) of ≥50% 
b. DLCO (Diffusing Capacity of the Lung for Carbon Monoxide) ≥50% of predicted 
corrected for hemoglobin 
c. Adequate liver function as defined by a serum bilirubin ≤1.8, AST or ALT ≤2.5 x 
upper limit of normal 
d. Creatinine clearance of ≥60 mL/min 
5) Patients must have adequate KPS and HCT-CI scores:  
a) Patients < age 60 years must have a KPS of ≥80% and an HCT-CI score of 5 or less 
b) Patients aged 60 to 65 years must have a KPS of ≥80% and an HCT-CI score of 4 or less 
c) Patients aged 66 to 69 years must have a KPS of 90% and an HCT-CI score of 3 or less 
d) Patients aged 70 years or more must have a KPS of 90% and an HCT-CI score of 2 or less 
 
Patients with greater than the allowable HCT-CI points for age can be enrolled for trial with approval 
of the PI and at least 1 Co-I not on the primary care team of the patient. This is an adjustment to 
account for healthy patients who meet the spirit of this protocol but have histories that result in higher 
than guideline HCT-CI points. An example is a patient with a solid tumor malignancy in their remote 
history (adds 3 points to HCT-CI total) where the treatment for the malignancy occurred years to 
decades before and there has been complete recovery of toxicities 
 
6) Patients must be willing to use contraception if they have childbearing potential 
7) Able to give informed consent. 
 
Exclusion Criteria 
1) HIV positive 
2) Active involvement of the central nervous system with malignancy 
3) Inability to obtain informed consent 
4) Pregnancy 
5) Patients with life expectancy of ≤6 months for reasons other than their underlying 
hematologic/oncologist disorder 
6) Patients who have received alemtuzumab or ATG within 8 weeks of the transplant 
admission. (documented by the absence of these agents in the medical record) 
7) Patients with evidence of another malignancy, exclusive of a skin cancer that requires 
only local treatment, should not be enrolled on this protocol. 

19 
Protocol v6.4 dated 2022-06-17 
 
 
Donor selection 
All donors are selected and screened for their ability to provide adequate infection-free apheresis 
products for the patient in a manner that does not put the donor at risk for negative consequences. 
Donor selection, evaluation and treatment will be in compliance with 21 CFR 1271 and all TJU 
BMT program SOPs relating to the use of allogeneic donor for HSCT. 
 
Specifically, donors will be tested, using the appropriate FDA-licensed and designated screening 
tests, for: 
1. HIV, type 1 
2. HIV, type 2 
3. HBV (HBsAg, anti-HBc IgG and IgM 
4. HCV 
5. Treponema pallidum 
6. Human T-lymphotropic virus, types I and II 
7. Cytomegalovirus 
8. West Nile Virus 
9. Trypanosoma cruzi 
 
As per the Jefferson Blood Donor Center Quality Plan, all allogeneic donor testing samples 
(including HPC donors) will be sent to a laboratory that is FDA and CLIA licensed. 
Agreements/contracts for these services will be developed according to TJUH policies and all 
pertinent regulatory requirements will be retained by the Blood Bank. 
 
Additional donor testing may be performed as required to assess the possibility of transmission 
of other infectious and non-infectious diseases. 
 
TJUH HPC transplant personnel will discuss the potential for disease transmission from donor to 
recipient (i.e. the purpose of infectious disease testing) during the donor evaluation. 
 
Infectious disease testing must be completed by the time of the recipient’s transplant admission 
date. 
 
As per FACT guidelines, pregnancy will be assessed during the initial donor evaluation and just 
prior to the initiation of the recipient’s conditioning regimen in female donors of childbearing 
age. 
 
4.0 Informed Consent 
Patients referred for the trial will have their eligibility criteria verified. On meeting the eligibility 
for the trial as outlined, informed consent will be obtained using forms approved by the Thomas 
Jefferson University Hospital Institutional Review Board and following guidelines related to the 
use of human subjects in research. This risks and hazards of the procedure, as well as alternative 
forms of therapy will be presented to the patient in detail. Patients will receive a signed copy of 
the consent form after the consent interview. In addition, donors will be asked to sign consent 
after they have been fully informed about the procedures and risks of donating. 
 

20 
Protocol v6.4 dated 2022-06-17 
5.0 Treatment Plan 
While the days of radiation and drug administration are fixed, the exact timing of these 
treatments on the day they are due is not specified because of expected variations in clinical care. 
Treatment Schema 
Patient Schedule 
Fri 
-12 
Sat 
-11 
Sun 
-10 
Mon 
-9 
Tues 
-8 
Wed 
-7 
Thur 
-6 
Fri 
-5 
Sat 
-4 
Sun 
-3 
Mon 
-2 
Tues 
-1 
Wed 
0 
Admit 
Fludara 
30  
mg/m2 
Fludara 
30  
mg/m2 
Fludara 
30  
mg/m2 
Fludara 
30  
mg/m2 
Rest 
TBI 
2 Gy 
Rest 
Rest 
CY 60 
mg/kg 
CY 60 
mg/kg 
Rest 
 
CD- 
34+ 
PBSC 
Infu-
sion 
 
 
Bu 3.2 
mg/kg 
Bu 3.2 
mg/kg 
 
 
DLI 
 
 
 
 
Start 
FK 
506 & 
MMF 
→ 
May not use voriconazole until day -1 
 
Table Definitions: Bu=Busulfan, DLI=Donor lymphocyte Infusion, Fludara=fludarabine, TBI=total body 
irradiation, Gy-gray, CY=cyclophosphamide, FK 506=tacrolimus, MMF=mycophenolate mofetil, PBSC=peripheral 
blood stem cell 
 
Donor Schedule 
 
Wed  
-7 
Thur  
-6  
Fri 
-5 
Sat 
-4 
Sun 
-3 
Mon 
-2 
Tues 
-1 
AM 
Lymphocyte 
Collection 
Lymphocyte 
Collection 
G-CSF 
G-CSF 
G-CSF 
G-CSF  
 
PBSC 
Collection 
G-CSF  
 
PBSC 
Collection 
PM 
 
 
G-CSF 
G-CSF 
G-CSF 
G-CSF 
 
G-CSF=granulocyte colony stimulating factor 
 
There should be no administration of agents that suppress lymphocyte reactivity from 
admission until day -1 in this protocol.  This includes steroids, calcineurin inhibitors, MMF, or 
monoclonal antibodies that affect lymphocyte number or function. If patients have previously 
required steroids as a premedication for transfusion, they may receive a dose of steroid 
equivalent to 5 mg of prednisone through day -10. After day -10, a significant portion of the 
conditioning regimen is complete. At this time, the immune system response to alloantigens 
should be somewhat attenuated. Diphenhydramine and meperidine may be used if necessary.  
Any use of steroids from day -10 through day 0 should not be administered without approval 
from the PI. 
 
Patients will not receive azole druges, Acetaminophen, Metronidazole, or any drug 
inhibiting Busulfan metabolism from day -11 through day -8. 
 
Voriconazole os prohibited until day-1 due to its interaction with cyclophosphamide. 
 

21 
Protocol v6.4 dated 2022-06-17 
The absence of prohibited medications in the medical record will serve as documentation 
that they were not given.  
 
All chemotherapy and HPC in this protocol are to be based on dosing weight (40% the difference 
between actual and ideal weight). 
 
5.1 Administration of Fludarabine and Busulfan 
Fludarabine is administered for 4 days on (days -11 through – 8) at a dose of 30 mg/m2 IV daily 
for 4 days. Creatinine must be checked prior to each dose of fludarabine. If renal insufficiency 
develops, the attending physician must be notified in cases where a dose adjustment needs to be 
made. 
 
Busulfan is administered for 2 days on days -10 and -9 at a dose of 3.2 mg/kg/day IV. The 
infusion can be started upon the completion of the fludarabine. 
 
PK levels are not required for Busulfan dosing based on the low dose and low number of 
administrations of the drug.  
 
Seizure prophylaxis is required with the use of Busulfan. The recommended schedule is: 
 
Clonazepam 0.5 mg and Levetiracetam 500 mg, both drugs administered orally and given BID, 
beginning the evening prior to the first Busulfan dose and ending the morning after the last dose 
of Busulfan, days -11 through -8. 
 
If patients cannot tolerate Levetiracetam, the suggested alternate regimen is: 
 
Lorazepam 0.02/kg (max 2 mg) orally or intravenously every 6 hours starting 30 minutes prior to 
the first dose of Busulfan. and continuing for 4 doses after the 2nd dose of Busulfan. The dosage 
should be reduced by 20-50% (to the nearest 0.5 mg) if the patient experiences excessive 
sedation 
 
Day -7 is a day of rest 
 
5.2 TBI 
2 Gy of TBI will be administered on day -6. . At this low dose, there is almost no clinical 
scenario in which this small dose of radiation would be associated with added toxicity from prior 
radiation. However, all patients will be evaluated by a radiation oncologist in preparation for 
radiation treatment. See Appendix A for radiation guidelines. 
 
5.3 Donor Lymphocyte Infusion 
Hematopoietic cell doses and cyclophosphamide dosing will be based on adjusted dosing weight 
(40% the difference between actual and ideal body weight + the actual body weight). The dose of 
the donor lymphocyte infusion (DLI) will be based on CD3+ T cells per kilogram of recipient 
adjusted body weight. Donor lymphocytes will be collected prior to the use of white cell growth 
factor for progenitor cell collection.   
 
The goal of the first day of donor lymphocyte collection is to process a blood volume that is both 

22 
Protocol v6.4 dated 2022-06-17 
safe for the donor as well as to obtain the prescribed dose of CD3+ T cells/recipient kg. It is 
expected that in many cases, a second day of donor lymphocyte collection will be required. 18-
27 liters will be processed the first day of donor lymphocyte collection. It is expected that in 
most cases, a second day of donor lymphocyte collection will not be required.  A 3rd day of 
collection for 2 x 108 T cells has never been required in over 200 previous 2 Step donor 
collections.   
 
DLI specimen handling and labeling conventions will be performed in accord with the relevant 
AABB (American Association of Blood Banks) and/or FACT (Foundation for Accreditation for 
Cell Therapy) regulations and guidelines. All DLI specimens must be appropriately labeled in 
accord with these standards to be accepted by the Processing Laboratory. A valid prescription 
and request form must be submitted by the requesting physician.  
 
Determination of the targeted T cell dose from the apheresis product is as follows: 
Total T-cells required for the initial infusion = (2x108 T-cells/kg) * (Weight in kg) 
Panel: 
          
FITC 
PE 
PE-Cy7 
APC 
APC-H7 
Tube1 
  
CD19 
CD16+56 
CD3 
CD45 
Tube2 
CD8 
  
CD4 
CD3 
CD45 
Tube3 
TCR-ab 
TCR-gd 
  
CD3 
  
  
CD3 count is calculated directly with single-platform flow cytometry. Reported CD3 
 
All donors will be apheresed for lymphocytes on day -7. If the target number of CD3+ T cell 
lymphocytes, 2 x 108/recipient kg is not obtained, apheresis will be repeated on day -6. 
 
Lymphocyte apheresis will be performed at Thomas Jefferson University Hospital or at the 
American Red Cross, by trained apheresis personnel using standard techniques. No 
hematopoietic growth factors will be administered to apheresis donors prior to lymphocyte 
collection. The donor will have venous catheters placed for the purposes of undergoing 
apheresis. Leukocyte collections will be performed using a standard apheresis machine.  
 
 
Patients will receive 2 x 108/kg T cells on day -6. During the infusion, the patient will be 
monitored for any untoward reactions. Donor lymphocyte infusions will be administered by 
nursing staff experienced in the administration of blood products 
 
DLI must NOT be irradiated. DLI should NEVER be administered through a leukocyte 
depletion (PALL) filter. If blood filtration is necessary, the filter should be a standard blood 
product filter with pore size of at least 170 microns. 
 

23 
Protocol v6.4 dated 2022-06-17 
5.4 Cyclophosphamide 
CTX 60 mg/kg IV will be administered on days –3 and –2 of the conditioning regimen. Mesna 
60 mg/kg continuous IV infusion over 24 hours X 2 doses will be infused on days –3 through –2.   
 
Voriconazole can block the conversion of CTX to its active metabolite, 4-
hydroxycyclophosphamide.  For this reason, patients may not receive voriconazole until 
day -1.   
 
Day -1 is a day of rest. 
 
5.5 Collection and Infusion of Progenitor Cells (PBSCs) 
Donors will begin G-CSF, 5µg/kg bid on day -5. Adjunctive or alternate white cell stimulators 
such as Pegfilgrastim and/or Plerixafor are acceptable substitutes for G-CSF. The donor will 
return for a primed progenitor cell collection of days -2 and -1. 18 to 27 liters will be process per 
day. CD34+ cell enrichment will be performed via the closed system method using the 
CliniMACS® CD34 Reagent Syste, (Miltenyi Biotec Inc., Auburn, CA). The CliniMACS 
system utilitizes super-paramagnetic particles composed of iron oxide and dextran conjugated to 
monoclonal antibodies. These antibodies bind to target cells with the corresponding cell surface 
antigen (in this case, CD34). After magnetic labeling, the cells are separated using a high-
gradient magnetic separation column. The magnetically labeled cells are retained in the column 
and separated from the unlabeled cells. Removing the magnetic field from the separation column 
elutes the retained cells. Eluted cells will be characterized using fluorescent-activated cell sorting 
(FACS) analysis. All procedures will be performed in a sterile environment with strict adherence 
to all applicable regulations regarding the processing and use of human stem cells. The use of 
this device will conform to TJU BMT Laboratory standard operating procedures. 
 
The target dose of donor PBSCs to be infused into the recipient is between 3 –5 x 106 CD34 
cells/kg of recipient dosing body weight. The acceptable minimum infusion target of PBSCs will 
be 1 x 106 CD34 cells/kg.  Recipients will receive no more than 10 x 106 CD34 cells/kg, the 
maximum dose.  
 
In our experience, the ideal amount of T-cells left in the PBSC product is no greater than 
5x104/kg, so that every effort will be made to keep T-cell amounts to below this threshold. It is 
recognized that because of donor heterogeneity, every product will have varying percentages of 
cells.  Thus, patients will be advised during the informed consent process that an excess amount 
of residual T-lymphocytes in the PBSC product may increase the risk of GVHD. 
 
Progenitor cell apheresis will be performed at Thomas Jefferson University Hospital or the 
American Red Cross, by trained apheresis personnel using standard techniques. The donor will 
have venous catheters placed for the purposes of undergoing leukopheresis. Leukocyte 
collections will be performed using a standard apheresis machine.  
 
Handling and labeling of the progenitor cell product will be performed in accord with the 
relevant AABB (American Association of Blood Banks) and/or FACT (Foundation for 
Accreditation for Cell Therapy) regulations and guidelines. All donor specimens must be 
appropriately labeled in accord with these standards to be accepted by the Processing Laboratory. 

24 
Protocol v6.4 dated 2022-06-17 
A valid prescription and request form must be submitted by the requesting physician.  
 
The donor PBSC product is infused ULFILTERED or through a filter of at least 170 micron size 
intravenously through a central catheter. PBSCs should only be piggybacked through normal 
saline and not other intravenous solutions. Contingency plans for an inadequate collection of 
progenitor cells via apheresis or non-viable donor cells will be made according to institutional 
policies. All donors will be available for a third day of progenitor cells apheresis and will be 
given extra neupogen in case there is a need for a third collection day. 
 
During the infusion, the patient will be monitored for any untoward reactions. Each infusion will 
take place at Thomas Jefferson University. PBSC infusions will be administered by nursing staff 
experienced in the administration of blood products. Patients will have vital signs taken before, 
during, and after the infusion. The patient will be observed for at least 15 minutes after the 
infusion is completed. PBSC products must NOT be irradiated. PBSC products should NEVER 
be administered through a leukocyte depletion (PALL) filter. If blood filtration is necessary, the 
filter should be a standard blood product filter with pore size of at least 170 microns.  
 
Significant red cell incompatibility between donor and recipient will be managed according to 
standard operating procedure, CL: Ppp040.07, of the Thomas Jefferson University Hospital 
Blood and Marrow Transplant Processing Lab. Pre-medications (if any) prior to PBSC infusion 
will be at the discretion of the physician. 
 
Benadryl, epinephrine, and hydrocortisone should be available at the bedside for emergency use 
if necessary. Oxygen with nasal cannula should be available.  
 
5.6 GVHD Prophylaxis 
Tacrolimus and MMF will be started on day -1. Tacrolimus dose titration will occur to target a 
goal level of 7 ng/ml +/- 2. It is recognized that there may be values beyond this target range due 
to interpatient variability.   
 
MMF will be dosed at 1 gram IV BID beginning on day -1. 
 
The tacrolimus taper can be initiated by day + 42 in the absence of concern for GVHD or 
interference with a GVHD plan of care that was developed prior to day +42. Because of the 
variability in patient outpatient office visit times and the need for GVHD assessment, it is not 
mandatory that the taper begins exactly day on +42. 
 
MMF will be discontinued beginning at day +28 +/- 3 days in the absence of GVHD.   
 
Tacrolimus and MMF may be discontinued earlier if there is count suppression from the drugs or 
other unforeseen circumstances in which the drug is felt to be deleterious to the plan of care, 
such as infection, count suppression, drug side effects, or a need for alternate GVHD treatment.   
 
The BMTU attending physician may change these GVHD prophylaxis guidelines if clinically 
indicated.  
 
 

25 
Protocol v6.4 dated 2022-06-17 
 
6.0 Study Measurements** 
The table below outlines the measurements and time points specific to this study. Only the day 
+28 studies are mandatory. The other elements are recommended. The attending physician may 
perform assessments/labs more or less frequently based on the patient’s unique course.   
 
GVHD Assessment 
Presence and degree 
of skin rash, presence 
and amount of 
diarrhea, LFT’s 
N/A 
Daily after 
engraftment 
until 
discharge and 
then weekly 
as indicated 
X 
As 
clinically 
indicated 
 
As clinically 
indicated 
 
 
 
 
 
As clinically 
indicated 
Chimerism/ 
Disease Assessment  
 
 
 
 
 
 
 
 
Baseline 
assessment  
During 
conditioning 
After 
Condition
ing 
through 
Day + 28 
Days 28-90 
Days 90-180 
 
 
Day 180 
 
Day 180- 
2 years post 
HSCT 
 
History and physical 
with vital signs 
including SPOs. 
Assessment of 
infectious signs, 
pregnancy test for 
females of 
childbearing potential 
done on baseline 
assessment 
X 
Every 1-2 
days 
Every 1-2 
days  if in 
hospital, 
weekly 
until day 
28 after 
discharge 
Monthly 
 As clinically 
indicated 
 
 As 
clinically 
indicated 
Laboratory Studies* 
X 
Every 1-2 
days 
Every 1-2 
days if in 
hospital 
weekly 
until day 
28 after 
discharge 
Twice 
monthly or 
as clinically 
indicated 
 
As clinically 
indicated 
 
 
 
 
As 
clinically 
indicated 
Quantitative 
cytomegalovirus 
CMV by polymerase 
chain reaction PCR 
 
Weekly or as 
clinically 
indicated 
Weekly 
until 
discharge 
or as 
clinically 
indicated 
Twice 
monthly or 
as clinically 
indicated 
As 
clinically 
indicated 
 
As 
clinically 
indicated 
Viral resp swab by 
PCR//sputum culture 
and sensitivity C&S 
 
If respiratory 
symptoms 
If 
respiratory 
symptoms 
If 
respiratory 
symptoms 
If respiratory 
symptoms 
 
If respiratory 
symptoms 
Stool culture (cx), 
viral screening & cx  
& fungal cx 
If clinically 
indicated 
 
 
 
 
 
 

26 
Protocol v6.4 dated 2022-06-17 
Peripheral blood for 
CD3+ chimerism & 
Buffy coat chimerism  
 
 
 
Twice 
monthly 
until >95% 
donor 
chimerism 
Once d+90 
X 
As clinically 
indicated 
Bone marrow exam 
(morphology, flow 
cytometry, 
cytogenetics, buffy 
coat chimerism) 
 
 
X 
Day +90 
Marrow is 
optional 
 
Day +180 
Marrow is 
optional 
 
 
 
Day +270 
Marrow is 
optional 
 
 
 
day +365 
marrow  
is optional 
 
Immune 
Reconstitution 
Studies 
 
 
 
 
 
 
 
Flow cytometry for 
lymphocyte subsets 
 
 
 
X 
Monthly 
Monthly 
Suggested at 
days+ 
180and +270 
At d+365 
Radiographic 
Studies 
In applicable 
situations for disease 
staging 
 
X 
 
 
 
 
 
Day +90 or as 
clinically 
indicated 
 
Day +90 or 
as clinically 
indicated 
* Study measurements are minimum requirement 
**Laboratory studies include a complete blood count with differential comprehensive metabolic 
panel,  and GVHD prophylaxis drug levels when applicable. 
 
It is recognized that due to scheduling issues, some of the required studies cannot be performed 
on the exact days noted on the table. Day +28 studies can be done 7 days before or 7 days after 
day 28.  Other required studies should be performed within 1 month before or after their due 
date. 
 
The formal endpoint of this study for efficacy is 2 years post HSCT and patients are required to 
follow-up with their TJU HSCT team during this time period for assessment of their major 
outcomes. Testing is performed as clinically indicated during the second year post HSCT.  
Patients will come off study after 2 years. Outcomes for patients undergoing HSCT at TJUH are 
followed programmatically indefinitely with results reporting allowable beyond the 2 year 
follow-up. 
 
6.1 Hematopoietic Engraftment 
Hematopoietic engraftment will be defined as: 
• ANC ≥ 0.5x10e9/L for at least 3 days 
• Platelet engraftment >20,000 with no transfusion x 7 days. 
 
6.2 Toxicity Criteria 
Regimen-related toxicity will be graded according to the NCI Common Toxicity Criteria, version 
4.0. These criteria can be found at:  
https://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03_2010-06-14_QuickReference_5x7.pdf 

27 
Protocol v6.4 dated 2022-06-17 
 
6.3 Disease Response 
Disease response will be measured according to the National Comprehensive Cancer Network 
Guidelines (NCCN).  The guidelines are disease specific and the guidelines for each disease can 
be found at: 
 
http://www.nccn.org/professionals/physician_gls/f_guidelines.asp#site  
 
6.4 GVHD Scoring 
GVHD will be graded according to standard criteria contained in Appendix B. 
 
6.5 Adverse Event Reporting 
All patients will be followed for adverse experiences (AEs) (serious and nonserious), regardless 
of relationships to study treatment, from the time of enrollment until d +100 after transplant. 
Expected non-life-threatening side effects of high-dose chemotherapy and transplant and will be 
recorded but will not be reported except as noted: 
• Alopecia, headache, dry skin 
• Emesis from chemotherapy or other agents unless refractory to standard supportive care, 
nausea, anorexia 
• Weight loss, cough, dry mouth, headache 
• Grades I-III hypoxia  
• Grades I-III fever 
• Grades I-III infectious sequellae 
• Grades I-III abnormalities in ALP, AST and ALT 
• Grade I-III electrolyte disturbance 
• Neutropenia/uncomplicated neutropenic fever, grades I-III infectious sequellae  
• Thrombocytopenia, Petechiae, ecchymoses, minor vaginal bleeding, epistaxis, 
hemorrhoidal bleeding, or other similar bleeding events will not be reported.  
• Anemia 
• Mucositis or esophagitis (non-life-threatening) 
• Diarrhea (non-life-threatening) 
• Allergic or other common reactions to drugs used for supportive care unless grade 4-5  
• 
Grades I-III Rash 
• 
Grades I-III Fatigue 
• 
Pancytopenia 
• 
Grade I - III Mucositis  
• 
Grade I - III Diarrhea  
• 
Allergic or other reactions to drugs used for supportive care or GVHD 
prophylaxis unless grade 4-5  
•  

28 
Protocol v6.4 dated 2022-06-17 
Serious adverse event reporting to the TJU Institutional Review Board will occur for grade 4 and 
grade 5 events and/or for an event that results in hospitalization or permanent disability 
regardless to the relationship to the study treatment. 
 
After d+100, only AEs that are considered by the investigator to be possibly or probably 
associated with the treatment regimen will be reported.   
 
The formal endpoint of this study is 2 years post HSCT. Therefore patients will not be followed 
for this study after this time. However, outcomes for patients undergoing HSCT at TJUH are 
followed programmatically beyond this study indefinitely. 
 
6.6 Reports to the Federal Drug Administration (FDA) 
All grade 3-5 hematopoietic cell infusion reactions and all unexpected SAEs as defined in 21 
CFR 312.32 will be reported to the FDA in an expedited fashion. 
 
All Unanticipated Adverse Device Effects will also be reported to the FDA within 10 working 
days as defined in 21 CFR 812.150. 
 
An annual report will be sent to the FDA regarding the progress to date of patients on the trial.  
In the report, a separate listing of infusion toxicities and all biological product deviations will be 
included in addition to the other required elements. 
 
6.7 Study Endpoints 
The endpoint of this study is OS at  2 years. 
 
7.0 Supportive Care 
7.1 Avoidance of Infection 
 
Patients who are post HSCT are susceptible to infection. BMT Clinical Program SOPs CP:P050.02 and 
CP:P001.04 address infectious prophylaxis and management of suspected infection.  
 
Central venous catheters will be removed as soon as clinically manageable. 
 
It is recommended that IVIG 0.5 g/kg IV will be administered every 4 weeks post transplant to 
support immune function, until IgG level is ≥ 500 mg/dL on 2 consecutive monthly 
measurements for haploidentical graft recipients. The first dose will be targeted for  day +7, but 
may be timed differently based on patient condition. 
 
The infusion of IVIG to patients undergoing matched sibling transplant is at the discretion of the 
attending physician. 
 
7.2 Infectious Prophylaxis-General Guidelines 
Patients post partially-matched related donor transplantation will be maintained on antifungal 
prophylaxis,  such as voriconazole or noxafil. . It is at the discretion of the treating attending 
physician to change agents or discontinue agents as clinically indicated. 

29 
Protocol v6.4 dated 2022-06-17 
 
Patients post partially-matched related donor transplantation will be maintained on HSV 
prophylaxis such as valacyclovir.. It is at the discretion of the treating physician to change agents 
or discontinue agents based on culture results and sensitivities as well as patient condition.  
 
Patients post partially-matched related donor transplantation will be maintained on PCP 
prophylaxis, such as TMP-SMZ. . It is at the discretion of the treating physician to change agents 
based on culture results, drug tolerance, and patient condition. 
 
Management of prophylactic post HSCT medications is per BMT SOP available on the TJUH 
Intranet.  
 
7.3 Growth Factor and Transfusion Support 
To prevent inadvertent lymphoid engraftment, all blood cell products must be irradiated.. 
 
All red cell and platelet products will be leukodepleted to prevent alloimmunization and decrease 
infectious sequela.   
 
Packed red blood cell transfusions will be given as necessary with the goal of keeping  the 
hemoglobin ≥ 7-8g/L. 
 
Platelet transfusions will be used as needed with the goal of keeping the morning count 
≥20x10e9/L, with 10x10e9/L used for situations without an excessive bleeding risk.  
 
GM-CSF (granulocyte-macrophage colony-stimulating factor) 250µg/m2 will be administered 
daily beginning on day +1. GM-CSF will be weaned/discontinued at the discretion of the 
attending physician. Every effort should be made to keep the ANC > 1000 for all patients post 
partially-matched related donor transplantation. G-CSF 5µg/m2 (or other white cell growth 
factors) can be substituted for GM-CSF in the event of a GM-CSF shortage or if a patient has a 
deleterious reaction to GM-CSF as determined by the BMTU attending physician. 
 
Red cell growth factors are permissible after transplantation. 
 
8.0 Drug Information and Administration 
8.1 Busulfan 
Mechanism: Busulfan is an alkylating agent which reacts with the N-7 position of guanosine and 
interferes with DNA replication and transcription of RNA. Busulfan has a more marked effect on 
myeloid cells than on lymphoid cells and is also very toxic to hematopoietic stem cells. Busulfan 
exhibits little immunosuppressive activity, and therefore in this protocol is given with 
fludarabine and TBI both of which have lymphopenic affects. Busulfan interferes with the 
normal function of DNA by alkylation and cross-linking the strands of DNA.  
 
Metabolism: Extensively hepatic; glutathione conjugation followed by oxidation 
 
Incompatibilties: Busulfan does not have an extensive list of medications that cause problematic 
interactions. However, there are a few drugs, commonly used with Busulfan that may affect its 
metabolism. Phenytoin may decrease the serum concentration of Busulfan and Azoles may 

30 
Protocol v6.4 dated 2022-06-17 
decrease the metabolism of Busulfan. Acetominophen and Metronidazole may increase the 
serum concentration of Busulfan.  
 
Toxicity: Side effects of Busulfan include but are not limited to: tachycardia, hypertension, 
insomnia, anxiety, headache, fever, vomiting, mucositis, diarrhea, anorexia, myelosupression, 
hyperbilirubinemia, VOD, weakness, and arthralgias, Administration: Busulfan is administered 
for 2 days on days -14 and -13 at a dose of 3.2 mg/kg/day IV.(Alatrash, deLimaAndersson 
McCune) The infusion can be started upon the completion of the fludarabine. 
 
Reference: http://online.lexi.com.proxy1.lib.tju.edu/lco/action/doc/retrieve/docid/patch_f/6487#f_adverse-reactions 
 
8.2 Cyclophosphamide 
Mechanism: A multistep process activates it by conversion to 4-hydroxycyclophosphamide by 
the liver microsomal oxidase system and to aldophosohamide by tautomerization in the 
peripheral tissues. Aldophosphamide spontaneously degrades into acrolein and phosporamide 
mustard, which cause cellular glutathione depletion and DNA alkylation. This results in 
inhibition of DNA replication and transcription. Cells expressing high levels of aldehyde 
dehydrogenase (e.g. stem cells, L1210 leukemia cells) resist cyclophosphamide-mediated 
cytotoxicity as aldophosphamide is inactivated by this enzyme. The drug also does not affect 
quiescent cells and therefore stem cells are generally protected, an important factor if autologous 
hematopoietic recovery is relied on in the event of graft failure.  
 
Metabolism: Cyclophosphamide is broken down as described above and the break down 
products are excreted by the kidneys. 
 
Incompatibilties: Phenobarbital or rifampin may increase the toxicity of cyclophosphamide. 
Concurrent allopurinol or thiazide diuretics may exaggerate bone marrow depression May 
prolong neuromuscular blockade from succinylcholine Cardiotoxicity may be additive with other 
cardiotoxic agents (cytarabine, daunorubicin, doxorubicin). May decrease serum digoxin levels.  
Additive bone marrow depression with other antineoplastics or radiation therapy. May potentiate 
the effects of warfarin. May decrease antibody response to live-virus vaccines and increase the 
risk of adverse reactions. Prolongs the effects of cocaine. 
 
Toxicity: Nausea, vomiting, water retention due to inappropriate secretion of anti-diuretic 
hormone (SIADH), cardiomyopathy with myocardial necrosis and congestive heart failure, 
hemorrhagic cystitis, alopecia, skin rash, pulmonary fibrosis, sterility and secondary 
malignancies. 
 
Administration: Patients will receive a dose of cyclophosphamide 60 mg/kg IV, on days –3 and -
2. The dose of cyclophosphamide will be calculated according to the dosing body weight. 
MESNA (sodium-2-mercaptoethane sulfonate) will be administered prior to cyclophosphamide 
infusion and ending approximately 24 hours after the last dose of cyclophosphamide. The dose 
of MESNA will also be calculated based on dosing body weight.  
Reference: Skeel R & Lachant N.  Handbook of Cancer Chemotherapy, 4th Ed. Little, Brown & Co.: Boston. 
 

31 
Protocol v6.4 dated 2022-06-17 
8.3 Donor Leukocyte Infusion (DLI) 
Administration: All patients will receive a dose of donor CD3+ T cells per kilogram of dosing 
body weight as outlined in the treatment design. Details of the apheresis procedure to obtain 
white blood cells, quantification of CD3+ T cells by flow cytometry, and administration of the 
white cells product to the recipient are provided in the treatment section. All drug that may cause 
lymphocyte suppression are starting on the day of admission through day 0 as detailed in the 
treatment section. 
 
Toxicity: Infusion reactions, GVHD. 
 
8.4 Fludarabine 
Mechanism: Fludarabine phosphate is fluorinated nucleotide and analog of antiviral agent 
vidarabine, that is relatively resistant to adenosine deaminase deamination. It is actively 
dephosphorylated to 2-fluoro-ara-A and phosphorylated further by deoxycytidine kinase to 2-
fluoro-ara-ATP, then acts by inhibiting DNA polymerase alpha, ribonucleotide reductase and 
DNA primase resulting in DNA synthesis inhibition. 
 
Metabolism: Renal Excretion  
In a pharmacokinetic study of patients treated with fludarabine for rheumatoid arthritis, the mean 
total clearance was 14.01 L/hr following a dose of 20 mg/m(2)/day, and 13.4 L following a dose 
of 30 mg/m(2)/day (Knebel et al, 1998). The median total body clearance was 9.6 L/hr after 
intravenous or subcutaneous fludarabine 30 mg/m(2) for 3 days in 5 patients with lupus nephritis 
(Kuo et al, 2001). 
 
Incompatibilities: Fludarabine has drug interactions with several vaccines and its simultaneous 
use with Rotavirus vaccine is contraindicated. 
 
Toxicities: Common: Endocrine/Metabolic: Shivering, Gastrointestinal: Loss of Appetite, 
Nausea, Vomiting, Neurologic: Asthenia, Other: Fatigue, Malaise, Serious: Cardiovascular: 
Edema (frequent), Dermatologic: Aplasia of skin (rare), Hematologic: Autoimmune Hemolytic 
Anemia, Graft versus host disease, Transfusion-associated, with non-irradiated blood (rare), 
Myelosuppression (frequent), Neurologic: Neurotoxicity, Respiratory: Pneumonia (frequent), 
Other: Fever (frequent), Infectious disease. 
 
Administration: In this protocol, Fludarabine is administered for 4 days on (days -11 through – 8) 
at a dose of 30 mg/m2/day IV for 4 days. Creatinine must be checked prior to each dose of 
fludarabine.  If renal insufficiency develops, the attending physician must be notified in cases 
where a dose adjustment needs to be made. 
 
Reference: MicroMedex Health Care Series, Thomson 
 
8.5 G-CSF 
Mechanism: G-CSF is a human granulocyte colony-stimulating factor produced by recombinant 
DNA technology. It is a glycoprotein which acts on hematopoietic cells by binding to specific 
cell surface receptors and stimulating proliferation, differentiation, commitment, and some end-
cell functions. 

32 
Protocol v6.4 dated 2022-06-17 
Metabolism: Absorption and clearance of G-CSF follows first-order pharmacokinetic modeling 
without apparent concentration dependence. The elimination half-life in both normal and cancer 
patients is 3.5 hours. 
 
Incompatibilties: Safety and efficacy of G-CSF when used simultaneously with chemotherapy or 
radiotherapy has not been evaluated. Donors receiving either of these 2 modalities will not be 
permitted on study. 
 
Toxicities: Allergic reactions consisting of rash, wheezing and tachycardia. Splenic rupture, 
ARDS, and exacerbation of sickle cell disease have been reported rarely. 
 
Administration: In this protocol, G-CSF will be administered to healthy donors at a dose of 10 
µg/kg (actual weight) subcutaneously on days -5 through day -1. 
 
Reference: Physician’s Desk Reference, Edition 58, 2004. 
 
8.6 GM-CSF 
Mechanism: GM-CSF is a recombinant human granulocyte-colony stimulating factor produced 
by recombinant DNA technology in a yeast expression system. It supports survival, clonal 
expansion, and differentiation of hematopoietic cells. GM-CSF is also capable of activating 
mature granulocytes and macrophages, and is a multilineage factor with effects on the 
myelomonocytic, erythroid, and megarkaryocytic lines.  
 
Metabolism: GM-CSF is detected in the serum at 15 minutes after injection. Peak levels occur 
about 1 to 3 hours after injection, and it is detectable in the serum for up to 6 hours after 
injection.  
 
Incompatibilities: Interactions between GM-CSF and other drugs have not been fully evaluated. 
Drugs which may potentiate the myeloproliferative effects of GM-CSF, such as lithium and 
corticosteroids, should be used with caution.  
 
Toxicities: Allergic and anaphylactic reactions have been reported. A syndrome characterized by 
respiratory distress, hypoxia, flushing, hypotension, syncope and or tachycardia has been 
associated with the first administration of GM-CSF in a cycle. These signs have resolved with 
treatment.  
 
Administration: In this protocol, GM-CSF will be given to the patients beginning on Day +1 in 
the PM. The drug should continue until the patient has a self-sustaining ANC of 1500.  
 
Reference: Physician’s Desk Reference, Edition 58, 2004. 
 
8.7 Mycophenolate Mofetil (MMF) 
Mechanism: Inhibits the enzyme inosine monophosphate dehydrogenase, which is involved in 
purine synthesis. This inhibition results in suppression of T- and B-lymphocyte proliferation.  
 
Metabolism: Following oral and IV administration, mycophenolate is rapidly hydrolyzed to 
mycophenolic acid (MPA), its active metabolite. Distribution is unknown. MPA is extensively 

33 
Protocol v6.4 dated 2022-06-17 
metabolized; <1% excreted unchanged in urine. Some enterohepatic recirculation of MPA 
occurs. Half Life: MPA¾17.9 hr. 
 
Incompatibilities: Combined use with azathioprine is not recommended (effects unknown). 
Acyclovir and ganciclovir compete with MPA for renal excretion and, in patients with renal 
failure, may increase each other's toxicity. Magnesium and aluminum hydroxide antacids 
decrease the absorption of MPA (avoid simultaneous administration). Cholestyramine and 
colestipol decrease the absorption of MPA (avoid concurrent use). Toxicity may be increased by 
salicylates. May interfere with the action of oral contraceptives (additional contraceptive method 
should be used). May decrease the antibody response to and increase risk of adverse reactions 
from live-virus vaccines, although influenza vaccine may be useful. When administered with 
food, peak blood levels of MPA are significantly decreased. 
 
Toxicities: GI: Bleeding, Diarrhea, Vomiting, Hematopoietic: Leukopenia Miscellaneous: 
Sepsis, Increased Risk of Malignancy  
 
Administration: In this protocol, MMF will be administered at a dose of 1 gram IV BID 
beginning on day -1. MMF will be discontinued on day +28 in the absence of GVHD. MMF may 
be stopped earlier if there is count suppression from the drug or intolerance to the drug. 
 
8.8 Tacrolimus 
Mechanism: Tacrolimus, it is a macrolide immunosuppressant. It inhibits lymphocytes by 
forming a complex with FKBP-12, calcium, calmodulin leading to the decrease in the 
phosphatase activity of calcineurin. This in turn prevents generation of NF-AT, a nuclear factor 
for initiating gene transcription for lymphokines like interleukin-2 and interferon-γ99. This drug is 
used with corticosteroids for prophylaxis of organ rejection in patients receiving allogeneic liver 
transplants. Its use is also currently being investigated in kidney, bone marrow, cardiac, 
pancreas, pancreatic island cell and small bowel transplantation.  
 
Metabolism: This drug is well absorbed orally. It is metabolized in the liver by unknown 
mechanisms and demethylation and hydroxylation has been proposed based on in vitro studies. 
The metabolized products are excreted in the urine.  
 
Incompatibilities: Nephrotoxic drugs, antifungals (azoles), calcium-channel blockers, cimetidine, 
danazol, erythromycin, methylprednisone and metoclopramide increase the bioavailabilty of 
tacrolimus. On the other hand phenobarbital, phenytoin, rifamycins and carbamazepine decrease 
tacrolimus levels.     
 
Toxicities: Adverse reactions include: tremor, headache, neurotoxicity; diarrhea, nausea; 
hypertension; TTP and renal dysfunction.     
 
Administration: Tacrolimus will be started on day -1 with  a goal target level of 7ng/ml +/- 2 as 
noted in section 5. It is suggested that a tacrolimus taper be initiated around d_42 in the absence 
of GVHD.  
9.0 Patient Safety 
To ensure patient safety, a number of steps will be taken.   

34 
Protocol v6.4 dated 2022-06-17 
 
The study will be monitored on an ongoing fashion by the Principal Investigator (PI) and the 
study medical monitor.  Monitoring reports will be submitted to the Clinical Research 
Management Office (CRMO) for review by the DSMC during their quarterly review. Adverse 
events and a report summarizing their impact on the conduct of the trial are submitted to the Data 
Monitoring and Safety Committee (DMSC) quarterly, and the DSMC reports are them submitted 
to the CCRRC and IRB. The PI will submit serious adverse events (SAE) to the TJU IRB 
utilizing the electronic Kimmel Cancer Center Clinical Trials Adverse Event Reporting system.  
Due to the nature of the study treatment as outlined in this protocol, expected grade 3 AE/SAEs 
that occur while receiving standard inpatient protocol treatment may be included on the patient’s 
AE log for quarterly review by the DSMC rather than be reported via the eSAEy System per the 
DSM Plan. It is the responsibility of the study Principal Investigator (PI) to report any grade 3 
AE/SAE to the DSMC per the DSM Plan should the length of standard protocol treatment 
hospitalization be extended and/or the grade 3 AE/SAE is more acute than expected as outlined 
in the informed consent form. Unexpected deaths related to this protocol will be reported within 
24 hours. 
 
In addition to the Cancer Center's DMSC, the TJU BMT program members meet weekly to 
discuss the status of patients on trial and generate discussion regarding the progress of the 
patients on the trial.  
 
The medical monitor will be a TJU physician who is not a collaborator in this trial. The medical 
monitor will review all adverse events (in addition to unexpected adverse events), safety data and 
activity data observed when this trial is ongoing. The medical monitor may recommend reporting 
adverse events and relevant safety data not previously reported, and may recommend suspension 
or termination of the trial. The summary of all discussions of adverse events will be submitted to 
the DSMC after completion and included in the PI's reports to the CCRRC and the TJU IRB as 
part of the study progress report. The CCRRC, DMSC, and/or the TJU IRB may, based on the 
monitor's recommendation suspend or terminate of the trial. The quarterly safety and monitoring 
reports will include a statement as to whether this data has invoked any stopping criteria (dose-
limiting toxicities) in the clinical protocol.  
 
Auditing and Inspecting 
The investigator will permit study-related monitoring, audits, and inspections by the IRB, the 
funding sponsor, government regulatory bodies, and University compliance and quality 
assurance groups of all study related documents (e.g. source documents, regulatory documents, 
data collection instruments, study data etc.).  The investigator will ensure the capability for 
inspections of applicable study-related facilities. 
 
Participation as an investigator in this study implies acceptance of potential inspection by 
government regulatory authorities and applicable University compliance and quality assurance 
offices. 
 
In addition to review by the DSMC, all studies initiated by KCC investigators are audited by an 
independent auditor once they have achieved 10% of target accrual. However, a study can be 
audited at any time based on recommendations by the IRB, DSMC, CCRRC and/or the Director 

35 
Protocol v6.4 dated 2022-06-17 
of Clinical Investigations, KCC. Studies are re-audited once they have achieved 50% of target 
accrual. Special audits may be recommended by the IRB, DSMC or CCRRC based on prior 
findings, allegations of scientific misconduct and where significant irregularities are found 
through quality control procedures. Any irregularities identified as part of this process would 
result in a full audit of that study.  
 
In addition to the audits at 10 and 50%, the CRMO randomly audits at least 10 percent of all 
patients entered into therapeutic KCC trials and other trials as necessary, on at least a bi-annual 
basis, to verify that there is a signed and dated patient consent form, the patient has met the 
eligibility criteria, and that SAEs are documented and reported to the TJU IRB.  
 
All audit reports are submitted to the DSMC for review and action (when appropriate). A copy of 
this report and recommended DSMC action is sent to the CCRRC and TJU IRB. The committee 
regards the scientific review process as dynamic and constructive rather than punitive. The 
review process is designed to assist Principal Investigators in ensuring the safety of study 
subjects and the adequacy and accuracy of any data generated. The TJU IRB may, based on the 
DSMC and auditor’s recommendation, suspend or terminate the trial.  
 
FDA Reports 
All grade 3-5 hematopoietic cell infusion reactions and all unexpected SAEs as defined in 21 
CFR 312.32 will be reported to the FDA in an expedited fashion 
All Unanticipated Adverse Device Effects will also be reported to the FDA within 10 working 
days as defined in 21 CFR 812.150. 
 
An annual report will be sent to the FDA regarding the progress to date of patients on the trial.  
In the report, a separate listing of infusion toxicities and all biological product deviations will be 
included in addition to the other required elements. 
 
Lastly, a current list of investigators, including the names and addresses of all investigators 
participating in this trial, will be provided to the FDA every six months. 
 
10.0 Statistical Analysis 
10.1 Study Design 
This is a one-arm study in patients with hematological malignancies with haploidentical family 
donors and treated with haploidentical transplant. The total of 40 patients will be accrued in 106 
months and then followed for at least 1 more year. 
 
10.2 Analysis of the Primary Endpoint 
The primary endpoint for this study is overall survival (OS). The primary null hypothesis is that 
2 year OS rate is at most 55%. This hypothesis will be rejected if the 95% confidence interval for 
year OS rate computed from the estimated Kaplan-Meier survival curves will be entirely above 
0.55. 
 
10.3 Sample Size 
Assuming that 40 patients will be accrued in 4 years and then followed for 1 more year there is 
92% power to show that 2-year survival is greater than 55% if the true 2-year survival Is 75% or 
higher (calculations are based on the assumptions of uniform accrual over time, no loss to 

36 
Protocol v6.4 dated 2022-06-17 
follow-up, exponentially distributed death times, and use of the exponential MLE one-side test 
with alpha=0.05). 
 
10.4 Assessment of the Secondary Endpoint 
The secondary endpoints include (1) relapse-related mortality (RRM) rate at 2 years; (2) 2 year 
relapse rate; (3) the incidence and severity of graft-versus-host disease (GVHD); (4) engraftment 
rates; (5) the incidence of treatment related mortality (TRM) at 100 days. 
 
The survival type secondary endpoints (relapsed-related mortality and relapse) will be evaluated 
similarly to the primary endpoint by estimating Kaplan-Meier survival curves. From these 
curves, the 95% confidence interval for 2 year rates will be computed. The estimates of 
incidence rates will be presented with corresponding 95% confidence intervals using the exact 
method.  
 
10.5 Analysis of Safety 
The safety date analysis will be descriptive. The estimates of the incidences rates will be 
presented with corresponding confidence intervals using the exact method. 
 
Patient outcomes are routinely monitored in an ongoing fashion for all patients on investigational 
trials, beyond their formal endpoints. Based on prior experience using a two-step approach 
similar to that described in this trial, we anticipate that the incidence of graft failure should be 
less than 10%, the incidence  of severe GVHD should be less than 20%, and the non-relapse 
mortality should be less than 30% at 100 days. If at any point incidences higher than these 
thresholds are seen, that would trigger a protocol review to assess whether there are any obvious 
reasons for the inferior outcomes observed. Depending on the results of the review, enrollment 
may continue on a limited basis with careful further observation, the protocol may be revised, or 
the protocol may be terminated. 
 
In addition, it is estimated that up to 15 patients with matched sibling donors will undergo HSCT 
on this approach during the time that the research is open. The small number of patients 
undergoing matched sibling RIC HSCT in out transplant program precludes a separate research 
protocol for that group. To prevent withholding of transplant therapy, these patients will be 
treated on this protocol. Only the outcomes of the patient group undergoing HSCT from 
haploidentical donors (2, 3, or 4 antigen mismatches in the GVH direction) will be used in the 
analysis of outcomes for the statistical ends of the trial. Outcomes for patients with matched 
sibling donors will be reported descriptively. 
 
11.0 References 
1. Grosso D, Brunner J, Carabasi M, et al. A two-step approach to haploidentical allogeneic 
hematopoetic stem cell transplantation (HSCT) for high risk patients with hematological 
disorders.[abstract]. Biology of Blood and Marrow Transplantation. 2008;14, abstract 135.  
 
2. Luznik L, O'Donnell PV, Symons HJ, et al. HLA-haploidentical bone marrow transplantation 
for hematologic malignancies using nonmyeloablative conditioning and high-dose, 
posttransplantation cyclophosphamide. Biology of Blood & Marrow Transplantation. 
2008;14:641-650.  
 

37 
Protocol v6.4 dated 2022-06-17 
3. O'Donnell PV, Luznik L, Jones RJ, et al. Nonmyeloablative bone marrow transplantation from 
partially HLA-mismatched related donors using posttransplantation cyclophosphamide. Biology 
of Blood & Marrow Transplantation. 2002;8:377-386.  
 
4. Grosso D, Alpdogan O, Carabasi M, et al. HLA Disparity and Rapid Immune Reconstitution 
Do Not Overcome Propensity to Relapse in Patients Undergoing Haploidentical Hematopoietic 
Stem Cell Transplant (HSCT) With Persistent Disease at the Time of Transplant. Biology of 
Blood and Marrow Transplantation. 2011;17:S225-S225.  
 
5. Burroughs LM, O'Donnell PV, Sandmaier BM, et al. Comparison of outcomes of HLA-
matched related, unrelated, or HLA-haploidentical related hematopoietic cell transplantation 
following nonmyeloablative conditioning for relapsed or refractory Hodgkin lymphoma. Biology 
of Blood & Marrow Transplantation. 2008;14:1279-1287.  
 
6. Bortin MM and Rimm AA. Increasing utilization of bone marrow transplantation. 
Transplantation. 1986;42:229-234.  
 
7. Thomas ED. Bone marrow transplantation: Past experiences and future prospects. Semin 
Oncol. 1992;19:3-6.  
 
8. Blume KG. A general overview of the status of bone marrow transplantation for hematologic 
diseases. Leukemia : official journal of the Leukemia Society of America, Leukemia Research 
Fund, U.K. 1993;7:1078-1079. 
  
9. Armitage JO. Medical progress: Bone marrow transplantation. N Engl J Med. 1994;330:827-
838.  
 
10. Thomas ED. History, current results, and research in marrow transplantation. Perspect Biol 
Med. 1995;38:230-237.  
 
11. Samson D. The current position of allogeneic and autologous BMT in multiple myeloma. 
Leukemia and Lymphoma. 1992;7:33-38.  
 
12. Ballester OF. Allogeneic bone marrow transplantation for multiple myeloma. Semin Oncol. 
1993;20:67-71.  
 
13. Zittoun RA, Mandelli F, Willemze R, et al. Autologous or allogeneic bone marrow 
transplantation compared with intensive chemotherapy in acute myelogenous leukemia. N Engl J 
Med. 1995;332:217-223.  
 
14. Reece DE, Shepherd JD, Klingemann H-, et al. Treatment of myeloma using intensive 
therapy and allogeneic bone marrow transplantation. Bone Marrow Transplant. 1995;15:117-
123.  
 

38 
Protocol v6.4 dated 2022-06-17 
15. Cavo M, Benni M, Cirio TM, Gozzetti A, Tura S. Allogeneic bone marrow transplantation 
for the treatment of multiple myeloma: An overview of published reports. Stem Cells. 
1995;13:126-131.  
 
16. Gahrton G, Tura S, Ljungman P, et al. An update of prognostic factors for allogeneic bone 
marrow transplantation in multiple myeloma using matched sibling donors. Stem Cells. 
1995;13:122-125.  
 
17. Gahrton G, Tura S, Ljungman P, et al. Prognostic factors in allogeneic bone marrow 
transplantation for multiple myeloma. Journal of Clinical Oncology. 1995;13:1312-1322.  
 
18. Bensinger WI, Buckner CD, Anasetti C, et al. Allogeneic marrow transplantation for multiple 
myeloma: An analysis of risk factors on outcome. Blood. 1996;88:2787-2793.  
 
19. Björkstrand B, Ljungman P, Svensson H, et al. Allogeneic bone marrow transplantation 
versus autologous stem cell transplantation in multiple myeloma: A retrospective case-matched 
study from the European Group for Blood and Marrow Transplantation. Blood. 1996;88:4711-
4718.  
 
20. Attal M, Harousseau J-, Stoppa A-, et al. A prospective, randomized trial of autologous bone 
marrow transplantation and chemotherapy in multiple myeloma. N Engl J Med. 1996;335:91-97.  
 
21. Vesole DH, Tricot G, Jagannath S, et al. Autotransplants in multiple myeloma: What have 
we learned? Blood. 1996;88:838-847.  
 
22. Samson D. High-dose therapy in multiple myeloma. Curr Opin Hematol. 1996;3:446-452.  
 
23. Barlogie B, Jagannath S, Vesole DH, et al. Superiority of tandem autologous transplantation 
over standard therapy for previously untreated multiple myeloma. Blood. 1997;89:789-793.  
 
24. Couban S, Stewart AK, Loach D, Panzarella T, Meharchand J. Autologous and allogeneic 
transplantation for multiple myeloma at a single centre. Bone Marrow Transplant. 1997;19:783-
789.  
 
25. Varterasian M, Janakiraman N, Karanes C, et al. Transplantation in patients with multiple 
myeloma: A multicenter comparative analysis of peripheral blood stem cell and allogeneic 
transplant. American Journal of Clinical Oncology: Cancer Clinical Trials. 1997;20:462-466.  
 
26. Mehta J, Tricot G, Jagannath S, et al. Salvage autologous or allogeneic transplantation for 
multiple myeloma refractory to or relapsing after a first-line autograft? Bone Marrow Transplant. 
1998;21:887-892.  
 
27. Archimbaud E, Thomas X, Michallet M, et al. Prospective genetically randomized 
comparison between intensive postinduction chemotherapy and bone marrow transplantation in 
adults with newly diagnosed acute myeloid leukemia. Journal of Clinical Oncology. 
1994;12:262-267.  

39 
Protocol v6.4 dated 2022-06-17 
 
28. Cassileth PA, Lynch E, Hines JD, et al. Varying intensity of postremission therapy in acute 
myeloid leukemia. Blood. 1992;79:1924-1930.  
 
29. Ferrara JLM and Deeg HJ. Graft-versus-Host disease. N Engl J Med. 1991;324:667-674.  
 
30. Champlin R. Immunobiology of bone marrow transplantation as treatment for hematologic 
malignancies. Transplant Proc. 1991;23:2123-2127.  
 
31. Irschick EU, Hladik F, Niederwieser D, et al. Studies on the mechanism of tolerance or graft-
versus-host disease in allogeneic bone marrow recipients at the level of cytotoxic T-cell 
precursor frequencies. Blood. 1992;79:1622-1628.  
 
32. Antin JH and Ferrara JLM. Cytokine dysregulation and acute graft-versus-host disease. 
Blood. 1992;80:2964-2968.  
 
33. Vogelsang GB and Hess AD. Graft-versus-host disease: New directions for a persistent 
problem. Blood. 1994;84:2061-2067.  
 
34. Brent L. Medawar prize lecture: Tolerance and graft-vs-host disease: Two sides of the same 
coin. Transplant Proc. 1995;27:12-14.  
 
35. Horowitz MM, Gale RP, Sondel PM, et al. Graft-versus-leukemia reactions after bone 
marrow transplantation. Blood. 1990;75:555-562.  
 
36. Gale RP, Horowitz MM, Ash RC, et al. Identical-twin bone marrow transplants for leukemia. 
Ann Intern Med. 1994;120:646-652.  
 
37. Drobyski WR, Keever CA, Roth MS, et al. Salvage immunotherapy using donor leukocyte 
infusions as treatment for relapsed chronic myelogenous leukemia after allogeneic bone marrow 
transplantation: Efficacy and toxicity of a defined T-cell dose. Blood. 1993;82:2310-2318.  
 
38. Porter DL, Roth MS, McGarigle C, Ferrara JLM, Antin JH. Induction of graft-versus-host 
disease as immunotherapy for relapsed chronic myeloid leukemia. N Engl J Med. 1994;330:100-
106.  
 
39. Mackinnon S, Papadopoulos EB, Carabasi MH, et al. Adoptive immunotherapy evaluating 
escalating doses of donor leukocytes for relapse of chronic myeloid leukemia after bone marrow 
transplantation: Separation of graft-versus-leukemia responses from graft-versus-host disease. 
Blood. 1995;86:1261-1268.  
 
40. Kolb H-, Schattenberg A, Goldman JM, et al. Graft-versus-leukemia effect of donor 
lymphocyte transfusions in marrow grafted patients. Blood. 1995;86:2041-2050.  
 

40 
Protocol v6.4 dated 2022-06-17 
41. Collins Jr. RH, Shpilberg O, Drobyski WR, et al. Donor leukocyte infusions in 140 patients 
with relapsed malignancy after allogeneic bone marrow transplantation. Journal of Clinical 
Oncology. 1997;15:433-444.  
 
42. Hamadani M, Awan FT, Copelan EA. Hematopoietic Stem Cell Transplantation in Adults 
with Acute Myeloid Leukemia. Biology of Blood and Marrow Transplantation. 2008;14:556-
567.  
 
43. Kroger N and Mesa RA. Choosing between stem cell therapy and drugs in myelofibrosis. 
Leukemia. 2008;22:474-486.  
 
44. Giralt S, Estey E, van Besien K, et al. Induction of graft-versus-leukemia without 
myeloablative therapy using allogeneic PBSC after purine analog containing regimens.[abstract]. 
Blood. 1996;88, Suppl 1:614a.  
 
45. Slavin S, Nagler A, Naparstek E, et al. Immunotherapy of leukemia in conjunction with 
reduced intensity conditioning: Engraftment of blood stem cells and eradication of host leukemia 
with reduced intensity conditioning based on fludarabine and anti-thymocyte globulin 
(ATG).[abstract]. Blood. 1996;88 Suppl 1:614a.  
 
46. Giralt S, Estey E, Albitar M, et al. Engraftment of allogeneic hematopoietic progenitor cells 
with purine analog-containing chemotherapy: harnessing graft-versus-leukemia without 
myeloablative therapy. Blood. 1997;89:4531-4536.  
 
47. Khouri IF, Keating M, Korbling M, et al. Transplant-lite: induction of graft-versus-
malignancy using fludarabine-based nonablative chemotherapy and allogeneic blood progenitor-
cell transplantation as treatment for lymphoid malignancies. Journal of Clinical Oncology. 
1998;16:2817-2824.  
 
48. Martino R, Iacobelli S, Brand R, et al. Retrospective comparison of reduced-intensity 
conditioning and conventional high-dose conditioning for allogeneic hematopoietic stem cell 
transplantation using HLA-identical sibling donors in myelodysplastic syndromes. Blood. 
2006;108:836-846.  
 
49. Aoudjhane M, Labopin M, Gorin NC, et al. Comparative outcome of reduced intensity and 
myeloablative conditioning regimen in HLA identical sibling allogeneic haematopoietic stem 
cell transplantation for patients older than 50 years of age with acute myeloblastic leukaemia: A 
retrospective survey from the Acute Leukemia Working Party (ALWP) of the European group 
for Blood and Marrow Transplantation (EBMT). Leukemia. 2005;19:2304-2312.  
 
50. Vela-Ojeda J, García-Ruiz Esparza MA, Tripp-Villanueva F, et al. Allogeneic peripheral 
blood stem cell transplantation using reduced intensity versus myeloablative conditioning 
regimens for the treatment of leukemia. Stem Cells and Development. 2004;13:571-578.  
 

41 
Protocol v6.4 dated 2022-06-17 
51. Fielding AK and Goldstone AH. Allogeneic haematopoietic stem cell transplant in 
Philadelphia-positive acute lymphoblastic leukaemia. Bone Marrow Transplant. 2008;41:447-
453.  
 
52. Stein A and Forman SJ. Allogeneic transplantation for ALL in adults. Bone Marrow 
Transplant. 2008;41:439-446.  
 
53. Armand P, Kim HT, Ho VT, et al. Allogeneic transplantation with reduced-intensity 
conditioning for Hodgkin and non-Hodgkin lymphoma: importance of histology for outcome. 
Biology of Blood & Marrow Transplantation. 2008;14:418-425.  
 
54. Smith SM. Reduced-intensity transplantation for lymphoma. Current Treatment Options in 
Oncology. 2006;7:295-305.  
 
55. Corradini P, Dodero A, Farina L, et al. Allogeneic stem cell transplantation following 
reduced-intensity conditioning can induce durable clinical and molecular remissions in relapsed 
lymphomas: Pre-transplant disease status and histotype heavily influence outcome. Leukemia. 
2007;21:2316-2323.  
 
56. Couriel DR, Saliba RM, Giralt S, et al. Acute and chronic graft-versus-host disease after 
ablative and nonmyeloablative conditioning for allogeneic hematopoietic transplantation. 
Biology of Blood & Marrow Transplantation. 2004;10:178-185.  
 
57. Slavin S, Nagler A, Naparstek E, et al. Nonmyeloablative stem cell transplantation and cell 
therapy as an alternative to conventional bone marrow transplantation with lethal cytoreduction 
for the treatment of malignant and nonmalignant hematologic diseases. Blood. 1998;91:756-763.  
 
58. Anderlini P, Saliba R, Acholonu S, et al. Reduced-intensity allogeneic stem cell 
transplantation in relapsed and refractory Hodgkin's disease: Low transplant-related mortality 
and impact of intensity of conditioning regimen. Bone Marrow Transplantation. 2005;35:943-
951.  
 
59. de Lima M, Anagnostopoulos A, Munsell M, et al. Nonablative versus reduced-intensity 
conditioning regimens in the treatment of acute myeloid leukemia and high-risk myelodysplastic 
syndrome: dose is relevant for long-term disease control after allogeneic hematopoietic stem cell 
transplantation. Blood. 2004;104:865-872.  
60. Herr A-, Labopin M, Blaise D, et al. HLA-identical sibling allogeneic peripheral blood stem 
cell transplantation with reduced intensity conditioning compared to autologous peripheral blood 
stem cell transplantation for elderly patients with de novo acute myeloid leukemia. Leukemia. 
2007;21:129-135.  
 
61. Kurosawa S, Yamaguchi T, Uchida N, et al. Comparison of Allogeneic Hematopoietic Cell 
Transplantation and Chemotherapy in Elderly Patients with Non-M3 Acute Myelogenous 
Leukemia in First Complete Remission. Biology of Blood and Marrow Transplantation. 2010.  
 

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Protocol v6.4 dated 2022-06-17 
62. McClune BL, Weisdorf DJ, Pedersen TL, et al. Effect of age on outcome of reduced-intensity 
hematopoietic cell transplantation for older patients with acute myeloid leukemia in first 
complete remission or with myelodysplastic syndrome. Journal of clinical oncology : official 
journal of the American Society of Clinical Oncology. 2010;28:1878-1887.  
 
63. Lim Z, Brand R, Martino R, et al. Allogeneic hematopoietic stem-cell transplantation for 
patients 50 years or older with myelodysplastic syndromes or secondary acute myeloid leukemia. 
Journal of Clinical Oncology. 2010;28:405-411.  
 
64. Das M, Saikia TK, Advani SH, Parikh PM, Tawde S. Use of a reduced-intensity conditioning 
regimen for allogeneic transplantation in patients with chronic myeloid leukemia. Bone Marrow 
Transplant. 2003;32:125-129.  
 
65. Stewart WA, Pearce R, Kirkland KE, et al. The role of allogeneic SCT in primary 
myelofibrosis: A British Society for Blood and Marrow Transplantation study. Bone Marrow 
Transplant. 2010;45:1587-1593.  
 
66. Lissandre S, Bay J-, Cahn J-, et al. Retrospective study of allogeneic haematopoietic stem-
cell transplantation for myelofibrosis. Bone Marrow Transplant. 2010.  
 
67. Majhail NS, Weisdorf DJ, Wagner JE, Defor TE, Brunstein CG, Burns LJ. Comparable 
results of umbilical cord blood and HLA-matched sibling donor hematopoietic stem cell 
transplantation after reduced-intensity preparative regimen for advanced Hodgkin lymphoma. 
Blood. 2006;107:3804-3807.  
 
68. Johansson J-, Remberger M, Lj Lazarevic V, et al. Allogeneic haematopoietic stem-cell 
transplantation with reduced intensity conditioning for advanced stage Hodgkin's lymphoma in 
Sweden: high incidence of post transplant lymphoproliferative disorder. Bone Marrow 
Transplant. 2010.  
 
69. Sarina B, Castagna L, Farina L, et al. Allogeneic transplantation improves the overall and 
progression-free survival of Hodgkin lymphoma patients relapsing after autologous 
transplantation: A retrospective study based on the time of HLA typing and donor availability. 
Blood. 2010;115:3671-3677.  
 
70. Armand P, Kim HT, Ho VT, et al. Allogeneic Transplantation with Reduced-Intensity 
Conditioning for Hodgkin and non-Hodgkin Lymphoma: Importance of Histology for Outcome. 
Biology of Blood and Marrow Transplantation. 2008;14:418-425.  
 
71. Hari P, Carreras J, Zhang M-, et al. Allogeneic Transplants in Follicular Lymphoma: Higher 
Risk of Disease Progression after Reduced-Intensity Compared to Myeloablative Conditioning. 
Biology of Blood and Marrow Transplantation. 2008;14:236-245.  
 
72. Khouri IF, McLaughlin P, Saliba RM, et al. Eight-year experience with allogeneic stem cell 
transplantation for relapsed follicular lymphoma after nonmyeloablative conditioning with 
fludarabine, cyclophosphamide, and rituximab. Blood. 2008;111:5530-5536.  

43 
Protocol v6.4 dated 2022-06-17 
 
73. Sorror ML, Storer BE, Sandmaier BM, et al. Five-year follow-up of patients with advanced 
chronic lymphocytic leukemia treated with allogeneic hematopoietic cell transplantation after 
nonmyeloablative conditioning. Journal of Clinical Oncology. 2008;26:4912-4920.  
 
74. Peres E, Braun T, Krijanovski O, et al. Reduced intensity versus full myeloablative stem cell 
transplant for advanced CLL. Bone Marrow Transplant. 2009;44:579-583.  
 
75. Dreger P, Brand R, Hansz J, et al. Treatment-related mortality and graft-versus-leukemia 
activity after allogeneic stem cell transplantation for chronic lymphocytic leukemia using 
intensity-reduced conditioning. Leukemia. 2003;17:841-848.  
 
76. Garban F, Attal M, Michallet M, et al. Prospective comparison of autologous stem cell 
transplantation followed by dose-reduced allograft (IFM99-03 trial) with tandem autologous 
stem cell transplantation (IFM99-04 trial) in high-risk de novo multiple myeloma. Blood. 
2006;107:3474-3480.  
 
77. Rosiñol L, Pérez-Simón JA, Sureda A, et al. A prospective PETHEMA study of tandem 
autologous transplantation versus autograft followed by reduced-intensity conditioning 
allogeneic transplantation in newly diagnosed multiple myeloma. Blood. 2008;112:3591-3593.  
 
78. Gahrton G. Progress in allogeneic transplantation for multiple myeloma. Eur J Haematol. 
2010;85:279-289.  
 
79. Mohty M, Boiron JM, Damaj G, et al. Graft-versus-myeloma effect following antithymocyte 
globulin-based reduced intensity conditioning allogeneic stem cell transplantation. Bone Marrow 
Transplant. 2004;34:77-84.  
 
80. Shimoni A, Hardan I, Ayuk F, et al. Allogenic hematopoietic stem-cell transplantation with 
reduced-intensity conditioning in patients with refractory and recurrent multiple myeloma: Long-
term follow-up. Cancer. 2010;116:3621-3630.  
 
81. Efebera YA, Qureshi SR, Cole SM, et al. Reduced-Intensity Allogeneic Hematopoietic Stem 
Cell Transplantation for Relapsed Multiple Myeloma. Biology of Blood and Marrow 
Transplantation. 2010;16:1122-1129.  
 
12.0 Appendices 
Appendix A: Guidelines for Total Body Irradiation 
Modality  
Photon irradiation is to be used for the TBI in all patients.  
 
Energy  
A linear accelerator with energy ≥ 4 MV may be used. Dose to superficial tissues near skin 
surface will be increased by using a beam “spoiler” lucite plate close to the patient.  
Since neoplastic infiltrates may be found in the skin, it is necessary for the superficial dose to 
satisfy the same total dose requirements as other locations.  

44 
Protocol v6.4 dated 2022-06-17 
 
Geometry  
The treatment configuration shall be such that the patient is entirely included within the 
treatment beam. It is essential that the correlation between the light field and the radiation field 
be established and verified for extended TBI distances.  
 
Dose Rate  
A dose rate of 0.05 to 0.25 Gy/minute at the prescription point shall be utilized. The physicist of 
record, involved with TBI treatments, shall be consulted to achieve correct range of treatment 
dose rate.  
 
Calibration & Beam Data Verification  
The calibration of the output of the machine, used for this protocol, shall be verified on a daily 
basis prior to start TBI treatments. All dosimetric parameters, necessary for the calculation of 
dose delivered during TBI treatments, shall be measured at the appropriate treatment distance. 
They shall be documented and made available for calculation of every patient treatment.  
 
Treatment Volume  
The patient shall be entirely included within the treatment beam. Care should be taken to 
guarantee that all of the patient is within the 90% decrement line at each depth. The 90% 
decrement line is defined as the line in each plane perpendicular to the central axis connecting 
the points which are 90% of the central axis dose, in that plane.  
 
Treatment Dose  
Prescription Point  
The prescription point is defined as the midplane point along the longitudinal axis at the level of 
the umbilicus.  
 
Dose Units  
All doses shall be specified in Gray (Gy) to muscle tissue.  
 
Tissue Inhomogeneity Considerations  
No inhomogeneity corrections shall be made in the calculation of the dose to the prescription 
point.  
 
Prescription Point Dose  
The total dose shall be 2 Gy.   
 
Time-Dose Considerations  
Dose Homogeneity  
The total absorbed dose along the patient's head to toe axis (in the midplane of the patient) shall 
not deviate more than 10% from the prescribed dose.  
 
Treatment Technique  
Treatment Fields  
Equally weighted parallel opposed portals shall be used. AP/PA fields shall be used.  

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Protocol v6.4 dated 2022-06-17 
 
Field Size  
The collimation and treatment distance shall be such that the patient will be entirely included 
within the treatment beam and that no part of the patient extends beyond that region. The 
agreement of the light field and the radiation field should be checked periodically for the 
extended TBI treatment distance.  
 
Treatment Position  
The patient shall be treated in any position that is compatible with the homogeneity requirement, 
allowing for the reproducibility of the patient setup and dosimetry.  
 
Field Shaping  
Patients will be treated with open fields.  
 
Calculations  
Central Axis Dose  
It is recommended that the dose calculation method be based upon measurements that are made 
in a unit density phantom with the following minimum dimensions:  
• Length equal to top of shoulder to the bottom of the pelvis.  
• Width equal to the patient width at the level of the umbilicus.  
• Thickness equal to the typical patient thickness at the umbilicus.  
• All measurements should be made at the appropriate extended SSD.  
 
Superficial Dose  
For the radiation beam with the Plexiglas plate in place, data should be available demonstrating 
that the skin dose is within 5% of the prescribed dose.  
 
Quality Assurance Documentation  
For purposes of quality assurance the following must be performed on every patient undergoing 
TBI:  
• A check of the monitor unit calculation by a second physicist and a radiation oncologist 
prior to first treatment. 
 
Appendix B: GVHD Grading System Grade 
 
Clinical Staging of Acute Graft-Versus-Host Disease 
Stage 
Skin 
Liver 
Gut 
+ 
Maculopapular rash < 
25% body surface 
Bilirubin, 2-3 mg/dl 
Diarrhea, 500-1,000 
ml/day or persistent 
nausea 
++ 
Maculopapular rash 25-
50% body surface 
Bilirubin, 3-6 mg/dl 
Diarrhea, 1,000-1,500 
ml/day 
+++ 
Generalized 
erythroderma 
Bilirubin, 6-15 mg/dl 
Diarrhea, > 1,500 
ml/day 
++++ 
Desquamation and 
bullae 
Bilirubin, > 15 mg/dl 
Pain +/- ileus 

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Protocol v6.4 dated 2022-06-17 
 
Clinical Grading of Acute Graft-Versus-Host DiseaseStage 
Overall Grade 
Skin 
Liver 
Gut  
Functional 
Impairment 
0 (none) 
0 
0 
0 
0 
I (mild) 
+ to ++ 
0 
0 
0 
II (moderate) 
+ to +++ 
+ 
+ 
+ 
III (severe) 
++ to +++ 
++ to +++ 
++ to +++ 
++ 
IV (life-
threatening) 
++ to ++++ 
++ to ++++ 
++ to ++++ 
+++ 
Tables from Glucksberg H, Storb R, Fefer A, et al. Clinical manifestations of graft-versus-host disease in human 
recipients of marrow from HL-A-matched sibling donors. Transplantation, 18: 295-304, 1974.